Depression in Diabetes: Have We Been Missing Something Important?
Jeffrey S. Gonzalez, PhD, Lawrence Fisher, PhD, and William H. Polonsky, PhD, CDE, wrote a commentary published in the January 2011 issue of Diabetes Care. In it, they address how focusing on the relationship between major depressive disorder (MDD) and long-term diabetes outcomes may, in fact, be misleading.
There may be a more nuanced approach to assessing the emotional effect of diabetes on patients—which may be more of a blend of diabetes distress and depressive symptoms than MDD. Additionally, the focus on MDD and diabetes may have unnecessarily limited the treatments studied, a topic the authors also address.
Finally, this commentary discusses how there may be another approach to current treatment for emotional distress in diabetes.
In this summary of the commentary, we will highlight the key points from each of those sections.
Assessing the Emotional Effect of Diabetes
Most of the questionnaires used to assess the effects of emotional distress are self-reports, and these “have been shown to be more reflective of general emotional distress than MDD.”
Also, these measurements tend to overlook the fact that some physical diabetes symptoms can be mistaken for MDD symptoms—so the symptoms are, indeed, captured, but they are inappropriately pathologized.
Ignoring the life context for the depressive symptoms is especially problematic for patients with diabetes. This life context—the ups and downs of living with a chronic condition—is crucial for understanding the link between diabetes and emotional distress caused by diabetes. As the authors write, “The current MDD-focused model ignores this context and when applied to patients with diabetes leads to an underappreciation of the impact demanding treatment regimens, ongoing threats of serious complications, and association functional impairment that may contribute to the experience of distress.”
Assessing the Effectiveness of Treatments
Since the assessment of depression in diabetes patients has focused on MDD, there has been a narrow focus on treatments. Antidepressants, for example, have been studied, but the commentary authors suggest that interventions “have not attended to the co-occurring, linked problems of living with and managing the stress of diabetes. Moreover, they have failed to show compelling evidence that amelioration of MDD leads to improved diabetes management or glycemic control.”
The authors suggest that addressing the co-occurring problems can lead to co-occurring improvements in diabetes distress and diabetes.
A New Treatment Model
While acknowledging that this does not fit with the current model of care in America, the authors suggest that ongoing clinical conversations about diabetes distress are crucial. As they write, “Even brief conversations that label feelings, link them to difficulties with self-management and normalize emotional reactions to diabetes issues can be re-assuring.”
This is an excellent review article of the key issues around emotional distress in diabetes and how distress differs from depression. Of key importance is the recognition that categorizing patients into mental health diagnostic categories, such as major depressive disorders, while useful may miss important psychological issues that have clinical relevance in patients with diabetes. The authors argue for ongoing conversations about how best to deal with this issue. As noted previously, global (SPD) and disease-specific (diabetes distress etc.) all seem to have significant detrimental effects on diabetes outcomes, yet until recently very few studies evaluated these effects. Even now, few clinicians are aware of these nuances and many are not incorporating the emerging evidence into their clinical decision-making process. Therefore, as rightfully noted by the authors, more research is needed to better understand the role of global and disease-specific distress in diabetes and strategies for treatment and prevention.