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Depression and Diabetes:Issues in Prevention and Treatment
Douglas K. Novins, M.D.National Center for American Indian and Alaska Native Mental Health ResearchDepartment of PsychiatryUniversity of Colorado School of Medicine
Presentation Overview
• What is Depression?• What do we know about Depression and Diabetes?• Addressing Depression in Diabetes prevention and
treatment– Treatment of Depression
– Diabetes Prevention/Treatment
• Case discussion
What is Depression?
What is Depression?
• Biomedical Conceptualization of Depression– DSM-IV
• Major Depression
• Dysthymic Disorder
• Minor Depression/Brief Depression
American Psychiatric Association
What is Depression?
• “Symptoms” of Depression– Psychological
• Frequent sadness
• Hopelessness
• Inability to feel any emotion (“emptiness”)
• Persistent boredom; low energy
• Guilt
• Poor concentration
• Difficulty making decisions
American Academy of Child and Adolescent Psychiatry, American Psychiatric Association
What is Depression?
• “Symptoms” of Depression– Psychological
• Increased irritability, anger, or hostility
• Change in perception of time
• Fear of “going crazy”
American Academy of Child and Adolescent Psychiatry, American Psychiatric Association
What is Depression?
• “Symptoms” of Depression– Psychological
• Negative Cognitive Style
– Low self-esteem
– High self-criticism
– Cognitive distortions
– Feeling of lack of control over events
American Academy of Child and Adolescent Psychiatry, American Psychiatric Association
What is Depression?
• “Symptoms” of Depression– Behavioral
• Tearfulness, crying
• Decreased interest in activities; or inability to enjoy previously favorite activities
• Social isolation, poor communication
• Inattention to personal hygiene
• Extreme sensitivity to rejection or failure
• Difficulty with relationships
• Poor “work” performance
• Suicidal thoughts and behaviors
American Academy of Child and Adolescent Psychiatry; American Psychiatric Association
What is Depression?
• “Symptoms” of Depression– Somatic
• Frequent complaints of physical illnesses such as headaches and stomachaches
• A major change in eating and/or sleeping patterns
• Weight gain or loss
American Academy of Child and Adolescent Psychiatry; American Psychiatric Association
What is Depression?
• Why should we care?– Depression is a significant mental illness with potentially
serious consequences.• Recurrence rate is 70% at 5 years
• Suicide
– 33% will attempt suicide
– 3-4% will die from suicide
• Depression is often associated with medical illnesses and may have impacts on treatment.
What do we know about Depression and Diabetes?
What do we know about Depression and Diabetes?
• Depression is common among people with diabetes– 10% - general population
– 17-27% - people with cardiovascular disease
– 09-26% - people receiving treatment for diabetes
Fenton & Stover, 2006
What do we know about Depression and Diabetes?
• Depression is a risk factor for developing diabetes• Diabetes may be a risk factor for developing depression
Fenton & Stover, 2006; Brown et al., 2006
What do we know about Depression and Diabetes?
• People with depression and medical illnesses have poorer medical outcomes– Cardiovascular Disease - increased risk of heart attack and
death (from any cause; 2-7 times people without depression)
– Diabetes - poorer glycemic control and increased risk of death (from any cause; 1.6-2.3 times people without depression).
Fenton & Stover, 2006
What do we know about Depression and Diabetes?
• People with depression and medical illnesses have poorer medical outcomes– In people with diabetes, depression is associated with
• poor metabolic control
• poor adherence to medication and diet
• reduced quality of life
• higher healthcare costs
– Poor diabetes control may worsen depression and impair antidepressant treatment response
Fenton & Stover, 2006
What do we know about Depression and Diabetes?
• People with depression and medical illnesses have poorer medical outcomes– Why?
• Depression disrupts physiologic functions associated with normal glucose-insulin regulation.
– Disregulation of the endocrine system (hypothalamic–pituitary–adrenal axis)
– Disrupted sleep physiology
– Decreased levels of physical activity
– Increased inflammatory responses
– Increased appetite
Fenton & Stover, 2006
What do we know about Depression and Diabetes?
