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ACCORD-MIND: Depression in diabetes linked to greater cognitive decline
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Data from the Action to Control Cardiovascular Risk in Diabetes-Memory in Diabetes study demonstrate that depression in patients with type 2 diabetes is associated with a greater risk for cognitive decline.
“This suggests that a potentially reversible factor may be promoting general cognitive decline in the broad population of patients with type 2 diabetes. Since dementia is one of the fastest growing and most dreaded complications of diabetes, our findings may be important for public health,” Mark D. Sullivan, MD, MPH, of the department of psychiatry and behavioral sciences at the University of Washington, Seattle, and colleagues wrote.
They examined cognition using the Digit Symbol Substitution Test, Rey Auditory Verbal Learning Test and the modified Stroop test; they measured depression using the 9-item Patient Health Questionnaire (PHQ-9) in a cohort (n=2,977) from the Action to Control Cardiovascular Risk in Diabetes-Memory in Diabetes (ACCORD-MIND) study.
Mark D. Sullivan
Risk for cognitive decline was not correlated with baseline cognition or age; intensive vs. standard glucose-lowering; blood pressure, lipid or insulin treatments; or previous CVD, researchers wrote.
They also reported greater cognitive decline among patients whose PHQ-9 scores indicated depression at the 40-month follow-up using the Digit Symbol Substitution Test (0.72; 95% CI, 0.25-1.19), the Rey Auditory Verbal Learning Test (0.18; 95% CI, 0.07-0.29) and Stroop interference test (–1.06; 95% CI, –1.93 to –0.18).
The researchers suggest a randomized clinical trial involving a depression treatment in patients with diabetes to monitor cognitive outcomes.
Disclosure: The following companies provided study drugs, equipment or supplies: Abbott Laboratories, Amylin Pharmaceuticals, AstraZeneca, Bayer HealthCare, Closer Healthcare, GlaxoSmithKline, King Pharmaceuticals, Merck, Novartis, Novo Nordisk, Omron Healthcare, Sanofi-Aventis and Schering-Plough.
Perspective
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Tamara L. Wexler, MD, PhD
Positive features of this study include a well-characterized population and the prospective study design (vs. the referenced retrospective analyses). The population is specifically one with cardiovascular disease or risk factors. The study does demonstrate that depression is independent of other measured factors in accelerating cognitive decline in patients with type 2 diabetes (including accounting for proxy measures for hypoglycemia).
The study’s title notes this is an association; of note, we do not know if results would be different in a population without type 2 diabetes due to the lack of a control population.
Tests employed in this study are of particular importance. For instance, PHQ-9 is a validated measure, but is not the most rigorous test primarily measuring depression. Specificity is one particular concern, as some signs of dementia can be read as depression and vice versa.
Limitations, appropriately noted by the authors, include not only the lack of control group, but a lack of information regarding antidepressive medications or other therapies, and the potential for confounders (e.g., increased waist circumference was associated with increased depression, and both may stem from decreased physical activity). In addition, it is possible that not only CVD but its therapies, such as beta-blockers, influence the outcome measures.
The clinical implication is that monitoring for depression is of particular importance. Further studies, examining the results of treating depression on development of dementia, would lend support to management decisions.
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