Researcher and clinician Sherita Golden, MD, MHS, FAHA (pictured) believes screening diabetes patients for depression in clinical settings is about asking the right questions, taking note of patients’ evolving conditions, and having an appropriate conversation with patients when depressive symptoms are observed.

By: John Parkinson, Clinical Content Coordinator,

One of the most devastating effects of diabetes is dealing with the whole host of physiological complications and co-morbidities associated with the disease. Fortunately, research has established that getting regular check-ups and maintaining good glycemic control can help to stave off such issues before they progress to serious or grave conditions.

This awareness has prompted medical professionals to practice preventative medicine by having ongoing dialogues with patients who have diabetes to prevent such issues. And while these open dialogues between practitioner and patients may be acceptable and more commonplace, another co-morbidity, depression, is one that may not be getting discussed in medical practices at all.

Once seen as solely a mental health issue, depression is another insidious condition that may be an underlying contributor to poor glycemic control in some patients. And studies are showing it is much more common in people with diabetes than previously thought. In one particular study done at Johns Hopkins, and led by Dr. Sherita Golden, researchers found that people with diabetes who were being followed had a 52 percent chance of developing depression in follow-up exams.

This is just one study, and there has been a growing body of evidence in the medical literature to suggest the importance of screening for depression in diabetes patients.

Still, many primary care and specialty practices do not screen for depression, and reasons for not doing so are multi-factorial including: patients’ unawareness of their depressive states; the lack of practitioners’ expertise in mental health; and the social stigma attached to depression.

Dr. Golden is an associate professor of medicine and epidemiology at the Johns Hopkins School of Medicine, and she believes screening for depression is not only vital to diabetes patients, but it does not have to be a difficult clinical process. In addition to seeing patients once a week at Hopkins Diabetes Center, Dr. Golden is conducting diabetes-related research. She has had previous work published in numerous medical journals. recently sat down with Dr. Golden to discuss her research findings on the bi-directional relationship between depression and diabetes, and applying clinical screening protocols for depression. Here are highlights from that conversation: How did you first come to be interested in studying and treating diabetes?

Dr. Golden: When I was a third year medical student I did my rotation on our in-patient diabetes floor. My attending physician at that time was a wonderful endocrinologist who was very knowledgeable, and I ended up doing a research rotation with him as a fourth-year medical student, and that is where I became interested in clinical diabetes research in general.

I was also a medical student in 1993 when the Diabetes Control and Complications trial was published. That was the trial that showed tight glucose control prevented microvascular complications with type 1 diabetes. I can actually remember the day it came out. Someone ran down the hall very excited with the New England Journal of Medicine. At that point, that was what sold me on diabetes because I knew then we now had interventions that we could use to prevent complications and that it empowered patients to manage their disease.

I am also African-American, and diabetes has a significant impact on that population as well as other minority populations such as Hispanic, Asian, and Native American communities. In your research, you have shown that depression and diabetes have a bidirectional association. Can you provide an overview of these findings?

Dr. Golden: Between 1995 and 2000, we began to understand that diabetes and depression were associated with one another, such that people with diabetes were twice as likely to have depression, compared to people that didn’t have diabetes. However, this raised the question, ‘does depression lead to diabetes or does diabetes led to depression?

What we looked at was data from the Multi-Ethnic Study of Atherosclerosis (MESA), which was a cohort study of cardiovascular disease but they also collected data on depression and diabetes over a number of years.

At the time we did our study, there were several other studies showing if you had depression you were at higher risk of developing type 2 diabetes over a number of years of follow-up. What was less clear was whether or not having diabetes led to depression. In that particular study, both associations were true. In our population, people that had symptoms of depression, had a 40 percent chance of developing type 2 diabetes within three years of follow-up. One of the reasons is that we know that people who are depressed are more likely to overeat, less likely to exercise, and less likely to be adherent to their medication. We adjusted for all of those factors and we still found people with depression had a higher risk of developing diabetes (34 percent developed the disease).

