Sulaiman Al- Khadhari , MBBCh , FRCPC Assisstant Professor of Psychiatry Faculty of Medicine,...

DEPRESSION AND DIABETESA 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, FRCPCAssisstant Professor of Psychiatry

Faculty of Medicine, Kuwait UniversityHead, 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).


Copyright restrictions may apply.

Zhang, X. et al. Am. J. Epidemiol. 2005 161:652-660; doi:10.1093/aje/kwi089

Survival functions in a diabetic population stratified by Centers for Epidemiologic Studies Depression (CES-D) Scale score, NHANES I Epidemiologic Follow-up Study, 1982-1992

Copyright restrictions may apply.

Zhang, X. et al. Am. J. Epidemiol. 2005 161:652-660; doi:10.1093/aje/kwi089

Survival functions in a nondiabetic population stratified by Centers for Epidemiologic Studies Depression (CES-D) Scale score, NHANES I Epidemiologic Follow-up Study, 1982-1992

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.

Diabetic population Non-diabetic population

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.


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 pro-inflammatory 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.

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.

Problem Impact

• Depression and diabetes symptoms overlap • Depression symptoms mimic diabetes

symptoms

• Patient and clinician may be unaware of depression, and may primarily attribute changed status to worsening diabetes self-care

• Depression may be associated with onset or amplification of physical symptoms

• Patient may not sense he/she is fully understood or supported by his/her clinician during health care visits when physical or lab results do not correspond to subjective complaints

• Depression is commonly associated with difficulties with diabetes self-management and treatment adherence

• 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

Practical problems arising from depression-diabetes comorbidity - I


Problem Impact

• Individuals with depression may attempt to regulate emotions with food or substances

• A clinician not understanding the underlying depressive 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 strategies and worsen diabetes status may also precipitate or exacerbate depression

• Patient and clinician may attribute poor diabetes outcomes to a decrease in self-management because of a busy lifestyle but may not appreciate the insidious development of depression and its consequences

• 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

• 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

Practical problems arising from depression-diabetes comorbidity - II


Problem Impact

• Depression may be associated with poor blood glucose control irrespective of behavioral actions

• This may lead to hopelessness, guilt, loss of empowerment, or a decreased 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 with difficulty organizing tasks

• What might have been easily understood in the past may need to be written, repeated and checked for comprehension while the patient is depressed

• Depression leads to a more pessimistic view of the future

• 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)

• Depression is commonly associated with anxiety

• 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

Practical problems arising from depression-diabetes comorbidity - III

Efficacy trials of psychotherapies for depression in diabetes

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.

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


Lu et al., 2005 Diabetes and cerebrovascular accident education + electromyographic treatment + psychological treatment vs. usual care


Simson et al., 2008 Individual supportive psychotherapy vs. usual care Improvement in depression as well as glycemic control in supportive psychotherapy vs. control group

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

Screen for:

• Depression with the Patient Health Questionnaire - 9 (PHQ-9)

• Helplessness/”giving up” or sense of being overwhelmed about disease self-

management

• 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

Depression care in patients with diabetes: Step 1


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



Support:

• Consider adjunctive brief psychotherapy for:

emotional eating (cognitive-behavioural therapy)

breaking down problems (problem-solving therapy)

improving treatment adherence (motivational interviewing)



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



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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.

Sulaiman Al- Khadhari , MBBCh , FRCPC Assisstant Professor of Psychiatry Faculty of Medicine,...

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