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Depression , Diabetes and Quality of life


Depression , Diabetes and Quality of life Prof. Ahmed Okasha M.D., PhD, F.R.C.P., F.R.C., Psych., F.A.C.P (Hon.) Founder and Director of WHO Collaborating Center – PowerPoint PPT presentation

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Title: Depression , Diabetes and Quality of life

Depression , Diabetes andQuality of life
  • Prof. Ahmed Okasha
  • M.D., PhD, F.R.C.P., F.R.C., Psych., F.A.C.P
  • Founder and Director of WHO Collaborating Center
  • For Research and Training in Mental Health
  • Okasha Institute of Psychiatry, Ain Shams
  • President Egyptian Psychiatric Association
  • Hon. President Arab Federation of Psychiatrists
  • President World Psychiatric Association (2002

What Is Happening in The Middle East?
Uprise in the Arab World
  • 60 of Arab World below 30 years
  • Tunisia, Egypt, Yemen, Libya, Syria
  • Common factors Despotism, Security torture, Long
    standining in power, violation of human
  • No democracy, transparency, accountability.
  • Revolutions of dignity to the Arab Citizens
  • Democracy, providing physical and mental health
    are assets to wellbeing and happiness.
  • In Egypt, first revolution by intellectual youth
    using the technology of social networking

Psychiatric Disorders in the Community
  • Out of every 100 citizens
  • 30 are suffering from a mental problem that
    needs attention.
  • 20 will seek traditional healers or general
    practitioners (GPs) help.
  • 10 will be recognized by the GP to be
    psychiatric cases.
  • 2.3 will be referred to the psychiatrist.
  • 0.5 will need inpatient treatment.

Ten leading causes of burden of diseases, world,
2004 and 2030
COPD , chronic obstructive pulmonary disease
Global burden of disease WHO 2004
Prevalence of Depressive Disorders in Different
Patient Populations
Chronically ill
  • Prevalence
  • There is a range of percentages depending on
    the study.

Diagnosis of Depression
  • Two questions
  • During last month, have you often been bothered
    by feeling down, depressed or hopeless?
  • During the last month, have you been bothered by
    having little interest or pleasure in doing
    things? (Interest)

  • Main presentation
  • Fatigue
  • Lack of concentration.
  • Somatic symptoms (masked depression) e.g.
    Headache, Backache, Paraesthesia.
  • Sleep (EMW), appetite, sex, behavior
  • Psychomotor agitation or retardation.
  • Malancholia.
  • Psychosis self depreciation, nihilism, guilt

Who gets depressed?
Knol MJ. Twisk JWR, Beekman ATF, Heine RJ, Snock
FJ, Pouver F. Depression as a risk factor for the
onset of type 2 diabetes meillitus.
Ameta-analysis Diabetologia 200649,837-845
Prevalence of DM
  • World Wide 285 Millions expected in
    2030 to be 439 Millions
  • Egypt 5 Millions 10 young.
  • Egypt rating among the World is number 10.

Life Time Prevalence of Depression in Diabetic
Face the Facts
Kaplan Sadock, 2002
The Stress Curve
  • Hazards
  • Fatigue
  • Irritability
  • Lack of concentration
  • Anxiety
  • Illness
  • Low productivity and creativity
  • Benefit
  • Vitality
  • Enthusiasm
  • Optimism
  • Mental alertness
  • High productivity and creativity

Causes of Depression in Diabetic Patients
  • Stress, dysregulation of HPA axis, dysregulation
    of blood glucose.
  • Reaction associated with having a chronic
    disease (e.g. denial, anger, depression, anxiety,
  • Strict dietary regimen.
  • Concern over guilt of inappropriate following of
    dietary restriction.

  • Significant chronic pain secondary to neuropathy.
  • Effect on brain function e.g. diabetes induces
    vascular (cerebral ischemia).
  • Coincidence (chance association).
  • Side effects or complications from medications.

Cognitive Dysfunctions in Diabetic Patients
  • Impaired attention
  • Information processing
  • Memory (Short)
  • Problems solving
  • Language function
  • Visuo-constructional skills
  • Significant reduction of IQ

Holmes, 1990
Causes of Cognitive Impairment
  • Metabolic dyscontrol.
  • Keto acidosis.
  • Hyperosmolar states.
  • Recurrent hypoglycemia.
  • Chronic hypoglycemia.
  • High prevalence of CVS.
  • Depression.

