Common Diseases Occurring Together Depression and Diabetes; The Link. Dr A. Shoka

Transcription

1 Common Diseases Occurring Together Depression and Diabetes; The Link Dr A. Shoka Consultant Psychiatrist & Lead Clinician NEPFT Honorary Lecturer, Essex University Dr Shoka 1

2 Declaration of interest I have no shares or ongoing business interest with any pharmaceutical company Dr Shoka 2

3 Overview Depression is a complex disorder Spectrum of depressive symptoms Depression is more than psychological symptoms ; somatic symptoms Depression and physical illnesses Depression and diabetes Dr Shoka 3

4 Dr Shoka 4

5 Introduction NICE guidelines define depression as low mood or loss of interest, usually accompanied by one or more of the following: low energy, changes in appetite, weight or sleep pattern, poor concentration, feeling of guilt and worthlessness and suicidal ideas. Major depressive disorder (MDD) is a psychiatric disorder that encompasses a broad range of emotional/psychological, behavioural, and physical symptoms Dr Shoka 5

6 Depressive disorder: An increasing cause of disability worldwide Rank Lower respiratory infections Diarrhoeal diseases Perinatal conditions Unipolar major depression Ischaemic heart disease 2020 (estimated) Ischaemic heart disease Unipolar major depression Road traffic accidents Cerebrovascular disease Chronic obstructive pulmonary disease Dr Shoka 6 Murray CJ, Lopez AD. Science 1996;274:740 3

7 Depression: A SAD FACE (S)(S) A-Appetite S-Sleep A-Anhedonia D-Depressed mood F-Fatigue A-Agitation C-Concentration E-Esteem S-Suicidal S-Somatic symptoms Dr Shoka 7

8 Risk factors Being female (twice the rates for men) Family history Previous depression Chronic physical illness Stressful life events Alcohol or substance abuse Family disadvantage in early life (Oxford Textbook of Psychiatry, 2008) Dr Shoka 8

9 Two questions to pick up depression During the last month have you often been bothered by feeling down, depressed or hopeless? During the last month have you often been bothered by little interest or pleasure in doing things? Dr Shoka 9

10 Asking about suicide Have things got so bad that you don t want to go on? Have you actually thought what you might do? Have you taken any steps to put such a plan in place? How close do you think you are to trying to kill yourself? Dr Shoka 10

11 Psychomotor changes Changes in sleep Aches and pains Changes in appetite Low energy Dr Shoka 11

12 NICE symptom classification for depression Dr Shoka 12 NICE National Institute for Clinical Excellence. Adapted from NICE guidelines, Management of depression, Dec 2004.

13 Depression And Physical Illness In medical illness, up to 50% of patients in USA studies develop clinical symptoms of depressive illnesses compared to a 6% prevalence in the general population. Depressive illness can be diagnosed in 50% of patients with a left hemispheric stroke and 10% of patients with right hemispheric stroke.(j.neyrolo. Neurosurg. Psychiatry 2001: 71: , August) There is an increased incidence of major depression in patients with (type I) DM compared to the general population. ( /4791 ) (K.D Barnard -2006) Dr Shoka 13

14 Depression And Physical Illness Several physical illnesses can cause depressive illness. This is indicated by the greater proportion of patients who become depressed when compared to other physical illnesses of equal severity. An example of this would be multiple sclerosis. For some chronic illnesses, the process of being chronically ill can induce depression. In other disorders, the medication given to treat the illness can cause a depressive mood change. More recently, it has been appreciated that depressive illness can cause physical illness, for example, CVS disease as MI, (Mausselman et al, 1998; Hippisley.Cox et al, 1998) Dr Shoka 14

15 Depression and Diabetes Several studies suggest that diabetes doubles the risk of depression (Anderson et al.,2001) Prevalence rates of co-morbid depressive symptoms in diabetic patients have been reported to range from 9% to 60 % (Maudsley Guidelines, 9 th Edition) The chances of becoming depressed increase as diabetes complications worsen Research shows that depression leads to poorer physical and mental functioning, so a person is less likely to follow a required diet or medication plan Studies suggest that people with diabetes who have a history of depression are more likely to develop diabetic complications than those without depression Causes underlying the association between depression and diabetes are unclear Depression often goes undiagnosed and untreated in people with diabetes Depression was significantly associated with increased risk for the occurrence of neuropathic pain, nephropathy,and macrovascular disease in adults with diabetes (de Groot et al., 2001) Dr Shoka 15

16 Diabetes and SMI In the UK Diabetes 2-5% Schizophrenia with Diabetes 12-20% Bipolar Disorder with Diabetes 20-25% BJP, Vol 184, Suppl.47 Dr Shoka 16

