depression , diabetes and quality of life
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Depression , Diabetes Depression , Diabetes andand
Quality of lifeQuality of life
Prof. Ahmed OkashaM.D., PhD, F.R.C.P., F.R.C., Psych., F.A.C.P (Hon.)
Founder and Director of WHO Collaborating CenterFor Research and Training in Mental Health
Okasha Institute of Psychiatry, Ain Shams University
President Egyptian Psychiatric Association Hon. President Arab Federation of PsychiatristsPresident World Psychiatric Association (2002 – 2005)
What Is Happening in The Middle East?What Is Happening in The Middle East?
EgyptTunis Libya
Bahrain
Yemen Morocco
Syria Jordan
• 60% of Arab World below 30 years
• Tunisia, Egypt, Yemen, Libya, Syria
• Common factors: Despotism, Security torture, Long standining in power, violation of human rights…etc
• No democracy, transparency, accountability.
• Revolutions of dignity to the Arab Citizens
• Democracy, providing physical and mental health are assets to wellbeing and happiness.
• In Egypt, first revolution by intellectual youth using the technology of social networking
Uprise in the Arab WorldUprise in the Arab World
Psychiatric Disorders in the Community
Out of every 100 citizens
30% are suffering from a mental problem that needs attention.
20% will seek traditional healers or general practitioner’s (GPs) help.
10% will be recognized by the GP to be psychiatric cases.
2.3% will be referred to the psychiatrist.0.5% will need inpatient treatment.
Ten leading causes of burden of diseases, world, Ten leading causes of burden of diseases, world, 2004 and 2030 2004 and 2030
2004
Disease or injury
As % of
total
DALYs
Rank Rank As % of
total
DALYs
2030
Disease or injury
Lower respiratory infections
6.2 1 1 6.2 Unipolar depressive disorders
Diarrhoeal diseases 4.8 2 2 5.5 Ischaemic heart disease
Unipolar depressive disorders
4.3 3 3 4.9 Road trafic accidents
Ischaemic heart disease 4.1 4 4 4.3 Cerebrovascular disease
HIV/AIDS 3.8 5 5 3.8 COPD
Cerebrovascular disease 3.1 6 6 3.2 Lower respiratory infections
Prematurity and low birth weight
2.9 7 7 2.9 Hearing loss, adult onset
Birth asphyxia and birth trauma
2.7 8 8 2.7 Refractive errors
Road trafic accidents 2.7 9 9 2.5 HIV/AIDS
Neonatal infections and other
2.7 10 10 2.3 Diabetes mellitus
COPD 2.0 13 11 1.9 Neonatal infections and others
Refractive errors 1.8 14 12 1.9 Prematurity and low birth weight
Hearing loss, adult onset 1.8 15 15 1.9 Birth asphyxia and birth trauma
Diabetes mellitus 1.3 19 18 1.6 Diarrhoeal diseasesCOPD , chronic obstructive pulmonary disease Global burden of disease WHO 2004
Prevalence*There is a range of percentages depending on the study.
39 %
45 %
47 %42 %
33 %36 %
33 %
9 %
6 %
0% 10% 20% 30% 40% 50%
Parkinson's disease
Stroke
Cancer outpatients
Hospitalized
General population
Prevalence of Depressive Prevalence of Depressive Disorders in Different Patient Disorders in Different Patient
Populations*Populations*
MI
Cancer.In-patients
Chronically ill
Geriatric
Two questions: During last month, have you often been
bothered by feeling down, depressed or hopeless? (Pleasure).
During the last month, have you been bothered by having little interest or pleasure in doing things? (Interest)
Diagnosis of DepressionDiagnosis of Depression
DepressionDepression
Main presentation:FatigueLack of concentration.Somatic symptoms (masked depression) e.g.
Headache, Backache, Paraesthesia.Sleep (EMW), appetite, sex, behaviorPsychomotor agitation or retardation.Malancholia.Psychosis: self depreciation, nihilism, guilt
Who gets depressed?Who gets depressed?
