Diabetes and

DepressionSteven Graybar, Ph.D.

Project ECHO

Reno, Nevada

Diabetes and

“Prolonged Sorrow”

• Depression occurs approximately 10% in general

population, 25% among our patients with DM

• The relationship between MDD and DM is bi-directional

• When MDD and DM co-occur they tend to worsen the

other

• Patients with MDD have 37% likelihood of developing DM

• MDD tends to: occur more often, be more severe and last

longer in our DM patients

Depression and

Diabetes

Co-Occurring MDD and Diabetes:

Decreased adherence

Poor metabolic control

Higher rates of complications

Decreased quality of life and Increased disability

Lost productivity and Increased health care utilization

Increased mortality

Chronic Disease v.

Chronic Illness

• Chronic Disease- is an objective process, a disease entity with an identifiable organic pathophysiology

• Chronic Illness- is a subjective process and concerns the unique and individual impact of a disease on the person and in his/her life

• It is the social, emotional intellectual, interpersonal and spiritual experience and expression of living with a chronic disease.

• Anger, anxiety, depression, shame, equanimity, etc.

• Adherence, complications, love and fear…… live

All Roads Lead to

Freud

• The ego is a body ego first- disease and disability is a

betrayal of the individual by his/her body

• Depression is about Real and Symbolic loss

• Loss of Invulnerability

• Loss of World as a Just and Meaningful Place

• Loss of Self Esteem

• Hyperglycemia, MDD and Habituation

The Big Three, plus

one

• Best long-term outcomes in serious, chronic and

terminal illness (including DM and MDD)

• Agency

• Communion

• Meaning

• Ping Pong Ball in the Shot Glass….

Identifying

Depression

• Change in sleep and appetite

• Problems with attention/concentration (memory)

• Loss of energy, stamina, motivation

• Lack of pleasure/enjoyment (activities, sex, people)

• Anxiety, Guilt, Suicidal Ideation

• Women?

• Men?

Treatment

• Anti-depressants weight gain 25% of patients

• Effexor, Serzone and Welbutrin (less so)

• 50-60% of patients experience sexual side effects

• 40% initial side effects

• 25% troubling enough to d/c

• Wt gain, sexual problems (desire, ED, Org), insomnia,

nausea, constipation, dry mouth and drowsiness

Psychotherapy

• Clinician must have working knowledge of C.I. i.e

differences between Type I and II

• Understanding and appreciation of treatment regimen

• Appreciation of Stigma, loss, shame and

embarrassment

• Function as an “enlightened witness” to the multi-

layered losses involved with disease and illness

Psychotherapies v.

psychotherapist

• CBT, IPT, Supportive and Psychodynamic approaches

have all shown treatment efficacy in relation to MDD

and co-occurring MDD and DM

• 40% non-specific factors

• 30% Therapeutic relationship

• 15% expectancy/placebo

• 15% specific treatment techniques

Making a referral

• Know the clinician or clinic you are referring to

• Discuss/describe psychotherapy (trained, obj, listener)

• “I have referred other patients who had positive

outcomes.”

• Write a script on your pad for psychotherapy

• Ask patient to call therapist or clinic from your office

Patient fears about

psychotherapy

• Crazy-worry about my patients who aren’t not who are

• Dependent-strong enough to change, leave, accept

• Weak-courage is never weak

• Confidentiality-HIPPA and consent

• It won’t work-no guarantees but…. 80%

Provider fears and

psychotherapy

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