Interpersonal Psychotherapy and Interpersonal Psychotherapy and Antidepressants in Major Depression Antidepressants in Major Depression

in Type 2 Diabetes Patientsin Type 2 Diabetes Patients

International Society for Interpersonal Psychotherapy

4th International ConferenceAmsterdam,2011

Gois C*, Duarte R**, Carmo I***, Barbosa A*Gois C*, Duarte R**, Carmo I***, Barbosa A*

*Psychiatry Department, Hospital de Santa Maria, Lisbon*Psychiatry Department, Hospital de Santa Maria, Lisbon

**Portuguese Diabetes Association, Lisbon**Portuguese Diabetes Association, Lisbon

***Endocrinology, Diabetes and Metabolism Department, ***Endocrinology, Diabetes and Metabolism Department, Hospital de Santa Maria, LisbonHospital de Santa Maria, Lisbon

Background

Type 2 diabetes (90%)

adult metabolic disease

lack or dysfunctional insulin (resistance)

life style association (obesity)

treatment: oral hypoglycemic/insulin,

diet, exercise, self management

Type 1 diabetes

young metabolic disease

lack of insulin (B cell pancreatic autoimune failure)

treatment: insulin, diet, exercise, self management

Type 2 Diabetes Mellitus: prevalence 12,9% Cowie et al, 2009

Background

Depression and Diabetes MellitusTwo pandemic morbidities

WHO predictions

2020 depression from 4th to 2nd main cause of disability

2030 diabetes doubles to 366 millions persons worldwide

Depression prevalence in chronic somatic diseases

Somatic Somatic DiseaseDisease

Major Major DepressionDepression

CancerCancer 1,5 – 50%1,5 – 50%

Post strokePost stroke 9 – 31%9 – 31%

ParkinsonParkinson 20 – 30%20 – 30%

Multiple sclerosisMultiple sclerosis 16 – 30%16 – 30%

Coronary DiseaseCoronary Disease 15 – 23%15 – 23%

Diabetes Diabetes MellitusMellitus

11 – 15%11 – 15%

HIVHIV 4 – 23%4 – 23%Raison et al, 2005

Background

Ramalheira, 1996; DSM IV-TR, 2000; Anderson, 2001; Jacobson, 2002; Nichols, 2003; Gusmão, 2005

GeneralGeneralPopulatioPopulatio

nn

Type 1 Type 1 Diabetes Diabetes

Type 2Type 2Diabetes Diabetes

MajorMajorDepressioDepressio

nn

3 – 9%3 – 9% 13 - 29%13 - 29% 11 - 33%11 - 33%

Prevalence

Background

2 – 3 times more Depression with Diabetes

Background

Depression Diabetes

Behavioral: ↓ self-care

Biologic: hormonal, glucose disfunction, neuroinflammation

may affect

Major Depression in DiabetesMajor Depression in Diabetes

↓↓ HHealthier behaviors: treatment adherence, smoking ealthier behaviors: treatment adherence, smoking

↑ ↑ Wasting with health, Wasting with health, ↑↑ Inpatient Inpatient admittancesadmittances

↑↑ Morbidity - chronic complications (severity and Morbidity - chronic complications (severity and

number)number)

↑↑ Mortality - Cardio Vascular DiseasesMortality - Cardio Vascular Diseases

DM + DEP = 2,4 DM + DEP = 2,4 x x Only DEP = 1,3 Only DEP = 1,3 x x Only DM = 2,3 xOnly DM = 2,3 x

Egede et al, 2005

Background

Comorbity depression and diabetes: worse decrements in health

Moussavi et al, 2007

Background

Explains 3% of HbA1c variance (more in type 1 diabetes) Explains 3% of HbA1c variance (more in type 1 diabetes) Depression treatment: Depression treatment: ↑↑41 to 58% persons with a good 41 to 58% persons with a good

controlcontrol

< 1% redution in HbA1c < 1% redution in HbA1c →→ 33% decrease of retinophaty 33% decrease of retinophaty (DCCT)(DCCT)

Lustman et al, 2000

Background

Depression and metabolic control in diabetes

Hamem, 2005; Kendler, 1999;Ludman et al, 2004

Background

2 – 3 times more Depression with Diabetes,

WHY?

illness intrusivenness

inflamation↑cortisol

attachmentsocial support

Background

Type 2 Diabetes

Attachment

Dismissing attachment ↓ Self-care

Ciechanowski et al, 2004

↓ depressive symptoms Others more reliable (↓ avoidance)Self more worthy of attention (↓ anxiety)

