Abstract
ObjectiveTo provide an estimate of the effect of interventions on comorbid depressive disorder (MDD) or subthreshold depression in type 1 and type 2 diabetes.MethodsSystematic review and meta‐analysis. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomized controlled trials evaluating the outcome of depression treatments in diabetes and comorbid MDD or subthreshold symptoms published before August 2019 compared to care as usual (CAU), placebo, waiting list (WL), or active comparator treatment as in a comparative effectiveness trial (CET). Primary outcomes were depressive symptom severity and glycemic control. Cohen's d is reported.ResultsForty‐three randomized controlled trials (RCTs) were selected, and 32 RCTs comprising 3,543 patients were included in the meta‐analysis. Our meta‐analysis showed that, compared to CAU, placebo or WL, all interventions showed a significant effect on combined outcome 0,485 (95% CI 0.360; 0.609). All interventions showed a significant effect on depression. Pharmacological treatment, group therapy, psychotherapy, and collaborative care had a significant effect on glycemic control. High baseline depression score was associated with a greater reduction in HbA1c and depressive outcome. High baseline HbA1c was associated with a greater reduction in HbA1c.ConclusionAll treatments are effective for comorbid depression in type 1 diabetes and type 2 diabetes. Over the last decade, new interventions with large effect sizes have been introduced, such as group‐based therapy, online treatment, and exercise. Although all interventions were effective for depression, not all treatments were effective for glycemic control. Effective interventions in comorbid depressive disorder may not be as effective in comorbid subthreshold depression. Baseline depression and HbA1c scores modify the treatment effect. Based on the findings, we provide guidance for treatment depending on patient profile and desired outcome, and discuss possible avenues for further research.
Highlights
No international consensus exists to guide treatment of comorbid depression in diabetes
Overall meta-analysis in the randomized controlled trials (RCTs) comparing all treatments with care as usual (CAU), waiting list (WL), or placebo for the combined effect on depressive outcome and glycemic control showed an effect size of 0.485; 95% confidence intervals (CIs) 0.360; 0.609, p < .0001 (Appendix pp 10–12)
The effect size of collaborative care increased from a small to moderate effect size as this treatment model has developed over the last decade, especially in the domain of comorbid long-term physical conditions and comorbid depression (O’Hagan & Boreham, 2013; Panagioti et al, 2016; Tully & Baumeister, 2015)
Summary
No international consensus exists to guide treatment of comorbid depression in diabetes. Over the last three decades, clinicians have been seeing increasing numbers of patients with comorbid depression of various severity in diabetes (Khaledi et al, 2019; Zheng et al, 2018) due to the exploding prevalence of both diabetes and depression (GBD Disease & Injury Incidence & Prevalence Collaborators, 2018) This can amount to up to 30% depending on severity of symptoms and it occurs especially where the person with diabetes has elevated HbA1c despite treatment, or frequent episodes of hypoglycemia and increased glucose variability, diabetesrelated complications, and disengagement from treatments (Groot et al, 2001; Lustman, Anderson, et al, 2000; O'Connor et al, 2009). Epidemiological studies indicate there is a bidirectional relationship between diabetes and depression (Golden et al, 2008; Katon, 2008; Katon et al, 2007), in which individuals with diabetes have an increased risk of depression and vice versa; the presence of a depressive disorder can increase the risk of metabolic diseases such as diabetes (Renn et al, 2011) and there is an association between depression and diabetes complications (Groot et al, 2001; Van Steenbergen-Weijenburg et al, 2011)
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