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Depressive symptoms affect sleep quality in women with type 2 diabetes
Depressive symptoms can lead to poor sleep and quality of life for women with type 2 diabetes, and nonpharmacologic therapies may be the best way to mitigate these negative effects, according to a study published in Diabetic Medicine.
“Depressive symptoms disproportionately affect women compared with men with diabetes, consistent with trends in the general population,” Suzanne C. Danhauer, PhD, associate professor in the department of social sciences and health policy at Wake Forest School of Medicine in Winston-Salem, North Carolina, and colleagues wrote. “The effects of depression among people with diabetes may depend, in part, on treatment for depression. ... Although antidepressant use can improve glycemic control in adults with comorbid depression and diabetes, it also is associated with poorer physical health-related quality of life; therefore, the effects of antidepressant use among adults with diabetes require further study.”
Danhauer and colleagues analyzed data from 8,895 women with type 2 diabetes participating in the Women’s Health Initiative who were assessed for depressive symptoms. Women in the entire initiative cohort (n = 161,809) were recruited from 1993 to 1998 at 40 clinical centers in the U.S. All women were postmenopausal and aged 50 to 79 years.
The researchers measured depressive symptoms using the Center for Epidemiologic Studies Depression scale, which scores depression from 0 to 1. Depressive symptoms are considered more likely with a score of greater than 0.06.
Four outcomes were also recorded, including sleep disturbance, physical activity, physical health-related quality of life and global quality of life. Sleep disturbance was ranked between 0 and 20 on the WHI Insomnia Rating Scale, with a higher score equating to more sleep disturbance. Physical activity was self-reported. Physical health-related quality of life used a component score from the RAND-36, including measures for general health perceptions, physical function, pain and limitations to daily activities. Lastly, global quality of life was assessed by asking participants to rate their overall quality of life on a scale of 0 to 10.
Depressive symptoms were reported in 16.2% of women in the cohort (n = 1,443; mean age, 62.9 years), and antidepressant use was identified in 20.7% of this population compared with 8.5% of the participants without depressive symptoms (n = 7,452; mean age, 64.7 years). Women with depressive symptoms had more sleep disturbance (P < .0001) and lower levels of physical activity (P < .0001), physical health-related quality of life (P < .0001) and global quality of life (P < .0001).
After adjustment for demographic information, antidepressant use, comorbidities, optimism levels and social support, the researchers found that women with depressive symptoms were more prone to sleep disturbance than women without depressive symptoms (P = .001). The adjusted analysis also showed that antidepressant use was associated with lower reported levels of physical health-related quality of life in women with depressive symptoms and women without (P < .0001). In contrast, reported optimism was linked to higher global quality of life in both groups of women (P < .05).
“This suggests that psychosocial factors other than depression (ie, optimism and social support) may be important targets for increasing physical activity and physical health-related quality of life, and that sociodemographic and medical characteristics may be used to identify women with the greatest need for interventions to improve these two outcomes,” the researchers wrote. “Our results, in combination with findings from previous studies, indicate that the health and well-being of women with type 2 diabetes may benefit from nonpharmacological approaches to decreasing depressive symptoms and increasing optimism.” – by Phil Neuffer
Disclosures: Danhauer reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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This study examined the effect of depressive symptoms on women with type 2 diabetes by measuring self-reported sleep disturbance, physical activity, physical health-related quality of life and global quality of life. The researchers found that women with depressive symptoms were more prone to sleep disturbance than women without. The analysis also showed that antidepressant use was associated with lower reported levels of physical health-related quality of life among women with depressive symptoms and women without. According to the authors, reported optimism was linked to higher global quality of life in both groups of women. The authors suggested that psychosocial factors other than depression, such as “optimism and social support,” may be important targets for increasing physical activity and physical health-related quality of life.
There appear to be two major shortcomings with this study. The first is the diagnosis of depression in the study population of women with diabetes. A depression score was measured according to the women’s self-report responses to eight items (combining two assessment forms). Based on the results of those scores, depressive symptoms were classified as present or absent.
Major depressive disorder is commonly recognized as frequently coexisting with diabetes, and it is estimated that nearly 19% of those with type 2 diabetes have significant depressive symptoms with women affected at a higher rate than men. However, there could be another explanation for the comorbidity of major depressive disorder and diabetes. It is important to recognize that people with diabetes can experience diabetes distress, a term that describes significant emotional reactions to the diagnosis, threat of complications, self-management demands, and unsupportive social structures surrounding diabetes.
Literature suggests that up to 45% of people living with type 2 diabetes may exhibit symptoms of diabetes distress and that approximately 70% of those individuals do not meet the criteria for major depressive disorder. The symptoms of diabetes distress may present similarly to major depressive disorder but lack the severity to qualify as such.
In people with diabetes, some of the symptoms may be attributed to uncontrolled blood sugars and should be carefully evaluated. For example, it is common that people with hyperglycemia experience fatigue and weight loss. Similarly, people with frequent hypoglycemia may experience insomnia and diminished ability to concentrate. Diabetes distress is also linked to suboptimal glycemic management and decreased self-management behaviors.
If pharmacotherapy is utilized to relieve the symptoms of depression in those with diabetes distress, the results may not demonstrate improvement of diabetes outcomes, such a glycemic management. As was the case in this study, pharmacotherapy did not benefit the study population. The authors concluded by suggesting that “the well-being of women with type 2 diabetes may benefit from nonpharmacological approaches to decreasing depressive symptoms and increasing optimism.”
The second shortcoming of this study is the authors’ recommendation to increase optimism. The authors’ cited dispositional optimism as “the tendency to expect positive future events” and hypothesized that “higher levels of optimism may be particularly important for maintaining quality of life in people with diabetes and comorbid depression, which is characterized by poor self-care.” However, optimism alone will not improve diabetes self-care without commensurate action. Literature has demonstrated that cognitive behavior therapy helps people change both cognitions and behaviors concurrently. People with diabetes should be encouraged to be realistic about their goals and management regimen to manage their self-care successfully. Focusing on increasing optimism without additional diabetes-specific action seems inadequate for decreasing depressive symptoms and improving self-care skills of women with diabetes.