OBJECTIVE -To estimate the odds and prevalence of clinically relevant depression in adults with type 1 or type 2 diabetes. Depression is associated with hyperglycemia and an increased risk for diabetic complications; relief of depression is associated with improved glycemic control. A more accurate estimate of depression prevalence than what is currently available is needed to gauge the potential impact of depression management in diabetes. RESEARCH DESIGN AND METHODS -MEDLINE and PsycINFO databases andpublished references were used to identify studies that reported the prevalence of depression in diabetes. Prevalence was calculated as an aggregate mean weighted by the combined number of subjects in the included studies. We used 2 statistics and odds ratios (ORs) to assess the rate and likelihood of depression as a function of type of diabetes, sex, subject source, depression assessment method, and study design.RESULTS -A total of 42 eligible studies were identified; 20 (48%) included a nondiabetic comparison group. In the controlled studies, the odds of depression in the diabetic group were twice that of the nondiabetic comparison group (OR ϭ 2.0, 95% CI 1.8 -2.2) and did not differ by sex, type of diabetes, subject source, or assessment method. The prevalence of comorbid depression was significantly higher in diabetic women (28%) than in diabetic men (18%), in uncontrolled (30%) than in controlled studies (21%), in clinical (32%) than in community (20%) samples, and when assessed by self-report questionnaires (31%) than by standardized diagnostic interviews (11%).CONCLUSIONS -The presence of diabetes doubles the odds of comorbid depression. Prevalence estimates are affected by several clinical and methodological variables that do not affect the stability of the ORs.

Hyperglycemia has been linked to the development of diabetic complications (1). Treatments that lower blood glucose levels reduce the risks of retinopathy, neuropathy, and nephropathy in patients with type 1 (2,3) or type 2 (4,5) diabetes. Accordingly, maintenance of good glycemic control is the focus of diabetes therapy, and the importance of other clinical factors is judged largely in relation to their effects on this parameter.Clinical and subclinical expressions of depression are present in Ͼ25% of patients with type 1 or type 2 diabetes (6-14) and have adverse effects on functioning and quality of life (15,16). The existing literature is not consistent and clear with regard to the association between depression and poor glycemic control. Such an association would suggest the possibility that depression treatment might have favorable effects on diabetic outcomes. We surveyed the scientific literature, identified studies that measured the association of depression (either by symptoms or the diagnosis) with glycemic control, and performed a metaanalysis to assess the reliability and strength of any association. RESEARCH DESIGN ANDMETHODS -Medline and PsycINFO were used to locate studies published in the last 25 years that reported the association of depression with glycemic control in adult diabetic subjects. The reference lists of these articles were examined to identify additional studies, and this led to the consideration of several unpublished papers and manuscripts. Inclusion and exclusion criteriaStudies were limited to adult participants (Ն18 years of age), to those that assessed glycemic control using a measure of glycohemoglobin (denoted as GHb within this article) (17,18), and to those that measured depression and GHb coincident to the study evaluation. Studies with Ͻ25 patients, those neither published nor available in English, and those that ascertained only a history of depression were excluded. Subjects in the included studies were patients diagnosed with type 1 or type 2 diabetes; studies of subjects with impaired glucose tolerance, borderline diabetes, or gestational diabetes were not considered. Studies were included without regard to the way the depression-glycemic control association was tested. In some studies, depression was the independent variable and glycemic control the dependent variable. Other studies used the reverse approach, and some reported only the correlation between the 2 variables.Study procedures and statistical analysis Study characteristics were recorded, and the studies were categorized by methodology. Type of diabetes and method of depression assessment were recorded, and effect sizes (ESs) were examined in relation to these factors. The diagnosis of depression (major depressive disorder) was established by using structured or semistructured clinical interviews and the diagnostic criteria in use at the time of the study (e.g., American Psychiatric Association' s Diagnostic and Statistical Manual of Mental Disorders [19,20] Depression and Poor Glycemic ControlA meta-an...

These findings demonstrate a significant and consistent association of diabetes complications and depressive symptoms. Prospective, longitudinal studies are needed to identify the pathways that mediate this association.

The combination of CBT and supportive diabetes education is an effective nonpharmacologic treatment for major depression in patients with type 2 diabetes. It may also be associated with improved glycemic control.

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Depression is common in both type 1 and type 2 diabetes and has significant effects on the course and outcome of this medical illness. Conventional antidepressant management strategies are effective and the regimen should be tailored to the individual patient. Enhanced efforts toward good glycemic control may also contribute to improvements in mood and perceptions of well-being.

An increased prevalence of depression in diabetes relative to the general population is highly suggested by the literature, but biases and methodological problems commonly encountered in prevalence studies may interfere with the strength of this conclusion. An increased prevalence of depression in diabetes relative to other somatic illnesses remains unproven. The pervasive impact of depression on quality of life and its potential negative effect on diabetes management warrant recognition and treatment of the affective disorder in diabetic individuals.

Abbreviations: ANCOVA, analysis of covariance; BDI, Beck Depression Inventory; DIS, National Institute of Mental Health Diagnostic Interview Schedule; HAMD, Hamilton Rating Scale for Depression; SSRI, selective serotonin reuptake inhibitor.A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Fluoxetine for Depression in DiabetesA randomized double-blind placebo-controlled trialOBJECTIVE -Depression is prevalent in patients with diabetes. It is associated with poor glycemic control and is linked to an increased risk for diabetic complications. In this study, we assessed the efficacy of fluoxetine for depression in patients with diabetes.RESEARCH DESIGN AND METHODS -Sixty patients with diabetes (type 1, n = 26; type 2, n = 34) and major depressive disorder entered an 8-week randomized placebo-controlled double-blind trial. Patients were given daily doses of fluoxetine (up to 40 mg/day). The Beck Depression Inventory (BDI) and Hamilton Rating Scale for Depression (HAMD) were used to measure the severity of depression and to determine the percentage of patients who achieved substantial improvement or complete remission. GHb levels were obtained to monitor glycemic control.RESULTS -Reduction in depression symptoms was significantly greater in patients treated with fluoxetine compared with those receiving placebo (BDI, Ϫ14.0 vs. Ϫ8.8, P = 0.03; HAMD, Ϫ10.7 vs. Ϫ5.2, P = 0.01). The percentage of patients achieving a significant improvement in depression per the BDI was also higher in the fluoxetine group (66.7 vs. 37.0%, P = 0.03). Additionally, trends toward a greater rate of depression remission (48.1 vs. 25.9%, P = 0.09 per the HAMD) and greater reduction in GHb (Ϫ0.40 vs. Ϫ0.07%, P = 0.13) were observed in the fluoxetine group.CONCLUSIONS -Fluoxetine effectively reduces the severity of depression in diabetic patients. Our study demonstrated that after only 8 weeks, this treatment also produced a trend toward better glycemic control.