Association between Major Depression and Type 2 Diabetes Mellitus: a Meta-Analysis and Meta-Regression of Observational Studies


  • Abigail Lopes Universidade do Extremo Sul Catarinense (UNESC)
  • Ingrid Schweigert Perry Universidade do Extremo Sul Catarinense (UNESC)
  • Daniela Vicente Bavaresco Universidade do Extremo Sul Catarinense (UNESC)
  • Lisiane Tuon Universidade do Extremo Sul Catarinense (UNESC)
  • Luciane Bisognin Ceretta Universidade do Extremo Sul Catarinense (UNESC)
  • Priscyla Waleska Simões Universidade do Extremo Sul Catarinense (UNESC)
  • Rita Suselaine Vieira Ribeiro Universidade do Extremo Sul Catarinense (UNESC)



Type 2 Diabetes Mellitus, Major Depressive Disorder, Systematic Review, Meta-analysis, Evidence-Based Practice.


The purpose of this review was to identify the prevalence of major depression in individuals with type 2 diabetes by means of a systematic review and meta-analysis. An electronic search was conducted for relevant studies published from January 1988 to December 2014. Cross-sectional and case-control studies in adults that evaluated the prevalence of major depression in individuals with type 2 Diabetes Mellitus were included. Meta-regression and sensitivity analyses were used to identify the sources of heterogeneity. Publication bias was assessed using a funnel plot and Egger’s test. After the selection process, 18 cross-sectional and four case-control studies were included in the meta-analysis. In total, the occurrence of major depression was investigated in 5554 patients with diabetes mellitus type 2. The prevalence of major depression varied from 6.67% (95% CI: 4.54% - 9.38%) to 55.38% (95% CI: 42.53% - 67.73%), with an overall average of 21.13% (95% CI: 15.80% -27.66%). In American continents, the prevalence was 20.83% (95% CI: 13.12% -31.43%; I²=96.8%), and in Europe it was 18.00% (95% CI: 8.58% -33.91%; I²=93.8%). Both were lower than the rate in Asia, which was 23.49% (95% CI: 15.63% -33.74%; I²=90.8%). Meta-regression analysis found no evidence that the analyzed cofactors represented the cause of the heterogeneity seen. The approximately symmetrical distribution of the points in Funnel Plot suggests an absence of publication bias that was confirmed by Egger's test (p=0.2345). Based on the data collected, we can infer that the prevalence of major depression in individuals with type 2 diabetes was high, independent of geographic location.


Ashcroft FM, Rorsman P. Diabetes mellitus and the beta cell: the last ten years. Cell. 2012;148(6):1160-71.

Ali S, Stone MA, Peters JL, Davies MJ, Khunti K. The prevalence of co-morbid depression in adults with Type 2 diabetes: a systematic review and meta-analysis. Diabet Med. 2006;23(11):1165-73.

Barnard KD, Skinner TC, Peveler R. The prevalence of co-morbid depression in adults with Type 1 diabetes: systematic literature review. Diabet Med. 2006;23(4):445-8.

American Psychiatry Association. Diagnostic and Statistical Manual of Mental disorders - DSM-5. 5th ed. Washington: American PsychiatricAssociation; 2013.

Mezuk B, Eaton WW, Albrecht S, Golden SH. Depression and type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care. 2008;31(12):2383-90.

Nouwen A, Winkley K, Twisk J, Lloyd CE, Peyrot M, Ismail K, et al. Type 2 diabetes mellitus as a risk factor for the onset of depression: a systematic review and meta-analysis. Diabetologia. 2010;53(12):2480-6.

Nouwen A, Nefs G, Caramlau I, Connock M, Winkley K, Lloyd CE, et al. Prevalence of depression in individuals with impaired glucose metabolism or undiagnosed diabetes: a systematic review and meta-analysis of the European Depression in Diabetes (EDID) Research Consortium. Diabetes Care. 2011;34(3):752-62.

