Patient Surveys: Day 26

Today was my final day of surveying patients! Over the past two days, I've interviewed ten more patients with PHQ-9, bringing my grand total to seventy subjects for my study after twenty-six days of patient surveys. These twenty-six days have certainly been the most involving days of my senior project and I can finally begin to analyze my results next week (the final working week of my research).



Patients 60 - 63 all had similar HbA_1c levels but their PHQ-9 scores were either a 0 or 6. A PHQ-9 score of 6 may seem high, considering it's more than halfway to a diagnosis of a DSM-IV depressive disorder (PHQ-9 score of 10 or greater). But at the same time, consider the PHQ-9 survey again. I feel that surveying some of my peers, for example, who are currently stressing about their AP exams (undoubtedly "Over the last 2 weeks"), could easily score a 6: "feeling tired or having little energy," "trouble falling or staying asleep," "poor appetite or overeating," "trouble concentrating on things" could all be symptomatic of this highly stressful time of year for any student. Likewise, Patients 60 - 63 could, in actuality, all be entirely not depressed; it could just be that Patients 60 and 62 showed more depressive symtoms on PHQ-9 because of recently stressful events, whether or not that's due to their diabetes.

My research project was structured as follows: during the first few weeks, I did some preliminary research solely to better understand and educate myself on the subject; during the bulk of the project, I conducted patient interviews and retrieved data while attempting to make well-informed observations based on whatever knowledge I had gained on the subject; finally, I will make a scientifically-based analysis with my data.

I just want to clarify (again) that over the past twenty-six days, the trends and observations I've noted have been purely conjecture, and my attempt to explain, as interestingly as possible, the data contained in these four hundred ninety-seven cells. The final data analysis won't contain any mention of these 'trends' (unless I note them to be my own conjecture) because they're not scientifically backed by data.


Lalani.

Patient Surveys: Day 24

It's been a short three months and the final days of my patient surveys are approaching. Since my last post on Day 18, I have interviewed ten patients bringing my total to sixty subjects.



Patients 51 - 60 are a mix of Type 1 and Type 2 diabetics. As a whole, there's nothing particularly erratic or noteworthy about their data — most were Type 2 diabetics, had relatively decent HbA_1c levels, and had very low PHQ-9 scores. Patient 54, however, is distinguished by his very high HbA_1c of 10.20%. His PHQ-9 score, though, is just as low as his relatively-normal-HbA_1c counterparts (PHQ-9 score = 0). He's not on antidepressants either. On Day 2, I pointed out how Type 1 diabetics obviously have a more difficult time maintaining glycemic control than Type 2 diabetic, since Type 1 diabetics are insulin-dependent. In other words, an HbA_1c of 10.20% in a Type 2 diabetic (as is the case with Patient 54) is not necessarily as severe as an HbA_1c of 10.20% in a Type 1 diabetic. Perhaps the reason why Patient 54 shows no symtoms of depression, whether it be persistent fatigue or feelings of hopelessness when it comes to controlling their diabetes, is because his lack of control is merely not severe enough to warrant depression.

Lalani.

Patient Surveys: Day 18

I surveyed Patients 47 through 50 today, all of whom are Type 2 diabetics.



Unlike yesterday, the Type 2 patients interviewed today didn't have very similar data. Patient 48's HbA_1c level of 5.9% juxtaposed with that of Patient 50's of 9.8% was certainly intriguing. Both HbA_1c levels are 'off the charts,' but in totally opposite respects. I found it interesting how two people who are approximately the same age and have the same type of diabetes can have such vastly different HbA_1c levels. I suppose this is a good example of how medical treatment (of any kind, really) is so subjective. When you're dealing with a chronic condition that can only be treated and has not yet been cured, there really is no one-size-fits-all method of treating all of those who come in, even if they present with identical conditions. There are inumerable factors that are taken into account when devising the optimal treatment. In this facility alone, new patients are inquired about the presence of alcoholism, kidney infections, allergies, anemia, migraine, anxiety, epilepsy, multiple sclerosis, asthma, obesity, atrial fibrillation, cirrhosis, high cholesterol, hypertension, hyperthyroidism, thyroid disease, and hypothyroidism, just to name a few. Depression is merely one of these factors that are taken into account for diabetic treatment.

This also elucidates the difficulties of isolating diabetic factors as the independent variable(s). There are so many other factors (consider alcoholism or obesity, alone) that could be at work, affecting depression scores. What's worse is that it's plainly unfeasible to take the other variables into account, i.e. only surveying diabetics who have no other medical complications. Diabetes itself introduces complications across the body, from the kidneys to the eyes to the nervous system, etc. Excluding diabetics with thyroid complications alone would be ludicrous; you would be left with a minuscule sample size. Consequently, despite numerous studies having been done on the subject, the relationship between diabetes and depression is still unclear.

