Taras I. Griadil, Ivan V. Chopey, Ksenia I. Chubirko
Introduction: According to the World Health Organization, depression is a common mental disorder characterized by despair, loss of interest or joy, feelings of guilt and low self-esteem, sleep disturbance or appetite, lethargy, and poor concentration. There is a series of studies that show the presence of depressive disorders in patients with obesity concomitant type 2 diabetes mellitus, but in our study, we wanted to demonstrate the degree of severity of these changes.
The aim: Diagnose depression in patients with obesity and concomitant type 2 diabetes mellitus.
Materials and methods: Examine patients with obesity and concomitant type 2 diabetes mellitus and select them for research. For the diagnosis of depression were used: Patient Health Questionnaire – 2 and 9, Hospital Anxiety and Depression Scale and Hamilton Depression Scale. Along with hypoglycemic therapy, all patients with diagnosed depression were given individual psychotherapy: cognitive behavioral therapy – 12 sessions per week, interpersonal therapy – 12 sessions per week and bibliotherapy.
Results: Using the questionnaires scales, we found depressive disorders in patients with obesity and concomitant type 2 diabetes mellitus. Along with the diagnosis of depression, we managed to correct it using individual psychotherapy.
Conclusions: Patients with obesity and concomitant type 2 diabetes mellitus are in a cohort with an increased risk of depression and should be diagnosed early. Given these patients polypharmacotherapy, treatment for depression should begin with non-drug therapy.
KEY WORDS: obesity, type 2 diabetes mellitus, depression, diagnostics
Wiad Lek 2019, 72, 4, 519-522
Depression is a common illness worldwide, with more than 300 million people affected . Depression is different from usual mood fluctuations and short-lived emotional responses to challenges in everyday life. Especially when long-lasting and with moderate or severe intensity, depression may become a serious health condition .
As of 2016, the worldwide estimated prevalence of diabetes mellitus (DM) was 8.5% (422 million)  whilst that of depression was estimated to affect 350 million . Depression risk is 1.33 times higher in people with DM . A 10–25% DM reduction could prevent 930,000–2.34 million depressions .
MEDLINE and PsycINFO databases and published references were used to identify studies that reported the prevalence of depression in DM. The prevalence of comorbid depression was significantly higher in diabetic women (28%) than in diabetic men (18%), in uncontrolled (30%) than in controlled studies (21%), in clinical (32%) than in community (20%) samples, and when assessed by self-report questionnaires (31%) than by standardized diagnostic interviews (11%) .
Some researchers have argued that diabetes precedes depression and increases the risk of developing depression due to the psychological trauma following diagnoses of diabetes and its burdens such as hyperglycemia leading to altered glucose transport or treatment of the disease itself or both combined as they pose significant challenges for clinical practice [6, 7].
A growing body of evidence suggests that obesity and metabolic syndrome (MetS) are associated with depression and that inflammation may play a role . Participants with metabolic unhealthy obese (MUO) had the highest prevalence of depression compared to the healthy group (14.8% vs 6.8, P<0.001). The mean Patient Health Questionnaire (PHQ) – 9 score was also highest among the MUO group (4.16 ± 0.09). While both obesity and MetS were independently associated with depression, there was a significant interaction between the two (P<0.001) Both obesity and MetS are associated with depression independent of each other, but participants with both conditions have the highest odds of depression. These findings underscore the importance of cardiometabolic disturbances as correlates of mental health status .
In the next study, which included 157 adults, which were divided into three groups (non-obese metabolic healthy group, Metabolically healthy obese (MHO) phenotype and MUO) according to the BMI cutoff and MetS criteria. MUO participants had significantly higher Beck depression score (P= 0.036) compared to MHO and non-obese metabolic healthy groups. There was a significant association between waist circumference (β = 0.142, p=0.023), BMI (β= 0.347, p= 0.037), and the number of MetS components (β= 1.71, p= 0.002) with depression score. MHO was a benign phenotype in relation to depression .
A 10-year longitudinal study, evaluated 269 elderly Japanese individuals aged ≥70 years, indicated that high serum adiponectin levels and low body mass index (BMI) were both associated with worsening depressive symptoms, detected with a short form of the Geriatric Depression Scale (GDS) . Furthermore, the combination of high adiponectin levels and low BMI was associated with worsening depressive symptoms .
