General Hospital Psychiatry 25 (2003) 246  252
The relationship of depressive symptoms to symptom reporting,
self-care and glucose control in diabetes
Paul S. Ciechanowski, M.D.,MPHa,*, Wayne J. Katon, M.D.a, Joan E. Russo, Ph.Da,
Irl B. Hirsch, M.D.b
a
Department of Psychiatry and Behavioral Sciences, University of Washington, Seatlle, WA 98195, USA
b
Department of Medicine, University of Washington, Seattle, WA, USA
Abstract
Depressive symptoms are common among patients with diabetes and may have a significant impact on self-management and health
outcomes. In this study we predicted that: 1) there would be a significant association between depressive symptoms and diabetes symptom
burden, physical functioning, diabetes self-care, and HbA1c levels; and, 2) that the association between depressive symptoms and HbA1c
levels would be significantly greater in type 1, as compared to type 2 diabetic patients. This cross-sectional observational study of 276 type
1 and 199 type 2 diabetes patients took place in a tertiary care specialty clinic. We collected self-reported data on depressive symptoms,
complications, medical comorbidity, diabetes symptoms, diabetes self-care behaviors, physical functioning, and demographics. From
automated data we determined mean HbA1c levels over the prior year. We performed linear regression analyses to assess the association
between depressive symptoms and diabetes symptom perception, diabetes self-care behaviors, physical functioning, and glycemic control.
Among patients with type 1 and 2 diabetes, depressive symptoms were associated with greater diabetes symptom reporting, poorer physical
functioning, and less adherence to exercise regimens and diet. There was a significant association between depressive symptoms and HbA1c
levels in type 1, but not type 2 diabetic patients. Because of their association with clinical aspects of diabetes care such as diabetes symptom
reporting and adherence to diabetes self-care, depressive symptoms are important to recognize in treating patients with diabetes. © 2003
Elsevier Inc. All rights reserved.
Keywords: Depression; Diabetes; Diabetes symptoms; Self-care; Glucose control
1. Introduction While a number of cross-sectional studies have shown
that depression is significantly associated with hyperglyce-
A recent meta-analysis has shown that among patients
mia in type 2 diabetic patients, as many studies have found
with diabetes, the prevalence of major depression and sig- that this association is not significant [5]. When examined
nificant depressive symptoms was 11% and 31%, respec-
meta-analytically, the association between poorer glucose
tively [1]. The presence of comorbid depressive symptoms
control and depression has been found to be more signifi-
can have a significant impact on health outcomes, health
cant in type 1 as compared to type 2 diabetic patients across
care utilization, and overall functioning in patients with
studies, particularly when standardized interviews were
diabetes [2,3]. In a recent study of predominantly type 2
used (Effect Size 0.28 vs. 0.15) [5]. A recent cross-sectional
primary care diabetes patients (N 367), we found that de-
study also found the correlation between Beck Depression
pressive symptoms were associated with significantly
Inventory scores and HbA1c levels in type 1 diabetic pa-
poorer physical and mental functioning, decreased adher-
tients was moderately high (r .44) as compared to that in
ence to dietary recommendations, less adherence to oral
type 2 diabetic patients (r .06) [6]. A number of differ-
hypoglycemic medications, higher health care costs and
ences in type 1 and 2 diabetes  such as different etiologies,
nonsignificant increases in HbA1c levels [4].
age of onset and treatment regimens  may lead to different
mechanisms operating to cause hyperglycemia in depressed
type 1 and 2 diabetic patients. In type 1 diabetes, patients
* Corresponding author. Tel.: [phone]; fax: [phone]-
develop complete insulin deficiency due to an autoimmune
5414.
