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Diabetes and depression have some unfortunate links. Depression isdisproportionately higher in patients with diabetes (DOC News, August2005), and patients dually diagnosed report worse self-care, take moredisease-control medications, suffer significantly more macro- andmicrovascular complications, and are at increased risk formortality.1,2
Two recent studies explored the value of aggressively treating depressionin patients who also have diabetes, with mixed results. A study that looked atthe health care balance sheet found that intensive depression treatment forelderly patients with diabetes did not cost more than usual care because itwas offset by savings in general medicalcosts.3 However, inanother study, enhanced depression treatment appeared to have little impact ondiabetes self-carebehaviors.4
DEPRESSION TREATMENT EFFECTIVE AND COST-NEUTRAL
"Patients with depression utilize 50–100% more in medicalcosts, and only 5–10% of these are mental health costs," saysWayne Katon, director of health services and psychiatric epidemiology at theUniversity of Washington School of Medicine in Seattle. Katon and colleaguesstudied the cost-effectiveness of enhanced treatment of depression for 418older adults (mean age 70 years) diagnosed with diabetes anddepression.3
Patients were randomly assigned to an intervention group or a usual-caregroup. The intervention, delivered by a nurse care-manager, included abehavioral intervention and either a psychotherapy program or antidepressantmedication as prescribed by a primary care physician. Care-managers followedintervention patients every 2 weeks over a course of 3–6 months, thenonce a month during the continuation phase of 6–12 months. The averagecost of the intervention program was $597. Antidepressant medication costswere $471 higher among intervention patients compared with usualcarepatients.
Ultimately, the expense of enhanced depression treatment was balanced bylower general medical costs. Although total mental health costs were $1,019higher for the intervention patients, costs for the intervention group after 2years were $271 less for non–mental health medication and $722 less forother outpatient services.
"The bottom line is that not only is [depression treatment]cost-neutral, it might even save you some money in the long run," Katonsays.
Enhanced depression treatment also significantly improved symptoms ofdepression. Compared with the control group, intervention patients experiencedapproximately 115 more depression-free days over 24 months.
"If you invest in this, you're going to have happier and healthierpatients," Katon says. "We got a lot of people better, and itdidn't cost more."
LESS DEPRESSION DOES NOT MEAN BETTER SELF-CARE
Another group of investigators, headed by Elizabeth Lin, MD, MPH, a primarycare physician and researcher with the Center for Health Studies in Seattle,investigated whether patients who exhibit fewer signs of depression managetheir diabetesbetter.4
The study randomized 329 patients with depression and diabetes to receiveeither collaborative depression treatment (pharmacotherapy, problem-solvingtreatment, or both) or usual primary care services for 12 months. Theintervention consisted of an initial hour-long visit by a nurse, followed bytwice-monthly 30-minute appointments. When patients reduced clinicaldepressive symptoms by 50%, they entered a new intervention phase consistingof monthly telephone calls. A team of a psychiatrist, psychologist, and familyphysician reviewed new cases and patient progress with the nurse.
Although the intervention did reduce depression symptoms, it had littleeffect on diabetes self-care behaviors. No changes in nutrition, physicalactivity, or smoking cessation resulted. The intervention group reported asmall decrease in body mass index but greater nonadherence to oralhypoglycemic agents.
"Initially, we had hoped that by improving depression other behaviorswould also improve. It was probably overly simplistic to expect thesechanges," Lin says. "Nonadherence is common among [people with]chronic conditions; the average rate is 50%. The problem is so huge, we maynot have emphasized it as much as we needed to."
Undeterred by the results, Lin offers insight on how these patients mightrespond better, starting with a more patient-centered approach.
"We need to look at how best to integrate treatment of both diseases,since both diseases contribute to how the patient is feeling," she says."We should ask them, `What do you see as most problematic in managingyour diabetes?' Let's focus on changing one behavior at a time."
Treating depression is probably the first step, according to Lin."Once we get patients to feel more hopeful, we've set the stage forgiving them more support to help with management of diabetes," she says."We just cannot give up on these patients, or let them give up onthemselves." 
Footnotes
The National Library of Medicine offers numerous links to depressionorganizations and resources at MedlinePlus,www.nlm.nih.gov/medlineplus/depression.html.
The National Institute of Mental Health's Web site also offers extensiveinformation about treating depression,www.nimh.nih.gov/healthinformation/depressionmenu.cfm.
References
2. Zhang X, Norris SL, Gregg EW, et al.: Depressive symptoms andmortality among persons with and without diabetes. Am JEpidemiol 161:652–660, 2005.
3. Katon W, Unutzer J, Fan M, et al.: Cost-effectiveness and netbenefit of enhanced treatment of depression for older adults with diabetes anddepression. Diabetes Care 29:265–270, 2006.
4. Lin EH, Katon W, Rutter C, et al.: Effects of enhanced depressiontreatment on diabetes self-care. Ann Fam Med 4: 46–53, 2006.
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