Why Checking for Depression Is Important for Patients With Diabetes

Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Annahita Forghan, Pharm.D. Candidate 2019, LECOM College of Pharmacy

Adults with high levels of HbA1c may be at risk of lowered adherence to diabetes medication during poor management of depression.

Way back in 2003, the World Health Organization (WHO) announced “increasing medication adherence might have a far greater positive impact on the health of the population than any improvement in specific medical treatments.”1 Non-adherence to recommended medications is a dangerous health behavior for people who have type 2 diabetes with toxic levels of glucose in their blood. Both the quality of life of patients with diabetes and health economics are compromised as an effect of non-adherence in following a long-term medication regimen.6

WHO stated that “Adherence to long-term therapy for chronic illnesses in developed countries averages 50%. In developing countries, the rates are even lower. It is undeniable that many patients experience difficulty in following treatment recommendations.”6 This is not a minor factor in treating chronic diseases. Jumping ahead to 2019, non-adherence continues to present a global problem of great significance that we should be concerned about. If adherence is improved, the patient’s diabetes disease outcomes can be improved overall, and there can also be a decrease in diabetic complications and related healthcare expenses.6

Clinical depression or major depressive disorder poses a concern in this population of patients with type 2 diabetes, due to the depressive behaviors that affect a person’s actions and level of function.4

Depressive behaviors that may affect adherence to diabetes medication regimens include: Loss of interest, pessimism


Difficulty remembering or making decisions

Difficulty sleeping, early-morning awakening, or oversleeping

Appetite and/or weight changes

Pains, cramps, or digestive problems without a clear physical cause and/or that do not ease with treatment.3

WHO had stated, “Patients who are struggling with negative emotions, including fear, self-blame, guilt, helplessness, and frustration, are at greater risk for medication nonadherence. Depression, which is more common in diabetes patients, is a significant risk factor for suboptimal medication adherence. Poor cognitive function and insufficient social support from family or friends are other factors that hamper medication adherence.”1 Therefore, in addition to other reasons why patients with diabetes may not take their medications, such as cultural beliefs, fear of adverse effects and/or interactions, doubts in the efficacy of the medication, doubting their own disease, etc., we know that depression plays a magnificent role in a patient’s reluctance to adhere to diabetes medications, whether the behavior is intentional or not.

In a study by the Journal of Diabetes and its Complications in ScienceDirect, 376 participants had an average age of 55.6 years, an average A1c of 9.1%, and werer taking oral diabetes medication. The patients being studied were given telephonic self-management support. The subjects self-reported their compliance with their diabetes medications as a measurement tool in addition to claims-based records. Depressive symptoms and non-adherence odds were analyzed using a multivariable logistic regression model.2

PHQ-8 (Patient Health Questionnaire) screening, included in the analysis, is a tool used to diagnose common mental disorders, such as depression. Positive PHQ-8 screen results were correlated with non-adherence to diabetes medications (OR = 1.40 [95%CI: 1.11–1.75]).2

As demonstrated in this randomized controlled trial, if the depressive behaviors are not managed, medication adherence in patients with diabetes is decreased. Although this study was limited in identifying independent symptoms related to non-adherence, depression symptom severity was a statistically significant association.

Interventions are needed in order to improve emotional hardship that may limit diabetes medication adherence. More studies on these specific interventions and how the interventions may or may not interact with treatment of clinical depression itself are needed.

Practice Pearls: Clinical depression affects an individual’s ability to function, which in turn has an effect on medication adherence in patients with type 2 diabetes.

A higher level of depression is correlated with higher incidence of non-adherence to diabetes medication.

Interventions should be developed for people with type 2 diabetes who also suffer from major depression.


Bussell, Jennifer K.; Cha, EunSeok; Grant, Yvonne E.; Schwartz, David D.; Young, Lara A.. “Ways Health Care Providers Can Promote Better Medication Adherence”. Clinical Diabetes 2017 Jul; 35(3): 171-177. http://clinical.diabetesjournals.org/content/35/3/171. 4 January 2019.

Cohen, Hillel W.; Gonzalez, Jeffrey S.; Hoogendoorn, Claire J.; Roy, Juan F.; Shapira, Amit; Walker, Elizabeth A.; “Depressive symptom dimensions and medication non-adherence in suboptimally controlled type 2 diabetes.” Journal of Diabetes and its Complications. 7 December 2018. ScienceDirect. www.sciencedirect.com/science/article/abs/pii/S1056872718307840?via%3Dihub. 3 January 2019.

“Depression”. National Institute of Mental Health. February 2018. www.nimh.nih.gov/health/topics/depression/index.shtml. 3 January 2019.

Depressive symptoms may interfere with diabetes medication adherence in adults with elevated HbA1c. Hoogendoorn CJ, et al. J Diabetes Complications.

www.healio.com/endocrinology/diabetes/news/in-the-journals/%7b8d1d7886-ab99-4da9-ade1-186021d20d04%7d/depressive-symptoms-may-interfere-with-diabetes-medication-adherence-in-adults-with-elevated-hba1c?M_BT=2469436429117. 3 January 2019.

Kroenke, Kurt; Spitzer, Robert L; Williams, Janet B W. “The PHQ-9; Validity of a Brief Depression Severity Measure.” J Gen Intern Med. September 2001. PMC. www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/. 3 January 2019.

Sabaté E. “Adherence to Long-term Therapies: Evidence for Action”. Geneva, Switzerland, World Health Organization. 2003. Google Scholar. https://books.google.com/books?hl=en&lr=&id=kcYUTH8rPiwC&oi=fnd&pg=PR5&ots=tB3Okq3ip-&sig=SS0I9nNfQRW_Octa__I6Eqw-1_s#v=onepage&q&f=false. 4 January 2019.

The Patient Health Questionnaire (PHQ-9) – Overview. www.cqaimh.org/pdf/tool_phq9.pdf. 3 January 2019.

Annahita Forghan, Pharm.D. Candidate 2019, LECOM College of Pharmacy

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