medwireNews: Subtypes of type 1 or type 2 diabetes are associated with different patient-reported outcomes (PROs) at diagnosis and determining these subtypes could help identify patients at risk for depression later in the disease course, suggests a study published in The Lancet Diabetes & Endocrinology.
Data on 1391 participants aged 18–69 years (mean age 48 years, 62% men) were collected from the German Diabetes Study (GDS) between 2005 and 2022. The investigators grouped patients diagnosed with diabetes within the previous 12 months into five novel subtypes, based on age, BMI, insulin resistance, glycated hemoglobin, homeostasis model assessment of beta-cell function, and the presence of glutamic acid decarboxylase antibodies (GADA).
The subtypes identified were severe autoimmune diabetes (SAID; 30.0%), severe insulin-deficient diabetes (SIDD; 2.4%), severe insulin-resistant diabetes (SIRD, 10.8%), mild obesity-related diabetes (MOD; 25.4%), and mild age-related diabetes (MARD; 31.4%).
The investigators assessed for four PROs, namely depression symptoms (Center for Epidemiologic Studies Depression [CES-D] Scale; scored out of 60, considered clinically relevant if score >22 points), wellbeing (World Health Organization 5-point Well-Being Index [WHO-5]; scored out of 100, <50 points indicates low wellbeing), health-related quality of life (HRQoL; 36-item Short-Form survey; scored out of 100, with higher scores indicating better HRQoL) and diabetes-related distress (Problem Areas in Diabetes Scale; scored out of 100, ≥40 points indicates severe distress). They compared these across the subgroups at baseline (up to 12 months after diagnosis) and again in a subsample of 659 participants available at follow-up 5 years later.
At baseline, for the whole sample, SIRD patients had the highest level of depression (mean 9.0 points) and the worst physical HRQoL (mean 46.6 points). SIDD patients had the lowest level of depression (mean 7.5 points), the highest level of wellbeing (mean score 66.1 points), and the least diabetes-related distress (mean 10.0 points).
SAID patients had the worst levels of wellbeing (mean score of 60.5 points), the most diabetes-related stress (mean 21.3 points), and the lowest scores for mental HRQoL (mean 47.8 points), but the highest scores for physical HRQoL (mean 52.8 points). And MARD patients had the best mental HRQoL (mean 50.9 points).
Baseline multiple regression models showed that patients with SIRD had significantly higher levels of depression than those with MARD after taking into account sociodemographic variables, as well as significantly less diabetes-related distress than those with SAID, and significantly poorer physical HRQoL than all the other subgroups.
This latter finding could be explained by this subtype being “typically older” and associated with “more overweight,” potentially restricting physical activity, say the investigators, who add that “lower levels of physical activity are in line with more pronounced subclinical inflammation, which is a hallmark of SIRD.”
SAID patients, who were the youngest group on average, also had significantly higher levels of depression than those with MARD and more diabetes-related distress, as well as significantly worse mental HRQoL, although significantly better physical HRQoL. Compared with patients with MOD, they had significantly better physical HRQoL, but significantly more diabetes-related distress.
The higher levels of diabetes-related distress in the patients with SAID “is consistent with the typical treatment for type 1 diabetes, which necessitates insulin-therapy and is associated with elevated levels of diabetes-related distress,” say Jana Sommer (Heinrich-Heine-University, Düsseldorf, Germany) and colleagues.
They note that, unlike more conventional diabetes-related somatic comorbidities and complications, there were no significant differences in PROs among the diabetes subtypes at the 5-year follow-up after multiple testing. However, descriptive analyses indicated that individuals with SIRD were more likely than those with MARD to experience clinically relevant depression (≥22 points on the CES-D scale) and low wellbeing (<50 points on WHO-5), at respective rates of 16% versus 6% and 31% versus 14%.
The investigators point out that the SIRD group “showed the largest increase and continued to have the highest mean depression symptom score” with a 2-point change from 9 points at baseline to 11 points at the 5-year follow-up. Scores decreased from 8 points to 7 points in those with MARD and similarly fell or remained the same in the other groups.
“Therefore, low insulin sensitivity might explain higher depression symptoms in the future, in line with findings on the biological and behavioral mechanisms of depression and diabetes,” they say. Sommer and team comment that “the analyses establish the basis for future research (eg, on depression among diabetes subtypes) and call for inclusion of mental health conditions in precision diabetology.”
They conclude: “[T]he present study highlights the importance of detecting depression very early in the course of diabetes, but also points to certain high-risk subtype requiring intensive management to maintain health and thereby reduce the risk of dysglycaemia and related complications.”
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Lancet Diabetes Endocrinol 2024; doi:10.1016/S2213-8587(24)00234-1
