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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 14-19

Insulin resistance factor in subjects suffering from depressive disorder


1 Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Biochemistry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Department of Psychiatry, EMS Memorial Hospital and Research Centre, Perintalmanna, Kerala, India

Date of Submission22-Dec-2015
Date of Acceptance26-May-2016
Date of Web Publication16-Jun-2016

Correspondence Address:
Mona Srivastava
Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-3069.184118

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  Abstract 

Objective: The purpose of this study was to find out the occurrence of depressive disorders in patients with freshly detected diabetes mellitus (DM) and its relationship with the sociodemographic status of the subjects, severity of the disease, and insulin resistance (IR) factor in the subjects suffering from depression and DM.
Materials and Methods: In this cross-sectional study, 100 patients aged between 30 and 60 years who fulfilled the criteria for diagnosis as per the World Health Organization criteria of DM were selected randomly from endocrinology outpatient department (OPD) of Sir Sunderlal Hospital, Institute of Medical Sciences, Banaras Hindu University, Varanasi. All patients who attended the OPD services from November 2014 to July 2015 were screened for participation in the study. The patients were assessed for depressive disorder as per the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria and IR by blood chemistry measure of fasting insulin (by enzyme-linked immunosorbent assay KIT) and fasting glucose (GOD-POD method) using homeostasis model assessment method (HOMA-IR scale).
Results: In the study group of 100 patients, 34% of the patients were found to be suffering from depressive illness and they were not on any treatment. Out of the 34% patients who had insulin resistance; most common psychiatric disorder was major depressive disorder found in 21%,mild to moderate depressive disorder in 7% and 4% were found to have depression mixed anxiety symptoms. The estimated IR by HOMA-IR scale was found higher in 25 patients (74%) with psychiatric illness.
Conclusions: This study highlights the high comorbidity of depressions in newly detected diabetes and also emphasizes the need of psychiatric evaluation in subjects who are vulnerable at the time of being diagnosed as a case of DM.

Keywords: Depression, insulin resistance factor, metabolism, type 2 diabetes mellitus


How to cite this article:
Srivastava M, Mishra SP, Gavel R, Nair A. Insulin resistance factor in subjects suffering from depressive disorder. J Curr Res Sci Med 2016;2:14-9

How to cite this URL:
Srivastava M, Mishra SP, Gavel R, Nair A. Insulin resistance factor in subjects suffering from depressive disorder. J Curr Res Sci Med [serial online] 2016 [cited 2019 Aug 18];2:14-9. Available from: http://www.jcrsmed.org/text.asp?2016/2/1/14/184118


  Introduction Top


Diabetes mellitus (DM) is one of the most common chronic diseases worldwide, with prevalence of about 3-4% and it is frequently comorbid with psychiatric problems or disorders. Diabetes and depression are commonly occurring conditions in the current scenario. Across the world, around 200 million people are found to be suffering from diabetes. If preventive measures are not formulated, this number is projected to increase and may exceed 333 million by the year 2025. [1] Furthermore, an estimated 121 million people currently suffer from depression: Around 6% of men and 10% of women are estimated to experience a depressive episode in any given year. [2] Identification and management of comorbid psychiatric problems are important for the management of diabetes itself. According to a recent meta-analysis, the prevalence of depression is doubled in individuals with type 2 diabetes in contrast to those without diabetes. [3] It is a well-known fact that psychiatric comorbidity, in general, medical illness lengthens the patient's hospital stay, increases the probability of his or her exposure to diagnostics procedures, escalates the cost of treatment, and reduces the efficiency of medical and surgical treatment. [4] An association between these disorders becomes an extremely important area for research with therapeutic and preventive implications. Counseling for psychological distress and treatment of depressive disorder would holistically improve the well-being and metabolic control in DM. [3]

Depressive symptoms are present in about 15-20% of patients with type 1 or 2 diabetes. [4] However, there is a significant controversy over whether or not depression in patients with diabetes is associated with poor glycemic control. A study found that patients with type 1 but not type 2 diabetes, who had a lifetime history of major depression, showed significantly worse glycemic control than those without a history of depression. [5] Studies have found that patients with depression have impaired insulin sensitivity and resultant hyperinsulinemia and on recovery from diabetes, these abnormalities also reverse. [6],[7] Insulin resistance (IR) has been investigated as one of the mechanisms linking depression to diabetes, and different potential pathways can be identified. In 40-60% of people with major depressive disorder (MDD), the hypothalamic-pituitary-adrenal axis is hyperactive. Excess circulating cortisol and its disruption of glucoregulatory mechanism is thought to lead to hyperinsulinemia and IR, eventually leading to diabetes. [8] Alternatively, the relationship between depression and type 2 diabetes may be explained by lifestyle factors associated with depression, which includes physical inactivity and poor dietary habits that increases the risk of developing IR. Common to both of these pathways is obesity, which is a significant risk factor for increasing IR and diabetes. [9],[10] In the above scenario, the present study was undertaken to understand the relationship between two major illnesses and to help in the formulation of holistic management strategies.

