Original Articles & Case Reports http://dx.doi.org/10.4093/jkd.2013.14.1.46 연세대학교의과대학강남세브란스병원내분비대사내과 1, 정신건강의학과 2 이영미 1, 이현정 1, 권은진 1, 하지윤 1, 김민경 1, 노태웅 1, 강신애 1, 박종숙 1, 석정호 2, 안철우 1, 김경래 1 Association Between Blood Sugar Level, Psychological Impact, and Emotional Symptoms in Patients Newly Diagnosed with Diabetes Young Mi Lee 1, Hyung Jung Lee 1, Eun Jin Kwon 1, Ji Yoon Ha 1, Min Kyung Kim 1, Tae woong Noh 1, Shinae Kang 1, Jong Suk Park 1, Jeong Ho Seok 2, Chul Woo Ahn 1, Kyung Rae Kim 1 1 Division of Endocrinology, Department of Internal Medicine, Endocrinology and Diabetes Center, 2 Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea 46 Abstract As the duration of diabetes mellitus (DM) increases, the risk of complications increases and the prevalence of depression becomes higher. Most studies on depression in Korean patients with DM have focused on a point 5-10 years after diagnosis, and there has not been much data reported regarding the early stages of DM, including newly developed DM. In this study, we examined whether blood glucose levels could be associated with emotional symptoms such as depression (DS) and anxiety (AS) in patients newly diagnosed with DM. Serum glucose and HbA1c were measured in 89 patients with DM. The Impact of Event Scale (IES) was used to investigate the extent of the psychological impact of a diagnosis of DM. The IES comprises four elements: hyperarousal, intrusiveness, avoidance, and sleep problems. DS and AS were investigated using the Hospital Anxiety and Depression Scales. DS was observed in 32 patients (36%) and AS was observed in 21 patients (23.6%), indicating a higher prevalence of DS and AS than in the general population. There was an inverse correlation between HbA1c and DS (Pearson s correlation coefficient: R = -0.227; P = 0.035), but no correlation was found for AS. The four elements of the IES had significant correlations with DS and AS. Logistic regression analysis showed that sleep problems (OR = 1.437) and HbA1c (OR = 0.51) were associated with DS, but only intrusiveness (OR = 0.629) showed a correlation with AS. In patients newly diagnosed with DM, DS is