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Article history: Aims: To analyse depression in German type 2 diabetes patients with or without diabetes complications
Received 16 November 2015 Methods: Longitudinal data from nationwide general practices in Germany (n = 1,202) were analysed.
Received in revised form 11 December 2015 People initially diagnosed with type 2 diabetes (2004–2013) were identified and 90,412 patients were
Accepted 13 December 2015 included (age: 65.5 years, SD: 11.7). The main outcome measure was the first diagnosis of depression (ICD 10:
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F32, F33) within ten years after index date in patients with and without diabetes complications. Cox
proportional hazards models were used to adjust for confounders.
Keywords:
Diabetes
Results: At baseline, most patients had diabetes complications and 6.4% of them had private insurance. Ten
Psychosocial stressors years after type 2 diabetes diagnosis, 30.3% of patients showed symptoms of depression. The prevalence of
Primary care depression was higher in women than in men (33.7% versus 26.8%), in patients with high HbA1c levels (31.3%
Prevalence when Hb1Ac ≥ 9 versus 27.5% when HbA1c b 7) and in patients with diabetes complications (37.7% when
Macrovascular disease there were more than two complications versus 29.1% when there were no complications). Women and
Microvascular disease patients without private health insurance were at a higher risk of developing depression. Retinopathy,
neuropathy, nephropathy, coronary heart disease, stroke and HbA1c levels higher than 7 were also positively
associated with depression.
Conclusions: Diabetes complications and high HbA1c levels had a substantial impact on depression in primary
care patients with type 2 diabetes.
© 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jdiacomp.2015.12.013
1056-8727/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Jacob, L., & Kostev, K., Prevalence of depression in type 2 diabetes patients in German primary care practices, Journal
of Diabetes and Its Complications (2015), http://dx.doi.org/10.1016/j.jdiacomp.2015.12.013
2 L. Jacob, K. Kostev / Journal of Diabetes and Its Complications xxx (2015) xxx–xxx
prevalent in people with diabetes, it was recently shown that patients 2.4. Independent variables
newly diagnosed with type 2 diabetes do not display an increased risk
of developing depression (Skinner et al., 2010). Another interesting Demographic data included age, gender and health insurance type
result is that patients exhibit low levels of distress and anxiety during (private or statutory). Several complications related to diabetes and
the first years of the chronic condition (Thoolen, de Ridder, Bensing, co-morbid conditions were determined based on primary care
Gorter, & Rutten, 2006), suggesting that early and intensive diagnoses (ICD-10 codes): retinopathy (E11.5), neuropathy (E11.4),
treatments can influence the occurrence of depression. Intriguingly, nephropathy including renal insufficiency (E11.2, N18, N19), coronary
people with diabetes also reported high distress upon diagnosis heart disease (I20, I24, I25), myocardial infarction (I21, I22, I23),
(85.2% of patients felt shocked, guilty, angry, anxious, depressed, or peripheral artery disease (E11.5, I73.9) and stroke (I63, I64, G45).
helpless) (Peyrot et al., 2005). Finally, several authors have shown These complications and conditions could occur throughout the entire
that complications related to diabetes are additional risk factors for follow-up period prior to initial diagnosis of depression or, when
depression (Badawi et al., 2013; Pouwer et al., 2003). The goal of the there was no depression diagnosis, prior to the end of follow-up. In
present study was to analyse depression in German patients with type addition, diagnosed hypertension (I10), lipid disorders (E78) and
2 diabetes, in the presence or absence of diabetes complications. obesity (E66) were assessed for each study individual. Mean HbA1c
values for the follow-up time of study patients were calculated and
2. Patients and methods included as an independent variable. Finally, prescriptions of oral
antidiabetic drugs and insulin treatments were determined for each
2.1. Database patient.
The Disease Analyzer database (IMS HEALTH) compiles drug 2.5. Statistical analyses
prescriptions, diagnoses, basic medical and demographic data
obtained directly and in anonymous format from computer systems Descriptive analyses were obtained for all demographic variables
used in the practices of general practitioners (Becher, Kostev, & and diagnoses and mean ± SD were calculated for normally distrib-
Schröder-Bernhardi, 2009). Diagnoses (ICD-10), prescriptions (Ana- uted variables. Depression-free survival analyses were carried out
tomical Therapeutic Chemical (ATC) Classification System) and the using Kaplan–Meier curves and log-rank tests. Kaplan–Meier curves
quality of reported data have been monitored by IMS based on a were stratified by gender, HbA1c levels and presence of diabetes
number of criteria (e.g. completeness of documentation, linkage complications. Multivariate Cox proportional hazards models (de-
between diagnoses and prescriptions). pendent variable: incident depression) were used to adjust for
In Germany, the sampling method used for the selection of confounders (gender, private insurance, diabetes complications,
physicians' practices is appropriate for obtaining a representative co-diagnoses and prescriptions). Diabetes duration is an important
database of primary care practices. The sampling is based on summary factor both in the development of diabetes complications and in the
statistics from all doctors in Germany published yearly by the German development of depression. Yet according to our study, diabetes
Medical Association. IMS uses these statistics to determine the panel duration is automatically considered as the follow-up time, since we
design according to the strata including specialist group, German start on the day of the first diabetes diagnosis. Since we present
federal state, community size category and age of physician (Becher et Kaplan–Meier curves showing time to development of depression,
al., 2009). they also automatically indicate the correlation between diabetes
This database was shown to be representative of general practice duration and depression incidence.
in Germany from the perspective of regional, gender and age P-values b 0.05 were considered statistically significant. The
stratification (Becher et al., 2009). analyses were carried out using SAS version 9.3.