Aim of the study

The aim of our study was to evaluate the psychiatric morbidities in patients with freshly detected diabetes and correlate MDD with sociodemographic characteristics of patients, severity of depressive illness of diabetic patients, and their IR.


  Materials and methods Top


Study site

The study was conducted in the Department of Psychiatry, Endocrinology, and Biochemistry of Sir Sunderlal Hospital, Institute of Medical Sciences, Banaras Hindu University, Varanasi. The data were collected from November 2014 to July 2015. The patients visiting the endocrine outpatient services were screened and 100 patients who had newly detected diabetes were enrolled in the study after taking a written informed consent. Ethical clearance to conduct the present study was obtained from the Ethical Committee of the institute. The inclusion criteria adopted were age 30-60 years, both genders, freshly diagnosed cases of DM, and those patients who were not on any medication including antidiabetic therapy before being selected for the study. Patients with any other associated physical illnesses and history of any psychiatric illnesses in the past or patients having any drug abuse history were excluded from the study. Patients suffering from any complications as a result of diabetes were also excluded.

Blood collection

We followed the National Diabetes Data and World Health Organization procedure for diagnostic criteria for DM. A diagnosis of diabetes must be confirmed on the subsequent day by measuring fasting plasma glucose (FPG), 2-h PG, or random plasma glucose. The FPG test is greatly preferred because of ease of administration, convenience, acceptability to patients, and lower cost. Fasting is defined as no caloric intake for at least 8 h. Blood samples were collected from newly detected diabetes subjects by venepuncture, taking all aseptic precautions. Fasting and random blood samples were taken from the patients attending the endocrine outpatient services of the hospital (between 8 AM and 2 PM). All patients were asked about the personal history concerning their sociodemographic details, psychiatric complaints, etc., and clinical examination was done for their diagnosis. About 5 mL of venous blood was sampled from each subject. The blood was allowed to stand for 30-60 min for spontaneous blood clotting. The serum was separated from the blood cells by centrifugation at 3000 rpm for 10 min at room temperature. The serum was decanted and centrifuged twice for 5 min at 3000 rpm to remove any blood cell remnants, decanted again, and then stored at -20°C in demonized Eppendorf tube vials until assay. The fasting blood glucose level was quantified by enzymatic method (GOD-POD method). The DRG® insulin enzyme immunoassay kit was used for the quantitative determination of fasting insulin in serum and plasma. This kit is a solid phase enzyme-linked immunosorbent assay based on the sandwich principle. All standards and samples should be run in duplicate concurrently so that all conditions of testing are the same. The OD is read at 450 ± 10 nm with a microtiter plate reader within 10 min after adding the stop solution. The average absorbance values for each set of standards and patient samples were calculated. A standard curve is constructed by plotting the mean absorbance obtained from each standard against its concentration with absorbance value on the vertical (Y) axis and concentration on the horizontal (X) axis.

Psychiatric measurement

The patients were assessed for psychiatric morbidities as per the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV TR) criteria. [11] The severity of psychiatric illness was assessed according to the following scales:

  • Hamilton rating scale for depression [12]
  • Hospital anxiety and depression scale. [13]


These scales are having high validity and reliability and are extensively used in research; these scales are rating scales for rating the severity of the symptoms.


