0031-5990 ?? 2ORIGINAL 43 The Blackwell 2007 Art of USA Publishing Prescribing in Publishing ARTICLE Psychiatric Inc2007 Care
Diabetes and Depression: Pharmacologic Considerations
Deborah Antai-Otong, MS, APRN-BC, FAAN
During the last year a large number
of patients with type II diabetes have been referred from primary care providers for evaluation and treatment of major depression. I know research findings are inconsistent concerning the co-occurrence of diabetes and depression, but what are the clinical implications for treating patients with diabetes and major depression? DEBORAH ANTAI-OTONG RESPONDS: The precise relationship between diabetes and depression continues to be debated. However, most research implicates a positive correlation between depression and type II diabetes (Anderson, Freedland, Clouse, & Lustman, 2001; Nichols & Brown, 2003). Controversy about this relationship and necessity to screen patients presenting with diabetes exists as well (Brown, Sumit, Majumdar, & Johnson, 2006). Depression is widespread in patients with diabetes, but it often goes unrecognized and undertreated in primary care settings. Left untreated, depression can result in negative clinical outcomes, increased healthcare and economic burden, and a threat to overall health integrity and quality of life. Psychiatric nurses must be prepared to collaborate with primary care and other healthcare providers to screen patients with diabetes who are at risk for depression. Accurate diagnosis ensures the initiation of pharmacologic and nonpharmacologic treatments that reduce complications of both chronic diseases. QUESTION:
Perspectives in Psychiatric Care Vol. 43, No. 2, April, 2007
Incidence of Depression in Type II Diabetes
Major depression occurs in one in four patients with type I and type II diabetes mellitus (Anderson et al., 2001) and is associated with poor glycemic control, negative clinical outcomes, reduced quality of life and level of function, and diabetic-related mortality (Katon et al., 2004; Zhang et al., 2005). Several studies demonstrated that individuals with diabetes experienced up to threefold incidence of depression compared to those without diabetes (Anderson et al.; Hermanns, Kulzer, Krichbaum, Kubiak, & Haak, 2005; Nichols & Brown, 2003). Major depression is frequently linked to diabeticrelated complications, particularly micro- and macrovascular conditions (Wexler, 2006). For instance, depressed patients are twice as likely to develop diabetes compared to those who are not depressed (Knol, Twisk, Beekman, Snoek, & Pouwer, 2006). Moreover, depressed patients with diabetes are likely to experience an accelerated risk of coronary artery disease and significantly higher incidence of diabetes-related mortality (Brown, Majumdar, Newman, & Johnson, 2005; Egede, Nietert, & Zheng, 2005; Katon et al., 2005). Evaluation and treatment is a priority because of the relationship between depression and poor glycemic and metabolic management in patients with type II diabetes. The pathogenesis of this relationship is still poorly understood and necessitates further study. However, behavioral, physiologic, genetic, and environmental stressors may alter neuroendocrine and neurotransmitter functions. It is imperative to recognize risk factors along with symptoms of co-occurring depression and their impact on chronic disease management because of negative prognostic implications associated with co-occurring diabetes and depression. Age, female gender, previous history of depression, complications from diabetes, such as peripheral neuropathic pain, impaired functional status and quality of life, and psychosocial stressors are risk factors (Hermanns et al., 2005; Legato et al., 2006). Steps to establish quality health care begin with 93
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collaboration with primary care providers, patients, and
their families to develop and implement an individualized treatment plan. Implications for Psychiatric Nursing Practice Treating depression in the diabetic patient is similar to treating other co-occurring chronic diseases. It is imperative to evaluate the patients physical condition by asking questions about prescribed and over-the-counter medications and adherence to treatment adherence. Ordering blood chemistries, hemoglobin A1C (HgbA1C), drug screens when appropriate, and lipid profile; measuring vital signs, height, and weight; and working with the primary care provider to evaluate metabolic/ glycemic control is advisable. It is equally important to rule out coexisting psychiatric (e.g., anxiety disorder, substance-related disorders) and medical conditions, including cardiovascular disease, hypertension high low-density lipoprotein cholesterol and triglyceride, and obesity. The decision to seek psychiatric evaluation and treatment can be unsettling to the patient who may deny the distress associated with diabetes and depression. Establishing collaborative relationships with the primary care provider helps ensure their support of mental health treatment. Open communication about the patients medical problems and history, including adherence to treatment, quality of support systems, cultural perceptions of diabetes and depression (e.g., gender, generational), and coping styles is helpful in co-collaborating. Advanced practice psychiatric nurses must perform a comprehensive psychiatric evaluation that includes the patient and familys perception of the mental health consult or referral, expectations from treatment, and motivation to participate and adhere to treatment. Health behaviors and lifestyles must also be evaluated and need to include adherence to treatment, suicide and homicide risk, glucose self-monitoring, exercise schedule, diet, quality of interpersonal relationships and leisure time, spiritual and religious beliefs, stress management skills, and tobacco use. Standardized 94
tools and instruments, such as the Beck Depression