• People with depression and medical illnesses have poorer medical outcomes– Why?
• Depression has a big impact on an individual’s thinking that interferes
– Lower sense of self-efficacy (less confidence that they can change their behavior)
– Sense of hopelessness and foreshortened sense of the future
– Poor concentration
– Difficulty making decisions
– Social isolation, poor communication, difficulty with relationships
Fenton & Stover, 2006
Treatment
Treatment
• General Principles– It is as important to treat depression as it is to treat risk
for developing diabetes, or the cardiovascular complications of diabetes
Treatment
• Treatment of Depression– Careful Assessment
– Appropriate Treatment• Cultural
– Traditional Healer
• Individual Psychotherapy
– Cognitive Behavioral Therapy
– Interpersonal Therapy
• Antidepressant Medication
Treatment
• Treatment of Depression– There is some limited evidence that effective treatment of
depression improves glycemic control
– There is no evidence that effective treatment of depression improves adherence to behavioral change interventions.
Treatment
• Self-Help Groups (Combined/Adjunctive Treatments)– Self-help groups seem to have short term effects on quality of life
and depression and engagement in behavioral changes for individuals with chronic medical conditions.
Foster et al., 2007
Treatment
• Treatment Contracts– No evidence for their effectiveness
Murray et al., 2007
Treatment
• Diabetes Prevention/Treatment for Individuals with Depression– No research to provide clear guidelines
– Dr. Novins’ recommends:• enhancing aspects of your prevention/treatment programs that address
some of the psychological and behavioral consequences of depression
• Considering increasing the frequency and level of contacts with participants suffering from depression as well as the frequency of metabolic monitoring.
Treatment
• Diabetes Prevention/Treatment for Individuals with Depression– Key psychosocial challenges
• Social isolation, poor communication, sensitivity to rejection and failure, negative cognitive style
– Key behavioral challenges:• Poor concentration• Difficulty making decisions• Decreased energy• Low self-esteem• Decreased sense of self-efficacy
Treatment
Intervention Adjustment Aspect of Depression Addressed
More frequent, shorter sessions Social isolation, poor communication, sensitivity to rejection, Poor concentration, Difficulty making decisions, Decreased energy, Low self-esteem
Treatment
Intervention Adjustment Aspect of Depression Addressed
Between session contacts by phone, especially is sessions cannot be held more frequently
Social isolation, poor communication, sensitivity to rejection, Poor concentration, Difficulty making decisions, Decreased energy, Low self-esteem
Treatment
Intervention Adjustment Aspect of Depression Addressed
Engage family/extended family/significant other in treatment
Social isolation, poor communication, sensitivity to rejection, negative cognitive style, Poor concentration, Difficulty making decisions, Decreased energy, Low self-esteem
Treatment
Intervention Adjustment Aspect of Depression Addressed
Provide transportation to appointments, groups, social activities.
Social isolation, poor communication, Difficulty making decisions, Decreased energy
Treatment
Intervention Adjustment Aspect of Depression Addressed
Between session contacts by phone, especially is sessions cannot be held more frequently
Social isolation, poor communication, sensitivity to rejection, Poor concentration, Difficulty making decisions, Decreased energy, Low self-esteem
Treatment
Intervention Adjustment Aspect of Depression Addressed
Focus on the positives – highlight every accomplishment, no matter how small
sensitivity to rejection and failure, low self-esteem, negative cognitive style
Provide individualized, simple written directions and feedback for person to take with them
Social isolation, poor communication, poor concentration, difficulty making decisions, negative cognitive style
Treatment
Intervention Adjustment Aspect of Depression Addressed
Start, enroll person in self-help support group
Social isolation, poor communication, sensitivity to rejection, poor concentration, difficulty making decisions, decreased energy, low self-esteem, negative cognitive style
Treatment
Intervention Adjustment Aspect of Depression Addressed
Consider using TeleHome Care Devices (Murray et al., 2007)
Social isolation, poor communication, sensitivity to rejection, poor concentration, difficulty making decisions, decreased energy, low self-esteem, negative cognitive style
Treatment
Intervention Adjustment Aspect of Depression Addressed
Increased use of motivational interviewing techniques
Poor communication, Difficulty making decisions, Decreased energy, Low self-esteem, negative cognitive style
Contemplation
Determination
Action
Maintenance
Relapse
Precontemplation
PermanentExit
Treatment
• Key Motivational Interviewing Techniques– Establish the Stage of Change the person is in for this
particular behavior change, as it will help guide your interventions
• Precontemplation: Raise doubt - increase the person’s perception of risks and problems with current behavior
• Contemplation: Tip the balance - evoke reasons to change, risks of not changing; strengthen the person’s self-efficacy for change of current behavior
• Determination - Help the person determine the best course of action to take in seeking change.
