Lecture Focuses on Treating Depression in Primary Care

By Dirk Hoffman

That was the overriding message from Leonard E. Egede, MD, 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.

He gave his address, titled “Managing Depression in Primary Care: A Case Based Approach,” Aug. 29 in the M&T Auditorium at the Jacobs School building.

Egede, who is president and CEO of UBMD Internal Medicine, is a general internist and health services researcher who is currently the 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, according to an introduction given by Nasir Khan, MD, clinical associate professor of medicine, one of the main organizers of the event.

“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,” he 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 percent of people with type 2 diabetes and about 31 percent 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 3-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.”

Another study Egede was involved in looked at survival rates.

“We wanted to look at mortality, so we studied about 10,000 individuals with Type 2 diabetes and in an eight-year follow-up, there were about 2,000 deaths in the group,” he said. “The mortality rate was highest in the group with both diabetes and depression.”

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 is 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.”

“There is a common fear of once you get onto antidepressant medications, you cannot get off them or a fear of addiction and the cost of medications if one is uninsured or underinsured.”

Egede said sometimes patients have religious or spiritual beliefs that depression can be handled spiritually.

“I have told patients this is a medical issue, a biologic issue just like diabetes, just like hypertension, and that allows them to be more receptive to treatment.”

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 percent 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.

The Golden Lectureship was founded in 2001 to expand the traditional medical model to a bio-psycho-social and spiritual model of care.

It is named in honor of Lawrence Golden, MD, a cardiologist, and his wife, family therapist Nancy Golden.

The lecture series aims to promote the theme Lawrence Golden reinforced during his career that there is an interaction between the brain, the mind, body and spirit.

Three of the Golden’s children were in attendance at the lecture: Grant Golden, MD, a radiologist in Amherst, NY; Catherine Golden, PhD, a professor of English at Skidmore College; and Pamela Golden, an artist in the Boston, Massachusetts, area.

Besides Khan, other members of the organizing committee for the Golden Lecture are:

• Joan S. Baizer, PhD, professor of physiology and biophysics
• Rachel de Perio, a second-year medical student
• Grant Golden, MD
• Linda Kahn, PhD, research professor in the Department of Family Medicine
• Jeffrey M. Lackner, PsyD, professor of medicine and chief of the Division of Behavioral Medicine