Depressive Disorders and Diabetes: More Than Just the Blues or Blahs

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Depressive Disorders and DiabetesMore Than Just
the Blues (or Blahs)

• DANIEL P. CHAPMAN
• Psychiatric Epidemiologist
• Emerging Investigations and Analytic Methods
  Branch
• Division of Adult and Community Health
• Centers for Disease Control and Prevention

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Objectives of Presentation

• Discuss diagnostic criteria for depressive
  disorders
• Describe the association(s) between diabetes and
  depressive disorders
• Discuss your experiences, concerns, and questions
  about depressive disorders in persons with
  diabetes tap into your expertise

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EVERYBODY THINKS THEY KNOW WHAT DEPRESSION IS
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BUT, IN REALITY, IT CAN OFTEN BE TRICKY TO
DETECT.
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Good News! Standardized tools and measurement
criteria for the detection of possible
depressive disorders exist and are not highly
difficult to learn to use!
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Types of Depressive Disorders

• Major Depressive Disorder
• Dysthymic Disorder
• Minor Depressive Disorder (currently undergoing
  further study)

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Major Depressive Episode

• Five (or more) of the following symptoms have
  been present during the same 2-week period and
  represent a change from previous functioning at
  least one of the symptoms is (1) depressed mood
  or (2) loss of interest or pleasure
• depressed mood most of the day, nearly every day,
  as indicated by either subjective report or
  observation made by others (e.g., appears
  tearful)
• markedly diminished interest or pleasure in all,
  or almost all, activities most of the day, nearly
  every day

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• insomnia or hypersomnia nearly every day
• psychomotor agitation or retardation nearly every
  day observable by others, not merely subjective
  feelings of restlessness or being slowed down)
• fatigue or loss of energy nearly every day
• feelings of worthlessness or excessive or
  inappropriate guilt (which may be delusional)
  nearly every day (not merely self-reproach or
  guilt about being sick)

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• diminished ability to think or concentrate, or
  indecisiveness, nearly every day (either by
  subjective account or observed by others)
• recurrent thoughts of death (not just fear of
  dying), recurrent suicidal ideation without a
  specific plan for committing suicide

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Dysthymic Disorder

• Depressed mood for most of the day, for more days
  than not, as indicated either by subjective
  account or observation by others, for at least 2
  years
• Presence, while depressed, of two (or more) of
  the followingdepressed mood most of the day,
  nearly every day, as indicated by either
  subjective report or observation made by others
  (e.g., appears tearful)
• poor appetite or overeating
• insomnia or hypersomnia
• low energy or fatigue
• low self-esteem
• poor concentration or difficulty making decisions
• feelings of hopelessness

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• During the 2-year period of the disturbance, the
  person has never been without the symptoms in
  Criteria A and B for more than 2 months at a time
• No Major Depressive Episode has been present
  during the first 2 years of the disturbance (1
  year for children and adolescents) i.e., the
  disturbance is not better accounted for by
  chronic Major Depressive Disorder or Major
  Depressive Disorder, In Partial Remission
• There has never been a Manic Episode, a Mixed
  Episode, or a Hypomanic Episode, and criteria
  have never been met for Cyclothymic Disorder

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• The disturbance does not occur exclusively during
  the course of a chronic Psychotic Disorder, such
  as Schizophrenia or Delusional Disorder
• The symptoms are not due to the direct
  physiological effects of a substance (e.g., a
  drug of abuse, a medication) or a general medical
  condition (e.g., hypothyroidism)
• The symptoms cause clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning

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Depressive
Disorders
Diabetes
HOW DO THEY INTERACT?
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Prevalence of Depression Among Persons with
Diabetes
Depression Prevalence ()
Diagnostic Interview (n7)
Self-Report Scale (n11)
Assessment Methods
Source Anderson et al., 2001
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Incidence Rates of Diabetes per 1,000
Person-Years by Depressive Symptoms Levels and
Education
ltHS Educ
gtHS Educ
Rate of Diabetes per 1,000 person-years
Depressive Symptoms Levels
Source Carnelthon et al., 2003 mean
follow-up15.6 years
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Factors Associated with Comorbid Depression or
Depressive Symptoms in Persons with Diabetes

• adaptation to the illness
• diabetic-related complications
• unemployment
• illness intrusiveness

Sources Peyrot Rubin, 1997 Lernmark et al.,
1999 Friis Nanjundappa, 1986 Talbot et al.,
1999
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Characteristics Distinguishing Depressed
Individuals from Nondepressed Individuals with
Diabetes

• lt 65 years of age
• female gender
• unmarried marital status
• poor self-reported physical health
• poor self-reported mental health

Source Egede et al., 2002
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Self-Care Characteristics Distinguishing
Depressed Individuals from Nondepressed
Individuals with Diabetes

• sedantariness
• frequent overeating of sweets and high-fat foods
• less able to adhere to diabetic diet away from
  home

Source Egede et al., 2002
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Relevance of Depressed Individuals with Diabetes
Receiving Diagnosis and Treatment for Depression

• Treatment of depression has been associated with
  improved glycemic control
• May also reduce diabetic complications and the
  likelihood of diabetes-related disability

Sources Lustman et al., 1998 de Groot et al,
2001
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And the Bottom Line Total Health Care
Expenditures for Persons with Diabetes
Diabetes without depression
Diabetes with depression
Total expenditures (millions)
Source Egede et al., 2002
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Yet, Diagnosis and Treatment of Persons with
Depression Among Persons With Diabetes Is
Relatively Infrequent
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Source Ruben et al., 2004
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Successful Interventions Among Persons with
Diabetes and Depression

• cognitive behavioral therapy
• antidepressant pharmacotherapy

Sources Lustman et al., 1998 Lustman et al.,
2000
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Cognitive Behavioral Therapy Among Persons with
Diabetes

• Individual monitors automatic thoughts,
  identifies cognitive traps, and furnishes
  rational rebuttal
• Example Having diabetes is going to ruin my
  life! Im not going to be able to eat anything
  good ever again and Ill wind up with all sorts
  of complications!
• Cognitive traps all-or-none thinking, fortune
  telling

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• Rational rebuttal Living with diabetes will
  present some new challenges for me, but Ive
  adapted to new challenges in the past. And in
  adapting to these new challenges, Ill likely
  minimize my risk for complications
• CBT has yielded significant improvements in
  depressive symptoms and glycosylated hemoglobin
  levels in patients with diabetes and major
  depression

Source Lustman et al., 1998
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Depressive
Disorders
Diabetes
HOW DO THEY INTERACT? BIDIRECTIONALLY!
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Conclusions

• Persons with diabetes may be at increased risk
  for depressive disorders
• Clinician vigilance for depressive symptomatology
  is warranted for persons with diabetes
  especially among those in identified groups at
  increased risk
• Depressive disorders appear to affect the
  etiology, course and treatment of persons with
  diabetes
• Depression screening tools exist which allow the
  clinician to provide holistic care for persons
  with diabetes