Abstract
The paper centers around the clinical question of depression treatment for patients with uncontrolled type 2 diabetes and comorbid depressive disorder. In order to answer the question, the literature review was conducted using the PubMed scholarly database. Twelve peer-reviewed articles published between 2017 and 2022 were chosen for the review. The review focused on five major themes: correlation between A1C levels and depression, non-pharmaceutical interventions for depression treatment, telehealth disease management, antidepressants’ effect, and opposing views on the issue. The data synthesis demonstrates that carefully chosen depression and anxiety treatment is likely to result in better A1C outcomes for the patient on the condition that the treatment is regular and convenient for the patients. Other recommendations include adhering to a diet, performing physical exercise, implementing telehealth technologies, and addressing mental counseling as a part of the coherent treatment of diabetes, anxiety, and depression.
Introduction
The present case study dwells on the health condition of a woman with a history of type 2 diabetes mellitus for over ten years. Currently, the patent is struggling with a diabetic foot infection, uncontrolled type 2 diabetes, and a series of comorbid health complications. Characteristics of this case are unique because the physical complications of a woman’s diabetes are followed by severe mental health issues such as depression and anxiety that stem from financial hardships and exhaustion. Currently, there is a proven link between hyperglycemia, diabetes, and depressive disorders (Geraets et al., 2020). Thus, it would be of utmost importance to discover the effect of depressive disorder treatment on the patient’s hyperglycemia and insulin intake levels.
As far as the nurse expertise at the master’s level is concerned, the American Association of Colleges of Nursing (AACN, 2011) presents nine fundamentals that clinical nurses are to incorporate on the practical level. In terms of this case study, such essentials as Background for Practice from Sciences and Humanities, Quality Improvement and Safety, and Interprofessional Collaboration for Improving Patient and Population Health Outcomes will be addressed (AACN, 2011, p. 5). The case study will include the formulation of the clinical question, literature review, and discussion of the potential clinical implications for the practice.
Case History
This case addresses the history of hospital admission of a woman with an infected diabetic foot ulcer. The patient has been living with type 2 diabetes for the past ten years, so she has a history of long-term insulin intake, diabetic retinopathy, persistent hyperglycemia, and previous admissions to the hospital care with infected leg ulcers. Currently, the woman has an uncontrolled stage of T2DM, and one of the comorbid complications of this condition is diabetic polyneuropathy, which eventually leads to frequent ulcers. Other known health complications include hypertension, coronary artery disease, venous insufficiency, cellulitis, lipidemia, glaucoma, and anemia.
There is no information regarding the patient’s age and ethnic background. However, there are some facts that provide insights into her daily life. Struggling with care for her husband, who has a history of three strokes, work, and her personal diabetes treatment, the patient feels extremely overwhelmed and stressed. As a result, she undergoes medical treatment for anxiety and depression. Her current treatment includes GLP-1 medications (Trulicity 4.5), long-acting insulin glargine (Lantus 40 units BID), and insulin lispro (Humalog). The treatment team includes a primary care physician, dietician, pharmacist, and health coach.
The patient appears frustrated with the fact that all of them present different treatment options, whereas she does not have enough time and money to pursue either of them. Currently, the patient has been prescribed treatment for her leg ulcer, including wound care management and compressions. No medications were excluded from the treatment plan, as there might be a risk of rapid hyperglycemia. Although the patient tries to follow the treatment procedures, there is a potential for recurrent ulcers since the condition of her uncontrolled diabetes does not improve with treatment, whereas the stress levels continue to increase.
Clinical Question
In the process of reviewing the patient’s medical history, it has been established that the woman struggles with severe anxiety and depression fueled by exhaustion, poor physical condition, and financial uncertainty. It is stated in her medical record that the patient receives treatment for her anxiety and depression, but the regularity of the medication intake is unknown because the woman continues to feel stressed and has to make choices in favor of certain medications due to financial issues in the family. Being aware of the dramatic effect diabetes has on one’s mental health, clinicians can rightfully wonder if such a correlation works in the opposite direction and, more precisely, whether efficient anxiety and depression treatment can positively contribute to one’s A1C levels. Hence, the patient’s record provokes the following clinical question: “Does prescribing medications for anxiety and depression reduce A1C levels in patients with persistent hyperglycemia who are already taking a GLP-1 receptor agonist and insulin?”
