Screening in Diabetes Care: Detecting and Managing Depression in Diabetes

Abstract

The analysis of depression screening in diabetes according to the four criteria of the United Kingdom’s National Screening Committee shows that both screening tests and treatment options are available. However, results of the Cochrane meta-analysis about depression screening in primary care settings indicate that the implementation of depression screening needs a structured approach to link these two components. A stepped-care approach comprising verification of positive screening results, treatment options, assessment of response to treatment, and adaptation may carry favorable results with regard to reduction of depression as well as cost-effectiveness. The association between diabetes and distress has long been recognized. In 1685 Thomas Willis, a British physician, suggested that diabetes might be a consequence of prolonged sorrow. In the middle of the 20th century Alexander regarded diabetes as one of the seven major psychosomatic diseases. In more recent years these historical observations have been supported by growing empirical evidence of a special relationship between emotional distress and diabetes. A meta-analysis regarding depression and diabetes onset showed that the presence of depressed symptoms increased the risk of developing diabetes by 37%. However, the effect is bidirectional. Meta-analytic findings suggest that the comorbidity of depression and diabetes is frequent: approximately one third of diabetic patients report symptoms of depression, and a smaller group of10%of diabetic patients meet the criteria of a clinical depression. In diabetes care settings the recognition rate of depression in diabetic patients is disappointingly low, ranging between20%and50%. Even in more specialized diabetes care settings approximately 50% of depressed diabetic patients remain undetected. Thus, there are strong and compelling arguments in favor of depression screening in diabetes, and this is also recommended by several guidelines for diabetes care (Fig. 16.1). However, there are also arguments against depression screening. Studies analyzing the effectiveness of depression screening in primary care settings do not all support large-scale implementation of depression screening. Increasingly, there is a need to justify depression screening in different medical conditions with regard to its effectiveness and ethical and clinical implications and to specify whether screening as a routine or more selective case-finding is warranted.12 Screening for depression potentially exposes both false positives and true positives (but otherwise unrecognized cases) to stigmatization and potential discrimination by health insurance companies or employers.