Diabetes: One of the Most Prevalent Diseases in the World - Dissertation Example

Diabetes has become one of the most prevalent diseases in the world. Its impact has also been considered significant due to its impact on the quality of life of the diabetic patient. Depression is one of the psychological issues suffered by patients with diabetes, especially as they have difficulties in coping with the changes in the quality of their life, and have to bear the physical impact of the disease. Recent thinking suggests that underlying physiological complications associated with the diabetic condition may contribute to the development of depression. This paper shall seek to establish further the connection between depression and diabetes, detailing the physiological aspects as well as the psychological connections between these two diseases. In principle, the higher risk of type 2 diabetes among depressed patients is suggested to be caused by elevated counter regulatory hormone release and action, including changes in glucose transport functions, as well as elevated immunoinflammatory activation. The biological changes seem to impact on insulin resistance as well as beta islet cell dysfunction, which later causes the development of the diabetes. For patients suffering from major depression, researchers were able to establish an increased accumulation of visceral fat. Based on these findings, treatment for both depression and diabetes covers a multidisciplinary and rich treatment which seeks to combine pharmacological, psychological, as well as combined therapies. These treatments seek to prevent one disease leading to the other or worsening the other, with the end goal of ensuring patient-centered care and improved general patient outcomes. Chapter Three: Management and Treatment of diabetic patients with depression A qualitative study sought to evaluate the various psychosocial tools seen through nine primary care clinics (Gask, et.al., 2006). The analysis indicated that various resources, including motivational interviewing and other therapeutic models may be effective in the management of diabetes and depression. Various interventions are available to health practitioners in the management of depression and some of these remedies have been evaluated in relation to patients with diabetes. 3.1 Negative impact of depression on diabetic patients The impact of depression on diabetic patients has been discussed above. Specifically though, the impact of depression on diabetic patients mostly relates to self-care behavior. Depression often causes an individual to not care anymore about his or her body and of taking the necessary precautions to manage his or her disease. The depressed patient is likely to manifest poor compliance with medications and self-care behavior, including diet and exercise. The motivation to get well is low for depressed patients, thereby affecting his health outcomes and behavior. The management of both diseases for patients is a difficult undertaking and it mostly involves the implementation of combined therapies which would provide pharmacological and therapeutic remedies for the affected patients. 3.2 Management of Depression in Diabetic Patients Integrated management Bogner and colleagues (2012) discussed that applying an integrated management of type 2 diabetes and depression was more likely to produce lower HbA1c levels, 7% lower than levels seen in patients receiving usual care. This group (Bogner et al. 2012) also emphasizes the bidirectional association between depression and diabetes mellitus. This would mean that depression can cause diabetes and vice versa, mostly due to the unmanaged and inadequately managed symptoms of either disease (Ragland, et al. 2010). Various studies also indicate that primary care interventions have been known to improve diabetes and depression health outcomes. These interventions refer to integrated care applied to improve the quality of care, the quality of life, and the efficiency of the system for patients having complex and long-term issues using multiple services and settings (Kodner and Spreeuwenberg, 2002). Bogner and his colleagues (2012) also agree that the treatment of depression and diabetes must also be integrated and founded on the preference and tolerance of patients. The authors discuss how patients’ depression may be caused by the diabetes, hence there is a need to manage the diabetes primarily based on what the patient prefers. The situation may also be reversed where the worsening of the diabetes is caused by depression and poor self-care. In this case, the depression must therefore be managed primarily before any major strides in the patient’s care can be made. An intense intervention for adults having major depression and diabetes was also recommended in the study by Katon et al. (2010) and the assistance of advanced practice nurses helped ensure the efficient implementation of such intensive intervention. In following vein of treatment – specifically, intensive management – various healthcare organizations have sought to establish such specific intensive treatment. One of these organizations is Partners Healthcare, (a not-for-profit health care system committed to patient care, research, teaching, and service to the local community). This organization also set out to evaluate the application of intensive treatment for adults with depression and uncontrolled diabetes. Their assessment process also revealed the importance of having trained therapists for patients. In the course of their application of intensive management, they observed that their patient manifested less depressed symptoms, lower HbA1c levels, and an improved adherence to depression and diabetic treatment. Using an integrated care intervention also proved to be effective for patients in the primary care setting (O’Donoghue, et al. 2005). Integrated care intervention helps provide structure to the complex treatment regimens for depressed diabetic patients, allowing patients to adhere to the treatment and to emphasize on the creation and promotion of clinical policies which seek to improve adherence (O’Donoghue, et al. 2005). Pharmacotherapy Various authors in randomized controlled trials in the treatment of depression and diabetes indicated the use of pharmacological treatment, specifically