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!!