17 Diabetes and psychiatric disorders Patients with Bipolar Affective Disorder are at increased risk of developing type II diabetes as part of the Metabolic Syndrome Anxiety disorders can be also common in people with diabetes Sexual dysfunctions can be caused by both diabetes and depression Dr Shoka 17

18 Depression and comorbidity Depression is associated with increased comorbidity of psychiatric and medical conditions 1 Depression worsens outcome of general medical conditions morbidity/mortality post-myocardial infarction 2 risk of mortality in nursing home patients 3 morbidity post-stroke 4 may worsen outcomes in cancer and HIV 5 1. Chisholm D et al. Br J Psychiatry 2003;183:121 31; 2. Frasure-Smith N et al. JAMA 1993;270: ; Dr Shoka 3. Rovner B et al. JAMA 1991;265:993 6; Pohjasvaara T et al. Eur J Neurol 2001;8:315 9; 5. Petitto JM. Depress Anxiety 1998;8(Suppl 1):80 4.

19 It is understandable from clinical experience that the coexistence of depression with diabetes will make the management and the control of blood sugar levels much more difficult and hence, diabetic complications can become problematic. Dr Shoka 19

20 Somatic Symptoms Of Depression These somatic, or physical symptoms as NICE refers to them, include reduced energy or fatigue, tearfulness, irritability, social withdrawal, reduced sleep, exacerbation of pre-existing pains, pains secondary to increased muscle tension and other pains, decreased appetite and lack of libido. Wide range of painful complaints such as headaches, stomach pain; vague, poorly localized pain; and back pain. Dr Shoka 20

21 What predicts recovery Clinical Factors * Recent onset * Less severe depression * low level of anxiety Social Factors * Current employment * No financial difficulties * High educational level * Reduction in social difficulties or a positive life event (Examination Notes in Psychiatry, Jonathan Bird & Glynn Harrison) Dr Shoka 21

22 Objectives of Treatment Achieve remission ( acute treatment) Prevent relapse ( continuation treatment) Prevent recurrence ( maintenance treatment) Dr Shoka 22

23 Treatment Goals Increase Remission Rates Prevent Relapse Restore Physical Functioning Restore Social Functioning Dr Shoka 23

24 Treatment phases of depression Response 2 ( 50% reduction in HAM-D 17 Remission 3 ( 7 score on HAM-D 17 ) Recovery 1 Recurrence 1 (A new episode) (Remission for significant period of time) Dr Shoka 1.Kupfer DJ. J Clin Psychiatry 1991;52 (5, Suppl): Fawcett J et al J Clin Psych 1997; 58(suppl 6): Ballenger JC. J Clin Psych 1999; 60(suppl 22):29 34.

25 The risk of relapse is significantly higher in patients that respond only partially to therapy compared with those who achieve remission ( 76% versus 25% ) Dr Shoka 25

26 Barriers To Effective Treatment Under-recognized Under-treated Under-recovered Dr Shoka 26

27 Why can outcomes be poor in depression? Under-recognition 1 Under-treatment 1,2 Poor treatment adherence 1 - A total of 50% of patients receiving an initial prescription for an antidepressant stop treatment in the first month 1 - Average drop-out rates are lower in trials of newer antidepressants compared with older agents (primarily tricyclic antidepressants) 1,3 Poor patient education 4 Lack of regular follow-up 1 1. Cassano P, Fava M. J Psychosom Res 2002; 53: Hirschfeld RMA, Keller MB, Panico S, et al. JAMA 1997; 277(4): Mulrow CD, Williams JW Jr, Chiquette E, et al. Am J Med 2000; 108(1): ZajeckaJM. J Clin Psychiatry 2003; 64(Suppl 15):7 12. Dr Shoka 27

28 Factors Affecting The Health Outcome In Patients With Depression A patient with depression may not be identified by the physician. This may be due to various reasons ranging from the stigma attached to depression itself to the misdiagnosis of or lack of identification of depression. Approximately a quarter of depressed patients are under-treated in primary care. The onset of adverse effects in patients taking antidepressants can contribute towards poor compliance. In primary care, about 50% of patients who receive an initial prescription for an antidepressant discontinues treatment within the first month.(cassano P& Fava.M 2002) Lack of regular follow up has also been associated with poor outcomes particularly during the first 3 months of treatment. Dr Shoka 28

29 A proposed model of symptoms mediated by 5-HT & NA* *Hypothetical neurobehavioural model using several data sources based mostly on animal studies 1. Lucki I. Biol Psychiatry 1998; 44: Frazer A. J Clin Psychiatry 2001; 62(Suppl 12): Jones CL. Prog Brain Res 1991; 88: Ressler KJ, Nemeroff CB. Depress Anxiety 2000; 12(Suppl 1): Dr Shoka 29