Lalani.

Patient Surveys: Day 17

There were few patients seen today who match the inclusion criteria for my study — only three patients were interviewed today. The results of the surveys have been compiled below.




Entirely coincidentally, Patients 44 through 46 have very similar data. They're approximately the same age, have Type 2 diabetes, have an HbA_1c level between 8.0% and 8.1%, and obtained a score of 0 on PHQ-9. The vast majority of the Type 2 diabetics that I have surveyed have data that is practically identical to that of these three patients. As the conclusion of my project is approaching, I think there is a clear trend to be observed with the Type 2 diabetics: Type 2 diabetics tend to have lower HbA_1c levels and PHQ-9 scores than their Type 1 counterparts.

At first glance, this still doesn't account for why the Type 2 diabetic's PHQ-9 scores don't reflect how uncontrolled each patient's diabetes is.Technically, their HbA_1c level lies in the "American Diabetes Association recommends reevaluation of therapy" category. So if there is indeed any positive correlation between diabetes and depression, why wouldn't their PHQ-9 scores be greater than 0 if their HbA_1c is considered high?

Earlier in March when I first noted this observation, having surveyed merely four patients, I suggested the following: "It follows that Type 1 diabetics would have a more difficult time maintaining glycemic control because Type 2 diabetics do not require as much of an active individual role in controlling their diabetes (e.g. Type 2 diabetics do not have to constantly monitor blood sugar levels and administer insulin appropriately)." Now, over a month later, I feel that the data of my new forty-two new patients can still attest to this: even if the HbA_1c level of a Type 2 diabetic is "high," it's not necessarily as severe (and perhaps, as a result, as anxiety-inducing or depression-invoking) as it would be with a Type 1 diabetic with the same HbA_1c level. This could be, as my aforementioned hypothesis suggests, because the latter would require much more of an active role to bring their blood sugar under control, i.e. the Type 1 patient would have a more difficult (and assumedly, a more stressful) time maintaining glycemic control.

Lalani.

Patient Surveys: Day 16

I interviewed five patients and the Type 1 diabetics' data from today has definitely proved to be some of the most interesting I've encountered thus far in this study.



Both Type 1 diabetics from today, Patients 40 and 41, are on the medication fluoxetine hydrochloride. Now, fluoxetine hydrochloride may mean nothing to you, as was the case with me about twenty minutes ago. Indeed, I felt foolish to find that fluoxetine hydrochloride is the chemical name for none other than Prozac®, perhaps the most well-known antidepressant.

I think what's interesting to note is that just because a patient is prescribed an antidepressant, it doesn't mean the patient is treated for their depression. Everyone responds differently to medications and it's common for side effects to outweigh the benefits of any given drug. For this reason, it's important to see whether the patient's depression has actually improved since the date the antidepressant was prescribed. Given that Prozac® is used to treat major depressive disorder (approximate PHQ-9 score of 14 or higher), I can presume that both patients' PHQ-9 score decreased since the start of their treatment for depression.

Patient 40's HbA_1c level was 8.1% when the patient was first prescribed for Prozac® on October 21, 2011 and is now 7.6%. Patient 41's HbA_1c level was 9.4% when the patient was first prescribed for Prozac® on January 16, 2012 and is now 8.8%. Even though Patient 40 has been on Prozac® for longer, it's clear that the drug hasn't worked as well for Patient 40 as it has for Patient 41 — Patient 41 scored a zero on PHQ-9, indicative of no depressive symptoms present, while Patient 40 scored an 8, indicative of some depressive symptoms still present. As a result, it seems that their respective drops in HbA_1c levels correlate with how well their depression treatment has gone, regardless of how long they've been on Prozac® — proportionally, Patient 41's HbA_1c has dropped more since January than Patient 40's HbA_1c has since October.

Again, I think there is an important distinction to be made that these two patients' data bring up: diabetes has been shown to improve if the depression improves; not merely if the patient is being treated (since certain treatments are not always optimally effective, as with Patient 40).

Lalani.

Patient Surveys: Day 15

I can't remember the last time that I interviewed six patients in one day. While six may not seem like a very large number of patients to survey in the course of a work day, it's actually quite difficult to find several patients who fit my inclusion criteria, all scheduled on the same day. 




