Download DEPRESSION AND DIABETES A Double Burden!

DEPRESSION AND DIABETES
A Double Burden!
A synopsis based on the WPA volume “Depression and Diabetes”
(Katon W, Maj M, Sartorius N, eds. – Chichester: Wiley, 2010)
Sulaiman Al-Khadhari, MBBCh, FRCPC
Assisstant Professor of Psychiatry
Faculty of Medicine, Kuwait University
Head, Department of Psychiatry, Kuwait Center for Mental Health (KCMH)
Chair, Faculty of Psychiatry, Kuwait Institute of Medical Specializations (KIMS)
Head, General and Geriatric Psychiatry Units (KCMH)
Epidemiology of depression and
diabetes
• In people with diabetes, the prevalence of clinically
relevant depressive symptoms is 31% and that of
major depression is 11% (Anderson et al., 2001).
• People with depressive disorders have a 65%
increased risk of developing diabetes (Campayo et
al., 2010).
• The prognosis of both diabetes and depression (in
terms of complications, treatment resistance and
mortality) is worse when the two diseases are
comorbid than when they occur separately.
From Lloyd CE et al. The epidemiology of depression and diabetes. In:
Depression and Diabetes. Katon W, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.
People with both depression and diabetes have a greater decrement in self-reported health than
those with depression and any other chronic disease (Moussavi et al., Lancet 2007;370:851-858).
From Lloyd CE et al. The epidemiology of depression and diabetes. In: Depression and Diabetes.
Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.
Health care utilization is significantly higher among depressed compared with non-depressed diabetes patients
(US 1996 data). From Egede LE. Medical costs of depression and diabetes. In: Depression and Diabetes. Katon W,
Maj M, Sartorius N (eds). Chichester: Wiley, 2010.
Health care expenditures are significantly higher in depressed than in non-depressed diabetes patients (US 1996
data). From Egede LE. Medical costs of depression and diabetes. In: Depression and Diabetes.
Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.
Depression and diabetes
complications
• A prospective association has been documented
between prior depressive symptoms and the onset of
coronary artery disease in people with diabetes (Orchard
et al., 2003).
• A prospective association has been found between
depression and the onset of retinopathy in children with
diabetes (Kovacs et al., 1995).
• Depressive symptoms are more common in diabetes
patients with macro- and micro-vascular problems, such
as erectile dysfunction and diabetic foot disease,
although the causal direction of the relationship is
unclear (Thomas et al., 2004).
From Lloyd CE et al. The epidemiology of depression and diabetes. In:
Diabetic population
Non-diabetic population
Survival functions in a diabetic population stratified by Centers for Epidemiologic Survival
Studies functions in a nondiabetic population stratified by Centers for Epidemiologic Studies
Depression (CES-D) Scale score, NHANES I Epidemiologic Follow-up Study, 1982-1992
Depression (CES-D) Scale score, NHANES I Epidemiologic Follow-up Study, 1982-1992
Zhang, X. et al. Am. J. Epidemiol. 2005 161:652-660; doi:10.1093/aje/kwi089
ght restrictions may apply.
Zhang, X. et al. Am. J. Epidemiol. 2005 161:652-660; doi:10.1093/aje/kwi089
Copyright restrictions may apply.
A strong association has been found between depressive symptoms (as assessed by the Center for
Epidemiological Studies - Depression Scale, CES-D) and increased mortality in people with diabetes,
but not in those without diabetes, after adjusting for socio-demographic and lifestyle factors
(Zhang et al., Am. J. Epidemiol. 2005;161:652-660). From Lloyd CE et al. The epidemiology of
depression and diabetes. In: Depression and Diabetes. Katon W, Maj M, Sartorius N
(eds). Chichester: Wiley, 2010.
The depression-diabetes link: behavioural
factors
• Depression is associated with reduced physical activity,
which increases the risk for obesity and consequently
for type 2 diabetes.
• Depression is associated with poor diabetes self-care
(including oral medication taking, dietary modifications,
exercising and monitoring of blood glucose).
• Emotional problems related to diabetes may lead to the
development of depression.
From Lloyd CE et al. The epidemiology of depression and diabetes. In:
Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester:
Wiley, 2010.