Literature Review
The relevant literature for the clinical question was found using the PubMed database. The keywords used during the search included “depression,” “antidepressants,” “type 2 diabetes,” and “A1C.”. There were two major search combinations used for an extensive search: “depression” AND “type 2 diabetes” AND “A1C”; “antidepressants,” “type 2 diabetes,” “A1C.” The first search combination demonstrated 169 results, whereas the second combination demonstrated 17 results with one cross-reference from the previous search. After analyzing the results in the database, 12 scholarly peer-reviewed studies were included in the paper (Ravona-Springer et al., 2017; Winkley et al., 2020; Chew et al., 2017; Cohen et al., 2020; Chai et al., 2018; Mansori et al., 2019; Hasanovic et al., 2020; Rohde et al., 2022; Whitworth et al., 2020; Liang et al., 2021; Rachdi et al., 2019; Kamil et al., 2017):
Table 1. Database search results (Note: human, peer-reviewed, 5-year range
Synthesis of Articles
One of the most commonly examined themes for research on the topic was the overall correlation between glycated hemoglobin (HbA1C) and the scopes of depressive disorders and anxiety in patients diagnosed with type 2 diabetes. Generally, there were three articles that explored such a correlation. Thus, in the observational study conducted Ravona-Spinger et al. (2017), the researchers estimated that roughly, every additional increase in HbA1C levels in diabetic patients results in a higher number of depressive disorders. Another study by Hasanovic et al. (2020) aimed at defining this correlation through the comparison of HbA1C levels and the results of the PHQ-9 questionnaire. The findings show that low control of HbA1C is correlated with an increased number of depressive symptoms in diabetic patients. Finally, the third study demonstrates that in T2DM patients with a predisposition to depression and anxiety, A1C levels contribute to significantly elevated anxiety levels. For this reason, there is a strong need to address both mental health and glycemic control in order to secure proper patient outcomes.
Two studies from the review were focused on the examination of the impact of psychological and educational interventions on the patients’ glycemic control. Thus, the research conducted by Winkley et al. (2020) demonstrates that such interventions as cognitive-behavioral therapy (CBT) and counseling have a positive impact on A1C levels in patients with type 2 diabetes. Moreover, “there was evidence that psychological interventions improved dietary behavior and quality of life” (Winkley et al., 2020, p. 2). The second study presented by Chai et al. (2018) focuses on the benefits of self-management education for controlling A1C levels in diabetic patients. These studies suggest that non-pharmaceutical interventions are key to the efficient management of T2DM patients with depressive disorders.
Three studies suggest that depression and anxiety management have little to no impact on glycemic levels. According to Chew et al. (2017), the existing evidence that demonstrates the benefits of psychological interventions is insufficient to state that they contribute positively to the A1C levels. Another study by Mansori et al. (2019) suggests that the overall correlation between depression and A1C levels is quite weak, so the examination of depression treatment and glycemic control correlation may be irrelevant as a whole. Finally, when it comes to antidepressants, Rachdi et. (2019) claims that one of the most common serotonin uptake inhibitor, sertraline, also known under the brand name Zoloft, has no impact on the reduction of A1C levels. These studies, however, do not imply that the correlation between the two phenomena should be eliminated entirely. Instead, they demonstrate the need to collect more substantial evidence in the future.
One study focuses on the prospects of telehealth in terms of treating T2DM and comorbid depressive and anxiety disorders. Thus, according to Cohen et al. (2020), pharmacist-led telehealth disease management tends to increase the adherence to medications, thus reducing both A1C levels and depression scores. These findings are especially relevant for patients who are incapable of coming to regular in-office doctor appointments due to limited mobility or residing in rural areas.