30 It is clear from the literature that psychological symptoms respond well to treatment. However, physical symptoms may be less responsive to traditional medications Dr Shoka 30

31 Evidence suggests that medications that inhibit the reuptake of both 5-HT and NA may pose superior efficacy in achieving remission and in reducing the severity of pain to those acting upon a single neurotransmitter. Dr Shoka 31

32 Treatment of Depression with Diabetes Scientists report that psychotherapy and antidepressant medications have positive effects on both mood and glycaemic control SSRIs (Fluoxetine & Sertraline) are good choice Avoid TCAs and MAOIs, due to their effects on weight and glucose homeostasis SNRIs do not disrupt glycaemic control and have minimal impact on weight Duloxetine may be effective in diabetic painfulneuropathy and has little influence on glycaemic control All patients with a diagnosis of depression should be screened for diabetes Optimal treatment of depression in diabetes may require comprehensive approach that couples specific depression treatment with efforts to improve glycaemic control (Prescribing Guidelines, 9 th Edition, David Taylor, Carol Paton, Robert Kerwin) Dr Shoka 32

33 Treatment discontinuation rates have been shown to be lower with newer antidepressants such as SSRIS and SNRIs compared with Tricyclic antidepressants. Dr Shoka 33

34 Response to treatment In determining the patient s treatment status, it is important to fully define the following terms: *Remission total resolution of all depressive symptoms for a period of time less than 2 months *Recovery absence of any depressive symptoms for a sustained period of time greater than 2 months *Relapse depressive episode occurring within 5-9 months of initial response to antidepressant therapy *Recurrence depressive episode occurring 12 months or more into recovery Dr Shoka 34

35 Clinically speaking remission is a patient s return to his or her premorbid state of mood and function Dr Shoka 35

36 Importance of continuous reassessment Managing depression into remission requires reassessment of symptoms and the patient s level of functioning throughout the course of treatment Adequate monitoring of a patient s response to treatment and remission status involves a qualitative clinical assessment of patient mood, functioning, and well being, and a quantitative measure of depressive symptoms obtained through use of a standardized depression scale (eg, Zung):Zung Self-rating depression scale, Arch.Gen.Psychiatry,1965:12:63-70 Dr Shoka 36

37 Likelihood of relapse or recurrence The 5- year estimated rates of recurrence among patients with major depression in the short term are: *50% after 1 depressive episode *75% after 2 episodes *90% after 3 episodes Over the long term, additional evidence suggests that patients who have experienced just 1 previous episode of depression can expect a relapse rate of 85% when followed for a 15- year period (Arch.Fam.Med., 1998:7: ) Dr Shoka 37

38 It is becoming more and more important to try preventing relapse by selecting the most appropriate medication at onset Dr Shoka 38

39 It has been shown in some studies that Depression Remission is better with SNRIs than SSRIs ( Harvey McConnell,BJPsych.,2001 & Thase and colleagues) Dr Shoka 39

40 When to refer? Concern about suicide risk Risk to vulnerable others Psychotic and agitated depression Patients who have not responded to two courses of antidepressant medication Patients with bipolar depression Specific psychological treatment Dr Shoka 40

41 Psychological treatments Activity scheduling Self help computer programmes Problem-solving treatments CBT Mindful CBT IPT Dr Shoka 41

42 Summary 1 Consideration should be given to both psychological and somatic symptoms when diagnosing depression 1 Some somatic symptoms may be less responsive to SSRI treatment 2 Depressions consists of both psychological and somatic symptoms Somatic symptoms may interfere with recognition of depression 3 Dr Shoka Tylee A, et al. Int Clin Psychopharmacol 1999; 14: Greco T et al. J Gen Intern Med 2004; 19: Kirmayer LJ et al. J Clin Psychiatry 2001;62 (suppl 13)22-28

43 Summary 2 Depressive illness still represents a major healthcare problem Untreated or poorly treated depression has the potential to negatively impact a patient s overall health and quality of life Once a diagnosis is made, appropriate antidepressant therapy must be initiated promptly and monitored meticulously Dr Shoka 43

44 Take Home Message All patients with a diagnosis of depression should be screened for diabetes In those who are diabetic: 1- Use SSRIs as first-line treatment; most data support fluoxetine and sertraline 2-SNRIs are likely to be safe 3-Avoid TCAs and MAOIS if possible, due to their effects on weight and glucose homestasis 4-Monitor blood glucose carefully when antidepressant treatment is initiated, the dose is changed and after discontinuation (Maudsley prescribing guidelines, 10 th edition) Dr Shoka 44

45 Thank you Dr Shoka 45