Journal of Psychosomatic Research 77 (2014) 457–461

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Journal of Psychosomatic Research

Suicidal ideation and suicide attempts among diabetes mellitus: The Korea National Health and Nutrition Examination Survey (KNHANES IV, V) from 2007 to 2012 Jae Ho Chung a, Kitae Moon b, Do Hyung Kim c, Joo-Won Min d, Tae Ho Kim a,⁎, Hee-Jin Hwang e,⁎⁎ a

Department of Internal Medicine, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Republic of Korea The Korean Society for Preventive Medicine, Seoul, Republic of Korea c Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Republic of Korea d Department of Internal Medicine, Myongji Hospital, Goyang, Republic of Korea e Department of Family Medicine, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Republic of Korea b

a r t i c l e

i n f o

Article history: Received 10 June 2014 Received in revised form 8 August 2014 Accepted 19 August 2014 Keywords: Suicidal ideation Suicidal attempt Diabetes mellitus

a b s t r a c t Objective: The present study evaluated the mental health of patients with diabetes mellitus (DM) in Korea and compared it with mental health in the general Korean population. Methods: All data included in the final analyses were collected from 34,065 subjects (20 years of age or older) who participated in the 2007–2012 Korea National Health and Nutrition Examination Survey (KNHANES). The mental health of 3846 DM patients were compared with that of 30,219 controls. Results: A depressed mood for 2 or more continuous weeks was reported by 13.6% of subjects with normal glucose tolerance (NGT), 14.3% of those with impaired glucose intolerance (IFG), and 17.6% of DM patients. Suicidal thoughts were reported by 15.3% of individuals with NGT, 15.6% of participants with IFG, and 17.6% of DM patients. Suicidal attempts were reported by 0.8% of people with NGT, 1.0% of those with IFG, and 1.3% of DM patients. In DM patients, the crude odds ratio (OR) for depressive mood was 1.376 (95% confidence interval [CI]: 1.258–1.504), the OR for suicidal ideation was 1.481 (95% CI: 1.361–1.611) and the OR for suicidal attempts was 1.413 (95% CI: 1.021–1.956). A multivariate analysis revealed that the ORs for depression, suicidal ideation, and suicidal attempts in DM patients were 1.178 (95% CI: 1.070–1.297), 1.152 (95% CI: 1.050–1.263), and 1.413 (95% CI: 1.021–1.956), respectively. Conclusions: The present study found that DM was associated with a marked increase in suicidal behaviors. © 2014 Elsevier Inc. All rights reserved.

Introduction Chronic medical conditions are often complicated by comorbid emotional or psychological disorders, but the issues associated with these conditions are often overlooked during primary medical care [1]. Depressive symptoms and syndromes are common in the medically ill but frequently go unrecognized and untreated [2]. A recent survey showed that the prevalence of depression is approximately 10% higher in patients with diabetes mellitus (DM) [3], and a longitudinal study

⁎ Correspondence to: T. H. Kim, Department of Internal Medicine, Division of Endocrinology, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Republic of Korea; Simgokro 100gil 25 Seo-gu, Incheon, Republic of Korea. Tel.: +82 32 290 2909; fax: +82 32 290 3879. ⁎⁎ Correspondence to: HJ Hwang, Department of Family Medicine, Catholic Kwandong University College of Medicine, Incheon, Republic of Korea, Simgokro 100gil 25 Seo-gu, Incheon, Republic of Korea. Tel.: +82 32 290 3993; fax: +82 32 290 3879. E-mail addresses: [email protected] (T.H. Kim), [email protected] (H.-J. Hwang).

http://dx.doi.org/10.1016/j.jpsychores.2014.08.008 0022-3999/© 2014 Elsevier Inc. All rights reserved.

found that over 40% of DM patients developed a major depressive disorder within 2 years of the initial study period [4]. Depressive symptoms have also been shown to be associated with impaired health-related quality of life [5], and although the association between DM and depression is clearly delineated, few studies have investigated the association between DM and the risk for suicide [6–9]. Furthermore, observational studies have suggested that patients with DM are at increased risk for future depression [10,11] and suicide [12,9]. However, these are not universal findings [13]. Suicide is a pressing public health concern in South Korea and around the world. The suicide rate has dramatically increased in Korea, and suicide is now the fourth leading cause of death [14]. There are a number of epidemiological differences among the studies that have evaluated suicidal behavior, and an investigation of the various comorbidities and risk factors that lead to suicide in different ethnic groups is therefore necessary. The purpose of the present study was to evaluate the mental health of patients with DM and compare this with mental health in the general Korean population.