 Stress may produceanxiety depression
hostility unexpressed anger - cynicism
Stress, Diabetes and Depression
1.  Reduction of vagal tone which is protective
for the heart2.  Endothelial function is
impaired ? injured ?
thrombosis3.  Platelets more hyper-coagulable,
more sticky,increases platelet
aggregation and adhesion.
4.  Haemoconcentration ? increased blood
Acute stress ? Activation of sympathetic system

1.      Platelets2.      Endothelium3.     
Vagal tone4.      Activating cortisol system
(Lipids Glucose, Hypertension)5.     
Ovarian dysfunction, oestrogen is
probably very protective ? it raises HDL
Chronic Stress
  • After an episode of major depression, the risk of
    myocardial infarction increased to fivefold.
  • Subsyndromal forms of depression had a twofold
    increased risk of myocardial infarction.

  • 6 months after MIMortality rate 17 in
    patients with depression , 3 without .
  • 12 months after bypass Those with depression
    had a higher incidence of subsequent cardiac
    events, angina , heart failure MI, repeat
  • MD is a significant risk factor for the
    development of coronary artery disease and

Frasure-Smith et al 1993 Connerney 2000 Nemeroff
Aims of Treatment
Treatment Options
  • Antidepressant medication
  • Psychotherapy
  • Electro-convulsive therapy (ECT)
  • (Brain synchronization treatment)

Antidepressant Medication Classes
  • TCAs
  • Clomipramine
  • Imipramine
  • Amitryptiline
  • MAOIs
  • Phenelzine
  • Isocarboxazide
  • RIMA
  • Moclobemide
  • SSRIs
  • Fluoxetine, Sertraline, Escitalopram,
    Paroxetine, Fluvoxamine
  • SNRI
  • Venlafaxine, Duloxetine
  • Others
  • Mianserin, Tianeptine, Nefazodone, Trazodone,
    Mirtazapine, Maprotiline.

Drug Drug Interaction
  • Use AD with the least Drug-Drug interaction e.g.
    Sertraline, Ecitalopram, Mianserin
    i.e. no induction
  • Or inhibition of liver enzymes
  • SSRI Bleeding, hyponitraerina

  • Taking moderate to high daily doses of
    antidepressants for more than 2 years is
    associated with an 84 increased risk for
    diabetes, according to a large observational
  • The increased risk was particularly notable for
    (SSRI) paroxetine and the tricyclic
    antidepressant amitriptyline.
  • Weight gain might explain much of the relation
    between antidepressant use and diabetes

Andersohn 2009
  • The study found a 4-fold increased risk for
    diabetes associated with the long-term use of
    paroxetine in daily doses above 20 mg/day, but
    not of fluoxetine, citalopram, or sertraline
  • Depression itself might be some how connected to
    diabetes and pointed out that there is evidence
    that patients who treat their depression in ways
    other than with antidepressants ( for example,
    with cognitive behavior therapy) are also at high
    risk of developing diabetes.

Andersohn 2009
  • New research suggest that a combination of type 2
    diabetes and smoking may place individuals with
    serious mental illness (SMI) at even greater risk
    for death than their counterparts with diabetes
    who smoke but who do not have SMI.

Norra MacReady 2009
Consequences of Psychiatric Morbidity in Diabetic
  • Poorer glucose control.
  • Increase risk of complications.
  • Affected medication adherence and self care
  • Impaired quality of life.
  • Lethal dose of insulin.
  • Poor outcome.
  • High frequency of (smoking, alcohol).

DM and Depression
The Myth The Reality
REALITY ? Depression disorders are overlapping,
hardly expressed by the patient and constitute a
major problem in symptom exaggeration
MYTH ? Depression is obvious and easily
recognized and expressed by the patient
DM and Depression
The Myth The Reality
REALITY ? Depression requires treatment
intervention and does not remit with relieve of
MYTH ? Depression is Secondary to GMD
activity Treatment of the medical disorder will
relief Depression.
What is Mental Health?
  • Mental health is more than the mere lack of
    mental disorders.
  • Mental health is a state of well-being whereby
    individuals recognize their abilities, are able
    to cope with normal stresses of life, work
    productively and fruitfully, and make a
    contribution to their communities

Quality of Life Versus Longevity of Life
  • Quality of life describes an individuals
    satisfaction with his or her general sense of
    wellbeing. It is often measured as physical ,
    psychological and social wellbeing.
  • Longevity of life at the expense of quality of
    life is an empty prize.

Psychosocial Factors
  • Psychological factors may affect health-related
    behaviours such as smoking, diet, alcohol
    consumption, or physical activity, which in turn
    may influence the risk of CHD and diabetes.
  • Psychosocial factors may cause direct acute or
    chronic pathophysiological changes, possibly by
    their effect on neuroendocrine or immune systems.
  • Access to and content of medical care may be
    influenced by social factors.