different kinds of antidepressants. In relation to the kinds of antidepressants, SSRIs seem to be the most common antidepressant used; they have also been generally consistent in managing depression and controlling blood glucose levels (Lustman, 2000). SSRI paroxetine and fluoxetine have been highlighted in various studies, however, their use has covered a limited period of time. This is an issue considering the fact that depression and diabetes may sometimes take months or years to resolve. In effect, longer term treatments seem to be more important in the management of depression among diabetes patients. The use of sertraline therefore seems to be a better choice SSRI for depressed patients with diabetes because of its longer-term use (Lustman, et.al., 2006). Selective serotonin reuptake inhibitors, e.g. Sertraline, have been used in various trials covering and manifested improvements for both depression and diabetes markers (Lustman, et al. 2006). The use of bupropion which is a noradrenaline and dopamine reuptake inhibitor used in the management of depression also presented favorable results, helping ensure short-term blood glucose control, decreasing HbA1c levels, decreasing BMI, and improving self-care (Lustman, et al. 2007). The use of tricyclic antidepressant nortriptyline has also been suggested for the management of depression; however, its use has not presented improvements in glucose control. It has also been known to adversely react to sulfonylureas which are anti-diabetes drugs (Lustman, et al. 1997). The use of monoamine oxidase inhibitors has also been suggested for these patients, helping to decrease glucose levels and depression markers; however, it has also been known to react negatively with sulfonylureas (Lustman, et.al., 2005). For both conditions therefore, various drugs are being suggested, but the recommended treatments mostly include: Sertraline and bupropion which is a noradrenaline and dopamine reuptake inhibitor. Non-pharmacologic treatment Most studies support the use of cognitive behavioral therapy, electroconvulsive or combined therapies. Lustman, et al. (1998) discusses the concurrent use of CBT and diabetes education for 10 weeks among patients with depression and diabetes. Georgiades, et al. (2007) also discussed the use of CBT for 12 weeks with follow-up observations. The studies declared that CBT assisted in improving depression rates and ensuring better glucose control. Results from the Lustman study indicated that patients with poor diabetes control may not have a strong response to CBT. In some cases, ECT has also been applied in the management of depressed diabetic patients (Netzel, et al. 2002). Studies featuring the use of CBT have also presented with promising results, helping to improve both depression and glucose control. In terms of collaborative care, the use of IMPACT, Pathways, and PROSPECT manifested significant reductions in depression and glucose levels. These treatments also show much promise when used as multimodal treatments, including pharmacotherapy for glucose control. These collaborative control mechanisms showed more promise especially when compared with usual care (Simon, et.al., 2007). CBT is founded on the understanding that depression pushes an individual to bring attention only to the negative things happening in one’s life. In effect, an individual may have automatic forms or roads of thinking. This may include an all or nothing thinking where a person thinks in absolutes, alongside words like always, never, and perfect. This type of thinking does not leave grey areas of thought in a person’s life. Another type of thinking would be the ‘shoulds.’ These individuals thinking this way are often strict and they usually set unreachable rules which do not leave room for other probabilities. This person would believe that he should get his blood glucose levels to a certain level or else he would be considered a bad diabetic (Behavioral Diabetes Institute). Others also have a catastrophizing though process where they only expect the bad things to happen, even before they happen. When individuals have any of the above thought processes, they are more likely to end up being depressed because they would feel hopeless, worthless, and helpless about their body and their disease. What CBT would do is to shift the thought process away from the usual directions and towards other more effective and less doom-filled possibilities. As the brighter possibilities are considered by individuals, they would likely feel better about themselves and about their chances for recovery. CBT helps patients oppose negative thoughts and fight against depression. Combined therapy There are different studies on the use of collaborative care for depressed diabetic patients. The IMPACT trial or the Improving Mood-Promoting Access to Collaborative Treatment evaluated a diabetic population, covering a smaller group of patients also suffering from depression (Williams, et al. 2004). Participants were evaluated by clinical specialists for 12 months with an evidence-based algorithm later applied to indicate antidepressant treatment in the primary care setting as well as structured psychotherapy. A stepwise method of management was indicated. Respondents who were able to manage their depression were later entered into a relapse prevention plan. For those not doing well in their initial treatment, a step 2 treatment with antidepressants was applied, later switched to another antidepressant after a certain period. Those not responding well after 10 weeks of step 2 treatment, had to go through additional treatments, psychotherapy, possible ECT, and hospitalization. In general, respondents for the study manifested a reduced severity in their depression; however, no significant changes in glucose control were seen. The Pathways study (Pathways Collaborative Care Intervention) was also applied as a stepped-care approach (Katon, et al. 2004). This Pathways study assigned respondents to either go through the stepped-care approach or usual care. Initial treatment under the Pathways stepped care included antidepressant treatment. Respondents with persistent depressed symptoms went on to step 2, which included psychiatric consult, support for initial therapy and the use of supplemental antidepressants or