Ciechanowski et al, 2005

Background

Major Depression

Attachment

Murphy & Bates, 1996

Negative view of self independently of view of other

Self-criticism

Anxiety/preoccupation and fearfull attachment

Positive association with depression

Dismissing attachment

Secure attachment

No association with depression

Negative association with depression

Depression treatment (≈ non diabetes)

11 RCTs, Petrak & Herpetz, 2009

Type 1 & 2 diabetes Depression Metabolic control

Psychological (3, n=140)

yes yes (except 1)

Pharmacological (4, n=289)

yes (except 1) no

Mixed (4, n=954) Yes (except 1) no (excepto 1)

11 RCTs e 3 Collaborative care, Katon & van der Feltz-Cornelis, 2010

Type 1 & 2 diabetes Depression (ef size)

Metabolic control (ef size)

Psychological (5, n=310)

moderate-large moderate-large

Pharmacological (6, n=215)

moderate small

Collaborative care (3) moderate-large no effect

Cognitive – behavior therapy vs control

Solution focused therapy vs usual

DM2, ↓ dep, ↓ HbA1c follow-up

DM2, ↓ dep, HbA1c ns

Background

Psychotherapy for Major Depression in Type 2 Diabetes

Citalopram vs Interpersonal Psychotherapy T vs usual

Katon et al, 2004; Bogner et al, 2007;Lustman et al,1998

Age 60 – 80 yrs, follow-up 5 yrs, ↓ mortality

Lustman et al, 1997,2000,2006,2007; Paile-Hyvarinen et al, 2003; Amsterdam et al, 2006;Goodnick et al, 1997

Acute Dep

Recor Dep

Dep HbA1c

nortriptiline yes no ↓ ↑

fluoxetine yes no ↓ ns; ↓

paroxetine yes no ↓ ns

escitalopram

yes no ↓ ns

sertraline yes yes ↓ ↓

bupropion yes yes ↓ ↓

Antidepressants for Major Depression in Type 2 Diabetes

Background

Background

IPT Theory: attachment communication theory social theory

IPT ObjectivesIPT Objectives:

↑ relationships

IP Communication

Problem solutions

Acute Major

DepressionAdapt Stuart S, 2008

Acute Depression and Interpersonal Psychotherapy

1st RCT: IPT+Amitriptiline > IPT = Amitriptiline Weissman et al, 1979

RCT: NIMH – TDCRP (Efficacy Evidence) IPT=CBT=Imipramine Elkin et al,1989

13 RCTs: Meta analisys Remission: IPT=Antidepressant=IPT+AntidepressantSymptom reduction: IPT > CBT

de Mello et al, 2005

Decrease in Symptoms, IP Problems and Attachment(anxiety and avoidance): IPT = IPT + Antidepressants

Outcome: symptoms

Outcome: symptoms + attachment + IP problems

Ravitz et al, 2008

Acute Depression in Somatic Patients and Interpersonal Psychotherapy

Outcome: symptoms

RCT: HIV patients IPT = Imipramine > CBT Markowitz et al, 1998

RCT: Coronary Artery PatientsCitalopram > IPT = Clinical Management

Lespérance F et al, 2007

Questions

1st outcome eficiency of treatment of major

depression

in type 2 diabetes patients with

IPT or sertraline or combo

and detect diferences between /within them

2nd outcomes detecting changes in attachment,

diabetes adaptation, diabetes self

efficacy and metabolic control after

treatment by the three treatment groups

and differences between them

Exclusion Criteria

<18>65 years

acute suicidality

antidepressant therapy

other somatic chronic condition

other mental disorder

alcohol or others drugs abuse/dependence

illiteracy, visual handicap

T2Diab

RandomiZaTion

1,5 month 3 month 4 month 5 month 6 month0 month

HADSMADRSMINIInterviiew

MADRSAttachmentDiabetes adjustmentDiabetesSelf EfficacyHbA1c

IPT

USUAL

MADRS MADRS MADRS

MDECOMBO

MADRSAttachmentDiabetes adjustmentDiabetesSelf EfficacyHbA1c

MADRSAttachmentDiabetes adjustmentDiabetesSelf Efficacy

Clinical - Experimental Study

Methodology

Consecutive screening of type 2 diabetes patients in two outpatient clinics (self-rated) HADS

