Dr.Rahiminejad Roozbeh Hospital TUMS

Transcription

1 Dr.Rahiminejad Roozbeh Hospital TUMS

2 Psychiatric disorders, particularly depression, anxiety and eating disorders, are prevalent in diabetes. Mental illness increases risk of diabetes and diabetic complications. Diabetes and depression are major public health problems associated with significant burden. Both the diseases have a very high prevalence, mortality, and disability.

3 Epidemiology of depression and diabetes Depression is common in both type 1 and type 2 diabetes and has significant effects on the course and outcome of this medical illness. The prevalence rate of depression is more than threetimes higher in people with type 1 diabetes and nearly twice as high in people with type 2 diabetes compared to those without. Roy T1, Lloyd CE Oct (a systematic review)

4 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). Depression is associated with hyperglycemia and an increased risk for diabetic complications. People with depressive disorders have a 65% increased risk of developing diabetes (Campayo et al., 2010).

5 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.

6 Several factors were correlated with depression in type 2 diabetes, such as low levels of education, physical inactivity, and physical impairments and limitations. In type 1 diabetes, low levels of education and physical impairment and limitation were correlated with depression. Women with diabetes and also women without diabetes experience a higher prevalence of depression than men.

7 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. In types 1 and 2 diabetes, a large proportion of subjects had one or more comorbid chronic somatic diseases with cardiovascular diseases being the most prevalent condition.

8 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. 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.

9 Depression is a phenotype for a range of stress-related disorders which lead to an activation of the hypothalamic-pituitary-adrenal axis, a dysregulation of the autonomic nervous system and a release of proinflammatory cytokines, ultimately resulting in insulin resistance. 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.

10 Depression is associated with reduced physical activity, which increases the risk for obesity and consequently for type 2 diabetes.

11 Concurrent depression is associated with: Decrease in metabolic control Poor adherence to medication, diet regimens, exercising and monitoring of blood glucose Increase in health care expenditures Reduction in quality of life In turn, poor metabolic control may exacerbate depression and diminish response to antidepressant regimens.

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13 Screening for depression and anxiety is important in patients with diabetes Purpose Diabetes-specific Quality of Life Depression/Anxiety Tools Problem Areas in Diabetes (PAID) Scale Diabetes Distress Scale (DDS) WHO-5 Hospital Anxiety and Depression Scale (HADS) Patient Health Questionnaire (PHQ-9) Beck Depression Inventory (BDI)

14 Treatment Psychotherapy and pharmacotherapy are effective in the presence of diabetes; both cognitive behavior therapy and selective serotonin reuptake inhibitors are weight neutral and have been associated with glycemic improvement in some studies.

15 Psychotherapy CBT is more effective at improving HbA1c levels at sixmonth follow-up than education alone. Psychosocial interventions should be integrated into diabetes care plans. Consider adjunctive brief psychotherapy for: Emotional eating (cognitive-behavioral therapy) Breaking down problems (problem-solving therapy) Improving treatment adherence (motivational interviewing)

16 Stress management strategies Coping skills training Family therapy Establishing relationships that are empowering and non-judgemental If a person feels judged, they will become defensive. If a person feels guilt/shame, they will become avoidant.

17 Medication adherence is one of the fundamental health behaviours of relevance to self-management and chronic disease outcomes. WHO estimates nonadherence to medication at 30% - 70% of medications for chronic conditions.

18 SSRIs Pharmacotherapy Fluoxetine (Prozac) Sertraline (Zoloft) Fluvoxamine (Luvox) Citalopram (Celexa) Escitalopram (Lexapro) Paroxetine (Paxil, CR) *Commonly used in anxiety disorders; + only FDA approved drug for pediatrics

19 The increased risk of diabetes was particularly notable for the selective serotonin-reuptake inhibitor (SSRI) paroxetine and the tricyclic antidepressant amitriptyline.

20 SSRIs Mechanism selective reuptake inhibition of serotonin First-line therapy Fluoxetine only FDA approved agent for children/adolescents Similar or superior efficacy to others Lower side effects, safer, convenient dosing Generally choose cheapest available Recognize differences between agents

21 SNRIs Venlafaxine (Effexor) Duloxetine (Cymbalta) Also has indications for diabetic peripheral neuropathy and generalized anxiety disorder

22 SNRI s Mechanism selective serotonin and norepinephrine reuptake inhibition Common side effects: Nausea, dizziness, insomnia, constipation, sweating Venlafaxine can cause hypertension

23 Catacholamine reuptake inhibitor Bupropion (Wellbutrin) Mechanism Weak inhibitor of norepinephrine and dopamine uptake, no effect on serotonin Lowers the seizure threshold, especially in bulimic patients Has mild stimulating properties May be useful for patients presenting with difficulty concentrating or fatigue Does not cause sexual dysfunction

24 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

25 Psychoactive Medications May Predispose to Diabetes Patients with schizophrenia are at increased risk of developing metabolic disorders like type 2 diabetes. Especially second-generation antipsychotics (olanzapine, clozapine, risperidone, quetiapine, aripiprazole, ziprasidone) Biochemical and lifestyle factors may also contribute

26 There are several potential mechanisms behind antipsychotic-induced diabetes, including the weight gain associated with these medications, the effects on pancreatic receptors and/or glucose transporters, or some other cause not yet discovered.

27 ساله ای با سابقه 5 ساله دیابت گزارشی ازشروع عالیم اساسی از یک ماه قبل می دهد.اولین اقدام مهم آقای 20 افسردگی

28 درمان در سنین نوجوانی درمان در بارداری و شیردهی درمان در سالمندان

29 Conclusions The prevalence of depression is 2 fold greater in patients with diabetes. Better detection/screening is essential to improving diabetes self-care Future multidisciplinary management approaches are critical in the identification, treatment and follow up in our diabetes patients.

30 Mental illness increases risk of diabetes and diabetic complications Mental Illness Diabetes Non-adherence to medication and self-care Functional impairment Risk of complications Healthcare costs Risk of early mortality Depression increases risk of DM by 60%!

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