Hospital Anxiety and Depression Scale (HADS) focuses on non-physical symptoms, it can be used to diagnose depression in people with significant physical ill-health. Any overlap, for instance impaired concentration secondary to pain rather than depression, is usually easy to separate on an individual basis. HADS does not include all of the diagnostic criteria of depression (Diagnostic and Statistical Manual of Mental Disorders, Fourth / Fifth Edition (DSM IV/V)) or all those required by the Health and Work Development Unit (HWDU) National Depression and Long Term Sickness Absence Screening Audit .
Diagnose depression in patients with obesity and concomitant type 2 diabetes mellitus. To note the peculiarities of the occurrence of depression in this group of patients.
Materials and methods
Patients were selected based on the hospital of the Therapeutic Department of the Communal Institution «Uzhhorod District Hospital» and the outpatient department of therapy and family medicine of the Faculty of Postgraduate And Pre-University Education of the Institute of higher education «Uzhhorod National University». In the course of the survey were selected 47 patients with obesity and concomitant type 2 diabetes mellitus (group 1) and 22 patients with obesity (group 2).
According to the American Diabetes Association and standards of Medical Care in Diabetes 2017, criteria for the diagnosis of type 2 diabetes mellitus, we used 2 criteria: 1) Glycated hemoglobin >6.5%, or 2) In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose >200 mg/dL (11.1 mmol/L) . Obesity was defined as body mass index ≥30 kg/m2.
The research design for diagnostic depression was developed in accordance with the recommendations of the Unified clinical protocol of primary, secondary (specialized) and tertiary (highly specialized) medical care (Order of the Ministry of Health of Ukraine dated December 25, 2014, No. 1003). For the diagnosis of depression were used: Patient Health Questionnaire – 2, Patient Health Questionnaire – 9, Hospital Anxiety and Depression Scale and Hamilton Depression Scale – 17. First testing on a scale we provide with Patient Health Questionnaire – 2 , if we received one positive response on this scale, then we switched to the Patient Health Questionnaire -9 scale. Patient Health Questionnaire – 9 scale includes 9 questions, each of which is rated 0 to 3, interpretation of total score: 1-4 – Minimal depression, 5-9 – Mild depression, 10-14 – Moderate depression, 15-19 – Moderately severe depression, 20-27 – Severe depression .
Hospital Anxiety and Depression Scale score for both scales, scores of less than 7 indicate non-cases: 8–10 – Mild (subclinically expressed anxiety / depression), (11 and above is a clinically expressed anxiety / depression), 11–14 – Moderate, 15–21 – Severe. Score anxiety and depression separately .
Hamilton Rating Scale for Depression – 17 comprises 17 items, which have been rated on a 3- or 5-point scale. The Hamilton Rating Scale for Depression – 17 total score ranges from 0 to 52 . The 17-item Hamilton Rating Scale for Depression -17 Anxiety/Somatization factor includes six items: Anxiety (psychic), Anxiety (somatic), Somatic Symptoms (gastrointestinal), Somatic Symptoms (general), Hypochondriasis and Insight . Clinicians have to assess intensity and frequency of depressive symptoms . The total score of the first 17 points: • 0-7 – normal, • 8-13 – mild depressive disorder, • 14-18 years – moderate depressive disorder, • 19-22 – severe depressive disorder, • more than 23 – extremely severe depressive disorder.
Along with hypoglycemic therapy by metformine 850 mg per day for patient with type 2 diabetes mellitus. All patient were on a hypocaloric diet, and also adhered to the recommended physical activity (at least 30 minutes per day). All patients with diagnosed depression were given individual psychotherapy: cognitive behavioral therapy – 12 sessions per week and interpersonal therapy – 12 sessions per week and bibliotherapy. Participants were divided into two groups: healthy normal weight, metabolic unhealthy obese with type 2 diabetes mellitus.
The statistical processing of the research results was performed using Excel spreadsheets for Windows 2003, which is part of the Microsoft Office 2003 suite of programs, and the STATISTICA 8.0 software. Statistical analysis of materials, summary and summary of conclusions are made by the method of variation statistics, taking into account the average values (mod, median, arithmetic mean) and average error (M±m), with the estimation of the reliability of the values by the Student’s t-criterion, as well as with the determination of the correlation coefficient using Pearson’s paired method to identify the relationships between the obtained indicators. For a minimum threshold of probability, values p<0.05 were taken.
