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Psychosomatics 50:16-23, January-February 2009
doi: 10.1176/appi.psy.50.1.16
© 2009 Academy of Psychosomatic Medicine
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Quality of Life and Suicide Risk in Patients With Diabetes Mellitus

Maurizio Pompili, M.D., David Lester, Ph.D., Marco Innamorati, Psy.D., Eleonora De Pisa, M.D., Mario Amore, M.D., Camilla Ferrara, Psy.D., Roberto Tatarelli, M.D., and Paolo Girardi, M.D.

Received February 8, 2007; revised May 17, 2007; accepted June 7, 2007. From the Dept. of Psychiatry, Sant’ Andrea Hospital, Sapienza University of Rome; Italy; McLean Hospital–Harvard Medical School, Cambridge, MA, United States; The Richard Stockton College of New Jersey, Pomona, NJ, the "Università Europea," Rome, Italy; and the Dept. of Neuroscience, University of Parma, Italy. Send correspondence and reprint requests to Maurizio Pompili, M.D., Dept. of Psychiatry, Sant’Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy. e-mail: maurizio.pompili{at}uniroma1.it
© 2009 The Academy of Psychosomatic Medicine


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
BACKGROUND: Diabetes mellitus may have profound effects on physical and emotional health and quality of life. OBJECTIVE: The authors evaluated the perceived quality of life and its association with suicide risk in Italian patients with diabetes mellitus. METHOD: Authors evaluated 100 patients with type 1 and type 2 diabetes. Patients completed the Beck Hopelessness Scale, the Suicide Score Scale, the SF–36 Health Survey Questionnaire, and the General Self-Efficacy Scale. RESULTS: Patients with diabetes showed greater hopelessness and suicide ideation than internal-medicine outpatients. Poor quality of life was related to low self-efficacy, high hopelessness, and suicidality. A stepwise multiple regression found that polytherapy and older age predicted suicidality. CONCLUSION: It would be useful in future research to follow up patient samples to determine how many and which patients engage in fatal and nonfatal suicidal behavior and the relationship of these parameters with quality of life.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Suicide is a major public health problem that has proved difficult to ameliorate. The worldwide suicide rate of 16 per 100,000 per year accounts for approximately 1 million lives lost each year, or 1 death every 40 seconds. In most cases, suicide is associated with psychiatric disorder, especially affective disorders (major depressive disorder and bipolar disorder). Suicide rates are usually lower in patients with medical illnesses, but, where suicide rates are high, the presence of depression and anxiety is often implicated as a contributing risk factor.1–3

Diabetes mellitus may have profound effects on physical and emotional health and quality of life. A recent metaanalysis of 42 studies concluded that the presence of diabetes doubled the odds of comorbid depressive disorder.4 Egede et al.5 found that the coexistence of diabetes and depression was associated with a significantly increased risk of death from all causes, above and beyond that due to having either diabetes or depression alone. Furthermore, a metaanalysis found that depression is associated with poor glycemic control, leading to hyperglycemia.6

de Groot et al.7 pointed out that higher levels of depression were common in patients with more diabetes-related complications. However, depression was not associated with the type of diabetes, although the two conditions are etiologically distinct and differ in age at onset, course of illness, and treatment regimens. Thus, there may be common pathways supporting the association between depression and type 1 and type 2 diabetes.

de Grauw et al.8 found that the physical fitness of type 2 diabetes patients was clearly impaired and that their functional health status decreased significantly with the presence of comorbidity. For example, cardiovascular comorbidity and a longer duration of diabetes were especially common in type 2 diabetes patients. However, this study found no negative effect on psychosocial adjustment. An association has been documented between psychiatric disorders and nonadherence to diet, exercise, and medication in patients with both type 1 and type 2 diabetes.9 Psychiatric disorders and poor diabetes outcome have been observed in the presence of intentional self-harm, including overuse and overdose of insulin.10 Indirect self-destructive behavior is generally characterized by a long-term and cumulative impact and by the patients’ denial of any intention to harm themselves.11 Suicidal intent among patients with diabetes has often been suspected as a contributor to their misuse of medications, including deliberate overdose of insulin.11

Although the association between diabetes and depression is clearly delineated, this is not true for the association between diabetes and suicide risk. Several reports on suicide risk have presented case histories of patients with diabetes with examples of poor self-care as an indirect indicator of demoralization and self-destructive behavior,11–14 and some authors, for example, Silvestein et al.,15 citing a statement from the American Diabetic Association, warned of a possible increase in suicide risk among adolescents with type 1 diabetes. Kyvik et al.3 reported that young men with insulin-dependent diabetes mellitus were at higher risk of suicide and concluded that suicide may be underestimated as a cause of death among such patients, but the results of other studies have not been conclusive.

