What Constitutes "Depression Care Management"?

My previous post, "Treat The Depression, Extend Life", discussed how treating depression could reduce the risk of dying in patients with diabetes. I was curious about what constituted "depression care management". What was the specific treatment?

The intervention which sought to decrease depressive symptoms was spelled out in the 2004 JAMA study below, also known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial):

Reducing Suicidal Ideation And Depressive Symptoms In Depressed Older Primary Care Patients

The treatment guidelines consisted of:

1. Formal screening using established depression scales.
   
2. ".. a first-line trial of a selective serotonin reuptake inhibitor (SSRI). The protocol specified citalopram because it is equally efficacious with other antidepressants, has limited drug interactions, low potential for central nervous system activation, and an insignificant withdrawal syndrome."
   
3. "When a patient declined medication therapy, the physician could recommend interpersonal psychotherapy."
   
4. "The depression care manager interacted with patients in person or by telephone at scheduled intervals, or when clinically necessary, to monitor depressive symptoms, medication adverse effects, and treatment adherence."

Citalopram is marketed under the brand name Celexa.

So, to achieve the benefits seen in both this study (which found that symptoms of depression and suicidal ideation could be decreased), and the previously posted study (which found that diabetes patients' lives could be extended), an intervention involving formal depression screening in the primary care setting, deployment of medication and/or psychotherapy, and regular follow-up - both scheduled and as-needed - by trained clinicians would have to be implemented.

It's also important to note that:

"Research funds covered the cost of interpersonal psychotherapy and citalopram."

So, cost and insurance coverage are also considerations.________

Treat The Depression, Extend Life

When depression occurs along with diabetes, it can hasten death. If you treat the depression, can you forestall that earlier death?

That's what researchers publishing in this month's issue of Diabetes Care asked. They analyzed data on 584 participants of the PROSPECT Trial (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) and found:

"Older depressed primary care patients with diabetes in practices implementing depression care management were less likely to die over the course of a 5-year interval than depressed patients with diabetes in usual-care practices."

The risk for death was reduced by about 50% over a 5-year period for patients with diabetes whose depression was being treated.

The authors concluded:

"These results should propel the development and dissemination of models of care that better integrate depression management for individuals with diabetes."

________For the study:
Diabetes, Depression, and Death; A randomized controlled trial of a depression treatment program for older adults based in primary care (PROSPECT)

Diabetes Increases Risk For Depression

Researchers reporting in the June 11 issue of Archives of Internal Medicine found:

"Among well-functioning older adults, DM [Diabetes Mellitus] is associated with increased risk of depressive symptoms."

Those whose diabetes was poorly controlled (whose HbA1c was > 7%) were particularly at risk.

It was a prospective study with a mean follow-up of 5.9 years. The 2522 participants, aged 70 to 79, were community-dwelling and did not have depression at the beginning of the study. (Although it was not known if depression existed prior to study entry.)

The causal mechanisms of a diabetes-depression association have not been unraveled. That is, we still don't know if one is primarily at the root of the other. This study however demonstrated that having diabetes can almost double the risk for depression (even after, as in this case, adjustments are made for age, sex, race, education, smoking, alcohol intake, activity level, and baseline depression score).

Although this study observed that "depressive symptoms may be in part explained by the global burden of comorbidities and impairments associated with DM," they pointed out that other organic causes may be contributing, particularly those related to HbA1c levels.

This is one more data point in the diabetes-depression narrative.

________
For the abstract:
Diabetes Mellitus, Glycemic Control, and Incident Depressive Symptoms Among 70- to 79-Year-Old Persons

Cymbalta Found to Raise Blood Glucose

Question: What is the most common complication of diabetes in the US?

If you've had diabetes for a number of years and you experience the characteristic burning, tingling, or numbness in your feet, legs, or arms, you'll probably guess this right off. Those are symptoms of peripheral neuropathy or diabetic nerve pain, which, according to the FDA affects up to 62% of Americans with diabetes ... making it the most common diabetic complication.

The FDA approved Cymbalta (duloxetine HCl) in August, 2004 for the treatment of depression. A month later they approved it for the treatment of pain associated with diabetic peripheral neuropathy. This month, a study in Diabetes Care asked the question "Does Treatment With Duloxetine for Neuropathic Pain Impact Glycemic Control?" Their answer was yes:

"Duloxetine treatment resulted in modest increases in fasting plasma glucose in short- and long-term studies (0.50 and 0.67 mmol/l, respectively)." [Approximately 0.9 and 12.1 mg/dl respectively]

The increase was modest. If you're taking Cymbalta and it is effective at easing your symptoms, your doctor may decide not to make changes. Although, it's helpful to be aware of the medication's effect on blood glucose.

