Download Diabetes Slide Kit - Sydney Local Health District

Diabetes and Depression- The Two
Headed Monster
Roger Chen MB BS (Hons), PhD (Sydney), FRACP
Senior Staff Specialist
Concord Hospital
Clinical Senior Lecturer, University of Sydney
1
Introduction
 Traditional Risk Factors for
Diabetes Mellitus
 Physical
 Traditional Complications and
Co-morbidities
 Physical
 Traditional Treatments
 Pharmacological
 Mental Health –
 Risk factor for and
complication of diabetes
2
Retinopathy
Blindness
Peripheral vascular
disease
Autonomic
neuropathy
GI, genitourinary
& CV symptoms &
sexual dysfunction
Cerebrovascular
disease
Cardiovascular
disease
Hypertension
Dyslipidaemia
Nephropathy, renal
failure
Peripheral
neuropathy
Ulcers
Charcot joints
Amputations
Expert Committee on the Diagnosis and Classification of
Diabetes Mellitus 1999
3
Case
 Mr GS: 52 year old male with a
20 year history of Type 1
Diabetes
 Depression: on multiple
medications and atypical
antipsychotic
 Glycaemic control poor till 2002
 Enrolled in clinical trial using new
long acting basal insulin
 Blood sugar levels improved
significantly overall
 Punctuated by periods of very
high blood glucose levels (usually
coinciding with periods of
depression)
4
 52 year old female with Type2 diabetes 12 years
 Obese, Waist circumference 120 cm, BMI 35
 Pain on walking and at rest- generalised, painful
knees, hips, back and shoulders
 Own family- disengaged with sisters, mother recently
died not allowed to go to the funeral
 Son just admitted for alcohol and drug rehab
 Unable to do much exercise (painful back)
 Not sleeping, puffed out continually
 Some weight gain- blames tablets (6kg in 6 months)
 Blames thyroid (convinced she wants thyroidectomy)
 HbA1c (10.2%) out of proportion to home monitoring
 Blood pressure 180/100 mHg
 Feels miserable
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The Global Burden of the 2 “Ds”
 Increase in Diabetes well recognised
 Increase in Mental Illness not as
appreciated
 World Health Organization 2007
 Depression prevalence ranges
from 2-15%
> 60 countries
 Greatest proportion of disease
burden attributable to non-fatal
health outcomes
 Depression produces the
greatest decrement in health
compared with other chronic
diseases
 Co-morbid state of depression
worsens health with diabetes
Moussavi et al, Lancet September 8 2007
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 “Probing Depression and its ties to diabetes
 Millions of people face a two-headed beastdiabetes and depression- that gnaws at them
from the inside out.
 The struggle of coping with diabetes feeds
deep sadness. Depression gets in the way of
dieting, exercising, and even taking the
medicines that can control diabetes. The
downward spiral can make the depression
unrelenting, increase diabetic complications,
and even double the risk of death “
> The Boston Globe Nov 1 2006
7
Depression rates double in patients with
diabetes

Meta-analysis of 42 studies to estimate the
prevalence of depression in adults with diabetes
(n=21,351)
Diabetes doubles the odds
of comorbid depression
 elevated depression
symptoms in 31%

Self-report-based estimates
were higher than interviewbased estimates, as
interviews identify major
depressive disorder, but
exclude other clinically
relevant presentations
60
Depression prevalence (%)
 major depressive disorder
present in 11%
Diagnostic interview
Self-report scale
*
40
*p<0.001 between
methods
34.9
*
31.0
*
26.1
20
14.2
9.0
11.4
0
(n=7) (n=11)
(n=7) (n=14)
(n=14) (n=25)
Controlled
studies
Uncontrolled
studies
All studies
Anderson RJ. Diabetes Care 2001;24:1069–78.
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Why do patients develop depression ?
 Chronic disease
 Self management
 Generally early
 Associated with more complications
 Common mechanism
 Late onset depression
 Microvascular
 Associated with brain infarcts (Chemerinski 2000)
 MRI white matter signal hyperintensities
9
Why do patients develop depression ?
 Type 1
 GAD antibodies may affect GABA synthesis
 ? Reduced GABAergic neurpns in occipital
and prefrontal cortices in depression
 2 peaks
> Year following diagnosis
> 2nd peak 10 years later, in some cases,
puberty/adulthood
10
Management of diabetes may contribute to
impaired HRQoL- and an increased risk of
depression