Knol MJ. Twisk JWR, Beekman ATF, Heine RJ, Snock FJ, Pouver F. Depression as a risk factor for the onset of type 2
diabetes meillitus. Ameta-analysis Diabetologia 2006:49,837-845
Prevalence of DMPrevalence of DM
World Wide 285 Millions expected in 2030 to be 439 Millions
Egypt 5 Millions 10% young.
Egypt rating among the World is number 10.
Life Time Prevalence of Depression in Diabetic Patients
Life Time Prevalence of Depression in Diabetic Patients
36%
DepressionFemale > Male
18%
Normal populationFemale > Male
Kaplan & Sadock, 2002Kaplan & Sadock, 2002
Face the FactsFace the FactsFace the FactsFace the Facts
The Stress CurveThe Stress Curve
Benefit- Vitality- Enthusiasm- Optimism- Mental alertness- High productivity and creativity
Benefit- Vitality- Enthusiasm- Optimism- Mental alertness- High productivity and creativity
Hazards- Fatigue- Irritability- Lack of concentration- Anxiety- Illness- Low productivity and creativity
Hazards- Fatigue- Irritability- Lack of concentration- Anxiety- Illness- Low productivity and creativity
Causes of Depression in Diabetic Causes of Depression in Diabetic PatientsPatients
Causes of Depression in Diabetic Causes of Depression in Diabetic PatientsPatients
1. Stress, dysregulation of HPA axis, dysregulation of blood glucose.
2. Reaction associated with having a chronic disease (e.g. denial, anger, depression, anxiety, acceptance).
3. Strict dietary regimen.
4. Concern over guilt of inappropriate following of dietary restriction.
1. Stress, dysregulation of HPA axis, dysregulation of blood glucose.
2. Reaction associated with having a chronic disease (e.g. denial, anger, depression, anxiety, acceptance).
3. Strict dietary regimen.
4. Concern over guilt of inappropriate following of dietary restriction.
5. Significant chronic pain secondary to neuropathy.
6. Effect on brain function {e.g. diabetes induces vascular (cerebral ischemia)}.
7. Coincidence (chance association).
8. Side effects or complications from medications.
5. Significant chronic pain secondary to neuropathy.
6. Effect on brain function {e.g. diabetes induces vascular (cerebral ischemia)}.
7. Coincidence (chance association).
8. Side effects or complications from medications.
Cont….
Cognitive Dysfunctions in Diabetic Cognitive Dysfunctions in Diabetic PatientsPatients
Impaired attention
Information processing
Memory (Short)
Problems solving
Language function
Visuo-constructional skills
Significant reduction of IQHolmes, 1990Holmes, 1990
Causes of Cognitive ImpairmentCauses of Cognitive Impairment
Metabolic dyscontrol.
Keto acidosis.
Hyperosmolar states.
Recurrent hypoglycemia.
Chronic hypoglycemia.
High prevalence of CVS.
Depression.
Stress may produce:anxiety – depression – hostility – unexpressed anger - cynicism – mistrust
Stress, Diabetes and DepressionStress, Diabetes and Depression
1. Reduction of vagal tone which is protective for the heart2. Endothelial function is impaired → injured → thrombosis3. Platelets more hyper-coagulable, more sticky,increases platelet aggregation and adhesion. 4. Haemoconcentration → increased blood viscosity
Acute stress → Activation of Acute stress → Activation of sympathetic system :sympathetic system :
1. Platelets2. Endothelium3. Vagal tone4. Activating cortisol system (Lipids – Glucose, Hypertension)5. Ovarian dysfunction, oestrogen is probably very protective → it raises HDL
Chronic StressChronic Stress
After an episode of major depression, the risk of myocardial infarction increased to fivefold.
Subsyndromal forms of depression had a twofold increased risk of myocardial infarction.
M.IM.I..
6 months after MI:Mortality rate : 17% in patients with depression , 3% without .
12 months after bypass: Those with depression had a higher incidence of subsequent cardiac events, angina , heart failure MI, repeat surgery.
MD is a significant risk factor for the development of coronary artery disease and stroke.
