Depression in chronic conditions: Updated NICE guidance

Diabetes carries a two-fold risk of suffering from depression, and adding end-stage renal disease or disabling foot complications trebles the risk. Other chronic conditions such as heart disease similarly increase the risk of depression (Anderson et al, 2001; Egede, 2007).

Depression is also an increasing burden on health budgets and a major economic cost due to reduced quality of life and days of work lost. It was this kind of steadily rising evidence that led NICE to publish a final draft of clinical guideline 91 in October 2009 on depression in people with a chronic condition (National Collaborating Centre for Mental Health, 2009). 

Even subclinical depression – but even more so, major depression – can have many disabling consequences: negative effects on work, relationships and family life, making health-impairing behaviours such as poor diet and physical inactivity more likely at the cost of health enhancing behaviours, such as treatment adherence. These behavioural consequences of depression can lead to poorer glycaemic control, and other medium- and long-term outcomes. In fact, depression has been shown to be a better predictor of diabetes-related disability than complications themselves (Von Korff et al, 2005).

NICE guidance
The key problem the new NICE guideline tries to address is selective screening for depression, diagnosis and treatment for the full range of comorbid depressive disorders. Adequately trained staff or mental health professionals are expected to work in collaboration with the individual to provide targeted interventions, ranging from group-based physical activity and support programmes for subclinical symptoms to combined medication and psychotherapy for major depression.

The focus on depression rather than other mental health issues reflects its dominance in recent research publications. However, considerable evidence also points to anxieties and more general emotional distress in people with diabetes (Fisher et al, 2007).

The NICE guideline acknowledges people experiencing “complex social difficulties” but – as a London depression guidance implementation team points out in a critical letter to the British Medical Journal (Brown, 2009) – treatment recommendations for this large patient group are insufficient. Such complex social difficulties have been on the rise for some time due to the ongoing downturn in the economy. It is worth remembering that people with diabetes are not immune to such problems.

Unpublished data collected very recently by Roehampton University on over 1000 individuals of working age suggest very high prevalences of mental health problems in a general population. Given the age profile of people with diabetes – the increased prevalence of mental health problems among older people and the effects of poverty in old age, worsened by economic developments – many older people with diabetes will feel that they have been dealt a double blow and suffer disproportionately from mental health and social problems.

Screening for other psychological problems
Instead of focusing narrowly on depression, the guidance suggests that healthcare professionals should be aware of wider issues and use rating scales for screening that assess more than depression symptoms. I recommend the Hospital Anxiety and Depression Scale (HADS) or perhaps the Depression Anxiety and Stress Scale (DASS), both giving a more comprehensive assessment than the widely recommended Patient Health Questionnaire (PHQ-9). One advantage of the HADS is that it is available in many languages. Similarly, the QOF screening questions are problematic from this point of view, apart from the frequent discomfort expressed to me both by clinicians and people with diabetes about the format and delivery of these questions.

Implementing recommendations
Implementing the guidance is another issue. Limited attention is given to staff training and planning services. The complexity of the recommendations reflects the intricacies of mental health issues, particularly for people with comorbidities. However, it also raises the question of whether simple interventions – low intensity interventions such as computerised cognitive behavioural therapy (CCBT) or paper-based CBT programmes – are suitable for people who typically find it difficult to persist with such self-paced programmes (Fosbury, 2009). These people may actually experience high stress levels rather than actual depression, but will nevertheless benefit from routine stress management techniques, commonly incorporated into CBT programmes.

While the guidance includes people with diabetes as a key target group, diabetes care with its well-developed structured education programmes actually has “structures” in place that can be very helpful in supporting people with mental health problems. For example, the DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed) programme has been shown to improve mental health considerably (Davies et al, 2008).

It is important to explore how resources are used most effectively by integrating education and mental health support, at least for those who only suffer mild to moderate mental health problems. The focus of future investment and service development needs to be carefully considered and further research is required to determine the extent to which CCBT or bibliotherapy reach a sufficient target audience or whether overreliance on what might be considered a “quick fix” detracts from better integrated services.

Pharmacological therapy
As a psychologist I am pleased to see that the guidance warns against the overuse of antidepressants for mild depression. The full guidance provides comprehensive details on interactions between antidepressants and drugs used in diabetes and other conditions. This is particularly relevant to older people with diabetes who frequently experience adverse drug effects due to polypharmacy.

Older people, including those living in care homes, are often burdened with advanced diabetes complications and are particularly prone to depression (The Information Centre, 2007). The dependence on antidepressant medication in this group has been criticised by researchers and stakeholders. While no cost estimate of the guidance has been provided so far (NICE, 2009a), Australian studies have shown that investment in psychological therapies and services are cost-effective and superior to pure pharmacotherapy (Vos et al, 2005).

Conclusion
The quick reference guide (NICE, 2009b), accompanying the full document, provides a summary of the four-step approach to dealing with the full range of depression from subclinical symptoms to major depression. This quick reference guide does reflect the complexity of screening, diagnosis and treatment and organises it within a stepped care approach. Despite some weaknesses and gaps, the guidance is definitely a welcome step forward, and should help healthcare professionals to improve the mental health of people with diabetes.

Further reading
An excellent 1-page summary is given by Titmarsh (2009). Various longer summaries have been provided, but I recommend going directly to the Quick Reference Guide (NICE, 2009b).

Please note: the final draft of Depression in Adults with a Chronic Physical Health Problem is available online. The final version is due to be published later this year. The current version is subject to editorial changes but the meaning of the guideline will not change.