There are a few studies on the prevalence of suicide in people with diabetes. For example, Tseng16 followed up a cohort of 256,036 Taiwanese patients with diabetes from 1990 to 2001 and found that 0.8% of the deaths were from suicide (0.14% of the total patient cohort), and, although the study did not make a distinction between types of diabetes, the authors believed that the results largely reflected the mortality of patients with type 2 diabetes. A population-based childhood-diabetes register study17 found 7 patients with type 1 diabetes who committed suicide during the 81,600 person-years of observation.

Data are also scarce when considering differences between types of diabetes by sex and age. Wibell et al.18 found that male patients were more likely to be at risk for suicide; 9 suicides occurred, whereas only 4.5 were expected (standardized mortality ratio: 2.0; 95% confidence interval [CI]: 1.0 – 3.8). When considering differences between types of diabetes, 4 persons with type 1 diabetes committed suicide, versus 3 with type 2 diabetes ({chi}2=2.56; p=0.11).5 Goldston et al.19 reported increased suicidal ideation among adolescents with insulin-dependent diabetes mellitus that was strongly associated with serious noncompliance with their medical regimen. However, the incidence of suicide attempts as compared with the general population was not higher. Quan et al.20 found that diabetes mellitus was not associated with an increased risk of suicide in elderly subjects.

This review of the literature indicates inconsistency in the knowledge about risk of suicide in patients with diabetes, while suggesting an association between diabetes and affective mood disorders. The present study was designed to study quality of life, hopelessness, and suicide risk in a sample of patients with diabetes and to investigate the association between psychological status and clinical and social variables.

However, because the rate of suicide in those with major affective disorders is much greater than the suicide rate in the general population,21 and the association between diabetes and mood disorders may result from independent genetic risks or from the adverse side effects of psychotropic drug treatment for their depression,22 we undertook a systematic psychiatric assessment, and only patients without comorbidities with DSM–IV Axis I disorders and with no current psychotropic drug treatment were selected for the study.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
One hundred patients with diabetes (52 women, 48 men) provided written, informed consent for participation in this study. Patients were recruited from two private medical clinics in Rome, whose Institutional Review Boards reviewed and approved the study protocol. The patients’ mean age was 50.8 years (SD: 15.9; range: 16–91 years).

Diagnoses were type 1 (insulin-dependent) diabetes mellitus in 21 women and 16 men (37% of the subjects) and type 2 in 31 women and 32 men (63% of the subjects). Hypoglycemic drugs or insulin treatment had been used for more than 6 years by 62% of the subjects, for 2–6 years by 28%, and for less than 2 years by 10%. At the time of the assessment, 11.1% of the patients with type 2 diabetes were following a diet therapy, 69.8% were taking oral hypoglycemic drugs, 7.9% were taking injected insulin, and another 11.1% were following a combined therapy with oral hypoglycemic drugs or injected insulin and diet therapy. Patients with type 1 diabetes had a treatment regimen of injected insulin (89.2%) or a combined insulin plus diet therapy (10.8%).

To control for variables such as mood disorders or the side effects of psychotropic drugs,22 patients were clinically evaluated by a psychiatrist, and those with DSM–IV Axis I disorders or those currently treated with any major psychotropic drugs (i.e., antidepressants, antipsychotics, anxiolytics, lithium, or mood-stabilizers) were excluded from the study.

We used four different control groups (Table 1). For suicide risk, the patients with diabetes were compared with 100 outpatients (39 women, 61 men; mean age 54.3 [SD]: 10.4 years) who sought consultation at the internal-medicine outpatient clinic of the Sant’Andrea Hospital for a general-medical condition. The individuals, who were consecutively admitted to the outpatient departments of cardiology, gastroenterology, and pneumonology, completed the questionnaires anonymously and voluntarily.


