DEPRESSION, DISTRESS & DIABETES Seven Things You Need To Know

DEPRESSION, DISTRESS & DIABETES Seven Things You Need To Know William H. Polonsky, PhD, CDE May 22, 2010 whp@behavioraldiabetes.org Motivation in Diabetes Almost no one is unmotivated to live a long, healthy life All are perfectly motivated to do what they do Poor self-care obstacles outweigh benefits Major medical benefits in diabetes, but also many, many obstacles Obstacles to Good Self-Care Poor social support Unachievable self-care plans Harmful health beliefs Lack of access to care Lack of knowledge/skill Common environmental barriers Depression Major Forms of Depression Major depression Dysthymia Adjustment disorder (depressed mood) Bipolar disorders DSM-IV, 1994 Common Depressive Features Cognitive characteristics Depressed mood Diminished interest or pleasure Feelings of worthlessness Diminished ability to concentrate Recurrent thoughts of death/suicidal ideation Common Depressive Features Somatic characteristics Significant change in appetite Insomnia or hypersomnia Fatigue or loss of energy Psychomotor agitation or retardation DSM-IV, 1994 DSM-IV, 1994 1

The Truth about Depression Let us make no bones about it: We do not really know what causes depression. We do not really know what constitutes depression. We do not really know why certain treatments may be effective for depression. We do not know how depression made it through h the evolutionary process. We do not know why one person develops a depressive disorder from circumstances that do not trouble another. Solomon, 2001 1. Prevalence Depression rates are 1.5 2.0x in diabetes In review of controlled studies (n = 21): 20.5% of patients vs. 11.4% of controls Kaiser Permanente study compared 16,000 Type 2 patients t vs. 16,000 matched controls: 17.9% of patients vs. 11.2% of controls Diagnostic interviews of 506 patients with diabetes: 9.9% with MDD, compared to national rates (NCSR) of 6.6%. 1. Prevalence Depressive symptoms are common: 32% (Gavard et al, 1993) 41% (Peyrot and Rubin, 1997) 45% (Gary et al, 2000) 37% (Polonsky et al, 2000) 31% (Hermanns et al, 2005) Anderson et al, 2001, Nichols and Brown, 2003; Fisher et al, 2007 Depression Risk Highest risk for depression: multiple long-term complications limited education not married female poverty No difference between diabetes types 2. Diabetes Impacts Depression Diabetes-linked neurovascular changes Genetic influences Elevated blood glucose levels Psychosocial burden Egede and Zhang, 2003; Peyrot and Rubin, 1997; 1999 Lustman et al, 1997 2

Psychosocial Burden Correlations between diabetes distress and CES-D depression Feel overwhelmed by DM demands r =.51 Feel that DM controls my life r =.40 Will develop serious complications, no matter what I do r =.44 Total DDS score r =.48 Fisher et al, 2007; Polonsky et al, in preparation 2. Diabetes Impacts Depression Diabetes-linked neurovascular changes Genetic influences Elevated blood glucose levels Psychosocial burden Illness burden Long-term complications Chronic pain Comorbid disease Lustman et al, 1997; Krein et al, 2005 Influence of Comorbid Disease HTN, CAD, chronic arthritis, stroke, COPD, and ESRD; n = 1794 djusted Odds Major Depression, Ad 5 4 3 2 1 0 Plus 1 Plus 2 Plus 3 Weighted effect sizes and 95% confidence intervals for study aggregations. All combined p values were p <.05; k indicates number of studies for which sufficient data were available for use in the effect size calculation. De Groot et al, 2001 Egede, 2005 Influence of Comorbid Disease Large community-based Dutch study (n=3107) found that depression prevalence was: 20%. Type 2 diabetes, co-morbid chronic disease 8%, Type 2 diabetes only 9%, healthy controls Influence of Comorbid Disease Not merely due to burden of diabetes per se More straws on the camel s back (broad burden of illness, especially perceived functioning) Linked to core feature of powerlessness Pouwer et al, 2003 3

3. Depression Impacts Diabetes Poor glycemic control But effect size is small; may account for only 3% variance in A1C Over 5 years, depression led to: 24% more adverse macrovascular outcomes 36% more adverse microvascular outcomes 54% greater mortality 3. Depression Impacts Diabetes Depression and Health Care Costs in Diabetes, Nationwide Sample (4.5x higher in depressed vs. non-depressed) Dollars, in millions 250 200 150 100 50 0 Not depressed Depressed Lin et al, 2010; Heckbert et al, 2010; Lustman et al, 2000; Rosenthal et al, 1998; Kovacs et al, 1995; Carney et al, 1994; Black et al, 2003; Zhang et al, 2005 Egede et al, 2002 3. Depression Impacts Diabetes Depression contributes to Type 2 onset: Major depressive disorders > 2x as likely to develop diabetes (8 year and 13 year studies) Large national sample, highest vs. lowest quartile of depression scores had 63% increased risk of diabetes over 6 years. BUT, several negative studies exist as well. 3. Depression Impacts Diabetes How might depression contribute to Type 2 onset? A metabolic pathway (insulin resistance) A behavioral pathway (self-care) An iatrogenic pathway (the role of anti- depressants) Eaton et al, 1996; Kawakami et al, 1999; Golden et al, 2004; Saydah et al, 2003 Okamura et al, 2000, Lawlor et al, 2003; Rubin et al, 2006 Depression and Self-Care Depression and Self-Care Associated with factors linked to poor control: Physical inactivity Smoking Obesity Limited diabetes knowledge Poor adherence to self-care behaviors Lustman et al, 1997; Solberg et al, 2004; Egede, 2004; Murata et al, 2003; Ciechanowski et al, 2003 Lin et al, 2004 4