Impact of diabetes
management on HRQoL:
 Demanding self-care
regimens1,2
 Significant lifestyle changes
 Multiple medications
 Treatment dissatisfaction
 Perceived treatment
inefficacy
 Fear of injections
 Fear of hypoglycaemia1,2
1. Rubin RR. Diabetes Spectrum 2000;13:21.
2. Barnett AH. Eur J Endocrinol 2004;151(suppl 2):T3–7.
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Diabetes causes psychological distress
Diabetes, Attitudes, Wishes and Needs (DAWN) survey
A large (n=5,104) international survey designed to identify a set of attitudes,
wishes and needs among diabetic patients and care providers in order to
investigate how diabetes management could be improved1,2
Community I live in is intolerant of diabetes
Family and friends pressurise
me about my diabetes
Diabetes causes worries about financial future
Worry about not being able to carry
out family responsibilities in the future
Constantly afraid of diabetes worsening
13.6
14.7
25.8
30.1
43.8
35.9
Diabetes ‘prevents me doing what I want’
18.1
‘Burned out’ because of diabetes
32.7
‘Stressed’ because of diabetes
1. The DAWN Study. Pract Diabetes Int 2002;19:22–4.
2. Skovlund S, et al. Diabetes Spectrum 2005;18:136–142.
0
10
20
30
40
50
Proportion of patients (%)
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Evaluating diabetes-specific HRQoL along
three major, interrelated dimensions
Psychological/
emotional
Physical
• Long-term complications:
•
•
•
•
•
•
•
vision loss, kidney damage,
heart disease, amputation
• Short-term complications:
fatigue, sleep disturbance,
infections, weight gain
• Symptoms:
glucose control (HbA1c),
hypo-/hyperglycaemia
& lifestyle changes
Depression
Anger
Fear
Persistent fatigue
Exhaustion
Helplessness
Chronic frustration
Social
• Changes in daily habits
• Relationships with family/friends
suffer
• Social life affected
Polonsky WH. Diabetes Spectrum 2000;13:36–41.
13
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Depression negatively impacts diabetes
management and progression

Significant association between
depression and hyperglycaemia1
 Improvements in depressive
symptoms predict
improvements in glycaemic
control2,3
 Improvements in glycaemic
control are correlated with
improvements in depressive
symptoms4,5