Inventory (BDI), Hamilton Depression Rating Scale (HDRS), and a more recently developed tool, the Depression Interview and Structured Hamilton (DISH) scale, can be used to gather baseline data about the severity of depressive symptoms and a means to determine the percentage of symptom reduction or remission. The DISH scale was designed specifically to evaluate and diagnose depression in patients with medical conditions (Freedland et al., 2002). The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association, 2000) criteria for major depression guides in making differential and accurate diagnosis of depression. After a definitive diagnosis is confirmed, treatment options must be discussed with the patient and family to determine a plan of care. Collaboration with the primary care provider is crucial throughout treatment to ensure a seamless plan of care. This is particularly important in light of potential drug interactions between medications used to treat diabetes and co-occurring medical conditions and antidepressants. Pharmacotherapy Treating the patient with diabetes is no different than treating other medical conditions. Due to potential negative consequences of untreated depression (e.g., suicide, impaired functioning) and diabetes it is critical to initiate treatment as soon as possible. Significant challenges for psychiatric nurses include choice of antidepressant with a safe side-effect profile, length of treatment to sustain remission, and parallel glycemic control. Relative to choice of antidepressant and duration of treatment, research indicates that selective serotonin reuptake inhibitors (SSRIs) have proven efficacy and are the first-line treatment of depression in diabetes. Sertraline, fluoxetine, and paroxetine demonstrated equal efficacy in most findings with doses ranging from 50200 mg, 2040 mg, and 20 mg, respectively (Gulseren, Gulseren, Hekimsoy, & Mete, 2005; Lustman et al., 2006; Paile-Hyvarinen, Wahlbeck, & Eriksson, 2003). Duration of antidepressant treatment Perspectives in Psychiatric Care Vol. 43, No. 2, April, 2007
ranged from 8 to 16 weeks in most randomized
controlled trials. Even though patients experienced significant improvements in mood and glycemic control, these results appear to be transitory and support the debate to provide maintenance antidepressant treatment in this population. Findings from earlier randomized controlled studies that provided short-term antidepressant management established that less than 40% of patients with co-occurring diabetes and depression were in remission one year later (Lustman, Freedland, Griffith, & Clouse, 2000; Lustman, Griffith, Freedland, & Clouse, 1997). Lustman et al. (2006) concluded that maintenance therapy with sertraline sustained symptom remission in depressed diabetic patients for at least 12 months. Conclusions from this study strengthen the argument to maintain antidepressant treatment for at least a year to prevent depression recurrence. Despite substantial improvement from antidepressants regardless of duration of treatment, findings are inconsistent regarding a parallel to glycemic control (Katon et al., 2004; Lustman et al., 2006). Patient education to improve self-management, symptom control, medications, and screening procedures must be an integral part of treatment for depressed diabetic patients. Collaboration with primary care providers and diabetic educators provides a holistic treatment plan to improve mood, facilitate glycemic control, promote adherence to treatment, prevent complications, and improve functional status and quality of life. Summary Obesity is a worldwide epidemic and a serious health problem with associated complications, such as diabetes and other chronic health problems. Depression is present in one in every four patients with diabetes. Psychiatric nurses are poised to collaborate with primary care providers and reduce complications associated with co-occurring diabetes and depression. Challenges to parallel improved mood with glycemic control need further research. Perspectives in Psychiatric Care Vol. 43, No. 2, April, 2007
Author contact: deborah.antai-otong@va.gov, with a copy to
the Editor: mary@artwindows.com References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. Anderson, R. J., Freedland, K. E., Clouse, R. E., & Lustman, P. J. (2001). The prevalence of comorbid depression in type 2 diabetes: A meta-analysis. Diabetes Care, 24, 10691078. Brown, L. C., Majumdar, S. R., Newman, S. C., & Johnson, J. A. (2005). History of depression increases risk of type 2 diabetes in younger adults. Diabetes Care, 28, 10631067. Brown, L. C., Majumdar, S. R., Newman, S. C., & Johnson, J. A. (2006). Type 2 diabetes does not increase risk of depression. Canadian Medical Association Journal, 175, 4246. Egede, L. E., Nietert, P. J., & Zheng, D. (2005). Depression and allcause and coronary heart disease mortality among adults with and without diabetes. Diabetes Care, 28, 13391345. Freedland, K. E., Skala, J. A., Carney, R. M., Raczynski, J. M., Taylor, C. B., Mendes de Leon, C. F., et al. (2002). The Depression Interview and Structured Hamilton (DISH): Rationale, development, characteristics, and clinical validity. Psychosomatic Medicine, 64, 897905. Gulseren, L., Gulseren, S., Hekimsoy, Z., & Mete, L. (2005). Comparison of fluoxetine and paroxetine in type II diabetes mellitus patients. Archives of Medical Research, 36, 159165. Hermanns, N., Kulzer, B., Krichbaum, M., Kubiak, T., & Haak, T. (2005). Affective and anxiety disorders in a German sample of diabetic patients: Prevalence, comorbidity and risk factors. Diabetic Medicine, 22, 292300. Katon, W. J., Rutter, C., Simon, G., Lin, E. H., Ludman, E., Ciechanowski, P., et al. (2005). The association of comorbid depression with mortality in patients with type 2 diabetes. Diabetes Care, 28, 26682672. Katon, W. J., Simon, G., Russo, J., Von-Korff, M., Lin, E. H., Ludman, E., et al. (2004). Quality of depression care in a population-based sample of patients with diabetes and major depression. Medical Care, 42, 12221229. Knol, M. J., Twisk, J. W., Beekman, A. T., Snoek, F. J., & Pouwer, F. (2006). Depression as a risk factor for the onset of type 2 diabetes mellitus: A meta analysis. Diabetologia, 49, 837845. Legato, M. J., Gelzer, A., Goland, R., Ebner, S. A., Rajan, S., Villagra, V., et al. (2006). Gender-specific care of the patient with diabetes: Review and recommendations. Gender Medicine, 3, 131 158. Lustman, P. J., Clouse, R. E., Nix, B. D., Freedman, K. E., Rubin, E. H., McGill, J. B., et al. (2006). Sertraline for prevention of depression recurrence in diabetes mellitus: A randomized, double-blind, placedbo-controlled trial. Archives of General Psychiatry, 63, 521 529. Lustman, P. J., Freedland, K. E., Griffith, L. S., & Clouse, R. E. (2000). Fluoxetine for depression in diabetes: A randomized, doubleblind, placebo-controlled trial. Diabetes Care, 23, 618623.
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