DEBORAH ANTAI-OTONG RESPONDS: The precise relationship between diabetes and depression continues to be debated. However, most research implicates a positive correlation between depression and type II diabetes (Anderson, Freedland, Clouse, & Lustman, 2001; Nichols & Brown, 2003). Controversy about this relationship and necessity to screen patients presenting with diabetes exists as well (Brown, Sumit, Majumdar, & Johnson, 2006). Depression is widespread in patients with diabetes, but it often goes unrecognized and undertreated in primary care settings. Left untreated, depression can result in negative clinical outcomes, increased healthcare and economic burden, and a threat to overall health integrity and quality of life. Psychiatric nurses must be prepared to collaborate with primary care and other healthcare providers to screen patients with diabetes who are at risk for depression. Accurate diagnosis ensures the initiation of pharmacologic and nonpharmacologic treatments that reduce complications of both chronic diseases.

Major depression occurs in one in four patients with type I and type II diabetes mellitus (Andersen et al., 2001) and is associated with poor glycemic control, negative clinical outcomes, reduced quality of life and level of function, and diabetic-related mortality (Katon et al., 2004; Zhang et al., 2005). Several studies demonstrated that individuals with diabetes experienced up to threefold incidence of depression compared to those without diabetes (Anderson et al.; Hermanns, Kulzer, Krichbaum, Kubiak, & Haak, 2005; Nichols & Brown, 2003).

Major depression is frequently linked to diabetic-related complications, particularly micro- and macrovascular conditions (Wexler, 2006). For instance, depressed patients are twice as likely to develop diabetes compared to those who are not depressed (Knol, Twisk, Beekman, Snoek, & Pouwer, 2006). Moreover, depressed patients with diabetes are likely to experience an accelerated risk of coronary artery disease and significantly higher incidence of diabetes-related mortality (Brown, Majumdar, Newman, & Johnson, 2005; Egede, Nietert, & Zheng, 2005; Katon et al., 2005). Evaluation and treatment is a priority because of the relationship between depression and poor glycemic and metabolic management in patients with type II diabetes. The pathogenesis of this relationship is still poorly understood and necessitates further study. However, behavioral, physiologic, genetic, and environmental stressors may alter neuroendocrine and neurotransmitter functions.

It is imperative to recognize risk factors along with symptoms of co-occurring depression and their impact on chronic disease management because of negative prognostic implications associated with co-occurring diabetes and depression. Age, female gender, previous history of depression, complications from diabetes, such as peripheral neuropathic pain, impaired functional status and quality of life, and psychosocial stressors are risk factors (Hermanns et al., 2005; Legato et al., 2006). Steps to establish quality health care begin with collaboration with primary care providers, patients, and their families to develop and implement an individualized treatment plan.

Implications for Psychiatric Nursing Practice

Treating depression in the diabetic patient is similar to treating other co-occurring chronic diseases. It is imperative to evaluate the patient’s physical condition by asking questions about prescribed and over-the-counter medications and adherence to treatment adherence. Ordering blood chemistries, hemoglobin A^sub 1C^ (HgbA^sub 1C^), drug screens when appropriate, and lipid profile; measuring vital signs, height, and weight; and working with the primary care provider to evaluate metabolic/ glycemic control is advisable. It is equally important to rule out coexisting psychiatric (e.g., anxiety disorder, substance-related disorders) and medical conditions, including cardiovascular disease, hypertension high low-density lipoprotein cholesterol and triglycéride, and obesity. The decision to seek psychiatric evaluation and treatment can be unsettling to the patient who may deny the distress associated with diabetes and depression. Establishing collaborative relationships with the primary care provider helps ensure their support of mental health treatment. Open communication about the patient’s medical problems and history, including adherence to treatment, quality of support systems, cultural perceptions of diabetes and depression (e.g., gender, generational), and coping styles is helpful in co-collaborating.