Depression and Diabetes: Issues in Prevention and Treatment Douglas K. Novins, M.D. National Center for American Indian and Alaska Native Mental Health

Depression and Diabetes:Issues in Prevention and Treatment

Douglas K. Novins, M.D.National Center for American Indian and Alaska Native Mental Health ResearchDepartment of PsychiatryUniversity of Colorado School of Medicine

Presentation Overview

• What is Depression?• What do we know about Depression and Diabetes?• Addressing Depression in Diabetes prevention and

treatment– Treatment of Depression

– Diabetes Prevention/Treatment

• Case discussion

What is Depression?

What is Depression?

• Biomedical Conceptualization of Depression– DSM-IV

• Major Depression

• Dysthymic Disorder

• Minor Depression/Brief Depression

American Psychiatric Association

What is Depression?

• “Symptoms” of Depression– Psychological

• Frequent sadness

• Hopelessness

• Inability to feel any emotion (“emptiness”)

• Persistent boredom; low energy

• Guilt

• Poor concentration

• Difficulty making decisions

American Academy of Child and Adolescent Psychiatry, American Psychiatric Association

What is Depression?


• Increased irritability, anger, or hostility

• Change in perception of time

• Fear of “going crazy”


What is Depression?


• Negative Cognitive Style

– Low self-esteem

– High self-criticism

– Cognitive distortions

– Feeling of lack of control over events


What is Depression?

• “Symptoms” of Depression– Behavioral

• Tearfulness, crying

• Decreased interest in activities; or inability to enjoy previously favorite activities

• Social isolation, poor communication

• Inattention to personal hygiene

• Extreme sensitivity to rejection or failure

• Difficulty with relationships

• Poor “work” performance

• Suicidal thoughts and behaviors

American Academy of Child and Adolescent Psychiatry; American Psychiatric Association

What is Depression?

• “Symptoms” of Depression– Somatic

• Frequent complaints of physical illnesses such as headaches and stomachaches

• A major change in eating and/or sleeping patterns

• Weight gain or loss

American Academy of Child and Adolescent Psychiatry; American Psychiatric Association

What is Depression?

• Why should we care?– Depression is a significant mental illness with potentially

serious consequences.• Recurrence rate is 70% at 5 years

• Suicide

– 33% will attempt suicide

– 3-4% will die from suicide

• Depression is often associated with medical illnesses and may have impacts on treatment.

What do we know about Depression and Diabetes?


• Depression is common among people with diabetes– 10% - general population

– 17-27% - people with cardiovascular disease

– 09-26% - people receiving treatment for diabetes

Fenton & Stover, 2006


• Depression is a risk factor for developing diabetes• Diabetes may be a risk factor for developing depression

Fenton & Stover, 2006; Brown et al., 2006


• People with depression and medical illnesses have poorer medical outcomes– Cardiovascular Disease - increased risk of heart attack and

death (from any cause; 2-7 times people without depression)

– Diabetes - poorer glycemic control and increased risk of death (from any cause; 1.6-2.3 times people without depression).



• People with depression and medical illnesses have poorer medical outcomes– In people with diabetes, depression is associated with

• poor metabolic control

• poor adherence to medication and diet

• reduced quality of life

• higher healthcare costs

– Poor diabetes control may worsen depression and impair antidepressant treatment response



• People with depression and medical illnesses have poorer medical outcomes– Why?

• Depression disrupts physiologic functions associated with normal glucose-insulin regulation.

– Disregulation of the endocrine system (hypothalamic–pituitary–adrenal axis)

– Disrupted sleep physiology

– Decreased levels of physical activity

– Increased inflammatory responses

– Increased appetite



• People with depression and medical illnesses have poorer medical outcomes– Why?

• Depression has a big impact on an individual’s thinking that interferes

– Lower sense of self-efficacy (less confidence that they can change their behavior)

– Sense of hopelessness and foreshortened sense of the future

– Poor concentration

– Difficulty making decisions

– Social isolation, poor communication, difficulty with relationships


Treatment

Treatment

• General Principles– It is as important to treat depression as it is to treat risk

for developing diabetes, or the cardiovascular complications of diabetes

Treatment

• Treatment of Depression– Careful Assessment

– Appropriate Treatment• Cultural

– Traditional Healer

• Individual Psychotherapy

– Cognitive Behavioral Therapy

– Interpersonal Therapy

• Antidepressant Medication

Treatment

• Treatment of Depression– There is some limited evidence that effective treatment of

depression improves glycemic control

– There is no evidence that effective treatment of depression improves adherence to behavioral change interventions.

Treatment

• Self-Help Groups (Combined/Adjunctive Treatments)– Self-help groups seem to have short term effects on quality of life

and depression and engagement in behavioral changes for individuals with chronic medical conditions.

Foster et al., 2007

Treatment

• Treatment Contracts– No evidence for their effectiveness

Murray et al., 2007

Treatment

• Diabetes Prevention/Treatment for Individuals with Depression– No research to provide clear guidelines

– Dr. Novins’ recommends:• enhancing aspects of your prevention/treatment programs that address

some of the psychological and behavioral consequences of depression

• Considering increasing the frequency and level of contacts with participants suffering from depression as well as the frequency of metabolic monitoring.

