Cholecalciferol on Depressive Symptoms in Type 2 Diabetes Mellitus Patients

Study Overview
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Brief Summary
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One in eleven adults falls ill with Diabetes Mellitus (DM) and 90% of them suffered from type 2 DM. Depression in type 2 DM patients had a big impact, acting as a major barrier to self-care in type 2 DM patients. Depression in diabetes patients is also associated with decreasing quality of life. Poor self-care behavior and adherence, poor glycemic control, and increased risk of mortality about 36-38% from cardiovascular complications are other known debilitating results. Vitamin D receptors are present in many organ systems, namely the pancreas, intestine, musculoskeletal, and nervous systems. Vitamin D has pleiotropic effects, which were seen from its mechanism as an anti-inflammatory, anti-apoptotic, and immunomodulatory agent. Based on the mechanism of Vitamin D action in the nervous system, which also plays a role in depression pathogenesis, vitamin D is hypothesized to have a beneficial effect on depression, both for depression prevention and treatment. Few studies denote that Vitamin D can improve depression in type 2 DM patients. Vitamin D may become an important adjuvant therapy to ameliorate depression in type 2 DM patients. These clinical trials concerning vitamin D in type 2 DM are relevant, reminding that type 2 DM resulted in higher morbidity, mortality, and numerous high-risk complications in the population.

Detailed Description
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According to World Health Organization report's, depression was estimated causing distress in most people on 2030. 1 In Indonesia, the prevalence of depression in 2017 was 3,7%.2 Depression often found in Internal medicine patient's as a comorbid in various chronic diseases. 3 One of the most common chronic disease is type 2 diabetes mellitus. There's one in eleven adults suffered from diabetes mellitus, and 90% of them had type 2 diabetes mellitus (DM). Basic Health Research Data on 2018 showed there were 10.9% case type 2 DM in Indonesia. 4 DKI Jakarta Province had 3,4% or 11.226 people aged 15 years and over with Diabetes Mellitus and had been a highest prevalence of Diabetes Mellitus among population aged 15 years and over. Meanwhile, prevalence of depression among adults aged 15 and over in DKI Jakarta was 5.9%. Seminkovics K et al5 reported one in four people with type 2 diabetes mellitus suffered from depression in United States. In Indonesia, Nasrun WMS6 reported there were 27,6% prevalence of depression in type 2 diabetes mellitus patients's with cognitive impairment, while Arshita et al7 found there were 60% patients with depression in type 2 diabetes mellitus patients with pedic ulcers in RSCM . Depression in type 2 Diabetes Mellitus patients had a big impact, such as: depression can be a major barrier to self-care in type 2 diabetes mellitus patients. 1,5 Depression in diabetes patients is also associated with decreasing quality of life. 6 Poor of self-care behavior and adherence, poor of glycemic control, and increased risk of mortality about 36-38% from cardiovascular complication are other known debilitating results. 8 Vitamin D receptors are present in various organs such as the pancreas, intestine, musculoskeletal, and nervous system. Vitamin D has a pleiotrophic effect which were seen from its mechanism as anti-inflammatory, anti-apoptotic, and immunomodulatory. 16 Based on mechanism of Vitamin D action in nervous system, which also plays a role in the depression pathogenesis, vitamin D is hypothesized to have a beneficial effect on depression, both for prevention and treat the pathomechanism. The protective effect of Vitamin D for prevent depression had been widely studied in copious observational epidemiological studies, although with diversified results. Many studies have been conducted to assess the beneficial effects of vitamin D on a variety outcomes including depression, which are summarized in systematic reviews and meta-analyzes of observational studies. A meta-analyses by Ju SY et al38 found that low plasma 25 (OH) D levels were associated with and increased risk of depression in a cross sectional study with 43,1377 participants. Vitamin D deficiency is a worldwide health problem. Vitamin D had known as an important role in biological processes, calcium homeostasis, and various health problems. In addition to its role in musculoskeletal, vitamin D is also associated with a few non-musculoskeletal diseases such as immunity, cancer, cardiovascular disease, hypertension, diabetes, and psychological problems like dementia or depression. 17 Both Vitamin D and its analogues are natural ligands for vitamin D receptor (VDR). Vitamin D receptors are widely distributed throughout body including brain and pancreas. Vitamin D receptors found in cerebellum, hippocampus, substantia nigra, basal forebrain, prefrontal cortex and hypothalamus. This explains the role of vitamin D in brain development and emotional disorders. In brain development, vitamin D played role in proliferation and differentiation of neuron cells. In adult brain, vitamin D played a role in neurogenesis in the hippocampus and synthesizes neurotransmitters such as dopamine, GABA, and serotonin. 18 It's known as depression neurotransmitter. Other studies showed that vitamin D might repair neurotransmitters, inflammation, metabolic, and oxidative stress. Cholecalciferol will activate 1-α hydroxylase enzymes and P450 cytochrome, which transformed calcifediol hydroxylation into activated vitamin D in central nervous system, so that improving depression. Anti depressants such as SSRIs (Selective serotonin reuptake inhibitors), can induce gastrointestinal bleeding in patients whose taking anti-platelets or anti-coagulants, increase weight and dyslipidemia. Thus, other studies therapy based on pathogenesis of depression, effective and side effects need to be done. Few studies denote that Vitamin D can improve depression in type 2 DM patients. Those studies used only Beck Depression Inventory test to assess depression without any biological markers. Vitamin D may become an important adjuvant therapy to ameliorate depression in type 2 DM. These clinical trials concerning vitamin D in type 2 DM are relevant, reminding that type 2 DM resulted in higher morbidity, mortality and numerous high risk complication in the population. Methods/Design: This is a prospective, randomized, double blind, and controlled clinical study to investigate the effects of cholecalciferol on depressive symptoms in type 2 diabetes mellitus patients. Patients included into the study will be randomized into two groups and receive placebo (as control group) or cholecalciferol administered orally for 3 months. Discussion : Vitamin D may become an important adjuvant therapy to ameliorate depression in type 2 DM patients. Thus, type 2 diabetes mellitus with depression symptoms will have a better quality of life.

