Dashboard Data Measure: % of adults with diabetes screened for depression using the PHQ-2 or PHQ-9 in the last year.
Depression is a common mental health condition experienced by individuals with type 2 diabetes.26 Depression may be a preexisting condition or may develop after diabetes is diagnosed. Symptoms of depression may contribute to other risk factors for new or poorly controlled diabetes. For example, someone with depression may experience low energy or motivation to engage in healthy behaviors. Similarly, the side effects of some psychotropic medications (e.g., sedation or increased appetite) may also interfere with A1C control.
Untreated depression can have a negative influence on diabetes control, for example, reducing the likelihood of checking glucose levels or taking medication.26 Conditions such as depression and anxiety are associated with increased mortality risk among those with type 2 diabetes.27 Given the high rates of behavioral health concerns such as depression, anxiety, and diabetes distress as well as the association between greater symptoms and worse diabetes and cardiovascular health outcomes,26-27 we recommend primary care teams establish standardized protocols to identify and address these concerns.
C1: Depression Screening and Treatment
We recommend using validated screening tools for depression annually in all patients with diabetes and as needed when a patient may be experiencing depressive symptoms.28 If the 2-item Patient Health Questionnaire (PHQ-2) is “positive”, use the 9- item Patient Health Questionnaire (PHQ-9) for a more in-depth screening. Then, follow up on positive PHQ-2 and PHQ-9 screenings with a full clinical assessment to conclusively diagnose depression. Using electronic health record tools to assist care teams in remembering to screen for depression is critical to improving screening rates. Depression treatment, including psychotherapy and pharmacotherapy, is recommended for treating major depression.29-32 In addition, Diabetes Self-Management Education and Support (DSMES; Key Driver D1) has been shown to reduce depressive symptoms.
C1.1: Instrument: Patient Health Questionnaire-2 (PHQ-2)
The PHQ is a self-administered version of the PRIME-MD tool for common mental health disorders administered by health care professionals. The PHQ-2 is a two-item measure that assesses the frequency of depressed mood over the past two weeks, with a score ranging from 0 to 6. The authors identify a cut-off score of 3 as the optimal cut point for screening purposes and stated that a cut point of 2 would enhance sensitivity.
C1.2: Instrument: Patient Health Questionnaire-9 (PHQ-9)
The PHQ-9 is a self-administered tool that is specific to depression. This scale simply scores each of the 9 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria based on the mood module from the original PRIME-MD. Scores range from 0-27. Per the authors, “scores of 5, 10, 15, and 20 represent cut-points for mild, moderate, moderately severe and severe depression.”
C1.3: Pharmacologic Treatment of Depression | AAFP
This article from AAFP provides an overview of the pharmacological treatment of depression and the use of antidepressant medications have risen steadily in the United States over the past three decades. Antidepressants are the most commonly prescribed medications for U.S. adults 20 to 59 years of age.
C1.4: Treating Depression in Diabetes: Emerging Findings
This systematic review reports effective treatments for depression in patients with diabetes: psychosocial interventions, anti-depressant medications, and collaborative care.
C2: Anxiety and Diabetes Distress Screening
Given the relationship between A1c in individuals with diabetes and other behavioral health conditions including anxiety and diabetes distress, you may consider adding screening measures such as the Generalized Anxiety Disorder 2-question screener (GAD2) or Diabetes Distress Screening Scale to screen for anxiety or diabetes distress. Diabetes distress includes feelings of being overwhelmed or stressed by diabetes and related disease management.33-35 Resource C2.1 is an American Diabetes Association (ADA) article on diabetes and emotional health. Pages 1-2 discuss a screening tool for anxiety (GAD-2). Resource C2.2 describes screening tools and intervention strategies for diabetes distress in primary care. Resource C2.3 provides an overview on treating anxiety in primary care. In addition, Diabetes Self-Management Education and Support (DSMES; Key Driver D1) has been shown to reduce anxiety, diabetes distress and depressive symptoms.
C2.1: Diabetes and Emotional Health A Practical Guide for Health Professionals Supporting Adults with Type 1 and Type 2 Diabetes
This ADA article describes screening using the GAD-2, assessing, and addressing anxiety.
C2.2: Development of a Brief Diabetes Distress Screening Instrument
This article describes the Diabetes Distress Screening Tool, including the questionnaires.
C2.3: Diabetes Distress: Screening Tools and Intervention Strategies
The Cardi-OH article helps define diabetes distress and familiarize primary care clinicians with screening tools and evidence-based interventions to help patients with diabetes distress.