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Studies focus on depression, disease self-management, and vaccination status among people with diabetes

About 6 percent of the U.S. population, 17 million people, have diabetes, and 1 million new cases are identified each year. People who have diabetes are twice as likely as other individuals to become depressed. Diabetes is also twice as prevalent among blacks as whites, with 13 percent of U.S. blacks having the disease. People with diabetes are susceptible to influenza and pneumonia and are more likely to die during flu epidemics than people without diabetes.

Three recent studies supported by the Agency for Healthcare Research and Quality (HS11418) and led by Leonard E. Egede, M.D., M.S., of the Medical University of South Carolina, examined these issues. The studies are summarized here.

Egede, L.E., and Zheng, D. (2003, January). "Independent factors associated with major depressive disorder in a national sample of individuals with diabetes." Diabetes Care 26(1), pp. 104-111.

The psychosocial burden of diabetes, especially the perception that it negatively affects overall health, may be the reason why depression is more prevalent among people who have the disease, according to this study. The researchers found that perceived worsening of health status among people with diabetes, along with other factors, was independently associated with major depressive disorder among those surveyed. The researchers analyzed data on 1,810 adults with diabetes from the 1999 National Health Interview Survey. They used a short-form interview to identify individuals with major depressive disorder and analyzed whether perceived poor physical health, duration of diabetes, and smoking were associated with major depressive disorder. They also examined factors such as age and education.

Overall, 9.3 percent of 10.4 million adults with diabetes in the United States in 1999 had major depressive disorder compared with 6.1 percent of those who did not have diabetes. Among people with diabetes, worsening health status was associated with nearly six times the likelihood of developing a major depressive disorder. Diabetics who were younger than age 65 were nearly three times as likely as those who did not have diabetes to develop a major depressive disorder, and females were nearly twice as likely. Major depressive disorder was nearly twice as likely among diabetics who smoked and three times as likely among those who had an income less than 124 percent of the Federal poverty level, compared with people who did not have diabetes. Also, the presence of depression increased primary care and emergency department visits and expenditures for people with diabetes.

This study strengthens the results of several earlier studies on the relationship between diabetes and depression. However, it did not find a relationship between depression and the presence of multiple diabetes complications, unemployment, marital status, type of treatment, lower levels of education, or duration of diabetes found in other studies. The researchers caution that this study did not differentiate type 1 from type 2 diabetes and was limited by the absence of data on blood sugar control.

Egede, L.E., and Bonadonna, R.J. (2003, January). "Diabetes self-management in African Americans: An exploration of the role of fatalism." Diabetes Educator 29(1), pp. 1-26.

Twice as many blacks suffer from diabetes as whites in the United States. Blacks who have diabetes also experience higher complication rates, greater complication-related disability, and 27 percent higher death rates than whites who have the disease. Effective self-management of diabetes is the key to achieving optimal control of blood glucose and decreasing the complications and premature death associated with diabetes. Patients ideally should watch their diet, exercise, measure their blood-sugar levels regularly, take insulin or other medications as directed, and get regular checkups to prevent the development or progression of eye, kidney, and other complications.

Unfortunately, due to a fatalistic view of their disease, blacks who have diabetes are less likely to manage their diabetes, conclude these researchers. They conducted seven focus groups in 2001 with 39 black patients (22 men and 17 women) with type 2 (adult-onset) diabetes. Most participants had less than a high school education and an annual household income less than $25,000; diabetes duration was a mean of 13 years for the group. Perceptions of hopelessness, meaninglessness, powerlessness, and social despair were expressed by focus group participants. Most of the participants felt that they had no control over their diabetes, that it was inherited, and that it would result inevitably in death, regardless of what they did.

Individuals who had diabetes longer, had friends or relatives with diabetes, were disabled from diabetes, or had poor social support appeared to be the most fatalistic. Despite experiences such as dialysis, amputations, and diabetes-related deaths of family members, many said they were unwilling to make the lifestyle modifications needed to avert complications associated with the disease. Individuals with negative coping responses appeared to have a fatalistic attitude toward diabetes outcomes and ineffective diabetes self-management behavior. In contrast, individuals with positive coping responses, such as hope for a cure, were less fatalistic in their outlook. People with strong religious or spiritual beliefs appeared to have more positive coping responses despite being more fatalistic.

Egede, L.E., and Zheng, D. (2003, February). "Racial/ethnic differences in adult vaccination among individuals with diabetes." American Journal of Public Health 93(2), pp. 324-329.

Current guidelines recommend influenza and pneumococcal vaccination for people with diabetes, who are more likely to contract these illnesses and to die from influenza. However, this study found that among people with diabetes, blacks and Hispanics had lower vaccination rates than whites, even after adjustment for socioeconomic status (SES), insurance coverage, and other factors influencing access to care. The researchers analyzed data on 1,906 individuals from the 1998 National Health Interview Survey to calculate national vaccination estimates, which they adjusted for race/ethnicity, age, access to care, health insurance, and SES.

Overall, 51 percent of adults with diabetes received influenza vaccine, and 33 percent received pneumococcal vaccine. However, more whites (55 percent) than blacks (39 percent) or Hispanics (42 percent) received influenza vaccinations. Similarly, 38 percent of whites compared with 22 percent of blacks and 17 percent of Hispanics received pneumococcal vaccinations. Vaccination rates were also higher in individuals older than age 65, those with household incomes under $20,000, and those who were employed. People born in the United States also had higher influenza and pneumonia vaccination rates, as did those with health insurance, access to a primary care provider, or other medical problems in addition to diabetes.

However, race/ethnicity was an important predictor of both pneumonia and influenza vaccination independent of access to care, health coverage, and SES. This suggests that cultural values may influence the differential acceptance of vaccination by patients or that physicians may recommend vaccination for minorities differently from whites. Clearly there were missed opportunities for vaccination of people, and particularly minorities, with diabetes seen in primary care settings (only 54 percent of diabetics who had contact with a primary care doctor received the influenza vaccine).

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