This section of the Web site will keep users current on: topics appearing in the peer reviewed literature relevant to depression and diabetes; related articles appearing in the medical and public health press; guidelines or position papers issued by authoritative sources; guidance on screening tools, and other selected resources that we identify and add to the guide. For access, simply click on any of the following topics:
Peer Reviewed Journal Reports
To access the full text of any of the studies listed, simply go to the home page of the respective journal, click on “Past Issues” and fill in the requested information or click on the specific date of the journal in which the article appeared.
Longitudinal Association Between Depressive Symptoms and Incident Type 2 Diabetes Mellitus in Older Adults
Mercedes R. Carnethon, PhD; Mary L. Biggs, MPH; Joshua I. Barzilay, MD; Nicholas L. Smith, PhD, MPH; Viola Vaccarino, MD, PhD; Alain G. Bertoni, MD, MPH; Alice Arnold, PhD; David Siscovick, MD.
Archives of Internal Medicine, 2007;167:802-807.
This study showed that elderly individuals with depressive symptoms are more likely to develop diabetes than those without such symptoms. The study followed 4,681 people 65 years old and older for a 10-year period who were free from diabetes at the outset. Researchers used the 10-item Center for Epidemiological Studies—Depression Scale (CES-D) annually to assess the presence and level of depressive symptoms. A single report of high depressive symptoms, an increase in symptoms during follow-up, and persistently high symptoms were each studied in relation to the incident of diabetes. Adjusting for physical activity, smoking, alcohol intake, body mass index, and C-reactive protein during follow-up, researchers found that each measure of depressive symptoms was significantly associated with the incident of diabetes. Lead researcher, Mercedes R. Carnethon of the Department of Preventive Medicine at Northwestern University was quoted as saying: “the findings suggest depression may play a role in causing diabetes.” She added: “The findings point to the importance of doctors screening older adults for depression and, if it is present, for diabetes risk.”
Factors Influencing Glycemic Control in Type 2 Diabetes During Acute-and Maintenance-Phase Treatment of Major Depressive Disorders With Bupropion.
Patrick J. Lustman, PhD, Monique M. Williams, MD, Gregory S. Sayuk, MD, Billy D. Nix and Ray E. Clouse, MD.
Diabetes Care, 30:459-466, 2007, DOI: 10.2337/dc05-1769
Researchers in Missouri found that treating depression in patients with diabetes with the drug bupropion resulted in
improved glycemic control. The drug was chosen because of its capability of reducing depression and weight simultaneously. Lustman and colleagues at Washington University, and Veterans Affairs Medical Center, both in St. Louis, wanted to determine whether findings from previous studies using the drug to achieve glycemic control were due to the drug per se or to BMI changes and diabetes self-care. Ninety-three patients with type 2 diabetes and a major depressive disorder received bupropion in a two-phase, open label trial—an acute phase of 10 weeks and a maintenance phase of 24 weeks. BMI, total fat mass, and AIC decreased, and depression severity lessened as glycemic control improved during the acute phase, whereas only depression reduction predicted glycemic control over the maintenance interval. Reporting in the March, 2007 issue of Diabetes Care, the authors concluded that: “In the short term, improvement in glycemic control during bupropion treatment is predicted independently by improvement in mood and body composition. Longer term improvements in glycemic control are predicted primarily by sustained improvement in mood via mechanisms independent of body measures and self-care modifications.”
Cost-effectiveness of Systematic Depression Treatment Among People With Diabetes Mellitus.
Gregory E. Simon, MD, MPH; Wayne J. Katon, MD; Elizabeth H.B. Lin, MD. MPH; Carolyn Rutter, PhD; Willard G. Manning, PhD; Michael Von Korff, ScD; Paul Clechanowski, MD; Evette J. Ludman, PhD; Bessie A. Young, MD, MPH
Archives of General Psychiatry, Vol. 64, No. 1, January, 2007
Dr. Gregory Simon of the Seattle-based Center for Health Studies and colleagues concluded that a systematic approach for treating depression in patients with diabetes results in health care costs savings. The treatment regimen involved specialized nurses who provided a 12 month stepped-care depression program using psychotherapy or antidepressant drugs or both with referral to more specialized care as needed. The report found that factoring in the effects of patient differences at study entry, systematic depression treatment was
associated with an increase of 61 depression-free days over the 12-month treatment period and an estimated cost-savings of more than $300 per person. On the basis of their findings, the investigators concluded: “For adults with diabetes, systematic depression treatment significantly increases time free of depression and appears to have significant economic benefits from the health plan perspective. Depression screening and systematic depression treatment should become routine components of diabetes care.”