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TABLE 1. Demographic Variables



For the SF–36, the patients were compared with two Italian groups of the IQOLA (International Quality of Life Assessment) Project,23 the first one composed of 98 patients with diabetes (52 women; 46 men) and the second composed of 2,031 individuals (1,032 women; 999 men) extracted from the general population.23 For the General Self-Efficacy Scale (GSE), the patients were compared with the Italian validation group composed of 144 professional nurses.

Assessment Instruments
Subjects were administered the Suicide Score Scale (SSS), a 12-item (Yes/No) questionnaire developed by the authors to obtain information about previous suicidal ideation, planning, or attempts, both in the previous year and lifetime. Patients were asked the following questions about the previous year: 1) Have you felt tired of living and thought that life was not worth living? 2) Have you thought that, for yourself, your family and your friends, it would be better if you were dead? 3) Have you thought of harming yourself but not to the point of dying? 4) Have you thought of ending your life? 5) Have you thought of a method for committing suicide? 6) Have you attempted suicide?

Referring to lifetime experience (excluding the last 12 months), patients were asked: 7) Have you ever felt tired of living and thought that life was not worth living? 8) Have you ever thought that, for yourself, your family, and your friends, it would be better if you were dead? 9) Have you ever thought of harming yourself, but not to the point of dying? 10) Have you ever thought of ending your life? 11) Have you ever thought of a method for committing suicide? 12) Have you ever attempted suicide?

The SSS had a Cronbach alpha ({alpha}) reliability of 0.75 for Part I and 0.80 for Part II, for 851 undergraduate students and an inter-item mean correlation of 0.35 (Part 1: 0.31; Part 2: 0.41). The SSS score correlates moderately with scores on the Reasons for Living Inventory (r = –0.32; p<0.001),24 the Zung Depression Scale (r = –0.41; p<0.001),25 and the Aggression Questionnaire (r = –0.53; p<0.001),26 indicating reasonable construct validity.

The Beck Hopelessness Scale (BHS)27 is a 20-item scale for measuring the cognitive component of the syndrome of depression. This scale assesses three major aspects of hopelessness: feelings about the future, loss of motivation, and (negative or positive) expectations. Research consistently supports a positive relationship between BHS scores and measures of depression, suicidal intent, and current suicidal ideation. Beck et al.28 carried out a prospective study of 1,958 outpatients and found that BHS scores were significantly related to eventual completed suicide. A cutoff score of ≥9 identified 16 (94%) of the 17 patients who eventually committed suicide. In a sample of 332 undergraduate students, the BHS had a moderate association with scores on the Reasons for Living Scale (RFL: r = –0.37; p<0.001) and the Zung Depression Scale (r=0.50; p<0.001), and had sufficient reliability (Cronbach {alpha}: 0.74).

The Short Form–36 Health Survey Questionnaire (SF–36)29 was administered to measure overall general health status. The SF–36 is a multipurpose, short-form health survey with 36 questions, yielding an eight-scale profile, as well as physical- and mental-health summary measures. The SF–36 is a generic measure, as opposed to one that targets a specific age, disease, or treatment group. As a result, the SF–36 has been useful both in comparing general and specific populations, differentiating the health benefits produced by a wide range of different treatments, and screening individual patients.30 Higher scores are associated with better health and quality of life.

The General Self-Efficacy Scale (GSE) is a 10-item questionnaire originally developed by Jerusalem and Schwarzer and adapted into several languages.31 A typical item is "I am confident that I could deal efficiently with unexpected events." Respondents answer items using a 4-point Likert scale, ranging from 1) Not At All True to 4) Exactly True. Scholz and colleagues,32 evaluating the scale in 25 countries, reported internal consistencies ranging from 0.75 to 0.91, with a Cronbach {alpha} higher than 0.75 for the Italian adaptation. The Italian validation sample was composed of 148 nurses, who reported an average score of 31.01 (SD: 3.94).


