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.