E-mail address: [e-mail] (P. Cliechanowski). destruction of the beta cells of the pancreas. In type 2
0163-8343/03/$  see front matter © 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0163-8343(03)00055-0
P. Ciechanowski et al. / General Hospital Psychiatry 25 (2003) 246  252 247
diabetes there is a relative lack of insulin based in part on the study and requested permission for a review of their
resistance to this hormone at both the liver and the muscle. automated records. Subjects not returning the questionnaire
The complete insulin deficiency in type 1 diabetes may within three weeks were sent an identical second question-
result in greater lability in glycemic control in response to naire and consent form. Subjects received a $3 compensa-
behavioral or neuro-hormonal effects of depression, than tion for their time in participating in the study. The ques-
may be the case in type 2 diabetes. There is also typically tionnaire and all patient correspondence were approved by
more treatment heterogeneity in type 2 patients who may be the University of Washington institutional review board.
treated with diet and exercise only, oral hypoglycemics,
insulin or a combination of these. The main  and essential 2.1. Self report instruments
 treatment in type 1 diabetes is insulin, though diet and
exercise also play an important secondary role in achieving 2.1.1. Depression
glucose control. Such differences in diabetes treatment may The Hopkins Symptom Checklist-90, Revised (SCL-
result in differential treatment outcomes given changes in 90-R) [9] is a self-report instrument, that has been validated
self-care behavior resulting from depression. For example, in previous studies of medical patients and has been found
in a type 2 diabetic patient treated with diet only, lack of to be highly reliable [10,11]. The twenty items from the
treatment adherence is not likely to cause as significant an depression and additional symptom subscales (SCL-20)
increase in glucose levels as lack of adherence to an insulin were used in the current study.
regimen in a type 1 diabetic patient.
Another important feature of the coexistence of diabetes 2.1.2. Diabetes complications
and depression is the increased potential for symptom re- Patients were given a score from 0 3 to reflect the
porting among depressed diabetic patients. While there is number of self-reported diabetes-related complications from
overlap of symptoms associated with both disorders (e.g., the following: retinopathy, nephropathy, and peripheral
fatigue, hyperphagia), depression is known to cause non- neuropathy [12]. This method has been shown to be highly
specific symptom amplification in patients with chronic correlated with ratings of severity of diabetes from indepen-
medical illnesses [7]. Thus, patients with depression may dent physicians (r .72, P .001) [12].
have a lower threshold in reporting all physical symptoms
including common diabetes symptoms such as thirst, poly- 2.1.3. Medical comorbidity
uria, and blurry vision. This tendency to amplify physical Based on the methods of Wells et al. [13], we estimated
symptoms may result in higher health care use and in- medical comorbidity by having patients check whether they
creased laboratory testing by providers [8]. did or did not have each of eighteen medical conditions
In the current study, we assessed the impact of depres- (e.g., asthma, hypertension, ulcer) on a checklist. The total
sive symptoms on patients with diabetes in a tertiary care number of conditions was calculated by summing positive
university-based clinic. We sought to determine if diabetes responses and for analyses each patient was given a score of
self-care behaviors, physical functioning, diabetes symptom 0, 1, 2 or more than 2 medical conditions.
reporting and glucose control correlated significantly with
depressive symptoms in both type 1 and 2 diabetes. We 2.1.4. Diabetes self-care
hypothesized that higher levels of depression would be The Summary of Diabetes Self-Care Activities [14] is a
significantly associated with greater diabetes symptom re- 12-item questionnaire that measures absolute levels of self-
porting, lower diabetes self-care, lower physical functioning care behavior and the percentage of activities recommended
in both type 1 and 2 diabetes, and we predicted that there by the physician that were actually performed. This ques-
would be effect modification so that higher levels of depres- tionnaire has been shown to be a valid and reliable measure
sion would be significantly associated with higher HbA1c of diabetes self-management in multiple trials. In this study,
levels in type 1, but not type 2 diabetes. diet amount, diet type, exercise, and glucose testing were
assessed, and since items within each domain have different
scales, raw scores for each were converted to standard
2. Materials and methods scores having a mean of 0 and an SD of 1. Standardized
scores were averaged to form a composite z score for each
This cross-sectional observational study was carried out regimen behavior. A higher z score indicates better adher-
at the University of Washington Diabetes Care Center ence to the self-care behavior.
