This study contributes valuable information to the growing body of literature on diabetes, depression, and healthcare utilization by examining these relationships in a currently understudied population, namely African-American primary care patients. In contrast to many previous studies with predominantly white samples that found a positive association between diabetes and depression, no association was found in this African-American sample. African-American patients with and without diabetes did not differ on the severity of depressive symptomology or on the presence of major depressive symptoms. However, the results do concur with research findings based on other samples, which report that the co-occurrence of depression with diabetes is associated with more acute care utilization, such as ER visits and inpatient hospitalizations. Specifically, the co-occurrence of major depressive symptoms with diabetes among African Americans was associated with nearly three times more reported ER visits and three times as many inpatient days but was only marginally associated with lower physician visits.
Given that this is a primary care sample, all the African-American patients had accessed primary care services at least once during the time period of consideration. Nevertheless, the depressed diabetic patients still had higher ER and inpatient utilization. This utilization pattern concurs with the finding in another clinical sample, while an HMO sample demonstrated a greater probability of any primary care, ER, or inpatient use by depressed diabetic patients. However, the only published study using a nationally representative sample found differences only in ambulatory care and prescriptions filled, with no difference in ER or inpatient utilization. While some of the variation in findings among these studies may be due to differences in methodology, it is important to consider that all of these samples were composed of predominantly white respondents. The pattern of utilization exhibited by the depressed diabetic patients in this African-American sample also parallels a pattern of disproportionate use of the ER that has been found in previous studies among African Americans, even when access to care is controlled.
Limitations and Future Research
The limitations of this study include the generaliz-ability of the sample, the self-report nature of the data, and the lack of data on diabetes-related complications. First, since this is a convenience sample drawn from a primary care clinic, we cannot be sure that the sample is completely representative of this primary care population. While the use of multivariate analysis with controls for demographic characteristics and comorbid chronic conditions helps to adjust for compositional effects of the sample while examining the relationship between the variables of interest, the findings are not conclusive. However, since a negligible amount of research has examined the relationship between diabetes and depression among African Americans—especially in terms of the effect of comorbid diabetes and depression on utilization outcomes—this study contributes important information toward a better understanding of the psychosocial impacts of diabetes on one of the groups most affected by this disease. Future prospective studies with a randomized design focusing on African Americans and other racial/ethnic minority groups—who are typically under-represented in national surveys—are needed.
Second, the data collected were exclusively based on self-reports of the respondents, without corroboration from medical or billing records. Medical confirmation of diagnoses for type-2 diabetes and comorbid chronic conditions would be ideal, although self-reports of these conditions are most likely accurate enough that they would not substantially bias the conclusions of the analyses. While some studies measure depression based on clinical diagnosis, it is also useful to consider self-reported symptoms because many depressed individuals are not diagnosed and because subclinical symptoms may also affect diabetes self-management and healthcare utilization. Self-reports of healthcare utilization were preferred for this sample since it would be logistically difficult and probably not possible to obtain utilization data from all of the health service providers that each clinic patient would have used during the prior six months or year. Complete utilization data on some individuals exist in the form of billing records for private insurance companies and for Medicaid or Medicare; however, only two-thirds of the patients in this sample were on TennCare (Tennessee’s Medicaid waiver-program). Indeed, some studies draw samples from Medicaid or Medicare beneficiary files, which is also a valid and useful approach to studying these issues. The drawback to using billing record data, though, is the lack of valuable data that can be obtained in a personal interview, such as complete demographic data, current level of depressive symptoms, and other psychosocial variables.
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Third, the study from which these data were drawn did not collect information on the number or types of diabetes complications experienced by respondents. This is another area in which little is known about African Americans and is important to consider since African Americans are disproportionately affected by certain diabetes complications, such as retinopathy, end-stage renal disease, and lower-extremity amputations. We theorized that depression would hinder diabetics’ self-care (e.g., diet, exercise, monitoring blood glucose levels, foot care), adherence to the recommended medical regime (e.g., medication, insulin shots), and regular check-ups with their physicians. This hindered disease management is expected to lead to greater diabetes complications and, in turn, greater acute care utilization. At the same time, however, diabetics who have high acute care utilization could be more depressed as a result of their more advanced diabetes disease process and related complications. Therefore, future prospective, longitudinal studies are needed in order to tease out the impact of depression on diabetes disease management, diabetes complications, and utilization patterns.
First, the findings of this study suggest that the combined burden of diabetes and concurrent major depressive symptoms may have negative impacts on health outcomes for the African Americans in this sample, as indicated by patterns of increased acute care utilization (ER visits and inpatient hospital days) without a similar increase in regular physician care. Because comorbid patients likely have a need to visit the doctor more often to effectively manage their multiple conditions, this lack of a significant effect for depression among diabetic patients could suggest that depression is hindering such individuals from seeking more frequent routine healthcare. This pattern of utilization could also be indicative of greater diabetes complications due to impaired self-care and medical adherence. Perhaps depressed individuals are less likely to control blood sugar levels and have more diabetes complications, or they are more likely to delay care until complications become severe. Further research tracking diabetic patients over time, including self-care behaviors and adherence to the recommended medical regimen, is needed to clarify this possible link between depression and utilization patterns among individuals with diabetes.
Second, in addition to the problem of poor health outcomes, this pattern of costly acute care utilization ultimately leads to increased healthcare costs among individuals with comorbid diabetes and depressive symptoms, regardless of race. In an HMO primary care study, Ciechanowski and colleagues found that among individuals with diabetes, those who were depressed had a greater probability of having any primary care, specialty care, emergency department, medical inpatient, and mental health costs than those who were not depressed. In another HMO study, Nichols and colleagues estimated that annual healthcare costs for patients with diabetes and depression averaged $6,787, while nondepressed diabetic patients had significantly lower costs of $4,233. In their analysis of MEPS data, Egede and colleagues estimated that individuals with diabetes and depression had 4.5 times higher total healthcare expenditures than those with diabetes who were not depressed, while adjusting for other factors. In addition, among elderly Medicare claimants with diabetes, those with major depression had 21% higher total annual payments and 7% higher inpatient payments (both nonmental health-related) than those without major depression in 1997, after adjusting for other factors. Again, all of these existing studies involve samples composed of mostly white respondents, and little is known about whether cost impacts are similar for African Americans with diabetes and depression. canadian pharmacy viagra
Finally, the findings of this study point to the need to incorporate mental health screening and support into the treatment and management of diabetes in primary care settings. The primary care setting represents a crucial point of possible intervention to diagnose and treat patients with comorbid diabetes and depression, particularly among high-risk, low-income and minority populations. In fact, most patients with diabetes are seen by primary care physicians, and nearly half of patients who receive treatment for depression are only seen by a physician in a primary care setting. Indeed, many depressed diabetic patients who are seen in primary care may not be diagnosed or treated for their depression, which could potentially interfere with the effective treatment of their diabetes. While the amount of available evidence is still limited, some studies suggest that interventions targeted at reducing symptoms of depression among patients with diabetes may produce benefits in terms of glycemic control. Future research should examine whether psychosocial interventions can also be effective among African-American populations.