The age limit of 35 years was also chosen to obtain a stable study population, which facilitates having a more prolonged follow-up. Depression and type two diabetes are more prevalent in the Finnish population after 35 years of age, therefore we decided to focus on the ≥35 year-old age group. The Ethics Committee of Central Finland Hospital District had approved the study protocol prior to the commencement of the study. Each enrolled patient gave her/his written consent. Enrolment was based on written and oral patient information. The study (Finnish Depression and Metabolic Syndrome in Adults (FDMSA) study) was conducted in both urban and rural municipalities that were part of the Central Finland Hospital District, Finland with a geographically unified catchment area of 274 000 inhabitants. Patients who were 35 years of age or older, who were having a new depressive episode, who were referred to depression nurse case managers in 2008–2009 and who also scored ≥10 on the Beck Depression Inventory (BDI) were enrolled in this study. Hyperglycaemia and insulin resistance may increase the risk of depression and also the risk of suicide, thus, we decided to study the associations between suicidal behaviour and disturbances in glucose metabolism in depressive patients that had been referred to depression nurse case managers. The role of insulin secretion is more obscure, though a longitudinal study found that low insulin secretion is a risk factor for depression in middle-aged women. A recent meta-analysis reported an association between depression and insulin resistance. Bot and co-workers reported an association between suicidal ideation and HbA1c levels in diabetic subjects. Studies on the associations between depression, suicidal behaviour, glucose levels or insulin resistance are scarce, although some previous studies suggest that higher glucose levels are associated with dysthymia and higher HbA1c concentrations with recurrent or psychotic depression. A possible underlying pathophysiological mechanism for the emergence of abnormal glucose metabolism in depression and suicidal behaviour could thus lie in the interplay between serotonin and proinflammatory cytokines. Type 2 diabetes is recognized as an immune-mediated disease in which cytokines play an important role that leads to impaired insulin signaling and to the selective destruction of the insulin-producing beta cells.
The inflammatory hypothesis of depression emphasizes the role of pro-inflammatory cytokines and cell-mediated immune activation that results in tryptophan depletion and serotonergic hypofunction.
Reduced serotonin levels associate with increased weight, increased waist circumference, elevated blood glucose levels and insulin resistance in addition to depressed mood.
The monoamine hypothesis states that depression is related to monoaminergic dysfunction. Another cardiometabolic risk factor, disturbances in lipid metabolism, may also associate with impulsiveness and suicidal behaviour. However, recent studies have reported an association between diabetes, depressive disorders and suicidal ideation, in addition to an association between higher high glycated haemoglobin (HbA1c) values and suicidal ideation in subjects with diabetes. Increased suicide risk in depression may be related to various psychosocial factors, interpersonal conflicts and negative life events. Numerous studies have also documented an association between suicide risk and depression. Depression is thought to have multifaceted pathophysiology and increased risk for having depression is related to type two diabetes and other cardiometabolic disorders.
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