The depression-diabetes link: biological
factors
• Depression is a phenotype for a range of stress-related
disorders which lead to an activation of the
hypothalamic-pituitary-adrenal axis, a dysregulation of
the autonomic nervous system and a release of proinflammatory cytokines, ultimately resulting in insulin
resistance.
• Metabolic programming at the genetic level and
undernutrition (in utero and childhood) may predispose
to both diabetes and depression.
From Ismail K. Unravelling the pathogenesis of the depression-diabetes link.
In: Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester:
Wiley, 2010.
Practical problems arising from depression-diabetes comorbidity - I
Problem
Impact
• Depression and diabetes symptoms overlap • Patient and clinician may be unaware of depression, and may
• Depression symptoms mimic diabetes
primarily attribute changed status to worsening diabetes selfsymptoms
care
• Depression may be associated with onset or • Patient may not sense he/she is fully understood or supported
amplification of physical symptoms
• Depression is commonly associated with
difficulties with diabetes self-management
and treatment adherence
by his/her clinician during health care visits when physical or lab
results do not correspond to subjective complaints
• Patient may feel resigned about the ability to make changes, e.g.
“I know what I am supposed to do and what I am not supposed
to do, but I still do the wrong things and I don’t know why!”
• Clinician may feel discouraged about the ability of the patient to
make relevant changes in his/her care
From Hellman R, Ciechanowski P. Diabetes and depression: management in ordinary
clinical conditions. In: Depression and Diabetes. Katon W, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.
Practical problems arising from depression-diabetes comorbidity - II
Problem
• Individuals with depression may attempt to
Impact
• A clinician not understanding the underlying depressive
regulate emotions with food or substances
symptoms and patient’s desperation to regulate emotional
pain may come across as judgmental because of the stigma
and associated response to these behaviors
• Stressors that interfere with self-management
• Patient and clinician may attribute poor diabetes outcomes to
strategies and worsen diabetes status may also
precipitate or exacerbate depression
• Depression may reduce the ability of affected
individuals to trust others or to be satisfied with
health care
• Depression is commonly associated with changes in
health care seeking patterns and follow-through
with appointments
a decrease in self-management because of a busy lifestyle but
may not appreciate the insidious development of depression
and its consequences
• Patient may be reluctant to make appointments, show up for
appointments, seek support of health care providers or
collaborate with health care providers during appointments
From Hellman R, Ciechanowski P. Diabetes and depression: management in ordinary
clinical conditions. In: Depression and Diabetes. Katon W, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.
Practical problems arising from depression-diabetes comorbidity - III
Problem
• Depression may be associated with
Impact
• This may lead to hopelessness, guilt, loss of empowerment, or a decreased
poor blood glucose control
irrespective of behavioral actions
sense of control of illness and may influence the motivation of the patient to
engage in further clinical treatment recommendations
• Unsuspecting clinicians may unwittingly blame the patient for a situation the
patient now has little control over
• Depression is commonly associated
• What might have been easily understood in the past may need to be written,
with difficulty organizing tasks
• Depression leads to a more
pessimistic view of the future
• Depression is commonly associated
with anxiety
repeated and checked for comprehension while the patient is depressed
• Clinicians may need to help depressed patients break down tasks into
manageable action steps that may have shorter-term pay-off (e.g., reduction
of physical symptoms)
• Clinicians need to consider presence of anxiety which heightens a patient’s
uncertainty around decision-making and increases a general sense of dread
about the likelihood of success
From Hellman R, Ciechanowski P. Diabetes and depression: management in ordinary
clinical conditions. In: Depression and Diabetes. Katon W, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.
