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Diabetes Standards of Care & Clinical Practice Resources

Depression

Depression is closely intertwined with type 2 diabetes, and the association between the two conditions is “bidirectional” – the presence of one increases the risk that the other will develop. Individuals with depression are at increased risk of developing diabetes, and as many as one-third of patients with diabetes may develop depression at some point. Depression may affect patient self-management tasks, such as medication adherence or lifestyle behaviors, and it also affects patient outcomes.

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Clinical Practice Recommendations

Recommendations for Depression

  • Screen adult patients with diabetes for depression annually.
  • Providers investigate positive screening results with patients to determine if depression is present and, if so, the severity.
  • A collaborative care team for the treatment and follow-up of patients with depression is established and accessible.
  • If depression is diagnosed, the collaborative care team develops and implements a treatment plan that includes routine monitoring using a standardized depression survey, stepped treatment intensification, and follow-up.

To screen for depression, use a screening tool that is simple to administer and assess such as the Patient Health Questionnaire (PHQ-2). Other screening tools may be used, however, the PHQ has been validated in many populations, is relatively short and simple to use, and is designed for use in the primary care setting. Its longer version, the PHQ-9, can also be used as a screening tool as well as to track depression severity over time and assist with decisions regarding treatment intensification. Routine use of the PHQ-9 at protocol-defined follow-up points in a manner similar to blood pressure tracking for hypertension is recommended. Even in higher risk populations, such as those with diabetes, the optimal frequency for depression screening is unknown.

Depression screening alone has not been shown to improve outcomes. Screening must be incorporated into an effective collaborative care system that provides ongoing treatment, appropriate treatment intensification at timely intervals, care coordination and assertive follow-up, patient self-management support, psychoeducation, and monitoring to ensure resolution of depressive symptoms. Collaborative care teams (primary care provider, nurse care manager or other case manager, and consulting psychiatrist) have been shown to be particularly effective, though protocol-driven case management even without ongoing psychiatric oversight can also be effective.