Relationship of Depression and Diabetes Self-Care, Medication Adherence, and Preventive Care

  1. Elizabeth H.B. Lin, MD, MPH1,
  2. Wayne Katon, MD2,
  3. Michael Von Korff, SCD1,
  4. Carolyn Rutter, PHD1,
  5. Greg E. Simon, MD, MPH1,
  6. Malia Oliver, BA1,
  7. Paul Ciechanowski, MD, MPH2,
  8. Evette J. Ludman, PHD1,
  9. Terry Bush, PHD1 and
  10. Bessie Young, MD3
  1. 1Center for Health Studies, Group Health Cooperative, Seattle, Washington
  2. 2Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington
  3. 3Department of Medicine, Veterans Administration Hospital, University of Washington, Seattle, Washington
  1. Address correspondence and reprint requests to Elizabeth H.B. Lin, MD, MPH, Center for Health Studies, Group Health Cooperative, 1730 Minor Ave., Suite 1600, Seattle, WA 98101. E-mail: lin.e{at}


OBJECTIVE—We assessed whether diabetes self-care, medication adherence, and use of preventive services were associated with depressive illness.

RESEARCH DESIGN AND METHODS—In a large health maintenance organization, 4,463 patients with diabetes completed a questionnaire assessing self-care, diabetes monitoring, and depression. Automated diagnostic, laboratory, and pharmacy data were used to assess glycemic control, medication adherence, and preventive services.

RESULTS—This predominantly type 2 diabetic population had a mean HbA1c level of 7.8 ± 1.6%. Three-quarters of the patients received hypoglycemic agents (oral or insulin) and reported at least weekly self-monitoring of glucose and foot checks. The mean number of HbA1c tests was 2.2 ± 1.3 per year and was only slightly higher among patients with poorly controlled diabetes. Almost one-half (48.9%) had a BMI >30 kg/m2, and 47.8% of patients exercised once a week or less. Pharmacy refill data showed a 19.5% nonadherence rate to oral hypoglycemic medicines (mean 67.4 ± 74.1 days) in the prior year. Major depression was associated with less physical activity, unhealthy diet, and lower adherence to oral hypoglycemic, antihypertensive, and lipid-lowering medications. In contrast, preventive care of diabetes, including home-glucose tests, foot checks, screening for microalbuminuria, and retinopathy was similar among depressed and nondepressed patients.

CONCLUSIONS—In a primary care population, diabetes self-care was suboptimal across a continuum from home-based activities, such as healthy eating, exercise, and medication adherence, to use of preventive care. Major depression was mainly associated with patient-initiated behaviors that are difficult to maintain (e.g., exercise, diet, medication adherence) but not with preventive services for diabetes.


  • A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

    • Accepted May 27, 2004.
    • Received February 12, 2004.
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