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.