paula m. trief, phd professor of psychiatry & medicine senior associate dean for faculty affairs...
TRANSCRIPT
PAULA M. TRIEF, PHDPROFESSOR OF PSYCHIATRY & MEDICINESENIOR ASSOCIATE DEAN FOR FACULTY
AFFAIRSSUNY UPSTATE MEDICAL UNIVERSITY-
SYRACUSE, NY
DIABETES AND DEPRESSIONDOUBLE THE TROUBLE
What is diabetes?
What is depression?
What are the burdens and outcomes when a patient has both disorders?
What can you do to address depression in patients with diabetes?
Diabetes 101:A Brief Overview of Diabetes
(slides prepared by the American Diabetes Association)
Diabetes in the United States
• Nearly 26 million people in the U.S. have diabetes• 7 million people with diabetes are undiagnosed• 8.3% of the U.S. population• 26.9% of U.S. residents aged 65 years and older
• 1.9 million Americans aged 20 years or older were newly diagnosed with diabetes in 2010• Every 17 seconds, someone is diagnosed with diabetes
Source: National Diabetes Fact Sheet, 2011
After eating, most food is turned into glucose, the body’s main source of energy. The pancreas produces insulin that
“unlocks” the cells to allow glucose to enter them.
What Happens When We Eat?
In people without diabetes, glucose stays in a healthy range because
Normal Blood Glucose Control
Insulin is released at the right times and in the right amounts Insulin helps
glucose enter cells
In diabetes, blood glucose builds up for several possible reasons…
High Blood Glucose (Hyperglycemia)
Too little insulin is made
Liver releases too much glucose
Cells can’t use insulin well- insulin resistance
Hyperglycemia Can Cause Serious Long-Term Problems
•Blindness•Kidney disease•Nerve damage•Amputation•Heart attack/disease•Stroke•Cognitive decline
Chronic complications of diabetes
Burden of Diabetes in the United States
•The leading cause of:• new blindness among adults• kidney failure • non-traumatic lower-limb amputations
•Increases the risk of heart attack and stroke by 2-4 fold•7th leading cause of death•Mortality rates 2-4 times greater than non-diabetic people of the same age
Source: Centers for Disease Control and Prevention
Two Main Types of Diabetes
Pancreas makes too little or no insulin
Type 1 diabetes (~10%)
Type 2 diabetes (~90%)
• Cells do not use insulin well (insulin resistance)• Ability of pancreas to make insulin decreases over time
Type 1 Diabetes
• 1 in 20 people with diabetes have type 1.• Most people are under age 20 when diagnosed.• Body can no longer make insulin.• Insulin is always needed for treatment- multiple daily injections or pump.
Type 2 Diabetes
•Most people with diabetes have type 2.•Most people are over age 40 when diagnosed, but type 2 is becoming more common younger adults, children and teens.•Type 2 is more likely in people who:
• Are overweight or obese• Are non-Caucasian• Have a family history of type 2
Treatment for Type 2 Diabetes May Change Over a Lifetime
Always Includes:•Education•Healthy eating•Blood glucose monitoring•Physical Activity
Will include:
•Medications, including insulin
Obesity* Trends Among U.S. Adults - BRFSS, 1991(*BMI ≥ 30, or ~ 30 lbs overweight for 5’4” person)
No Data <10% 10%–14% 15%–19%
Obesity* Trends Among U.S. Adults - BRFSS, 1994(*BMI ≥ 30, or ~ 30 lbs overweight for 5’4” person)
No Data <10% 10%–14% 15%–19%
Obesity* Trends Among U.S. Adults - BRFSS, 2000(*BMI ≥ 30, or ~ 30 lbs overweight for 5’4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity* Trends Among U.S. Adults - BRFSS, 2006(*BMI ≥ 30, or ~ 30 lbs overweight for 5’4” person)
15%–19% 20%–24% 25%–29% ≥30%
Diabetes Trends Among U.S. Adults(Includes Gestational Diabetes)
BRFSS, 1990, 1995 and 2001
1990 1995
2001
No Data <4%
4%-6% 6%-8%
8%-10% >10%
Source: Behavioral Risk Factor Surveillance System, CDC
Is There Any Good News?
