Frequent Companions:Frequent Companions:Depression and DiabetesDepression and Diabetes

Ann Bullock, MDAnn Bullock, MDDivision of Diabetes Treatment and PreventionDivision of Diabetes Treatment and Prevention

Indian Health ServiceIndian Health Service

Childhood Trauma Predicts Childhood Trauma Predicts Adult HealthAdult Health

Children born in Helsinki, Finland between 1934-44Children born in Helsinki, Finland between 1934-44 320 were evacuated abroad during WW II—320 were evacuated abroad during WW II—

separated from their parentsseparated from their parents Average age at evacuation: 4.8 years oldAverage age at evacuation: 4.8 years old Average duration of evacuation: 1.7 yearsAverage duration of evacuation: 1.7 years

60 years later, compared with children not 60 years later, compared with children not evacuated, evacuees were much more likely to have:evacuated, evacuees were much more likely to have: Heart disease (OR 2.0) and hypertensionHeart disease (OR 2.0) and hypertension Type 2 Diabetes (OR 1.4)Type 2 Diabetes (OR 1.4) Depressive symptoms (OR 1.7)Depressive symptoms (OR 1.7)

““This study is among the first to show that early life This study is among the first to show that early life trauma predicts higher prevalence of cardiovascular trauma predicts higher prevalence of cardiovascular disease and type 2 diabetes in late adulthood...”disease and type 2 diabetes in late adulthood...” Ann MedAnn Med 2009;41:66-72, 2009;41:66-72, Am J EpidemiolAm J Epidemiol 2007;166:1126-33, 2007;166:1126-33, Am J Hum BiolAm J Hum Biol

2008;20:345-512008;20:345-51

AI/AN PeopleAI/AN People Rates of childhood and adult stress and trauma exposures

are higher in AI/AN people compared with the general population significantly associated with ↑ risk of having diabetes (Manson, 2005; Jiang,

2008)

Depression rates in AI/AN are several times higher than for the general U.S. population (Singh, 2004)

Overall rate of major depression in people with diabetes was 8.3% in the 2006 Behavioral Risk Factor Surveillance System (BRFSS), but in AI/AN it was 27.8% (Li, 2008)

A1C levels are higher in AI/AN patients with diabetes and depression 1.2% higher in Pima study (Singh, 2004; Sahota,

2008)

Newer ApproachesNewer Approaches Trauma narration in presence of empathic Trauma narration in presence of empathic

nonjudgmental therapist or lay personnonjudgmental therapist or lay person Narrative Exposure Therapy Narrative Exposure Therapy JAMAJAMA 2011;306:549-551 2011;306:549-551

Working with how trauma is held in the bodyWorking with how trauma is held in the body EMDR (Eye Movement Desensitization and Reprocessing)EMDR (Eye Movement Desensitization and Reprocessing) Somatic ExperiencingSomatic Experiencing

Mindfulness-based: Dialectical Behavior Therapy Mindfulness-based: Dialectical Behavior Therapy Biofeedback: “Coherence”Biofeedback: “Coherence”

Connection to our deepest selves and to all things: “flow”Connection to our deepest selves and to all things: “flow” Can be experienced through positive emotions: gratitude, Can be experienced through positive emotions: gratitude,

compassioncompassion Has physiological definition: Heart rate variability pattern Has physiological definition: Heart rate variability pattern

Balance of sympathetic and parasympathetic systemsBalance of sympathetic and parasympathetic systems Coherent state assoc with better health, mental healthCoherent state assoc with better health, mental healthAltern Ther Health Altern Ther Health

MedMed 2010;16:10-24 2010;16:10-24

Integrative ApproachesIntegrative Approaches Progressive Muscle Relaxation Yoga, Qi Gong, Tai Chi Meditation Acupuncture, Massage Traditional AI/AN Medicine

Studies show that: decreasing chronic pain can result in better functional

and diabetes outcomes emotional coping skills and meditative techniques

reduce blood pressure, lipids, depressive symptoms, etc. having a sense of connection with a power greater than

oneself is associated with better health outcomes

It Isn’t Just About It Isn’t Just About Medical CareMedical Care

Psychosocial and socioeconomic factors play Psychosocial and socioeconomic factors play large roles in Depression (and Diabetes risk)large roles in Depression (and Diabetes risk)

Assess needs and link patients with Assess needs and link patients with resourcesresources--Education (e.g. GED), Literacy programs--Education (e.g. GED), Literacy programs--Food resources: food stamps, commodities--Food resources: food stamps, commodities--Job programs, incl Vocational Rehabilitation--Job programs, incl Vocational Rehabilitation--Home health, respite services--Home health, respite services--Senior services, incl for socialization--Senior services, incl for socialization--Domestic violence shelters--Domestic violence shelters--Transportation --Transportation --Child Care--Child Care

RelationshipsRelationships ““Collective efficacy”Collective efficacy” Soc Sci Med Soc Sci Med 2006;62:769-78 2006;62:769-78 the willingness of community members to look out for each other and intervene the willingness of community members to look out for each other and intervene

when trouble ariseswhen trouble arises

lack of it is associated with obesity (incl in adolescents), CVD and premature deathlack of it is associated with obesity (incl in adolescents), CVD and premature death

Encourage all Encourage all supportivesupportive relationships in patients’ lives relationships in patients’ lives ““Who do you talk to?”Who do you talk to?”

