2型糖尿病并发抑郁患者血浆皮质醇分泌节律和胰岛素抵抗的研究

Study of the diurnal rhythm of cortisol secretion and insulin resistance in the type 2 diabetes mellitus patients with depression

目的探讨2型糖尿病（T2DM）并发抑郁患者血浆皮质醇分泌节律的特点和胰岛素抵抗程度。方法选择常熟市第二人民医院内分泌科、常熟市精神卫生中心临床心理科门诊及住院患者216例，单纯抑郁组（D组）44例，单纯糖尿病组（DM组）124例，糖尿病并发抑郁组（DM—D组）48例，并取健康体检者40名作为健康对照组（NC组），分别测定空腹血糖（FPG）、糖化血红蛋白（HbA1c）、空腹胰岛素、空腹C肽以及8：00、16：00、24：00血浆皮质醇（Cor）及血促肾上腺皮质激素（ACTH）等。结果DM—D组FPG、HbA1c、胰岛素抵抗指数（HOMA-IR）明显高于D组、DM组、NC组[（11．51±2．05）mmol／L与（5．18±0．22）、（9．47±3．46）、（5．11±0．25）mmol／L，（10．28±2．12）％与（5．36±0．34）％、（8．89±2．21）％、（5．53±0．32）％，3．78±1．08与1．58±0．21、2．70±1．54、1．14±0．24]，8：00、16：00、24：00的血浆Cor水平及8：00、16：00的ACTH水平均明显高于D组、DM组、NC组，胰岛素敏感指数（ISI）低于D组、DM组、NC组（-4．41±0．27与-3．57±0．13、-3．92±0．60、-3．22±0．22），差异均有统计学意义（P均〈0．05）；DM—D组皮质醇分泌节律消失者比率为77．1％，显著高于D组、DM组（50．0％、47．6％，P均〈0．05）。多元逐步回归分析显示8：00Cor、ISI是汉密尔顿抑郁量表（HAMD）评分的相关因素（95％C1分别为2．355～3．867、-7．903～-2．780，P均〈0．001）；Logistic回归分析表明8：00Cor是T2DM并发抑郁的危险因素（OR=3．024，95％C1为1．613～5．668，P=0．002）。结论T2DM并发抑郁患者血浆皮质醇水平更高、皮质醇分泌节律消失者更多、胰岛素抵抗更严重；高皮质醇血症与2型糖尿病患者发生抑郁状态相关。

Objective To explore the changes of the diurnal rhythm of cortisol secretion and insulin resistance of the type 2 diabetes mellitus（T2DM） patients with depression. Methods The 216 cases outpatient and inpatient of Department of Endocrinology of the Second People＇s Hospital Changshou, Clinical Psychology of City Mental Health Center of Changshou, were divided into depression without T2DM group （ D group, 44 cases）, T2DM without depression group（ DM group, 124 cases） and the T2DM with depression group （DM-D group, 48 cases）. And 40 healthy people were from the medical center and as the normal control（NC） group. The levels of fasting blood glucose （ FPG）, glycosylated hemoglobin （ HbA1c ）, Fins, fasting C peptide （ FC-P ）, rhythm in cortisol （Cor） secretion at 3 time points （ 8 ： 00, 16 ： 00,24 ： 00） and plasma adrenocorticotropin （ACTH） were detected for studies. Results Compared with the D group, DM group and NC group, there were increases of FPG,HbA1c, insulin resistance index （HOMA-IR） in the DM-D group （（ 11.51 ±2. 05） vs. （5.18 ±0. 22）, （9.47±3.46）,（5.11±0.25） mmol/L;（10.28±2.12）% vs. （5.36±0.34）%,（8.89±2.21）%,（5.53 ±0. 32） % ;3.78±1.08 vs. 1.58 ± 0. 21,2. 70 ± 1.54, 1.14± 0. 24）. Plasma cortisol levels and ACTH levels at time points of 8：00,16：00 in the DM-D group were higher than the group D, DM group and NC group, while insulin sensitivity index（ISI） in the DM-D group was lower than the D group, D M group and NC group （-4. 41 ±0. 27 vs. -3.57 ±0. 13,-3.92±0. 60,-3.22± 0. 22）, and the differences were significant （P〈 0. 05 ）. The loss of normal diurnal rhythm of cortisol secretion were significantly more often in DM-D group than in D group and in DM group（ 77.1% vs. 50. 0%, 47. 6%, P〈 0. 05 ）. The multiple stepwise regression analysis showed that 8：00 Cor and ISI were the related factors for the Hamilton Depression Scale （HAMD） score （95% CI：2. 355-3. 867, -7. 903-2. 780,P〈0. 001 ）. Logistic regression analysis showed that the level of 8：00 Cor was significant risk factor of the T2DM patients with depression（OR= 3. 024,95%CI： 1. 613-5. 668,P= 0. 002）. Conclusion The T2DM patients with depression have higher plasma cortisol level, more abnormal rhythm of cortisol secretion and higher level of insulin resistance. The high level of plasma cortisol maybe significantly related to depression in T2DM patients.