Series
Depression and diabetes: treatment and health-care delivery

https://doi.org/10.1016/S2213-8587(15)00045-5Get rights and content

Summary

Despite research efforts in the past 20 years, scientific evidence about screening and treatment for depression in diabetes remains incomplete and is mostly focused on North American and European health-care systems. Validated instruments to detect depression in diabetes, although widely available, only become effective and thus recommended if subsequent treatment pathways are accessible, which is often not the case. Because of the well known adverse effects of the interaction between depression and diabetes, treatment goals should focus on the remission or improvement of depression as well as improvement in glycaemic control as a marker for subsequent diabetes outcome. Scientific evidence evaluating treatment for depression in type 1 and type 2 diabetes shows that depression can be treated with moderate success by various psychological and pharmacological interventions, which are often implemented through collaborative care and stepped-care approaches. The evidence for improved glycaemic control in the treatment of depression by use of selective serotonin reuptake inhibitors or psychological approaches is conflicting; only some analyses show small to moderate improvements in glycaemic control. More research is needed to evaluate treatment of different depression subtypes in people with diabetes, the cost-effectiveness of treatments, the use of health-care resources, the need to account for cultural differences and different health-care systems, and new treatment and prevention approaches.

Introduction

Depression is frequently associated with diagnosed diabetes and has a profound effect on the well-being and medical outcomes of people affected by both disorders. Depression in people with diabetes adversely affects glycaemic control,1, 2 heightens risk of microvascular and macrovascular complications,3 and increases the chances of admission to the intensive care unit4 and the use of health care in general.5 Depression in diabetes also increases mortality,6, 7 especially after myocardial infarction,8 in elderly people9 and in women.10 Depression affects psychosocial outcomes in patients with diabetes.11, 12 It is associated with increased diabetes-related distress (hereafter diabetes-distress),13 decreased quality of life,11, 12 and decreased adherence to diabetes treatment.14 Recommendations for a healthy lifestyle (eg, physical activity, eating habits) are often ignored in patients with both depression and diabetes.15 Despite the well-established adverse effects of the interaction between depression and diabetes, depression remains underdiagnosed and undertreated in people with diabetes.16, 17 The best treatments to address medical and psychological outcomes simultaneously in patients with depression and diabetes are not known. Since most studies have been undertaken in high-income countries (mostly USA and Europe), whether these results can be extrapolated to other countries and cultures worldwide remains unclear.

This Series paper aims to summarise the evidence regarding screening and treatment for depression in adults with type 1 and type 2 diabetes. Most of the scientific literature does not differentiate between the two types of diabetes. Therefore, we approach both types of diabetes together and specify in the text whenever the work discussed did not distinguish between the two types of diabetes. Diabetes-distress,18, 19 which is a concept related to depression but that should be considered separately from depression symptoms or depression as a mental disorder, is outside the scope of this article but is discussed in-depth in Paper 1 in this Series.19 We also focus on the prevention of depression in people with diabetes and address whether research in this area can be applied to different cultures and health-care systems, where such research has not yet been done. Finally, we provide recommendations to guide clinical practice.

Section snippets

Overview

Since depression often remains undetected in people with diabetes,16, 17, 20 various diabetes guidelines21, 22, 23, 24, 25 have recommended screening for depression. Screening for depression with questionnaires is not specific and results in a substantial overestimation of depression.26, 27 Therefore, a positive screening questionnaire needs to be followed up by a formal clinical assessment to confirm the diagnosis and to consider differential diagnoses. Diagnostic interviews, such as the

Prevention of depression in people with diabetes

Despite the clear clinical need and the appreciation by health-care professionals of many of the general and diabetes-specific risk factors that predict depression in people with diabetes,3, 57 few studies have assessed interventions to prevent depression in diabetes. A 2012 systematic review58 concluded that insufficient evidence exists to recommend low-intensity psychological interventions to prevent the relapse or recurrence of depression. Moreover, despite established evidence of the

Prioritising treatment goals—glycaemic control or depression outcomes?

Since depression has an adverse effect on psychological wellbeing and on outcomes for diabetes, treatment of depression in people with diabetes should be directed towards the improvement of both psychological and medical outcomes.62 These goals are formulated specifically in the present evidence-based guidelines of the German Diabetes Association,63 which place equal emphasis on psychological and medical targets during the treatment of depression in diabetes. For the psychological targets, the

Applicability of interventions to different cultural and societal groups

According to the International Diabetes Federation, 77% of people with diabetes live in low-income and middle-income countries.110 However, most studies of depression in diabetes originate from high-income countries. For example, a 2013 meta-analysis on depression as a risk factor for the development of diabetes included only one study from outside Europe or North America.111 Two core dimensions—economic development and cultural differences—need to be considered whenever conclusions from the

Recommendations for treatment

As acknowledged in the Global Guidelines for Type 2 Diabetes of the International Diabetes Federation, “in many parts of the developing world the implementation of particular standards of care is limited by lack of resources”.21 This situation results in different levels of care ranging from limited care (lack of standard medical resources and fully trained health professionals) to recommended care (evidence-based cost-effective care), to comprehensive care (the most up-to-date, complete range

Conclusion

The comorbidity of diabetes and depression remains a clinical challenge for patients and health-care professionals alike. Changes in the undergraduate and postgraduate education and training of health-care professionals who deliver clinical care for patients with diabetes and depression are urgently needed (panel 3). Training must account for the complex aspects of these comorbidities. Training materials created by specialists often neglect the importance of concurrent treatment and management

Search strategy and selection criteria

The search strategy and selection criteria for the included references follows a mixed narrative and systematic approach with specific search strategies for the sections on the evidence for screening. The searches included all articles, published in English. We searched PubMed for all publications with the search terms “diabetes” AND “depression” AND “screening” from incipience until Sep 2, 2014. The evidence from RCTs for the treatment of depression in diabetes follows a meta-review approach.

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