Transcript Depression_and_Diabetes_Slides_ENG

DEPRESSION AND DIABETES
A synopsis based on the WPA volume “Depression and Diabetes”
(Katon W, Maj M, Sartorius N, eds. – Chichester: Wiley, 2010)
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: Depression and
Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.
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 hypothalamicpituitary-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.
Practical problems arising from depression-diabetes comorbidity - I
Problem
• Depression and diabetes symptoms overlap
• Depression symptoms mimic diabetes
Impact
• Patient and clinician may be unaware of depression, and may
primarily attribute changed status to worsening diabetes self-care
symptoms
• Depression may be associated with onset or
amplification of physical symptoms
• Depression is commonly associated with
difficulties with diabetes self-management and
treatment adherence
• 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
• 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 regulate
emotions with food or substances
• Stressors that interfere with self-management
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
Impact
• 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
• 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
• 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
poor blood glucose control irrespective
of behavioral actions
• Depression is commonly associated
with difficulty organizing tasks
Impact
• 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
• 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 • Clinicians may need to help depressed patients break down tasks into
view of the future
• Depression is commonly associated
with anxiety
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 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
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 selfmanagement 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.
Acknowledgements
This synopsis is part of the WPA programme aiming to raise the
awareness of the prevalence and prognostic implications of depression
in persons with physical diseases. The support to the programme of the
Lugli Foundation, the Italian Society of Biological Psychiatry, Eli-Lilly and
Bristol-Myers Squibb is gratefully acknowledged. The WPA is grateful to
Dr. Andrea Fiorillo, Naples, Italy for his help in the preparation of this
synopsis.