(DCC), Seattle, Washington. Eligible participants included
all English-speaking DCC patients already enrolled in both 2.1.5. Functional impairment
1998 and 1999, age 18 or over. Potential subjects with The Short-Form 12 Health Survey (SF-12) [15] is a
severe cognitive or language deficits were excluded. In July generic measure of health status that is a shorter version and
1999, 826 potential subjects were sent an approach letter valid alternative to the SF-36 [16]. The SF-12 measures
briefly describing the study. Two weeks later subjects were functioning in medical populations and assesses physical
sent a questionnaire and consent form which fully explained functioning, role limitations due to physical health prob-
248 P. Ciechanowski et al. / General Hospital Psychiatry 25 (2003) 246  252
lems, bodily pain, general health, and social functioning, the significance of the demographic variables [age, gender,
which are represented in mental and physical component marital status, education, race and income] was tested using
scores. We report only the physical component score since backward and forward stepwise techniques in the first step.
there is typically strong collinearity between depression and Only significant demographic variables were retained in the
the mental functioning score. models. In the second step, medical comorbidity and num-
ber of diabetes complications was forced into each model.
2.1.6. Symptom reporting In the third and fourth steps diabetes type (type 1 1; type
To assess diabetes symptoms, we used the Self-Comple- 2 0) and depression score were entered, respectively. In
tion Patient Outcome [17] instrument to measure the fol- the model assessing the association between depression and
lowing diabetes symptoms: blurred vision, thirst, polyuria, HbA1c levels, the a priori hypothesis that diabetes type
excessive hunger, shakiness, fatigue, parasthesias, and feel- would modify this association was tested by forcing in, as
ing faint. Items were rated on a Likert scale and we calcu- the fifth step, the interaction of diabetes type and depres-
lated the total number of symptoms that were experienced at sion.
least  several days in the past month.
Demographic and clinical data were determined from
questionnaire responses (race, education, income, and mar- 3. Results
ital status) and from automated data (age, gender and dia-
betes type). We also used automated data to determine mean Of 826 patients, 475 (58%) responded to the survey, of
glycosylated hemoglobin (HbA1c) values for each subject which 276 (58%) had type 1 diabetes and 199 (42%) had
from the preceding twelve months. Mean number of HbA1c type 2 diabetes. There were no significant differences be-
tests in this population was 2 per year (range 0 6). To tween respondents and nonrespondents in age (48.8 15.9
analyze HbA1c levels, the University of Washington DCC vs. 50.0 16.4, respectively; t 1.13, df 825, P .26) and
uses a Bayer DCA2000, which is certified by the National gender (52.5% in both groups; 2 (df 1) 0.04, P .95).
Glycohemoglobin Standardization Program as having doc- All subsequent analyses are based on those respondents who
umented traceability to the Diabetes Control and Compli- had at least one HbA1c level documented in the electronic
cations Trial Reference Method. records within a twelve-month period (N 407). Clinical
and demographic characteristics of the respondents are out-
2.2. Diabetes classification lined in Table 1.
Subjects were classified in this clinic based on their 3.1. Glycemic control
clinical characteristics. In general, individuals with type 1
diabetes presented in childhood, adolescence, or as young In the multiple regression model (Table 2), being married
adults with acute symptoms, often ketoacidosis. Those with was associated with a lower HbA1c level, whereas number
type 2 diabetes usually presented later in life and were of complications was strongly positively associated with
overweight. Since 1991 the clinic staff has had access to the HbA1c level. There was a significant statistical interaction
measurement of islet antibodies (islet cell antibody, glu- of diabetes type and depression with respect to HbA1c level.
tamic acid decarboxylase, insulinoma-associated-2 autoan- We chose clinically meaningful cut-scores to illustrate this
tibodies, and insulin autoantibodies) and in those cases interaction in Fig. 1. A cut-score of 1.72 on the SCL-20 is
where the diagnosis was not obvious, these antibodies were associated with the highest positive predictive value for the
measured. If one of these antibodies was positive the patient diagnosis of major depression [18]. A cut-score of 8% for
was considered to have type 1 diabetes. HbA1c levels was chosen since current clinical guidelines
recommend additional clinical action for patients whose
2.3. Statistical analysis HbA1c levels are above this range [19]. The proportion of
subjects with HbA1c levels over 8% was significantly
Data were analyzed using SPSS 10.0 for Windows. Two- higher among patients with type 1 diabetes who were de-
tailed t tests or 2 tests with corrections for continuity were pressed (66.7%) compared to those with type 1 who were
used to compare respondents and nonrespondents on age not depressed (38.6%) as well as compared to both de-
and gender. Appropriate human subjects approval to utilize pressed and nondepressed type 2 diabetes patients (37.5%
aggregate data of nonrespondents on these variables was and 40.3%, respectively) ( 2 (df 3) 9.6, P .02).