Hetero-evaluation: MDDExclusion criteria revised

MADRSMINI

Clinical evaluation, IP inventoryITP Area Problem, Other instruments

Informed consent

EVAATT

DSESHbA1c

IPT3 months

weekly sessions

SSRI - Sertraline (usual)Dose: 50-150mg

3 monthsfortnightly consultation

Randomization

MethodologyCombo procedure

week 6th MADRS

IPTtill 3 months

weekly

Sertraline (usual)till 3 monthsfortnightly

≤ 25% initial no 25% reduction

IPT + Sertralinetill 3 months

fortnightly

Sertraline + ITPtill 3 months

weekly

more 3 months follow-up monthly

IPTweekly

Sertraline (usual)fortnightly

Randomization

raters don´t treat patients, are blind to treatment type and inter-rater attuned

Methodology

MADRS regular evaluations

Data concerning COMBO intervention include baseline data (before COMBO formal beginning ) as a third treatment

group

Same care provider for all patients

Some instruments description

ATT 18

EVA

Methodology

Diabetes adaptation, Core Diabetes Integration ConceptPortuguese short version of ATT39 (Dunn et al, 1986)high values – better adaptation, correlates with HbA1c

Portuguese version Adult Attachment Scale – R (Collins & Read, 1990)3 attachment dimensions: Close, Anxiety and DependClose/Secure; Anxiety/Insecure; Depend/↓Avoidant (confidante)

DSESPortuguese version of Diabetes Self-Efficacy Scale (Crabtree 1986)2 dimensions: diet and exercise

Results

Global sample = 34

Age 55.17 ± 5.9 yrs

Education 6.85 ± 3.07 yrs

♀ 30 (88.2%)

≥ 2 chronic complications 14 (41.2%)

Insulin users 18 (52.9%)

Diabetes duration 12.55 ± 5.75 yrs

HADS dep 10.44 ± 2.87

HADS anx 13.14 ± 4.05

MADRS 24.32 ± 5.27

HbA1c 9.05 ± 2.13

Results

TIP=17 USUAL=17

No differences between patients at baseline:

age, gender, diabetes duration, ≥2 chronic complications, insulin users, diabetes adaptation, depression, anxiety,attachment, sub-scales,diabetes ,self-efficacy, HbA1c

Treatment sub-groups:

TIP – 10 USUAL – 12

COMBO - 8 (Usual – 3 IPT – 5)

Drop-outs: USUAL – 3 Combo IPT - 1

Results

(COMBO data analyzed altogether)

No differences between patients at baseline:

Except COMBO: < HADS depression < secure attachment

Results

TIP - USUAL

Total patients Area Problem

Problem IP Area Number %

Mourning 6 4,3

IP conflicts 18 28,3

Role Transition(3 DM) adaptation

10 10,9

MADRS

**

* ***

**

Adjustment to diabetes

*

Preoccupied Attachment

*P<0.05**P<0.01***P<0.001

* *

Secure Attachment

*P<0.05**P<0.01***P<0.001

Trusting others (reversed dismissing attachment)

*P<0.05**P<0.01***P<0.001

Diabetes Self-efficacy DIET

*P<0.05**P<0.01***P<0.001

Diabetes Self-efficacy EXERCISE

*P<0.05**P<0.01***P<0.001

*

Glicohemoglobin A1c

*P<0.05**P<0.01***P<0.001

IPT n=10 USUAL n=12 COMBO n=8

MADRS 0-4 m 0.011 0.003 0.028

MADRS 0-6 m 0.021 0.005

ATT 0-4 m (1)

ATT 0-6 m 0.025

Preoc attach 0-4 m (1)

Preoc attach 0-6 m 0.019 0.044

Secure attach 0-4 m

0.027

Secure attach 0-6 m

0.042

Trust others 0-4 m

Trust others 0-6 m

S Effic diet 0-4 m (1) 0.018

S Effic diet 0-6 m (1) 0.018

S Effic exercise 0-4 m

(1) (1) 0.012 (KW*)

S Effic exercise 0-6 m

0.005

HbA1c 0-6 m (1) 0.045

(1) Wilcoxon signed ranks test. KW*= Kruskall Wallis test; p<=0.05 Results: only P significant.

Significant differences between/within groups

Conclusions

Preliminary results, small sample

Both IPT and USUAL reduce MADRS score

Both COMBO and IPT better decrease insecure attachment

COMBO better increase secure attachment

COMBO was not related to depression and metabolic outcome

IPT was not related with metabolic control

USUAL better with diabetes adaptation, self-efficacy and metabolic control