Frasure-Smith et al 1993Connerney 2000 Nemeroff 2001
Aims of TreatmentAims of Treatment
R ed u ce / R em oves ig n s & sym p tom s
R es to rero le fu n c tion
M in im ize risk o fre lap se / recu rren ce
Trea tm en t
Treatment OptionsTreatment Options
Antidepressant medicationPsychotherapyElectro-convulsive therapy (ECT) (Brain synchronization treatment)
Antidepressant Medication ClassesAntidepressant Medication Classes
TCAs
Clomipramine
Imipramine
AmitryptilineMAOIs
Phenelzine
IsocarboxazideRIMA
Moclobemide
SSRIs
Fluoxetine, Sertraline, Escitalopram, Paroxetine, Fluvoxamine
SNRI
Venlafaxine, DuloxetineOthers
Mianserin, Tianeptine, Nefazodone, Trazodone, Mirtazapine, Maprotiline.
Use AD with the least Drug-Drug interaction e.g. Sertraline, Ecitalopram, Mianserin i.e. no induction
Or inhibition of liver enzymes
SSRI Bleeding, hyponitraerina
Drug: Drug InteractionDrug: Drug Interaction
Taking moderate to high daily doses of antidepressants for more than 2 years is associated with an 84% increased risk for diabetes, according to a large observational study.
The increased risk was particularly notable for (SSRI) paroxetine and the tricyclic antidepressant amitriptyline.
Weight gain might explain much of the relation between antidepressant use and diabetes
Andersohn 2009
AntidepressantsAntidepressants
The study found a 4-fold increased risk for diabetes associated with the long-term use of paroxetine in daily doses above 20 mg/day, but not of fluoxetine, citalopram, or sertraline
Depression itself might be some how connected to diabetes and pointed out that there is evidence that patients who treat their depression in ways other than with antidepressants ( for example, with cognitive behavior therapy) are also at high risk of developing diabetes.
Andersohn 2009
SSRISSRI
New research suggest that a combination of type 2 diabetes and smoking may place individuals with serious mental illness (SMI) at even greater risk for death than their counterparts with diabetes who smoke but who do not have SMI.
Norra MacReady 2009
SmokingSmoking
Consequences of Psychiatric Consequences of Psychiatric Morbidity in Diabetic PatientsMorbidity in Diabetic Patients
Poorer glucose control.Increase risk of complications.Affected medication adherence and self
care regimes.Impaired quality of life.Lethal dose of insulin.Poor outcome.High frequency of (smoking, alcohol).
MYTH
Depression is obvious
and easily recognized and expressed by the
patient
MYTH
Depression is obvious
and easily recognized and expressed by the
patient
REALITY
Depression disorders are overlapping, hardly
expressed by the patient and constitute a major problem in symptom
exaggeration
REALITY
Depression disorders are overlapping, hardly
expressed by the patient and constitute a major problem in symptom
exaggeration
MYTH
Depression is Secondary to GMD
activityTreatment of the medical
disorder will relief Depression.
MYTH
Depression is Secondary to GMD
activityTreatment of the medical
disorder will relief Depression.
REALITY
Depression Depression requires treatment intervention and does not remit with relieve
of symptoms
REALITY
Depression Depression requires treatment intervention and does not remit with relieve
of symptoms
What is Mental Health?What is Mental Health?
Mental health is more than the mere lack of mental disorders.
Mental health is a state of well-being whereby individuals recognize their abilities, are able to cope with normal stresses of life, work productively and fruitfully, and make a contribution to their communities
Quality of Life Versus Longevity of LifeQuality of Life Versus Longevity of Life
Quality of life describes an individual’s satisfaction with his or her general sense of wellbeing. It is often measured as physical , psychological and social wellbeing.
Longevity of life at the expense of quality of life is an empty prize.
1. Psychological factors may affect health-related behaviours such as smoking, diet, alcohol consumption, or physical activity, which in turn may influence the risk of CHD and diabetes.
2. Psychosocial factors may cause direct acute or chronic pathophysiological changes, possibly by their effect on neuroendocrine or immune systems.
3. Access to and content of medical care may be influenced by social factors.
Psychosocial FactorsPsychosocial Factors
Psychological traits ( type A behaviour, hostility, workaholic, time urgency)
Psychological states ( depression, anxiety)
Psychological work characteristics ( job control , demands, support)
Social networks and social supports.
Personality and Social NetworksPersonality and Social Networks
Evidence that high levels of social support are protective against CHD and diabetes, while social isolation is related to increased mortality risk.
