Page 11 - The SA Journal Diabetes & Vascular Disease Volume 9 No 4 (November 2012)
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VOLUME 9 NUMBER 4 • NOVEMBER 2012
153
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
Correspondence to: Prof Dr Christina M van
der Feltz-Cornelis
Department of Clinical Psychology, Tilburg
University, Tilburg, the Netherlands; Trimbos
Institute, Utrecht; GGz Breburg, Tilburg,
the Netherlands.
Tel: +31 134662167; Fax: +31 134662067
E-mail:
Originally in
Br J Diabetes Vasc Dis
2011;
11
: 276–281.
S Afr J Diabetes Vascular Dis
2012;
9
: 153–157
Depression in diabetes mellitus: to screen or
not to screen? A patient-centred approach
CHRISTINA M VAN DER FELTZ-CORNELIS
Abstract
Background
:
Comorbidmajordepressivedisorder(MDD)occurs
frequently in diabetes mellitus and is associated with high
symptom burden, disability and costs. Effective treatments
are available but persons with diabetes with comorbid MDD
are generally under-detected. A survey showed that comorbid
MDD should be identified in a systematic way, such as by
screening.
Aim:
To identify and describe possible strategies to screen
for MDD in persons with diabetes.
Methods
:
After a survey exploring patients’ needs, a
description of best practice is provided based on a review of
the literature and clinical experience.
Results:
Valid instruments for screening are the Center
for Epidemiological Studies-Depression Scale (CES-D), the
Beck Depression Inventory (BDI), and the Patient Health
Questionnaire (PHQ-9). Research shows that screening and
informing patients and physicians about comorbid MDD
in diabetes is inadequate and more intensive treatment as
follow-up is needed to change treatment and outcomes.
Screening should identify patients willing and able to
follow treatment if comorbid MDD is detected and should
be followed by a stepwise approach to tailor treatment to
patient need and ability.
Conclusion
:
Screening is best performed in a clinical setting,
not by mail, and may be achieved by healthcare professionals
using a collaborative care model.
Keywords:
best practice, depression, diabetes mellitus, patient-
centred, review, screening, stepped care, treatment
Introduction
Depressive symptoms occur as often in patients with diabetes
mellitus as in those with cerebrovascular accident and acute cardiac
symptoms, with a range from 31 to 33%.
1
Several reviews indicate
that the prevalence of comorbid MDD in persons with diabetes
ranges from 11 to 33% and that this comorbidity is associated
with high symptom burden and disability.
2,3
A mail survey of 4 168
persons with diabetes found that ‘those with major depression
(
n
= 487) reported significantly more diabetic symptoms (mean =
4.40)
than participants without depression (mean = 2.46)’. The nine
factors considered symptomatic of diabetes were cold/numb hands
and feet, polyuria, excessive hunger, abnormal thirst, shakiness,
blurred vision, feeling faint and feeling sleepy. The overall number
of diabetic symptoms was significantly related to the number
of depressive symptoms.
4
Comorbid depressive symptoms are
associated with poor glycaemic control
5
and an increased number
and severity of complications of diabetes in terms of microvascular
and macrovascular complications.
6
A systematic review of 12 studies on depression and 13 on
anxiety showed that, compared with non-depressed persons with
diabetes, the odds were three times greater that depressed persons
with diabetes would be non-compliant with medical treatment
recommendations. No such association was found in the studies
concerning anxiety.
7
The clinician should therefore be aware that
self-management of diabetes may be impaired in patients with
comorbid MDD, with less physical activity, less compliance with
dietary advice, less adherence to treatment advice and greater
difficulty to stop smoking.
8
Comorbid MDD in diabetes decreases
the ability to work and leads to higher absenteeism.
9
It is also linked
to a decreased quality of life
10
and with high healthcare use and
costs.
11
In an e-mail survey conducted by the Trimbos Instituut and the
DDD with the GAMIAN-EUROPE and GAMIAN-ISRAEL patient
organisations, persons with diabetes were asked about their needs
with regard to depressive symptoms linked to diabetes.
12
They
indicated needs in terms of recognition of the comorbid condition
and treatment. Concerning the recognition of the condition, they
indicated that the clinician and mental healthcare professionals who
treated them needed to be aware of the possibility of comorbid MDD
in diabetes. They also asked for training of mental health professionals
to explore this and of diabetes professionals to routinely screen for
depression. Moreover, they also expressed the need for an easy tool
to routinely screen patients with diabetes for MDD.
Regarding treatment, persons with diabetes described the
need for professional expert care with an integrated holistic and
individual approach. They wanted treatment with medicines with
fewer side effects, information and psycho-education, relapse-
prevention treatment and consultations with psychologists and diet
specialists on a regular basis. They preferred this to be provisioned
in one setting within a combined treatment programme. The
survey therefore generated qualitative input about patients’ needs
concerning comorbid MDD in diabetes, which may be used for
clinical work and research.
In a survey held during a South Asian regional meeting in Hong
Kong in March 2011 on diabetes treatment with 100 diabetes
