How Depression And Anxiety Affect Patient Adherence

Author(s): 
Nancy R. Megas MSN, CRNP

   We have all bemoaned non-adherent patients with out-of-control blood sugars who nod agreeably and then ignore everything we say. Not surprisingly, their wounds heal poorly and discouragement sets in with these patients. Their behavior appears to defy logic until we look at how prevalent depression and anxiety disorders are among patents with diabetes and how these disorders affect healing. The picture begins to make even more sense when we consider the effect of prolonged hyperglycemia on the brain.

   Extensive studies have established a strong link between diabetes and depression. Patients with diabetes are twice as likely to be depressed as the general population with their estimated prevalence of depression ranging from an estimated 11.4 percent to as high as 31.7 percent, depending on the survey methodology and the subpopulation studied.1

   Peyrot and Rubin found a substantially higher prevalence of depressive symptoms among patients with diabetes (41.3 percent) than that estimated for the general population (16.7 percent). They found even higher rates among patients with multiple complications (47.1 percent) or hemoglobin A1c levels above 12 (43.6 percent).2 In a 2007 cohort study of patients with diabetes with their first foot ulcer, Ismail found that one-third of patients with their first diabetic foot ulcer had clinically significant depression and a threefold risk of death after 18 months.3

   The effect of depression on our patients includes non-adherence to treatment regimens for diabetes and their foot ulcers, as well as significantly impaired wound healing.4,5,6 Monami and his colleagues studied 80 patients 60 years and older with chronic foot ulcers and found that the risk of non-healing within six months was significantly higher among those patients with Geriatric Depression Scale (GDS) scores over 10 (30.2 percent vs. 10.8 percent).5 Adherence, as measured by the percent of patients wearing prescribed footwear at follow-up, was significantly lower among patients with a GDS score over 10 (21.4 percent versus 53.8 percent).5

How Anxiety And Stress Complicate The Picture

   In addition to depression, diabetes is associated with a higher prevalence of anxiety disorders. Li and associates estimated that the overall age adjusted prevalence of lifetime diagnosis of anxiety was 19.5 percent in people with diabetes and 10.9 percent in people without diabetes.9 Even after adjusting for education, marital status, employment, smoking, leisure activities, physical activity and body mass index (BMI), patients with diabetes had a 20 percent higher prevalence of diagnosed anxiety.9

   The comorbidity of a mood or anxiety disorder exacerbates the patient’s already impaired wound healing. Researchers have shown this in numerous animal and human studies investigating psychological stress and wound healing. Mice subjected to restraint stress healed 27 percent more slowly than control mice and had serum levels of corticosterone that were four times higher. Human studies have shown stress-induced increases in glucocorticoids suppress IL-1B, TNF and PDGF.10

   Using a skin blister model to collect wound fluid from people during periods of high and low stress (university exam periods versus non-exam periods), Roy found stress to be associated with decreased growth hormone levels and impaired wound healing.11

   Keicolt-Glaser, et al., reported similar findings in their investigation of wound healing among patients stressed by their roles as caregivers versus a control group. Wound healing took significantly longer in the stressed group than the control (an average of 48.7 days versus 39.3 days) and stressed patients produced less interleukin-1 beta than the control group. Research has shown that interleukin-1 beta regulates the production, release and activation of metalloproteinases, which play an important role in the formation of the connective tissue matrix.11

Comments

Great article! I couldn’t agree more with the concept that too many physicians overlook the possibility of anxiety and depression as major contributing factors in certain symptoms experienced by their patients.

I guess that our education is still too classical in that it doesn’t encourage us to see the clear-cut causality between mental states and physical phenomena. Hopefully, articles such as this will help people realize that even their wounds will heal faster if they nourish a happy and content state of being.

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