Mindfulness-based Diabetes Management :

Transcription

1 Sky of Joshua Tree

2 Mindfulness-based Diabetes Management : A targeted intervention for depression, anxiety and diabetes-distress OHSU Psychiatry Grand Rounds Sept. 20th, 2011 Jeff Horacek M.D./ Steven Alper L.C.S.W.

3 A personal and professional journey My journey brings me here with more questions than answers Diabetes support group (depression/stress/isolation/shame/self-criticism) Oprah Winfrey podcast moment with Jon Kabat- Zinn Meditation in the desert

4 Discuss confusion about prevalence of Major Goals Depressive Disorder (MDD) in diabetes. Distinguish between MDD and Diabetes-distress. Identify Diabetes-distress as normal part of DM. (Non-psychiatric distress). Discuss broader approaches to treating Diabetesrelated distress as opposed to standard treatment approaches for MDD. Introduce a Mindfulness-based approach to

5 International Diabetes Federation stats 366 million people worldwide with diabetes 4.6 million deaths annually due to DM 1 person dies every 7 seconds Health care spending 465 billion annually UN Summit on non-communicable dz s today Diabetes will be an ever-growing part of ALL practices!

6 What is Prevalence of depression (MDD) in Diabetes? Previous estimates of MDD prevalence 2-3 times greater than general population. CESD-Center for Epidem. Studies Depress. Scale (self-report questionnaire may over diagnose) Diabetes Care 2001, Anderson RJ et al. (meta-analysis) MDD only 60% more common than general pop. CIDI-Composite International Diag. Interview (structured clinical interviews are gold standard) Diabetes Med 2008, Fisher L et al

7 Distressed or Depressed? Self-report measures more reflective of general emotional distress than MDD. Coyne JC, Psychol. Bull Self-report measures may inappropriately pathologize Diabetes-distress and depressive symptoms. Adequate sensitivity for MDD but high % of false positives. Thombs BD, JAMA 2008

8 70% of diabetic patients with elev. self-reported depressive symptom scores did not meet diagnostic criteria for MDD on structure clinical interview. Fisher L, Diabetes Care 2007 MDD more common with DM but not as high as previously thought.

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10 Diabetes-distress is a part of having diabetes and is non-psychiatric distress. (in other words...self-care for people with diabetes can be very hard work)

11 What is Diabetes Distress Scale? Questionnaire for measurement of 4 domains: -Emotional burden -Physician-related distress (yes, we can add to burden!) -Regimenrelated distress - Diabetes-related interpersonal distress Polonsky WH, et al, Diabetes Care 2005;28:

12 Overapplication of MDD conceptual model to Diabetes-distress may be linked to fact that diagnostic system for MDD is based only on symptom assessment and ignores life context. (great book for residents!) (Horowitz/Wakefield, The Loss of Sadness:How Psychiatry Transformed Normal Sorrow into Depressive Disorder. 2007) If we miss Diabetes-distress then we increase risk of treatment failure. Even if dx is MDD, it is still important to address selfmanagement of diabetes and Diabetes-distress.

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14 Which approach for treatment in Diabetes? Meta-analysis of antidepressant use may be no more effective than placebo for mild to mod. severity MDD. (this used to be my practice!) Fournier JC, et al, JAMA 2010 Improving MDD with psychotherapy and antidepressants fail to show compelling improvement of glycemic control in diabetes. Markowitz S, et al, Psychosomatics Jan 2011 Over-application of MDD-model to address Diabetesdistress is not appropriate.

15 Diabetes Distress vs MDD Addressing Diabetes-distress improves both self-care and glycemic control. -negative emotional reactions to dx of DM -threat of complications -self-management demands -unresponsive providers -unsupportive interpersonal relationships Fisher L et al Diabet. Med. 2008, Diabetes Care 2007, Diabetes Care 2010

16 Novel approaches addressing diabetes management and MDD Nurse-led self-management support Gonazalez JS,et al, J Cogn Psychother 2010 Psychological treatment with exercise training Katon W, et al, Contemp Clin trials 2010 Nurse-, dietitian- and mental health specialist- delivered self-management interventions. Amsberg S, et al, Patient Educ Couns 2009

17 Novel approaches addressing Diabetes-distress CBT adapted to address DM-relevant behavior improved both glycemic control and diabetes distress. Lorig K, et al, Diabetes Care 2008 Peer-delivered self-management intervention with Spanish speaking type 2 patients: both glycemic control and diabetes-related distress improved. Carver CS, et al, Pers Soc Psychol Rev 2011 Mindfulness-based approach!

18 Mindfulness-based Stress Reduction (MBSR) MBSR pilot study (observational) n=14, improvement in glycemic control, blood pressure and measurement of general psychological distress. Rosenzweig S, et al, Altern Ther Health Med. Sept-Oct 2007 DiaMind- Dutch study testing effectiveness of MBSR to reduce emotional distress in outpatients with diabetes. Outcomes to be measured: measures of distress, quality of life, dispositional mindfulness, self-esteem, self-care, bp, and glycemic control.

19 Summary Prevalence of depression is approx. 60% higher than general population. Distinguishing between MDD and Diabetes-distress is crucial. They can co-exist! Diabetes-distress can be a normal part of diabetes and is non-psychiatric distress. When treating MDD in diabetes, it is also important to address Diabetes-distress and diabetes selfmanagement.

20 Joshua Tree Sunset