DIABETES AND DEPRESSION
DOUBLE THE TROUBLE
PAULA M. TRIEF, PHD
PROFESSOR OF PSYCHIATRY & MEDICINE
SENIOR ASSOCIATE DEAN FOR FACULTY
AFFAIRS
SUNY UPSTATE MEDICAL UNIVERSITYSYRACUSE, NY
 What is diabetes?
 What is depression?
 What are the burdens and outcomes when a patient
has both disorders?
 What can you do to address depression in patients
with diabetes?
Diabetes 101:
A Brief Overview of Diabetes
(slides prepared by the American Diabetes Association)
Diabetes in the United States
• Nearly 26 million people in the U.S. have diabetes
•7 million people with diabetes are undiagnosed
•8.3% of the U.S. population
•26.9% of U.S. residents aged 65 years and older
• 1.9 million Americans aged 20 years or older were newly
diagnosed with diabetes in 2010
• Every 17 seconds, someone is diagnosed with diabetes
Source: National Diabetes Fact Sheet, 2011
What Happens When We Eat?
After eating, most food is turned into glucose,
the body’s main source of energy. The pancreas produces insulin that
“unlocks” the cells to allow glucose to enter them.
Normal Blood Glucose Control
In people without diabetes,
glucose stays in a healthy range because
Insulin is
released at
the right
times and in
the right
amounts
Insulin helps
glucose enter
cells
High Blood Glucose (Hyperglycemia)
In diabetes, blood glucose builds up
for several possible reasons…
Liver releases
Too little
too much
insulin is
glucose
made
Cells can’t use
insulin wellinsulin
resistance
Hyperglycemia Can Cause
Serious Long-Term Problems
Chronic complications of diabetes
•Blindness
•Kidney disease
•Nerve damage
•Amputation
•Heart attack/disease
•Stroke
•Cognitive decline
Burden of Diabetes in the United States
•The leading cause of:
•new blindness among adults
•kidney failure
•non-traumatic lower-limb amputations
•Increases the risk of heart attack and stroke by 2-4 fold
•7th leading cause of death
•Mortality rates 2-4 times greater than non-diabetic people of the
same age
Source: Centers for Disease Control and Prevention
Two Main Types of Diabetes
Type 1 diabetes (~10%)
Pancreas makes too little or no insulin
Type 2 diabetes (~90%)
•Cells do not use insulin well (insulin resistance)
•Ability of pancreas to make insulin decreases over time
Type 1 Diabetes
• 1 in 20 people with
diabetes have type 1.
• Most people are under
age 20 when diagnosed.
• Body can no longer make
insulin.
• Insulin is always needed
for treatment- multiple
daily injections or pump.
Type 2 Diabetes
•Most people with diabetes have
type 2.
•Most people are over age 40 when
diagnosed, but type 2 is becoming
more common younger adults,
children and teens.
•Type 2 is more likely in people who:
•Are overweight or obese
•Are non-Caucasian
•Have a family history of type 2
Treatment for Type 2 Diabetes May
Change Over a Lifetime
Always Includes:
•Education
•Healthy eating
•Blood glucose monitoring
•Physical Activity
Will include:
•Medications,
including insulin
Obesity* Trends Among U.S. Adults - BRFSS, 1991
(*BMI ≥ 30, or ~ 30 lbs overweight for 5’4” person)
No Data
<10%
10%–14%
15%–19%
Obesity* Trends Among U.S. Adults - BRFSS, 1994
(*BMI ≥ 30, or ~ 30 lbs overweight for 5’4” person)
No Data
<10%
10%–14%
15%–19%
Obesity* Trends Among U.S. Adults - BRFSS, 2000
(*BMI ≥ 30, or ~ 30 lbs overweight for 5’4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity* Trends Among U.S. Adults - BRFSS, 2006
(*BMI ≥ 30, or ~ 30 lbs overweight for 5’4” person)
15%–19%
20%–24%
25%–29%
≥30%
Diabetes Trends Among U.S. Adults
(Includes Gestational Diabetes)
BRFSS, 1990, 1995 and 2001
1990
1995
2001
Source: Behavioral Risk Factor Surveillance System, CDC
No Data
<4%
4%-6%
6%-8%
8%-10%
>10%
Is There Any Good News?
•Yes, we can reduce the chances of developing type 2 diabetes in
high-risk people (weight loss, exercise, medications).
•Yes, we can reduce the chances of developing diabetes
complications through:
•Blood glucose control (diet, monitoring, medication)
•Blood pressure control
•Cholesterol control
•Regular visits to healthcare providers
•Early detection and treatment of complications
Diabetes is unique among chronic
illnesses in the degree that patient
behavior influences disease course
and outcomes.
WHAT IS DEPRESSION????
Depression includes several diagnoses
Major Depressive Disorder:
Diagnostic Criteria
5 of following symptoms, must include one of
first two, occurred almost every day for two
weeks