Efficacy trials of psychotherapies for depression in diabetes
Study
Interventions
Outcome
Lustman et al., 1998
Cognitive-behavioural therapy (CBT) plus diabetes
education vs. diabetes education alone
Improvement in depression as well as
glycemic control in CBT vs. control group
Huang et al., 2002
Antidiabetics + diabetic education + psychological
treatment + relaxation and music treatment vs.
antidiabetics only
Improvement in depression as well as
glycemic control in treatment vs. control
group
Li et al., 2003
Antidiabetics + diabetic education + psychological
treatment vs. antidiabetics only
Improvement in depression as well as
glycemic control in treatment vs. control
group
Lu et al., 2005
Diabetes and cerebrovascular accident education +
electromyographic treatment + psychological
treatment vs. usual care
Improvement in depression as well as
glycemic control in treatment vs. control
group
Simson et al., 2008
Individual supportive psychotherapy vs. usual care
Improvement in depression as well as
glycemic control in supportive psychotherapy
vs. control group
From Katon W, van der Felz-Cornelis C. Treatment of depression in patients with
diabetes. In: Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester:
Wiley, 2010.
Efficacy trials of medications for depression in diabetes
Study
Interventions
Outcome
Lustman et al., 1997
Glucometertraining + nortriptyline vs.
placebo
Improvement in depression but not in glycemic
control with nortryptiline vs. placebo
Lustman et al., 2000
Fluoxetine vs. placebo
Improvement in depression but not in glycemic
control with fluoxetine vs. placebo
Paile-Hyvärinen et al.,
2003
Paroxetine vs. placebo
After initial improvement in paroxetine group at 3
months, no significant improvement for both
outcomes at the end of follow-up
Xue et al., 2004
Paroxetine vs. placebo
Improvement in depression but not in glycemic
control with paroxetine vs. placebo
Gülseren et al., 2005
Fluoxetine vs. paroxetine
Both groups improved significantly in depression
but not in glycemic control
Paile-Hyvärinen et al.,
2007
Paroxetine vs. placebo
No significant improvement in depressive
outcomes and glycemic control
From Katon W, van der Felz-Cornelis C. Treatment of depression in patients with
diabetes. In: Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester:
Wiley, 2010.
Depression care in patients with diabetes:
Step 1
Screen for:
• Depression with the Patient Health Questionnaire - 9 (PHQ-9)
• Helplessness/”giving up” or sense of being overwhelmed about disease selfmanagement
• Comorbid panic attacks and post-traumatic stress disorder
• Inability to differentiate anxiety symptoms from diabetes symptoms (e.g.,
hypoglycemia)
• Associated eating concerns
• Emotional eating in response to sadness/loneliness/anger
• Binge eating/purging
• Night eating
From Katon W, van der Felz-Cornelis C. Treatment of depression in patients with diabetes.
In: Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.
Depression care in patients with diabetes:
Step 2
Improve self-management:
• Explore “loss of control” of disease self-management
• Explore understanding of bidirectional link between stress and suboptimal
disease self-management and outcomes
• Define depression and how it overlaps with and is distinct from “stress”
• Review symptoms of depression and how these symptoms overlap with or
mimic diabetes symptoms
• Discuss depression-related medical symptom amplification
• Break down tasks in self-management of diabetes, depression, other illnesses
• Help patient prioritize order of importance of specific tasks
From Katon W, van der Felz-Cornelis C. Treatment of depression in patients with diabetes.
In: Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.
Depression care in patients with diabetes:
Step 3
Support:
• Consider adjunctive brief psychotherapy for:
emotional eating (cognitive-behavioural therapy)
breaking down problems (problem-solving therapy)
improving treatment adherence (motivational interviewing)
From Katon W, van der Felz-Cornelis C. Treatment of depression in patients with diabetes.
In: Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.
Depression care in patients with diabetes:
Step 4
Consider medication:
• Comorbid depression and anxiety: SSRI or SNRI
• Sexual dysfunction: use bupropion or, if already responding to SSRI, add
buspirone
• Significant neuropathy: choose bupropion, venlafaxine or duloxetine due to
effectiveness in treating neuropathic pain
From Katon W, van der Felz-Cornelis C. Treatment of depression in patients with diabetes.
In: Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.
$25.000
Savings
Intervention
$5.000
Usual Care
$10.000
Savings
$15.000
Intervention
Total Medical
Costs Over a 2Year Period
Usual Care
$20.000
$0
Katon et al., 2006
Simon et al., 2007
Enhanced treatment of depression in patients with diabetes is associated with lower health care
costs over a 2-year period. From Katon W, van der Felz-Cornelis C. Treatment of depression in
patients with diabetes. In: Depression and Diabetes. Katon W, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.