The Importance of Screening for Depression

What keeps your patients from managing their diabetes? One common cause is depression. Screening and treating patients for depression can often start them feeling better and improving their glucose control.

According to the American Diabetes Association (ADA)1, people with diabetes are at greater risk of depression. Reasons for depression can include the hassle of self-management, the inconsistent results, effects on mood of high or low blood sugar, and feelings of guilt or failure for getting diabetes or not managing it well. Diabetes can also impair family relationships, which can lead to depression.

According to an analysis in Diabetes Care2, depression interferes with diabetes self-management in several ways. Depressed people lose motivation and energy needed for care. They often experience anxiety, and loss of confidence (self-efficacy).

Major depression interfered with “patient-initiated behaviors that are difficult to maintain (e.g. exercise, diet, medication adherence) but not with preventive services for diabetes,” the authors wrote. “When depression accompanies diabetes, there is evidence of poorer glycemic control, decreased physical activity, higher obesity, and potentially more diabetes end-organ complications and impaired function. There is also evidence that depression is associated with decreased adherence to oral hypoglycemic prescriptions.”

The ADA notes to patients, “If you are depressed and have no energy, chances are you will find such tasks as regular blood sugar testing too much. If you feel so anxious that you can’t think straight, it will be hard to keep up with a good diet. You may not feel like eating at all. Of course, this will affect your blood sugar levels.”

Depression is common in both Type 1 and Type 2 diabetes. A study in The Diabetes Educator found that depression is not being screened for often enough in Type 2, especially with low-income people, who often have more reasons to be depressed.

In youth with Type 1, Australian doctors found that depression “was observed in 10–26% of study samples using both self and/or parent-report.” The impact on health-related quality of life (HRQoL) was comparable to children “with life-threatening disease such as cystic fibrosis and leukemia.”

Patients may not tell clinicians they are depressed. They may not realize it themselves, because depression does not always present as sadness or crying. A person may be depressed if they experience:

• Difficulty sleeping or sleeping too much;
• Overeating or not eating enough;
• Waking too early in the morning;
• Long periods of sadness;
• Feelings of worthlessness or hopelessness;
• Loss of pleasure in things they used to like;
• Low energy levels; and/or
• Difficulty motivating themselves to do things they previously did.

Note that low energy and lack of initiative are common to both depression and Type 2 diabetes.

Screening for depression

A study3 in Archives of Internal Medicine in 2000 found that depressive symptom severity is associated with poorer outcomes and higher health care costs in primary-care diabetic patients. Authors recommended annual depression screening.

Screening for depression is simple, and tools have been developed that will fit the process into a regular appointment.

A study reported4 at the American Association of Nurse Practitioners conference in 2017 found that diagnosis and treatment of depression led to improved HbA1c levels. The authors recommended a two-step screening process: the two-question PHQ-2, which can be filled out and scored in less than a minute, followed by the longer PHQ-9 for those who scored positive on the first test.

Treatment

Screening doesn’t help much unless the people who test positive get treated. Fortunately, treatment is usually effective and covered by most health insurance. A study reported5 at the ADA Scientific Sessions in 2017 found that both cognitive-behavioral therapy (CBT) and exercise, separately or together, had significant benefits for depressed diabetes patients. Patients receiving CBT were 12.6 times as likely as the control group to achieve partial or full remission of their depression, while those who exercised were 5.8 times as likely to improve. CBT plus exercise was associated with a decrease in A1C levels by an average of 0.7 percent.

Of course, exercising is a challenge for people with depression, as for many people with diabetes. Outside of a study context, they might need a group, an exercise partner, a structured program or tips like these to keep moving.

Depression can also be treated with medications, although some anti-depressants have distressing side effects. Between therapy, exercise and medication, nearly all depression can be helped in cost-effective ways, with significant benefits in QoL and diabetes control.

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PHQ-2, Two-Question Depression Screen

Over the past two weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things
___ Not at all ___ Several days __ More than half the days ___ Every day

2. Feeling down, depressed or hopeless
___ Not at all ___ Several days __ More than half the days ___ Every day

Scoring: Not at all = 0, Several = 1, More than half = 2, Every day = 3

Add the points for each question. If the total is 3 or great, major depressive disorder is likely. A score of 1 or 2 indicates that some level of depression is likely. Patients who screen positive should be further evaluated with the PHQ-9, other diagnostic instruments or direct interview.
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Access additional resources and practical information to enhance the care and treatment of your diabetes patients.

About our experts: David Spero, BSN, RN, Registered Nurse

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