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

Epidemiology/Health Services/Psychosocial Research

¹Center for Health Studies, Group Health Cooperative, Seattle, Washington
²Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington
³Department of Medicine, Veterans Administration Hospital, University of Washington, Seattle, Washington

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}ghc.org

Diabetes Care 2004 Sep; 27(9): 2154-2160. https://doi.org/10.2337/diacare.27.9.2154

Article Figures & Tables

Table 1—

Clinical characteristics

Clinical characteristics	n	Means ± SD or percent
Type 2 diabetes		95.6
Treatment intensity
Diet		25.4
Oral hypoglycemic		59.0
Insulin, alone, or plus oral medications		30.1
Number of HbA_1c tests in prior year		2.2 ± 1.3
HbA_1c level (%)		7.8 ± 1.6
Number of diabetes complications		1.4 ± 1.5
Major depression		12.0
BMI >30 kg/m²		48.9
Smoker		8.7
General self-care activities (days performed in the past week)	4,463
Healthy eating once weekly or less		9.8
Five servings of fruits/vegetables once weekly or less		21.6
High-fat foods ≥6 days		12.4
Physical activity once weekly or less (≥30 min)		29.3
Specific exercise session once weekly or less		47.8
Diabetes-specific self-care (patients on hypoglycemic medications or insulin)	3,439
Tested blood sugar once weekly or less		17.9
Tested recommended times once weekly or less		24.8
Checked feet once weekly or less		20.1
Checked inside of shoes once weekly or less		59.9
Medication adherence	2,655
Nonadherence to oral hypoglycemic medicines in prior year		19.5 (64.7 days)

Table 2—

Diabetes self-care and depression*

Self-care activities (past 7 days)	n	No major depression	Major depression	Odds ratio†	95% CI	P
Diet
Healthy eating once weekly or less		8.8%	17.2%	2.1	1.59–2.72	<0.0001
Five servings of fruits/vegetables once weekly or less		21.1%	32.4%	1.8	1.43–2.17	<0.0001
High-fat foods ≥6 times weekly		11.9%	15.5%	1.3	1.01–1.73	<0.04
Exercise
Physical activity (≥30 min) once weekly or less		27.3%	44.1%	1.9	1.53–2.27	<0.0001
Specific exercise session once weekly or less		45.8%	62.1%	1.7	1.43–2.12	<0.0001
Smoking
Yes		7.7%	16.1%	1.9	1.42–2.51	<0.0001
Glucose monitoring (patients on medications)	3,439
Test blood glucose less than once weekly		17.8%	18.2%	1.1	0.80–1.44	NS
Test blood glucose as recommended less than once weekly		24.5%	26.7%	1.1	0.89–1.47	NS
Foot check (patients on medications)	3,439
Checked feet less than once weekly		20.1%	19.7%	1.0	0.76–1.29	NS
Checked inside of shoes less than once weekly		59.7%	61.4%	1.1	0.88–1.36	NS
Total		3,927	536

*
↵* Percentages are unadjusted;
†
↵† Odds ratios are adjusted for the covariates age, sex, marital status, education, race/ethnicity, medication risk, complications, treatment intensity, clinic, and physician generalized estimating equation (GEE).

Table 3—

Medication adherence and use of preventive diabetes services*

	Unadjusted means/proportions			Model-based (adjusted) estimates
		No major depression	Major depression	Mean difference	Odds ratio	95% CI	P (n)
Nonadherence to medication
Oral hypoglycemic	18.8%	24.5%	3.62	—	1.18–6.06	<0.005
Lipid lowering	19.3%	27.2%	6.79	—	3.11–10.46	<0.0005
ACE inhibitors	21.6%	27.9%	5.59	—	1.41–9.78	0.01
Preventive diabetes services
No HbA_1c test within the last year	4.0%	6.3%	—	1.9	1.27–2.87	<0.005 (4,347)
Fewer than three HbA_1c tests per year among patients with HbA_1c >8%	55.1%	55.5%	—	0.9	0.70–1.21	NS (1,922)
No retinal examination within the last year	19.4%	17.2%	—	1.0	0.74–1.24	NS (4,347)
Less than two examinations within 2 years among patients with retinopathy	24.8%	22.5%	—	0.8	0.55, 1.31	NS (1,179)
No microalbumin urine test within the last year among patients not taking ACE inhibitors	47.0%	45.6%	—	1.0	0.80–1.33	NS (1,831)

*
↵* Nonadherence to medication outcomes are continuous measures of the percentage of nonadherent days for each individual. Preventive diabetes services outcomes are dichotomous, indicating use or no use. Model-based estimates of percentage point difference in adherence and odds ratios with corresponding CIs and P values are adjusted for age, sex, marital status, education, race/ethnicity, medication risk (a pharmacy-based comorbidity measure), diabetes complications, and treatment intensity. Models also adjust for clustering by clinic and physician.