As usual, most of the patients I interviewed are Type 2 diabetics: Patients 32, 34, 35, and 37. The two Type 1 diabetics, Patients 33 and 36, had a very healthy (for a diabetic) HbA_1c of 6.40% (<7.0% meets the American Diabetes Association's recommended goal for therapy). It follows that their depression survey score could have been so low (PHQ-9 score = 0) partially because their diabetic treatment going so well.

Of the Type 2 diabetics' data, nothing is particularly trend-setting or erratic to be noteworthy. Patient 37, however, seems to be the exception. Nothing in Patient 37's column stood out to me initially — the patient's HbA_1c level is not out of control, nor is their PHQ-9 score high enough to consider a diagnosis of a DSM-IV depressive disorder. However, if you look closely at that long list of medications, you'll find bupropion hydrochloride, also known as Wellbutrin®, an antidepressant. Wellbutrin® is prescribed to treat major depressive disorder (MDD), one of the only two DSM-IV depressive disorders that I am considering in this study. According to the severity scoring of the Patient Health Questionnaire-9 (PHQ-9), if the patient has been diagnosed with MDD, they would have to have scored at least a 14 on the survey to be diagnosed with mild MDD. Evidently, this patient's treatment for depression is going well, considering their PHQ-9 score has (presumably) more than halved, but in the very least, has decreased considerably. Additionally, Patient 37's HbA_1c level has decreased from 9.0% to 8.3% since their last visit on March 8, when the patient was first prescribed for Wellbutrin®. Keep in mind that glycosolated hemoglobin, or HbA_1c, is a three-month average of the amount of sugar in the blood. So a 0.7%-decrease is actually quite considerable of a drop, given that the last HbA_1c  test was recorded merely one month ago.

So...
Patient 37 is a good example of how depression can impair the proper treatment of diabetes and how treating the depression, in this case, by prescribing the antidepressant Wellbutrin®, actually improves the treatment of the patient's diabetes, as seen by the HbA_1c drop. This is consistent with the 'circular' theory between diabetes and depression that I discussed earlier of how the treatment of one condition can improve the treatment of the other when both are present.

Lalani.

Patient Surveys: Day 13

Over the past two days, I have interviewed six more patients.



Patients 26-29 are all Type 2 diabetic and have normal HbA_1c levels ranging from 6.0% to 7.2%. As consistent with most of the Type 2 diabetics that I've surveyed, Patients 26-29 present with no depression symtoms (PHQ-9 score = 0). Patient 30's higher HbA_1c than their Type 2, normal-HbA_1c counterparts (Patients 26-29) could be responsible for the higher PHQ-9 score as well. In other words, Patient 30 could be presenting more depression symptoms than Patients 26-29 because of Patient 30's lack of maintaining as good diabetic control as Patients 26-29 are. Patient 31 reflects how merely the difference of the type of diabetes, irrespective of all other factors, seems to affect the depression survey score.

Lalani.

Patient Surveys: Day 11

Today was the eleventh day of surveying patients. Below are the compiled results of all of my trials thus far.



Of the five patients that I interviewed today, four are Type 2 diabetics. Patients 22, 23, and 25 all presented with very low PHQ-9 scores, relatively normal HbA_1c levels, and have Type 2 diabetes. Thus far, their data is characteristic of Type 2 diabetics' tendency to have lower HbA_1c levels and PHQ-9 scores than their Type 1 diabetic counterparts. Of course, this observed 'tendency' is just conjecture, as are essentially all of these preliminary observations; I am merely pointing out that Patients 22, 23, and 25's data reflect nothing new or erratic.

On the other hand, I think it is just as important to examine some of the inconsistencies with previously noted trends. Patient 21 is a Type 1 diabetic with a relatively normal HbA_1c, 7.30%. Yet, their PHQ-9 score is 9, just one point short of a diagnosis of a DSM-IV depressive disorder. Patient 24 is a Type 2 diabetics with a PHQ-9 score of 0. But their HbA_1c level is a very high 13.60% (see Figure 5). This means that the highest HbA_1c that I have recorded to date belongs to a Type 2 diabetic (when previously, all of the very high HbA_1c levels that I recorded belongs to Type 1 diabetics). Additionally, a patient who is on the verge of depression can still maintain such good control of their diabetes.

These interviews that I conduct consist of merely surveying the patients with a set list of questions. As much as I would like to inquire more from the patient in the event that such inconsistencies arise, I wouldn't know where to begin. Perhaps a recent personal development over the last two weeks (PHQ-9 asks "Over the last 2 weeks, how often have you been bothered by any of the following problems?") resulted in a high PHQ-9 score that would have been far lower had I surveyed the patient a month ago. And maybe, as simplistic as this may sound, Patient 24 has chronically poor habits, from inconsistent glucose monitoring to unhealthy eating; the reason they're not depressed may be simply be because Patient 24 is more comfortable with their inactive lifestyle. After all, not all unhealthy people want to change their ways.

