• Diabetes Mellitus
• Mood Disorders

Comorbid depression in diabetes is highly prevalent and has a negative impact on well-being and diabetes control [van der Feltz-Cornelis CM et al. Gen Hosp Psychiatry 2010]. Diabetes patients with comorbid depression are less likely to engage in physical activity, comply with dietary advice, and stop smoking [DiMatteo MR et al. Arch Intern Med 2000]. They have increased disease burden, greater symptom severity, and more work disability and make greater use of medical services [Lin E et al. Diabetes Care 2010].

In a longitudinal cohort study of 4623 primary care patients with type 2 diabetes mellitus (T2DM), major depression was associated with significantly higher risks of adverse microvascular (HR, 1.36; 95% CI, 1.05 to 1.75) and macrovascular outcomes (HR, 1.24; 1.0 to 1.54; Table 1) [Lin EH et al. Diabetes Care 2010]. Treatment of depression in people with diabetes is a necessary step, but improvement of their general medical condition, including glycemic control, is likely to require simultaneous attention to both conditions [van der Feltz-Cornelis CM et al. Gen Hosp Psychiatry 2010].

According to Cristina van der Feltz-Cornelis, MD, PhD, MSc, University of Tilburg, Tilburg, The Netherlands, T2DM patients with depression need the awareness of the clinician and of mental health professionals; routine screening for depression; integrated, holistic, individualized care; medicines with the fewest number of side effects; information and psychoeducation; relapse prevention; and consultations with psychologists and diet specialists on a regular basis.

Patients can be treated with psychotherapy that is combined with diabetes self-management, medications, or a combination of the two in the primary care setting. Dr. van der Feltz-Cornelis explained that among antidepressants, fluoxetine, sertraline, nortriptyline, and paroxetine significantly improve depressive symptoms. Fluoxetine helps with weight loss and lowers glucose and lipids. Sertraline is effective for relapse prevention, and sertraline and paroxetine improve comorbid anxiety, quality of life, and general functioning. Sertraline is the only antidepressant that influences glycemic control.

Valid instruments for screening include the gold-standard clinical interview, the Beck Depression Inventory (BDI) [Lustman PJ et al. Psychosom Med 1997], Center for Epidemiological Studies-Depression Scale (CES-D), the Hospital Anxiety and Depressions Scale (HADS), the Silverstone Concise Assessment for Depression (SCAD), Depression in the Medically Ill Questionnaire (DMI) [McHale M et al. Psychosom Med 2008], and the Patient Health Questionnaire-9 (PHQ-9) [van Steenbergen-Weijenburg KM et al. BMC Health Serv Res 2010].

For depressed patients, screening alone plus information is insufficient treatment. Pouwer et al. [Diabetologia 2011] found that depression screening by Composite International Diagnostic Interview plus information about the diagnosis made no significant difference in depression scores, diabetes outcomes, or health care utilization.

Screening can be done with CES-D, BDI, or PHQ-9 (cutoff point ≥12 to find major depressive disorder) [van Steenbergen-Weijenburg KM et al. BMC Health Serv Res 2010] and should be followed by a strong intervention that includes psychotherapy or medication (eg, collaborative care).

Depressed patients who are willing and able to engage in treatment should be filtered out from those who are not. Motivational interviewing can be used to improve adherence by the latter. Effective care requires identification of symptoms of depression and appropriate treatment (Table 2).

Additional Reading: Van der Feltz-Cornelis et al. Depression in Diabetes Mellitus: to screen or not to screen? The British Journal of Diabetes and Vascular Disease. In Press. http://dvd.sagepub.com

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