Treatment
• Key Motivational Interviewing Techniques– Establish the Stage of Change the person is in for this
particular behavior change, as it will help guide your interventions
• Action: Help the person to take steps toward change.
• Maintenance: Help the person to identify and use strategies to prevent relapse.
• Relapse: Help the person to renew the processes of change without becoming stuck or demoralized.
Treatment
• Key Motivational Interviewing Techniques– Emphasize those principles that are less likely to feed into
depressive symptoms• Expression of Empathy
• Develop Discrepancy
• Avoid Argumentation
• Roll with Resistance
• Support Self-Efficacy
Slesnick et al., 1998
Treatment
• Key Motivational Interviewing Techniques– Emphasize those principles that are less likely to feed into
depressive symptoms• Avoid Argumentation: “Ambivalence and discrepancy can resolve
into defensive coping strategies that reduce the client’s discomfort but do not alter [behavior]. The client and not the therapist should voice the arguments for change. The therapist employs strategies to assist the client to see accurately the consequences of [their behavior] and to begin devaluing [its] perceived positive aspects.”
Slesnick et al., 1998
Treatment
• Key Motivational Interviewing Techniques– Emphasize those principles that are less likely to feed into
depressive symptoms• Expression of Empathy: “The therapist seeks to communicate great
respect for the client as a supportive companion and knowledgeable consultant. The client’s freedom of choice and self-direction are respected. In this view, only the client can decide to make a change in their [behavior] and carry out that choice. Persuasion is gentle, subtle, and always with the assumption that change is up to the client.”
Slesnick et al., 1998
Treatment
• Key Motivational Interviewing Techniques– Emphasize those principles that are less likely to feed into
depressive symptoms• Support Self-Efficacy: People who are persuaded that they have a
serious problem will still not move toward change unless there is hope for success. Hence, clients must be persuaded that it is possible to change their [behavior] thereby reduce related problems.”
Slesnick et al., 1998
Treatment
• Key Motivational Interviewing Techniques– De-emphasize those principles that are more likely to feed
into depressive symptoms• Develop Discrepancy: “Motivation for change occurs when people
perceive a discrepancy between where they are and where they want to be. MET seeks to enhance and focus the client’s attention on such discrepancies with regard to drinking behavior. It may be necessary to first develop such discrepancy by raising client’s awareness of the personal consequences of their drinking.”
Slesnick et al., 1998
Treatment
• Key Motivational Interviewing Techniques– The motivational phase of many interventions is usually 1-2
sessions:• Develop motivation to change
• Consolidate commitment to change
– A person with depression may require more than 2 sessions to commit to change
– A person with depression may need to return to these motivational issues throughout the intervention, not just at the beginning
Slesnick et al., 1998
Treatment
• Key Motivational Interviewing Techniques– Be sure to provide the person with depression a written
motivational treatment plan once they commit to change:• The changes I want to make are …. (include positive goals)
• The most important reasons why I want to make changes are …
• The steps I plan to take in changing are …
Slesnick et al., 1998
Treatment
• Key Motivational Interviewing Techniques– Be sure to provide the person with depression a written
motivational treatment plan once they commit to change:• The ways other people can help me are …
• The benefits I expect from this change are …
• Some things that could interfere with my plan are ...
– Keep a copy of this motivational treatment plan so that you can review it with the person when their motivation to change wanes
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