Hallo Bettina,

Chronic illness goes with depression more often than not. Then you should test all people for depression. Antidepressant medication is the most used medication at least in Finland. Females are more inclined to depression than males; this may be an artefact while females are also more inclined to visit the doctor than males. I attach a couple of papers of my own:

Thank you very much for your reply and the link to your wonderfull publications!

You are right, but I wonder, how we can track the health of people with chronic diseases still only in relation to physiological conditions without taking into consideration the emotional state. We have still disease management programs only including physiological parameters. Psychological aspects are only accepted as a separate diseases, but not regular integrated in the treatment of people. There are plenty of good self management programs addressing emotional , social and embodied issues and resources, but they are not included in the delivery of health issues in our system.

Thank you very much for your answer, hopefully we might be able to discuss this issue further.

SIncerely

Bettina Berger

Dear Bettina,

I suppose this has to do with money and time. As psychological treatment are long and time-consuming, a general practitioner would not like to vaste time on

depression besides diabetes. And the nurses lack time. After surgery you really have to beg for being in the hospital for some extra hours and you are not always granted these. Who cares then about your depression?

Mit freundlichen Grüßen und vielen Dank für die schönen Worte,

Béatrice

Appropriate screening takes very little time and can be integrated into other paperwork patients typically fill out from time to time at even wellness checkups. From two to a maximum of nine questions can screen for depression. In the US, the federal government recommends depression screening. However, substance use disorders are also prevalent, and six questions are sufficient to screen for those.

Positive indications can be referred to appropriate professionals for further assessment and possible treatment. Physicians in the US typically are not sufficiently trained to treat behavioral health issues appropriately. Given the nexus between physiological and emotional health appropriate screening and referral are likely to be of benefit to both.

Thank you for your comment. At least , even in Diabetes Guidelines, screening of depressions belongs to regulary care in US, but not in Germany. Asking why, doctors say, they do not know, what to do with peoples suffering from depression. But there are relevant interventions to improve depression by self management tools, ressource orintieted approaches and exercises. Looking for opportunities to include programms in regulare delivery.

BB

Some of the resistance to screening for behavioral health problems from depression to substance use disorders involves "institutional" bias. If medical students are essentially "taught" that only physical diseases and problems are "real" conditions, as practicing physicians they will tend to avoid dealign with behavioral health conditions.

This is an old paradigm, that deseases like diabetes mellitus are regarded mainly as physical problems, although psychic risks and traumatic history can be one of the causing facts of diabetes. I wonder when we will be able to take into account both in the way, which would be appropriate to the needs of the patients.

BB

There is controversy about the indications for systematic screening for depression. In unselected primary care patients it could lead to an over-diagnosis that is not beneficial.

However, in patients with chronic diseases, such as chronic pain or diabetes, where the deleterious effects of undetected and untreated depression may be greater, the indication for screening may be clearer. However, a positive screenings must be followed by a careful diagnostic evaluation to confirm or rule out the diagnosis of depression, and adequate therapeutic management must be available. This is not always the case, and adequate treatment and follow-up cannot always be guaranteed, so the screening could lead to psychiatrization that is not beneficial for the prognosis and quality of life of these chronic patients.

I would agree with Enric Aragonès, this isnt my area in regard to mental health but specificity is important and with something as nebulous as depression, people who might be feeling more 'down' but not depressed may come away with an unfair diagnosis/label they would have to deal with or suddenly make them more aware that they are at risk and lead it down that path where adequate follow up may not be available. But also depending on the chronic illness they are working through that might change their outlook like well controlled and managed T1DM, compared to uncontrolled. I think maybe instead of probing questions that could lead to more harm doctors should offer advise and help and let the patient ask to go through the questions unless there is a clear clinical indication. Its down to training too as has been said. Again not my profession, just my 2 cents.