associated with sleep problems and low HbA1c levels. Emotional symptoms should be considered as part of glucose control, and efforts to mitigate psychological stress during the initial period of diabetes management should be made. (J Korean Diabetes 2013;14:46-53) Keywords: Anxiety, Depression, Diabetes mellitus 서론 당뇨병은말초에서의인슐린저항성및췌장베타세포에서인슐린분비저하등의원인으로고혈당이생기게되고, 이로인해여러가지합병증을초래하는심각한 만성질환이다. 2010 년보고에따르면당뇨병의유병률은성인의약 10% 이고, 당뇨병전단계인공복혈당장애의유병률은약 20% 에달하는것으로알려져있다 [1]. 당뇨병을진단받은환자는인슐린자가주사및하루 교신저자 : 안철우, 서울시강남구언주로 211 연세대학교의과대학강남세브란스병원내과학교실 E-mail: ACW@yuhs.ac 석정호, 서울시강남구언주로 211 연세대학교의과대학강남세브란스병원정신과학교실 E-mail: JOHNSTEIN@yuhs.ac
수차례의자가혈당측정으로인한스트레스및심리적부담감이우울및불안증상을유발할수있으며 [2], 질환자체의증상및합병증으로인한정신질환의유병률도증가하는것으로알려져있다 [3,4]. 또한이러한스트레스와정신질환이혈당조절에좋지않은영향을끼치게되고, 불량한혈당조절은여러가지신체적합병증을유발하여악순환을초래할수있다. 일반적으로, 당뇨병환자에서우울증의유병률은일반인구에비해두배정도높은것으로알려져있다 [5]. 제 2 형당뇨병과우울증은환경및유전적원인뿐만아니라, 인슐린저항성과같은다양한병인을가지는질환이다 [2]. 우울증과당뇨병의관계에대해서는여러가지연구가진행되어왔는데, 일부연구에서는불량한혈당조절이기분변화와같은정동에영향을끼친다는것을증명하였다 [6,7]. Lustman 등은제 1 형당뇨병환자에서고혈당이불안증상을가중시킬수있다는가설을제시한바있으며 [6], Testa 등은제 2 형당뇨병환자에서혈당조절이호전되면우울증상이호전된다고기술하였다 [7]. 또다른연구에서는우울증상이있는환자에서우울증상이없는환자에비해인슐린저항성이증가되어있음을보고하였는데, 경구 Table 1. Baseline characteristics of the subjects Variables Mean or n (%) 49.2 ± 10.6 20-29 3 (3.4) 30-39 12 (13.5) 40-49 32 (36.0) 50-59 24 (27.0) 60-69 18 (20.2) Sex FPG (mg/dl) HbA1c (%) HADS-a HADS-d voidance Intrusiveness Male Female 15-20 20-25 25-30 30-35 포도당부하검사에서고인슐린혈증이있는환자일수록우울증상이심한것을통해이를증명하였다 [2,8,9]. 당뇨병환자에서는일반인구에비해상대적으로높은비율로우울증상을호소함에도불구하고실제로우울증을진단받고, 치료까지받게되는환자는많지않아, 당뇨병환자에서의우울증의진단및치료의병행이필수적이나많은수에서그중요성이간과되고있다는사실을알수있다 [10]. 한연구에의하면중등도이상의우울증상을보인그룹에서, 당화혈색소가 8% 이상으로혈당조절이불량한환자의비율이 55% 에달하여, 약한우울증상이나, 우울증상이없었던그룹에비하여, 혈당조절이잘되지않은환자의비율이높은것으로보고된바있다 [11]. 당뇨병의유병기간이길면합병증의빈도가증가하게되고, 우울증의발병에영향을끼칠수있는데 [12], 이전의한국인당뇨병환자에대한연구는주로평균당뇨병유병기간이 5~10 년정도인환자를대상으로한반면 [13,14], 처음당뇨병을진단받은환자의정서적특성에대해기술한연구는많지않았다. 이에저자들은당뇨병을처음진단받은환자를대상으로하여당뇨병진단시점에서의혈당조절정도와 64 (72) 25 (28) 166.7 ± 54.9 8.6 ± 2.1 25.6 ± 3.5 2 (2.2) 42 (47.2) 37 (41.6) 8 (9.0) 5.3 ± 3.1 6.1 ± 3.3 11.0 ± 9.5 11.0 ± 7.3 5.9 ± 5.3 5.3 ± 4.7 FPG, fasting plasma glucose; HbA1c, hemoglobin A1c;, body mass index; HADS-a, average scores for anxiety subscale of the Hospital Anxiety and Depression Scale; HADS-d, average scores depression subscale of the Hospital Anxiety and Depression Scale. 47