________
For the January, 2007 Diabetes Care article:
Does Treatment With Duloxetine for Neuropathic Pain Impact Glycemic Control?

For FDA's press release:
FDA Approves Drug for Neuropathic Pain Associated With Diabetes

For Cymbalta's site:
Cymbalta

Depression and Diabetes Management

Whether being depressed can increase your risk for diabetes, or vice versa, there's no doubt that coping with a diagnosis of diabetes can sometimes feel overwhelming. That stress can impact how well you manage your blood sugars - a situation supported by research.

From the ADA's 66th Scientific Sessions:

• Diabetes-Related Emotional Distress Reduces the Clinical Efficacy of Intensive Diabetes Management Interventions
  Abstract Number: 848-P
  
• Effect of Depression on Diabetes Knowledge, Diabetes Self-Management, and Perceived Control in an Indigent Population with Type 2 DiabetesAbstract Number: 830-P

The ADA has a useful brochure on how to recognize and deal with depression. You can download the short pdf file at:
Recognizing and Handling Depression for People with Diabetes

If you'd like to read more about depression, its symptoms and treatments, a good place to start is the National Institute of Mental Health's site on depression.

News on the Relationship Between Depression and Diabetes

Can depression predict diabetes? Does having diabetes predict depression?

The jury is still out on whether one of these conditions can cause the other. A number of teams presenting at the American Diabetes Association's 66th Scientific Sessions last week took a look at the relationship between diabetes and depression. Here are 2 highlights:

• Researchers from Rockville, MD, examined 3187 participants of the NIH's Diabetes Prevention Program. They found that depression did not predict diabetes. But taking antidepressant medication did.
  - Depression Symptoms, Antidepressant Medicine Use and Risk of Developing Diabetes in Diabetes Prevention Program Participants
  Abstract Number: 896-P
  
  
• Researchers from Atlanta, GA examined 443 healthy adults without known diabetes or glucose intolerance (a form of prediabetes). Some were being treated for depression and some were not. They found the depressed patients did not have a higher incidence of glucose intolerance than nondepressed patients. In this case, having glucose intolerance did not predict depression.
  - Unrecognized Glucose Intolerance Is NOT Associated with Depression
  Abstract Number: 11-OR

________
To read the abstracts of these presentations, visit the ADA'a Abstract Search and enter their Abstract Number.

For a press release on these and other Session papers dealing with depression (pdf):
Antidepressants Associated with Increased Risk of Diabetes in Pre-Diabetics

To access the Sessions' other papers, visit the ADA's 66th Scientific Session home page

Depression Among People with Diabetes

Two recent studies in the journal Diabetes Care analyzed the relationship between diabetes and depression

The first, in the journal's March issue, found the rate of clinically significant depression among those with diabetes (type 1 or type 2) was high, at least 25%. For a loose comparison, The National Institue of Mental Health (NIMH) reports that mood disorders affect about 9.5% of the US population age 18 and older in a given year.

The second, in the jounal's April issue, found a relationship between depression and A1C*, although it also found that depression could not predict changes to A1C levels. The authors suggested that depression could impact other measures besides A1C, and urged further study.

The NIMH advises that anyone who experiences 5 or more of the following symptoms every day for at least 2 weeks seek an evaluation for depression:

• Persistent sad, anxious, or "empty" mood
  
• Feelings of hopelessness, pessimism
  
• Feelings of guilt, worthlessness, helplessness
  
• Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
  
• Decreased energy, fatigue, being "slowed down"
  
• Difficulty concentrating, remembering, making decisions
  
• Insomnia, early-morning awakening, or oversleeping
  
• Appetite and/or weight changes
  
• Thoughts of death or suicide, or suicide attempts
  
• Restlessness, irritability

* HbA1C or just A1C is an abbreviation for glycosylated hemoglobin, blood levels of which can identify average glucose levels for an individual over approximately 120 days, the life span of a red blood cell.

________
For the March article:
Depression Treatment and Satisfaction in a Multicultural Sample of Type 1 and Type 2 Diabetic Patients

For a summary of the March article:
Depression Rate High Among People with Diabetes

For the April article:
Depression and Glycemic Control in Elderly Ethnically Diverse Patients With Diabetes

For the NIMH's fact sheet on diabetes and depression:
Depression and Diabetes