Depression, Diabetes and Obesity
This is a case study on a 58-year-old male, Mr. H.Y. who worked at a supermarket and is now retired. He has a supportive wife who works full time and children who are all independent .He has a history of smoking, but quit 10 years ago and drinks alcohol twice a week. He is obese and a known case of diabetes for one year. He has gained 8 kg over the past four months, his blood glucose levels are uncontrolled. He denies feeling sad but doesn’t like to take part in activities he once enjoyed, he feels tired and lethargic after doing any work, his sleep pattern is also disturbed. His drug history reveals that he is taking glyburide and multi-vitamins. He has scored 14 on his PHQ-9 score which indicates moderate depression. The patient has been diagnosed with depressive disorder not otherwise specified (DSM IV 311).
Mr H.Y has type 2 diabetes which is also known as non-insulin dependent diabetes. It is a metabolic disorder in which the beta cells of the pancreas do not produce enough insulin or there is resistance to the action of insulin on the cells of the body. (Kumar, et al., 2010). It affects 8.3% of the U.S. population. (CDC, 2011) . He has not been taking his medications for diabetes regularly. This increases his chances of developing complications of diabetes. He is also obese which is caused by various factors such as environmental, genetic, cultural, dietary habits, socioeconomic status, endocrine abnormalities, sedentary lifestyle, etc. In Mr. H. Y’s case it is most likely due to his sedentary lifestyle, his lack of exercise, and depression. Obesity is prevalent amongst 35.7% of the U.S. population and one-fourth of obese patients are likely to develop depression (CDC, 2011) .Obesity can lead to the development of certain cancers, diabetes, coronary heart disease and may even lead to death.
The social and lifestyle determinants responsible for Mr. H.Y’s condition are most likely him retiring from work at an early age due to his co-morbid conditions, more free time at hand, alcohol consumption, past history of smoking, full-time working wife and a chronic illness (diabetes).
DIAGNOSIS
According to the DSM IV, this patient has been diagnosed with Depressive Disorder Not Otherwise Specified as it does not meet the category of Major Depressive Disorder, Dysthymic Disorder, Adjustment Disorder With Depressed Mood, or Adjustment Disorder With Mixed Anxiety and Depressed Mood. It includes premenstrual dysphoric disorder, minor depressive disorder in which 2 to 5 of the symptoms of major depressive disorder are present for more than two weeks, recurrent brief depressive disorder, depressive disorder due to any underlying medical condition or substance abuse, post-psychotic depressive disorder of schizophrenia. (American Psychiatric Association, 2000)
To be able to be categorized as major depressive disorder, the patient must have more than one episode of at least five of the following symptoms for more than two weeks. These symptoms include feeling of emptiness, sadness, decreased pleasure in activities once enjoyed, significant weight loss or weight gain, disturbance in sleep pattern (insomnia or hypersomnia), fatigue, suicidal thoughts, feeling of guilt for no valid reason and slowing down of neurologic function and inability to concentrate. (American Psychiatric Association, 2000). Mr. H.Y. has denied feeling sad, has no feeling of guilt and does not have suicidal thoughts, but is suffering from all the other symptoms of depression.
Depression occurs in about 1 in 10 adults in the United States and is influenced by biological factors as studies show that there is a high incidence of depression amongst first degree relatives even if they have not been raised together. It is also influenced by environmental facts. Lack of support from family members, stress, financial problems, occupational problems are all situational factors that worsen a depressive disorder. (NANDA nursing, 2012).