Patients included in these studies were adult (≥45 years of age).
The average age of patients in the 1st group was 54,1±1,2 years, compared with 52,6±1,3 years in patients in the 2nd group (p>0,05).
BMI in group 1 was 32,11±0,15 kg/m2, instead of 2nd group 34,09±0,13 kg/m2 (p>0,05).
Glucose levels in the 1st group are 4,6±0,2 mmol/l, whereas in the 2nd group 5,9±0,1 mmol (p<0,05). Glycated hemoglobin (HbA1c) in the 1st group are 5,1±0,2%, instead of 2nd group 5,8±0,1% (p<0,05).
The data from the PHQ-2 questionnaire in group 1 revealed one positive response from two questions in 14 patients, while in the 33 patients two positive responses were found. Instead, in the patients of group 2, according to the results of the PHQ-2 questionnaire, one positive response was found out of two questions in 7 patients, and two positive responses were revealed in 2 patients. 15 patients in group 2 were excluded from this study because they did not pass a positive response questionnaire PHQ-2.
The data from the PHQ-9 questionnaire in group 1 patients in the group dominated Moderate depression (13,5±2,1, n=24), followed by patients in the group of Mild depression (7,3±0,2, n=15), and patients in the group Moderately severe depression (17,6±0,3, n=6), and patients in the group of Severe depression (22,1±0,6, n=2).
The data from the PHQ-9 questionnaire in group 2 in the group dominated patients in the group Mild depression (5,9±1,2, n=5), and patients in the group of Moderate depression (11,4±1,3, n=2).
At the beginning of the study on a scale HADS in patients of 1st group: 15 patients (31.91%) had clinically expressed (CE) anxiety (A) / depression (D), A – 16,07±0,83 points, D – 15,68±0,8 points, instead 23 patients (48,94%) had subclinically expressed (SE) A/D, A – 8,2±0,74 points, D – 9,1±0,74 points, in 9 patients (19,15%) values were within normal limits.
At the beginning of the study on a scale HADS in patients of 2nd group: 3 patients had clinically expressed (CE) anxiety (A) / depression (D), A – 12,19±0,74 points, D – 11,82±0,71 points, instead 4 patients had subclinically expressed (SE) A/D, A – 8,1±0,63 points, D – 8,3±0,67 points.
At the beginning of the study on a scale HAM-D–17 in patients of 1st group: in 13 patients (27.66%) – the rates were within the norm, 18 patients (38.3%) – 10,61±0,42 points – depressive disorder (DD) mild severity (MS), 11 patients (23,40%) – 16,09±0,41 points DD middle degrees of severity (DS), 5 patients (10,64%) – 20,2±0,58 points – DD heavy DS.
At the beginning of the study on a scale HAM-D–17 in patients of 2nd group: in 2 patients – the rates were within the norm, 3 patients – 9,24±0,31 points – depressive disorder (DD) mild severity (MS), 2 patients – 15,37±0,33 points DD middle degrees of severity (DS).
Instead, after treatment on a scale HADS in patients of 1st group: 7 patients had CE A/D, 30 patients (48,94%) had subclinically expressed (SE) A/D, in 10 of patients were within the normal range.
Instead, after treatment on a scale HADS in patients of 2nd group: 7 patients had CE A/D, 2 patients had subclinically expressed (SE) A/D, in 5 of patients were within the normal range.
Instead, the data is on a scale HAM-D-17 in patients of 1st group: in 24 patients – the rates were within the normal range, in 21 patients DD easy DS, 2 patients – DD middle DS.
Instead, the data is on a scale HAM-D-17 in patients of 2nd group: in 4 patients – the rates were within the normal range, in 2 patient DD easy DS, 1 patient – DD middle DS.
When comparing the indicators of the 1st and 2nd groups on the PHQ-2 scale, we found statistically significant changes (p<0,05). When comparing the indicators of the 1st and 2nd groups on the PHQ-9 scale, statistically significant data were not available (p>0,05). When comparing the indicators of the 1st group and the 2nd group on a scale HAM-D-17 and HADS we found statistically significant changes (p<0,05).
