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Letters to the Editor

Psychiatric Pharmacist Management of Depression in Patients With Diabetes

Psychiatric Pharmacist Management of Depression in Patients With Diabetes

To The Editor: Previous studies have concluded that depression is a risk factor, as well as a consequence, of diabetes.1-3 The presence of untreated depression in patients with diabetes has been associated with a multitude of negative consequences and cost implications, including poor self-care and poor treatment adherence, worsening glycemic control, an increase in severity or number of diabetic complications, an increased likelihood of adverse cardiovascular events, higher rates of functional disability, higher all-cause mortality, and an increase in health care use and expenditures.4,5

Despite the well-established relationship between depression and diabetes, depression is underdiagnosed and undertreated in patients with diabetes.6 A growing body of evidence suggests that collaborative care may be an effective intervention to improve outcomes in patients with depression and diabetes.7-9 This report describes the outcome of depression management in patients with diabetes treated by a psychiatric pharmacist within a collaborative practice model in a safety net clinic in downtown Los Angeles, California.

 

Method. A chart review was conducted to identify adults with diabetes who were diagnosed with depression and subsequently referred to the psychiatric pharmacist for management. The psychiatric pharmacist clinic occurred 1 day per week. Referrals were made by the primary care providers or the clinic psychologist. Upon referral, a diagnosis of major depressive disorder (MDD) was confirmed by the psychiatric pharmacist using DSM-IV-TR criteria.10 Demographic information, hemoglobin A1c (HbA1c) levels, Patient Health Questionnaire-9 (PHQ-9)11 scores, and types of depression treatment (ie, medication, psychotherapy) were recorded. Patients were excluded from analysis if they had fewer than 2 appointments or if they had comorbid schizophrenia, bipolar disorder, or active substance abuse. Depressive symptoms were treated in accordance with the American Psychiatric Association’s practice guideline for treating patients with MDD.12 Diabetes care was delivered by the primary care provider. According to the collaborative practice agreement, the psychiatric pharmacist could initiate, change, or discontinue medications and obtain laboratory measures. Other services such as reviewing laboratory results, obtaining medication histories, and offering medication education were also provided. Response was defined as a reduction in PHQ-9 score from baseline greater than or equal to 50%, and remission was defined as a PHQ-9 score less than 5.13,14

Results. During the 6-month study period (from October 2011 through March 2012), the psychiatric pharmacist treated a total of 15 patients with diabetes and depression. The majority of patients were male (n = 9, 60%) and obese (mean BMI [kg/m2] = 31.8), with a mean age of 55.6 years. Patient ethnicities were predominantly African American and Hispanic (> 80%). Patients had a mean of 3 medical conditions, including diabetes. The mean PHQ-9 score at baseline was 18.6, which reflects moderately severe depression. The mean HbA1c level of 8.5% indicates that patients were above the American Diabetes Association treatment goal.15

Patients were followed for an mean of 3.75 months. Of the 15 initial patients, 6 (40%) were lost to follow-up. The mean change in PHQ-9 scores from baseline for the 9 remaining patients was −9.5 (range, 0 to −15). Response to therapy was achieved in 89% of patients (n = 8), and one third of patients (n = 3) attained remission of depressive symptoms. Selective serotonin reuptake inhibitors and mirtazapine were the only prescribed antidepressants (Figure 1).

 

Figure 1

Click figure to enlarge

Findings from this study demonstrate that medication management by a psychiatric pharmacist can effectively improve depressive symptoms in patients with diabetes. Psychiatric pharmacists complete 2 years of postgraduate training16 with an emphasis on providing comprehensive medication therapy management to patients with medical and psychiatric disorders.17 The psychiatric pharmacist was able to dedicate 30-60 minutes at each visit obtaining medication/medical histories, providing medication education to dispel myths, and building rapport with patients so they were more comfortable taking psychotropic medications. Forty percent of patients were lost to follow-up; however, this high attrition rate is common among the homeless population.18 Future work will focus on a larger-scale analysis of the effectiveness of psychiatric pharmacists’ abilities to improve outcomes for the low-income and homeless subset of patients with coexisting diabetes and MDD.