TREATMENT
The treatment of diabetes entails tight glycemic control and lifestyle modifications such as exercise and a diet which is low in carbohydrates and high in protein. Pharmacologic treatment is essential in maintaining blood glucose levels. Sulfonylureas are drugs that stimulate the release of insulin from the beta cells of the pancreas. Meglitinides also stimulate their release of insulin from the pancreas, but they are short acting compared to sulfonylureas. Biguanides reduce the production of glucose by the liver and increase utilization of glucose in the peripheries thereby controlling blood glucose levels. Alpha glucosidase inhibitors delay the absorption of glucose and prevent a rise in glucose levels after a meal. Glitazones work by increasing insulin sensitivity of cells. Incretin mimetic agents reduce glucagon and stimulate the release of insulin. If all therapy fails insulin can be added to the diabetes drug regimen. Mr. H.Y should aim to drop his weight by regularly exercising, reducing intake of alcohol, behavioural changes by joining support groups. Diet pills and liposuction or other weight reducing surgeries can help reduce weight . (NANDA nursing, 2012)
Depression is effectively treated with pharmacologic therapy along with cognitive behavioural and interpersonal therapy. There is a wide range of drugs used to treat depression. Selective serotonin reuptake inhibitors such as citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline are the best drugs offered to treat depression. They act by inhibiting the uptake of 5 HT and stimulating 5 HT-1 receptors thus causing antidepressant and anxiolytic effects. They have a good safety profile, are easy to administer and they don’t require a dose adjustment. They may however cause depression, nausea, anxiety and insomnia, sexual dysfunction. Serotonin modulators such as trazodone,, nefazodone, mirtazipine block 5 HT -2 receptors and prevent reuptake of 5 HT and norepinephrine. Nefazodone does not cause sexual dysfunction and produce peaceful sleep without suppression of rapid eye movement sleep, however it may cause liver toxicity. Mirtazapine causes the blockage of 5HT 2 and 3 receptors. It increases the function of serotonin and does not cause nausea and sexual dysfunction. It causes weight gain and sedation. Selective norepinephrine reuptake inhibitors such as duloxetine and venlafaxine have the same action as 5HT and norepinephrine. They have the same toxicity as SSRI’s. They may cause loss of appetite, dizziness, fatigue, weight loss, nausea, sexual dysfunction, urinary retention and elevated blood pressure. Norepinephrine dopamine reuptake inhibitors such as bupropion do not effect on the 5- HT system, rather they effect the catecholaminergic, nonadrenergic and dopaminergic function. They can cause agitation and hypertension. Monoamine oxidase inhibitors act by increasing the availability of norepinephrine, dopamine and other phenylamphetamines. They are used as a last resort when depression is refractory to all other antidepressants and even electroconvulsive therapy. They should never be taken with a tyramine diet or along with other sypathomimetic drugs. Heterocyclic antidepressants act by increasing availability of 5HT and norepinephrine. They are very effective but rarely used due to the overdose toxicity and have more adverse effects than other antidepressants. (Mycek, Harvey & Champe, 2010)
There are also several non-pharmacologic modes of treatment for patients with depressive disorder; out of which psychotherapy is the most studied. The sole role of psychotherapy is beneficial for treatment of patients with mild to moderate depression. However, psychotherapy is often combined with pharmacologic drugs for the treatment of severe depressive disorder. Out of all the forms of psychotherapy, Cognitive Behavioral Therapy, CBT, and Inter-Personal Therapy have yielded the most positive results. (Gelenburg et al., 2010)
Cognitive behavioral therapy is a combination of two techniques, that is, cognitive therapy and behavioral therapy. Cognitive therapy focuses on a person’s thoughts and beliefs, and how they affect a person’s mood and actions. It analyzes a person’s perception of certain situations. The combination of cognitive therapy with behavioral therapy allows a person to change the way they think and to be more adaptive and healthy. It helps patients get rid of unhealthy behavior patterns. (Wood & Wood, 2008)
In CBT, the therapist facilitates the patient in identifying healthy behaviors from those that are harmful. The patient is then allowed to identify ways to change such negative behavior into positive ones. The role of CBT in treating depressive disorder with type 2 diabetes is significant and is associated with improved glycemic control. According to a study, eighty five percent of patients who received CBT achieved remission of moderate depressive disorder after ten weeks of therapy. About seventy percent of patients remained symptom free at the six-month follow-up period. (Williams, Clouse & Lustman, 2006)
Inter-Personal Therapy is another mode of therapy that is useful for the treatment of mild and moderate depression. This mode of therapy focuses on the interpersonal context and on building such skills. This mode of therapy stems from the universal belief that mood disorders are related to three components and should be treated in regards to these components. This model is called the behavioral-psycho-social model. IPT plays a significant role in establishing such a model of care. The major emphasis of this mode of therapy is on interpersonal processes and it aims on changing a person’s interpersonal behavior by helping the patient adapt to current interpersonal roles and situations. (Wood & Wood, 2008)
Electro-Convulsive Therapy, ECT, is a somatic therapy that is a treatment of choice for patients with severe major depressive disorder that is not responsive to other psychotherapies or pharmacological treatments or a combination of both. ECT is of particular benefit in patients who have significant functional impairment or have not responded to various trials of combination treatments. This mode of therapy may also be used for individuals who have major depressive disorder with associated psychotic or catatonic features or in those who require an urgent response, for example, in patients with suicidal tendencies. (Gelenburg et al., 2010) The mode of active of ECT is unknown. In this somatic therapy, seizures are electrically induced in anesthetized patients for a therapeutic effect.