Official Title
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Effects of Cholecalciferol on Depressive Symptoms in Type 2 Diabetes Mellitus Patients: Study of Neurotrophin-3, Serotonin, and C-Peptide

Conditions
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Diabetes Mellitus, Type 2, Depressive Symptoms

Intervention / Treatment
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* Drug: Cholecalciferol 4000 IU Oral Capsule, Liquid Filled
* Drug: Placebo


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Male or female subjects with aged 18 and over Living in around Jakarta Type 2 diabetes mellitus patients with depression symptom Patients with Body mass index 20-30 m/kg2 Patients are able and willing to maintain diet, physical activity, and lifestyle for 3 months Patients are able and willing to control for follow up Exclusion Criteria: - Presence of severe hepatic dysfunction, defined as cirrhosis hepatic Presence of severe renal dysfunction, defined as chronic kidney disease stage 5 or e-GFR ≤15 or history of hemodialysis Patients with acute coronary syndrome Presence of acute systemic inflammatory response syndrome (SIRS). The term SIRS describes a clinical state arising from a non-specific cause, infective, or otherwise Recent obtained vitamin D therapy within the last 3 months Current or regular use of corticosteroids within immunosuppressant dosage Presence of major depression Presence of psychosis Current or regular use of anti-depressant Current or regular use of phenytoin or phenobarbital For females: current pregnancy and lactation period Patients who refuse the studies

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Factorial Assignment
Interventional Model Description: This is a prospective, randomized, double blind, and controlled clinical study to investigate the effects of cholecalciferol on depressive symptoms in type 2 diabetes mellitus patients. Patients included into the study will be randomized into two groups and receive placebo (as control group) or cholecalciferol administered orally for 3 months.
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Cholecalciferol<br>-Vitamin D 25 (OH) 4000 IU capsules, tablet @ 1000 IU One capsule for once a day for 30 days of study period. | Drug: Cholecalciferol 4000 IU Oral Capsule, Liquid Filled<br>* -Vitamin D 25 (OH) or Cholecalciferol 4000 IU capsules, each capsules contain Vitamin D3 tablet @ 1000 IU Patients included into the study will be randomized into two groups and receive placebo (as control group) or cholecalciferol administered orally for 3 months.<br>* Other names: Vitamin D3;|
| Placebo Comparator: Control Group<br>Placebo will be administrated orally, One capsule once a day for 30 days of study period | Drug: Placebo<br>* Placebo will be given to control group. It would be administrated orally, one capsule once a day for 30 days of study period<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Evaluating the effects of cholecalciferol for depression symptoms with BDI II score | Improvement rate on days 90 (end of study) as defined by a proportion of subjects with category of BDI II score below 13. The BDI II scale was a subjective measurement of depressive symptoms. Interpretation of BDI II were 0-13 for minimal depression, 14-19 for mild depression, 20-28 for moderate depression, and 29-63 for major depression. Cholecalciferol with doses of 4000 IU a day expected to demote BDI II scale or depressive symptoms in participants. | 90 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Evaluating the effects of cholecalciferol against neuroplasticity (NT-3) | NT-3 concentration (pg/ml) in the sample was determined by comparing the sample against the standard curve. Some studies have shown that neurotrophin-3 (NT-3 pg/ml) levels decreased in depression. Thus, cholecalciferol (for doses of 4000 IU a day) with expected could increase NT-3 pg/ml plasm levels. Furthermore, the enhancement of NT-3 pg/ml concentrates expected to had correlated with scale BDI II improvement. | 30 days | 
| Evaluating the effects of cholecalciferol against serotonin | Studies have shown that serotonin (ng/mL) in depressive patients had lower levels than patient without depressive syndrome. The serotonin levels were measured by the ELISA method. Cholecalciferol expected could increase levels of serotonin concentration (ng/mL) significantly 2-3 times after administrated. | 30 days | 
| Evaluating the effects of cholecalciferol against C-Peptide | C-peptide hormone is an indicator of insulin secretion. Specifically, a c-peptide level of less than 0.2 nmol/l is associated with a diagnosis of type 1 diabetes mellitus. C-peptide measured using ELISA at a minimal room temperature for 24 hours. Cholecalciferol expected could improve C-peptide levels concentration in type 2 Diabetes Mellitus. | 30 days | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Diabetes Mellitus, Type 2, Cholecalciferol, Depression