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Raja" "autores" => array:1 [ 0 => array:2 [ "nombre" => "S.G." "apellidos" => "Raja" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256514004329?idApp=WRCEE" "url" => "/00142565/0000021500000003/v1_201504010035/S0014256514004329/v1_201504010035/en/main.assets" ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "What can screening measures tell us about risk for depression in patients with diabetes?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "169" "paginaFinal" => "170" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.S. Gonzalez, A. Shapira" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J.S." "apellidos" => "Gonzalez" "email" => array:1 [ 0 => "jeffrey.gonzalez@einstein.yu.edu" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Shapira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, United States" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Diabetes Research Center, Albert Einstein College of Medicine, Bronx, NY, United States" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Qué medidas de detección nos informan sobre el riesgo de depresión en pacientes con diabetes?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Depression is more prevalent among patients with diabetes than in individuals without diabetes<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a>; this has been clearly noted in the literature. Patients reporting elevated symptoms of depression are more likely to have worse glycemic control,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> increased risk for complications,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> poor adherence to medications, self-management<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> and increased health costs.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> For these reasons, early detection of depression among patients with diabetes is an emerging concern – based on the reasonable expectation that identifying and treating these patients for depression would improve health outcomes. Though reasonable, this assumption remains mostly untested, as few well-designed studies are available to speak to the question of health outcome benefits of depression screening and treatment programs in large samples of patients with diabetes. However, much research has focused on assessing the prevalence of depression in various patient populations and evaluating its relationship to health behaviors and indicators of health in patients with type 2 diabetes.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Rodríguez Calvín et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> reported on interesting data from a random sample of mostly older adult patients diagnosed with diabetes who were being treated at the University Hospital of Fuenlabrada, Spain. Their design allows them to partially address the question of whether identification of diabetes patients with depression could help identify those at risk for poor diabetes outcomes. They identified cases of depression with a screening cutoff score, further validated in the current sample, on a widely used self-report questionnaire for depressive symptoms. Hospital records-based diagnosis of depression and documentation of prescribed treatments were also available.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Consistent with past research, analyses showed that prevalence of depression was closely associated with marital status, sex, age, socioeconomic status, education level, characteristics of the diabetes treatment regimen, glycemic control, obesity, self-reported medication adherence and physical activity. The general prevalence rate of depression (32.7%) was on the higher end of the range of estimates from previous research,<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,7,8</span></a> with women at much higher risk (43.3% [95% <span class="elsevierStyleSmallCaps">CI</span>, 43.8–52.3]) than men (24.6% [95% CI, 18.4–31.8]). In addition, 35% of the patients who screened positive for depression had not been identified by their physicians or other care providers, based on hospital records. Although the study was not powered to detect differences in diagnosis and some cell sizes are small, the general lack of significant differences in Table 3 suggests that the factors associated with elevations in self-reported depressive symptoms are not related to likelihood of diagnosis among patients with positive screening results. These findings are potentially alarming in that they suggest that a large portion of patients had depression but were not correctly identified or treated by hospital care providers.</p><p id="par0020" class="elsevierStylePara elsevierViewall">While we agree with most of these authors’ conclusions and believe their study makes a valuable contribution to the field, we would argue that one issue has been overlooked in their closing comments – patients with positive screening results are simply that and should not be equated with true positive cases of depression. Although there is much value in improving the identification of true positives and providing appropriate treatment, self-report questionnaires identify a mix of true positives and false positives. A review suggests that as many as 50% of diabetes patients who screened positive are actually false positives.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> It is as inappropriate to refer to the 35% of individuals in this study who screened positive but were not diagnosed as cases of “undiagnosed depression” as it would be to refer to a group of women with positive mammogram results as undiagnosed cases of cancer. We focus on this seemingly minor point because it reflects a limitation of the broader literature on the links between diabetes and depression. Commonly used self-report measures assess a heterogeneous group of symptoms, including somatic disturbances in sleep, appetite and energy, which can be confounded with the burdens of illness and the experience of chronic stress. Thus, it is unclear what high scores on these measures indicate. Socio-economic stress, poorly controlled diabetes, functional limitations, emotional distress, social isolation, and comorbid illness could all influence scores on such scales. Indeed, many of these factors are related to depression score elevations in the Fuenlabrada sample.</p><p id="par0025" class="elsevierStylePara elsevierViewall">To identify true cases of clinical depression, diagnostic interviews are recommended. However, only 20% of the studies reviewed by Roy and colleagues used the gold standard approach for depression evaluation – a semi-structured diagnostic interview by a trained assessor.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> Greater use of these interviews, which are more costly and time-consuming, is needed to advance the field. How far would we get in understanding breast cancer by focusing on the epidemiology of positive mammogram results?</p><p id="par0030" class="elsevierStylePara elsevierViewall">If we see the measure used by the current study as an indicator of emotional and physical distress, which can range in intensity from non-pathological situational distress to true psychopathology, results can be interpreted as providing information about the contextual factors that may explain this distress.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> Recent studies suggest that the emotional distress reported by patients is often most reflective of the emotional toll of living with diabetes and the burdens of self-management, rather than a psychiatric disorder.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">10,11</span></a> Even low levels of depressive symptoms that fall below screening cutoffs are associated with increased risk of poor diabetes self-management.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> Depressive symptoms are also closely linked with diabetes symptoms.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> Most recently, Wiltink et al.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> conducted a population-based survey of over 15,000 adults and examined differences in the types of depressive symptoms that distinguish between those with and without diabetes. Symptoms were classified as somatic (e.g., sleep disturbance, appetite disturbance, low energy) and cognitive–affective (e.g., sad mood, concentration difficulties, low motivation, pessimistic thoughts). Somatic symptoms were found to be more prevalent in people with diabetes than in non-diabetic individuals. No significant differences were found for cognitive–affective symptoms. Furthermore, elevations in depressive symptoms were only seen among those with diagnosed diabetes – no relation was observed for undiagnosed diabetes.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> Other epidemiological research also shows that depression symptoms are only elevated among patients with diagnosed diabetes; those who are unaware of their diabetes are no more likely to have elevations in depressive symptoms than those who do not have diabetes.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Multiple lines of evidence, including results reported by Rodríguez Calvín et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> suggest that diabetes-related health and treatment burdens are closely linked to risk for depressive symptoms. Whether these symptoms are more reflective of the somatic burden of illness, diabetes-related emotional distress, social disadvantage or psychopathology deserves further attention in future studies. Attention to the context of diabetes and its management, as well as the larger social context in which self-management occurs, may be just as important to understanding emotional distress in diabetes as screening for specific depression symptoms. 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