Seven Things To Know 1. PREVALENCE. Depression is widespread among patients with diabetes 2. DIABETES IMPACTS DEPRESSION. Both biological and psychosocial elements of diabetes may exacerbate depression. 3. DEPRESSION IMPACTS DIABETES. Depression negatively influences self-care, glycemic control, development of complications and health care costs. 4. Identifying Depression Substandard identification/treatment of MDD Standard patients presenting with symptoms of major depressive disorder visited 152 family yp physicians and general internists In 35% of cases, no diagnosis indicated In 44% of cases, no treatment offered (medication, referral or two-week week follow-up) Kravitz et al, 2005 Hx of depression Eight Warning Signs Hx of mental health treatment Family history of depression Reported sexual dysfunction Eight Warning Signs Chronic pain as a primary complaint Symptoms that are out of proportion to the objective findings Poor glycemic control (and/or poor adherence to self-care) Diabetes-related emotional distress Lustman and Clouse, 1997 Lustman and Clouse, 1997 The Two Cardinal Symptoms During the past month, have you often: been bothered by feeling down, depressed or hopeless? had little interest or pleasure in doing things? 4. Identifying Depression Center for Epidemiological Studies - Depression Scale (CES-D) Beck Depression Inventory (BDI-II) II) Patient Health Questionnaire-9 (PHQ-9) Broader measures (SF-36, SCL-90, PRIME-MD) MD) 5

Talking about Depression Your responses suggest that you might be having a problem with depression. By any chance, does this fit your experience? 5. Treatment of Depression in Diabetes Medication tx (4 RCT s, n = 289) Positive psych outcome 3/4 Positive medical outcome 0/4 Petrak and Herpertz, 2009 Anderson et al, 2009 5. Treatment of Depression in Diabetes Medication tx (4 RCT s, n = 289) Positive psych outcome 3/4 Positive medical outcome 0/4 Psych tx (3 RCT s, n = 140) Positive psych outcome 3/3 Positive medical outcome 2/3 Mixed (psych and/or medication, n = 954) Positive psych outcome 3/4 Positive medical outcome 1/4 5. Treating Depression Pharmacotherapy Cognitive-behavioral therapy Regular physical activity Petrak and Herpertz, 2009 6

Treatment Considerations Special attention to those with chronic pain and/or complications Poorer outcomes Increased risk of depression recurrence. When prescribing anti-depressants, follow- up evaluations are critical. Limited efficacy (Rush et al, 2006) Weight gain Treatment of Depression in Diabetes Medication tx (4 RCT s, n = 289) Positive psych outcome 3/4 Positive medical outcome 0/4 Psych tx (3 RCT s, n = 140) Positive psych outcome 3/3 Positive medical outcome 2/3 Mixed (psych and/or medication, n = 954) Positive psych outcome 3/4 Positive medical outcome 1/4 Petrak and Herpertz, 2009 6. Important Role for Diabetes Distress Something is very odd about findings to date: Depression rates are not elevated in patients without complications or co-morbid disorders Presence of complications retards depression treatment With depression treatment, glycemic control does not improve In diabetes, > 70% of patients with high scores on CES-D are not clinically depressed, but they are quite distressed about diabetes. 6. Important Role for Diabetes Distress a large number of nonclinically depressed patients display a high level of distress and that a significant amount of this distress is related to diabetes and its management. In fact, scoring high on the CESD is more related to these markers than receiving a diagnosis of MDD alone. This may explain why even successful treatments for clinical depression among patients with diabetes have little or no effect on diabetes management; they were based on studies of MDD, and the distress substantively linked to biological and behavioral disease management variables may not have been directly addressed. Fisher et al, 2007 Fisher et al, 2007 6. Important Role for Diabetes Distress patients with diabetes who are significantly distressed but who are not clinically depressed may not profit from interventions that are derived from studies of the clinically depressed. Instead, addressing the personal, healthrelated, and social causes of their distress, including diabetes-specific distress with problem-solving or coping interventions, may be more meaningful and effective than initiating treatments specifically directed at clinical depression. 6. Important Role for Diabetes Distress What has been called depression among type 2 diabetic patients may really be two conditions, MDD and diabetes distress, with only the latter displaying significant associations with A1C. Ongoing evaluation of both diabetes distress and MDD may be helpful in clinical settings. Fisher et al, 2007 Fisher et al, 2010 7