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Methods Study participants The present study was based on data obtained from the fourth Korean National Health and Nutrition Examination Survey (KNHANES IV), conducted during 2007–2009, and the KNHANES V, conducted during 2010–2012. KNHANES studies are periodically conducted to assess health and nutritional status in the Korean civilian non-institutionalized population. Each KNHANES comprises a health interview survey, a health examination survey, and a nutrition survey that are administered by trained investigators. Annually in Korea, 10,000–12,000 individuals from 4600 households are selected from a panel to represent Koreans 18 years of age or older using a multistage, clustered, stratified, random sampling method based on national census data. The sampling frame was developed based on the 2005 population and housing census in Korea, and the household units were selected by a stratified multistage probability sampling design created for the South Korean population. Thus, KNHANES IV and V were nationally representative cross-sectional surveys conducted by the Division of Chronic Disease Surveillance, Korea Centers for Disease Control and Prevention and included data from approximately 260,000 primary sampling units, each of which contained approximately 60 households. After the exclusion of 2455 non-responders, the present study analyzed data regarding DM, depression, and suicidal ideation from 34,065 participants (14,601 males and 19,464 females) who were 20 years of age or older. Diabetes mellitus DM was defined as a fasting glucose level ≥126 mg/dL, the current use of anti-diabetic medications, or a self-reported physician diagnosis of DM. Fasting plasma glucose (FPG) concentrations were measured with an enzymatic assay (Pureauto SCHON, DAIICHI; Tokyo, Japan) and an automated analyzer (Hitachi Automatic Analyzer 7600; Hitachi, Tokyo, Japan). The glucose tolerance status of the participants was categorized as follows: normal glucose tolerance (NGT; defined as FPG b100 mg/dL), impaired fasting glucose (IFG; defined as FPG 100–125 mg/dL), and DM (defined as FPG ≥ 126 mg/dL). Participants were classified as having DM regardless of the fasting glucose level if their self-reported diagnosis of DM was confirmed by a physician, they had used oral hypoglycemic agents, or they had taken insulin injections. Fasting insulin levels were measured with an immunoradiometric assay using a 1470 WIZARD gamma counter (PerkinElmer; Finland).

Suicide-related thoughts and behaviors are associated with health behaviors such as cigarette smoking [16], alcohol consumption [17], and physical exercise [18]. Thus, the present study assessed health behaviors such as smoking, drinking, physical activity, and sleep using self-reported questionnaires. Smokers were classified as current, former, or non-smokers. Risky drinking was defined as ingesting more than five alcoholic beverages on one occasion, and individuals who had ingested more than 12 drinks on one occasion during the previous year were classified as risky drinkers [19]. Regular exercise was defined as routine walking at least five times per week for at least 30 min at a time or engaging during the survey period in regular moderate (at least five times per week for at least 30 min at a time) or strenuous (at least three times per week for at least 20 min at a time) exercise as defined by the American College of Sports Medicine Guidelines [20]. Mental health measures Psychosocial factors can affect the relationship between suicidal ideation and mortality, and suicidal ideation may also be considered an indicator of psychosocial factors. Mental health surveys that included the same questions as those in the KNHANES IV and V were provided to all participants. Three dimensions of mental health were determined within the domains of health status and mental health, namely stress, depression, and suicidal thoughts and attempts. Participants reported their level of stress as none, mild, moderate, or severe. Depression was screened using the Korean version of the World Health Organization (WHO) Composite International Diagnostic Interview-Short Form (CIDI-SF), which was validated as a cost-effective screening instrument that could be easily integrated into health surveys [21]. The WHO CIDI-SF includes questions such as “In your lifetime, have you ever had 2 weeks or more when nearly every day you felt sad, blue, or depressed?” and “Have there ever been 2 weeks or longer when you lost interest in most things such as work or hobbies or things you usually like to do for fun?” To assess depression, subjects answered “yes” or “no” to a question of whether they had experienced a depressed mood for 2 or more continuous weeks during the previous year. Suicidal ideation was assessed by participants' positive answer to the question “In the last 12 months, did you think about committing suicide?” A “yes” or “no” response was also used to determine whether the subjects had suicidal thoughts; if the subject answered “yes,” they were asked about their suicide attempts, if any. This indicator is a well-documented predictor of suicide attempts that has been previously used in other surveys of adults [22] and in previous KNHANES studies.

