In the Journals Plus

Neuropathy associated with greater distress, depression in older adults with type 1 diabetes

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May 18, 2017

In older adults with longstanding type 1 diabetes, neuropathy is the strongest predictor of diabetes distress and depression, regardless of the presence of painful symptoms, according to findings from a cross-sectional study.

“Diabetic neuropathy has been shown to be independently linked to depression, distress and reduced quality of life — especially in older patients — though the mechanisms driving this interaction are not completely understood,” Johnny-Wei Bai, MD, of the Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital in Toronto, and colleagues wrote. “Previous studies have suggested that it is the painful symptomatology associated with sensory neuropathy that contributes to poor psychological outcomes. However, some evidence shows that poor psychological outcomes in neuropathy stem from non-pain factors, such as restricted quality of life, perception of symptom and treatment unpredictability, and changes in social self-perception. Elucidating the link between neuropathy and its psychological sequelae may allow for more comprehensive management of diabetic neuropathy.”

Wei and colleagues analyzed data from 323 Canadian adults with type 1 diabetes for at least 50 years participating in the Canadian Study of Longevity in Type 1 Diabetes between April 2013 and December 2014 (mean age, 65 years; mean diabetes duration, 54 years; 43.8% men; mean HbA1c, 7.5%). Participants in the study completed a questionnaire that included an assessment of distress and depression via the Problem Areas in Diabetes (PAID) scale and the Geriatric Depression Scale (GDS), respectively. Complications were determined using the Michigan neuropathy screening instrument, fundoscopy reports, renal function tests, and self-reported peripheral and cardiovascular disease. Researchers used Poisson regression analysis to assess associations between neuropathy and distress or depression symptoms.

Within the cohort, 207 (69.5%) had retinopathy, 137 (42.4%) had neuropathy, 113 (36.5%) had nephropathy, 95 (29.4%) had CVD and 31 (9.8%) had peripheral vascular disease.

Among participants with neuropathy, researchers observed a higher prevalence of distress (9.5% vs. 3.3%; P = .029) and depression (24.9% vs. 6.5%; P < .001) vs. those without neuropathy. After adjusting for diabetes complications, neuropathy was associated with higher scores on the PAID scale (adjusted RR = 1.44; 95% CI, 1.14-1.82) and a higher GDS score (adjusted RR = 1.57; 95% CI, 1.18-2.11).

Bruce Perkins
Bruce A. Perkins

Associations with neuropathy were not fully explained by neuropathic pain, according to the researchers.

“Our study shows that older Canadians with type 1 diabetes for at least 50 years have overall low prevalence rates of distress and depression, but the subset of patients with symptomatic diabetic neuropathy — regardless of painful symptomatology — has substantially higher levels of depressive symptoms and distress,” the researchers wrote. “These results support more intensive mental health screening and multidisciplinary management of older patients with longstanding diabetes and with diabetic neuropathy.”

“We need to determine strategies to identify and manage distress and depression, other than the use of medications to counteract pain,” Bruce A. Perkins MD, MPH, FRCP, associate professor and clinician scientist at the Institute of Health Policy, Management and Evaluation at the University of Toronto, told Endocrine Today. “We feel that clinical trials of neuropathy need to consider distress as a clinically meaningful outcome measure.” – by Regina Schaffer

For more information:

Bruce A. Perkins, MD, MPH, FRCP, can be reached at the Leadership Center for Diabetes at Mount Sinai Hospital, L%-210, 60 Murray Street, Mailbox 16, Toronto, Ontario, Canada M5T 3L9; email:

Disclosure: One researcher reports receiving honoraria, consultant fees or grant support from Boehringer Ingelheim, GlaxoSmithKline Canada, Johnson & Johnson, Medtronic, Neurometrix and Roche. Another researcher reports receiving speaking fees and research grant support from AstraZeneca, Boehringer Ingelheim, Janssen, Eli Lilly and Merck.