  Observation and results Top


The patients were assessed for psychiatric morbidities as per the DSM-IV TR [11] criteria, and if found to have psychiatric morbidities, severity was rated according to the rating scales used. The study population was divided into 2 major groups - those with psychiatric illness and those without psychiatric illness, with psychiatric illness subdivided into three groups (1) MDD (2) Mild-to-moderate depressive disorder (3) other psychiatric disorder. [Table 1] shows that out of the 100 patients, 34% of the patients were found to have psychiatric morbidity. MDD was the most common psychiatric illness found in 21 patients. Nearly, 13% of the patients were found to have other psychiatric disorder (depression with anxiety, dysthymia, etc.). Patients' sociodemographic characteristics are shown in [Table 2]. The maximum number of patients diagnosed with MDD were between the age group of 41 and 50 years of age. This table also suggests that out of the 64 males, nearly, 15% of the males were diagnosed with MDD and out of 36 females, nearly, 6% of the females were diagnosed with MDD. According to the area of residence, this table shows that maximum number of depressive patients were from rural area and according to socioeconomic status table, the maximum number of depressive patients were from middle class family. This table shows no significant difference with respect to age (P = 0.95), sex (P = 0.58), area of residence (P = 0.72), and socioeconomic status (P = 0.41). As per [Table 3], the maximum number of depressed patients belonged to the moderate severity group (47%). [Table 4] shows the results for the prevalence of IR factor in subjects suffering from depressive disorders. IR was highly significant in diabetic patients with depression. [Table 4] shows that out of 21 patients suffering with depression, all patients showed IR and in 13 patients of other psychiatric illness, only 4 patients showed IR. In the group without psychiatric illness, out of 66 patients, 28 patients showed IR. Chi-square test value is 24.16 (P < 0.001). We applied test in the group of MDD versus mild-to-moderate depression at z = 4.45 (P < 0.001), MDD versus group of without psychiatric illness at z = 4.43 (P < 0.001), and mild-to-moderate versus without psychiatric illness at z = 0.70 (P = 0.22) as shown in [Chart 1 [Additional file 1]],[Chart 2 [Additional file 2]],[Chart 3 [Additional file 3]] and [Chart 4 [Additional file 4]]. For statistical analysis, we combined the groups having mild-to-moderate depression and other psychiatric illness. The analysis was done using SPSS 16 (IBM) for windows.
Table 1: Prevalence of psychiatric morbidities

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Table 2: Sociodemographic status versus major depressive illness in the study

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Table 3: Severity in patients with major depressive disorder

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Table 4: Prevalence of insulin resistance in newly detected diabetes mellitus

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  Discussion Top


The association between depression and diabetes was first described in the 17 th century by Thomas Willis, an English physician and anatomist, who stated, "diabetes is caused by sadness or long sorrow." [14],[15] Indeed, the statement is refuted by a systematic review which found that depression earlier in life increased the risk of development of type 2 diabetes by up to 40%. [16] Inter-relationships of DM and psychiatric disorders have been noted by careful observers like Sir Maudsley who commented, "diabetes is a disease which often shows itself in families in which insanity prevails." [17] A recent study by Australian Institute of Health and Welfare brings forth some important findings regarding the epidemiology of diabetes and psychiatric illness. [4] The study showed that diabetes and poor mental health and well-being are both common health conditions in Australia, with over 800,000 adults estimated to have diabetes and over 4 million adults estimated to have medium, high, or very high levels of psychological distress, adults with diabetes had a significantly higher prevalence of medium, high, or very high psychological distress than those without diabetes (43.4% and 32.2%, respectively), after adjusting for age differences in the groups, based on the 2007-2008 National Health Survey. In 2007-2008, diabetes hospitalizations were more likely to have a comorbid mental health condition than other hospitalizations (age-standardized rates of 8.4% and 7.5%, respectively). [7],[8] Substance use, dementia of Alzheimer's disease, and depression were the most common mental health conditions found as comorbidity, and people with diabetes who were current smokers were more likely to have a mental disorder and more likely to have medium, high, or very high levels of psychological distress than people with diabetes who were nonsmokers. [17],[18],[19]

Type 2 DM is the predominant form of diabetes worldwide, accounting for 90% of cases globally. [8] Type 2 diabetes has become one of the world's most important public health problems. [9],[10] Type 2 diabetes represents 85% of all cases of diabetes and it may originate from IR and relative insulin deficiency or from a secretory defect. Sex, age, and ethnic background are important factors in determining the risk of developing type 2 diabetes. [18],[19]

