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Depression, Self-Care, and Medication Adherence in Type 2 Diabetes

Relationships across the full range of symptom severity

¹ Behavioral Medicine, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
² Diabetes Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
³ Institute for Technology Assessment, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
⁴ Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
⁵ General Medicine Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts

Address correspondence and reprint requests to Jeffrey S. Gonzalez, PhD, Department of Psychiatry, WACC 812, Massachusetts General Hospital, 15 Parkman St., Boston, MA 02114. E-mail: jsgonzalez{at}partners.org

OBJECTIVE—We examined the association between depression, measured as either a continuous symptom severity score or a clinical disorder variable, with self-care behaviors in type 2 diabetes.

RESEARCH DESIGN AND METHODS—We surveyed 879 type 2 diabetic patients from two primary care clinics using the Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS), the Summary of Diabetes Self-Care Activities, and self-reported medication adherence.

RESULTS—Of the patients, 19% met the criteria for probable major depression (HANDS score 9), and an additional 66.5% reported at least some depressive symptoms. After controlling for covariates, patients with probable major depression reported significantly fewer days' adherent to diet, exercise, and glucose self-monitoring regimens (P < 0.01) and 2.3-fold increased odds of missing medication doses in the previous week (95% CI 1.5–3.6, P < 0.001) compared with all other respondents. Continuous depressive symptom severity scores were better predictors of nonadherence to diet, exercise, and medications than categorically defined probable major depression. Major depression was a better predictor of glucose monitoring. Among the two-thirds of patients not meeting the criteria for major depression (HANDS score <9, n = 709), increasing HANDS scores were incrementally associated with poorer self-care behaviors (P < 0.01).

CONCLUSIONS—These findings challenge the conceptualization of depression as a categorical risk factor for nonadherence and suggest that even low levels of depressive symptomatology are associated with nonadherence to important aspects of diabetes self-care. Interventions aimed at alleviating depressive symptoms, which are quite common, could result in significant improvements in diabetes self-care.

Abbreviations: HANDS, Harvard Department of Psychiatry/National Depression Screening Day Scale • SDSCA, Summary of Diabetes Self-Care Activities Questionnaire • SMBG, self-monitoring of blood glucose

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