DEPRESSION: ONE OF THE MOST DIFFICULT BARRIERS
The relationship between depression and diabetes is bi-directional. Over time patients who are depressed are at increased risk for diabetes, and patients with diabetes are at heightened risk for depression.12 Over 60% of persons with diabetes have some form of depression, and it is often unrecognized. If a patient has difficulty in achieving glycemic control, depression should be considered.
In the statements listed in the Box, 3 patients mention depression that is not being addressed by their primary care clinician. The patient who made the statement “It doesn’t do any good to worry about my diabetes because I can’t do anything about it,” as well as others, may be depressed.
Effect of depression on adherence and outcomes. There is a significant association between depression and treatment nonadherence in patients with diabetes. A number of studies have shown that depression is associated with worse diabetes outcomes, such as poor quality of life, increased complications, functional impairment, and mortality. A recent meta-analysis indicated that depression had the greatest impact on missed medical appointments and self-care.13
Depressed patients depress their health care providers. Missed medical appointments increase provider frustration, decrease empathy, and are associated with less continuity of care.14 Depressed patients also report more dissatisfaction with their providers.15
If depression is not addressed, the vicious circle of dissatisfaction continues as the complications of diabetes continue to grow. Increased recognition and treatment of depression in the primary care setting is critical to effective diabetes care.13 Depression may be the most treatable of all barriers to care.
Screening for depression. Effective screening tools are available to aid in the recognition of depression in the primary care setting.
Two of the best-validated ones are the Patient Health Questionnaire–9 (PHQ-9) and its 2-item version, the PHQ-2.16,17 The PHQ-9 is 81% sensitive and 92% specific for major depressive disorder, and the PHQ- 2 is 87% sensitive and 78% specific for major depressive disorder.
The PHQ-2 contains the following questions:
- During the past month, have you often been bothered by feeling down, depressed, or hopeless?
- During the past month, have you often been bothered by little interest or pleasure in doing things?
If answers to these 2 questions are positive, the patient is most likely depressed. Additional questionnaires, such the PHQ-9, are needed to assess severity and impact on daily activity.
For increased efficiency, a staff member could ask the 2 questions of all patients with diabetes when they are brought to the examination room. Those who respond positively could be given the PHQ-9 to complete for the clinician’s review.