Integrating Depression Care With Diabetes Care in Real World Settings: Lessons Learned from the Robert Wood Johnson Foundation (RWJF) Diabetes Initiative
Daren Anderson, MD, Claire Horton, MD, Mary L. O’Toole, PhD, Carol A. Brownson, MSPH. Patrick Fazzone, DNSc, MPH, RN, and Edwin B. Fisher, PhD.
Diabetes Spectrum, Volume 20, Number 1, 10-16, Winter, 2007
Of the 14 clinic and community health sites participating in the RWJF Diabetes Initiative to develop models on the self-management of diabetes, nine sites decided to focus on the relationship between diabetes and depression. Reporting in an article in Diabetes Spectrum, the authors said program officials at the sites regarded depression as a significant barrier to self management in patients with diabetes. Using the PHQ-9 as a depression screening instrument, they found that 30 to 70 percent of patients with diabetes suffered with moderate to severe depression. The nine sites developed their own interventions to treat patients with both illnesses in a coordinate manner in primary care and community settings. They included enhancement of primary care, integrated mental health services, group therapy, and approaches emphasizing cultural traditions and mind-body focus. The patients were underserved and ethnic minorities whom the authors noted represented high rates of co-morbid conditions. On the basis of reports from nine sites, the authors concluded that addressing depression as an essential part of diabetes care can be accomplished in a coordinated manner in real-world settings.
Improving the Management of Chronic Disease at Community Health Centers
Bruce E. Landon, MD. MBA, Leroi S. Hicks, MD, MPH, A. James O’Malley, PhD, Tracy A. Lieu, MD. MPH, Thomas Keegan, PhD, Barbara J. McNeil, MD. PhD, and Edward Guadagnoli, PhD
New England Journal of Medicine, Volume 356:921-934, March 1, 2007, Number 9
A study conducted by Harvard University showed that those community health centers participating in quality improvement collaboratives (the Health Disparities Collaboratives sponsored by HRSA—the Health Resources and Services Administration) had better disease management outcomes than those centers not participating in the collaboratives. Quality care measures were monitored for patients treated for diabetes, asthma, and hypertension. Over nine thousand, six hundred patients were enrolled in 44 interventions centers which participated in collaboratives, and in 20 centers that were not participating. Reporting in the New England Journal of Medicine, investigators found that: “the Health Disparities Collaboratives significantly improved the processes of care for two of the three conditions studied--diabetes and asthma.” These improvements included a 14% increase in the assessment of glycated hemoglobin. In a news release issued by the Harvard Medical School, the HRSA administrator, Betty Duke, was quoted as saying: “The lessons learned from studies conducted at HRSAs Health Disparities Collaboratives have the potential to save lives and improve the health of thousands of Americans.” In the same news release, the Director of the Agency for Healthcare, Research and Quality (AHRQ), Carolyn Clancy, M.D., said: “These findings will guide our quality improvement efforts in the overall health-care system and at health centers, which are a critically important component of a national strategy to deliver quality care to the medically vulnerable.”
Articles in the Medical/Public Health Press
For many patients and some health professionals, the media often serves as a significant if not major source of health information. It is useful for health professionals to know what news stories related to depression and diabetes are being carried in the medical, public health or lay press since this may influence a patient’s understanding or the public’s awareness of the respective diseases or the co-morbidity itself. We will highlight such stories and add updated stories as they appear.