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Suicide Risk and Self-Efficacy
Patients with diabetes had a moderate-to-high average score for hopelessness (Table 2), with 40 patients reporting a score of ≥9 on the BHS. Patients also indicated a high percentage of suicidal ideation on the SSS (Table 2). For example, 40% of the patients reported that they had felt tired of living and thought that life was not worth living during the last 12 months, and 23% patients admitted to having thought of ending their own life. However, only one patient reported having attempted suicide during his lifetime. Compared with the general-medical control group, patients with diabetes had higher scores on two subscales of the BHS (Loss of Motivation and Future Expectations) and greater suicidality on the SSS (Table 2).


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TABLE 2. Descriptive Statistics for Suicide Risk, t-Test, Effect Sizes, and Reliability for Patients With Diabetes and Clinical Control Subjects



Women with diabetes had greater suicidality than men, both overall (3.08 [3.71] versus 1.27 [2.14]; F=8.40; p<0.01), in the last 12 months (1.56 [1.87] versus 0.73 [1.18]; F=6.64; p=0.01) and lifetime (1.52 [1.86] versus 0.54 [1.01]; F=10.07; p<0.01). Patients over the age of 50 scored higher on the BHS (8.46 [4.81] versus 6.29 [4.16]; F=5.58; p<0.05), and on two of the subscales: Feelings About the Future (1.46 [1.41] versus 0.90 [1.06]; F=5.04; p<0.05) and Future Expectations (3.10 [1.67] versus 2.21 [1.25]; F=8.49; p<0.01).

Patients with type 1 diabetes scored higher than Type 2 diabetes patients, both on the BHS (8.14 [4.18] versus 7.00 [4.84]; F=6.64; p=0.01), and on two subscales: Future Expectations (3.32 [1.36] versus 2.29 [1.53]; F=14.13; p<0.001) and Loss of Motivation (3.24 [2.25] versus 2.95 [2.39]; F=4.56; p<0.05).

Patients with diabetes had an average score of 27.23 (SD: 4.49) on general self-efficacy, and they showed significantly lower self-efficacy than the comparison subjects from the Italian validation sample (t=6.97; p<0.001; Cohen’s {delta}=0.89), indicating only moderate self-efficacy. Patients over the age of 50 reported worse self-efficacy than younger patients (26.10 [5.08] versus 28.46 [3.40]; F=6.98; p=0.01).

General Health
When comparing patients with diabetes versus the Italian IQOLA sample, the former group evidenced worse perception of their health status on all the measures (Table 3). However, compared with an Italian IQOLA sample of patients with diabetes,23 significant differences were found only in Physical Functioning and Role Limitations: Emotional (Table 3). The present sample had better physical functioning and fewer problems regarding work and social functioning due to emotional symptoms than the patients reported by Apolone and colleagues.23


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TABLE 3. Descriptive Statistics for Quality of Life: t-Tests and Effect Sizes for Comparisons Between Patients With Diabetes and Control Subjects



There was a significant effect of treatment on SF–36 scores (Wilks’ {lambda}=0.60; F=1.64; p<0.05), in particular, for Social Functioning (F=4.14; p<0.01), Role Limitations: Emotional (F=3.36; p=0.05) and Mental Health (F=5.26; p<0.01). Post-hoc Tukey’s Honestly Significant Difference tests showed that patients with combined treatment (oral hypoglycemic drugs or injected insulin and diet therapy) had lower scores on dimensions such as Social Functioning, Mental Health, and Role Limitations: Emotional, indicating a worse quality of life, more depression and nervousness, and more reporting of problems in the workplace and in social activity because of physical and emotional problems.

Patients over the age of 50 had poorer quality of life, with significantly lower scores on Physical Functioning (62.98 [28.63] versus 86.25 [19.09]; F=22.16; p<0.001), Role Limitations: Physical (38.46 [43.01] versus 64.58 [41.53]; F=9.58; p<0.01), Pain (48.83 [36.43] versus 75.25 [27.13]; F=16.60; p<0.001), Energy (47.50 [18.62] versus 55.63 [19.83]; F=4.11; p<0.05), and Social Functioning (55.53 [28.49] versus 73.96 [20.28]; F=13.53; p<0.001).