Original Articles & Case Reports 우울및불안증상과의연관성을알아보고자한다. 또한당뇨병진단이라는사건을받아들이는정도는환자마다모두다를수있는데, 이를사건충격척도라는설문조사법을이용하여당뇨병을진단받은환자에서의심리적충격과우울및불안증상과의연관성에대해살펴봄으로써당뇨병을처음진단받은환자에서의정서증상과관련된임상적특성을기술하고자한다. 또한이러한특성이기존에주로연구되었던유병기간이긴당뇨병환자에서의특성과어떠한차이가있는지확인하고자한다. 대상및방법 1. 당뇨병환자및임상학적분석 대상으로연구를진행하였다. 모든참여자에게설문을시작하기전에연구의목적및의의에대해내분비내과의사가직접설명하였고, 모든참가자에게사전동의를얻어채혈및설문조사를시행하였다. 이연구는연세대학교강남세브란스병원연구윤리위원회의승인을받아진행하였다. 채혈은당뇨병을진단받은시점으로부터 2 주이내에 8 시간공복상태에서시행하였으며, 혈중포도당농도는표준포도당산화법으로측정하였고 (747 Automatic Analyzer, Hitachi, Tokyo, Japan) 당화혈색소는면역혼탁법 (Cobas integra 800, Roche, Mannheim, Germany) 으로측정하였다 (National Glycohemoglobin Standardization Program Certified method, inter- & intra-assay CV, 2.4% & 2.3%). 48 2010 년부터 2011 년까지강남세브란스병원에내원해제 2 형당뇨병을처음진단받은 20 세이상의환자를대상으로하였다. 제 2 형당뇨병의진단기준은아래의네가지중한가지이상이 2 회이상만족하는경우로정의하였다. 1) 공복혈당 126 mg/dl, 2) 75g 경구포도당부하검사후 2 시간혈당 200 mg/dl, 3) 당뇨병의전형적인증상이있으면서임의혈당이 200 mg/dl 이상, 4) 당화혈색소 6.5%[15] 우울증등의정신과적병력이있거나, 암, 말기콩팥병증, 급성심근경색이나간경화등과같이우울증상에영향을미칠수있는급성, 만성의중대한질병이있는경우는제외하였다. 총 110 명의환자중채혈을거부하였거나, 불성실한설문지작성으로자료의신뢰성이의심되는경우, 연구기간중연구참여를거부한환자 21 명을제외하여최종 89 명의환자를 2. 정서증상및진단에따른심리적충격의평가 연구대상자의정신적스트레스를우울증상및불안증상그리고당뇨병을처음진단받았을때환자가느끼는충격정도의세가지측면에서분석하고자하였다. 우울증상과불안증상은병원불안우울척도 (HADS[16]) 를이용해서조사하였으며, 처음진단시의충격정도는사건충격척도 (I E S[17]) 를사용해서설문조사를실시하였다. HADS 는신체질환이있는환자들의우울과불안증상의정도를평가하는데널리쓰이는질문지로서총 14 개의문항으로구성되어있으며그중 7 개는우울증상 (HADS-d) 을, 그리고 7 개는불안증상 (HADS-a) 에대한질문들을포함하고있다. 각증상의점수는최저 0 에서최고 21 점까지이며우울, 불안증상이심할수록점수가높다. 8 점이상의높은 Table 2. T-test comparisons between newly diagnosed diabetic patients who have HADS-d scores of less than 8 and more than or equal to 8 No. Sex (M:F) HbA1c (%) FPG (mg/dl) Avoidance Intrusion HADS-d < 8 HADS-d 8 P value 57 40 : 17 47.1 ± 10.8 25.3 ± 2.9 8.7 ± 2.8 158.3 ± 74.1 8.1 ± 7.5 9.3 ± 6.2 4.7 ± 4.5 3.7 ± 3.7 32 24 : 8 52.9 ± 9.2 26.3 ± 4.5 7.8 ± 1.5 155.6 ± 48.9 16.1 ± 10.6 13.9 ± 8.3 7.9 ± 5.8 8.1 ± 5.1 0.81 0.01 0.33 0.002 0.853 0.001 0.009 0.004 0.001 Values are presented as mean ± SD or number (%). FPG, fasting plasma glucose; HbA1c, hemoglobin A1c;, body mass index; HADS-a, average scores for anxiety subscale of the Hospital Anxiety and Depression Scale; HADS-d, average scores depression subscale of the Hospital Anxiety and Depression Scale.