obtained. Because we looked at HbA1c over the prior year, and the
Multiple regression modeling with a combination of hi- self-report measure of depression asks about symptoms in
erarchical and stepwise techniques was used to determine if the past 2 weeks, we conducted a sensitivity analysis to
depressive symptoms were associated with the following examine the correlation of depression and HbA1c levels
dependent variables: HbA1c levels, diabetes symptoms, when only considering those HbA1c levels from the past 4
self-care behaviors [diet type, diet amount, exercise, glu- months (N 253) and past 2 months (N 146), after control-
cose monitoring] and physical functioning. In each model ling for the covariates from the linear model (married status
P. Ciechanowski et al. / General Hospital Psychiatry 25 (2003) 246  252 249
Table 1
Demographic and clinical characteristics by diabetes type
Characteristic Diabetes Type
Type 1 (N 235) Type 2 (N 172)
Total (N 407) Analysis
Mean SD Mean SD Mean SD t
Age (years) 48.8 15.9 41.5 13.8 58.7 13.0 12.7***
HbAlc (%) 7.82 1.29 7.81 1.29 7.84 1.29 .29
SCL-20 score* 0.92 0.75 .85 0.74 1.01 0.77 2.25
N %** N %** N %** 2 (df 1)
Female gender 214 52.7 127 54.3 87 50.6 .54
Caucasian race 369 91.1 222 94.5 147 86.5 7.8**
At least 1 year college 363 89.4 212 90.2 151 88.3 .38
Married or cohabitating 278 68.8 162 69.2 116 68.2 .05
Income $40,000 255 65.9 155 69.2 100 61.3 2.6
At least 1 medical comorbidity 313 77.3 165 70.5 148 86.5 14.5***
At least 1 diabetes complication 189 47.3 108 46.6 81 48.2 .11
Diabetes treatment in type 2
diabetes patients
Insulin only   63 42.3 
Oral hypoglycemics only   53 35.6 
Insulin and oral hypoglycemics   22 14.8 
Diet only   11 7.4 
* Range of SCL-20 values: type 1 diabetes: 0  3.4; type 2 diabetes: 0 3.3.
**Number of subjects on which percents are based varies because of missing data from some items. SCL Symptom Checklist
and complications). In type 1 and 2 diabetic patients the which represent a mixture of dysthymic, and minor and
correlations were: 1) for 4 months, r .33, P .001, r .08, major depressed patients, as well as patients with adjust-
NS, respectively; and, 2) for 2 months, r .42, P .001, ment disorders with anxious and/or depressed mood [20
r .14, NS, respectively. Therefore, when SCL-20 scores 22].
and HbA1c levels were more tightly associated in time of
measurement, there was a higher correlation in type 1 dia- 3.2. Diabetes symptom reporting
betes between the two measures. The mean SCL-20 depres-
sion score in this sample (0.9 0.8) corresponds to a sub- In the multiple regression model assessing diabetes
diagnostic range of depressive and anxiety symptoms, symptom reporting, being married and higher education
Table 2
Multiple regression modeling of the association of depression and selected variables
Diabetes Physical
Symptom Component Glucose
HbAlc Reporting Score Diet Amount Diet Type Exercise monitoring
t t t t t t t
Demographic
covariates
age .17** 3.50 .20** 3.23 .32 5.14
marital status .14** 2.69 .10* 2.21
income .12** 2.78
education .10* 2.14
Clinical covariates
comorbidity .01 .20 .01 .12 .36 7.32 .05 .79 .003 .05 .06 1.00 .03 .37
complications .29 5.24 .13* 2.46 .12** 2.68 .03 .59 .04 .64 .07 1.29 .07 1.08
Diabetes type .18* 2.24 .03 .60 .05 .99 .18 2.85 .11 1.68 .11* 2.14 .03 .44
Depression .08 1.01 .41 8.50 .23** 5.13 .25 4.53 .14* 2.58 .15** 2.78 .07 1.10
Diabetes type .22* 2.47
depression
Overall model F(6,361) 10.42, F(6,362) 23.23, F(6,364) 42.90, F (5,351) 9.58, F(5,359) 8.90, F(5,361) 6.24, F(4,305) .56,
R2 0.15, R2 0.28, R2 0.44, R2 0.12, R2 0.11, R2 0.07, R2 0.01,
p .0001 p .0001 p .0001 p .0001 p .0001 p .0001 p .69

*p .05, **p .01, p .001
250 P. Ciechanowski et al. / General Hospital Psychiatry 25 (2003) 246  252
Fig. 3. Association between depression quartiles and diabetes self-care.