Correlations Among Variables
For the patients with diabetes, quality of life was moderately associated with lower risk of suicide and higher self-efficacy (Table 4). Having good self-efficacy is a major contributor to mental health as well as feelings of fitness and energy. On the other hand, negative feelings about the future, loss of motivation, and feeling hopeless had a negative association with quality of life. Suicidality correlated significantly with all the quality-of-life components except Physical Functioning (and this was true for both components of the SSS). When patients rated their general health as good in the last year, there were fewer negative expectations for the future and less overall hopelessness (r = –0.55; r = –0.44). Having no bodily pain was associated with perception of both good general health and vitality (r=0.60; r=0.62). Vitality had also a strong association with mental health (r=0.78), whereas mental health was associated with social functioning (r=0.51).


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TABLE 4. Correlations Among Variables



Toward a Predictive Model of Suicide Risk
In order to create a predictive model for suicide risk, a stepwise multiple regression evaluating the role of such variables as sex, age, type of diabetes, and type of therapy was performed. We found that type of therapy and age explained 8% and 13%, respectively, of the total variance, both statistically significant. Statistical analysis revealed two additional predictive models: 1) polytherapy predicted suicide risk (t=3.0; p<0.01), and 2) the age of patients (>50 years) predicted hopelessness (t=2.25, p=0.05).


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
This study investigated suicide risk and quality of life among patients diagnosed with diabetes mellitus. The patients with diabetes had greater loss of motivation, worse future expectations, and higher suicidality than internal-medicine outpatients. Patients with diabetes mellitus had moderate-to-high scores on a hopelessness index, with 40% scoring ≥9, the threshold above which suicide risk is dramatically increased.28

The results are not wholly consistent with the warnings of Kyvik et al.3 and Silvestein et al.15 of a possible increase in suicide risk among adolescents with type 1 diabetes. Variables relating to individuals and treatment variables were both related to hopelessness and suicide risk, but women, patients over age 50, and patients affected by type 1 diabetes mellitus showed a higher risk for hopelessness and suicidal ideation. Only polytherapy and being over age 50 predicted hopelessness.

However, only one patient with diabetes had made an earlier suicide attempt. It appears, therefore, that suicidal ideation may often be present in patients with diabetes, but that, at least in the present sample, suicidal acts (fatal and nonfatal) may not be common.

The results indicated that patients with diabetes perceive a poor quality of life caused by their physical limitations, physical pain, and emotional symptoms. The perceived quality of life relates to individuals’ adjustment: individuals who described themselves with better health also reported less hopelessness and suicidal ideation. Moreover, having high self-efficacy was a major contributor to emotional and physical healthiness: individuals with high general self-efficacy depicted themselves as more energetic and socially satisfied.

The present study was limited by the small sample size and the low frequency of attempted and completed suicide. This necessitated a reliance on self-report of suicidal ideation, which may not be a valid measure of the degree of suicide risk. However, although the mean hopelessness score was below the recommended cut-off score for high suicide risk, the elevated hopelessness levels and high frequency of suicidal ideation in the patients with diabetes, as compared with the control subjects, suggests that physicians working with diabetes patients should consider treating any accompanying depression and hopelessness. Patients who are less depressed and hopeless may better adhere to the treatment regimen, and their elevated mood may improve their physiological response to treatment. Furthermore, the Beck Hopelessness Scale has never been validated in this particular population. Also, the Suicide Score Scale was developed for the purpose of this research, and validation data for this instrument are not available at this stage.

One important limitation in studies involving patients with diabetes regards how clinicians, patients with diabetes, and the general public perceive the effect that diabetes has on quality of life. Landy et al.33 concluded that, in their samples, clinicians tended to overemphasize the effect that diabetes had on quality of life as compared with patients without diabetes and the general public. This finding is important because it points to the fact that clinicians are aware of the comorbidities that occur secondary to prolonged diabetes. The opposite has been found among patients with multiple sclerosis, who have been found to score lower on the SF–36 questionnaire,34 suggesting that these patients had a lower quality of life than their clinicians perceived.

It would be useful in future research to follow up samples of this type of patient to see how many and which patients do engage in fatal and nonfatal suicidal behavior. Future studies should also be carried out with scheduled follow-up visits so as to monitor changes in suicide risk and the occurrence of attempted and completed suicide as well as quality of life. A focus on these issues may help the understanding of the interplay of factors involved in the health status of individuals suffering from diabetes.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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