Emotional distress found to be additional health risk for people with type 1 diabetes

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People with type 1 diabetes can face multiple health complications including high blood pressure with potential damage to nerves, kidneys, eyes and heart.

But add symptoms of emotional distress, as measured by the Beck Depression Inventory, and the risk of premature death for those with type 1 increases dramatically. The inventory is a 32-point scale with scores of 16 and higher strongly indicating the likelihood of clinical depression. 

"For every 1 point increase on the scale, participants showed a 4-percent increase in risk for mortality, even after controlling for other relevant factors, such as age, gender, smoking, cholesterol levels and high blood pressure,“ said Catherine Fickley, a Ph.D. candidate at the University of Pittsburgh Graduate School of Public Health and the study‘‍s lead author. 

The risk of premature death due to emotional distress can be three times higher than the general population, the study found.

Concerns about the impacts of emotional distress represent the latest findings from the growing database of evidence about type 1 diabetes the graduate school has collected during the 25-year Pittsburgh Epidemiology of Diabetes Complications Study. The findings were presented this month during the American Diabetes Association’s 74th Annual Scientific Sessions in San Francisco.

The Pitt study focused on 458 participants with type 1 diabetes who were patients at Children’s Hospital of Pittsburgh between 1950 and 1980. The National Institutes of Health recently renewed study funding for another five years.

Trevor Orchard, the Pitt graduate school professor of epidemiology who led the study, said his team will continue following the patients to better understand the long-term health impacts of type 1 diabetes. The autoimmune disease leaves one unable to produce sufficient levels of insulin -- the pancreatic hormone that turns blood sugar into cellular energy.

The study previously had found that people with type 1 can face a near-normal life span by avoiding such complications as high blood pressure and protein (albumin) in the urine.

As it turns out, the incidence of clinical depression is no higher in those with diabetes than occurs in the general population. But 39 percent of people with type 1 diabetes -- four times the rate in the general population -- experience emotional distress, said Lawrence Fisher, a University of California, San Francisco, professor who wasn’‍t involved in the Pitt study but studies the impact of emotional distress on those with diabetes.

It’‍s a chicken-and-egg puzzle, he said, because emotional distress and diabetes complications are inexorably linked. The challenges of managing diabetes can cause emotional distress, which then can contribute to high blood pressure, heart disease and other health effects. On the other hand, such complications alone can cause emotional distress, which exacerbates the disease process.

The study shows that emotional distress for those with type 1 causes health impacts comparable to high cholesterol and high blood pressure, with symptoms of emotional distress, as measured by the inventory, “strongly related to the risk of dying.”

“We found that depression symptoms are strongly related to the risk of dying for people with type 1 and it could be two to three times the risk, if they have higher scores” on the inventory, Dr. Orchard said. “This link between premature mortality and depression adds to our previous findings, which show that depressive symptoms predict cardiovascular disease and demonstrate that doctors need to consider more than adjusting insulin doses when treating type 1 diabetes.”

The impact of symptoms of depression, Dr. Orchard said, “does seem to be pretty independent of other factors we measured.” 

“It does seem that individuals who scored the worst on the depression score had increased levels of heart disease and more severe depressions,” he said.

New funding for the study is important, Dr. Orchard said, because “we can now say for sure that diabetes is not just a sugar disease.”

“It is far more complicated. With genetic and psycho-social components, as well as the usual physiologic risk factors, there is a lot to put together,” he said. “We’ve got a lot more research to do before we solve all the puzzles.”

Over a quarter century, the study has changed the way the medical field looks at type 1 diabetes. It has provided a means to predict complications based on duration of elevated blood-sugar levels, with insights about other health risks associated with diabetes, including oral health, all of which affect well-being and even longevity.

“Through this study, we’ve been able to alert physicians and patients to health conditions they might not have otherwise been aware of, allowing for preventative treatments and better quality of life for those with type 1 diabetes,” Dr. Orchard said.

Mr. Fisher, who described the study as “very good and very thorough,” said its conclusions linking emotional distress and premature death were surprising. But it also reveals the challenges of living with diabetes.

“Emotional distress occurs if you are worried about complications or you have burnout from management,” he said. “This is a tough disease and it upsets people over time.”

David Templeton: dtempleton@post-gazette.com or 412-263-1578.

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