Personality and Social Networks
  • Psychological traits ( type A behaviour,
    hostility, workaholic, time urgency)
  • Psychological states ( depression, anxiety)
  • Psychological work characteristics ( job control
    , demands, support)
  • Social networks and social supports.

Social Support
  • Evidence that high levels of social support are
    protective against CHD and diabetes, while
    social isolation is related to increased
    mortality risk.
  • It has been proposed that social supports may act
    to buffer the effect of various environmental
    stereos and hence increase susceptibility to

Alloway 1987
Social interaction
  • Social interaction leads to neurogenesis and
    proliferation of dendrites in cells of the
    hippocampus and increased dopamine in the
    dopaminergic reward pathways.
  • Lack of social interaction leads to atrophy in
    cells of the hippocampus, decreased dopamine
    together with hopelessness and helplessness.

Spitzer, 2002
  • Depressive?????? ?????????
  • Cyclothymic?????? ???????
  • Irritable ?????? ??????
  • Anxious ?????? ?????
  • Hyperthymic ?????? ?????

Akiskal 2003
Characters (Environmental)
  • ??????? ?????
  • Self- directedness how well is a person,
    responsible, reliable, goal oriented and self
  • ???????
  • Cooperativeness how a person is considered a
    part of human society. (i.e., tolerant, helpful,
    compassionate), and self-transcendence.
  • ????? ?????
  • Self-transcendence a part of the universe as a

  • Well-being is not enhanced by wealth, power, or
    fame, despite many people acting as if such
    accomplishments could bring lasting satisfaction.
  • Character development does bring about greater
    self-awareness and hence greater happiness.
  • The most effective methods of intervention all
    focus on the development of positive emotions and
    the character traits that underlie well-being.

  • Social Capital" is defined as the ties that bind
    families, neighborhoods , workplaces,
    communities, and religious groups together and
    find that it correlates strongly with
    subjective wellbeing.
  • In fact the breadth and depth of individuals'
    social connections are the best predictors of
    their happiness.

Money can buy you happiness, but not
much. and above a modest threshold, more
money does not mean more happiness.
Individuals usually get richer during their
lifetimesbut not happier.
  • As for individuals, so for countries. Ghana,
    Mexico, Sweden, the United Kingdom , and the
    United States all share similar life satisfaction
    scores despite per capita income varying 10-fold
    between the richest and poorest country.
  • If money does not buy happiness, what does?
  • In all 44 countries surveyed in 2002 by the Pew
    Research center, family life provided the
    greatest sources of satisfaction.

  • Married people live on average three years longer
    and enjoy greater physical and psychological
    health than the unmarried.
  • Having a family enhances wellbeing, and spending
    more time with one's family helps even more.
  • In fact the breadth and depth of individuals'
    social connections are the best predictors of
    their happiness.

  • Work is central to wellbeing, and certain
    features correlate highly with happiness. These
    include autonomy over how, where, and at what
    pace work is done.
  • Trust between employer and employee.
  • Procedural fairness.

  • The more that governments recognize individual
    references, the happier their citizens will be.
  • Free choice, and citizens' belief that they can
    affect the political process, increase subjective
  • An association between unhappiness and poor
  • Be happy with what you have got, look
    outwardsnot to compare yourself unfavorably with
    others, but to develop your relationship! with
  • It is a surer route to happiness than the pursuit
    of wealth.

Get Happy It Is Good For You
  • Embark on a loving relationship with another
    adult, and work hard to sustain it.
  • Plan frequent interactions with friends, family,
    and neighbours (in that order).
  • Make sure you are not working so hard that you
    have no time left for personal relationships, and

  • In your spare time, join a club, volunteer for
    community service or take up religion.
  • Happiness should become the goal of public policy
    and the progress of national happiness should be
    measured and analyzed as closely as the growth of
    gross national product.
  • This means that public policy should be judged by
    how it increases human happiness and reduces
    human misery.

Happy Lives
  • Pleasant life
  • Where you experience a succession of pleasures
    that lose their effect with repetition.
  • Good life
  • Where you play your strengths and are engaged.
  • Meaningful life
  • Where you put your strengths at the services of
    something higher than yourself.

Positive Steps for Mental Health (WHO)
  • Accepting who you are
  • Talking about it
  • Keeping active
  • Learning new skills
  • Keeping in touch with friends
  • Doing something creative
  • Getting involved
  • Asking for help
  • Relaxing
  • Surviving

Make Your Choice
  • Be successful, competitive, workaholic and die
  • OR
  • Be less ambitious, lower income, more relaxed and
    live longer.