Association of Depression With Increased Risk of Severe Hypoglycemic Episodes in Patients With Diabetes

I read this new study by Katon and colleagues (2013) with great interest (Katon et al. 2013). The authors begin by noting that many factors that influence diabetes management and prognosis have little to do with healthcare per say, and occur outside the clinical setting. Indeed, the behaviors that increase risk of type 2 diabetes and diabetes prognosis (e.g., poor diet, tobacco and alcohol use, physical inactivity) are adopted early in the life course and are difficult to modify in a healthcare setting. Depression and risk factors for depression (e.g., social stressors, low socioeconomic status) are established risk factors for these poor health behaviors. Any attempt to understand the drivers of sustainable behavior change must acknowledge the role of mental health.

Depression is treatable in primary care, and the costs of failing to treat, or inappropriately treating, depression in primary care are considerable. Data from the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) shows that effective depression care management in primary care is associated with a significant- on the order of 50% - reduction in mortality for patients with comorbid depression and diabetes (Bogner, et al. 2007). This new evidence of depression and risk of severe hypoglycemia from Katon and colleagues, combined with prior work showing that depression is associated with increased risk of poor glycemic control and risk of diabetes complications (de Groot et al. 2001; de Groot et al. 1999), provide unequivocal support for the argument that promoting and preserving mental health is part of diabetes care. If practitioners want to help their patients with diabetes adhere to medication regimens, they must address their mental health needs. If practitioners want their patients to make substantial lifestyle changes to control their glucose, they must address their mental health needs. If practitioners want to reduce the risk of diabetes complications and mortality, they must address their mental health needs. Not as an afterthought, or if there is time during a visit, but always and as a healthcare priority. As Martin Prince succinctly stated in the Lancet, "There is no health without mental health," (Prince et al. 2007).

Depression can be a difficult disease to treat clinically, but this is simply a way that depression care management parallels diabetes care management, and no one claims that diabetes should not be treated in primary care simply because it is a complex process. Numerous randomized controlled trials have identified effective care models to manage comorbid depression and diabetes in primary care (Bogner et al. 2007; Bogner et al. 2012; Katon et al. 2004), and given the evidence summarized here there is simply no defensible argument for not adopting these in every primary care practice.

References

Bogner HR, Morales KH, Post EP, Bruce ML. Diabetes, depression, and death: A randomized controlled tirla of a depression treatment program for older adults based in primary care (PROSPECT). Diabetes Care 2007; 30(12): 3005-3010.

Bogner HR, Morales KH, de Vries HF, Cappola AR. Integrated management of type 2 diabetes mellitus and depression treatment to improve medication adherence: A randomized controlled trial. Annals of Family Medicine 2012; 10(1): 15-22.

De Groot M, Jacobson AM, Samson JA, Welch G. Glycemic control and major depression in patients with type 1 and type 2 diabetes mellitus. Journal of Psychosomatic Research 1999; 46(5): 425-435.

De Groot M, Anderson R, Freedland KE, Clouse RE, Lustman PJ. Association of depression and diabetes complications: A meta-analysis. Psychosomatic Medicine 2001; 63(4): 619-630.

Katon WJ, Young BA, Russo J, Lin EH, Ciechanowski P, Ludman WJ, Von Korf MR. Association of depression with increased risk of severe hypoglycemic episodes in patients with diabetes. Annals of Family Medicine 2013; 11: 245-250.

Katon WJ, Von Korff M, Lin EH, et al. The Pathways Study: A randomized controlled trial of collaborative care in patients with diabetes and depression. Archives of General Psychiatry 2004; 61(10): 1042 -1049.

Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, Rahman A. No health without mental health. Lancet, 2007;370(9590): 859-877.

Competing interests:   None declared