Liebe Frau Berger,

leider habe ich diese Diskussion bisher übersehen. Eigentlich kann ich ihre Frage nicht ganz nachvollziehen. In den Praxisleitlinien der DDG "Psychosoziales und Diabetes" wird ein regelmäßiges Screening auf Depression empfohlen und es werden auch geeignete Screening-Instrumente vorgestellt. Auch im Gesundheitspass Diabetes wird ein regelmäßiges Screning des psychischen Wohlbefinden mit dem WHO-5 Fragebogen empfohlen. Wenn dieses Thema für Sie aktuell noch relevant ist, kann ich gerne ausführlicher antworten / diskutieren. MK

While I am not familiar with diabetes clinics, it is a United States requirement for routine physical examinations to screen for major depression.

Sehr geehrter Herr Kirschbaum,

Danke für Ihre Antwort! Kann es sein, dass die DDG Praxisleitlinien "Psychosoziales und Diabetes" vielen Diabetologen nicht bekannt sind? Oder dass sie ggf. nicht wissen, wie sie mit einem positiven Screeningergebnis umgehen könnten?

Ich habe in meinem 44 jährigen Diabetesdasein mindestens 2 mittelschwere depressive Episoden gehabt. Diese wurden aber nicht in der Diabetologie entdeckt, sondern ich bin in meiner Not auf die Suche gegangen nach einer angemessenen Diagnose - entweder zum Hausarzt oder zum Psychiater. Ich habe in meiner 44 jährigen Diabetesgeschichte, also in mindestens 176 Praxisbesuchen nicht einmal einen WHO Fragebogen, einen PAID oder irgendein anderes Screening-Instrument gesehen, die Ursachen meiner schwankenden Blutzuckerwert sind nicht einmal hinsichtlich einer eventuell zugrunde liegenden Depression abgeklärt worden. Die Zeiten der Not und der schlechten Werte hätten ggf. sehr viel kürzer sein können.....und ich kenne so viele Diabetiker, denen es ähnlich geht...gerne können wir das ausführlicher diskutieren....

Bettina Berger

The results of scientific studies are not always easy to translate into clinical practice. In the case of the systematic screening of depression in diabetic patients, I see two relevant limitations: (1) the fear of clinicians to unravel psychological suffering that they will then not be able to manage properly, or will not have the resources to do so, and (2) the risk of false positive results in screening that lead to inadequate or pernicious medicalization

From my experience, the first of Enric's limitations is the most likely. Physicians with limited knowledge about behavioral health conditions are reticent to venture into an area with which they are not familiar. Given that (at least in the US) many medical schools provide inadequate information or training of medical students with respect to behavioral health conditions.

I disagree that screening would lead to "pernicious medicalization" if physicians performed as they do in other situations and make a referral to a clinician appropriately versed in addressing the condition in question. In other words make a referral to an appropriate specialist - who in some cases would be a clinical psychologist or other non-medical professional. The "specialist" would then be the clinician who would make definitive diagnostic determinations and a treatment plan where appropriate.

In our department, we evaluate patients in the view of the comprehensive geriatric assessment. Thus, we are screening for depression using GDS-15 questioner. 7.6 % of older diabetic patients had depression (defined as GDS-15 score ≥ 10).

DOI: 10.1111/ggi.14171

Functional categories based on cognition and activities of daily living predict all-cause mortality in older adults with diabetes mellitus: The Japanese Elderly Diabetes Intervention Trial

But then, we have to confess that nice guidelines are useless as long as medical doctors do not have any idea what to do with huge amount of patients with depressive symptoms. I learn and realized several program, which might be able even to help reducing depression in typ 1 diabetes.....and there are several professional groups which are able to teach and realize this programs.....like Zürcher Resource model etc...

@bettina berger, i agree with you. Diabetes is usually associated with many psychiatric and psychological manifestations, apart from just depression. So it will be great to screen all diabetic patients with atleast all major psychological problems besides depression.

This might not be possible in all the LMIC , but general physicians should be very vigilant for identifying , diagnosiing these disorders

We have identified a total of 10 questions that could be used to screen for substance use disorders, depression, and PTSD. If anyone would wish to contact me at [email protected] I can send the peer-reviewed articles for the screening items.