Hospital Dr Issue 3 - Irish Medical Information

It is increasingly recognised that depression constitutes a significant long-term complication of diabetes and is associated with debilitating rates of reduced quality of life, poor self care, reduced life expectancy and increased healthcare costs. The lifetime risk of suffering major depression is up to three times higher in patients with diabetes compared with the general population. In a session dedicated to the clinical management of depressive symptoms in patients with predominantly Type 2 diabetes, Dr. Jim Bolton from London discussed the means of assessing depression in this patient group and highlighted some common clues and pitfalls.

Depression typically has a multi-factorial aetiology. Some of the contributing factors relate to the illness itself and the treatment; diabetes is a chronic and potentially life-threatening condition and its complications can be extremely painful. The treatment can be very unpleasant, due to adverse effects from oral medications or having to self-administer insulin injections several times a day. In addition, the vast majority of diabetes patients will sooner or later be admitted to hospital; for most patients hospital stay means loss of independence and privacy as well as any social support, and the patient’s normal means of coping with their condition will be disrupted.

Other factors that contribute to the development of depression in diabetes relate to the patient as an individual and his/her social situation. Patients with newly-diagnosed diabetes differ greatly in how well they cope, depending on their ability to understand the diagnosis, assimilate the information given by the different members of the multidisciplinary team and understand the implications for themselves. Patients also have very different ways of coping with the great upheavals associated with early diabetes: changing treatment regimens, deterioration, progressive disability, hospitalisation and the prospect of early death. The individual patient’s risk of developing depression will be influenced by these coping strategies together with the patient’s personality and previous experience of long-term illness, as well as any previous history of psychiatric morbidity. A lack of social support and a confiding relationship will also put the patient at higher risk of becoming depressive.

It is important that the multidisciplinary team members caring for diabetic patients are capable of distinguishing the symptoms of depression from the usual signs of distress when confronted with the diagnosis. Whilst the latter typically manifest themselves as brief changes in mood which are perfectly normal during the initial adjustment reaction, the former involve symptoms that are persistent, extreme in character, disabling, and may include suicidal ideation. The symptoms of depression affect the patient’s mood, motivation and thinking, takes away any interest and pleasure in activities, and makes him/her feel worthless and guilty. Biological symptoms such as weight changes and altered libido and sleep patterns are common but may be less reliable for diagnosis.

There are screening questionnaires available for assessing patients for depression, but these are often long and cumbersome to use, and it is doubtful whether they actually change the clinical outcome. Dr. Bolton finished his session by reminding the audience that the simplest way of screening for depression is to simply ask the patient; if he/she has felt down and depressed in the last month and had little interest in or pleasure from doing the things they normally enjoy doing, this should trigger further assessment and possibly a referral. Particularly important is to explore any thoughts of suicide that the patient may have - such cases should be referred as a matter of urgency. Whilst asking about suicidal thoughts, however awkward it may be, does not increase the risk of suicide per se, not asking may be fatal.