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Management of Depression in Diabetes: a Review of Psycho‑Social Interventions

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Management of Depression in Diabetes: a Review of Psycho‑Social Interventions [Downloaded free from http://www.joshd.net on Friday, October 26, 2018, IP: 182.73.182.38] Review Article Management of depression in diabetes: A review of psycho‑social interventions Yatan Pal Singh Balhara, Rohit Verma1 Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, 1Lady Hardinge Medical College and SSK Hospital, New Delhi, India ABSTRACT Diabetes and depression are major public health problems associated with significant burden. They share many commonalities. Both the diseases have a very high prevalence, mortality, and disability. The current article reviews the available evidence on psycho‑social interventions in management of depression in diabetes. A literature search was performed using MEDLINE, PubMed, PsycINFO, Embase, and Cochrane Review for English language articles published during 1960‑2012. There is limited published literature on role of psycho‑social interventions in management of depression among diabetics. The available evidence suggests that psycho‑social interventions, particularly CBT, are effective in improving depression in patients with diabetes. However, these interventions are not consistently associated with improvement in markers of glycemia control (HbA1c levels). Key words: Cognitive behavioral therapy, collaborative care, depression, diabetes, psycho‑social interventions Introduction in people with diabetes was 11% and the prevalence of clinically relevant depression was 31%. A study conducted Diabetes and depression are major public health problems by World Health Organization across 60 countries found associated with significant burden. They share many health decrement to be greater with co‑morbid depression commonalities. Both diabetes and depression are and diabetes in comparison to either of them present considered as civilization disease, i.e., diseases, which alone.[4] Individuals with diabetes and depression had a increases with the development of the society, due to change 2‑fold increase in health care costs compared with those in the environmental and social factors. Diabetes and who did not have depression.[5] Diabetics with co‑morbid depression also share a bi‑directional causal association.[1] depression had a 36‑38% increased risk for mortality over a 2‑year period.[6] Both the diseases have a very high prevalence, mortality, and disability. When present together, these conditions impact Most cases of depression among diabetics get undetected individuals’ quality of life significantly. The prevalence due to commonality of the symptoms of the two of depression in diabetes ranges between 15‑40% in conditions (fatigue, weight gain or weight loss, appetite multi‑national studies.[2] Anderson et al.[3] in a meta‑analysis changes, and sleep disturbances), associated stigma and negative perception of depression. The current of 42 studies found that the prevalence of major depression article reviews the available evidence on psycho‑social interventions in management of depression in diabetes. Access this article online Quick Response Code: Website: Methodology www.joshd.net A literature search was performed using MEDLINE, PubMed, PsycINFO, Embase, and Cochrane Review for DOI: *** English language articles published during 1960‑2012. Key search terms were “diabetes,” “depression,” “cognitive Corresponding Author: Dr. Yatan Pal Singh Balhara, Department of Psychiatry, Room No. 4096, 4th Floor, Teaching Block, AIIMS, Ansari Nagar, New Delhi ‑ 110 029, India. E‑mail: [email protected] 22 Journal of Social Health and Diabetes / Vol 1 / Issue 1 / Jan-Jun 2013 [Downloaded free from http://www.joshd.net on Friday, October 26, 2018, IP: 182.73.182.38] Balhara and Verma: Management of depression in diabetes behavioral therapy,” “treatment or management or CI: 33‑82 percentage points, P < 0.001], and 66.6% of intervention or trial,” “collaborative care,” “primary care,” patients in the CBT group achieved CSI compared with “psycho‑social,” and “psychotherapy.” Only publications 29.6% of controls. At 6‑month follow‑up, 70% of patients focused on managing depression in diabetic individuals in the CBT group remained in remission compared were included. with 33.3% of controls [Difference: 36.7 percentage points, 95% CI: 9‑65 percentage points, P = 0.03] while Psycho‑social interventions were those in which the 58.3% of the CBT group reported CSI compared to participants received some type of talk therapy designed only 29.6% of the controls (P = 0.01). HbA1c levels were to improve depressive symptoms without prescribing any similar between the two groups at pre‑and post‑treatment medications. Only these interventions have been reviewed assessments, but at 6‑month follow‑up, 9.5% patients in in this article. the CBT group had significantly lower levels compared to 10.9% patients of control group (P = 0.03). No statistically Four published and completed randomized controlled significant difference was observed among the groups for trial (RCT) of psycho‑social therapies for depression self‑monitoring of blood glucose levels. in diabetes,[7‑10] two uncontrolled pilot studies of group cognitive behavioral therapy (CBT),[11,12] and two The second published RCT of psycho‑social intervention RCTs of CBT intervention designs but unpublished for treating depression in diabetes was a pilot study and [8] results were retrieved.