점수는임상적으로의미있는불안과우울증상을판단하는기준점이된다 [18]. 사건충격척도 (IES) 는특정충격을겪은뒤의주관적스트레스의정도를평가하기위한질문지로, 침습 (intrusiveness) 7 항목과, 회피 (avoidance) 8 항목, 수면문제 (sleep problem) 와관련된 2 개의항목및과다각성 (hyperarousal) 5 항목의총 22 문항, 5 점척도 (0~4 점 ) 로구성되어있다. 이연구에서모든연구참여자는당뇨병을진단받은시점으로부터 2 주이내에 HADS 와 IES 를이용한설문조사를받았다. 3. 자료분석 연속형변수의분석을위해 t- 검정을, 범주형자료의분석을위해 χ2 검정을시행하였다. 두연속형변수간의상관관계를확인하기위해피어슨상관분석을시행하였고로지스틱회귀분석을이용하여우울, 불안증상유무에영향을주는유의한요인들을확인하였다. 수집된자료의분석은 Statistical Package for the Social Sciences (SPSS), version 19.0 for Windows 프로그램을사용하였으며, 통계적유의수준은 P < 0.05 로하였다. 결과 1. 연구참여자의일반적특성 연구에참여한당뇨병을처음진단받은환자들의전반적인특성을확인하기위해평균분석및빈도분석을시행하였다 (Table 1). 전체 89 명의환자중성별은남자가 72% 로여자보다많았으며평균나이는약 49 세로나타났는데그중 40 대와 50 대가가장많은비율을차지하였다. HADS 로측정된불안점수및우울점수의평균은모두 8 점이하로측정되어, 연구참여자전반적으로불안증상및우울증상은심하지않은 것으로나타났다. 2. 혈당조절정도와사건충격척도가우울증상에미치는영향 전체 89 명의환자중 32 명 (36%) 의환자가 HADS-d 점수 8 점이상이었으며, 그중 9 명 (10%) 는 HADS-d 11 점이상에해당하는것으로나타났다. HADS-d 8 점을기준으로, 임상적으로유의한우울증상을보이는그룹과, 우울증상을보이지않는그룹으로나누어서두그룹의특성및차이를확인하였다 (Table 2). 두그룹간성별및 의차이는없었으며, 우울증상이있는그룹의평균연령이우울증상이없는그룹의평균연령보다높은것으로나타났다. 환자들의공복혈당수치는두그룹간차이를보이지않았으나, 당화혈색소는우울증상을보이는환자군의평균값이우울증상을보이지않는환자군의평균값보다낮은결과를보였다. 또한사건충격척도의세부인자와우울증상과의관계를보면, 과다각성, 회피, 침습, 수면문제의네가지항목에대한각각의점수가우울증상이있는그룹에서유의하게높은것을확인할수있었다. 다음으로당뇨병진단당시의혈당수준및진단에따른심리적충격과우울증상간의연관성을확인하기위해당화혈색소값및사건충격척도의네가지요소와우울증상간의피어슨상관분석을시행하였다. 분석결과당화혈색소값과우울증상간상관계수 R = -0.227 (P = 0.035) 로유의미한음의상관관계를확인할수있었고, 사건충격척도의요소와우울증상간에는과다각성 (R = 0.363, P < 0.001), 회피 (R = 0.219, P = 0.039), 침습 (R = 0.257, P = 0.015) 과수면문제 (R = 0.419, P < 0.001) 모두에서유의미한상관관계를확인할수있었다. 마지막으로우울증상과, 우울증상에영향을미칠수있는나이, 당화혈색소,, 과다각성, 회피, 침습, 수면의변수간의상호작용을확인하기위해로지스틱 49 Table 3. Odds ratio for the prediction of depression symptom in logistic regression model HbA1c Avoidance Intrusion β Odds ratio 95% confidence interval P value 0.063 0.236-0.677-0.211 0.132 0.146 0.363 1.065 1.266 0.508 0.81 1.141 1.158 1.437 0.977-1.160 0.901-1.779 0.264-0.977 0.571-1.148 0.822-1.585 0.899-1.491 1.020-2.025 0.152 0.175 0.042 0.237 0.431 0.257 0.038 Adjusted for age, HbA1C,, hyperarousal, avoidance, intrusion and sleep problem., body mass index; HbA1c, hemoglobin A1c.
