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Sherita Golden, M.D., M.H.S.
01-12-2010
- Depression is a mental disorder, diagnosed using specific criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), characterized by depressed mood and/or loss of pleasure in most activities (anhedonia), along with the signs and symptoms described below.
- Symptoms must be present for at least 2 weeks.
- Depressive disorders are a significant co-morbidity in diabetes; worldwide, estimated 43 million people with diabetes have symptoms of depression.
- People with diabetes are twice as likely to have depressive symptoms as those without diabetes (Anderson).
- In a meta-analysis of individuals with diabetes, the aggregate prevalence of Major Depressive Disorder (MDD) was 11.4% while the prevalence of elevated depressive symptoms was higher, estimated at 31% (Anderson).
- Individuals with elevated depressive symptoms have an approximately 30-60% increased risk of developing type 2 diabetes and individuals with type 2 diabetes have an approximately 12-50% increased risk of developing elevated depressive symptoms (Mezuk, Golden).
- Depressive disorders in diabetes are associated with poor glycemic control and microvascular and macrovascular complications (Lustman, deGroot).
- Depressive disorders are most accurately diagnosed using a structured clinical interview based on criteria from the (DSM-IV). Two commonly used clinical interviews are the Diagnostic Interview Scheduled (DIS) and the Structured Clinical Interview for Depression (SCID).
- Diagnostic criteria for depressive disorders based on DSM-IV criteria are listed in Table 1.
- Depressive symptoms can also be assessed by self- or interviewer-administered questionnaire. Patient Health Questionnaire-9 (PHQ-9) is most often used in primary care settings, screening for MDD and significant depressive symptoms (Kroenke). A score of > 10 with 5 symptoms (including either depressed mood or lack of pleasure in usual activities) present for more than half the days is consistent with major depression.
- Another efficient screening tool for MDD in the clinical setting is the PHQ-2, (see Kroenke K, Spitzer RL, and Williams JB reference) an abbreviated version of the PHQ-9 (see Kroenke K, Spitzer RL, and Williams JB reference).
- See symptoms listed in table 1
- Psychotherapies studied to treat depressive disorders in diabetes include cognitive behavior therapy (CBT) and problem-solving therapy for depression. Both psychotherapeutic treatments improve depressive symptoms in people with diabetes (Petrak).
- In the one study of CBT, hemoglobin A1c was lower in the CBT group (9.5%) compared to the control group (10.9%) 3 months after discontinuation of treatment but problem-solving therapy did not result in significant improvements in glycemic control (Petrak).
- Pharmacological therapies that have been shown to improve depressive symptoms in people with diabetes include the selective serotonin reuptake inhibitors (SSRIs)--fluoxetine, sertraline, or paroxetine (Kroenke).
- Therapeutic effects may take 4-6 weeks after which, if no improvement in symptoms, dose should be titrated upward until symptoms are improved. Recommended initial dosing titration and maximum dosing is included in Table 2.
- Common side effects of SSRIs include gastrointestinal effects (nausea, vomiting, diarrhea, xerostomia [dry mouth]), central nervous system effects (anxiety, nervousness, insomnia, drowsiness, fatigue, dizziness, tremor, headache, suicidal ideation), platelet dysfunction, and diaphoresis.
- Other effects relevant to diabetes: Fluoxetine and Sertraline may be associated with weight loss, improvement in hyperglycemia, and improvement in insulin sensitivity.
- Use of atypical antipsychotics in patients with bipolar disorder may be associated with weight gain and worsening of glycemic control.
- If depressive symptoms do not improve on initial pharmacological therapy, which can be assessed by re-administering the PHQ-9, then anti-depressant therapy should be titrated as outlined in Table 2.
- Clinicians should suspect a depressive disorder in patients whose glycemic control is not improving despite intensification of glucose-lowering therapy and consider screening for depression using the PHQ-2 or PHQ-9.
- Because elevated depressive symptoms are associated with poor health behaviors, such as increased caloric intake and physical inactivity, overweight and obesity can worsen and contribute to poor glycemic control.
- Behavioral treatments for depression should also address motivating patients to participate in physical activity and healthy lifestyle choices.
- Work collaboratively with a mental health provider (i.e. psychologist or psychiatrist) to treat this comorbidity of diabetes.
- Petrak F, Herpertz S;
Treatment of depression in diabetes: an update.;
Curr Opin Psychiatry;
2009; Vol.
22; pp.
211-7;
ISSN:
1473-6578;
PUBMED: 19553878
Rating:
Basis for recommendation
Comments:Provides an excellent overview of psychotherapies and pharmacological treatments for depression. In summary, most depression treatments improve depressive symptoms but do not significantly improve glycemic control in diabetes.
- Kroenke K, Spitzer RL, Williams JB;
The Patient Health Questionnaire-2: validity of a two-item depression screener.;
Med Care;
2003; Vol.
41; pp.
1284-92;
ISSN:
0025-7079;
PUBMED: 14583691
Rating:
Basis for recommendation
Comments:Describes the validity of using the PHQ-2 screening questionnaire to identify individuals at increased risk for having a depressive disorder.
- Kroenke K, Spitzer RL, Williams JB;
The PHQ-9: validity of a brief depression severity measure.;
J Gen Intern Med;
2001; Vol.
16; pp.
606-13;
ISSN:
0884-8734;
PUBMED: 11556941
Rating:
Basis for recommendation
Comments:Describes the validity of using the PHQ-9 questionnaire to identify individuals with depressive disorders.
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