Depression Linked to Low Insulin Sensitivity in Type 2 Diabetes--Researchers at the University of Connecticut in Farmington report that depression is associated with low insulin sensitivity and that treatment of depression decreases insulin resistance. "Depressed subjects have a 37% increased risk of developing diabetes." Read the full article at: http://www.diabetesincontrol.com/index.php?option=com_content&view=article&id=8036&Itemid=8
Diabetes and depression in older women-double the risk, double the burden--In the USA, approximately 24 million people have diabetes; more than half are women, and projections to 2050 suggest that women of all ages will continue to represent more than half of all cases. A growing concern for women with diabetes is the increased risk to many of developing major depression. The results from a recent meta-analysis of 42 studies showed that women with diabetes have a higher prevalence of depression (28%) than men with diabetes (18%). The authors of this report define major depression, identify factors that make older women susceptible, discuss management issues, and make recommendations to address the needs of older women with diabetes and depression. Download the full article at: http://www.diabetesvoice.org/en/articles/diabetes-and-depression-in-older-women-double-the-risk-double-the-burden
Black Heart Patients are More Likely to be Undertreated for Depression--In a press release from Duke Medicine News, it was reported that blacks and whites with heart disease are both likely to experience symptoms of depression, but blacks are only half as likely to receive treatment for the mental disorder. James Blumenthal, Ph.D., a psychologist at Duke and co-author of the study, said: “this is an important finding because we know that depression is associated with a 2-to-4-fold increase in the risk of complications and death from heart disease.” He added: “Under-treatment of depression is a serious clinical issue.” Duke researchers said that depression was common in the 864 patients they studied. Thirty-five percent of the black patients and 27 percent of the white patients had elevated measures of symptoms of depression. Whereas 21 percent of white patients were taking antidepressants, only 11.7 percent of black patients were receiving treatment. Women of both races with depression were much more likely to be on medications than men. The study is being carried on the online version of the American Heart Journal.
Depression Hampers Glucose Control in People with Diabetes--A study of older veterans with type 2 diabetes found that depression can cause patients to suffer from higher glucose levels over time. Researchers from the Medical University of South Carolina analyzed data from 11,525 veterans with type 2 diabetes who received care at a Veterans Administration facility in the Southeast. Ninety-eight percent of the patients were men with an average age of 66. The online news service, Newswise, quoted Leonard Egede, M.D., the co author of the study as saying: “Our study shows that depression is a major and important co-morbidity in people with type 2 diabetes. Commenting on the study, Evette Joy Ludman, Ph.D., of the Group Health Center for Health Studies, said: “although the link between depression and diabetes complications might seem daunting, it is possible for adults to follow treatment orders for their depression while also managing their diabetes.” She added: “I think it is a reasonable expectation that health care teams can help patients who have both depression and diabetes managed both conditions.” The study appeared in the November/December issue of the journal, General Hospital Psychiatry.
Study Shows That Clergy Sometimes Dismiss Mental Illness Complaints in Those They Counsel--A Baylor University study found that clergy often deny or dismiss mental health complaints in their church members who turned to their church for assistance. In a report by the online news service, Newswise, it was reported that 32 percent of church members were told by their pastors that they or their loved one did not really have a mental illness, and that the cause of their problem was solely spiritual in nature. All of the 293 participants in the study had diagnosed by a licensed mental health provider as having a serious mental illness, like depression, bipolar disorder and schizophrenia prior to approaching their local church for assistance. The lead researcher for the study, Dr. Matthew Stanford, Professor of Psychology and Neuroscience at Baylor,said: “Those whose mental illness is dismissed by clergy are not only being told they don’t have a mental illness, they are also being told they need to stop taking their medication. That can be a very dangerous thing.” The Baylor study was published in Mental Health, Religion and Culture.
AHRQ Reports One in Five Hospital Admissions is for Mental Illness--The Agency for Healthcare Research and Quality reported that 1.4 million hospitalizations (one in five) in 2006 involved patients who were admitted for a mental illness, including depression. Another 7.1 million were found to have a mental disorder in addition to the physical condition for which they were admitted, such as diabetes or heart disease. In a news release from AHRQ, it was noted that 730,000 of the mental illness admissions were for depression or other mood disorders. The report was from a News and Numbers brief from the federal agency, based on data from Hospital Stays Related to Mental Health, 2006 (HCUP Statistical Brief #62) which can be found at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb62.pdf.