The last three studies from the review tackle the notion of antidepressants intake and their effect on the A1C levels. Thus, the study by Rohde et al. (2022) concludes that the intake of antidepressants by T2DM patients has a beneficial impact on the HbA1C levels. The research by Liang et al. (2021) and Kamil et al. (2017) focus on a more detailed examination of the antidepressant groups prescribed for the patients. For example, Liang et al. (2021) discovered that while both fluoxetine and agomelatine contribute to the reduction of A1C levels, the latter is more appropriate for patients aged 50-70. Kamil et al. (2017), for their part, discovered the positive impact of sibutramine, especially when the medication is combined with diet and exercise.
Discussion
The findings synthesized from the literature review contribute significantly to answering the clinical question, as they provide insights into the specific procedures and approaches to depression and anxiety treatment for diabetic patients. Thus, considering the case study presented, it is reasonable to assume that adherence to depression and anxiety treatment is vital for securing progress in diabetes treatment. While Ravona-Springer et al. (2017) claim that an increase in A1C levels leads to the deterioration of depressive disorders, it becomes evident that increased depression score will also lead to poor treatment adherence and lack of internal motivation to continue consistent insulin treatment.
However, while the initial clinical question addresses the notion of antidepressant intake, further analysis shows that there should be a combination of medications and non-pharmaceutical treatment for the patient. Thus, the patient can be recommended counseling or CBT as a way to address stress and poor health outcomes (Winkley et al., 2020). Moreover, it would be beneficial for the patient to be educated on the matter of self-management techniques, including physical activity, exercise, and proper rest, as increasing one’s ability to control physical health and mood will result in beneficial A1C level outcomes (Chai et al., 2018). As a result, timely interventions will reduce the overall rates of frustration.
One of the most valuable insights for the patient from the study is the possible implementation of pharmacist-led telehealth management (Cohen et al., 2020). According to the patient, she feels upset and frustrated because of her inability to visit doctor’s appointments due to a 45-minute commute to the hospital. Thus, by implementing telehealth disease management with her PCP and pharmacist, the chance of better treatment adherence is higher, whereas another reason for stress and anxiety is eliminated.
Lastly, findings show that it is of paramount importance to reconsider the depression medications prescribed to the patient, as different groups of antidepressants have a different impact on the patient’s well-being. For example, if such medications as Zoloft tend to have no effect on A1C levels, the treatment team should consider medications such as sibutramine, agomelatine, or fluoxetine, as their intake has been proven to contribute to reduced HbA1C rates (Rachdi et al., 2019; Liang et al., 2021; Kamil et al., 2017).
In order for the patient to achieve the desired results, there is a strong need for close interprofessional collaboration and evidence-based practice. By creating a coherent plan of insulin intake, nutrition, exercise, depression medications, and therapy, the patient will be more likely to adhere to the treatment. Consequently, the overall health outcomes will be more positive, including increased rates of life satisfaction, lower ulcer risks, and the less explicit manifestation of depressive disorders.
Conclusion
The present case study dwells on the patient with uncontrolled type 2 diabetes with various comorbid conditions and severe depressive and anxiety disorders. As a result, the clinical question was whether the treatment of depression and anxiety could improve the patient’s hyperglycemia and high HbA1C levels. The findings reveal that while there is no definite answer to the potential A1C outcomes from the depression treatment, the attention paid to depressive and anxiety disorders is likely to have a positive effect on the T2DM treatment.
As far as the AANC essentials are concerned, the first essential of background practice from science was addressed by a thorough literature review and data synthesis. The third essential of quality improvement was addressed with the help of presenting evidence and potential solutions for better patient care with the help of integrating various treatment approaches and psychological safety of the patient. The seventh essential of interprofessional collaboration was addressed by involving PCP, dietician, counselor, and pharmacist in the process of treatment.
The synthesis of scholarly data presents a series of recommendations for dealing with the patient. The first recommendation is to reconsider the antidepressant intake in favor of the medications that have a positive effect on A1C levels. The second recommendation includes the involvement of a multidisciplinary telehealth team in the treatment. Finally, it is also highly recommended to suggest professional counseling and therapy for the patient.
References
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