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treatment of depression in patients with T1D and T2D.

      6. Additional research is needed to investigate effective means of depression prevention in patients with diabetes.

      7. Additional research is needed to establish the cost-effectiveness of all modes of depression treatment in patients with T1D and T2D.

       Recommendations for Screening and Care

      Depression is a frequent comorbid condition in patients with T1D and T2D. The following recommendations for clinical care are based on the literature and expert opinion (Evans 2005):

      1. Depression screening is recommended at every visit for diabetes patients, accompanied by procedures to review patient responses and address clinically significant levels of symptoms. Increased concern is indicated for patients presenting with elevated blood glucose and with worsening diabetes complications and those who report a lifetime history of depression and may therefore be at increased risk for future depressive episodes. Providers may use a variety of brief screening tools to detect depressive symptoms in diabetes patients.

      2. Providers are recommended to maintain a low threshold for depression treatment and promote rigorous, ongoing treatment of depression, once identified. Adequate adjustment of dosing for antidepressant medications, well-monitored maintenance therapy, and referrals to mental health services should be routinely provided by health care providers. Coordination of depression and diabetes care across providers is also recommended to ensure adequate depression treatment and follow-up care in light of the persistence and recurrence of depression in diabetes patients and the association with poor medical management.

      3. Evidence supports the use of a stepped-care approach (medication and therapy) and monitored maintenance therapy to achieve symptom remission and improvements in glycemic control.

      4. Use of a collaborative care approach that integrates therapy and antidepressant medication within primary care settings is suggested. This intervention paradigm has demonstrated the capacity to reduce some barriers, such as social stigma, to the effective treatment of depression in diabetes patients and has been shown to be cost-effective to health care organizations.

      5. Incorporation of depression curricula into diabetes education and routine communication with patients about the role of depression in diabetes outcomes is recommended to reduce patient perceptions of stigma associated with mental illness and improve patient awareness of treatment options.

      6. Incorporation of depression screening measures into clinical care outcomes within health care organizations is recommended.

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      Gary

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