Diabetes & Mental Health in primary care
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This presentation discusses the relationship between type 2 diabetes and depression. It finds that depression is more common in people with type 2 diabetes, with prevalence rates ranging from 10-30%. Depression is also identified as a risk factor for developing type 2 diabetes. Chronic stress may also increase the risk of depression and diabetes. While depression in diabetes often goes underrecognized and untreated, the document outlines new effective treatments such as online cognitive behavioral therapy, mindfulness therapy, and stepped care models in primary care settings.
![Depression in diabetes
In the 17th century, the Famous
English physician Thomas Willis
(1621-1675) noted that diabetes
often appeared among patients
who had experienced significant
life stresses, sadness or long
sorrow.
T. Willis (1674-75) Pharmaceutice rationalis sive diatriba de medicamentorum
operationibus in humano corpore. [Oxford] : E Theatro Sheldoniano, M.DC.LXXV.](https://image.slidesharecdn.com/diabetesmentalhealthwonca2015pouwer-151031133602-lva1-app6891/85/Diabetes-Mental-Health-in-primary-care-13-320.jpg)
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Diabetes & Mental Health in primary care
- 1. Diabetes & Mental Health in primary care focus on type 2 diabetes and depression Prof. François Pouwer
- 2. Tilburg University, The Netherlands Prof. dr. F. Pouwer Center of Research on Psychology in Somatic diseases (CoRPS) Department Medical and Clinical Psychology Tilburg University, The Netherlands
- 3. This presentation: Epidemiological perspective • Depression in type 2 diabetes: prevalence • Depression and type 2 diabetes: longitudinal associations • Depression in type 2 DM: impact on health outcomes • Stress and diabetes • New treatments against depression in diabetes • Conclusions
- 4. Diabetes (type 1 or 2) doubles the odds of depression. Anderson RJ et al: Diabetes Care 2001; 24:1069-1078 (meta-analysis). Depression: a common complication of dm:
- 5. DM DMControls Controls Anderson RJ et al: Diabetes Care 2001; 24:1069-1078 (meta-analysis).
- 6. Nouwen et al, Diabetes Care 2011
- 7. Undiagnosed DM vs. Normal Glucose Metabolism Undiagnosed DM vs. Impaired Glucose Metabolism Undiagnosed DM vs. Previously Diagnosed DM
- 8. Impaired Glucose Metabolism vs. Normal Glucose Metabolism Impaired Glucose Metabolism vs Previously Diagnosed Diabetes Less depression IGM More depression IGM
- 9. Depression in DM2 Rates of pervasive depression (CES-D > 15) in subjects with type 2 dm only, type 2 dm with co-morbid disease(s) , compared with healthy subjects. n Depression n (%) OR (95% CI) adjusted OR (95% CI) No chronic disease 1184 8.9% 1.0 (-) 1.0 (-) Type 2 dm only 51 7.8% 0.88 (0.3-2.5) 0.94 (0.3-2.7) No chronic disease 1184 8.9% 1.0 (-) 1.0 (-) Type 2 dm & Co-Morb 162 19.8%***2.53 (1.6-3.9) 2.0 (1.1-3.5)¶ Type 2 dm only 51 7.8% 1.0 (-) 1.0 (-) Type 2 dm & Co-Morb 162 19.8%***2.89 (1.0-8.6) 2.52 (0.8-8.5)¶ *** P < 0.001; ¶ adjusted for age, sex, marital status, education, BMI and smoking. Pouwer et al. Diabetologia 2003 46(7):892-8
- 10. Diabetes and incident depression Nouwen A, Winkley K, Twisk J, Lloyd CE, Peyrot M, Ismail K, Pouwer F; European Depression in Diabetes (EDID) Research Consortium. Type 2 diabetes mellitus as a risk factor for the onset of depression: a systematic review and meta-analysis. Diabetologia. 2010;53(12):2480-6. Diabetes type 2: 24% higher risk for developing depression
- 11. Incident and recurrent/persistent depression in people with DM2 in primary care Nefs G, Pouwer F, Denollet J, Pop V (2012). Diabetologia;55(3):608-616. N=2416 people with type 2 diabetes (PoZoB diabetescohort) Three assessments: 2005, 2007, 2008 High depression score on at least 1 assessment: 26% Incident depression: 14% (“new” cases of depression in 2007/2008) 66% of those with a high depression score at baseline had a high depression score in 2007 en/of 2008 (persistent/ recurrent depression). Thus: best predictor of depression in the future was: a history of depression
- 12. Depression in diabetes: underrecognition by physicians and nurses Underdetection and undertreatment in 50-60% of the cases with depression (Penn JV et al 1997, Pouwer et al. 2006) Intensive education of primary care physicians in recognising and treating depression did not improve detection and treatment/outcome of depression (Thompson C et al: Lancet 355: 185-191, 2000). Use of self-report measures (PHQ-9, CESD, WHO5) increases detection rates of depression! Focus on vulnerable patients, e.g. monitor depression in those with a history of depression. Pouwer et al. Diabetes Care, 2001; Pouwer F. Nature Reviews Endocrinology, 2009. Pouwer F et al Diabetologia. 2011;54(4):741-8.
