Does Home Glucose Monitoring Make Diabetic Patients Depressed?
Abstract & Commentary
By Joseph E. Scherger, MD, MPH, Clinical Professor, University of California, San Diego. Dr. Scherger reports no financial relationship to this field of study.
Synopsis: A randomized controlled trial of newly diagnosed type 2 diabetic patients not on insulin showed an increased depression score in those performing home glucose monitoring and no improvement in glycemic control.
Source: O'Kane MJ, et al. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): Randomised controlled trial. BMJ 2008;336:1174-1177.
Recent studies, including a meta-analysis,1 have questioned the value of home glucose monitoring in type 2 diabetic patients not on insulin. Controlled trials have shown that when patients come for visits quarterly, with measurement of HbA1c, there appears to be no additional benefit of home glucose testing, a well established practice that is very expensive. Previous studies on home monitoring have used established diabetic patients and have only focused on the issue of control and not the impact monitoring may have on the experience of having diabetes.
O'Kane et al in Northern Ireland randomized 184 patients with newly diagnosed type 2 diabetes for treatment according to established protocol beginning with lifestyle change and metformin, with the monitoring group also being instructed in home glucose testing and the control group not testing. The monitoring group was asked to check four fasting and four postprandial blood sugar measurements each week. Both groups came in every three months for one year and the outcome measures were: HbA1c, medication review, body mass index, reported hypoglycemic rates, and a well-being questionnaire (psychological index).
Both groups improved their HbA1c over the 12 months. The baseline HbA1c in the monitoring group was 8.8% and in the control group 8.6%. Both groups achieved an average HbA1c of 6.9%. There was no difference between the groups in medication compliance and BMI measurement. However the monitoring group had a 6% higher score on the depression subscale of the well-being questionnaire (P = 0.01).
Commentary
This study adds to the growing literature that home glucose monitoring of patients with type 2 diabetes not on insulin gives no added benefit to control of the disease. This study provides new information suggesting that home glucose monitoring may do harm by increasing the rate of depression.
Depression is a major comorbidity in diabetic patients. A person's well-being is profoundly affected by a chronic illness. There is a loss of normalcy with a chronic illness that has a pervasive impact on the patient's life. Diabetes is a chronic illness that must be considered at every meal throughout the day. It may be that home glucose monitoring intensifies the patient's focus on the disease and contributes to depression.
In 2005, I reviewed a meta-analysis on home glucose monitoring for Internal Medicine Alert and suggested that we become more practical with our type 2 diabetic patients and request less home testing.2 This more recent study did not use the multiple daily testing that is common practice. The monitoring patients were only asked to check their blood sugars eight times a week, four fasting and four postprandial measurements. Even this frequency contributed to an increased rate of depression.
One study of this size and location does not prove that home glucose monitoring contributes to depression among type 2 diabetic patients, but the results are suggestive. My own practice has changed since 2005 to not recommend home testing in patients not on insulin. One might question the need for home testing in patients receiving a single bedtime dosage of basal insulin once control has been established. Certainly frequent and persistent testing may not have benefit that exceeds the harm uncovered by this study. This study is also an important reminder that we must always be cognizant of the impact our management has on the patients' experience of their disease and on potential underlying depression.
References
1. Welschen LM, et al. Self-monitoring of blood glucose in patients with type 2 diabetes who are not using insulin: A systemic review. Diabetes Care 2005;28:1510-1517.
2. Scherger JE. Getting practical with monitoring in type 2 diabetes. Intern Med Alert 2005;27:163-164.
A randomized controlled trial of newly diagnosed type 2 diabetic patients not on insulin showed an increased depression score in those performing home glucose monitoring and no improvement in glycemic control.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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