Diabetes Specific Features. Dealing with Diabetes and Depression. Diabetes Nepal Depression. Overview. Depression. Risk factors for Depression

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1 Nepal 13 Dealing with and Overview Prevalence of and Potential Mechanisms Consequences of co-morbidity Clinical Implications Richard IG Holt Professor in and Endocrinology Nepal, Kathmandu 16 February 13 Albrecht Surer: Melencolia c11 Prevalence of in People with Affects 3 million people worldwide is twice as common in people with diabetes than the general population 1 in 7 people will develop depression during their lives Accounts for 1% of global disability Predicted to become nd leading cause of disability by (after CVD) Although depression can be reliably diagnosed & treated, <% receive effective treatment 3 Prevalence (%) No. 11. People with Diagnostic Interview Self-report Scale (n=7) (n=1) (n=11) (n=) Assessment Method The No group consisted of subjects from controlled studies; the People with group consisted of subjects from controlled and uncontrolled studies. n=number of studies. Anderson RJ, et al. Care. 1;: Risk factors for Female Gender Social Class Genetics Childhood Adversity Marital Status Specific Features Physical Illness Personality 1

2 Nepal 13 in T1DM TDM (no insulin) TDM (insulin) Retinopathy Heart attack and stroke Percentage 1 1 Hermanns et al Li et al Nephropathy Erectile Dysfunction Foot Problems Neuropathy Amputations T1DM=Type 1 diabetesmellitus; TDM=Type diabetesmellitus. Hermanns N, et al. Diabet Med. ;:93 3; Li et al: Care 8. 31: de Groot M, et al. Psychosom Med. 1;63: and Potential Mechanisms Psychological stress Treatment Demands Hyperglycaemia Altered Neurotransmitters Inflammation Hermanns N, et al. Diabetologia. 7;:93 3; Lyoo IK, et al. Arch Gen Psychiatry. 9;66(8): Mental Illness Altered motivation Thomas Willis Genetics Early Environment Neuro-endocrine dysfunction inflammation Lifestyle Diet Exercise Psychotropic drugs is a consequence of prolonged sorrow Weight Gain Change in body composition Knol MJ, et al. Diabetologia. 6;9: Adapted from Holt et al Diabet Med. ;1(6):1-3 1

3 Nepal 13 & Quality-of-Life in Consequences of comorbidity SF 36 Score 1 7 No DM/No DM Only* Only DM and * General Health Vitality Mental Health Physical Function Social Function Quality-of-Life *Those with diabetes and depression experience the most severe comparative impact on quality-of-life for every dimension. overall and the diabetes without depression groups have a moderate-to-severe impact on the physical functioning and general health scales (p.). SF-36=Short form health-related quality-of-life questionnaire. Goldney RD, et al. Care. ;7: and Self-care Behaviour Low Medium High and Medication Low Medium High Depressive Symptom Severity Tertile (Mean SD Score) * (SD.7).* (SD.9).1*.1* (SD.9) (SD.63).8* (SD.91).*.*.3* (SD.9) (SD.8).7* (SD.66) (SD.87).1*.1* (SD.87).18* (SD.7) (SD.93) SMBG Exercise Diet Amount Diet Type P<.1 Depressive Symptom Severity Tertile (Mean SD Score) * (SD.) 9.3* (SD 1.) 7.1* (SD 1.) n=6 n=67 n=68 Days in OHTI (%) *Adjusted for co-variates. SD=Standard scores; SMBG=Self-monitoring of blood glucose. Ciechanowski PS, et al. Arch Intern Med. ;16: *Adjusted for co-variates. OHTI=Oral Hypoglycaemic Therapy Interruption Ciechanowski PS, et al. Arch Intern Med. ;16: Effect of on Development of Complications Mortality and Co-morbid & 1 No Mild Mod/Severe. 8 No DM or depression only Hazard Ratio (9% CI) Microvascular Macrovascular Adjusted for any prior event, demographic characteristics, clinical characteristics, and self-care and diabetes control measures. Lin EHB, et al. Care. 1;33: Survival (%) Follow up (years) Egede et al Care. ;8(6): only DM and 18 3

4 Nepal 13 Effect of on the Cost of Treatment of 36±8 The Need for Integrated Care Mean Cost (USD$)* 3 1 9± 3 63± 68 Mild Moderate Severe n=11 n=117 n=118 Unadjustedsix-month data only. Ciechanowski PS, et al. Arch Intern Med. ;16: Over-shadowing Healthcare professionals focus solely on the mental disorder and fail to take note of physical health needs Leads to decreased screening rates for diabetes and inferior diabetes care Less likely to be examined for eye or foot complications Despite more clinic visits Less likely to be screened for HbA 1c or cholesterol Less likely to receive a statin Receive less diabetes education Disability Rights Commission. Equal Treatment: Closing the gap. A formal investigation into physical health inequalities experienced by people with learning difficulties and mental health problems. London, Disability Rights Commission; Screening for Short screening questionnaires Beck Inventory (BDI) Center for Epidemiologic Studies Scale (CES-D) Patient Health Questionnaire (PHQ-9) Treatment Modalities Psychological therapies e.g. CBT I am hopeless because I am always hypo Antidepressants SSRIs are 1 st line Rx Consider weight gain Drug drug interactions Hospital Anxiety and Scale (HADS) Collaborative Care Roy T, et al. Diabet Med. 1;9(): CBT=Cognitive behavioural therapy; SSRIs=Selective serotonin-reuptake inhibitors.

5 Nepal 13 Predictors of Poor Response Severe depression Poor metabolic control Poor adherence to selfmonitoring of blood glucose Presence of diabetes complications Provision of psychological support Most care will be provided by primary care or diabetes teams Extra training and awareness are needed Need for more psychological support Non-specialists are better able to provide care if expert psychological support is available Optimal management of depression in diabetes requires equal emphasis on both medical and mental disorders 6 Novel Delivery of Care Conclusion RCT of Web based cognitive behaviour therapy Reduced depressive symptoms by 1% v % in usual care group 6% v % in per protocol group Also reduced diabetes distress is associated with a -fold increase in the prevalence in depression Precise nature of the relationship is not fully understood but is bi-directional, at least for type diabetes Co-morbid diabetes and depression has significant adverse consequences for the patient and for society Prompt screening and treatment is needed if we are going to achieve the best for our patients van Bastelaar KM et al. Care. 11 Feb;3(): Any questions? righ@soton.ac.uk 9