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The Art of Prescribing

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Perspectives
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43
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2007
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Care

Diabetes and Depression: Pharmacologic Considerations


Deborah Antai-Otong, MS, APRN-BC, FAAN

During the last year a large number


of patients with type II diabetes have been referred
from primary care providers for evaluation and
treatment of major depression. I know research
findings are inconsistent concerning the
co-occurrence of diabetes and depression,
but what are the clinical implications for
treating patients with diabetes and major
depression?
DEBORAH ANTAI-OTONG RESPONDS: The precise
relationship between diabetes and depression
continues to be debated. However, most research
implicates a positive correlation between
depression and type II diabetes (Anderson,
Freedland, Clouse, & Lustman, 2001; Nichols &
Brown, 2003). Controversy about this
relationship and necessity to screen patients
presenting with diabetes exists as well (Brown,
Sumit, Majumdar, & Johnson, 2006). Depression
is widespread in patients with diabetes, but it
often goes unrecognized and undertreated in
primary care settings. Left untreated, depression
can result in negative clinical outcomes, increased
healthcare and economic burden, and a threat to
overall health integrity and quality of life.
Psychiatric nurses must be prepared to collaborate
with primary care and other healthcare providers
to screen patients with diabetes who are at risk for
depression. Accurate diagnosis ensures the
initiation of pharmacologic and nonpharmacologic
treatments that reduce complications of both
chronic diseases.
QUESTION:

Perspectives in Psychiatric Care Vol. 43, No. 2, April, 2007

Incidence of Depression in Type II Diabetes


Major depression occurs in one in four patients with
type I and type II diabetes mellitus (Anderson et al.,
2001) and is associated with poor glycemic control,
negative clinical outcomes, reduced quality of life and
level of function, and diabetic-related mortality (Katon
et al., 2004; Zhang et al., 2005). Several studies demonstrated that individuals with diabetes experienced up
to threefold incidence of depression compared to those
without diabetes (Anderson et al.; Hermanns, Kulzer,
Krichbaum, Kubiak, & Haak, 2005; Nichols & Brown,
2003).
Major depression is frequently linked to diabeticrelated complications, particularly micro- and
macrovascular conditions (Wexler, 2006). For instance,
depressed patients are twice as likely to develop
diabetes compared to those who are not depressed
(Knol, Twisk, Beekman, Snoek, & Pouwer, 2006).
Moreover, depressed patients with diabetes are likely to
experience an accelerated risk of coronary artery disease
and significantly higher incidence of diabetes-related
mortality (Brown, Majumdar, Newman, & Johnson, 2005;
Egede, Nietert, & Zheng, 2005; Katon et al., 2005).
Evaluation and treatment is a priority because of the
relationship between depression and poor glycemic
and metabolic management in patients with type II
diabetes. The pathogenesis of this relationship is
still poorly understood and necessitates further study.
However, behavioral, physiologic, genetic, and environmental stressors may alter neuroendocrine and
neurotransmitter functions.
It is imperative to recognize risk factors along with
symptoms of co-occurring depression and their impact
on chronic disease management because of negative
prognostic implications associated with co-occurring
diabetes and depression. Age, female gender, previous
history of depression, complications from diabetes, such
as peripheral neuropathic pain, impaired functional
status and quality of life, and psychosocial stressors
are risk factors (Hermanns et al., 2005; Legato et al.,
2006). Steps to establish quality health care begin with
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The Art of Prescribing

collaboration with primary care providers, patients, and


their families to develop and implement an individualized treatment plan.
Implications for Psychiatric Nursing Practice
Treating depression in the diabetic patient is similar
to treating other co-occurring chronic diseases. It is
imperative to evaluate the patients physical condition by
asking questions about prescribed and over-the-counter
medications and adherence to treatment adherence.
Ordering blood chemistries, hemoglobin A1C (HgbA1C),
drug screens when appropriate, and lipid profile;
measuring vital signs, height, and weight; and working
with the primary care provider to evaluate metabolic/
glycemic control is advisable. It is equally important to
rule out coexisting psychiatric (e.g., anxiety disorder,
substance-related disorders) and medical conditions,
including cardiovascular disease, hypertension high
low-density lipoprotein cholesterol and triglyceride,
and obesity. The decision to seek psychiatric evaluation
and treatment can be unsettling to the patient who may
deny the distress associated with diabetes and depression. Establishing collaborative relationships with the
primary care provider helps ensure their support of
mental health treatment. Open communication about
the patients medical problems and history, including
adherence to treatment, quality of support systems,
cultural perceptions of diabetes and depression (e.g.,
gender, generational), and coping styles is helpful in
co-collaborating.
Advanced practice psychiatric nurses must perform
a comprehensive psychiatric evaluation that includes
the patient and familys perception of the mental
health consult or referral, expectations from treatment,
and motivation to participate and adhere to treatment.
Health behaviors and lifestyles must also be evaluated
and need to include adherence to treatment, suicide
and homicide risk, glucose self-monitoring, exercise
schedule, diet, quality of interpersonal relationships
and leisure time, spiritual and religious beliefs, stress
management skills, and tobacco use. Standardized
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tools and instruments, such as the Beck Depression


