Treatment of Depression in Diabetes: an Update

Frank Petrak; Stephan Herpertz


Curr Opin Psychiatry. 2009;22(2):211-217. 

In This Article

Depression and Diabetes: The Size of the Problem

According to a meta-analysis of controlled studies, 9% of patients with diabetes are affected by depressive disorders. When subclinical depression is included, the proportion of patients who have clinically relevant depressive symptoms increases to 26%. Diabetes doubles the odds of depression independent of the study design, source of patients, and method of assessing depression.[1] Recent data on type 2 diabetes demonstrate that the increased risk of elevated depressive symptoms applies only to individuals with treated - but not with untreated - type 2 diabetes.[2••] These findings may reflect the psychological stress or burden associated with diabetes management and the greater number of diabetic complications and comorbidities in adults receiving diabetes treatment compared with those who are untreated. On the basis of estimates of the global prevalence of diabetes in the year 2000, approximately 43 million people with diabetes worldwide have symptoms of depression.[3] Recent results of the Sequenced Treatment Alternatives to Relieve Depression (STAR-D) study, the largest study of depression ever conducted in the United States, indicated an overrepresentation of men elderly people, and minority populations (blacks and Hispanics) in patients with major depression and diabetes.[4•] The economic burden of diabetes alone is significant,[5•] but when depression is present along with diabetes, there is an additional increase in health-service costs of 50-75%.[6]

The interaction between depression and diabetes has been studied extensively in cross-sectional and longitudinal studies in the last decade.[7,8••,9] Most results demonstrated that depression is associated with nearly all important medical and psychosocial outcome parameters of diabetes. Results from a meta-analysis demonstrated that depression was associated with an increased risk for 'subsequent' type 2 diabetes in adults by 37%.[10] In people diagnosed with type 1 or type 2 diabetes, depression increases the risk for persistent hyperglycemia,[11] microvascular and macrovascular complications, and mortality.[12,13,14••] It is important to note that the associations with complications and mortality are present even when patients have mild depression. Elderly patients with type 2 diabetes seem to represent a high-risk group; this outcome was demonstrated, in a 7-year longitudinal study, by a five-fold increase in mortality without any substantial differences between mild and severe depression.[13]

Depression has a strong impact not only on medical outcomes in diabetes but also on psychological and social outcomes. Generic quality of life is considerably reduced with respect to psychological, physical and social functioning (e.g. the ability to work).[15••] Diabetes-related burdens are perceived as more severe, and satisfaction with diabetes treatment is lower when a depressive comorbidity is present.[16] Furthermore, it was demonstrated that patients with depression and diabetes were physically less active, were more likely to smoke tobacco, had less healthy eating habits and adhered less to diabetes treatment.[17,18••]

Unfortunately, depression in diabetes is considerably underdiagnosed and undertreated. As an example, results of a US study that included more than 9000 patients with diabetes revealed a recognition rate for major depression of 51%, whereas 43% of the patients received one or more antidepressant prescriptions and only 6.7% had received four or more psychotherapy sessions over a 12-month period.[19]

Considering the significant evidence base that depression has an adverse effect on both psychological well being and diabetes outcomes, treatment of depression in diabetes should be directed toward improving both psychological and medical outcomes. Improvement in depressive symptoms or remission is the major objective regarding the mental aspects. The physical treatment targets include an improvement in glycemic control and a reduction in risk for short-term and long-term complications and premature mortality.


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