Black SA, Markides KS, Ray LA. Depression predicts increased incidence of adverse health outcomes in older Mexican Americans with type 2 diabetes. Diabetes Care. 2003;26(10):2822-8.

Scherrer JF, Garfield LD, Chrusciel T, Hauptman PJ, Carney RM, Freedland KE, et al. Increased risk of myocardial infarction in depressed patients with type 2 diabetes. Diabetes Care. 2011;34(8):1729-34.

Zhang X, Norris SL, Gregg EW, Cheng YJ, Beckles G, Kahn HS. Depressive symptoms and mortality among persons with and without diabetes. Am J Epidemiol. 2005;161(7):652-60.

Justo LP, Calil HM. Depression – does it affect equally men and women? Arch clin psychiatry (São Paulo, Impr). 2006:74-9.

Boing AF, Melo GR, Boing AC, Moretti-Pires RO, Peres KG, Peres MA. [Association between depression and chronic diseases: results from a population-based study]. Rev Saude Publica. 2012;46(4):617-23.

Cooper JK, Harris Y, McGready J. Sadness predicts death in older people. J Aging Health. 2002;14(4):509-26.

DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000;160(14):2101-7.

Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24(6):1069-78.

Gavard JA, Lustman PJ, Clouse RE. Prevalence of depression in adults with diabetes. An epidemiological evaluation. Diabetes Care. 1993;16(8):1167-78.

Hasan SS, Clavarino AM, Mamun AA, Doi SA, Kairuz T. Population impact of depression either as a risk factor or consequence of type 2 diabetes in adults: a meta-analysis of longitudinal studies. Asian J Psychiatr. 2013;6(6):460-72.

.Roy T, Lloyd CE. Epidemiology of depression and diabetes: a systematic review. J Affect Disord. 2012;142 Suppl:S8-21.

Deeks JJ BP, Gatsonis C. Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy Version 1.0.0.: The Cochrane Collaboration; 2009.

Egger M, Smith GD, Altman D. Systematic reviews in health care: meta-analysis in context.: John Wiley& Sons; 2008.

Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. Bmj. 2003;327(7414):557-60.

Huedo-Medina TB, Sanchez-Meca J, Marin-Martinez F, Botella J. Assessing heterogeneity in meta-analysis: Q statistic or I2 index? Psychol Methods. 2006;11(2):193-206.

DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177-88.

Deville WL, Buntinx F, Bouter LM, Montori VM, de Vet HC, van der Windt DA, et al. Conducting systematic reviews of diagnostic studies: didactic guidelines. BMC Med Res Methodol. 2002;2:9.

Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. Bmj. 1997;315(7109):629-34.

Sterne JA, Egger M. Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis. J Clin Epidemiol. 2001;54(10):1046-55.

Langan D, Higgins JP, Gregory W, Sutton AJ. Graphical augmentations to the funnel plot assess the impact of additional evidence on a meta-analysis. J Clin Epidemiol. 2012;65(5):511-9.

Sterne JA, Sutton AJ, Ioannidis JP, Terrin N, Jones DR, Lau J, et al. Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. Bmj. 2011;343:d4002.

Whiting PF, Sterne JA, Westwood ME, Bachmann LM, Harbord R, Egger M, et al. Graphical presentation of diagnostic information. BMC Med Res Methodol. 2008;8:20.

Dirmaier J, Watzke B, Koch U, Schulz H, Lehnert H, Pieper L, et al. Diabetes in primary care: prospective associations between depression, nonadherence and glycemic control. Psychother Psychosom. 2010;79(3):172-8.

Kokoszka A, Pouwer F, Jodko A, Radzio R, Mucko P, Bienkowska J, et al. Serious diabetes-specific emotional problems in patients with type 2 diabetes who have different levels of comorbid depression: a Polish study from the European Depression in Diabetes (EDID) Research Consortium. Eur Psychiatry. 2009;24(7):425-30.