Lalani.

Patient Surveys: Day 10

Patients 18 - 20 were interviewed since yesterday. All three Type 2 diabetics presented with relatively low HbA_1c levels. In fact, Patient 18's HbA_1c, 5.80%, tends to be consistent with non-diabetics.



Last month, I noted that my depression survey is actually often used to diagnose depression as opposed to merely scale depression symptoms (see "PHQ-9 as a Diagnostic Tool"). As a result, I decided to take advantage of PHQ-9's credibility as a diagnostic tool to answer the following question: is there a higher incidence of depression (a PHQ-9 score greater than or equal to 10) in diabetics than in the general population on average?

"Despite the enormous advances in brain research in the past 20 years, depression often goes undiagnosed and untreated. People with diabetes, their families and friends, and even their physicians may not distinguish the symptoms of depression."¹ 

National Institute of Mental Health

Precisely one of the reasons why I chose this research project, the fact that depression often goes undiagnosed, is now proving to be a complication with data retrieval. For purposes of my research, I had to 'set' depression (the incidence of an actual depressive disorder) at a PHQ-9 score of 10 or greater (see Figure 4). But depression isn't just a high number on a survey; it's not that quantitative (e.g. like diabetes is, with a concrete list of criteria that constitutes a diabetic). Evidently, all depressed people can't be diagnosed with a mere survey because their symptoms are rarely distinguishable, even to an experienced physicians, much less a high school senior. On top of that, when you add the fact that diabetes is already present, it proves difficult to determine whether the symptoms on the survey are due to depression or to diabetes. 

This is not to say that my results lack credibility. Rather, there could have been surveyed patients who are indeed depressed but have scores less than 10. That being said, three out of all twenty patients have been diagnosed as depressed according to my criteria. Though it is susceptible to change, this ratio is practically double the incidence of depression in the normal population.

Lalani.

¹Psych Central. (2008). Diabetes and Depression. Retrieved from http://psychcentral.com/lib/2008/diabetes-and-depression/.  

Patient Surveys: Day 9

For the past three weekdays, I have interviewed four more patients:





If you look at Figure 5 in my first post from last week, "Patient Surveys: Day 4," you can see that Patients 15 - 17 have an HbA_1c level (10.30%, 11.30%, and 10.60%, respectively) that is so high that the American Diabetes Association (ADA) would recommend "reevaluation" of treatment.

You will also notice that these three patients each scored higher than their (approximately) normal-HbA_1c counterpart, Patient 14 (HbA_1c level 7.20%). I think it's particularly interesting to note that the data of these four patients seem to indicate that regardless of the type of diabetes present, if the patient is maintaining little control over their condition, they are scoring higher on the depression scale. In the past, no such general trend was apparent, seeing as the Type 2 diabetics previously surveyed had low PHQ-9 scores and HbA_1c levels making their data inconclusive in this regard (i.e. it was uncertain whether scores were low because of the type of diabetes, the good control over the diabetes, or both).

Of course, I am still in the early stages of these interviews. By no means do I have enough data to conclusively claim that any of these noted day-to-day trends apply to the diabetic population at large.

Lalani.

Patient Surveys: Day 6

Over the past two days, I've surveyed four more patients, bringing me to a total of thirteen subjects in my study thus far. Below are the compiled results of all thirteen.




All four of these patients are Type 2 diabetics and scored a zero on PHQ-9. If you have taken a look at my survey, you would probably wonder how four middle-aged or older people with a chronic medical condition can manage to rank a symtom like "feeling tired or having little energy" or "trouble falling or staying asleep, or sleeping too much" with a zero (i.e. "not at all" in response to the question, "Over the last 2 weeks, how often have you been bothered by any of the following problems?") when even I feel that I would respond with at least a one in ranking either of those problems. 

This is because PHQ-9 is administered in such a way that if the patient indicates zero incidence of the first two symtoms, "little interest or pleasure in doing things" and "feeling down, depressed, or hopeless," then the seven remaining questions are not asked and the patient's final total score is zero. I would suspect that the survey is designed this way because if the first two (aforementioned) problems are not present while some of the other seven are, then it can be concluded that the presence of those 'other' problems (questions three to nine on PHQ-9) are not symptomatic of depression, but rather of other, not necessarily serious, medical issues (e.g. recent stress).

It seems that Type 2 diabetics have consistently scored lower than Type 1 diabetics on PHQ-9, except in the case of Patient 4. However, having surveyed only thirteen subjects, it is most definitely too soon to generalize.