Baseline physical health

Ethical issues

Physical health can affect an individual's mental health and future mortality risk. Conditions are comorbid that include stroke, hypertension, ischemic heart disease, liver cirrhosis, arthritis, asthma, and chronic renal failure. Thus, the number of conditions comorbid with DM was evaluated in the present study. To avoid biases generated by a subjective assessment, subjects with one or more cancers of the stomach, liver, lung, colon, cervix, or breast were defined as “major cancer” patients based on their answering “yes” to the question “Were you diagnosed with cancer(s) by a physician?”

The institutional review board at the Korea Centers for Disease Control and Prevention approved the study protocol (nos. 2007-02CON04-P, 2008-04EXP-01-C, 2009-01CON-03-2C, 2010-02CON-21-C, 201102CON-06-C, 2012-01EXP-01-2C), and all participants signed informed consent forms.

Socioeconomic status Indicators of socioeconomic status are associated with suicidal ideation [15], and the present study therefore evaluated education, occupation, and household income. Self-reported smoking, alcohol intake, and physical activity were estimated from questionnaire responses, and household income was categorized according to quartiles of total income for each member in the household. Marital status was categorized as married, single, or divorced/separated/widowed.

Data analysis All sampling and weight variables were stratified, and the SPSS survey procedure was used for all statistical analyses to ensure appropriate estimates and standard errors. Additionally, survey sample weights were used for all analyses to produce non-biased estimates for the descriptive and analytical data analyses. Descriptive statistical methods were used to describe the basic characteristics of the study population; the numbers and percentages are reported for each variable. Student's t- and Chi square tests were used to compare the DM patients with the controls, and a multivariate logistic regression analysis that adjusted for age, sex, marital status, smoking, alcohol intake, education, personal income, physical activity, and number

J.H. Chung et al. / Journal of Psychosomatic Research 77 (2014) 457–461

of chronic diseases, and the presence of major cancer was used to examine independent risk factors for suicidal behavior among the DM patients. All data were analyzed using SPSS for Windows (Version 20.0; SPSS, Inc.; Chicago, IL, USA).

Results The baseline characteristics of the study population are described in Table 1. Compared with the general population, patients with DM were more likely to be older, male, less educated, and divorced/separated/widowed; less likely to have a job, to suffer from major cancer (stomach, liver, lung, cervix, breast, and colon cancers), and to suffer from chronic disease (stroke, hypertension, ischemic heart disease, liver cirrhosis, arthritis, asthma, and chronic renal failure); and more likely to earn a lower income and to exhibit more current smoking and less binge drinking, Table 2 presents the differences in mental health between the study population and the control group. The proportion of patients with DM that reported moderate to severe stress was 26.2% compared to 27.1% for controls (p = 0.076). Depressed mood for 2 or more continuous weeks was reported by 17.6% of patients with DM and 13.8% of controls (p b 0.001). Suicidal thoughts were reported by 20.7% of patients with DM and 15.3% of controls (p b 0.001). Suicide attempts were reported by 1.3% of patients with DM and 0.8% of controls (p = 0.006). Table 3 presents the differences in mental health according to glucose tolerance status. The experiences of depressive mood for 2 or more continuous weeks, suicidal thoughts, and suicidal attempts increased in association with blood glucose levels. Depressive mood for 2 or more continuous weeks was reported in 13.6% of NGT participants, 14.3% of IFG participants, and 17.6% of DM patients. Suicidal thoughts were reported by 15.3% of NGT participants, 15.6% of IFG participants, and 20.7% of DM patients. Suicidal attempts were reported by 0.8% of NGT participants, 1.0% of IFG participants, and 1.3% of DM patients. In patients with DM, the crude odds ratio (OR) for depressive mood was 1.376 (95% confidence interval [CI]: 1.258–1.504), the OR for suicidal ideation was 1.481 (95% CI: 1.361–1.611), and the OR for suicidal attempts was 1.413 (95% CI: 1.021–1.956). A multivariate analysis of patients with DM revealed that the OR for depression was 1.178 (95% CI: 1.070–1.297), that for suicidal ideation was 1.152 (95% CI: 1.050–1.263), and the OR for suicide attempts was 1.413 (95% CI: 1.021–1.956; Table 4).

