Relationship of Depression to Medical Outcomes

Of further concern is the relationship between comorbid depression and medical outcomes among those with DM1. Several studies have investigated the influence of depression on glycemic control and other adherence measures. Studies have found that individuals with DM and a history of depression showed significantly worse glycemic control as measured by glycosylated hemoglobin (18,27,28). Additionally, afew meta-analytic studies now exist and have shown a significant relationship between depression and poorer metabolic control among those with both DM1 and DM2 (29,30). Not surprisingly, depression has also shown a relationship to greater complications of persistent hyperglycemia (31). Inquiry continues regarding the exact nature of this relationship between depression and hyperglycemia. One study sought to determine whether depression induced a decrease in diabetes self-care and whether changes in self-management mediated the relationship between depression and hyperglycemia. Although the inclusion of the score from the summary of diabetes self-care activities in regression analyses attenuated the relationship between depression and glycosylated hemoglobin among individuals with DM1, it did not account for a significant mediation of the depression ^ hyperglycemia relationship (30). As such, continued investigation of this relationship is necessary, to determine the strength of the depression ^ reduced self-management ^ hyperglycemia mechanism, or evaluate other psychological and psychophysiological mechanisms for this relationship (30).

The course of depression in the DM population is chronic and severe (16,32,33), and the presence of depression in individuals with DM may significantly worsen the course of both disorders (34). There is sufficient data in the literature demonstrating the (i) increased prevalence of depression in the DM1 population, (ii) deleterious impact of depression on medical outcomes, and (iii) evidence that effective treatments exist. However, depression continues to be underdiagnosed and undertreated (35). In a study of nine primary care practices, 49% of patients with a diagnosis of either DM1 or DM2, reporting clinically significant depression in a systematic screening, were not diagnosed or treated. Only 43% of those patients who were appropriately diagnosed with depression were receiving antidepressant pharmacotherapy, and only 6.7% received four or more psychotherapy sessions during the previous year (36). This suggests that not only were many patients with depression not initially diagnosed, but those who were diagnosed were not adequately treated.

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