Lalani.

Patient Surveys: Day 4

Since last Friday, I have interviewed five more patients with my survey, the results of which are compiled below.

  Figure 5. 

At a level of 11.50% (see Figure 5), Patient 6 has the highest HbA_1c level out of all subjects surveyed to date. Consistent with what I mentioned in my last post (how Type 1 diabetics would likely have a higher HbA_1c than Type 2 diabetics, since Type 1 diabetes is more difficult to control), Patient 6 is a Type 1 diabetic. Their PHQ-9 score of 9, one point short of a diagnosis of depression (according to DSM-IV), could be indicative of the patient's frustration and feelings of fatigue that stem from their uncontrolled diabetes.

Definitely the most interesting data I have collected to date comes from Patient 8. Patient 8 has already been diagnosed as depressed — this is consistent with their high PHQ-9 score of 12.  Additionally, Patient 8 is a Type 1 diabetic. Yet, Patient 8's HbA_1c is at a very healthy 6.30%. They don't even meet the ADA diagnostic criteria for diabetes!

How is it that a patient who is diagnosed with Type 1 diabetes and a DSM-IV depressive disorder can maintain such a low level of glycemic control (blood sugar control) that is inconsistent with essentially all other diagnosed diabetics?

This brings us to the extensive list of medications that even I have ignored thus far. Patient 8 is on Sertraline HCl, which is in a class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs). Perhaps Patient 8's treatment for depression has enabled his excellent glycemic control. This is also consistent with my main hypothesis of how diabetes and depression work in a circular fashion — where each of these chronic conditions often impairs the proper treatment of the other (see FIgure 3 in "Which Comes First?"); if this is the case, it follows that treating one of these conditions would help treat the other, as it appears with Patient 8.

As always, thanks for reading!

Lalani.

Patient Surveys: Day 2

I surveyed two more patients today. Both Patient 3 and Patient 4 are Type 2 diabetics, in contrast to the Type 1 patients from yesterday. Patient 3 is 51, has an HbA_1c level of 6.10%, and scored 0 on PHQ-9.  Patient 4 is 28, has an HbA_1c level of 6.0%, and scored 4 on PHQ-9.

Of course, there are no accurate generalizations that can be made having surveyed only four patients. But, as I continue my patient interviews over then next month and a half, I think it would be interesting to note some of the trends that appear in the data, even if they're neither credible nor conclusive as broad generalizations.



I think what stands out most is the disparity between the HbA_1c  levels of the Type 1 diabetics from yesterday (8.7% and 10.2%) and those of the Type 2 diabetics from today (6.1% and 6.0%). Recall that the HbA_1c level indicates how well the patient's blood glucose control has been in the recent months. Patients 3 and 4 have lower HbA_1c levels and therefore are maintaining better control over their blood sugar levels. It follows that Type 1 diabetics would have a more difficult time maintaining glycemic control because Type 2 diabetics do not require as much of an active individual role in controlling their diabetes (e.g. Type 2 diabetics do not have to constantly monitor blood sugar levels and administer insulin appropriately).

For right now, it doesn't seem like there are any noticeable trends with the PHQ-9 scores. I suppose I will just have to wait until I've interviewed more patients.

Lalani.

Patient Surveys: Day 1

Welcome back! Today, I began my patient surveys. Approximately sixty to seventy patients are seen everyday here. Though it may seem like an endocrinologist is primarily involved with diabetic patients, there are far more endocrinological complications that patients are seen for at an endocrinology practice than just diabetes. As a result, of those sixty to seventy patients seen in one day, few of them actually meet my inclusion criteria, i.e. few are eligible for participation in my study. But that doesn't mean my sample size contains few patients — seeing as I have over a month left of my senior project and I will be doing nothing more than these surveys during my time on-site, I don't currently feel that interviewing three or four patients daily on average will result in a small sample size.

Two patients were surveyed today. Patient 1 (age 34) is a Type 1 diabetic and presents with an HbA_1c  level of 8.7% and a PHQ-9 score of 0. Patient 2 (age 70) is also a Type 1 diabetic and presents with an HbA_1c  level of 10.2% and a PHQ-9 score of 7. Recall that scores of 5 to 9 indicate the presence of minimal depression symptoms and any score above 10 indicates a provisional diagnosis of a DSM-IV depressive disorder (see "PHQ-9 as a Diagnostic Tool"). 

Below are the results from today's patient interviews. You'll also notice that I've added a new tab to my blog entitled "Data Collected to Date" which contains all of the data from my patient surveys, compiled into one document. 



Lalani.

"One plus one equals much more than two..."