Treatment

• Diabetes Prevention/Treatment for Individuals with Depression– Key psychosocial challenges

• Social isolation, poor communication, sensitivity to rejection and failure, negative cognitive style

– Key behavioral challenges:• Poor concentration• Difficulty making decisions• Decreased energy• Low self-esteem• Decreased sense of self-efficacy

Treatment

Intervention Adjustment Aspect of Depression Addressed

More frequent, shorter sessions Social isolation, poor communication, sensitivity to rejection, Poor concentration, Difficulty making decisions, Decreased energy, Low self-esteem

Treatment


Between session contacts by phone, especially is sessions cannot be held more frequently

Social isolation, poor communication, sensitivity to rejection, Poor concentration, Difficulty making decisions, Decreased energy, Low self-esteem

Treatment


Engage family/extended family/significant other in treatment

Social isolation, poor communication, sensitivity to rejection, negative cognitive style, Poor concentration, Difficulty making decisions, Decreased energy, Low self-esteem

Treatment


Provide transportation to appointments, groups, social activities.

Social isolation, poor communication, Difficulty making decisions, Decreased energy

Treatment


Between session contacts by phone, especially is sessions cannot be held more frequently

Social isolation, poor communication, sensitivity to rejection, Poor concentration, Difficulty making decisions, Decreased energy, Low self-esteem

Treatment


Focus on the positives – highlight every accomplishment, no matter how small

sensitivity to rejection and failure, low self-esteem, negative cognitive style

Provide individualized, simple written directions and feedback for person to take with them

Social isolation, poor communication, poor concentration, difficulty making decisions, negative cognitive style

Treatment


Start, enroll person in self-help support group

Social isolation, poor communication, sensitivity to rejection, poor concentration, difficulty making decisions, decreased energy, low self-esteem, negative cognitive style

Treatment


Consider using TeleHome Care Devices (Murray et al., 2007)

Social isolation, poor communication, sensitivity to rejection, poor concentration, difficulty making decisions, decreased energy, low self-esteem, negative cognitive style

Treatment


Increased use of motivational interviewing techniques

Poor communication, Difficulty making decisions, Decreased energy, Low self-esteem, negative cognitive style

Contemplation

Determination

Action

Maintenance

Relapse

Precontemplation

PermanentExit

Treatment

• Key Motivational Interviewing Techniques– Establish the Stage of Change the person is in for this

particular behavior change, as it will help guide your interventions

• Precontemplation: Raise doubt - increase the person’s perception of risks and problems with current behavior

• Contemplation: Tip the balance - evoke reasons to change, risks of not changing; strengthen the person’s self-efficacy for change of current behavior

• Determination - Help the person determine the best course of action to take in seeking change.

Treatment

• Key Motivational Interviewing Techniques– Establish the Stage of Change the person is in for this

particular behavior change, as it will help guide your interventions

• Action: Help the person to take steps toward change.

• Maintenance: Help the person to identify and use strategies to prevent relapse.

• Relapse: Help the person to renew the processes of change without becoming stuck or demoralized.

Treatment

• Key Motivational Interviewing Techniques– Emphasize those principles that are less likely to feed into

depressive symptoms• Expression of Empathy

• Develop Discrepancy

• Avoid Argumentation

• Roll with Resistance

• Support Self-Efficacy

Slesnick et al., 1998

Treatment


depressive symptoms• Avoid Argumentation: “Ambivalence and discrepancy can resolve

into defensive coping strategies that reduce the client’s discomfort but do not alter [behavior]. The client and not the therapist should voice the arguments for change. The therapist employs strategies to assist the client to see accurately the consequences of [their behavior] and to begin devaluing [its] perceived positive aspects.”


Treatment


depressive symptoms• Expression of Empathy: “The therapist seeks to communicate great

respect for the client as a supportive companion and knowledgeable consultant. The client’s freedom of choice and self-direction are respected. In this view, only the client can decide to make a change in their [behavior] and carry out that choice. Persuasion is gentle, subtle, and always with the assumption that change is up to the client.”


Treatment


depressive symptoms• Support Self-Efficacy: People who are persuaded that they have a

serious problem will still not move toward change unless there is hope for success. Hence, clients must be persuaded that it is possible to change their [behavior] thereby reduce related problems.”


Treatment

• Key Motivational Interviewing Techniques– De-emphasize those principles that are more likely to feed

into depressive symptoms• Develop Discrepancy: “Motivation for change occurs when people

perceive a discrepancy between where they are and where they want to be. MET seeks to enhance and focus the client’s attention on such discrepancies with regard to drinking behavior. It may be necessary to first develop such discrepancy by raising client’s awareness of the personal consequences of their drinking.”


Treatment

• Key Motivational Interviewing Techniques– The motivational phase of many interventions is usually 1-2

sessions:• Develop motivation to change

• Consolidate commitment to change

– A person with depression may require more than 2 sessions to commit to change

– A person with depression may need to return to these motivational issues throughout the intervention, not just at the beginning


Treatment

• Key Motivational Interviewing Techniques– Be sure to provide the person with depression a written

motivational treatment plan once they commit to change:• The changes I want to make are …. (include positive goals)

• The most important reasons why I want to make changes are …

• The steps I plan to take in changing are …


Treatment

• Key Motivational Interviewing Techniques– Be sure to provide the person with depression a written

motivational treatment plan once they commit to change:• The ways other people can help me are …

• The benefits I expect from this change are …

• Some things that could interfere with my plan are ...

– Keep a copy of this motivational treatment plan so that you can review it with the person when their motivation to change wanes

Documents

Depression and Diabetes: Issues in Prevention and Treatment Douglas K. Novins, M.D. National Center for American Indian and Alaska Native Mental Health