Merlino G, Valente M, Serafini A, Fratticci L, Del Giudice A, Piani A, et al. Effects of restless legs syndrome on quality of life and psychological status in patients with type 2 diabetes. Diabetes Educ. 2010;36(1):79-87.

Bai YL, Chiou CP, Chang YY, Lam HC. Correlates of depression in type 2 diabetic elderly patients: a correlational study. Int J Nurs Stud. 2008;45(4):571-9.

Khamseh ME, Baradaran HR, Javanbakht A, Mirghorbani M, Yadollahi Z, Malek M. Comparison of the CES-D and PHQ-9 depression scales in people with type 2 diabetes in Tehran, Iran. BMC Psychiatry. 2011;11:61.

Madhu M, Abish A, Anu K, Jophin RI, Kiran AM, Vijayakumar K. Predictors of depression among patients with diabetes mellitus in Southern India. Asian J Psychiatr. 2013;6(4):313-7.

Makine C, Karsidag C, Kadioglu P, Ilkova H, Karsidag K, Skovlund SE, et al. Symptoms of depression and diabetes-specific emotional distress are associated with a negative appraisal of insulin therapy in insulin-naive patients with Type 2 diabetes mellitus. A study from the European Depression in Diabetes [EDID] Research Consortium. Diabet Med. 2009;26(1):28-33.

Raval A, Dhanaraj E, Bhansali A, Grover S, Tiwari P. Prevalence & determinants of depression in type 2 diabetes patients in a tertiary care centre. Indian J Med Res. 2010;132:195-200.

Yoshida S, Hirai M, Suzuki S, Awata S, Oka Y. Neuropathy is associated with depression independently of health-related quality of life in Japanese patients with diabetes. Psychiatry Clin Neurosci. 2009;63(1):65-72.

Badawi G, Page V, Smith KJ, Gariepy G, Malla A, Wang J, et al. Self-rated health: a predictor for the three year incidence of major depression in individuals with Type II diabetes. J Affect Disord. 2013;145(1):100-5.

Colunga-Rodriguez C, Alva JEG, Salazar-Estrada JG, Ãngel-González M. Diabetes Tipo 2 y Depresión em Guadalajara, México. RevSalud Publica. 2008:137-49.

De la Roca-Chiapas JM, Hernandez-Gonzalez M, Candelario M, Villafana Mde L, Hernandez E, Solorio S, et al. Association between depression and higher glucose levels in middle-aged Mexican patients with diabetes. Rev Invest Clin. 2013;65(3):209-13.

Fisher L, Glasgow RE, Strycker LA. The relationship between diabetes distress and clinical depression with glycemic control among patients with type 2 diabetes. Diabetes Care. 2010;33(5):1034-6.

Fu-Espinosa M, Trujillo-Olivera LE. Depressive disorder and issues related to DiabetIMSS beneficiaries. Rev Med Inst Mex Seguro Soc. 2013;51(1):80-5.

Kogan SM, Brody GH, Chen YF. Depressive symptomatology mediates the effect of socioeconomic disadvantage on HbA(1c) among rural African Americans with type 2 diabetes. J Psychosom Res. 2009;67(4):289-96.

Moreira RO, Papelbaum M, Fontenelle LF, Appolinario JC, Ellinger VC, Coutinho WF, et al. Comorbidity of psychiatric disorders and symmetric distal polyneuropathy among type II diabetic outpatients. Braz J Med Biol Res. 2007;40(2):269-75.

Skaff MM, Mullan JT, Almeida DM, Hoffman L, Masharani U, Mohr D, et al. Daily negative mood affects fasting glucose in type 2 diabetes. Health Psychol. 2009;28(3):265-72.

Wagner JA, Tennen H, Osborn CY. Lifetime depression and diabetes self-management in women with Type 2 diabetes: a case-control study. Diabet Med. 2010;27(6):713-7.

