MAJOR DEPRESSION
Major depression is the most severe form of depression. 

The essential feature of major depression is depressed mood, or loss of interest in usual activities, which is experienced most of the day and nearly every day,  for a period of at least 2 weeks.  Accompanying these symptoms are appetite disturbance and weight change,  sleep problems,  either physical agitation or slowing down, decreased energy, feelings of worthlessness or excessive guilt, difficulty concentrating or thinking,  and recurrent suicidal thoughts. 

Major depression is present in 15% to 20% of patients with diabetes, regardless of diabetes type (53). Several studies have found glycemic control significantly worse among depressed versus nonde-pressed diabetes patients (54 - 56).

The course of the illness is generally chronic; even after successful treatment it will reoccur in as many as 80% of diabetic patients and reoccur on an average of four episodes during a subsequent 5-year period (57). Depression is recognized and treated in only one third of cases. Depression also doubles the risk of type 2 diabetes onset, independent of its association with other risk factors (58 - 61). Randomized controlled trials have shown both psychotherapy (i.e.,  cognitive behavioral therapy that targets negative thought patterns)  and psychopharmacy [i.e.,  tricyclics and selective serotonin-reuptake inhibitors (SSRIs)] to have significant beneficial effects on both mood and glycemic control (53,62).

A meta-analysis of relevant studies demonstrated a significant and consistent association of diabetes complications and depressive symptoms (63).  Both diabetes complications and hyperglycemia are associated with diminished response to depression treatment and with an increased risk of recurrence.  This suggests that optimal relief of depression in diabetes may require vigorous, simultaneous treatment of both the blood sugar control and psychiatric conditions.

Dysthymia, defined as persistent presence with fewer symptoms of depression, can occur in the absence of major depression. Moreover, it is commonly found in patients with chronic medical conditions,  and is responsive to depression treatments.  Patients with dysthymia may seem like chronic complainers and so their depressions may be misread as “personality problems.”

There are a number of barriers that make detection of depression particularly challenging for the physician in the medical setting (64). These include:

• Lack of time (i.e., brief visits)
• Somatization (patient presents the physical symptoms of depression such as fatigue, appetite change, or sleep disruption, but not the affective or cognitive symptoms)
• Stigmatization (which inhibits explicit questioning)
• Comorbid medical conditions (camouflage depression by sharing somatic symptoms)

In the latter case,  special attention should be paid to the affective components of depression such as mood, loss of interest in usual activities, guilt, or suicidal thoughts the patient may also be experiencing.

If time constraints are a particular problem, a single question “Have you felt depressed or sad much of the time in the past year?” has been found to have a sensitivity of 85% and specificity of 66% (65).

Garry W. Welch, Alan M. Jacobson, and Katie Weinger
Behavioral and Mental Health Research, Joslin Diabetes Center, Boston, Massachusetts, U.S.A.

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