January 2014

Can Subthreshold Depression Put Patients With Diabetes At Risk For Poor Health Outcomes?

By Brian McCurdy, Senior Editor

A recent study in Diabetes Care suggests that subthreshold depressive episodes are a risk factor for poor health outcomes for patients with diabetes and early monitoring of depressive symptoms may lead to better functioning and quality of life.

   The study focused on 1,064 patients. Five yearly assessments between 2008 and 2013 revealed that almost half of the patients experienced at least one episode of subthreshold depressive symptoms. After adjusting for potentially confounding factors, the study notes that for those with four subthreshold depressive episodes, the risk of poor functioning/impaired health related quality was almost three times higher in comparison to people with no or minimal depression.

   Saying there is “absolutely no doubt” that depression is associated with diabetes, Kathleen Satterfield, DPM, says those who are newly diagnosed with diabetes will face many of the realities that cancer patients face. The diagnosis of diabetes, she notes, is going to change everything in that patient’s life, such as traditional family gatherings with fatty holiday foods and birthdays with ice cream.

   “In a very real sense, they feel like outsiders in their own lives,” says Dr. Satterfield, an Associate Professor/Assistant Dean of Pre-Clinical Education and Outcomes Assessment in the College of Podiatric Medicine at the Western University of Health Sciences. “My patients told me this time and time again in their own way. Life isn’t as fun anymore. Trying to decide how to eat is now work. Many had never been active before and their friends and family aren’t too interested in taking up a new activity either. So they are facing this alone. How depressing is that?”

   Andrew Rice, DPM, concurs, saying multiple comorbidities, longstanding illness, a feeling of helplessness or fear of losing employment due to long disability periods from the complications of diabetes can contribute to or may exacerbate depression.

   When choosing medications, Dr. Rice suggests avoiding those medications that may worsen depression, and particularly when treating neuropathy, one should use medications that may have a positive effect to reduce depressive symptoms. Aside from making referrals to mental health professionals, Dr. Rice, an Assistant Clinical Professor in the Department of Orthopaedics and Rehabilitation at the Yale University School of Medicine, suggests podiatric physicians be empathetic and alert family to assist. Dr. Satterfield also suggests getting the help of office staff and nurses to speak to patients and find out how they feel.

   Dr. Satterfield recalls that when she practiced at the Texas Diabetes Institute in San Antonio, there was an outstanding amputee support group that the patients ran with support from her nurse case manager, Sabrina Shoe, and the podiatric residents who rotated through the clinic.

   “One patient told the others a story about slipping out of his prosthetic limb while he was at the grocery store, pushing his cart. He took a step before he realized what had happened. Only his support group members could share in that embarrassment and really understand how a person would feel,” says Dr. Satterfield.

   What red flags for depression should podiatric physicians look for in patients with diabetes? Dr. Satterfield suggests looking for a patient who doesn’t follow instructions and appears unkempt. Both she and Dr. Rice note other red flags are those who are uncommunicative or have sleep disturbances.

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