title: Does co-morbid depression impact diabetes related costs? Evidence from a cross-sectional survey in a low-income country.
abstract: OBJECTIVE
  The economic implications of co-morbid depression in patients with chronic medical disorders have been studied mainly in high-income countries. However, the applicability of such findings in developing countries cannot be assumed. In the present study we estimate diabetes related costs and explore the link between depression and diabetes related costs in Romania. In this former communist country, the general perception of practitioners and policy-makers is that psychological issues are far less important than medical concerns for patients with diabetes, a perception that may lead to the misallocation of already scarce resources.
  
  
  METHODS
  Data related to costs of diabetes care and to co-morbid depression were collected from a sample of 1,171 diabetes patients at the Nutrition and Diabetes Center in Cluj-Napoca, Romania, using the Diabetes Costs Questionnaire (DCQ) and the Patient Health Questionnaire 9 (PHQ9). The gathered data were subjected to a bivariate analysis of the depression-cost relationship, as well as a regression analysis in order to isolate the effect of depression on diabetes related costs from the effect of covariates.
  
  
  RESULTS
  Direct and indirect diabetes related costs equally contributed to the total costs. The repartition of the cost burden between the public system and private agents is nearly equal as well. The bivariate analysis of the depression-cost relationship reveals statistically significant larger diabetes related costs for patients with major depression than for patients with minor depression, and the latter have larger diabetes related costs than patients free of depression symptoms. When the pure effect of depression on diabetes related costs was isolated by means of regression techniques, the provisional diagnosis of major depression was found to significantly increase diabetes related costs.
  
  
  CONCLUSIONS
  The equal distribution of diabetes related costs between direct and indirect measures, as well as the cost burden equally split between the public system and private agents can be explained by the costs of medication and the costs associated with time lost by the non-compensated caregivers. Consistent with Romanian cultural traditions, most of the patients rely on their relatives in an informal diabetes caregiving market for assistance. Alongside depression, the multivariate analysis revealed that factors such as Hungarian ethnicity, income, and number of years since diagnosis also significantly contribute to diabetes related costs.
  
  
  CONCLUSIONS
  Findings that depression increases diabetes related costs bear potential implications for health policies and health care provision (i.e., the effect of depression on costs can be minimized by adequate recognition and treatment). As such, screening and treatment of co-occurring depression in diabetes patients should become part of the diabetes treatment protocol, not only in Romania but in other Central and Eastern European countries as well.
authors.affiliation: Babes-Bolyai University, Center for Health Policy and Public Health, Cluj Napoca, Romania.
authors.forename: Răzvan M
authors.initials: RM
authors.lastname: Chereches
authors.forename: Cristian M
authors.initials: CM
authors.lastname: Litan
authors.forename: Alina M
authors.initials: AM
authors.lastname: Zlati
authors.forename: Joan R
authors.initials: JR
authors.lastname: Bloom
mesh_terms: D000328:Adult; D015897:Comorbidity; D017281:Cost of Illness; D003430:Cross-Sectional Studies; D003863:Depression / Q000453:epidemiology; D003866:Depressive Disorder / Q000453:epidemiology*; D003920:Diabetes Mellitus / Q000191:economics* / Q000453:epidemiology* / Q000628:therapy; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data; D006296:Health Services / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D011203:Poverty / Q000706:statistics & numerical data; D012383:Romania / Q000453:epidemiology; D012959:Socioeconomic Factors; D013997:Time Factors