Depression is an important issue in the treatment of diabetes, said Katie Weinger, EdD, RN, FAADE, associate professor of psychiatry at Harvard Medical School in Boston and an investigator in behavioral research at Joslin Diabetes Center in Boston. "Just recognizing the possibility of depression is key," Weinger said. And the possibility is high: Individuals with diabetes have double the risk of depression as the general population, according to the CDC. As an under-recognized and undertreated condition, Weinger said depression can affect a diabetic's self care and lifestyle management. Nurses are in an optimal position to recognize the signs and symptoms of depression and to advocate for patients needing assessment and treatment. "Depression plays a huge role in how well patients will manage their treatment," said Emily Sorensen, DNP, RN, APRN, CN, a nurse practitioner in endocrinology at the Mayo Clinic in Rochester, Minn. Patients will be less compliant with lifestyle changes, diet, physical activity and medications and their overall psychological health will suffer, all of which affect their diabetes, she said. The incidence of depression is also related to factors such as poor health or other chronic illness, unemployment and lower socioeconomic status, said Jamie Adam, DNP, FNP, RN, associate professor of nursing at Belmont University in Nashville, Tenn. Ethnicity is also a factor. Adam said Hispanic patients with diabetes have a higher risk of distress and depression, but are less likely to show signs. Weinger added that many minority groups with diabetes in the U.S. have higher rates of depression, including Native Americans, Alaskan Indians, Pacific Islanders and African-Americans.
Distress versus depression
Weinger points out a distinction between diabetes-related emotional distress and depression. "Because diabetes is a chronic illness with so many lifestyle and treatment demands, and it's associated with severe complications, there's a certain amount of distress involved. This can be confused with depression." Emotional distress, she said, interferes with quality of life; it's more a response to health changes. As people get a better grip on their diabetes management, stress levels go down. Research from the American Diabetes Association distinguishes between distress and depression, and states that symptoms of depression in patients with Type 2 diabetes can be reduced using interventions for diabetic distress.
The nurse's role
Adam said patients who are the most successful in coping with diabetic distress are those who receive a lot of intervention, not just teaching at time of diagnosis, but also ongoing teaching. She said studies show that phone call follow-ups make people feel like they're cared for. Sorensen pointed out that bedside and ambulatory care nurses are key healthcare personnel who can spot the signs and symptoms of distress or depression. She recommends the PHQ survey, an 8- or 9-question self-administered questionnaire. The PHQ9 is used routinely at Mayo Clinic with every high-risk patient, she said. The pencil-and-paper survey may reveal symptoms of depression that conversation fails to uncover. Adam said she has worked with patients, particularly of diverse ethnicities, who act and speak as if all is well, but will report their altered emotional state on paper. Patients tend to tell nurses more than they may tell a provider, Sorensen said. If patients admit to feeling down, sleeping more than usual or not keeping medical appointments, nurses can advise the provider of their observations. Patients tend to tell nurses more than they may tell a provider, Sorensen said. If patients admit to feeling down, sleeping more than usual or not keeping medical appointments, nurses can advise the provider of their observations. Weinger suggested additional screening conversation, such as whether the patient has lost interest in usual activities, has become less active or is sad or tearful. "Nurses can help normalize depression," she said. "Any mental health condition, including depression, has a treatment associated with it. Help people to understand that depression comes with the territory of diabetes -- that it's a fairly common comorbidity and that it happens to a lot of people, and there's help for it." "Don't wait until someone shows symptoms," she said. "Nurses can be coaches; they need to make it routine to ask questions about a person's emotional state." Instead of asking, "Are you OK?" ask "Where are you struggling?" she said. Adam said the nurse needs to pull out the issues and then if there's a sense that there is depression, advocate for help. Advocacy is a significant part of the nurse's role, Adam said. She also cautioned that nurses not assume that patients who have long-standing diabetes are not facing depression. "Early recognition is the key" to managing depression in diabetic patients, Weinger said. "Diabetes is hard enough without being faced with depression."