switching treatments. Step 3 was applied if the step 2 care did not yield improvements in depression levels or where there was failed participation with the client. When compared with usual care, the Pathways stepped care manifested improvements in depression levels with general improvements in diabetes self-care (Ciechanowski, et al. 2006). The use of PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) was evaluated by Bogner, et al. (2007). This is an intervention seeking to reduce suicide ideation among depressed patients. A subgroup analysis seeking to evaluate the impact of collaborative-care intervention on mortality rates for diabetic patients was carried out. Such intervention included the participation of a primary care physician who recognized geriatric depression and suicide ideation as well as the application of the treatment algorithm by specialists, including nurses, social workers, and psychologists. Respondents within the collaborative-care group manifested decreased mortality rates as compared to those subjected to usual care. In effect, the results indicated survival benefits. Assessment and screening of depression One of the most important aspects of managing depression is the diagnosis and screening of the disease. There are numerous undiagnosed cases of depression among diabetic patients. Diagnosing it is important in order to ensure that appropriate measures are in place to manage its symptoms and ensure that the disease would not impact on diabetes management. Effective screening measures are present in order to ensure the recognition of depression in the primary care setting. The Patient Health Questionnaire screening tool is one of the most validated tools for screening. It includes various questions which help determine the presence of the disease and the severity of its symptoms. Where answers to the questions are positive, the patient would likely be depressed and an additional questionnaire would be used in order to detect the severity of the disease and its impact on daily activities. Recognizing depression can be improved if the nurse and other health professionals would interview diabetic patients whose blood glucose levels are not being controlled well. Those who are deemed depressed based on the questionnaire would therefore have to be managed alongside depression interventions. Depression is a treatable disease and the management can be secured within the primary care setting. Its treatment can help reduce symptoms and improve self-care behavior; it can also help improve social relations. Treatment is also based on the extent of depression. Counseling is needed for most patients and medications are essential in cases of major depression. Common antidepressants include SSRIs and SNRIs. Medication options are based on the individual qualities and preferences of patients, including the side-effects and adverse interactions these antidepressants have with antidiabetic medications. Some antidepressants can cause weight gain and worsen glucose control. For patients who gain weight, switching to other antidepressants may be important. Atypical antipsychotics are related with weight gain and decreased metabolic control when compared with SSRIs and SNRs. In effect, the following drugs are not recommended for depressed diabetic patients: clozapine, olanzapine, risperidone, quetiapine, aripiprazole, and ziprasidone. Patients administered with antidepressants call for regular monitoring, mostly on their metabolic indicators (25). Favorable effects observed must outweigh the negative effects. Psychiatrists may also have to be consulted in order to ensure appropriate recommendations on treatment. Primary care clinicians are engaged on maintenance and in monitoring on the impact of medication. As was already mentioned above, depression is associated with poor self-care and poor adherence to treatment. Counseling techniques must therefore focus on assisting patients in self-management and in adhering to their medication intake. The counseling must be carried out by the primary care clinicians because this clinician has the most contact with the patient and is the most accessible to the patient. Referrals to other health professionals would be needed if the primary care clinician would be unable to improve the patient’s adherence to the treatment. CBT remains to be the best treatment for these patients as this therapy helps patients resolve their negative and unrealistic thoughts. 3.3 Conclusion Based on the above discussion diabetes is a metabolic disease which is marked by problems with the insulin causing inadequate glucose control and management. As a result, it causes high levels of glucose in the blood. Depression on the other hand is a mental health disorder marked by low mood, as well as feelings of worthlessness, helplessness, and hopelessness. Depression Visceral fat deposits were quantified based on computed tomography and even as body mass index was not different for these groups, the visceral fat deposits were higher in depressed patients compared to other subjects. Basal cortisol concentrations were also higher for depressed patients as compared to the non-depressed clients (Schlaepfer and Nemeroff, 2012). Studies on co-morbid depressed patients reveal decreased insulin sensitivity associated with a high level of visceral fat. With higher intra-abdominal fat deposits in depressed patients the risk of depression and diabetes has been higher. With higher levels of cortisol, often seen among the obese patients, impaired sensitivity is also observed. When present in a diabetic patient it affects self-care and medication adherence, often leading to poor diabetic health outcomes. Managing these diseases is important in order to ensure improved health outcomes and reduce mortality rates. Collaborative therapies using CBT and SSRIs seem to be the most effective interventions for these patients as the CBT can reduce the patient’s depression and improve self-care, and the SSRIs do not react unfavorably to the antidiabetic medications. It is also important for clinicians to focus on patient preferences as well as interventions which can be sought in the primary care setting. In cases where inadequate management is observed in the primary care setting, referral to psychiatrists may be essential. Read More