Depressed mood
Anhedonia- Loss of pleasure or interest
Appetite changes- more/less
Sleep disturbance- too much or too little
Agitation or retardation
Fatigue, less energy
Feelings of worthlessness or guilt
Difficulty concentrating or deciding
Recurrent thoughts of death
Major Depressive Disorder
Depression Statistics
 14.8 million American adults(6.7% incidence)
 Lifetime risk = 17%
 Leading cause of disability in Americans aged




15-44 years
Men: women = 1:2
Minorities > whites
50% recurrence rate
12% become chronically depressed
Increased Risk of Depression
 Losses (divorced)
 Stressful life events-




poor, less education,
unemployed
Lack of social support
(lives alone)
Physical illness
Familial factors
Genetic factors
Depression
Treatment of Depression
 Medications- work (40% placebo vs. 60% meds),




but not for 40-50% of patients
No evidence that one med is better than another,
trial and error
Psychotherapy- works, but not for 40-50%
No evidence that one therapy is better than another,
choice depends on the therapist
Psychotherapy + meds better than either one alone
for moderate chronic/severe depression
Collaborative Primary Care for Depression
 Two core components:
- care managers:
-to educate patients about depression
-close patient follow-up to promote
adherence to meds/therapy
-encourage increased medical visits if
needed
- back-up psychiatrist to supervise care managers
and support providers
Collaborative Primary Care for Depression
 Gilbody et al., Arch Int Med, 2007
- meta-analysis of 37 RCTs
- N= 12,355 pts.
- Collaborative Care vs. primary care
- CC -> 2X greater adherence to anti-deps.
- CC -> improved depression @ 12 and 18 month
follow-up and @ 5 years (1 trial)
DIABETES and DEPRESSION:
DOUBLE the TROUBLE
Depression and Diabetes-Prevalence
 Major depressive disorder
--9.3% people with diabetes vs.
--6.1% in general population
 Clinical Depression lifetime prevalence:
Men:
Women:
Medical Outpatients:
Diabetes patients:
5-12%
9-26%
6-26%
24-33%
Egede 2003; Anderson et al, 2001; Fisher 2010
Depression, Diabetes and Distress
It’s not always Major DepressionDepressive symptoms are common:
31-45% of diabetes patients report significant
depressive symptoms
Importance of “Diabetes Distress”Evidence that diabetes distress is related to high A1c
is stronger than evidence that depression is.
Severity of Depression in Diabetes
 Natural course is chronic/severe.
 Depressive episodes may last
longer.
 Depression in diabetes may be
more resistant to treatment.
Kovacs et al, 1997
Depression and Diabetes Outcomes
Depression in diabetes is associated with:
 Higher A1c levels, i.e., poorer blood sugar control
 CVD risk factors (hi BP, hi BMI, smoking)
 More complications
 Less active self-care
 Higher mortality rates
 3.5x higher health care costs
Ciechanowski 2000, 2003;Lustman 2000;de Groot 2001;Zhang 2005,
Katon 2005; Egede 2002; Rubin 2010
Why do individuals with
diabetes get depressed?
 Possible biological factors –
–
changes in brain chemicals and/or
hormones associated with both
diabetes and depression?
–
chronic high or low (or variable)
blood sugar levels may  depression?
Psychosocial “Burden” of Diabetes
 N= 4747, Utrecht Health Project:
- normal
- pre-diabetes
- diagnosed with type 2 diabetes
- not yet diagnosed, but found to have type 2 diabetes
Results: Diagnosed type 2 diabetes associated with
depression, but undiagnosed and pre-diabetes were
not.
Implication: Relationship between diabetes and
depression may reflect the psychosocial burden of the
disease.
Knol et al, Psychosom Med, 2007
Depression <-> Diabetes- Bi-directional
Depression
Brain
chemicals
Hormones
Behavior
Diabetes/
High blood
sugar
Why do individuals with diabetes get
depressed/distressed?
Challenges > Resources
Psychological challenges of diabetes
 Need for careful control of basic activity (eating)
 loss of autonomy & sense of control over
body
 Diabetes is a hidden disease  low support
 Stigma  shame  hiding (e.g., keep blood
sugar levels high to avoid hypoglycemia)
Why do individuals with diabetes get
depressed/distressed?
Psychological challenges of diabetes