It has been proposed that social supports may act to buffer the effect of various environmental stereos and hence increase susceptibility to disease.
Alloway 1987
Social SupportSocial Support
Social interaction leads to neurogenesis and proliferation of dendrites in cells of the hippocampus and increased dopamine in the dopaminergic reward pathways.
Lack of social interaction leads to atrophy in cells of the hippocampus, decreased dopamine together with hopelessness and helplessness.
Spitzer, 2002
Social interactionSocial interaction
TemperamentsTemperaments(Genetic(Genetic))
1. Depressive اإلكتئابى المزاج2. Cyclothymic النوابى المزاج3. Irritable العصبى المزاج4. Anxious القلق المزاج5. Hyperthymic النشط المزاج
Akiskal 2003
Characters (Environmental) Characters (Environmental) الذات مصداقية
• Self- directedness: how well is a person, responsible, reliable, goal oriented and self confident.
التعاون • Cooperativeness: how a person is considered
a part of human society. (i.e., tolerant, helpful, compassionate), and self-transcendence.
الذات تجاوز• Self-transcendence: a part of the universe as a
whole.
• Well-being is not enhanced by wealth, power, or fame, despite many people acting as if such accomplishments could bring lasting satisfaction.
• Character development does bring about greater self-awareness and hence greater happiness.
• The most effective methods of intervention all focus on the development of positive emotions and the character traits that underlie well-being.
Well-beingWell-being
“Social Capital" is defined as the ties that bind families, neighborhoods , workplaces, communities, and religious groups together and find that it correlates strongly with subjective wellbeing.
In fact the breadth and depth of individuals' social connections are the best predictors of their happiness.
Money can buy you happiness, but not much. and above a modest threshold, more money does not mean more happiness.
Individuals usually get richer during their lifetimes—but not happier.
As for individuals, so for countries. Ghana, Mexico, Sweden, the United Kingdom , and the United States all share similar life satisfaction scores despite per capita income varying 10-fold between the richest and poorest country.
If money does not buy happiness, what does?
In all 44 countries surveyed in 2002 by the Pew Research center, family life provided the greatest sources of satisfaction.
Married people live on average three years longer and enjoy greater physical and psychological health than the unmarried.
Having a family enhances wellbeing, and spending more time with one's family helps even more.
In fact the breadth and depth of individuals' social connections are the best predictors of their happiness.
Work is central to wellbeing, and certain features correlate highly with happiness. These include autonomy over how, where, and at what pace work is done.
Trust between employer and employee.
Procedural fairness.
The more that governments recognize individual references, the happier their citizens will be.
Free choice, and citizens' belief that they can affect the political process, increase subjective wellbeing.
An association between unhappiness and poor health:
Be happy with what you have got, “look outwards—not to compare yourself unfavorably with others, but to develop your relationship! with them.
It is a surer route to happiness than the pursuit of wealth.
• Embark on a loving relationship with another adult, and work hard to sustain it.
• Plan frequent interactions with friends, family, and neighbours (in that order).
• Make sure you are not working so hard that you have no time left for personal relationships, and leisure.
Get Happy … It Is Good For You Get Happy … It Is Good For You
• In your spare time, join a club, volunteer for community service or take up religion.
• Happiness should become the goal of public policy and the progress of national happiness should be measured and analyzed as closely as the growth of gross national product.
• This means that public policy should be judged by how it increases human happiness and reduces human misery.
Happy LivesHappy Lives
Pleasant life:
• Where you experience a succession of pleasures that lose their effect with repetition.
Good life:
• Where you play your strengths and are engaged.
Meaningful life :
• Where you put your strengths at the services of something higher than yourself.
Positive Steps for Mental Health Positive Steps for Mental Health (WHO)(WHO)
1. Accepting who you are 2. Talking about it 3. Keeping active4. Learning new skills 5. Keeping in touch with friends6. Doing something creative 7. Getting involved 8. Asking for help 9. Relaxing 10.Surviving
ConclusionConclusion
Make Your Choice Make Your Choice
Be successful, competitive, workaholic and die younger. .
OR
Be less ambitious, lower income, more relaxed and live longer. .
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