Transcript Diabetes, Depression, and Overwhelm

Diabetes, Depression,
and Overwhelm
Peggy Odegard, PharmD, CDE
(with helpful notes from Paul
Ciechanowski, MD!)
You are in clinic today…
O You just completed a visit with Mr. James, a 72
year old male with type 2 DM. He attended this
clinic visit with his wife, Sally, who seems to be a
very attentive and helpful. Although his glucose
control is not ideal, A1c is now improved from
9.4% to 8.2%. You recommend keeping up the
good work and continue meds with metformin
1000 mg BID and glipizide 10 mg daily, in
addition to his other 9 meds. He is to return to
clinic (RTC) in 3 months…
A call from the front desk…
O Mr. James asks the front desk clerk at the clinic if he can have
just a few more minutes of your time for a quick question. You
are paged to the front desk while his wife handles scheduling
his next appointment
O Upon taking Mr. James back to the exam room, he reports to
you that he felt funny mentioning something in front of his wife.
O You invite his concern and he shares with you that he doesn’t
feel it is worth it any longer and wonders if it would be easier to
just call it quits, perhaps even end it all.
O He is tearful, expresses their joint overwhelm with the diabetes
and all the responsibilities, and indicates he feels it might be
easier to leave his wife without him as a burden.
Diabetes, depression, and overwhelm
(not to mention anxiety)
O Pharmacist’s role
O Assessment, screening, triage
O The diabetes connection
O Symptoms and problems
O Approach to treatment & support
Managing DM in the face of stress
O Hypothetical situation…You have a
therapeutics exam fast approaching on
Monday… how will your life be different this
week?
Depression Realities
O It exists – is actually twice as likely to occur
in people with diabetes
O Depression can mimic and amplify DM sx
O Fatigue
O Impaired concentration
O Changes in appetite
O Changes in sleep
O Agitation or feeling slowed down
Clin Diab 2011;29(2):43-9
Depression Realities
O Associated with
O poor self-management & poor adherence
O adverse lifestyle habits
O changes in health care utilization
O Reduced trust and satisfaction
Clin Diab 2011;29(2):43-9
Assessment
O Depression
O PHQ-9
O Geriatric Depression Scale
O Comorbid anxiety
O GAD-7
O Eating disorder
Treatment Options
O Cognitive Behavioral Therapy (CBT)
O Antecedents
O Behaviors
O Consequences
O Different behaviors
As effective as antidepressant medication for
mild to moderate depression, no physical side
effects, helps with stereotypical thinking
Decisional balance and
motivation interviewing
Benefits (Pros)
Change (e.g losing
weight)
No change (e.g not
losing weight)
acknowledgement: P Ciechanowski, MD, UW
Costs (Cons)
Medication
O Efficacy
O Onset
O Targeted symptoms
O Safety – match side effects to patient needs
O Consider ability to tx comorbid conditions
O Neuropathy
O Sleep disturbances
O Weight management
Medications
O http://accesspharmacy.mhmedical.com/Vie
wLarge.aspx?figid=45316430
Case
Mrs. B is a 42 year old female who has had diabetes for 12 years. Current labs/vitals:
BP 112/74 mmHg, Wt 328 lbs, Ht 5’6”, HR 72, A1c 8.1% (up from 6.2% 6 months
ago), LDL 78 mg/dL. Medical problem list: cardiomyopathy (EF 41%), hyperlipidemia,
allergic rhinitus, hypothyroidism, asthma.
Meds
O Carvedilol 25 mg tablet twice daily as needed
O Furosemide 20 mg tablet daily to control peripheral edema
O As-needed 2 puffs very 4-6 hours, Albuterol inhaler
O Advair 250/50 inhaled daily
O Levothyroxine 0.1 mg tablet daily
O Losartan 25 mg tablet twice daily
O Orsythia 1 tablet daily
O Simvastatin 5 mg tablet in the evening
O NPH 42 units SC BID
O Novolog 10-15 units before meals (uses prn, has not used in 3 months)
O Liraglutide 1.8 mg SC daily
O Metformin 2 gm ER daily
Since last visit 6 months prior
O Insomnia and some neuropathic pain on
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walks, precluding exercise
Fatigue
Decreased concentration at work
Increased isolation (hard to do things with
her active group of friends)
Grazing, admits to eating more carbs
Work is stressful
Denies depressed mood
The conundrum
O “I know what I am supposed to do and I
what what I am not supposed to do, but I
still can’t quite pull it together to get this
controlled”
A bit more about Mrs. B
O Seeks care for help but cancels
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appointments frequently (9 out of last 10
except for 2 phone questions regarding
concerns)
Admits to reduced frequency of monitoring
(now just a few times weekly)
Ran out of metformin 2 weeks ago
Concerned about med side effects
History of poor adherence