resulting in racial and ethnic disparities in the use of depression treatment (Egede 2002a, de Groot 2006, Wagner 2007a); lack of screening and adequate diagnosis by primary care physicians (Katon 2004a); lack of dose adjustment of antidepressant medications by primary care providers (Katon 2004a); and lack of referrals to psychotherapy services in addition to antidepressant medication treatment (Katon 2004a). Patient satisfaction with the use of antidepressant medications and mental health providers has been shown to be favorable among those who have received depression treatment (Katon 2004c, de Groot 2006).
Recommendations for Future Research
Based on the available literature, a number of areas merit additional research attention to further define the etiology, course, outcomes, and treatment of comorbid depression and diabetes.
1. Little is known about the physiologic factors responsible for apparent increased rates of depression in T1D and T2D. Further research is needed to evaluate the neurochemical, hormonal, immune/inflammatory, and neurological contributors to depression in diabetes.
2. Although there is mounting evidence for increased prevalence of depression in T1D and T2D, the majority of studies have been cross-sectional and uncontrolled in design. Prospective, controlled studies are needed to better characterize the course and impact of clinical depression in diabetes as well as the unique contribution of depression on the development of metabolic syndrome and T2D. Clinical definitions and thresholds should be used to distinguish depression syndromes from short-term emotional states (e.g., adjustment to the diagnosis of diabetes or the development of a complication) and diabetes-related distress.
3. There is currently a paucity of literature addressing rates and correlates of depression among children with T2D and women with gestational diabetes.
4. Although there is strong evidence for the efficacy of one tricyclic antidepressant medication and four SSRI medications, more research is needed to characterize the efficacy of short- and long-term use and relationship to glycemic control of the full spectrum of SSRI and SNRI (serotonin and norepinephrine reuptake inhibitor) antidepressant medications in both adults and children with diabetes.
5. Additional research is needed to evaluate exercise as an efficacious and effective treatment modality for the treatment of depression in patients with T1D and T2D.
6. Additional research is needed to investigate effective means of depression prevention in patients with diabetes.
7. Additional research is needed to establish the cost-effectiveness of all modes of depression treatment in patients with T1D and T2D.
Recommendations for Screening and Care
Depression is a frequent comorbid condition in patients with T1D and T2D. The following recommendations for clinical care are based on the literature and expert opinion (Evans 2005):
1. Depression screening is recommended at every visit for diabetes patients, accompanied by procedures to review patient responses and address clinically significant levels of symptoms. Increased concern is indicated for patients presenting with elevated blood glucose and with worsening diabetes complications and those who report a lifetime history of depression and may therefore be at increased risk for future depressive episodes. Providers may use a variety of brief screening tools to detect depressive symptoms in diabetes patients.
2. Providers are recommended to maintain a low threshold for depression treatment and promote rigorous, ongoing treatment of depression, once identified. Adequate adjustment of dosing for antidepressant medications, well-monitored maintenance therapy, and referrals to mental health services should be routinely provided by health care providers. Coordination of depression and diabetes care across providers is also recommended to ensure adequate depression treatment and follow-up care in light of the persistence and recurrence of depression in diabetes patients and the association with poor medical management.
3. Evidence supports the use of a stepped-care approach (medication and therapy) and monitored maintenance therapy to achieve symptom remission and improvements in glycemic control.
4. Use of a collaborative care approach that integrates therapy and antidepressant medication within primary care settings is suggested. This intervention paradigm has demonstrated the capacity to reduce some barriers, such as social stigma, to the effective treatment of depression in diabetes patients and has been shown to be cost-effective to health care organizations.
5. Incorporation of depression curricula into diabetes education and routine communication with patients about the role of depression in diabetes outcomes is recommended to reduce patient perceptions of stigma associated with mental illness and improve patient awareness of treatment options.
6. Incorporation of depression screening measures into clinical care outcomes within health care organizations is recommended.
BIBLIOGRAPHY
Ali S, Stone MA, Peters JL, Davies MJ, Khunti K: The prevalence of co-morbid depression in adults with type 2 diabetes: a systematic review and meta-analysis. Diabet Med 23:1165–1173, 2006
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders - DSM-IV-TR. 4th ed. Washington, D.C., American Psychiatric Association, 2000
Anderson RJ, Freedland KE, Clouse RE, Lustman PJ: The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care 24:1069–1078, 2001
Arroyo CG, Hu FB, Ryan L, Kawachi I, Colditz G, Speizer F, Manson J: Depressive symptoms and risk of type 2 diabetes in women. Diabetes Care 27:129–133, 2004
Asghar S, Hussain A, Alit SMK, Khan AKA, Magnusson A: Prevalence of depression and diabetes: a population-based study from rural Bangladesh. Diabet Med 24:872–877, 2007
Barnard KD, Skinner TC, Peveler R: The prevalence of co-morbid depression in adults with type 1 diabetes: systematic literature review. Diabet Med 23:445–448, 2006
Beck AT, Steer RA, Brown GK: BDI-II Beck Depression Inventory Manual. 2nd ed. San Antonio, TX, The Psychological Corporation, Harcourt, Brace & Company, 1996
Bruce DG, Davis WA, Davis TME: Longitudinal predictors of reduced mobility and physical disability in patients with type 2 diabetes. Diabetes Care 28:2441–2447, 2005
Carnethon M, Biggs M, Barzilay JJ, Smith N, Vaccarino V, Bertoni AG, Arnold A, Siscovick D: Longitudinal association between depressive symptoms and incident type 2 diabetes mellitus in older adults: the Cardiovascular Health Study. Arch Intern Med 167:802–807, 2007
Carnethon M, Kinder L, Fair J, Stafford R, Fortmann S: Symptoms of depression as a risk factor for incident diabetes: findings from the National Health and Nutrition Examination Epidemiologic Follow-Up Study, 1971–1992. Am J Epidemiol 158:416–423, 2003
Ciechanowski PS, Russo JE, Katon WJ, Von Korff M, Simon GE, Lin EHB, Ludman EJ, Young BA: The association of patient relationship style and outcomes in collaborative care treatment for depression in patients with diabetes. Med Care 44:283–291, 2006
Ciechanowski PS, Katon WJ, Russo JE: Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. Arch Intern Med 160:3278–3285, 2000
Clouse RE, Lustman PJ, Freedland KE, Griffith LS, McGill JB, Carney RM: Depression and coronary heart disease in women with diabetes. Psychosom Med 65:376–383, 2003
de