[13,14] Additionally, there were five the only study including SP as intervention. It enrolled systemic reviews/meta analyses for assessing effectiveness 30 in‑patients with diabetic foot syndrome, of which of psycho‑social treatment of depression in diabetics.[15‑19] 80% had type 1 diabetes. The subjects had a mean The findings from these studies have been presented in age of 60.5 ± 10.9 years. Depression was rated using the subsequent sections. hospital anxiety and depression scale (HADS). Outcome measure for diabetic status was problem areas in diabetes scale (PAID). Participants were randomized to either an RCTs intervention group (n = 15) with weekly (average five sessions) supportive psychotherapy treatment or a control There were two RCTs on CBT, one using a web‑based group (n 15) receiving only treatment as usual (TAU). model.[7,10] Among the other 2 RCTs, minimal psychological = There was significant improvement in depressive scale intervention (MPI) was used in one study while other used of HADS in intervention group as compared to the supportive therapy (SP).[8,9] control group [‑1.6 versus 0.3, P = 0.02] along with 75% improvement in the diabetic foot syndrome. The study Lustman et al.[7] conducted the first RCT of psycho‑social lacked follow‑up, and the assessments did not include intervention for treating depression in patients with treatment conditions or HbA1c levels. diabetes enrolling 51 participants of age 21‑70 years. All the participants had type 2 diabetes. Depressive disorder The depression in elderly with long‑term afflictions was diagnosed by diagnostic interview schedule, and (DELTA) study was a RCT that aimed to assess the severity was assessed by beck depression inventory (BDI). effectiveness of a nurse‑led MPI in elderly individuals with The participants were randomized to either intervention diabetes and depression. The DELTA study has several group receiving individual CBT for 10 weeks (n = 20) publications on multiple stages.[9,20,21] This RCT included or control group receiving no specific anti‑depressant 361 primary care elderly patients with type 2 diabetes treatment (n = 22). All participants received a one‑hour or chronic obstructive pulmonary disease. Depression diabetes education program with a trained diabetes was assessed by the mini international neuropsychiatric educator every other week. Glycemic control was assessed interview (MINI). Patients were randomized to either MPI using glycosylated hemoglobin levels. Assessments intervention receiving group or control group receiving were made immediately after treatment and 6 months TAU. The home visit MPI was provided by 4 nurses later. An intent‑to‑treat (ITT) analysis revealed that a consisting of 1‑hour session over 3‑month period (average 4 greater percentage of patients achieved remission of sessions). Depression score as assessed on beck depression depression (BDI score ≤ 9) and clinically significant inventory (BDI) was the main outcome measure with improvement (CSI) (defined as ≥ 50% reduction in follow‑up at 9 months. Diabetes‑related assessments were BDI score) in the experimental group than in the made using diabetes symptom checklist‑revised (DSC‑R) control group. At post‑treatment, 85% of patients in the and PAID scales. The study concluded that MPI CBT group achieved remission compared with 27.3% significantly reduced depressive symptoms with a 50% of controls [difference: 57.7 percentage points, 95% or more reduction in BDI relative to baseline values. Journal of Social Health and Diabetes / Vol 1 / Issue 1 / Jan-Jun 2013 23 [Downloaded free from http://www.joshd.net on Friday, October 26, 2018, IP: 182.73.182.38] Balhara and Verma: Management of depression in diabetes Overall, there was a statistically significant improvement and self‑efficacy for diabetes scale. There was significant only in higher educated individuals for both emotional improvement in depressive symptoms (Pre‑CDI = 19.4 and distress and symptom distress at 9 months (DSC‑R post‑CDI = 9.9, P < 0.05). Additionally, improvement was total score at 9 months P = 0.001; PAID, 9 months observed for self‑concept, diabetes self‑efficacy, anxiety, P = 0.03) in
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