Inventory (BDI), Hamilton Depression Rating Scale
(HDRS), and a more recently developed tool, the Depression Interview and Structured Hamilton (DISH) scale,
can be used to gather baseline data about the severity
of depressive symptoms and a means to determine the
percentage of symptom reduction or remission. The DISH
scale was designed specifically to evaluate and diagnose depression in patients with medical conditions
(Freedland et al., 2002). The Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR) (American
Psychiatric Association, 2000) criteria for major
depression guides in making differential and accurate
diagnosis of depression. After a definitive diagnosis is
confirmed, treatment options must be discussed with the
patient and family to determine a plan of care. Collaboration with the primary care provider is crucial throughout
treatment to ensure a seamless plan of care. This is
particularly important in light of potential drug interactions between medications used to treat diabetes and
co-occurring medical conditions and antidepressants.
Pharmacotherapy
Treating the patient with diabetes is no different than
treating other medical conditions. Due to potential
negative consequences of untreated depression (e.g.,
suicide, impaired functioning) and diabetes it is critical
to initiate treatment as soon as possible. Significant
challenges for psychiatric nurses include choice of
antidepressant with a safe side-effect profile, length of
treatment to sustain remission, and parallel glycemic
control. Relative to choice of antidepressant and
duration of treatment, research indicates that selective
serotonin reuptake inhibitors (SSRIs) have proven
efficacy and are the first-line treatment of depression
in diabetes. Sertraline, fluoxetine, and paroxetine
demonstrated equal efficacy in most findings with
doses ranging from 50200 mg, 2040 mg, and 20 mg,
respectively (Gulseren, Gulseren, Hekimsoy, & Mete,
2005; Lustman et al., 2006; Paile-Hyvarinen, Wahlbeck,
& Eriksson, 2003). Duration of antidepressant treatment
Perspectives in Psychiatric Care Vol. 43, No. 2, April, 2007

ranged from 8 to 16 weeks in most randomized


controlled trials. Even though patients experienced
significant improvements in mood and glycemic control,
these results appear to be transitory and support the
debate to provide maintenance antidepressant treatment
in this population. Findings from earlier randomized
controlled studies that provided short-term antidepressant management established that less than 40% of
patients with co-occurring diabetes and depression
were in remission one year later (Lustman, Freedland,
Griffith, & Clouse, 2000; Lustman, Griffith, Freedland,
& Clouse, 1997). Lustman et al. (2006) concluded that
maintenance therapy with sertraline sustained symptom
remission in depressed diabetic patients for at least
12 months. Conclusions from this study strengthen the
argument to maintain antidepressant treatment for at
least a year to prevent depression recurrence. Despite
substantial improvement from antidepressants regardless of duration of treatment, findings are inconsistent
regarding a parallel to glycemic control (Katon et al.,
2004; Lustman et al., 2006).
Patient education to improve self-management,
symptom control, medications, and screening procedures must be an integral part of treatment for
depressed diabetic patients. Collaboration with primary
care providers and diabetic educators provides a
holistic treatment plan to improve mood, facilitate
glycemic control, promote adherence to treatment,
prevent complications, and improve functional status
and quality of life.
Summary
Obesity is a worldwide epidemic and a serious
health problem with associated complications, such as
diabetes and other chronic health problems. Depression
is present in one in every four patients with diabetes.
Psychiatric nurses are poised to collaborate with primary
care providers and reduce complications associated
with co-occurring diabetes and depression. Challenges
to parallel improved mood with glycemic control need
further research.
Perspectives in Psychiatric Care Vol. 43, No. 2, April, 2007

Author contact: deborah.antai-otong@va.gov, with a copy to


the Editor: mary@artwindows.com
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Perspectives in Psychiatric Care Vol. 43, No. 2, April, 2007