Table 1 Clinical characteristics of study populations.

Age (years) Sex (male %) Smoking status Never Ex-former Current Risky drinking Regular exercise Marital status Married Single Divorced/separated/widowed Job Family income Low Moderate–low Moderate–high High Education ≦Elementary Middle school High school ≧College Major cancer No of chronic disease 0 1 2 ≧3

DM (n = 3846)

No DM (n = 30,219)

P-value

62.3 (12.4) 1905 (49.5)

48.4 (16.0) 12,696 (42.0)

b0.001 b0.001 b0.001

1937 (52.1) 550 (14.8) 1228 (33.1)) 1576 (40.9) 1862 (48.4)

17,640 (59.3) 2920 (9.8) 9182 (30.8) 15,897 (52.6) 15,213 (50.3)

2825 (74.2) 89 (2.3) 895 (23.5) 1718 (44.7)

22,202 (73.8) 4228 (14.0) 3669 (12.2) 18,079 (59.8)

1325 (35.5) 998 (26.7) 748 (20.0) 664 (17.8)

5395 (18.2) 7492 (25.2) 8280 (27.9) 8493 (28.6)

1795 (48.4) 570 (15.4) 865 (23.3) 477 (12.9) 141 (3.7)

7248 (24.4) 3163 (10.7) 10,287 (34.6) 8995 (30.3) 483 (1.6)

1207 (32.4) 1457 (39.1) 819 (22.0) 244 (6.5)

20,286 (68.2) 6763 (22.7) 2267 (7.6) 427 (1.4)

b0.001 0.129 b0.001

b0.001 b0.001

b0.001

b0.001 b0.001

Values are presented as number (%) or mean (SD). Major cancer: stomach, liver, lung, cervix, breast and colon cancers. Chronic disease: stroke, hypertension, ischemic heart disease, liver cirrhosis, arthritis, asthma and chronic renal failure.

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Table 2 Mental health of DM patients.

Stress Moderate to severe None to mild Experiences of depressive mood for 2 or more continuous weeks Suicidal thoughts during the previous year Suicidal attempts during the previous year

No DM (n = 30,219)

DM (n = 3846)

P value

8187 (27.1) 22,032 (72.9) 4160 (13.8)

969 (26.2) 2877 (73.8) 678 (17.6)

b0.001

4633 (15.3) 253 (0.8)

796 (20.7) 49 (1.3)

b0.001 0.006

0.076

Discussion The present study demonstrated that DM was associated with a marked increase in suicidal ideation and suicide attempts. Additionally, depressive mood for 2 or more continuous weeks, suicidal thoughts, and suicide attempts increased in association with blood glucose levels. The few studies that have investigated suicide and suicidal behaviors in DM patients have found a higher prevalence of suicidal ideation in DM patients compared to subjects without DM [23,24,6]. Tseng [25] followed up with a cohort of 256,036 Taiwanese patients with DM from 1990 to 2001 and found that 0.8% of the deaths were attributed to suicide (0.14% in the total patient cohort). Although this study did not distinguish between the various types of DM, the authors believed that their findings largely reflect the mortality of patients with type 2 DM. There is also a scarcity of data concerning differences in suicidal behaviors among patients with various types of DM according to sex and age. Male DM patients are more likely to be at risk for suicide [26], and there is an increase in suicidal ideation among adolescents with insulin-dependent DM, which is strongly associated with serious noncompliance with one's medical regimen [24]. However, the incidence of suicide attempts in DM patients did not differ from that in the general population in these studies. In contrast, African–American patients with type 1 DM exhibit an increased risk for suicide attempts compared with African–Americans without DM [6]. Pompili et al. [7] evaluated perceived quality of life in Italian patients with type 1 or 2 DM and its association with suicide risk. These authors found that patients with DM exhibit greater hopelessness and suicidal ideation than did internal medicine outpatients and that the poor quality of life in DM patients was related to low self-efficacy, high hopelessness, and suicidality. Similarly, a higher prevalence of depressive episodes, recurrent depressive episodes, dysthymia, mood disorders with psychotic symptoms, and suicidal ideation has been reported in type 2 DM patients compared with controls [8], and young men with insulin-dependent DM (type 1 DM) were found to be at higher risk for suicide [9]. Moreover, Kyvik et al. [9] concluded that suicide may be underestimated as a cause of death among such patients. In the present study, 20.7% of patients with DM expressed suicidal thoughts, and 1.3% of these patients had attempted suicide; however, these findings do not agree with previous studies. It is thought that these differences in results may be due to methodological variations in the assessment of suicidal ideation and suicide attempts. The present findings also demonstrate that depression, suicidal thoughts, and suicidal attempts increased in association with blood glucose levels. For example, high levels of glycated hemoglobin (HbA1C) were associated with depression as well as with suicidal behaviors. Papelbaum et al. [27] found that type 2 DM patients who had also been diagnosed with recurrent depression exhibit higher levels of HbA1C than did DM patients without mood disorders. Independent factors such as age, hospital admissions for ketoacidosis, and insulin dose are also associated with depression in patients with type 1 DM [28]. HbA1c levels are positively correlated with cardiovascular disease in older, apparently healthy, non-diabetic Korean adults [29], and cardiovascular disease results in a heightened risk for suicide. Recent