WeWe may be the only person some of our patients really talk to may be the only person some of our patients really talk to

Relationship-centered Care (beyond “patient-centered” care?)Relationship-centered Care (beyond “patient-centered” care?) A provider’s individual nature and personal experiences are as important as and A provider’s individual nature and personal experiences are as important as and

interact with the patient’sinteract with the patient’s Clinicians are encouraged to empathize rather than maintain professional Clinicians are encouraged to empathize rather than maintain professional

detachmentdetachment Clinicians impact a patient’s health, but a patient can also influence the clinician’s Clinicians impact a patient’s health, but a patient can also influence the clinician’s

well-being (“reciprocal influence”)well-being (“reciprocal influence”) Clinicians’ self-awareness improves cultural competence and relationships with Clinicians’ self-awareness improves cultural competence and relationships with

patients, other clinicians and the communitypatients, other clinicians and the community J Gen Intern Med J Gen Intern Med, Supplement, Jan 2006, Supplement, Jan 2006

Maybe not all Depression is Maybe not all Depression is all bad...all bad...

Sometimes it might be a sign that something needs Sometimes it might be a sign that something needs to change in someone’s lifeto change in someone’s life

Avoid the temptation to “fix” only the pain and not Avoid the temptation to “fix” only the pain and not slow down enough for the patient to discern the slow down enough for the patient to discern the causescauses ask the patient with a neuropathic foot ulcer if not having pain ask the patient with a neuropathic foot ulcer if not having pain

is always a good thingis always a good thing many mental health providers prefer that antidepressants not many mental health providers prefer that antidepressants not

be started until they see thembe started until they see them pain is a good motivator for changepain is a good motivator for change sometimes understanding the meaning (and acting on it as sometimes understanding the meaning (and acting on it as

needed) is the best treatment of all needed) is the best treatment of all ““spirit of sadness” spirit of sadness” Duran et al, Duran et al, J Counseling & Development J Counseling & Development 2008;86:288-2008;86:288-

295295

And when, by that mysterious alchemy And when, by that mysterious alchemy of genes, environment and life of genes, environment and life

experience, some of us absorb more of experience, some of us absorb more of the pain of the journey, we can be there the pain of the journey, we can be there to help lighten the load, to remind them to help lighten the load, to remind them

of the importance of their presence, of the importance of their presence, and to mirror back to them their own and to mirror back to them their own

beauty until they can remember.beauty until they can remember.

“Dance with Desire to Make the World Well”

““We cannot heal only the physical. We must We cannot heal only the physical. We must remember our Spirit. If we focus only on food remember our Spirit. If we focus only on food

and exercising and forget our emotions, then we and exercising and forget our emotions, then we become out of balance. I tell myself to listen to become out of balance. I tell myself to listen to my Spirit. But sometimes I become spiritually my Spirit. But sometimes I become spiritually

bankrupt. I feel alone and empty. When I don’t bankrupt. I feel alone and empty. When I don’t listen to my Spirit, I may feed my physical body listen to my Spirit, I may feed my physical body with too much food. But it is not my physical with too much food. But it is not my physical body that needs nourishment. It is my Spirit body that needs nourishment. It is my Spirit

that is hungry. that is hungry. …The death of my mother was piled high on top …The death of my mother was piled high on top

of other losses—failed relationships, lost of other losses—failed relationships, lost children and loved ones. Like many of our children and loved ones. Like many of our

Native people, I carry the burden of the Native people, I carry the burden of the injustices of boarding schools and loss of land.injustices of boarding schools and loss of land.…I think I understand my people, and why we …I think I understand my people, and why we

are sometimes called ‘noncompliant.’ When the are sometimes called ‘noncompliant.’ When the Spirit is in pain, what does it matter if you take Spirit is in pain, what does it matter if you take your medication or take a walk? Look within your medication or take a walk? Look within

and see where you are with grief. Reach out to and see where you are with grief. Reach out to someone. someone.

…Let the healing begin.”…Let the healing begin.”Jacquie Arpan, Jacquie Arpan, Health for Native Life Health for Native Life 2002(4) : 39-412002(4) : 39-41

Adverse Childhood Experiences Adverse Childhood Experiences (ACE) (ACE)

Physical, emotional, sexual abuse; Physical, emotional, sexual abuse; mentally ill, substance abusing, mentally ill, substance abusing, incarcerated family member; seeing incarcerated family member; seeing mother beaten; parents mother beaten; parents divorced/separateddivorced/separated--Overall Exposure: 86%--Overall Exposure: 86% (among 7 tribes) (among 7 tribes)