Prescription statistics for several drugs were very similar to data
available from pharmaceutical prescription reports (Becher et al., 3. Results
2009). The age groups for given diagnoses in Disease Analyzer also
agreed well with those in corresponding disease registries (Becher et 3.1. Patient characteristics
al., 2009).
A total of 90,412 primary care patients were diagnosed with diabetes
2.2. Study population in German practices between January 2004 and December 2013. The
clinical characteristics of these patients are shown in Table 1. As
Patients initially diagnosed with type 2 diabetes mellitus (ICD 10: expected, the mean age was 65.5 years and most of these older patients
E11) between January 2004 and December 2013 (index date) were had diabetes complications or co-diagnoses, most commonly hyper-
identified by 1202 general practitioners (GPs) in the IMS Disease tension, lipid metabolism and coronary heart disease (79.7%, 56.0% and
Analyzer database. Patients were included in the analysis only if: (i) 28.8% respectively). 19.7% of them also had high levels of Hb1Ac,
they did not suffer from depression prior to index date, (ii) their indicating poor glycaemic control. 5786 patients (6.4%) had private
follow-up lasted more than a year, (iii) they were more than 40 years insurance. Finally, 75.0%, 5.5% and 12.5% of patients were treated with
old. Selected patients were observed for up to ten years after the index oral antidiabetic drugs, insulin, and both medications, respectively (7.0%
date, the latest follow-up date for any patient being March 31, 2015. A of them did not receive any antihyperglycaemic therapy).
total of 90,412 patients were available for analysis.
3.2. Shares of patients with depression
2.3. Study outcome
The Kaplan–Meier curve for time to diagnosis of depression in
The main outcome measure was the first diagnosis of depression patients newly diagnosed with type 2 diabetes is shown in Fig. 1. 5.9%,
(ICD 10: F32, F33) within ten years after index date. Only confirmed 17.7% and 30.3% of patients displayed depression one, five and ten
diagnoses were included, meaning that depression was documented years after the diabetes diagnosis, respectively. The same analyses
by general practitioners after a first diagnosis either performed by a were performed for gender, mean HbA1c value and number of
psychiatrist or a general practitioner. The share of patients with complications and co-diagnoses (Figs. 2, 3 and 4 respectively). The
depression was estimated in presence and in absence of different prevalence of depression was higher in women (33.7%) than in men
diabetes complications. (26.8%) ten years after diagnosis of type 2 diabetes. We also showed
Please cite this article as: Jacob, L., & Kostev, K., Prevalence of depression in type 2 diabetes patients in German primary care practices, Journal
of Diabetes and Its Complications (2015), http://dx.doi.org/10.1016/j.jdiacomp.2015.12.013
L. Jacob, K. Kostev / Journal of Diabetes and Its Complications xxx (2015) xxx–xxx 3
Fig. 1. Kaplan–Meier curve for time to diagnosis of depression in primary care patients newly diagnosed with type 2 diabetes.
Please cite this article as: Jacob, L., & Kostev, K., Prevalence of depression in type 2 diabetes patients in German primary care practices, Journal
of Diabetes and Its Complications (2015), http://dx.doi.org/10.1016/j.jdiacomp.2015.12.013
4 L. Jacob, K. Kostev / Journal of Diabetes and Its Complications xxx (2015) xxx–xxx
Fig. 2. Kaplan–Meier curves for time to diagnosis of depression in primary care patients newly diagnosed with type 2 diabetes by gender.
Fig. 3. Kaplan–Meier curves for time to diagnosis of depression in primary care patients newly diagnosed with type 2 diabetes by HbA1c value.
Fig. 4. Kaplan–Meier curves for time to depression diagnosis in primary care patients newly diagnosed with type 2 diabetes patients by number of complications.
Please cite this article as: Jacob, L., & Kostev, K., Prevalence of depression in type 2 diabetes patients in German primary care practices, Journal
of Diabetes and Its Complications (2015), http://dx.doi.org/10.1016/j.jdiacomp.2015.12.013
L. Jacob, K. Kostev / Journal of Diabetes and Its Complications xxx (2015) xxx–xxx 5
Please cite this article as: Jacob, L., & Kostev, K., Prevalence of depression in type 2 diabetes patients in German primary care practices, Journal
of Diabetes and Its Complications (2015), http://dx.doi.org/10.1016/j.jdiacomp.2015.12.013
6 L. Jacob, K. Kostev / Journal of Diabetes and Its Complications xxx (2015) xxx–xxx
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Please cite this article as: Jacob, L., & Kostev, K., Prevalence of depression in type 2 diabetes patients in German primary care practices, Journal
of Diabetes and Its Complications (2015), http://dx.doi.org/10.1016/j.jdiacomp.2015.12.013