Sunday, March 30, 2014

Is depression a link between diabetes and kidney disease?

A team of epidemiologists and nephrologists led by Margaret K. Yu from the University of Washington and the VA recently published strong evidence that among diabetics, depression raises the risk of End-Stage Renal Disease (ESRD or renal failure) by 85%. This is a very big deal. There are lots of diabetics and lots of them have major depression.

Although it is not yet clear if treatment for depression can avert or delay ESRD for these folks, there are plenty of other reasons to identify and treat them. Even if treating depression doesn't prevent ESRD, it probably saves money, improves productivity, averts suicides, reduces morbidity and makes life better for the patient, the family, the neighbors and the rest of us. Given that the most effective treatment for depression is non-pharmacologic (Cognitive Behavioral Therapy) and doesn't impair glucose metabolism or renal function, the main issue is how so we get these patients into therapy?

Endocrinologists have a role, but they only see a small fraction of diabetic patients, and they often aren't equipped to diagnose and manage depression. This is one of those things that Primary Care does - and is getting better at all the time. More and more PCPs are routinely screening their patients for depression (often with the PHQ-9 - the same instrument used in Yu's study) and are developing systems to provide therapy either in the practice or by referral.

However, PCPs are prone to the same tunnel vision as every other doctor. If the patient isn't in the office, often nothing happens - no diagnosis, no treatment, no prevention. So, here is one more reason to use systematic patient engagement strategies to make sure that the PCP and the patient are interacting. Because that's when the good stuff happens!

Yu MK, Weiss NSDing XKaton WJZhou XHYoung BAAssociations between Depressive Symptoms and Incident ESRD in a Diabetic Cohort.  2014 Mar 27. [Epub ahead of print]

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