AHA Calls for Routine Depression Screening in CHD Patients--The American Heart Association issued a statement saying that patients with coronary heart disease should be screened early and regularly for depression. The statement was produced by an AHA Working Group Co-Chaired by Erika Froelicher, Ph.D of the University of California at San Francisco who said “the statement was prompted by the growing body of evidence that shows a link between depression in cardiac patients and a poorer long-term outlook.” The statement noted that multiple studies have shown that major depression is associated with worse prognosis in patients with coronary disease. Moreover, it added, most studies have demonstrated a dose-response relationship: increasing severity of depression is associated with earlier and more severe cardiac events. A news report on the new statement was carried by one online service, MedPage Today, which can be accessed at http://www.medpagetoday.com/Cardiology/CoronaryArteryDisease/tb/11104. The AHA recommends using the Patient Health Questionnaire (PHQ-9) to screen coronary disease patients for depression. All patients should be asked the first two of 9 questions which are: “do you have little interest or pleasure in doing things?” and “do you feel down, depressed, or hopeless?” Patients who answer in the affirmative, the statement noted, should then be given the other seven questions of the questionnaire which probe deeper into the severity of the depressive state. The statement noted that effective therapies were available for depression and gave support to medications such as selective serotonin reuptake inhibitors as well as cognitive therapy. It also calls for coordination of care between physical and mental health specialists “to ensure that heart disease and depression are both adequately treated and do not have adverse consequences for each other.” The full AHA statement can be found in the September issue of Circulation, the Journal of the American Heart Association. (Circulation 2008; 118: DOI: 10.1161./circulationaha.108.190769.)
Depression in Elderly Patients With Diabetes Linked to Higher Death Rates--Research involving more than 10 thousand Medicare beneficiaries with diabetes found that those with depression had an increased risk of 36 to 38 percent of dying from any cause during the two years of the study. The findings were reported by the online news service. Newswise, based on an article appearing in the October, 2008 issue of the Journal of General Internal Medicine. The patients, enrolled in a disease management program in Florida, were surveyed at the start of the study with a health assessment questionnaire. Evidence of depression came from physician diagnosis, patient reports of having a prescription for an antidepressant in the year before the survey, or patient answers to a brief screening test. The lead author of the study, Dr. Wayne Katon, Professor of Psychiatry and Behavioral Sciences at the University of Washington, noted that earlier research indicated a lethal mix of depression and diabetes in young and middle age patients. This study, he added, suggests that depression is a risk factor for mortality in older patients as well. The study authors identified several reasons why depression worsens chronic diseases such as diabetes. Depression, they said, has been associated with inadequate self-care and harmful habits like smoking or overeating. Depression is also associated with nervous system and endocrine system problems, and with inflammatory markers. In addition to Dr. Katon, the researchers included Drs. Ming-Yu Fan and Jurgen Unutzer of the University of Washington, Dr. Jennifer Taylor from Green River health in Tampa, FL, Dr. Harold pincus from Columbia University, and Michael Schoenbaum from the National Institutes of Mental Health. The study was funded by the NIMH.