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Table 3 Mental health according to the glucose tolerance status.

Stress Moderate to severe None to mild Experiences of depressive mood for 2 or more continuous weeks Suicidal thoughts during the previous year Suicidal attempts during the previous year

NGT (n = 23,862)

IFG (n = 6357)

DM (n = 3846)

P value

6588 (27.5) 17,074 (72.5) 3253 (13.6)

1599 (25.2) 4758 (74.8) 907 (14.3)

969 (26.2) 2877 (73.8) 678 (17.6)

b0.001

3643 (15.3)

990 (15.6)

796 (20.7)

b0.001

192 (0.8)

61 (1.0)

49 (1.3)

b0.001

0.008

NGT: normal glucose tolerance, IFG: impaired glucose intolerance.

studies have also shown that patients with major depression are more likely to develop DM [6]. This association may be explained by the fact that individuals with depression often have a high caloric intake and rarely engage in physical activity, which likely contributes to obesity [30]. Nevertheless, depressive symptoms activate the hypothalamic– pituitary–adrenal (HPA) axis and cause changes in the immune system, which can lead to insulin resistance and the development of DM [31]. A number of studies investigating this specific outcome have been conducted in Korea using data from the KNHANES assessments. Suicidal ideation was significantly more prevalent among patients who had injected insulin, had suffered from DM for more than 5 years, and/or had HbA1c levels that were at least 6.5 times higher than those without DM [32]. DM was a significant risk factor for suicidal ideation, and the coexistence of DM and depression was associated with a much higher risk for suicidal ideation than DM alone [33], which is in agreement with the findings of the present study. However, other studies have found that DM did not increase the risk for suicidal behavior [32]. The inconsistent findings regarding the relationship between DM and suicidal ideation may be related to methodological differences in sampling methods and sample composition. For example, the present study included patients who were 20 years of age or older and used data from the 2007–2012 KNHANES, whereas Lee et al. [32] used patients who were 40 years of age or older and data from the 2010–2011 KNHANES, and Han [33] used data from the 2007–2009 KNHANES. There are several limitations in the present study that should be considered when evaluating its findings. First, suicidal ideation and suicide attempts were assessed over participants' lifetime; therefore, it was not possible to determine the sequence of these events. Additionally, the distinction between current and remitted DM may be helpful when interpreting the nature of the relationship between DM and suicidal behaviors. More, specifically, it was not possible to determine whether the suicidal thoughts and attempts occurred contemporaneously with DM or preceded DM. However, because a history of suicidal thoughts and attempts is the strongest predictor of future suicidal behavior, this information will be useful to clinicians when evaluating potential risks for suicide, particularly in the presence of other risk factors for suicidal behavior. Second, because this was a cross-sectional study, the establishment of cause and effect relationships between suicidal behaviors and the studied variables remains limited. Table 4 Depression and suicidal behaviors among DM patients.

