Page 13 - The SA Journal Diabetes & Vascular Disease Volume 9 No 4 (November 2012)

VOLUME 9 NUMBER 4 • NOVEMBER 2012 155
SA JOURNAL OF DIABETES & VASCULAR DISEASE REVIEW
PHQ-9
Van Steenbergen-Weijenburg et al. validated the PHQ-9 against
the MINI as gold standard in 197 patients with type 2 diabetes
in a general hospital diabetes outpatient clinic.27 The cut-point of
a summed score of ≥ 12 on the PHQ-9 resulted in a sensitivity of
76% and a specificity of 80%. The conclusion was that the PHQ-9
is a valid instrument, but that the cut-point needed is higher
than that of ≥ 10 to detect MDD in patients without diabetes.28
With this difference in the cut-point, the PHQ-9 can distinguish
symptomatology that may seem depressive from the diabetes
symptoms.
Patients willing to collaborate with screening and
follow-up treatment
Pouwer et al. established that depression screening by Composite
International Diagnostic Interview (CIDI) with written feedback to
patient and physician had a limited impact on their use of mental
healthcare and did not improve depression scores compared
with care as usual.29 This strongly suggests that simply providing
information after screening is insufficient to change mental
healthcare use patterns in patients and improve clinical outcomes.
It appears that more intensive depression management is required
to improve depression outcomes in those with comorbid MDD in
diabetes. 29 However, Van Steenbergen-Weijenburg et al. found that
many patients identified with MDD by screening in the hospital
outpatient setting did not want to follow such a treatment as they
considered it too intensive.27 Therefore, after screening, a step is
needed that assesses the motivation of hospital outpatient
clinic patients for treatment and that tailors the subsequent
treatment steps. This post-screening assessment requires a
motivational interview. In view of these findings and of those of
Gilbody et al., that screening per se is insufficient to change the
recognition and treatment behaviour of the physician,15 screening
in a clinical setting might be better than screening by mail. This can
be done by the diabetes physician or by a trained diabetes nurse.
Collaboration between physician and nurse in a collaborative care
model as elaborated in the Pathways Study30 could be a means to
achieve this systematically, while providing the physician and nurse
with the organisational support suggested by Gilbody et al .17
Risk profile
Such screening in a clinical setting should be followed by treatment
tailored to patient needs in a stepwise approach. For this purpose,
a risk profile should be made that charts the comorbid MDD, and
the existence of intricate problems associated with diabetes that
will need special attention in the treatment process. This is because
people with comorbid MDD in diabetes are a heterogeneous group
that might contain subtypes of depressions. These subtypes may
require different treatment and management.
Subtypes of depression in persons with diabetes
In people with diabetes, MDD may not be a singular biological
entity. These persons can have symptoms that appear depressive;
however, these are not symptoms of MDD but related to the being ill
as a consequence of diabetes. Such patients should be approached
with psycho-education and self-management advice. People with
diabetes can also have an MDD which is rather similar to an MDD
in patients without chronic illness. In such a case, treatment with
the main focus on the MDD is probably enough to improve the
clinical condition and depressive outcomes. However, the person’s
MDD may also be closely associated with complicated diabetes.
For example, it has been established that occurrence of comorbid
MDD in persons with diabetes correlates with the occurrence and
number of complications. Persons with diabetes with two or more
complications have a more than twice elevated risk of comorbid
MDD. 31 Apersonwith such a profilewill need treatment for theMDD,
and special attention on self-management and case-management
of diabetes. A person with diabetes may have complicated or brittle
diabetes and thus be at risk of developing an MDD, but not have
it yet. Screening not only for MDD but also assessing if intricate
problems associated with the diabetes exist can determine the
need for preventive self-management or close monitoring of such
a patient. Therefore, screening should not only detect MDD but
also identify persons in need of specific interventions aimed at
glycaemic control or management of complications. The risk profile
and subsequent indications for stepwise treatment can be charted
as in Table 2.
Screening: a recommended approach
The following best practice for screening, with tailored treatment
steps as follow up, has been recommended for clinical settings.32
This stepwise approach is shown in Fig.1 and summarised here.
The first step is to look for intricate problems of comorbid
depression. These can include biological phenomena, such
as elevated glucose level or neuropathic pain, and healthcare
utilisation behaviour, such as signs of less self-management, missed
appointments or high healthcare use, dissatisfaction with care, and
diminished trust in healthcare providers.
The second step is to look for signs of distress. This can be
emotional distress, such as feelings of helplessness, ‘giving up’,
demoralisation or being overwhelmed with managing diabetes.
The distress can be cognitive, such as the inability to discern anxiety
from diabetes symptoms, such as hypoglycaemia. The distress can
also be expressed as emotional behavioural reactions that interfere
with the management of diabetes, for example, emotional eating
as a response to grief, loneliness or anger, bulimia, purging, or
eating at night. In the case of such signs, screening for MDD in the
clinical setting is recommended, by the PHQ-9 questionnaire, using
a score of ≥ 12 as the cut-off point.
If MDD is diagnosed in such a screening, the next step is to
improve diabetes self-management, as self-management is often
Table 2. Risk profile and treatment indication
MDD as indicated by
PHQ-9, CES-D or BDI
and clinical interview No MDD
Diabetic hypoglycae-
mia, brittle diabetes,
hyperglycaemia, micro-
and macrovascular
complications
Treatment should
address diabetes
management as well
as MDD
Preventive attention to
self-management may
be provided
No such diabetes-
associated intricate
problems
Treatment should pri-
marily address MDD
Monitoring is sufficient
BDI = Beck Depression Inventory; CES-D = Center for Epidemiological Studies-
Depression Scale; MDD = major depressive disorder; PHQ-9 = Patient Health
Questionnaire.