New Report Says the Poor,Women, Middle-aged People and Blacks at Higher Risk of Depression--CDC’s National Center for Health Statistics released data from the 2005-2005 National Health and Nutrition Examination Survey (NHANES) which underscored the higher prevalence of depression among the poor, women, blacks and people between the ages of 40 and 59. The report indicated that as many as 5.4% of Americans 12 years or older experienced depression in any two-week period. It noted that the figure may be even higher since people with severe depression may have chosen not to participate in the survey. Among the report’s key findings: Rates of depression were higher among poor persons (one out of seven) than those with higher incomes; Approximately 80% of persons with depression reported some level of functional impairment because of their depression, and 27% reported serious difficulties in work and home life; and only 29% of all people with depression reported contacting a mental health professional in the past year, and among the subset with severe depression, only 39% reported contact. The report, called an NCHS Data Brief, was prepared by Laura Pratt, Ph.D., and Debra Brody, M.P.H., both of the National Center for Health Statistics, who noted that despite the fact that depression is a treatable condition, so few—even those with severe depression—sought appropriate treatment. They identified several possible reasons that might contribute to that situation. They said some depressed people do not realize that they have the illness. Others may not believe that treatment works and still others may be influenced by the stigma of mental health. They also cited the lack of health insurance for mental illnesses. The Patient Health Questionnaire (PHQ-9) was used in the survey. The instrument asks 9 questions about the frequency of symptoms over the past two weeks. The NCHS data brief can be accessed at: http://www.cdc.gov/nchs/data/databriefs/db07.htm
New Study Links Another Chronic Disease to Depression--A new Italian study reports that people with the immune condition called sarcoidosis often suffer from mental health problems, particularly depression. African-Americans are at particular risk for the chronic disease which afflicted comedian Bernie Mac who died last month. According to the National Heart, Lung, and Blood Institute, tens of thousands of Americans have the disease. Arriana Goracci, M.D., of the University of Sienna examined 80 sarcoidosis patients who sought treatment for the disease from November 2004 to September 2005. She and colleagues found that 44 percent of the patients showed signs of mental illness. One in four reportedly had depression. The findings were reported in a press release from the Health Behavior News Service which sought reaction to the study from Dr. Marc Judson, Director of the Sarcoidosis Center at the Medical University of South Carolina. He said: “It is not clear if the higher rate of mental illness in the patients is due to sarcoidosis itself or to the strain of living with a chronic disease. Instead, it is likely that both factors are at play. Some of it relates to being a chronic disease and some of it is related to the mechanism of the disease.” Dr. Judson co-authored an earlier study that found that 60 percent of American patients suffering from sarcoidosis also suffered from depression. The study by Dr. Goracci and colleagues can be found in the September-October issue of the journal, General Hospital Psychiatry.
Women--More than Men--Get Depression Relief from Inexpensive Drug--A multi-year, national study has found that women with depression may be much more likely than men to get relief from a commonly used, inexpensive drug. Researchers from the University of Michigan Depression Center reported that the persistence of a gender difference in response to the drug suggests that there’s a real biological difference in the way the medication affects women compared with men. The study involved citalopram, a commonly used antidepressant that is available both as a generic drug and a brand name—Celexa. The University of Michigan was one of 14 sites participating in the clinical trial which the sponsor—the National Institute of Mental Health--described as the largest and longest study ever to evaluate depression treatment. In a press release from the University (carried by the online news service, Newswise), the lead author of the new report, Elizabeth Young, M.D., Professor of Psychiatry, said the study was large enough and sufficiently controlled for complicating factors which made us “feel confident that there is a true difference.” The gender differences emerged from an analysis of data from 2,876 men and women who had a clear diagnosis of major depression, and took citalopram over a number of weeks, with the doses increasing over time. Women were 33 percent more likely to achieve a full remission of their depression, despite the fact that women in the study were more severely depressed than the men when the study began. The new study appears was reported in the Journal of Psychiatric Research (Reference: doi:10.1016/j.psychires.2008.07.002). Information on the overall clinical trial—Sequenced Treatment Alternatives to Relieve Depression Study—can be found at www.nimh.nih.gov/health/trials/practical/stard.
CDC Reports that Almost 24 Million Americans Have Diabetes--The Centers for Disease Control and Prevention (CDC) announced that the number of people with diabetes in the United States has grown to almost 24 million. In a late June (2008) press release, CDC noted that the new total represents an increase of more than 3 million in approximately two years, and brings the number of Americans with diabetes to 8 percent of the population. For those 60 years and older, the percentage with diabetes was almost 25 percent. The new data reaffirmed the fact that ethnic and minority populations, including Native Americans, blacks and Hispanics suffered a higher rate of diabetes than the general population. In addition to the 24 million, another 57 million people were reported to have pre-diabetes, a condition that puts people at high risk of developing diabetes. CDC also reported that the number of people with diabetes who do not know they have the disease dropped from 30 percent to 25 percent. The new data is published in CDC’s 2007 National Diabetes Fact Sheet. To view the press release, go to: http://www.cdc.gov/media/pressrel/2008/r080624.htm. To access the 2007 National Diabetes Fact Sheet, visit http://www.cdc.gov/diabetes/pubs/factsheet07.htm.
