Diabetes accounts for nearly 22 million physician visits annually and is the third leading cause of repeat outpatient visits in the United States. Depression is also strongly related to increased medical (nonpsychiatric) health care utilization, although its specific effect in diabetes has not been studied. Depression is 304 times more prevalent in diabetes than in the general US population. Depression in diabetes has been associated with several factors (e.g., poor glucose regulation, poor compliance with the diabetes regimen) that could lead to increased health care use. We proved during the last period of NIH support, in a double-blind, placebo- controlled trial, that antidepressants were significantly more effective than placebo in managing depression; 65% of treated patients remitted. We also have shown that in the absence of treatment, diabetic depressions are chronic. We plan to recruit 60 depressed patients with NIDDM from a metropolitan primary care practice, and treat them with antidepressant pharmacotherapy for a period sufficient to detect an effect on health care utilization (1 year). Because of the extended treatment interval, the chronicity of untreated depression in diabetes, and the known response/ nonresponse to pharmacotherapy, it is not ethical, practical, or methodologically necessary to include a depressed, no-treatment control group. A comparison sample of 60 nondepressed NIDDM patients matched for age, sex, other comorbid medical illnesses, treating physician, and diabetes type, severity, and method of treatment is included. Health care utilization will be assessed in both depressed and control patients for the year prior to study enrollment and during the year of treatment. Measurements of psychiatric disease activity, family history of depression, personality characteristics, life stress, diabetes symptoms, glucose regulation, and functional status and well-being, will be taken at specified points during the year of depression treatment. We hypothesize that: 1) depressed diabetic patients will make greater demands for medical health care than the nondepressed matched control sample; 20 medical health care utilization will be greater in depressed diabetic patients whose depression persists compared to patients who become nondepressed during treatment; and 3) utilization in the depression improvement group will be similar to that measured in the nondepressed controls. Failure to recognize and treat active depression in diabetes may fuel higher health care utilization. A component study is described that aims to develop a brief psychometric screening tool with positive and negative predictive values for major depression in diabetes greater than 0.80. Witnessing that improvement in depression is associated with a favorable reduction in health care utilization by NIDDM patients would suggest the potential benefits of depression recognition and treatment to society in general, over and above the recognized patient benefits in mood and quality of life.
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