Diabetes Distress The felt burden of living with a tough disease Key issue: Perceived lack of controllability Measuring Diabetes Distress PAID (Problem Areas in Diabetes Scale) 20 items, 5-point Likert scale, no subscales DDS (Diabetes Distress Scale) 17 items, 5-point Likert scale, four subscales Reliability and validity are well-established Linked to self-care and glycemic control Polonsky et al, 1995; Ishii et al, 1999; Lerman-Garber et al, 2003; Nichols et al, 2000; Snoek et al, 2000; Weinger and Jacobson, 2001; Polonsky et al, 2005; Fisher et al, 2008 DDS Sample Items 1. diabetes is taking up too much of my mental and physical energy every day. 2. I am often failing with my diabetes regimen. 3. friends or family are not supportive enough of my self-care efforts. 4. diabetes controls my life. 5. I will end up with serious long-term complications, no matter what I do. 6. overwhelmed by the demands of living with diabetes. Prevalence Diabetes-related emotional distress is not uncommon 506 type 2 patients, DDS measured thrice, at 9-month intervals 18% significantly distressed at time 1 (DDS>3) 29.2% significantly distressed at one or more of the three time points Fisher et al, 2008 Diabetes Distress Impairs Glycemic Improvement over 12 Months Diabetes Distress Impairs Glycemic Improvement over 12 Months Hemoglobin A 1c Level 11 10 9 8 7 Low Distress High Distress n = 22 n = 24 Baseline 6 Months 12 Months Polonsky et al, 2006 Change in A1C over 12 months was associated with baseline distress, after adjusting for depression, sex, age, diabetes duration, use of insulin and number of case management contacts (Beta = 0.48, p <.01) Polonsky et al, 2006 8

Addressing Diabetes Distress Challenge the hopelessness belief FACTS AND FICTIONS Q. Diabetes is the leading cause of adult blindness, amputation, and kidney failure. True or false? A. False. To a large extent, it is poorly controlled diabetes that is the leading cause of adult blindness, amputation and kidney failure. Well-controlled diabetes is the leading cause of NOTHING. DCCT/EDIC Research Group, 2009 Good News about Type 2 Diabetes STENO-2: Intensive treatment to normalize glycemia, blood pressure and lipids 7.8 years of intervention, 5.5 years follow-up Intervention group deaths: 24/80 Usual care group deaths: 40/80 Lesson for our patients: Good care is likely to DOUBLE the likelihood that you will be alive a decade from now. Gaede et al, 2008 Addressing Diabetes Distress Challenge the hopelessness belief Emphasize positive reinforcement Provide tangible evidence to patients that their efforts are making a difference Sam s Exercise Experiment Daily walk (30 minutes) For 1 week, measure BG right before and after my walk Day Pre- Exercise Post- Exercise BG Change 1 140 mg/dl 111 mg/dl 29 mg/dl 2 185 mg/dl 102 mg/dl 83 mg/dl 3 122 mg/dl 90 mg/dl 32 mg/dl 4 176 mg/dl 153 mg/dl 23 mg/dl 5 150 mg/dl 145 mg/dl 5 mg/dl 6 205 mg/dl 134 mg/dl 71 mg/dl 7 132 mg/dl 94 mg/dl 38 mg/dl Average BG change: 40 mg/dl 9

Addressing Diabetes Distress Challenge the hopelessness belief Emphasize positive reinforcement Provide tangible evidence to patients that their efforts are making a difference Promote a collaborative relationship Shared decision making Motivational Interviewing Rollnick S, et al. Motivational Interviewing in Health Care. NY: Guilford Press; 2008. Polonsky WH. Techniques for Effective Patient Self-Management. http://www.chcf.org. Jeannie s Story 21 year old, female University student Type 1 diabetes for 18 years Major depressive disorder Elevated blood glucose levels Jeannie s Story Ten treatment sessions Treatment focus on: global distress (poor self-esteem, esteem, school- related distress, loneliness) diabetes-related issues (hopelessness, diabetes police, feeling limited by diabetes, perfectionist approach towards self-care) 40 30 Jeannie s Story Pre-post tx change in depression and DM-related distress 20 10 0 Pre CESD Global Doctor Regimen Social Post Seven Things To Know 1. PREVALENCE. Depression is widespread among patients with diabetes 2. DIABETES IMPACTS DEPRESSION. Both biological and psychosocial elements of diabetes may exacerbate depression. 3. DEPRESSION IMPACTS DIABETES. Depression negatively influences self-care, glycemic control, development of complications and health care costs. 10

Seven Things To Know 4. IDENTIFYING DEPRESSION. It is relatively easy to screen for depression in diabetes and to address the issue with patients. 5. TREATING DEPRESSION. Moderately effective treatments have been demonstrated, but there appears to be little positive impact on metabolic control. Something is missing! Seven Things To Know 6. ADDRESS DIABETES-RELATED DISTRESS. The missing ingredient: feeling distressed by diabetes may help to explain the confusing data to date. Effective treatment of depression may require attention to diabetes distress. 7. SUMMARY VALUE. Attending to depression and diabetes-related distress in patients with diabetes is worth the effort. Behavioral Diabetes Institute Website: www.behavioraldiabetes.org INFO: info@behavioraldiabetes.org CALL: 858-336 336-8693 me: whp@behavioraldiabetes.org 11