As I will not be collecting any data until March 12, I want to share some of the interesting facts I've been finding during my preliminary research on diabetes and depression. Did you know that depression is the most prevalent psychiatric disorder observed in the diabetic population?¹

In my first blog post, "And so it begins…," I described how I wanted to study diabetes in conjunction with an unconventionally thought-of diabetic complication, depression. So if depression is the most prevalent psychiatric disorder that is diagnosed in diabetics, why is it that I felt it was unconventionally thought-of?

It's because even if depression is the most commonly diagnosed psychiatric disorder in diabetics, this doesn't mean that it's commonly diagnosed. In fact, depression commonly goes undiagnosed and untreated¹, which is why I thought it was a particularly dangerous complication. Additionally, Patrick Lustman, Ph.D at Washington University School of Medicine in St Louis simply puts,

"One plus one equals much more than two when you add diabetes and depression. Because of physiologic and behavioral interactions between diabetes and depression, each becomes more difficult to control, increasing the risks of cardiovascular disease, diabetic retinopathy causing blindness, neuropathy and other complications."²

When you take into account that diabetes is already the seventh leading cause of death³ in the United States, it really puts into perspective the potential lethality of having depression in addition to diabetes. I am very much looking forward to conducting my patient interviews next week. As always, thanks for reading.

Lalani.


¹Diabetes.co.uk - The Global Diabetes Community. (2012). Diabetes and depression. Retrieved from http://www.diabetes.co.uk/diabetes-and-depression.html. 
²McMan's Depression and Bipolar Web. (2004). Depression and Diabetes. Retrieved from http://www.mcmanweb.com/article-42.htm. 
³National Diabetes Information Clearinghouse. (February 2011). National Diabetes Statistics, 2011. Retrieved from http://diabetes.niddk.nih.gov/DM/PUBS/statistics/#fast.

The Timing Bias

Unfortunately, I will have to postpone the start of my patient surveys. I will be out of the country for a week and a half starting tomorrow. My mentor explained that starting patient interviews today would result in potentially discreditable data. This is because starting surveys at this time followed by an eight-day interruption period (of no patient surveys) would result in data that would be considered compromised by the timing bias, a type of intervention (or exposure) bias.

In clinical research studies like mine, data should be collected consecutively as much as possible. Otherwise, the mere fact that several subjects who fit my research sample's inclusion criteria are not being surveyed,
AND fit no apparent exclusion criteria (e.g. not having diabetes), raises many questions as to whether the researcher is favoring the data collected before and after this supposedly arbitrary period of exclusion (i.e. whether the researcher has a timing bias against those perfectly eligible candidates who could have been surveyed). 

Considering that I'm already heavily relying on having a large sample size to account for various uncontrolled variables, I think it is important that I limit whatever potential bias(es) that could compromise the credibility of my results. For example, I am measuring the patient's HbA_1c  (see Glossary) as an indication for how well the patient's diabetic treatment is going. Surely, the amount of time that the patient has been undergoing endocrinological treatment influences how well the patient's diabetic treatment is going; however, it is not feasible for me to take this, or other similar variables into account — if I limited my sample's criteria to 1.) diabetic patients, 2.) with no other health complications, 3.) who have been undergoing treatment for their diabetes for only A to B years, 4.) who have no family history of depression, 5.) who have not undergone treatment for depression, 6.) who are not on medications X, Y, Z, etc., 7.) who are between the ages of N and M, I would have a minuscule sample size from which I could make no fair generalization about the 25.8 million¹ who comprise the U.S. diabetic population. 

For this reason, I will be waiting until the week of March 12 to begin my patient interviews in order to ensure maximum credibility of my data — a minor setback, sure, but a worthwhile one nevertheless. Thank you for reading.


Lalani. 


¹American Diabetes Association. (2011). Diabetes Statistics. Retrieved from http://www.diabetes.org/diabetes-basics/diabetes-statistics/. 

PHQ-9 as a Diagnostic Tool

Seeing as I will start my patient interviews this week, it seems fitting that I should first tie up any loose ends relating to my survey. As I mentioned in my previous blog post, "Nine Questions," I will be using the Patient Health Questionnaire-9 (PHQ-9). Unlike HAM-D which is usually administered after a patient is diagnosed with depression, PHQ-9 is often used to diagnose depression.

Earlier, I said that I would only use my survey to rank the severity of depression symptoms. But after finding that PHQ-9 is well-validated as a diagnostic tool for depression (as opposed to merely a depression scale), I figure that I may as well take full advantage of the PHQ-9 scores. So what exactly does that entail?

Figure 4. Severity scoring of the Patient Health Questionnaire-9 (PHQ-9).