A recent meta-analysis [3],[4] reveals a mean prevalence of depressive disorder in patients with diabetes to be 14% in studies which used diagnostic interviews when compared to a higher prevalence of moderate-to-severe depressive symptoms (mean = 32% and range of 22-60%) for studies making use of self-report depressive symptom scales. [19],[20] The most commonly used tools for assessment have been the Beck Depression Inventory scale and the Centre for Epidemiological Studies Depression Scale; however, we used a simple scale, i.e., the Hamilton scale. [21] Diabetic patients are at a higher risk for suffering from depression, have lesser education, are unmarried or have poor social support, and experience chronic stressors and negative life events. [22] While being of female gender, having poor education, and homemaker status was found to be a risk factor, [23] our study failed to replicate this finding. Studies from Palestine, [23] Taiwan, [22] and Ethiopia [24] give a somewhat similar picture to our study. The above-mentioned studies highlight the need for a strong liaison network. The analysis also highlights the limitations of the existing data for obtaining accurate estimates of the prevalence of poor mental health among people with diabetes. [25] Our study carries some major limitations, since we did not consider the body mass index, lifestyle factors, HbA(1c) assessments, and the calorie intake. [24],[25] Nevertheless, our study is a recent of its kind in our setup and was needed for enhancing existing administrative and survey data collections or undertaking more specific surveys focused on people with diabetes. The psychosocial issues need to be addressed in diabetic patients so as to enhance their care taking, drug compliance, and quality of life considerations. [23],[26]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53.  Back to cited text no. 1
    
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Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: A meta-analysis. Diabetes Care 2001;24:1069-78.  Back to cited text no. 3
    
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Begum A, Mahtab H, Khan AK. Psychiatric morbidity in recently diagnosed diabetes subjects. J Diabet Assoc Bangladesh 1991;19:16-21.  Back to cited text no. 5
    
6.
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Harris MI, Eastman RC, Cowie CC, Flegal KM, Eberhardt MS. Comparison of diabetes diagnostic categories in the U.S. population according to the 1997 American Diabetes Association and 1980-1985 World Health Organization diagnostic criteria. Diabetes Care 1997;20:1859-62.  Back to cited text no. 8
    
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11.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Text Revision. 4 th ed. Washington, DC: American Psychiatric Association; 2000.  Back to cited text no. 11
    
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Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56-62.  Back to cited text no. 12
    
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Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361-70.  Back to cited text no. 13
    
14.
Rubin RR, Peyrot M. Was Willis right? Thoughts on the interaction of depression and diabetes. Diabetes Metab Res Rev 2002;18:173-5.  Back to cited text no. 14
    
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Willis T. Pharmaceutice Rationalis Sive Diatriba de Medicamentorum Operationibus in Humano Corpore. Oxford: E Theatro Sheldoniano MDCLXXV; 1674.  Back to cited text no. 15
    
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Sweileh WM, Abu-Hadeed HM, Al-Jabi SW, Zyoud SH. Prevalence of depression among people with type 2 diabetes mellitus: A cross sectional study in Palestine. BMC Public Health 2014;14:163.  Back to cited text no. 16
    
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Maudsley H. The Pathology of the Mind [Book]. New York: D. Appleton and Company; 1899.  Back to cited text no. 17
    
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Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC. Homeostasis model assessment: Insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia 1985;28:412-9.  Back to cited text no. 18
    
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Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA 2001;285:2486-97.  Back to cited text no. 19
    
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Okamura F, Tashiro A, Utumi A, Imai T, Suchi T, Tamura D, et al. Insulin resistance in patients with depression and its changes during the clinical course of depression: Minimal model analysis. Metabolism 2000;49:1255-60.  Back to cited text no. 20
    
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Roy T, Lloyd CE, Pouwer F, Holt RI, Sartorius N. Screening tools used for measuring depression among people with type 1 and type 2 diabetes: A systematic review. Diabet Med 2012;29:164-75.  Back to cited text no. 21
    
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Wu SF, Huang YC, Liang SY, Wang TJ, Lee MC, Tung HH. Relationships among depression, anxiety, self-care behaviour and diabetes education difficulties in patients with type-2 diabetes: A cross-sectional questionnaire survey. Int J Nurs Stud 2011;48:1376-83.  Back to cited text no. 22
    
23.
Domingo AK, Asmal L, Seedat S, Esterhuizen TM, Laurence C, Volmink J. Investigating the association between diabetes mellitus, depression and psychological distress in a cohort of South African teachers. S Afr Med J 2015;105:1057-60.  Back to cited text no. 23
    
24.
Weber B, Schweiger U, Deuschle M, Heuser I. Major depression and impaired glucose tolerance. Exp Clin Endocrinol Diabetes 2000;108:187-90.  Back to cited text no. 24
    
25.
Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes epidemic. Nature 2001;414:782-7.  Back to cited text no. 25
    
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Azad N, Gondal M, Abbas N, Shahid A. Frequency of depression and anxiety in patients attending a diabetes clinic. J Ayub Med Coll Abbottabad 2014;26:323-7.  Back to cited text no. 26
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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