Depression Suicidal thoughta Suicidal attempt

Unadjusted

P-value

Adjustedb

P-value

1.376 (1.258–1.504) 1.481 (1.361–1.611) 1.562 (1.148–2.125)

b0.001 b0.001 0.005

1.178 (1.070–1.297) 1.152 (1.050–1.263) 1.413 (1.021–1.956)

0.001 0.003 0.037

a Suicidal ideation was assessed by a positive answer to the question “In the last 12 months, did you think about committing suicide?” b Multivariate logistic analysis, adjusted by age, sex, marital status, smoking, alcohol intake, education, personal income, physical activity, number of chronic disease and presence of major cancer.

Despite these limitations, the present findings have important implications for clinical practice and experimental research. The primary strength of the present study is that all data were obtained from a nationwide population study with a high response rate (65.8% in 2007, 74.3% in 2008, 79.2% in 2009, 77.5% in 2010, 76.1% in 2011, and 75.9% in 2012), and they provide representative information regarding the general Korean population. Furthermore, these surveys produce extensive data regarding potential confounds and include a large sample size, which increases accuracy and permits multiple statistical adjustments. The present findings demonstrate that Korean patients with DM report higher levels of suicidal thoughts than does the general Korean population. Therefore, it is important for practicing general physicians to be aware that DM patients are at risk for significant mental health problems and that they should be screened for such issues so they may be promptly diagnosed and referred to the appropriate mental health professionals. The present findings also contribute to the growing body of evidence demonstrating that DM is associated with increased suicidal ideation and suicide attempts by Korean adults. These data also support the need for further investigation into the severity and nature of disabilities associated with DM and other common chronic diseases and their relationships with suicidal ideation and behaviors. Furthermore, the present findings also provide an empirical foundation for including DM in the clinical assessment of suicide risk, which may ultimately aid in the identification of individuals at high risk for suicide. Finally, given that the results of the baseline medical examination were provided to those who participated in the study, the information regarding their condition, particularly if initially diagnosed by this study, could have precipitated a significant mental health problem that may have led to a successful attempt at suicide. Conflict of interest No potential conflict of interest relevant to this article was reported. Acknowledgments This study was supported by the Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital (grant no. 2014-013). All authors contributed conception, analysis, interpretation, revising, and final approval of the manuscript. JH Chung served as a principal investigator and had full access to all of the data in the study. TH Kim and HJ Hwang take responsibility for co-corresponding authors for the integrity of the data and the accuracy of the data analysis. KT Moon contributed to interpretation of data. JW Min and DH Kim provided study management. References [1] Turner J, Kelly B. Emotional dimensions of chronic disease. West J Med 2000;172: 124–8. [2] Rodin G, Voshart K. Depression in the medically ill: an overview. Am J Psychiatry 1986;143:696–705. [3] Egede LE, Simpson K. Epidemiology, treatment and costs of depression in adults with Type 2 diabetes. Expert Rev Pharmacoecon Outcomes Res 2003;3:251–62. [4] Bot M, Pouwer F, Ormel J, Slaets JP, de Jonge P. Predictors of incident major depression in diabetic outpatients with subthreshold depression. Diabet Med 2010;27: 1295–301. [5] Choi YJ, Lee MS, An SY, Kim TH, Han SJ, Kim HJ, et al. The relationship between diabetes mellitus and health-related quality of life in Korean adults: The Fourth Korea National Health and Nutrition Examination Survey (2007–2009). Diabetes Metab J 2011;35:587–94. [6] Roy A, Roy M, Janal M. Suicide attempts and ideation in African–American type 1 diabetic patients. Psychiatry Res 2010;179:53–6. [7] Pompili M, Lester D, Innamorati M, De Pisa E, Amore M, Ferrara C, et al. Quality of life and suicide risk in patients with diabetes mellitus. Psychosomatics 2009;50:16–23. [8] Ceretta LB, Reus GZ, Abelaira HM, Jornada LK, Schwalm MT, Hoepers NJ, et al. Increased prevalence of mood disorders and suicidal ideation in type 2 diabetic patients. Acta Diabetol 2012;49:S227–34. [9] Kyvik KO, Stenager EN, Green A, Svendsen A. Suicides in men with IDDM. Diabetes Care 1994;17:210–2.

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Suicidal ideation and suicide attempts among diabetes mellitus: the Korea National Health and Nutrition Examination Survey (KNHANES IV, V) from 2007 to 2012.

The present study evaluated the mental health of patients with diabetes mellitus (DM) in Korea and compared it with mental health in the general Korea...
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