Original Articles & Case Reports 회귀분석을시행하였다 (Table 3). 분석결과, 우울증상은수면문제와통계적으로유의한상관관계를가졌으며, 당화혈색소와는음의상관관계를가지는것으로확인되었다. 3. 혈당조절정도와사건충격척도가불안증상에끼치는영향 < 0.001) 모두에서의미있는상관관계를확인할수있었다. 마지막으로불안증상과, 불안증상에영향을미칠수있는나이, 당화혈색소,, 과다각성, 회피, 침습, 수면문제의변수간의상호작용을확인하기위해로지스틱회귀분석을시행하였다 (Table 5). 분석결과, 침습만이불안증상에영향을미치는변수로확인되었다. 50 전체 89 명의환자중 21 명 (23.6%) 의환자가 HADS-a 점수 8 점이상이었으며, 그중 7 명 (7.8%) 는 HADS-a 11 점이상에해당하는것으로나타났다. HADS-a 8 점을기준으로, 임상적으로의미있는불안증상을보이는그룹과, 임상적으로의미있는불안증상을보이지않는그룹으로나누어서두그룹의특성및차이를확인하였다 (Table 4). 두그룹간성별및 의차이는없었으며, 불안증상이있는그룹의평균연령이불안증상이없는그룹의평균연령보다높은것으로나타났다. 환자들의공복혈당수치및당화혈색소값은두그룹간차이를보이지않았다. 또한사건충격척도의네가지요소와불안증상과의관계를보면, 과다각성, 회피, 수면문제의세가지항목의점수가불안증상이있는그룹에서더높은것을확인할수있었다. 다음으로, 당뇨병진단당시의혈당수준및진단에따른심리적충격과불안증상간의연관성을확인하기위해, 당화혈색소값및사건충격척도의네가지요소와불안증상간의피어슨상관분석을시행하였다. 분석결과당화혈색소값과불안증상간상관계수 R = -0.196 (P = 0.069) 로유의한연관성은관찰되지않았으며, 사건충격척도의요소들과불안증상간에는과다각성 (R = 0.5, P < 0.001), 회피 (R = 0.323, P = 0.002), 침습 (R = 0.337, P = 0.001) 과수면문제 (R = 0.476, P 고찰 당뇨병과우울증은상호적으로작용하여각질환의유병률을높일수있는것으로알려져있다 [5,19]. 이연구에서는당뇨병을처음진단받은환자에서우울증상을보이는빈도를확인하였으며 HADS-d 8 점이상으로임상적으로의미있는우울증상을보인환자는 36% 이었고, 11 점이상의중한우울증상을보이는환자는 7.8% 에달하는것으로확인되어일반인구에비해당뇨병환자에서우울증이많다는이전의여러연구와일치하는결과를보여주었다 [5,20]. 특히이연구는당뇨병을처음진단받은환자에서도우울증상이많이나타난다는결과를보여주었는데, 이전의연구에서는당뇨병을처음진단받은환자에서우울증상이많이나타나는지여부를확인한바가많지않다. Hoorn study 에서는일반인구에비해당뇨병및당뇨병전기 (prediabetes) 의여성에서우울증상이더많은것을확인하였는데 [21], 이러한연구는당뇨병전기, 혹은당뇨병의초기부터우울증상이흔하게나타난다는점을시사한다. 또한본연구에참여한환자의 72% 가남성으로, 여성보다많았는데, 일반적으로여성에서의우울증유병률이더높은것을감안한다면, 실제로처음진단받은당뇨병환자에서우울증상을보이는비율은본 Table 4. T-test comparisons between newly diagnosed diabetic patients who have HADS-a scores of less than 8 and more than or equal to 8 No. Sex (M:F) HbA1c (%) FPG (mg/dl) Avoidance Intrusion HADS-a < 8 HADS-a > 8 P value 68 48 : 20 47.4 ± 10.3 25.2 ± 3.2 8.8 ± 2.1 157.3 ± 72.0 8.8 ± 8.0 9.8 ± 6.7 5.1 ± 4.5 4.3 ± 4.2 21 16 : 5 54.9 ± 9.7 27.5 ± 4.5 7.8 ± 1.8 157.3 + 41.1 18.2 ± 10.4 14.8 ± 7.9 8.3 ± 6.8 8.6 ± 4.8 0.78 0.005 0.052 0.053 0.99 0.001 0.005 0.056 0.001 Values are presented as mean ± SD., body mass index; HbA1c, hemoglobin A1c; FPG, fasting plasma glucose; HADS-a, average scores anxiety subscale of the Hospital Anxiety and Depression Scale.