•Yes, we can reduce the chances of developing type 2 diabetes in high-risk people (weight loss, exercise, medications).•Yes, we can reduce the chances of developing diabetes complications through:
• Blood glucose control (diet, monitoring, medication)• Blood pressure control• Cholesterol control• Regular visits to healthcare providers• Early detection and treatment of complications
Diabetes is unique among chronic
illnesses in the degree that patient
behavior influences disease course
and outcomes.
WHAT IS DEPRESSION????
Depression includes several diagnoses
Major Depressive Disorder: Diagnostic Criteria
5 of following symptoms, must include one of first two, occurred almost every day for two weeks
Depressed moodAnhedonia- Loss of pleasure or interest Appetite changes- more/lessSleep disturbance- too much or too littleAgitation or retardationFatigue, less energyFeelings of worthlessness or guiltDifficulty concentrating or decidingRecurrent thoughts of death
Major Depressive Disorder
Depression Statistics
14.8 million American adults(6.7% incidence)
Lifetime risk = 17%Leading cause of disability in Americans
aged 15-44 yearsMen: women = 1:2Minorities > whites50% recurrence rate12% become chronically depressed
Increased Risk of Depression
Losses (divorced)Stressful life events-
poor, less education, unemployed
Lack of social support (lives alone)
Physical illnessFamilial factorsGenetic factors
Depression
Treatment of Depression
Medications- work (40% placebo vs. 60% meds),
but not for 40-50% of patientsNo evidence that one med is better than
another, trial and errorPsychotherapy- works, but not for 40-50%No evidence that one therapy is better than
another, choice depends on the therapistPsychotherapy + meds better than either one
alone for moderate chronic/severe depression
Collaborative Primary Care for Depression
Two core components:- care managers:
-to educate patients about depression -close patient follow-up to promote adherence to meds/therapy -encourage increased medical visits if
needed - back-up psychiatrist to supervise care
managers and support providers
Collaborative Primary Care for Depression
Gilbody et al., Arch Int Med, 2007- meta-analysis of 37 RCTs
- N= 12,355 pts. - Collaborative Care vs. primary care - CC -> 2X greater adherence to anti-deps. - CC -> improved depression @ 12 and 18
month follow-up and @ 5 years (1 trial)
DIABETES and DEPRESSION:
DOUBLE the TROUBLE
Depression and Diabetes-Prevalence
Major depressive disorder--9.3% people with diabetes vs.
--6.1% in general population
Clinical Depression lifetime prevalence:Men: 5-12%Women: 9-26%Medical Outpatients: 6-26%Diabetes patients: 24-33%
Egede 2003; Anderson et al, 2001; Fisher 2010
Depression, Diabetes and Distress
It’s not always Major Depression- Depressive symptoms are common: 31-45% of diabetes patients report
significant depressive symptoms
Importance of “Diabetes Distress”- Evidence that diabetes distress is related to
high A1c is stronger than evidence that depression is.
Severity of Depression in Diabetes
Natural course is chronic/severe.Depressive episodes may last
longer.Depression in diabetes may be
more resistant to treatment.
Kovacs et al, 1997
Depression and Diabetes Outcomes
Depression in diabetes is associated with:Higher A1c levels, i.e., poorer blood sugar
control CVD risk factors (hi BP, hi BMI, smoking)More complications Less active self-careHigher mortality rates3.5x higher health care costs
Ciechanowski 2000, 2003;Lustman 2000;de Groot 2001;Zhang 2005,
Katon 2005; Egede 2002; Rubin 2010
Why do individuals with diabetes get depressed?
Possible biological factors – – changes in brain chemicals and/or
hormones associated with both diabetes and depression?
– chronic high or low (or variable) blood sugar levels may
depression?
