PSYCHOLOGICAL CHALLENGES OF DIABETICS Does Depression Correlate to Diabetic Foot Ulcer Outcomes? Garneisha Torrence, PGY-3 DVA Puget Sound Health Care System
Disclosure No relevant financial or non-financial relationships to disclose
Diabetes Statistics 29.1 million diabetics 21 million diagnosed 8.1 million undiagnosed By 2030, DM Type 2 will be 7 th leading cause of death worldwide Estimated annual cost of care = $245 billion $176 billion direct medical costs $69 billion productivity lost Maydick, et al., 2016
Diabetic Foot Ulcer Statistics 15 to 25% of diabetics will develop a DFU Only two-thirds heal within 6 months Approx. 60% have a recurrence in 1 year 5 year mortality following amputation 39 to 80% Pearson, et al., 2014
Depression Overview Statistics Affects 15 million adults 4 th leading cause of disability worldwide 2 nd by 2020 (Kessler, et al., 2013) Diagnosis Gold standard Structured patient interview Diagnosis that conforms to Diagnostic and Statistical Manual of Psychiatric Disorders, 5 th edition (DSM-V) Assessment via self-administered questionnaires
Patient Health Questionnaire (PHQ-9) Sample questions Little interest or pleasure doing things? Feeling tired or having little energy? Trouble concentrating? Excellent correlation to structured interview Pearson, et al., 2014 Kroenke, et al., 2014
Depression and Diabetes Depression 2X more common in DM Prevalence of 11%; up to 32% in patients with DFU Depression related to: Poorer glycemic control Poorer self management behavior Increased risk of morbidity and mortality Clinical depression associated with 2X greater risk of DFU incidence Fisher, et al., 2007 Williams,et al., 2010
Key Literature A Cohort Study of People With Diabetes and Their First Foot Ulcer (Ismail, et al., 2007) Goal Examine whether depression was associated with mortality in 253 patients with their first DFU over an 18 month period Results One-third of patients with first DFU were depressed Depression not associated with healing, ulcer recurrence or amputation Depression three-fold increased risk of death Mortality at 5 year follow-up (Winkley, et al., 2012) Two-fold increased risk of mortality
Key Literature The Diabetic Person Beyond a Foot Ulcer: Healing, Recurrence, and Depressive Symptoms (Monami, et al., 2008) Goal Assess the role of depression in healing and recurrence of DFUs in DM Type 2 patients 60 Results Healed ulcers had significantly lower scores on geriatric depression scale (GDS) Scores of 10 had significantly higher risk of not healing at 6 months Patients with recurrent ulcerations had significantly higher GDS scores
Key Literature Depression and Incident Lower Limb Amputations in Veterans with Diabetes (Williams, et al., 2011) Goal Determine the association between diagnosed depression and incident non-traumatic lower limb amputations in veterans with DM Results Depression associated with 33% increased risk of major lower limb amputations in veterans with DM Related to more severe arterial ischemia? No increased risk of minor lower limb amputations
Key Literature Depression Symptoms in People with Diabetes Attending Outpatient Podiatry Clinics for Treatment of Foot Ulcers (Pearson, et al., 2014) Goals Determine effect of depression on DM self-management, health related quality of life (HRQoL), and ulcer status Results Depression prevalence of 51.7% Maintenance pharmacotherapy not effective in treating symptoms Association with poorer DM self-management and HRQoL No association between depression and ulcer outcomes at 6 month follow-up
Depression or Distress Most diabetic patients with high levels of depressive symptoms are not clinically depressed (Fisher, et al., 2010) Diabetic Emotional Distress Unique and separate from depression Caused by burden of disease and its management Can affect up to 50% of patients in an 18 month period Associated with less self-active care
Diabetic Emotional Distress Problem Areas in Diabetes Questionnaire (PAID) Are you having trouble accepting your diabetes? Do you feel overwhelmed or burned out by the demands of diabetes management? Do you get the support you need from your family for diabetes management? Do you worry about diabetic complications? Polonsky, et al., 2005
Diabetic Emotional Distress Models of Behavior Change (Peyrot, et al., 2007) Motivators Perceived benefits, expectations, rewards Inhibitors/facilitators Barriers to or lack of resources for action Intentions Internal desire to change Triggers Predisposed action action state
Depression and Distress Screening Controversy Feasibility, cost-effectiveness, who performs assessment Reimbursement CPT Code 96127 May be used to report brief behavioral or emotional assessments for reimbursement Includes standardized screening instruments providing both scoring and further documentation to the healthcare provider Not limited to mental health specialists
The Podiatrist's Role Podiatrists care for diabetics across the continuum of care More sensitive to subtle changes in mental health Recognize symptoms of psychological distress and depression Make the proper mental health referral Engage other collaborative care specialties Help mitigate known risk factors Aid in overcoming counterproductive behaviors
Conclusion More research is needed relating DFU outcomes and depression Diabetic distress is a separate entity and can have a significant role in DFU outcomes Utilizing behavior change models can be pivotal for success The podiatric physician should recognize mental health issues in order to promote better DM related outcomes
References Maydick, D.R and Acee, A. M. (2016). Comorbid depression and diabetic foot ulcers. Home Healthcare Now. 34(2):62-67. Pearson, S., Nash, T., Ireland, V. (2014). Depression symptoms in people with diabetes attending outpatient podiatry clinics for treatment of foot ulcers. J Foot Ankle Res. 7(47) Kessler, R.C. and Bromet, E.J. (2013). The epidemiology of depression across cultures. Annu Rev Public Health. 34: 119-138. Kroenke, K., Spitzer, R.L. and Williams J.B.W., et al. (2001). The phq-9: validity of a brief depression severity measure. J Gen Intern Med. 16:606-616 Williams, L.H., Rutter, C.M., Katon, W.J. et al. (2010). Depression and incident diabetic foot ulcers: a prospective cohort study. Am. J. Med. 123(8): 748-754. Fisher, L., Mullan, J.T., Arean, P., et al. (2010). Diabetes distress but not clinical depression or depressive symptoms is associated with glycemic control in both cross-sectional and longitudinal analyses. Diabetes Care. 33(1):23-28. Ismail, K., Winkley, K., Chalder, T. et al., (2007). A cohort study of people with diabetes and their first foot ulcer: the role of depression on mortality. Diabetes Care. 30 (6) 1473-1479.
References Winkley, K., Sallis, H., Kariyawasam, D., et al. (2011). Five-year follow up of a cohort of people with their first diabetic foot ulcer: the persistent effect of depression on mortality. Diabetologia. 55:303-310. Monami, M., Longo, R., Desideri, C.M., et al. (2008). The diabetic person beyond a foot ulcer: healing, recurrence, and depressive symptoms. J Am Podiatr Med Assoc. 98(2):130-136. Williams, L.H., Miller, D.R, Fincke, G., et al. (2011). Depression and incident lower limb amputations in veterans with diabetes. J Diabetes Complications. 25(3):175-182. Peyrot, M. and Rubin, R.R. (2007). Behavioral and psychosocial interventions in diabetes: a conceptual review. Diabetes Care. 30 (10):2433-2440. Polonsky, W., Fisher, L., Earles, J. et al., (2005). Assessing psychosocial distress in diabetes: development of the diabetes distress scale. Diabetes Care. 28 (3) 626-631. Fisher, L., Mullan, J.T., Arean, P., et al. (2007). Clinical depression versus distress among patients with type 2 diabetes. Diabetes Care. 30(3):542-548.
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