Diabetes & Mental Health in primary care - focus on type 2 diabetes and depression

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