In the other part of our analysis, we wanted to look in the other direction. We found that people who had diabetes at baseline compared to those who did not, had about a 52 percent chance of developing depression at follow-up. A meta-analysis that one of my former students did showed that there was a modest association between diabetes and developing depression. From the John Hopkins site, you were quoted as saying, ‘it is important for endocrinologists to recognize the impact that stress and mental health issues have on patient self-management behaviors in diabetes.’ How would you characterize how professional colleagues approach addressing depression, anecdotally speaking?

Dr. Golden: A lot of physicians recognize that depression is important in disease management and outcomes, but I think there are a couple of potential barriers in the clinical setting. One is that a lot of visits, particularly diabetes visits, are not very long and are focused on the medical management. It can often take 15 minutes to sort through what insulin a patient is taking, if they have had any low blood sugar, and if there are other problems or complications that need to be addressed. There can be limited time and the uncertainty about the availability of referral to mental health services even if depression is uncovered.

Yet, at the same time, depression clearly needs to be addressed. We need to have a multi-disciplinary approach and refer patients to the appropriate mental health setting. I also think there might be some discomfort on the part of the patient, because there is a stigma associated with having depression, patients might be uncomfortable raising the issue with their practitioner. We need to validate for the patients that depression is a complication of diabetes, like eye disease, high blood pressure, and kidney disease. If we can couch it in that perspective to the patient, it might make it more likely for them to endorse and get the appropriate treatment. Have we gotten to the point we should have a defined gold standard for depression screening?

Dr. Golden: I think we should have a gold standard, but there are a couple of useful tools out there already. We use the patient health questionnaire two (PHQ2). It is two questions taken off the patient health questionnaire nine (PHQ 9), which is a longer questionnaire.

One of the questions asks, ‘How often do you experience a depressed mood?’And the second question asks, ‘Have you lost pleasure in your usual activities?’ The questionnaire gives them options on a scale of 0 to 3, including not at all to very often with a range in between. It really gets to two key required components to diagnose depression. You need to have depressed moods and have anhedonia (loss of interest in activities). If people endorse those symptoms and they have a score of 3 or greater on the PHQ2, they have a 75 percent chance of having some type of depressive disorder.

We implemented these two questions in our patient screening questionnaire in the last year.

This can be easily incorporated into patients’ screenings. It can be included on the same form asking other health questions like do you have high blood pressure and when was your last eye exam?

Signs of Depression

Here are a few exhibiting signs a patient might be experiencing a depressive state. Patients experiencing these signs should be asked follow-up questions to obtain if there is enough criteria to recommend a referral to a mental health professional.

• Continuous poor glycemic control despite ongoing adjustments in medication and diet.
• Insomnia or hypersomnia.
• Significant weight loss or weight gain (A swing of 5 percent of body weight or greater within a month).
• Depressed mood.
• Crying spells If the patient is found to have a score of 3 or greater with the PHQ2 questions, how do you address that with the patient?

Dr. Golden: What we do is speak with the patient and see if they will endorse or acknowledge their possible depressive state by saying something like, ‘I see that you have elevated depressive symptoms.’ Now sometimes, a patient might say, ‘This is an active issue for me. I am seeing a psychiatrist or a counselor.’ The patient might be in treatment, but if they are not in treatment, it is an opportunity to make them aware that they have significantly elevated depressive symptoms that we ought to consider referring them for counseling to really determine if they fit the formal criteria for depression, and helping them to understand that their symptoms might be impairing their ability to actively care for their diabetes. In that context, it can be very eye-opening to patients.
Is there anything else you recommend whether it is observation or something like lack of control, or are there other criteria that practitioners should consider as signs for depression?

Dr. Golden: Absolutely. If you notice that a patient is continually under poor glucose control, despite medication and diet adjustments, that is a person to ask what else is going on and see if they will endorse if depression or something else might be contributing. If someone has ongoing poor glycemic control despite treatment adjustment that can be a sign.

If they have had unintentional weight loss or weight gain, that is generally 5 percent or more of their body weight within a month - that can be a sign.

Another might be for patients who come into the office and have crying spells. That is a sign that should be followed up on.

Frankly, asking questions about whether they have been having any problems with depressed moods or feeling stressed. It is about figuring out a way to help them identify their feelings so they can express that.


Originally posted by on June 24, 2011.