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Adual diagnosis of diabetes with depression doesn't mean just another disorder to treat. Typically, it means worse health outcomes because it can affect a patient's ability to follow self-care treatment plans.
The presence of diabetes doubles the odds of comorbid depression, according to a 2001 meta-analysis.1 An estimated 15–20% of patients with diabetes meet criteria for depression, compared with 2–9% of the general population, the study finds.
"Depression predicts a different course [for diabetes] if untreated," says co-author Patrick J. Lustman, PhD, professor of psychiatry at Washington University School of Medicine in St. Louis.
A study published in the May issue of Diabetes Care reports that 30% of 92,000 adults with newly diagnosed diabetes were more likely to have had a previous history of depression than those without diabetes.2
"Previous depression seems to accelerate the development of diabetes in those who are at risk," says investigator Jeffrey A. Johnson, PhD, of the University of Alberta.
He offers three possible explanations: behaviors of depressed individuals, such as having a sedentary lifestyle and poor eating habits; a physiological relationship in which chemical imbalances associated with depression also affect systems for glucose control; and the influence of antidepressant medications, some of which may adversely affect glucose control.
New data presented to the American Psychiatric Association in May 2005 show depressed diabetic subjects are dying at twice the rate as the nondepressed, says investigator Wayne Katon, MD, of the University of Washington Medical School.
But depression in diabetes patients has been proven treatable with multiple medications and specific forms of talk therapy, experts point out.
"Treatment significantly increases the likelihood of becoming depression-free and achieving the kind of diabetes control that's important to preventing and delaying complications," Lustman says.
SCREENING FOR DEPRESSION
The American Diabetes Association (ADA) added a standard of psychosocial assessment to its 2005 Clinical Practice Recommendations.3 ADA points to multiple opportunities for screening psychosocial status and making appropriate referrals—at diagnosis, during management visits, during hospitalizations, when complications are discovered, or any time the clinician identifies problems with glucose control, quality of life, or adherence.
"It is important to establish that emotional well-being is part of diabetes management," ADA states. Screening should include assessing a patient's attitudes about the illness, expectations for medical management and outcomes, mood, general and diabetes-related quality of life (financial, social, and emotional), and psychiatric history, according to the ADA recommendations.
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Psychologist Mary de Groot, PhD, director of the Diabetes and Depression Laboratory at Ohio University, also supports incorporating mental health questions into the diabetes office visit. She suggests checking for depression as a vital sign.
"Screening can be as simple as asking the patient, `How is your mood? How has it been since I saw you last?'" de Groot says. "The most important piece is that we ask the question. One of the lessons we've learned from extensive research on patient/provider communication is when we ask about the emotional functioning of our patients, patients are more likely to tell us how they're doing. This can give us insight to other components affecting their health."
For a more systematic approach, de Groot recommends the screening tool called PRIME MD (Primary Care Evaluation of Mental Disorders), developed for primary care practices to assess the nine hallmark symptoms of depression (available online at www.depression-primarycare.org). Plus, appointment staff can easily conduct the screening so the physician can review the results before the visit, she says.
Several steps need to be taken even after screening. First, the primary care provider needs to be aware that there are effective treatments for depression. Second, the provider should talk about the options with the patient.
"There may be medications that can be prescribed by primary care physicians, or it may involve a referral," de Groot says.
Explaining the referral to patients is helpful, she adds. "Without an explanation, many patients may have the incorrect assumption, `The doc thinks I'm crazy.' You need to explain that depression is a treatable condition with experts who can treat it."
EFFECTIVE TREATMENT OF DEPRESSION
Treating both diabetes and depression may sound like a tall order, but researchers have known for several years that it can be done with multiple approaches.
"The behavioral approaches of psychotherapy and exercise are at least equally effective for treatment of depression as the medication, and in terms of their benefits for glycemic control," Lustman says.
In a 1998 study, Lustman and colleagues assigned 51 patients with type 2 diabetes and major depression to one of two groups.4 Half the subjects received 10 weeks of individual cognitive behavioral therapy (CBT); the other half received no antidepressant treatment. All patients participated in a diabetes education program.
After treatment, 85% of subjects in the CBT group achieved remission of depression, compared with 27% of those in the control group. The CBT group also demonstrated better glycemic control at a 6-month follow-up. Glycated hemoglobin (A1C) levels averaged 9.5%, compared with 10.9% among the control group.
A pharmacological treatment approach aimed strictly at reducing symptoms of depression also improved diabetes symptoms.
In another study, Lustman and associates divided a group of 60 patients with depression and diabetes into two smaller groups.5 One group received a daily dose of fluoxetine (Prozac, Lilly) for 8 weeks while the control group received a placebo. Those in the fluoxetine group achieved a depression remission rate of 48% compared with 26% among the control group. Glucose levels among the fluoxetine group also improved significantly. Lustman suggests that this dual effect may result from the antidepressant inhibiting the body's response to the hormone cortisol.
SYSTEMATIC FOLLOW-UP
Monitoring the diabetic patient's progress is an important aspect of identifying and treating depression. "Unless you have a systematic follow-up of how patients are doing with treatment, there's no way to really know," says Elizabeth Lin, MD, MPH, a primary care physician and researcher with the Center for Health Studies in Seattle.
De Groot recommends checking in with patients at subsequent visits by
asking: How did the referral go? Were you able to attend the appointment? If
the patient did not keep the appointment, de Groot suggests asking about
potential barriers such as insurance status, time availability, or the
patient's concern about how the visit might go. If the referral was
successful, the health care provider should reinforce that experience, de
Groot says. "Support can be very important for adherence."
Footnotes
Experts recommend using the one-page Primary Care Evaluation of Mental Disorders (PRIME MD) patient health questionnaire to screen for depression.
The MacArthur Initiative on Depression and Primary Care has developed a toolkit to help clinicians recognize and manage depression. The toolkit includes downloadable versions of PRIME MD in Spanish and English, available online at www.depression-primarycare.org.
National Depression Screening Day is Oct. 6, 2005. A free kit to help primary care providers screen for mood and anxiety disorders, as well as postpartum depression, is available to download at www.mentalhealthscreening.org.
References
2. Brown LC, Majumdar SR, Newman SC, et al.: History of depression increases risk of type 2 diabetes in younger adults. Diabetes Care 5:1063–1067, 2005.
3. American Diabetes Association: Standards of medical care in
diabetes (Position Statement). Diabetes Care 28: S4–S36, 2005.
4. Lustman PJ, Griffith LS, Freedland KE: Cognitive behavior therapy
for depression in type 2 diabetes mellitus: A randomized, controlled trial.
Ann Intern Med 129(B):613
–621, 1998.
5. Lustman PJ, Freedland KE, Griffith LS, et al: Fluoxetine for depression in diabetes: A randomized double-blind placebo-controlled trial. Diabetes Care 5:618–623, 2000.
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