Position Papers and Guidelines
There exists an array of guidelines and position papers on the detection and treatment of diabetes per se and on the detection and treatment of depression per se. But, there is relatively little in addressing depression as a co-morbidity for diabetes (or other chronic illnesses). That may change as interest grows in depression as a co-morbidity for diabetes.
One would presume that most users of this particular Web site are familiar with the treatment guidelines that periodically are updated by the American Diabetes Association. On the depression side, the American Psychiatric Association issues “Practice Guideline for the Treatment of Patients With Major Depressive Disorder,” the second edition of which was released in 2005. It can be accessed at:
In 2006, the Michigan Quality Improvement Consortium (MQIC) issued guidelines on both depression and diabetes. In the diabetes guidelines, the consortium urges that patients with diabetes should routinely undergo screening for depression. The consortium is comprised of health plans, medical societies, and quality improvement organizations. The MQIC focuses on primary care and emphasizes the prevention and management of chronic conditions. Its guidelines can be accessed at:
The Texas Department of State Health Services has a Texas Medication Algorithm Project for major depressive disorders and bipolar disorders. These guidelines, reflecting the current state of knowledge, are in the public domain, and may be used and reprinted without special permission (except noted copyright materials). They can be accessed at:
The MacArthur Foundation’s Depression and Primary Care Initiative offers a tool kit for primary care physicians which assists them in recognizing and diagnosing depression, educating patients and using evidence-based guidelines and management tools for treating patients. It can be accessed at:
A number of government agencies, academic centers, and medical associations have issued guidelines, some of which are geared towards specialists, others towards primary care physicians, and still others towards social workers and patients. A number of these can be found on the “Best Practices Treatment Guidelines” Web Page of Washington University in St. Louis. Go to:
http://gwbweb.wustl.edu/CMHSR/best/best_practice.html and click on “D.”
Another guideline source is the National Guideline Clearinghouse (NGC) operated by the Agency for Healthcare Research and Quality (AHRQ). The Clearinghouse features a guideline on Major Depression in Adults in Primary Care, which was developed by the Institute for Clinical Systems Improvement in (ICSI) Bloomington, MN. In noting the frequency of chronic disease co-morbidities with depression, the guidelines state that “screening and treatment of depression in this patient (diabetes) group should be emphasized.” The NGC guidelines can be accessed at :
In reviewing some of the treatment described in the previous section, it is interesting to note how importantly screening is regarded. Like the Institute for Clinical Systems Improvement, the Wisconsin Diabetes Prevention and Control Program (also listed on the National Guidelines Clearinghouse site) call for all patients with diabetes to be screened for depression.
Screening for Mental Health--http://www.mentalhealthscreening.org/acog/
With support from the National Institutes of Mental Health, Clinical Tools , Incorporated offers “Screening for Depression in Adults in Primary Care,” a 29-page site which provides a comprehensive perspective on various facets of screening. It can be accessed at:
The Beck Depression Inventory (BID) is another site that provides a self-administered tool that includes 21 items in measuring supposed manifestations of depression. The site cautions that the tool is incorporated and can be used only by registered professionals. It can be accessed at:
Some state health plans offer guidance on screening tools as part as their overall guidelines on detection and treatment.
ConnectiCare, for example, provides a site that has “Clinical Practice Guidelines for the Management of Major Depressive Disorder.” The site addresses treatment, detection and assessment, and intervention, and appropriate referrals. It also provides “Hints for Consumers & Families.” It can be accessed at:
New Jersey’s Horizon Blue Cross/Blue Shield plan provides a “Clinical Practice Guidelines for Detection and Treatment of Depression.” The two-page document can be accessed at:
Another useful reference on screening is “Screening for Depression Across the Lifespan: A Review of Measures for Use in Primary Care Settings.” It comes from the American Family Physician and can be found at:
Screening recommendations from the U.S. Preventive Services Task Force (USPSTF):