Psychosocial “Burden” of Diabetes
N= 4747, Utrecht Health Project: - normal - pre-diabetes - diagnosed with type 2 diabetes - not yet diagnosed, but found to have type 2 diabetes
Results: Diagnosed type 2 diabetes associated with depression, but undiagnosed and pre-diabetes were not.
Implication: Relationship between diabetes and depression may reflect the psychosocial burden of the disease.
Knol et al, Psychosom Med, 2007
Depression <-> Diabetes- Bi-directional
Brain chemicalsHormonesBehavior
Diabetes/High blood
sugar
Depression
Why do individuals with diabetes get depressed/distressed?
Challenges > ResourcesPsychological challenges of diabetesNeed for careful control of basic activity
(eating) loss of autonomy & sense of control over body
Diabetes is a hidden disease low support
Stigma shame hiding (e.g., keep blood sugar levels high to avoid hypoglycemia)
Why do individuals with diabetes get depressed/distressed?
Psychological challenges of diabetes
guilt, need to “be good,” “it’s my fault” anxiety about future complications when first complication hits:
-well-controlled feel betrayed-poorly-controlled feel guilty
Why do individuals with diabetes get depressed/distressed?
Psychological challenges of diabetes
role changes – within family, at work effect of complications, e.g., dialysis,
impaired vision, impotence pain, disability/functional impairment
Why don’t all individuals with diabetes get depressed/distressed?
Psychological resources life environments, stress
- other health problems- family health- work stability- financially secure- health insurance
Psychological Resources
Ways of coping Positive:
Gather information, educate yourself Seek support
Make a spiritual connectionExercise
Negative:DenialAvoidanceAlcohol, drugs
Psychological Resources
Sense of Self-Efficacy- “I can do it!”
- Overall self-efficacy-attitude towards problems
- Specific self-efficacy-exercise self-efficacydiet self-efficacy
Psychological Resources
Social Support
- Different types of support
- Importance of a “confidante”
Psychological Resources
Self Esteem
Do I like myself?
Am I worth taking care of?
Treatment of Depression for Diabetes Patients
MedicationsPsychotherapyEducationFamily involvementExercise
Depression Management and Diabetes Outcomes
Treatment of depression works for diabetes patients, as it does for others.
Limited evidence that treatment of depression leads to better blood glucose control or better adherence to self-care regimen.
SUMMARY
1. PREVALENCE. Depression and diabetes often occur together.
2. SEVERITY. Depression in patients with diabetes may be more severe, i.e., more likely to recur, lasts longer
3. DIABETES can make DEPRESSION worse, either due to biology, emotional burden, or both.
SUMMARY
4. DEPRESSION can make DIABETES worse, i.e., poorer self-care and blood sugar control -> complications, hospitalizations and higher health care costs.
5. TREATING DEPRESSION WORKS, but more effective treatments are needed.
SUMMARY
6. TREATING DEPRESSION MAY HELP BLOOD SUGAR CONTROL, but even if it doesn’t, it’s the
right thing to do.7. DIABETES DISTRESS is also important to
address.8. FAMILY MEMBERS can also get depressed,
anxious, guilty and distressed.
A Conversation
What can you do in your role as care manager about depression for your diabetes patients?
What are the barriers you experience when you try to help your patients?
What can you do about depression in your diabetes patients?
1. MAKE EVERY VISIT THERAPEUTIC a. “There is no greater loan than a sympathetic ear." - Frank Tyger, cartoonist, columnist and
humorist b. Close follow-up to promote adherence to meds/therapy
2. HELP PATIENTS BUILD STRENGTHS! Educate, educate, educate- make depression-diabetes linkHelp them find ways to cope positively.Help them reach out to others.Help them tell themselves they can do it, by establishing realistic goals, supporting small steps, praising all achievements, and believing they can.Help them tell themselves they’re worth it, by believing they are.
3. IF CHALLENGES ARE TOO GREAT, HELP PATIENTS GET HELP!
Thank you for your insights and attention!!