Implications for the PCP
Research supports a clear association between diabetes and depression, even though the mechanisms underlying this relationship are not well understood. PCPs are frequently responsible and well positioned to manage these comorbid disorders and are advised to proactively screen for, diagnose, and treat depression to optimize patient outcomes, yet a number of barriers contribute to depression being inadequately managed in primary care. Suboptimal recognition can be addressed by increasing provider knowledge and following current treatment guidelines for routine depression screening of all diabetic patients, whether or not known risk factors for depression are present. Several screening tools have been validated in diabetic patients that can be completed in less than 10 minutes; use of the PHQ-2 to determine whether further investigation with PHQ-9 is warranted may help optimize the efficiency of the screening process. Providers should also be aware that presenting symptoms of depression can differ and should be sensitive to patients' gender, race, ethnicity, and individual values and beliefs.[2,108,142]
Management of depression in diabetes should be approached in a comprehensive manner, which potentially includes both medication and referral for psychotherapy such as CBT. Patients resistant to treatment should be educated to understand that benefits extend beyond improved mood and may include pain relief; decreased anxiety; improved social, occupational, and physical activity; enhanced general and sexual functioning; decreased preoccupation with somatic symptoms; more normal sleep and eating habits; improved coping skills; and better diabetes care.[2,94] Other patient barriers can be circumvented by selecting a treatment(s) that match an individual's symptoms, taking his or her preferences into consideration, and including patients' partners or other key family members whenever possible. Management barriers imposed at the system level include time constraints limiting close follow-up and monitoring, competing clinical priorities, and poor integration with mental health care. Treatment studies have demonstrated a clear need for PCPs to have additional mental health support, which may relieve some of the burden experienced by providers in primary care. Treatment algorithms for pharmacological treatment of depression in primary care patients with diabetes provide further assistance for PCPs clinical decisions.[31,89] Concordant with the research summarized here, these guidelines recommend initial treatment with an SSRI or other new antidepressant, taking into account patients' personal or familial responses to specific medications, in addition to side effects.[31,89] The timeline and further indications for follow-up assessment based on these recommendations are listed in Figure 1.
PCPs are also likely to be aided by future research addressing gaps in the current body of literature. Much of the research on comorbid depression in diabetic patients is limited to MDD; treatment for subclinical or other depressive disorders has received little study, even though these conditions may produce similar effects to MDD. Trials of newer antidepressants are promising, although there is little research on their use in the diabetic population. Antidepressant maintenance therapy has been identified as necessary, yet the long-term outcomes associated with it are unknown. Moreover, there is a need for collaborative care programs to identify effective and efficient ways to integrate treatment for these conditions in primary care.
Journal for Nurse Practitioners. 2009;5(7):523-535. © 2009 Elsevier Inc.
Cite this: Depression as a Comorbidity to Diabetes: Implications for Management - Medscape - Jul 08, 2009.