References

1. Ali S, Stone MA, Peters JL, et al. The prevalence of co-morbid depression in adults with Type 2 diabetes: a systematic review and meta-analysis. Diabet Med. 2006;23(11):1165-1173. PubMed doi:10.1111/j.1464-5491.2006.01943.x

2. Anderson RJ, Freedland KE, Clouse RE, et al. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24(6):1069-1078. PubMed doi:10.2337/diacare.24.6.1069

3. Renn BN, Feliciano L, Segal DL. The bidirectional relationship of depression and diabetes: a systematic review. Clin Psychol Rev. 2011;31(8):1239-1246. PubMed doi:10.1016/j.cpr.2011.08.001

4. Egede LE, Zheng D, Simpson K. Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes. Diabetes Care. 2002;25(3):464-470. PubMed doi:10.2337/diacare.25.3.464

5. Rustad JK, Musselman DL, Nemeroff CB. The relationship of depression and diabetes: pathophysiological and treatment implications. Psychoneuroendocrinology. 2011;36(9):1276-1286. PubMed doi:10.1016/j.psyneuen.2011.03.005

6. Katon WJ, Simon G, Russo J, et al. Quality of depression care in a population-based sample of patients with diabetes and major depression. Med Care. 2004;42(12):1222-1229. PubMed doi:10.1097/00005650-200412000-00009

7. Ell K, Katon W, Xie B, et al. Collaborative care management of major depression among low-income, predominantly Hispanic subjects with diabetes: a randomized controlled trial. Diabetes Care. 2010;33(4):706-713. PubMed doi:10.2337/dc09-1711

8. Katon WJ, Von Korff M, Lin EHB, et al. The Pathways Study: a randomized trial of collaborative care in patients with diabetes and depression. Arch Gen Psychiatry. 2004;61(10):1042-1049. PubMed doi:10.1001/archpsyc.61.10.1042

9. Katon WJ, Lin EHB, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363(27):2611-2620. PubMed doi:10.1056/NEJMoa1003955

10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.

11. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. JAMA. 1999;282(18):1737-1744. PubMed doi:10.1001/jama.282.18.1737

12. American Psychiatric Association. Practice Guideline for the Treatment of Patients With Major Depressive Disorder. Washington, DC: American Psychiatric Association; 2010.

13. Löwe B, Unützer J, Callahan CM, et al. Monitoring depression treatment outcomes with the Patient Health Questionnaire-9. Med Care. 2004;42(12):1194-1201. PubMed doi:10.1097/00005650-200412000-00006

14. Wittkampf KA, Naeije L, Schene AH, et al. Diagnostic accuracy of the mood module of the Patient Health Questionnaire: a systematic review. Gen Hosp Psychiatry. 2007;29(5):388-395. PubMed doi:10.1016/j.genhosppsych.2007.06.004

15. American Diabetes Association. Executive summary: Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(suppl 1):S4-S10. PubMed doi:10.2337/dc12-s004

16. Stoner SC, Ott CA, Dipaula BA. Psychiatric pharmacy residency training. Am J Pharm Educ. 2010;74(9):163. PubMed doi:10.5688/aj7409163

17. Ramalho de Oliveira D, Brummel AR, Miller DB. Medication therapy management: 10 years of experience in a large integrated health care system. J Manag Care Pharm. 2010;16(3):185-195. PubMed

18. Levy BD, O’ Connell JJ. Health care for homeless persons. N Engl J Med. 2004;350(23):2329-2332. PubMed doi:10.1056/NEJMp038222

Pargol Khorsandi Nazarian, PharmD

Julie A. Dopheide, PharmD, BCPP

dopheide@usc.edu

Author affiliations: Clinical Pharmacy, Pharmaceutical Economics and Policy, University of Southern California School of Pharmacy, Los Angeles.

Potential conflicts of interest: None reported.

Funding/support: None reported.

Previous presentations: These findings were presented at the 2012 College of Psychiatric and Neurological Pharmacists (CPNP) Annual Meeting; April 29-May 2, 2012; Tampa, Florida; and the 2012 Western States Conference; May 22-25, 2012; Pacific Grove, California.

Acknowledgments: Mimi Lou, MS, University of Southern California School of Pharmacy, Los Angeles, provided consultation and analysis of descriptive statistics used to report results of the intervention. Paul Gregerson, MD, MBA, is the supervising physician named on the collaborative practice agreement that makes the psychiatric pharmacist-run clinic possible at the Center for Community Health JWCH Institute Inc, Los Angeles, California, at which he is the Chief Medical Officer. Neither Ms Lou nor Dr Gregerson reports any potential conflict of interest relevant to the subject of this letter.

Published online: October 17, 2013.

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