Poorer self management where
diabetes and depression co-exist
1. Lustman PJ, et al. Diabetes Care 2000;23:434–2.
2. Lustman PJ, et al. Psychsom Med 1997;59:241–50.
3. Lustman PJ, et al. Ann Intern Med 1998;129:613–21.
4. Mazze RS, et al. Diabetes Care 1984;7:360–6.
5. Testa MA, et al. JAMA 1998;280:1490–6.
Exacerbation
of diabetes
symptoms
Increased
risk of long-term
complications
Poor
glycaemic
control
Depression
Reduced
motivation
to maintain
good health/diet
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Depression as risk factor for Type 2 diabetes
 Thomas Willis 1684 “ Grief or sadness could bring on diabetes”
 Meta-analysis of 9 studies1
 37% increased risk of developing Type2 diabetes
 Increased HPA axis, increased catecholamines, CRP, TNF-alpha,
IL-6
 Impaired omega 3 polyunsaturated fatty acid metabolism
 Increased inactivity, tobacco
 ? Genes
 Problems
 Undetected / undiagnosed diabetes
 Method of diagnosis
 Baseline risk
 Follow-up duration
Knol et al; Diabetologia 49;837-845, 2006
 Multiple ways of assessing depression
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 Depression 40% more likley to precede than follow onset of Type 2
diabetes (Mezuk 2008)
 Mechanisms
 Lifestyle: sedentary, social withdrawal, poor motivation
 Socioeconomic- increase in depression and diabetes
 Environmental stress (Catecholamines, Cortisol)
 Hippocampal glucose transporters inhibited by Cortisol
 Inflammatory markers: TNF, CRP, IL-6
17
Endocrine Response to Stress
 HypothalamicPituitary: Cortisol
 Sympathetic-AdrenalMedullary:
Catecholamines:
Adrenaline and
Noradrenaline
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Chronic Stress
 Link with chronic
disease- heart, lung,
diabetes, infections,
malignancy
 Makes self care difficult
 Diabetes: Par
Excellence
> Need for blood
glucose
monitoring,
healthy food,
physical activity
 Shift work
 Travel
19
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Depression and heart disease
A ‘chicken vs egg’ debate:
 Depression as a significant risk factor for development of
heart disease1,2
 Comorbid depression confers a poorer prognosis in heart
disease1
1. Jiang et al. CNS Drugs 2002;16:111–27. 2. NHFA and CSANZ. Reducing risk in heart disease 2007 (Updated 2008).
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Among patients with diabetes, depression is
strongly associated with mortality
Patient mortality (%)
16
1.67-fold increase in
mortality (p=0.002)
2.30-fold increase in
mortality (p<0.0001)
13.6%
12
(n=48)
11.9%
(n=59)
8
8.3%
(n=275)
4
0
Without
depression
(n=3303)
Minor
depression
(n=354)
Major
depression
(n=497)
Katon WJ et al. Diabetes Care 2005;28:2668–72.
22
Impact of diabetes in patients with
depression
 10 000 participants in National Health and Nutrition
Examination Survey
 First study to compare effects of depression on mortality in
subjects with and without diabetes
 Over 8 years of follow-up and after adjustment for
confounders, subjects with both co-morbidities had
 1.3 fold increased risk of death vs diabetes itself
 2 fold increased risk of death vs depression itself
 2.5 fold increased risk of death vs neither
Egede et al, Diabetes Care 28:1339-1345, 2005
Adriaanse 2008
Li 2009
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Depression increased CV mortality postMI and in stable CHD
Post-MI1
Stable CHD (adjusted for age)3
HR: 5.74, p = 0.0006
n=186 baseline; n=7
endpoint
n=768 baseline; n=36
endpoint
Adapted from Frasure-Smith et al.1
Adapted from Whooley et al.3
1. Frasure-Smith et al. JAMA 1993;270:1819–25. 2. Frasure-Smith et al. Circulation 1995;91:999–1005.
3. Whooley et al. JAMA 2008;300:2379–88.
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Acute mental stress and heart
attacks
 Natural disasters and stressful events are associated
with a spike in rates of MI and lethal cardiac arrhythmias
 Earthquakes: e.g. Los Angeles
19941
 September 11, 20012
 Bushfire disasters3
 World Cup soccer matches4
1. Leor et al. N Eng J Med 1996;334:413–19. 2. Feng et al. Clin Cardiol 2006;29:13–17.
3. Kolbe & Gilchrist. NSW Public Health Bull 2009;20:19–23. 4. Wilbert-Lampen et al. N Eng J Med 2008;358:475–83.
Adapted from Leor et al.1
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Depressive illness is a risk factor for
development of heart disease
 13 studies prospectively followed > 40,000 patients with major
depressive disorder
 Depression was a significant independent risk factor for
development of coronary heart disease
 Comparable to the risk associated with smoking
1. Jiang et al. CNS Drugs 2002;16:111–27.
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How does stress trigger MI and
sudden death?
Most commonly occurs in patients
with pre-existing coronary artery
narrowing
At rest
 Sympathetic nervous system
activation – lethal arrhythmias1
 BP surge – rupture of plaques
leading to thrombosis1
Panic
attack
 Adrenaline secretion leading to1
 Platelet activation
 Low potassium levelscausing cardiac arrhythmias
Adapted from Esler et al.1
 Sympathetic activation and augmented
adrenaline secretion during panic attacks
can increase cardiac risk2
1. Esler et al. Stress Health 2008;24:196–202. 2. Esler et al. Ann NY Acad Sci 2004;1018:505–14.
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Risk Factors for Diabetes
GENERAL
Mental Health Population
 Age (rate  >45)
 Depression
 Ethnicity
 Schizophrenia
 Family History
 History Gestational Diabetes
 Hypertension (>140/90)
 Smoking
 Obesity (esp. central)
 Dyslipidaemias (HDL, TG)
 Diet
 Inactivity
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Complication Screening in diabetes
 Physical
 CV
 Eyes
 Feet
 Kidneys
 Neuropathy
 Psychological
 Depression
> Multiple Depression Questionnaires
30
AHA recommendation: Routine
depression screening post-MI
 AHA recommendation 2008:
“Routine screening for depression in patients with CHD…”1
 Recommended screening tools:
 PHQ-2 for rapid, initial assessment
> “During the past month, have you often been bothered by
feeling down, depressed, or hopeless?”
> “During the past month, have you often been bothered by little
interest or pleasure in doing things?”
 PHQ-9 for more detailed assessment
1. Lichtman et al. Circulation 2008;118:1768–75. 2. Stafford et al. Gen Hosp Psychiatry 2007;29:417–24.
3. McManus et al. Am J Cardiol 2005;96:1076–81
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What to do
 Screen for depression
 Typical clinical features
 Multiple complications, poor metabolic control
 Refer if uncomfortable
 Treatment options
 Cognitive Behavioural Therapy
 Pharmacological Therapy: TCA, SSRI
 Combinations
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Thank You
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