Ranges of quartiles of SCL-20 depression scores are as follows: 1st: 0-.34;
Fig. 1. Association between depression and HbA1c levels by diabetes type.
2nd: .35-.69; 3rd: .70 1.35; 4th:1.36 3.40.
Depressed group has SCL-20 score 1.72, nondepressed group has
SCL-20 score 1.72.
3.4. Diabetes self-care
were significantly associated with lower symptom reporting
Increasing age was significantly associated with higher
whereas higher levels of diabetes complications and depres-
self-reported adherence to diet amount and type, while a
sion were significantly and independently associated with
higher level of depression was associated with lower self-
more diabetes symptom reporting (Table 2). To illustrate
reported adherence to diet amount, diet type and exercise.
this relationship graphically, quartiles of depression were
Type 1 diabetes was significantly associated with higher
used to derive means of symptom reporting in each quartile.
self-reported adherence with exercise. Glucose monitoring
Fig. 2 shows the mean number of diabetes symptoms re-
was not associated with any of the variables in our model.
ported as occurring at least several days in the prior month
Fig. 3 illustrates the association between self-care and de-
by quartiles of SCL-20 depression scores.
pression for those domains of self-care that have been
shown to be significantly associated with depression (diet
3.3. Physical functioning
type, diet amount and exercise). Again, depression severity
was grouped into quartiles and mean z-score for each do-
Increasing age, and higher levels of medical comorbid-
main of self-care was obtained for each quartile. As shown
ity, diabetes complications and depression were all signifi-
in the figure, as depression increased, levels of diet and
cantly associated with poorer physical functioning in our
exercise adherence decreased.
sample, while higher income was associated with better
physical functioning (Table 2).
4. Discussion
Depressive symptoms were found to be significantly
associated with lower adherence to dietary recommenda-
tions and exercise, poorer physical functioning, and higher
diabetes symptom reporting among patients with type 1 and
type 2 diabetes in a tertiary care diabetes specialty clinic.
These associations were robust after controlling for diabetes
type and complications. These results are consistent with
other studies. For example, in our previous study of a
primary care sample of predominantly type 2 diabetic pa-
tients, dietary recommendations were not followed as
closely in patients with greater levels of depression [4].
Common symptoms of depression such as changes in ap-
petite and decreased energy and motivation may signifi-
Fig. 2. Association between depression quartiles and diabetes-related
cantly affect diet and exercise. While changes in motivation
symptom reporting. Number of symptoms refers to total number of diabe-
and concentration that occur in depression can conceivably
tes symptoms reported as occurring at least several days in prior month.
affect frequency of glucose monitoring, no evidence for this
Ranges of quartiles of SCL-20 depression scores are as follows: 1st: 0-.34;
2nd: .35-.69; 3rd: .70 1.35; 4th: 1.36 3.40. could be found in our sample. In our previous study, we also
P. Ciechanowski et al. / General Hospital Psychiatry 25 (2003) 246  252 251
observed an association between physical functioning and per patient [32]. One recent randomized controlled trial has
depression [4]. suggested that improved outcomes of depression with cog-
There was also a strong and significant association be- nitive behavioral therapy versus diabetic educational treat-
tween depression and diabetes symptom reporting even af-
ment were associated with significantly improved HbA1c
ter controlling for diabetes severity and medical comorbid-
levels at 6 months follow up [33]. Another randomized
ity. This corresponds to previous research in which it was
controlled trial [34] has shown that a serotonin-selective
shown that depression was associated with diabetes symp-
reuptake inhibitor was more effective than placebo in treat-
toms even after adjusting for HbA1c levels [8]. In post hoc
ing major depression in diabetic patients. The clinician
analyses, we found that by controlling for HbA1c, as a final
treating diabetic patients should strive to recognize depres-
step in our linear regression model, depressive symptoms
sion among these patients because of the strong possibility
still remained highly correlated with symptom reporting.