연구의결과보다높을것으로생각해볼수있다. 반대로우울증상이있는사람에서의당뇨병유병률을살펴보면, Eaton 등은 1800 명을대상으로한 13 년간의전향적연구를통해경도의우울증상이있는사람에서는제 2 형당뇨병의위험도가증가하지않으나, 주요우울장애환자에서는제 2 형당뇨병의위험도가증가한다는것을밝힌바있다 [19]. 또한혈당조절정도와우울증상간의관계에대한이전의결과들을보면, 우울증상이혈당조절에악영향을끼친다고한연구가있는반면 [6], 우울증상과혈당간에는관계가없다고결론지은연구들도있다 [22,23]. 이연구에서는당뇨병을처음진단받은시점에도우울증상을보이는환자와우울증상이없는환자간의혈당상태의차이가있는지여부를보고자하였는데, 처음당뇨병을진단받은환자에서우울증상이있는환자의당화혈색소값이더낮다는것을확인할수있었다. 당화혈색소값이최근 2~3 개월간의혈당수치의평균이라는점을고려해보면, 우울증상을보이지않는환자군에비해우울증상을보이는환자군에서지난 2~3 개월간혈당수치가더양호했다는것을보여준다. 또한일반적으로우울증상을보이는환자일수록건강을염려하는경향이많고, 가벼운증상으로도병원을방문하는횟수가많다고알려져있다 [24]. 그러므로이연구에서우울증상을보이는환자군의당화혈색소값이낮은이유는우울증상을보이는환자가자신의혈당증가에따른증상의변화에더예민하게반응하여병원에빨리내원하였기때문으로생각해볼수있다. 임상적으로의미있는우울증상을보이는지에따라사건충격척도의요인점수를비교해본결과, 당뇨병을진단받음으로인해서과다각성되는정도, 당뇨병에걸렸다는사실을회피하려고하는정도, 비의도적으로당뇨병이반복해서생각나는침습정도, 수면문제점수모두임상적으로의미있는우울증상을보이는군에서높은것을확인할수있었다. 그러나나이,, 당화혈색소및사건충격척도의네가지요소를보정한 회귀분석모형에서는당화혈색소및수면장애만이임상적으로의미있는우울증상과관련이있는것으로확인되었다. 따라서, 초기우울증상을보이는당뇨병환자에서의료인의더적극적이고지지적인혈당조절과우울증상의관리를위한노력이필요할것이다. 불안증상의경우에도, 일반인구에비해당뇨병환자에서불안증상을더많이보인다는여러연구결과가보고된바있다 [25,26]. 본연구에서도 HADS-a 점수 8 점이상의임상적으로의미있는불안증상을보이는환자가 23.6% 이었으며, 그중 7.8% 는 HADS-a 11 점이상의중한불안증상을보여, 현재까지알려진일반인구에서의불안증상의유병률에비교하여당뇨병을처음진단받은환자에서불안증상이더높은빈도를보이는것이확인되었다. 또한불안증상의유의성여부에따른임상적요인의비교에서는, 임상적으로의미있는불안증상을보이는그룹의평균연령및과다각성, 회피, 수면문제요인점수가높은것으로확인되었으나, 회귀분석모형에서는, 침습경향만이불안증상과연관성을보였다. 당뇨병환자에서우울증상및불안증상을많이보이는이유는현재까지정확히알려지지않았으나, 사이토카인 (cytokine) 인인터루킨 -1, 인터루킨 -6, TNF 등이당뇨병환자에서염증반응을유도하며, 무기력감, 피로감, 의욕저하등의증상을유발한다는연구결과가보고된바있다 [27,28]. 특히 TNF 의경우인슐린저항성을높이고, 우울증상을많이가져온다는연구가있다 [27,29]. 또한당뇨병환자에서우울증상과불안증상이혈당조절에영향을미치는두가지기전이제시되고있는데, 첫번째는우울증상및불안증상과관련된길항호르몬의증가로인한고혈당과베타세포의기능저하를초래하는것이고 [30,31], 두번째는우울증상으로인한의욕저하및운동량감소가치료에대한순응도를낮추고, 이는혈당상승및비만을초래할수있다는것이다 [32,33]. 또한혈당조절의실패는 51 Table 5. Odds ratio for the prediction of anxiety symptom in logistic regression model HbA1c Avoidance Intrusion β Odds ratio 95% confidence interval P value 0.066 0.196-0.01 0.624-0.397-0.463 0.011 1.068 1.217 0.99 1.866 0.673 0.629 1.011 0.950-1.202 0.784-1.890 0.571-1.718 0.943-3.693 0.404-1.120 0.400-0.991 0.672-1.522 0.269 0.382 0.972 0.073 0.128 0.046 0.957 Adjusted for age, HbA1C, hyperarousal, avoidance, intrusion and sleep problem., body mass index; HbA1c, hemoglobin A1c.