Figure 4 shows the corresponding provisional diagnosis and recommended treatment for a given PHQ-9 score. DSM-IV defines criteria for two depressive disorders: dysthymia and major depressive disorder. Though there are many other depressive disorders that have been defined within the scientific community with their own set of criteria, for the purposes of my research, dysthymia and major depression are the only ones I am concerned with. Scores equal to or above 10 are indicative of some depressive disorder, or, in the least, depressive symptoms that should not go ignored. 

So...
I can use this survey to answer the question, "Is there a higher incidence of depression (a PHQ-9 score greater than or equal to 10) in diabetics than in the general population on average?" So what is the incidence of depression in the general population on average? The National Institute of Mental Health puts this number at

6.7%* for Major Depressive Disorder

and

1.5%* for Dysthymic Disorder.

*of the U.S. adult population

You might ask why I am not going to retrieve my own version of these numbers by surveying the non-diabetics here as well. Since I am working at a specialist's office (an endocrinology practice), almost all patients that are seen here were referred by a primary care physician who felt it was necessary due to the patient's specific case. In other words, just because I can survey patients here who aren't diabetic, this doesn't mean that the non-diabetic patients here are very representative of the general non-diabetic population. This is because they're being seen for other endocrinology-related complaints (e.g. thyroid disorders) that could — for all I know — affect their PHQ-9 scores. It wouldn't be a good idea to trust their scores because there could be many extraneous variables at work other than my main independent variable, the presence of diabetes mellitus.

So keep these two numbers in mind! They will remain in the "largest"-sized font on my blog for the rest of my project. At the end of my last sixty days of high school, I will hopefully be able to compare my results against these numbers from the NIHM.

Lalani.

Which Comes First?

"I was in shock. Most days, I couldn't take my insulin shot. I would just sit for hours. I tried to live what I thought was a 'normal' life. I did not take care of myself, and I did not control my diabetes….I felt hopeless, overwhelmed. I didn't know what to do, where to begin, where to turn. And I cried a lot."

Judy Abendschein was diagnosed with Type 1 diabetes at the age of eighteen. In the years that followed, Abendschein became suicidal and was eventually hospitalized. It seems clear that regardless of which came first — her diabetes or depression — each debilitating condition perpetually worsened the treatment of the other to the point of hospitalization.

For this reason, there are many theories that depression and diabetes interact in a circular manner. Poor control over one's diabetes (e.g. poor glycemic control) can be a risk factor for depression; likewise, depression symptoms (e.g. poor dietary habits) can result in poor diabetic control (see Figure 3).¹

Figure 3.  Diabetes and depression are often thought to interact in a circular manner.²

After researching various symptoms of diabetes and depression, I created the diagram above to depict how these symptoms may interact in a circular, i.e. causal, manner. Hopefully, by the end of these last sixty days of high school, I can attest to this theory — that each of these chronic conditions often impairs the proper treatment of the other. If this is indeed the case, I suppose the question of which condition comes first is irrelevant. With the presence of either one, prevention and detection of the other should be a priority; otherwise, a situation like Judy Abendschein's may arise.

Bottom line: diabetes and depression combine to form a potentially fatal mix.

Lalani.

¹American Diabetes Association. (2011). Living with diabetes. Retrieved from http://www.diabetes.org/living-with-diabetes/complications/mental-health/depression.html. 
²Burton, M. (1997). Depression and diabetes. (cover story). Countdown, 18(3), 20.

Nine Questions

My survey has been completed and approved! You can view it here or click on the tab entitled "Patient Survey." This means I will likely start conducting patient interviews within the week. Originally, I was planning on using the Hamilton Rating Scale for Depression (HAM-D) to survey patients. However, HAM-D is an extensive twenty-one question multiple-choice questionnaire.

My mentor felt that the more brief, but well-validated, Patient Health Questionnaire-9 (PHQ-9) is more appropriate for the scope of my research. As I indicated in my proposal, the scores from the survey would be used to rank the severity of depression symptoms; not to declare patients who score above a certain point as depressed and those who score below that point as not depressed. PHQ-9 scores each of the nine DSM-IV criteria for depression symptoms from “0,” i.e. "not at all," to “3,” i.e. "nearly every day" (see Figure 1).

Figure 1. The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) contains criteria for two major depressive illnesses: major depressive disorder (MDD) and dysthymic disorder (less severe than MDD).¹ PHQ-9 contains nine questions that address each of these depressive symptoms.

Figure 2. Hemoglobin A1c is a component of hemoglobin 
to which glucose is bound.