Adriaanse MC, Dekker JM, Heine RJ, Snoek FJ, Beekman AJ, Stehouwer CD, et al. Symptoms of depression in people with impaired glucose metabolism or Type 2 diabetes mellitus: The Hoorn Study. Diabet Med. 2008;25(7):843-9.

Shehatah A, Rabie MA, Al-Shahry A. Prevalence and correlates of depressive disorders in elderly with type 2 diabetes in primary health care settings. J Affect Disord. 2010;123(1-3):197-201.

Thomas J, Jones G, Scarinci I, Brantley P. A descriptive and comparative study of the prevalence of depressive and anxiety disorders in low-income adults with type 2 diabetes and other chronic illnesses. Diabetes Care. 2003;26(8):2311-7.

Viinamaki H, Niskanen L, Uusitupa M. Mental well-being in people with non-insulin-dependent diabetes. Acta Psychiatr Scand. 1995;92(5):392-7.

Maudsley H. The patology of mind. 3 ed. New York: Appleton; 1979.

Leedom L, Meehan WP, Procci W, Zeidler A. Symptoms of depression in patients with type II diabetes mellitus. Psychosomatics. 1991;32(3):280-6.

Tavano-Colaizzi L, Arroyo P, Loria A, Perez-Lizaur AB, Perez-Zepeda MU. Clinimetric testing in mexican elders: associations with age, gender, and place of residence. Front Med (Lausanne). 2014;1:36.

Katon WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry. 2003;54(3):216-26.

American Diabetes Association. Diagnosis and Classification of Diabetes Mellitus: Diabetes Care; 2010.

The International Expert Committee. International Expert Committee Report on the Role of the A1C Assay in the Diagnosis of Diabetes: Diabetes Care; 2009.

Ismail-Beigi F. Pathogenesis and glycemic management of type 2 diabetes mellitus: a physiological approach. Arch Iran Med. 2012;15(4):239-46.

Klein S, Sheard NF, Pi-Sunyer X, Daly A, Wylie-Rosett J, Kulkarni K, et al. Weight management through lifestyle modification for the prevention and management of type 2 diabetes: rationale and strategies: a statement of the American Diabetes Association, the North American Association for the Study of Obesity, and the American Society for Clinical Nutrition. Diabetes Care. 2004;27(8):2067-73.

Gross R, Olfson M, Gameroff MJ, Carasquillo O, Shea S, Feder A, et al. Depression and glycemic control in Hispanic primary care patients with diabetes. J Gen Intern Med. 2005;20(5):460-6.

Lustman PJ, Clouse RE, Griffith LS, Carney RM, Freedland KE. Screening for depression in diabetes using the Beck Depression Inventory. Psychosom Med. 1997;59(1):24-31.

Zauszniewski JA, Chung C, Krafcik K, Sousa VD. Psychometric testing of the depressive cognition scale in women with type 2 diabetes. J Nurs Meas. 2001;9(1):61-72.

Williams JW, Jr., Pignone M, Ramirez G, Perez Stellato C. Identifying depression in primary care: a literature synthesis of case-finding instruments. Gen Hosp Psychiatry. 2002;24(4):225-37.

Arnarson TO, Olason DT, Smari J, Sigurethsson JF. The Beck Depression Inventory Second Edition (BDI-II): psychometric properties in Icelandic student and patient populations. Nord J Psychiatry. 2008;62(5):360-5.

Allen J, Annells M. A literature review of the application of the Geriatric Depression Scale, Depression Anxiety Stress Scales and Post-traumatic Stress Disorder Checklist to community nursing cohorts. J Clin Nurs. 2009;18(7):949-59.

Kroenke K, Spitzer RL, Williams JB, Lowe B. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry. 2010;32(4):345-59.

Segal DL. Diagnostic Interview Schedule for DSM-IV (ADIS-IV); 2010.






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