Non-Native Non-Native NativeNativePhysical Abuse-M 30% 40%Physical Abuse-M 30% 40%Physical Abuse-F 27 42Physical Abuse-F 27 42Sexual Abuse-M 16 24Sexual Abuse-M 16 24Sexual Abuse-F 25 31Sexual Abuse-F 25 31Emotional Abuse 11 30Emotional Abuse 11 30Household alcohol 27 65Household alcohol 27 65Four or More ACEs 6 33Four or More ACEs 6 33

Am J Prev Med 2003;25:238-244Am J Prev Med 2003;25:238-244

ACEs and Adult HealthACEs and Adult Health ACE Score ≥4ACE Score ≥4

4-12 x risk for alcoholism, drug abuse, depression, suicide attempt4-12 x risk for alcoholism, drug abuse, depression, suicide attempt 2-4 x risk for smoking, teen pregnancy, STDs, multiple sexual 2-4 x risk for smoking, teen pregnancy, STDs, multiple sexual

partnerspartners 1.4-1.6 x risk for severe obesity1.4-1.6 x risk for severe obesity Strong graded relationship at Strong graded relationship at allall levels of ACEs for almost all levels of ACEs for almost all

outcomes, including heart disease outcomes, including heart disease Am J Prev Med Am J Prev Med 1998;14:245-258 and 1998;14:245-258 and Circulation Circulation

2004;110:1761-62004;110:1761-6

Childhood maltreatment associated with:Childhood maltreatment associated with: ↑↑risk of recurrent, persistent depressive episodes (OR risk of recurrent, persistent depressive episodes (OR

2.27)2.27) Lack of response or remission during depression Lack of response or remission during depression

treatmenttreatment Am J Psychiatry Am J Psychiatry 8/14/11 8/14/11

doi:10.1176/appi.ajp.2011.11020335doi:10.1176/appi.ajp.2011.11020335 Childhood depressive sx predict ↑insulin resistance Childhood depressive sx predict ↑insulin resistance

independentindependent of changes in BMI of changes in BMI Diabetes Care Diabetes Care 2011;34:2458-2011;34:2458-24632463

Offer Relationship-based Care Options

Group medical visits Improve A1C, blood pressure and lipids beyond an Improve A1C, blood pressure and lipids beyond an

equivalent amount of one-on-one careequivalent amount of one-on-one care Diabetes CareDiabetes Care 2001;24:995-1000, 2001;24:995-1000, Diabetes Care Diabetes Care 2003;26:2032-2036, 2003;26:2032-2036,

Diabetes Care Diabetes Care 2004;27:670-675, 2004;27:670-675, Clinical Diabetes Clinical Diabetes 2008;26:58-62, 2008;26:58-62, Ann Ann Intern Med 2010;152:689-69Intern Med 2010;152:689-69

Collaborative care management VA study: patients in case management were more VA study: patients in case management were more

than twice as likely to achieve goals for A1C, BP than twice as likely to achieve goals for A1C, BP and lipids than pts in usual careand lipids than pts in usual care Diabetes Diabetes Care Care 2011;34:1689-16942011;34:1689-1694

Web-based or online care support groups, social media case management

Major depression is associated with 25% increased risk of macrovascular complications 36% increased risk of microvascular complications in

patients with type 2 diabetes Only partly explained by increased A1C (Lin,

2010)

Large VA study—over 7 year period: Pts with either DM or MDD: ~30% ↑ risk of MI Pts with both DM and MDD: 82% ↑ risk of MI (Scherrer,

2011)

Depression increases risk of death beyond the risk from diabetes alone (Lin, 2009)

And diabetes is associated with a substantial excess of deaths from intentional self-harm

(The Emerging Risk Factors Collaboration, 2011)

Cultural/Group SupportCultural/Group Support Pima Pride/ActionPima Pride/Action

-DPP pilot study-DPP pilot studyPeople randomized to “Action” groupPeople randomized to “Action” group

-Structured diet/exercise meetings-Structured diet/exercise meetingsPeople randomized to “Pride” control People randomized to “Pride” control

groupgroup-Unstructured activities -Unstructured activities

emphasizingemphasizingPima culture and historyPima culture and history

--“Pima Pride” group showed more “Pima Pride” group showed more positive outcomes on every biological positive outcomes on every biological parameter measuredparameter measured

Narayan Narayan et al, Diabet Med 1998;15:66-72et al, Diabet Med 1998;15:66-72

How do we see our How do we see our patients and ourselves?patients and ourselves?

Old ModelOld Model: Stereotyping, paternal: Stereotyping, paternal Patients are a bit lazy and must be Patients are a bit lazy and must be

reminded, coaxed, educated and even reminded, coaxed, educated and even guilted/threatened into following our good guilted/threatened into following our good medical advice.medical advice.

New ModelNew Model: Relationships, partnering: Relationships, partnering Given the context of their past and current Given the context of their past and current

life circumstances, patients are doing the life circumstances, patients are doing the best they can—clinicians can be important best they can—clinicians can be important educators, counselors, cheerleaders, and educators, counselors, cheerleaders, and non-judgmental supports to patients on non-judgmental supports to patients on their life journeys.their life journeys.