198 Diabetes Mellitus
Ford, & Brancati (2000) reported a signi“cant graded rela-
tionship between greater depressive symptoms and higher
serum levels of cholesterol and triglycerides in African
American patients with diabetes. Similar to the aforemen-
tioned study, the temporal relationship between depression
and metabolic control is unknown. Despite this limitation,
such an association emphasizes the importance and bene“t
of providing depression treatment for individuals with dia-
betes to improve health outcomes.
Assessment
Identifying depression in diabetes can be problematic since
somatic symptoms of depression usually included in assess-
ment scales are often similar to the somatic symptoms of di-
abetes (Bradley, 2000). Thus, this commonality of symptoms
could potentially compromise the sensitivity and speci“city
of psychiatric diagnosis, leading to overdiagnosis of depres-
sion (Lustman, Clouse, Grif“th, Carney, & Freedland, 1997).
Current psychodiagnostic procedures, as speci“ed in the
Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV;American Psychiatric Association
[APA], 1994), account for this symptom overlap when deter-
mining the diagnosis of depression by excluding depression
symptoms resulting from a medical condition. Self-report
measures have also successfully identi“ed depression in
diabetes patients. For example, the Beck Depression Inven-
tory (Beck et al., 1961; Lustman, Clouse, et al., 1997) was
found to effectively differentiate depressed diabetes patients
from nondepressed patients by using the 21-item BDI as well
as the cognitive and somatic items alone.
Treatment
Similar to the general population, the most common treat-
ments for depression in diabetic patients involve psycho-
therapy and medication. Lustman, Freedland, Grif“th, and
Clouse (1998) conducted the “rst randomized, controlled
trial of the ef“cacy of cognitive-behavioral therapy (CBT) for
major depression in diabetes. The cognitive-behavioral
strategies included encouraging patients to reengage in
enjoyable social and physical activities, employing problem-
solving skills to cope with environmental stressors, and re-
structuring cognitive distortions by replacing them with more
rational and functional thought processes. The outcome of
their 10-week study suggests that CBT in combination with a
diabetes education program is more effective in treating
depression than diabetes education alone in the short and
long term. Moreover, although there were no differences be-
tween groups immediately after treatment, HbA1clevels at
the six-month follow-up were signi“cantly better in the CBT
group as compared to the control group. Higher HbA1c, lower
SMBG compliance, and higher weight were related to failure
to achieve full remission of depression in the overall sample
(Lustman et al., 1998). Thus, the authors propose that pa-
tients who exhibit poor compliance with SMBG may be less
likely to bene“t from CBT, a type of therapy that involves the
use of self-management skills.
Studies investigating the ef“cacy of pharmacological treat-
ment for diabetes patients suffering from depression are
scarce. Lustman, Freedland, Grif“th, and Clouse (2000) con-
ducted a randomized placebo-controlled double-blind trial
employing ”uoxetine with 60 type 1 and type 2 diabetes pa-
tients. Results pointed toward the effectiveness of reducing de-
pression with patients treated with ”uoxetine as compared to
placebo. Moreover, although not statistically signi“cant, pa-
tients in the experimental group showed greater improvements
in mean HbA1clevels after eight weeks of treatment.
These more recent studies suggest the burgeoning of treat-
ments that aid diabetes patients in managing their depression.
Thus, it is incumbent upon health practitioners to select inter-
ventions that speci“cally match patients• needs (Lustman,
Grif“th, Clouse, Freedland, et al., 1997). To further clarify,
pharmacological treatment may be most effective for patients
lacking self-management skills or for those who exhibit so-
matic complaints, whereas psychotherapy may be most con-
ducive for patients experiencing interpersonal dif“culties or
cognitive distortions. Nonetheless, empirical support for de-
pression management in diabetes is clearly lacking, and con-
trolled studies are needed to elucidate the most effective
strategies to reduce depression and improve BG control in di-
abetes patients.SummaryIt is well-known that depression is highly prevalent in the
diabetes population. However, the etiology of depression in
diabetes remains speculative, with a less clear understanding
of the patterns of causality for type 1 diabetes. Such uncer-
tainty highlights the need for future empirical studies to
examine the causal relationship between depression and
diabetes. Other primary areas of empirical investigations
have included uncovering factors that prevent diabetes com-
plications or affect health behaviors and outcomes within a
depressed diabetes population. Positive outcomes of pre-
liminary treatment studies involving cognitive-behavioral
strategies and pharmacological management are providing
practitioners with more effective intervention strategies to
lower depressive symptomatology as well as to enhance
metabolic control in depressed patients with diabetes.