Earlier this week, I posted about how I ultimately want to show the implications of a relationship between diabetes and depression. You will notice on my survey that I am recording the patient's HbA_1c level, or glycosylated hemoglobin (see Figure 2). This is the average amount of sugar in blood over three months, i.e. the level of glycemic control (blood glucose control) that the patient has maintained over the previous three months. Because glycemic control is the most important aspect of maintaining control over your diabetes, the HbA_1c level is a very good indicator of how well the patient's treatment is going. It is for this reason that I have chosen to include the patient's HbA_1c on my survey. The recorded 
HbA_1c values will hopefully provide for a comparative analysis of how well the treatment is for diabetics with depression and diabetics without depression.

As I continue to update you on my progress, check out the “Glossary” tab at the top of the page where I have compiled a list of various terms I use. And as always, thank you for your readership.

Lalani.

¹ Mondimore, F. M. (2007, September 15). Never-Ending Winter: Chronic Depression. Psychiatric Times. Retrieved
  from http://www.psychiatrictimes.com/display/article/10168/54361.

So What?

"They say, 'you'd be depressed too if you were this sick.' People just assume that depression is a kind of natural reaction, a part of the disease."

Today was my first day at the Scottsdale Healthcare Endocrinology Institute. As my proposal indicates, the majority of my time here will consist of one-on-one patient interviews. But before I begin, I need to finalize the survey that I will use with my on-site mentor so that it is appropriate and comprehensive for the scope of my research - all of the data that I want to use must solely be attained from this survey (to be in accordance with 45 CFR 164.502(d), and 164.514(a) — (c) of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule). That is, everything from age to type of diabetes must be on the questionnaire. Once it is completed and approved by my mentor, I will be sure to post a link to it.

Before I go any further, I want to address perhaps the most relevant question to my research that I feel I have overlooked. Ultimately, the purpose of my research is to attempt to evaluate the implications of the relationship between diabetes and depression, not just the relationship itself. In other words, assuming I gain a better understanding of this relationship over the next sixty days, so what?

Diabetes demands a very active life: checking blood pressure and blood sugar level as needed, scheduling regular appointments, making dietary changes, and incorporating exercise into your life are all vital activities that are required for proper treatment after a diagnosis of diabetes. The outcome of treating an infection is merely getting rid of it. But diabetes is not an infection. It's a chronic condition. And as of right now, the outcome for treating it is control — control of all of its hindering effects. According to my mentor, an endocrinologist, unless you treat a depressed diabetic for their depression, you won't get a person who is ready to treat their diabetes.

This brings me to the above quotation from Patrick Lustman, Ph.D., associate professor of psychiatry at Washington University in St. Louis, who reported in the June issue of Psychosomatic Medicine. Unfortunately, as Dr. Lustman indicates, symptoms of depression are often downplayed in diabetic patients. So as far contributing to the scientific community, my long-term goal for this project is to not only attest to the relationship between diabetes and depression, but also convey the importance of getting proper treatment for depression to effectively treat diabetes when both conditions are present.

Lalani.

And so it begins...

Allow me to start off by expressing how pleased I was to find that I had forty-one page views before I even published my first post – yes, that is indeed forty-one views of a blank blog. I figure that if my page views do not exceed an average of forty-one per week during the next few months, I will have actually managed to captivate a larger audience with the blank version of blog. So if my empty blog warranted forty-one viewers to linger on the page, I suppose I can only hope that the actual content I post compares to the Times New Roman, three-word title on a black background that previously comprised this entire blog.

Welcome!

I am a senior at BASIS Scottsdale High School. At my school, the third trimester of senior year is dedicated to pursuing a three-month research project. During the approval process of my research proposal, as I sat before the Senior Research Project Committee, I was reminded of the very reason I chose to pursue research in the field of endocrinology. As my college counselor simply put, "Everyone knows a diabetic." Unfortunately, merely knowing a person with diabetes is not enough to demonstrate a true concern over the implications of the disease.

Considering the complications of diabetes that conventionally come to mind (e.g. increased risk of heart disease, stroke, hypertension), I specifically chose to study diabetes in conjunction with an 'unconventionally' thought-of diabetic complication: increased risk of depression. Hopefully, by delving further into the specific factors that correlate between diabetes and yet another serious medical condition that is tied to diabetes, depression, I can convey to my readers the debilitating effects of this disease.

As of one year ago, according to the American Diabetes Association, 25.8 million Americans have diabetes. Even if you aren't part of this 8.3% of the population or do not have close family or friends who are diabetic, I encourage you to share in my endeavors at the Scottsdale Healthcare Endocrinology Institute, during my last sixty days of high school, as I attempt to show you just how worthy of concern this topic is.

Lalani.