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DOI: 10.2337/dc07-0677
© 2007 by the American Diabetes Association
Online Letters: Comments and Responses |
Clinical Depression Versus Distress Among Patients With Type 2 Diabetes: Not Just a Question of Semantics
Response to Vale
1 Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California
2 Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, San Francisco, California
3 Department of Psychiatry, University of California, San Francisco, San Francisco, California
4 Department of Medicine, University of California, San Francisco, San Francisco, California
5 Kaiser Permanente of Colorado, Denver, Colorado
Address correspondence to Lawrence Fisher, PhD, Department of Family and Community Medicine, Box 0900, UCSF, San Francisco, CA 94143. E-mail: fisherl{at}fcm.ucsf.edu
Dr. Vale (1) suggests that the current definition of major depressive disorder is too heterogeneous and that there are many distinct depressive subtypes that manifest differently but that share a similar physiological profile. He argues that biological markers should be included in studies of disease-related psychosocial stress. We agree in principle that there are a variety of syndromes that include negative affect as a major component and that clinical depression presents in a variety of forms. We raise two issues with respect to Dr. Vale's thoughtful comments.
First, although we reported in our study that the prevalence of clinical depression, defined as major depressive disorder, was 
50% higher among patients with diabetes than among community dwellers (2), we also reported that many more patients were not clinically depressed, but were, instead, distressed and worried about their diabetes and its management. Although a patient's level of disease-related distress is of considerable concern, we and others (3) have cautioned against the common practice of considering distress and stress as conditions characterized as psychopathology. Even though most chronic stress has physiological ramifications, as do some forms of common pleasure, we argue against both the increasing "medicalization" of sometimes painful but understandable affective states and the tendency toward biological reductionism regarding explanations and interventions (4,5). Although we fully support the study of the physiology of distress, we distinguish between states that should be considered psychopathological and conditions that are part of the broad spectrum of human experience. A major problem with this modern tendency toward medicalization is that it narrows our understanding of the processes involved, and it tends to shift interventions away from the personal, social, and environmental determinants of distress to often expensive and sometimes unnecessary medical interventions (5). Thus, patients return for medications or are referred for narrowly defined treatment for conditions that are really part and parcel of living with and coping with a chronic disease. This tendency, in our view, disempowers patients, enhances their dependency, increases health care costs, and reduces intervention options.
Second, our argument against medicalization of diabetes-related distress does not imply a lack of concern about the impact of distress on quality of life and on diabetes-related markers. Our report is but one of many that attests to the importance of recognizing distress as part of good diabetes care (6). We are dismayed by the absence of any indicator of distress, quality of life, clinical depression, or any patient-centered measure in current versions of HEDIS (Health Plan Employer Data and Information Set) or the National Committee for Quality Assurance, while at the same time targets for biological markers are becoming more stringent and are applied without reference to patient goals, comorbid conditions, or other factors (7,8). The literature has clearly documented the importance of both clinical depression and distress on disease outcomes, and it is time that measures of quality of care include these dimensions to provide a comprehensive picture of patient status, as recommended by the Institute of Medicine (9) and widely used in other countries (10).
References
- Vale S: Clinical depression versus distress among patients with type 2 diabetes: not just a question of semantics (Letter). Diabetes Care 30:e73, 2007. DOI: 10.2337/dc07-0536
[Free Full Text] - Fisher L, Skaff MM, Mullan JT, Arean P, Mohr D, Masharani U, Glasgow R, Laurencin G: Clinical depression versus distress among patients with type 2 diabetes: not just a question of semantics. Diabetes Care 30:542–548, 2007
[Abstract/Free Full Text] - Coyne JC: Self-reported distress: analog or ersatz depression? Psychol Bull 116:29–45, 1994[Medline]
- Glasgow RE, Fisher EB, Haire-Joshu D, Goldstein MG: NIH Science Agenda: A public health perspective. Am J Public Health. In Press
- Kaplan RM, Ong M: Rationale and public health implications of changing CHD risk factor definitions. Ann Rev Public Health 28:321–324, 2007[Medline]
- Anderson D, Horton C, O'Toole MI, Brownson CA, Fazone P, Fisher EB: Integrating depression care with diabetes care in real-world settings: lessons from the Robert Wood Johnson Foundation Diabetes Initiative. Diabetes Spectrum 20:10–16, 2007
[Abstract/Free Full Text] - Glasgow R: The case for self-management indicators as diabetes performance measures. Paper presented at the Annual Meeting of the Society of Behavioral Medicine, 21–24 March 2007, Washington, DC
- Hayward R: All or none treatment targets make bad performance measures. Am J Managed Care 13:126–128, 2007[Medline]
- Institute of Medicine Committee on Quality of Care in America: Crossing the Quality Chasm. Washington, DC, National Academy Press, 2001
- Rubin RR, Peyrot M, Siminerio LM: Health care and patient-reported outcomes: results of the cross-national DAWN study. Diabetes Care 29:1249–1255, 2006
[Abstract/Free Full Text]
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