Original Articles & Case Reports 52 다양한합병증을초래하여우울증상을악화시켜결과적으로당뇨병환자의예후에좋지않은영향을미치게된다. 이연구는다음과같은몇가지한계점을가지고있다. 첫째, 연구참여인원이많지않고, 서울의특정지역에있는대학병원내분비내과를내원한환자를대상으로하였기때문에, 전체당뇨병환자에게일반화하기에는부족하다는점이다. 둘째, 정상대조군이없어우울증상및불안증상의유병률에있어일반인구로대변되는대조군과의명확한비교가힘들다는점이다. 셋째, 문진및진료기록만으로환자의정신과적과거력여부를확인하였기때문에혈관성우울증과같은질환의배제가충분히되지않았을가능성이있다. 넷째, 환자의결혼상태및사회경제적배경을고려하지않아, 이러한인자들의그룹간차이를완전히배제할수없다는점이다. 결론적으로이연구에서는처음당뇨병을진단받은환자에서우울증상을더많이보일수록당화혈색소수치가양호하며당뇨병에대한충격정도가높을수록우울증상이더많이나타나는데특히수면장애가있을수록우울증상이더심해질수있다는것을보여준다. 따라서당뇨병진단초기부터당뇨병환자의우울및불안증상에대한고려가혈당관리와심리적충격의완화를위해필요할것으로생각된다. 요약 당뇨병환자에서우울증의유병률은일반인구에비해두배정도로높으며, 일반적으로당뇨병환자에서혈당조절과정동변화는상호연관성을보인다고알려져있다. 당뇨병의유병기간이길면합병증이증가하면서우울증의유병률이높아지게되는데, 이전의한국인당뇨병환자에서우울증에대한연구는주로평균당뇨병유병기간이 5~10 년정도인환자를대상으로하였고, 처음당뇨병을진단받은환자에서당뇨병과우울, 불안증상의관계에대해조사한연구는많지않았다. 이연구에서는당뇨병을처음진단받은환자에서, 혈당수준및당뇨진단으로인한심리적충격과우울과불안등의정서증상사이에어떠한연관성을갖고있는지알아보았다. 2010 년부터 2011 년까지제 2 형당뇨병을처음진단받은 20 세이상의환자 89 명을대상으로하여당화혈색소값을구하였고, 설문조사를통해우울증상과불안증상 (HADS), 사건충격척도 (IES) 를알아보았다. 사건충격척도는당뇨병진단으로인한심리적충격정도를나타내는것으로과다각성, 침습, 회피, 수면문제의네가지요소로구성되어있다. 89 명의처음진단받은당뇨병환자중 32 명 (36%) 에서우울증상이관찰되었으며, 21 명 (23.6%) 에서불안증상이관찰되어, 일반인구에비해높은빈도로우울증상과불안증상이관찰되었다. 당뇨병진단당시의혈당수준과우울증상사이에서는유의미한음의상관관계를보였으나 ( 피어슨상관계수 R = -0.227, P = 0.035), 불안증상과혈당수준사이의연관성은유의하지않았다 (R = -0.196, P = 0.069). 사건충격척도의네가지요소와우울증상사이에서는유의한상관관계를보였으며 ( 과다각성 R = 0.363, P < 0.001; 회피 R = 0.219, P = 0.039; 침습 R = 0.257, P = 0.015; 수면문제 R = 0.419, P < 0.001), 불안증상과사건충격척도사이에서도유의한상관관계가관찰되었다 ( 과다각성 R = 0.5, P < 0.001; 회피 R = 0.323, P = 0.002; 침습 R = 0.337, P = 0.001; 수면문제 R = 0.476, P < 0.001). 로지스틱회귀분석결과, 우울증상은수면과통계적으로의미있는상관관계를가졌으며 (OR = 1.437), 당화혈색소와는음의상관관계를가지는것으로 (OR = 0.51) 나타났고, 불안증상에서는침습만이영향을미치는변수로확인되었다 (OR = 0.629, P = 0.046). 처음제 2 형당뇨병을진단받은환자에서우울증상은수면장애및낮은당화혈색소수치와연관성을보이며, 불안증상과는심리적충격척도의침습요인만이연관성을보였다. 당뇨병진단초기부터당뇨병환자의우울및불안증상에대한고려가혈당관리와심리적충격의완화를위해필요할것으로생각된다. 참고문헌 01. S Kim DJ. The epidemiology of diabetes in Korea. Diabetes Metab J 2011;35:303-8. 02.S Okamura F, Tashiro A, Utumi A, Imai T, Suchi T, Tamura D, Sato Y, Suzuki S, Hongo M. Insulin resistance in patients with depression and its changes during the clinical course of depression: minimal model analysis. Metabolism 2000;49:1255-60. 03.S Gavard JA, Lustman PJ, Clouse RE. Prevalence of depression in adults with diabetes. An epidemiological evaluation. Diabetes Care 1993;16:1167-78. 04.S Nichols GA, Brown JB. Unadjusted and adjusted prevalence of diagnosed depression in type 2 diabetes. Diabetes Care 2003;26:744-9. 05.S Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care 2001;24:1069-78. 06.S Lustman P, Carney R, Amado H. Acute stress and
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