that diabetes symptoms, physical functioning, diabetes self-
Furthermore, post hoc Pearson correlations showed that all
care and HbA1c levels may all improve with depression
8 symptoms were significantly correlated (P .005) with
treatment.
depression ranging from r .43 for sleepiness to r .15 for
There are several limitations of this study. Although this
shakiness in the following order from highest to lowest
was a population-based study of diabetic patients from a
correlation: sleepiness, blurry vision, thirst, parasthesias,
tertiary care clinic, there is possibly a lack of generalizabil-
hunger, polyuria, feeling faint, and shakiness. Research in
ity of this predominantly Caucasian, educated, employed
patients with other chronic medical illnesses such as hepa-
and insured health care population to other settings. Fur-
titis C, inflammatory bowel disease, coronary artery disease,
thermore, it is possible that the intensity of the care received
and patients with closed head injury have all shown that
from a diabetologist and diabetes treatment team in this
depression comorbidity is associated with increased physi-
sample, not to mention possible selection biases of patients
cal symptom reporting even after controlling for severity of
who chose to come to a tertiary care center, may make this
illness [23].
sample less generalizable to a typical primary care popula-
Depressive symptoms were associated with a significant
tion. As a result, there may be less variability in treatment
increase in glycosylated hemoglobin (HbA1c) in type 1, but
not type 2 diabetic patients. This is consistent with the outcomes particularly with type 2 diabetic patients as
results of a recent study by Van Tilburg and colleagues [6]. compared to similar patients in primary care.
These results suggest that whether the impact of depres- Another possible limitation of this study is the use of
sion on glucose control is mediated through its effect on
self-report questionnaires to derive levels of depressive
self-care behaviors, or via central effects such as by influ-
symptom severity rather than using structured interviews to
encing the hypothalamic-pituitary adrenal axis [24], that the
make a diagnosis of major depression. Similarly, self-re-
impact is considerably greater for type 1 diabetic patients.
ported instruments were used to assess self-care behaviors,
This may be because of increased complexity of self-care
and may be less accurate than objective measures of adher-
regimens in type 1 diabetes, or because of neurohormonal
ence as a result of social desirability bias. Because this study
differences in regulation of glucose between type 1 and 2
reports cross-sectional observational data, we cannot make
diabetes.
causal inferences about depressive symptoms on the re-
Prior researchers have reported the effect of depression
ported outcomes. Alternative explanations, such as that de-
on worsening adherence to medical regimens in general
pressive symptoms resulting from poorer diabetes outcomes
[25], and to various self-care strategies (glucose monitoring,
or the possibility that unmeasured third factors may be
exercise, diet, medications) in diabetes [26,27]. The im-
responsible for this relationship, must be considered. Larger
portance of improving adherence to treatment of diabetes
scale randomized controlled trials need to be planned that
has been emphasized in both the Diabetes Control and
measure the effect of interventions that improve depressive
Complications Trial (DCCT) [28] and the UK Prospective
outcomes on symptom burden, functional impairment, self-
Diabetes Study [29] which both showed that strict ad-
management and HbA1c levels.
herence to diabetes treatment (and lowering of blood sugar)
in type 1 and type 2 diabetic patients, respectively, resulted
in a decreased risk of long-term complications. Other
Acknowledgments
studies have shown that depression is associated longitudi-
nally with an increased risk of diabetic complications,
The authors thank Anthony D Amico and Larry
especially retinopathy and macrovascular complications
Mix for their assistance with collection of data for this
[30,31]. The implications of untreated depression on long-
study.
term complications are even more significant when one
Supported by Group Health Cooperative/Kaiser Perma-
considers that depression tends to be recurrent or chronic in
nente Community Foundation Grant #66-0404 and Bayer
most patients with diabetes, e.g., in one study, 79% of
patients reporting a history of major depression relapsed Institute for Health Care Communication Grant #98-439
over a 5-year follow-up period with a mean of four episodes and NIDDK grant K23 DK60652-01.
252 P. Ciechanowski et al. / General Hospital Psychiatry 25 (2003) 246  252
[18] Mulrow CD, Williams JS, Gerety MB, Ramirez G, Montiel OM,
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