The world-wide practice of diagnosing depressive disorders is based on the Diagnostic and Statistical Manual of Mental Disorders, the Fourth / Fifth Edition (DSM IV / V). However, today there are no optimal scales that take into account all the features of the diagnosis and the course of depression.
Depression risk is 1.33 times higher in people with DM. A 10–25% DM reduction could prevent 930,000–2.34 million depressions . Participants with metabolic unhealthy obese (MUO) had the highest prevalence of depression compared to the healthy group (14.8% vs 6.8, P<0.001) . The prevalence of comorbid depression was significantly higher in diabetic women (28%) than in diabetic men (18%), in uncontrolled (30%) than in controlled studies (21%), in clinical (32%) than in community (20%) samples, and when assessed by self-report questionnaires (31%) than by standardized diagnostic interviews (11%) .
In our study for the diagnosis of depressive disorders, we used the following questionnaires: Patient Health Questionnaire – 2, Patient Health Questionnaire – 9, Hospital Anxiety and Depression Scale and Hamilton Depression Scale – 17. Comparison of data obtained using the PHQ-2, PHQ-9 and BMI questionnaires we have confirmed world data that obese people are more prone to obesity. Instead, the HADS and HAM-D-17 questionnaires made it possible to detail the severity of depressive disorders, and these changes were worse in people with concomitant type 2 DM.
Prospects for further research is the comparison of biochemical, anthropometric data with questionnaires on the scale of depression in this patient cohort.
Patients with obesity and concomitant type 2 DM are in a cohort with an increased risk of depression and should be diagnosed early. Given these patients polypharmacotherapy, treatment for depression should begin with non-drug therapy. Health-care providers may offer psychological treatments (such as behavioural activation, cognitive behavioral therapy (CBT) and interpersonal therapy (IPT)) or antidepressant medication (especially selective serotonin reuptake inhibitors and tricyclic antidepressants).
2. NCD Risk Factor Collaboration (NCD-RisC) Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4 ∗ 4 million participants. Lancet, 387 (10027) (2016), pp. 1513-1530.
4. Batholomew Chireha, Muzi Li, Carl D’Arcy. Diabetes increases the risk of depression: A systematic review, meta-analysis and estimates of population attributable fractions based on prospective studies. Preventive Medicine Reports. Volume 14, June 2019. https://doi.org/10.1016/j.pmedr.2019.100822
8. Moazzami, K., Lima B., Sullivan S. et al. Abstract P247: Combination of Obesity and Metabolic Syndrome is Associated With Highest Rate of Depression Secondary to Increased Inflammation. 2019; Circulation, 139(Suppl_1), AP247-AP247. https://doi.org/10.1161/circ.139.suppl_1.P247
9. Yosaee, S., Djafarian, K., Esteghamati, A. et al. Depressive symptoms among metabolically healthy and unhealthy overweight/obese individuals: a comparative study. Medical journal of the Islamic Republic of Iran, 2018:32, 95.
10. Huang C, Kogure M, Tomata Y et al. Association of serum adiponectin levels and body mass index with worsening depressive symptoms in elderly individuals: a 10-year longitudinal study. Aging Ment Health. 2019 Mar; (18)1-7. doi: 10.1080/13607863.2019.1584877.
12. American Diabetes Association. “Standards of medical care in diabetes—2017 abridged for primary care providers.” Clinical diabetes: a publication of the American Diabetes Association 35.1 (2017): 5.
14. Wagner S., Helmreich I., Lieb K. et al. Standardized Rater Training for the Hamilton Depression Rating Scale (HAMD17) and the Inventory of Depressive Symptoms (IDSC30). Psychopathology, (2011): 44(1), 68.
15. Farabaugh A., Mischoulon D., Fava, M. et al. The relationship between early changes in the HAMD-17 anxiety/somatization factor items and treatment outcome among depressed outpatients. International clinical psychopharmacology (2005), 20(2), 87-91.
According to the order of the Authorship.
Conflict of interest:
The Authors declare no conflict of interest.
Taras I. Griadil
Uzhhgorod National University
71 Mynaiska St., 88009 Uzhhgorod, Ukraine