guilt, need to “be good,” “it’s my fault”
anxiety about future complications
when first complication hits:
-well-controlled feel betrayed
-poorly-controlled feel guilty
Why do individuals with diabetes get
depressed/distressed?
Psychological challenges of diabetes



role changes – within family, at work
effect of complications, e.g., dialysis,
impaired vision, impotence
pain, disability/functional impairment
Why don’t all individuals with
diabetes get depressed/distressed?
Psychological resources

life environments, stress
- other health problems
- family health
- work stability
- financially secure
- health insurance
Psychological Resources
 Ways of coping
Positive:
Gather information, educate yourself
Seek support
Make a spiritual connection
Exercise
Negative:
Denial
Avoidance
Alcohol, drugs
Psychological Resources
 Sense of Self-Efficacy- “I can do it!”
- Overall self-efficacy-attitude towards problems
- Specific self-efficacyexercise self-efficacy
diet self-efficacy
Psychological Resources
 Social Support
- Different types of support
- Importance of a “confidante”
Psychological Resources
 Self Esteem
Do I like myself?
Am I worth taking care of?
Treatment of Depression
for Diabetes Patients
 Medications
 Psychotherapy
 Education
 Family involvement
 Exercise
Depression Management and Diabetes Outcomes
 Treatment of depression works for diabetes patients,
as it does for others.
 Limited evidence that treatment of depression leads
to better blood glucose control or better adherence to
self-care regimen.
SUMMARY
1. PREVALENCE. Depression and diabetes often occur
together.
2. SEVERITY. Depression in patients with diabetes
may be more severe, i.e., more likely to recur, lasts
longer
3. DIABETES can make DEPRESSION worse, either
due to biology, emotional burden, or both.
SUMMARY
4. DEPRESSION can make DIABETES worse, i.e., poorer
self-care and blood sugar control -> complications,
hospitalizations and higher health care costs.
5. TREATING DEPRESSION WORKS, but more effective
treatments are needed.
SUMMARY
6. TREATING DEPRESSION MAY HELP BLOOD
SUGAR CONTROL, but even if it doesn’t, it’s the
right thing to do.
7. DIABETES DISTRESS is also important to
address.
8. FAMILY MEMBERS can also get depressed,
anxious, guilty and distressed.
A Conversation
What can you do in your role as care manager about
depression for your diabetes patients?
What are the barriers you experience when you try to
help your patients?
What can you do about depression in your
diabetes patients?
1.
MAKE EVERY VISIT THERAPEUTIC
a. “There is no greater loan than a sympathetic ear."
- Frank Tyger, cartoonist, columnist and humorist
b. Close follow-up to promote adherence to meds/therapy
2.
HELP PATIENTS BUILD STRENGTHS!
Educate, educate, educate- make depression-diabetes link
Help them find ways to cope positively.
Help them reach out to others.
Help them tell themselves they can do it, by establishing realistic
goals, supporting small steps, praising all achievements, and
believing they can.
Help them tell themselves they’re worth it, by believing they are.
3. IF CHALLENGES ARE TOO GREAT, HELP PATIENTS GET HELP!
Thank you for your insights and attention!!