Golden lecture focuses on treating depression in primary care

There are many effective tools available for managing depression, but it’s crucial for primary care providers to carefully assess symptoms in order to make accurate diagnoses and recommend the most appropriate treatment options.

That was the overriding message from Leonard E. Egede, the Charles and Mary Bauer Professor and Chair of medicine at the Jacobs School of Medicine and Biomedical Sciences, who was the featured speaker at the 2024 Lawrence and Nancy Golden Memorial Lectureship on Mind-Body Medicine.

The lecture, titled “Managing Depression in Primary Care: A Case Based Approach,” took place last month at the Jacobs School.

Egede, who is also president and CEO of UBMD Internal Medicine, is a general internist and health services researcher who is currently principal investigator on five National Institutes of Health R01 grants focused on addressing social determinants and structural inequalities in helping to improve health outcomes for adults with Type 2 diabetes.

Egede has expertise in several different research methodologies and has published more than 475 peer-reviewed manuscripts related to health disparities, psychosocial risk factors, health care costs and social determinants of health.

“Managing depression in clinical care is a topic I got involved in early in my career,” Egede said. “The idea is to use a case-based approach, and these are real cases of people I treated, and it actually motivated some of my work.”

The first case Egede presented was of a 36-year-old man with Type 2 diabetes, who complained of fatigue, feeling down, slight irritability and frustration with treating his diabetes.

“He was a truck driver who was afraid of losing his license,” Egede said. “Depression is actually highly prevalent in patients with diabetes and in a lot of comorbid conditions.”

Studies have shown that depression was present in 11% of people with Type 2 diabetes and about 31% had major or mild depression combined, Egede noted.

“Depression also affects physical function, so you find people with decreases in vitality, social function and emotional activities,” he said.

Egede also talked about a study that was conducted at a Veterans Administration hospital, where researchers tracked almost 12,000 veterans with Type 2 diabetes for about 10 years.

“We wanted to know what happens to glycemic control over time in individuals with Type 2 diabetes,” he said. “We found over each three-month period, there was a significant difference in A1C levels between depressed and nondepressed.”

“And across the entire timeline, all those with depression had higher A1C levels with consistency after controlling for all other instances and covariants,” Egede added. “This was one of the first studies to show that there was a longitudinal relationship with depression and it actually impacted A1C levels over time.”

His next study looked at depression with diabetes complications.

“The idea was to ask the question, since we know depression causes hypoglycemia, does it actually lead to complications,” Egede said. “Across multiple studies and meta-analyses it was associated with retinopathy, neuropathy, nephropathy, microvascular complications and sexual dysfunction.”

Egede said studies have shown depression in people with diabetes also results in higher health care costs

“It is not just a mortality issue, or just a quality-of-life issue,” he said. “There is also a higher cost, so there is a real benefit in treating depression in people with diabetes.”

Egede said there are many reasons why it’s important for clinicians to screen for depression — such as tracking progression and needing to recognize barriers to treatment.

Health system barriers include limited referral sites, health insurance limitations and inadequate staff support.

“It is really hard to get patients into psychiatry. There are not enough psychiatrists in most environments and especially in more rural areas,” Egede said. “Many insurance companies will not pay. We have a system in this country where we do not pay equally for medical and mental health conditions, so you have a fragmentation of care and disparities in coverage.”

Patient-level barriers exist as well, Egede pointed out.

“There is a lot of misinformation about depression. People are worried about the stigma of mental illness; they may see it as a sign of personal weakness,” he said. “There is also a general distrust of physicians and a lot of denial because people do not want to talk about mental health.”

Egede said it is also important for clinicians to assess patients with depression for the risk of suicide.

“The reason for this is because about 50% of patients who commit suicide have seen a primary care physician within the last month,” he said. “Many times, people come in and present with depression and someone talks to them, but never assesses them for suicide.”

Egede said it is also important for primary care providers to know when to refer patients to psychiatry.

Examples include patients with high suicide risks, depressed patients with psychotic features and patients with severe mania.