- 13. Depression in diabetes In the 17th century, the Famous English physician Thomas Willis (1621-1675) noted that diabetes often appeared among patients who had experienced significant life stresses, sadness or long sorrow. T. Willis (1674-75) Pharmaceutice rationalis sive diatriba de medicamentorum operationibus in humano corpore. [Oxford] : E Theatro Sheldoniano, M.DC.LXXV.
- 14. Knol M, Twisk J, Beekman A, Heine R, Snoek F, Pouwer F. Depression as a risk factor for the onset of type 2 diabetes mellitus: a meta-analysis. Diabetologia (2006) Depression is a risk factor for type 2 diabetes: Golden, 2004 Arroyo, 2004 Carnethon, 2003 Kawakami, 1999 Eaton, 1996 Everson-Rose, 2004 Palinkas, 2004 Kumari, 2004 Pooled RR: fixed effects model Pooled RR: random effects model Akker vd, 2004 0.5 1.0 2.0 5.0 Relative risk Pooled RR (95% CI) FEM: 1.26 (1.13-1.39) REM: 1.37 (1.14-1.63)
- 15. Estimated probability of survival (all-cause mortality) according to diabetes and depression diagnosis in 1982. Egede et al. Depression and all-cause and coronary heart disease mortality among adults with and without diabetes. Diabetes Care 28:1339-45, 2005
- 16. Systematic review and meta-analysis: All-cause mortality (n=16): HR=1.46 (95% CI 1.29-1.66) Cardiovascular mortality (n=5): HR=1.39 (95% CI 1.11-1.73) Van Dooren FE, Nefs G, Schram MT, Verhey FR, Denollet J, Pouwer F. Depression and risk of mortality in people with diabetes mellitus: a systematic review and meta-analysis. PLoS One. 2013;8(3):e57058.
- 17. Stress and diabetes risk• Longitudinal studies • Chronic stress, sleep problems and anger: risk factor for the development of DM2. • Conflicting results: “childhood neglect”, “life events”, “work stress”. • Fishing? • Publication-bias? • We need prospective registration of publication plans for cohort studies, analogous to trail registries • Research question OK? Methods OK? Paper should be published regardless of the results!
- 18. Treatment of depression in diabetes We know that depression can be treated with anti-depressant medication, and also with CBT (Cognitive Behavioral Therapy) Are new treatments available?
- 20. EPA contents red blood cell membrane 0,0 0,5 1,0 1,5 2,0 2,5 EPA(%) baseline week 12 baseline week 12 EPA placebo
- 21. Depression severity over time 0 5 10 15 20 25 30 35 40 week 0 week 1 week 3 week 5 week 7 week 9 week 12 time MADRSscore EPA placebo In conclusion: EPA fish oil is NOT an effective treatment of depression in diabetes
- 22. Web-based CBT therapy against depression in people with diabetes www.diabetergestemd.nl
- 23. Online CBT against depression in diabetes Randomized controlled trial (n=255 adults with diabetes and elevated depression scores). Internet-CBT was effective Depression-scores decreased (P = 0.04, d = 0.29; clinical improvement 41% vs. 24% P < 0.001). Decrease in diabetes-specific emotional distress (P = 0.03) No effect on HbA1c(P > 0.05). http://www.diabetergestemd.nl/ Van Bastelaar KM, Pouwer F, Cuijpers P, Riper H, Snoek FJ. Web-based depression treatment for type 1 and type 2 diabetic patients: a randomized, controlled trial. Diabetes Care. 2011;34(2):320-325.
- 24. Mindfulness-therapy against stress and depression in people with diabetes Van Son et al, Diabetes Care, 2012
- 25. Stepped care for depression and anxiety in diabetes in primary care is effective
- 26. Conclusions: • Depression is common problem in patients with type 2 diabetes (10-30%) • Depression is a risk factor for DM2 and its complications • Chronic Stress is a risk factor for depression/DM2 • Depression in diabetes can be treated with anti- depressant medication • New effective treatments are available: online CBT, mindfulness-based cognitive therapy, and stepped care Depression and type 2 diabetes
- 27. Thank you for your attention. Any Questions? www.tilburguniversity.nl/corps f.pouwer@uvt.nl Mental health & diabetes Focus on depression and DM2