Page 14 - The SA Journal Diabetes & Vascular Disease Volume 9 No 4 (November 2012)

156 VOLUME 9 NUMBER 4 • NOVEMBER 2012
REVIEW SA JOURNAL OF DIABETES & VASCULAR DISEASE
Key messages
C•omorbid depression in diabetes mellitus occurs frequently and
is associatedwith a high symptomburden, more complications,
lower quality of life and higher disability and costs
CES-D, BDI and PHQ-9 are validated instruments for screening •
for comorbid major depressive disorder in diabetes mellitus
More intensive treatment as follow up is needed •
Screening is best performed in the clinical setting, not by •
mail
impaired in MDD and needs specific attention to prevent worsening
of diabetes. The clinician can improve this by exploring if ‘loss of
control’ of self-management in illness occurs in the patient, or a
lack of insight into the bidirectional association between stress and
sub-optimal self-management. If this is the case, the clinician should
explain to the patient the difference between MDD and ‘stress’ and
the overlap with diabetes symptoms, as well as depression-related
symptom amplification. They can then identify and prioritise self-
management tasks together.
It may be that the patient needs support in fulfilling these
self-management tasks. Support can be provided by short-term
psychotherapy, preferably in the same clinical setting. Supportive
diabetes education from specialist nurses can also be of great
value. Also, in the case of not being able to identify and prioritise
problems, problem-solving treatment can be offered and if there
is a lack of adherence to treatment, motivational interviewing
might be useful, which might be performed by trained nurses.
A recent pilot described screening for psychological problems
and common mental disorder by diabetes nurses, followed by a
psycho-educational and motivational intervention by those nurses,
as a feasible method with positive outcomes in an open design.33 If
the patient suffers from moderate to severe depressive disorder or
significant neuropathy, antidepressant medication may be needed
as well.
Conclusion
The needs expressed by persons with diabetes, the high prevalence
of MDD and the availability of effective treatment interventions
warrant screening for comorbid MDD in diabetes via a patient-
centred approach. Screening can be done by CES-D, BDI or PHQ-9,
which are valid instruments for detecting MDD in persons with
diabetes. Research shows that screening and informing both the
patient and the physician about comorbid MDD in diabetes is not
enough to change treatment and outcomes.
More intensive treatment as follow up after screening is needed.
However, screening should include a risk profile of the patient
in order to tailor stepwise follow-up treatment and identify the
patients willing and able to follow the treatment. For these reasons,
screening is best performed in the clinical setting by the diabetes
physician or by a trained diabetes nurse such as in a collaborative
care model.
Acknowledgements
Corine Stoop, MSc, performed the survey with assistance of Cathy
Lloyd and Helen Millar from the DDD, the Dialogue on Diabetes
and Depression – the international collaborative effort addressing
problems related to the comorbidity of diabetes and depression –
and Global Alliance of Mental Illness Advocacy Networks (GAMIAN)
Europe and Gamian Israel. Yoram Cohen, vice president of GAMIAN
Fig. 1. Screening and stepwise patient-centred treatment for comorbid major depressive disorder in diabetes in the clinical setting