Psychodynamic therapy and problem solving therapies are less common models of help in depressive disorder. Psychodynamic therapy focuses on a person’s subconscious mind and its processes. These processes affect a person’s behavior. The aim of this mode of therapy is to allow the patient to be fully aware of the influences of the past on present behavior. This allows the patient to examine unresolved conflicts and symptoms that arise from past dysfunctional relationships. This mode of therapy may be useful in patients with depressive disorder who have associated alcoholism or other substances of abuse. (Wood & Wood, 2008)
Problem solving therapy is a brief psychological intervention. This mode of therapy has about seven sessions, during which the psychiatrist helps the patient to identify the problems occurring in the patient’s life. After these problems are identified, each one of them is discussed individually. The clinician helps the client with a structured approach to solving each problem. (Wood & Wood, 2008)
Light therapy, also known as phototherapy, is another way of treating Seasonal Affective Disorder. This disorder is a type of depression that occurs at a certain time each year, usually near fall or winter. In this mode of therapy, the patient is asked to sit or work near a device, called a light box which uses artificial light. Light therapy acts by stimulating neurotransmitters in the brain. These transmitters cause an improvement in depressive symptoms. Light therapy may also be used in other types of depressive disorders, sleep disturbances and a few other conditions linked to abnormal transmission of impulses. (Wood & Wood)
There are also studies that regard hypnotherapy as an effective means of treating depression associated with comorbid conditions. Even though such studies have proven yielding results when hypnotherapy was combined with cognitive behavioral therapy, sufficient evidence is still unavailable to base a recommendation. (Gellenburg et al., 2010)
There are several determining factors that affect the frequency and type of psychotherapy sessions. These include: severity of depressive disorder, co-morbid conditions, cooperation on part of the patient, availability of social support systems, frequency of visits necessary to create and maintain a patient-clinician relationship to insure an effective therapeutic model of help through treatment compliance and to monitor progress, address complications and suicide risk. (Gelenburg et al., 2010)
D) RECOMMENDATION FOR TREATMENT
Nurses play a significant role in the treatment of depressive disorders. There are certain guideline recommendations on how to deal with such patients. All health care providers should be empathetic in attitude and conversation. A touch or a nod may help with non-verbal cues that encourage patient comfort. When dealing with patients, a health care provider should not be judgmental and should provide the patient time to express feelings. Words can be provided when the patient hints for it. A soft, low tone voice with clear, concise and easy to understand words should be used while talking to the patient. (NANDA nursing, 2012)
Patients should be asked of their coping mechanisms to overcome such feelings. Nurses should also discuss various coping and problem solving strategies, while being careful not to interrupt the patient. The risk of suicide and self-harm should be identified during the conversation. (NANDA nursing, 2012)
Patients should be told about support groups and should be helped in identifying sources of help, which may be through family members or an existing belief system. Nurses should record drugs used by the patients, along with their dosages, and any side effects that they may be causing. (NANDA nursing, 2012)
Even though the treatment for depression follows professional guidelines, the major dilemma usually arises when deciding when to treat. According to the DSM IV criteria, Mr. H.Y. suffers from Depressive Disorder Not Otherwise Specified (NOS). The reason for this classification could be based on the diagnostic un-surety of it being a primary disorder or due to existing medical conditions.
The reason for this dilemma may be due to certain problems that have been associated with the NOS classification. Unpublished data by Mark Olfson revealed that about 37%-38% of all depressive disorders are classified as NOS. This high prevalence has not been accompanied by specific diagnostic codes or an inclusion threshold for each of the causes described under NOS 311. This low threshold has led to an increased number of individuals with psychiatric diagnosis, causing medicalization of normal distress. For this reason, under the given scenario, some clinicians may prefer non-pharmacological methods and subsequent follow-ups for close observation. (American Psychiatric Association, 2010) A major disadvantage associated with pharmacological therapy is the need for long-term treatment and a higher relapse rate, especially if drugs are discontinued early or not tapered down appropriately. The duration for effective treatment may vary from person to person and is therefore, difficult to determine. (Ellis & Smith, 2002)
This approach may also be justified through a meta-analysis conducted by Ellis and Smith (2002). In this analysis, no significant difference was found between pharmacological treatments vs. psychological therapy for mild to moderate depression. Clinicians may want to try psychological therapy in this case for moderate depression before classifying MR. H.Y. under major depressive disorder. Second and third line treatments may be initiated if adequate response to psychological therapy is not achieved.
Features included under the Depressive Disorder 311 classification may fall into three categories: features that provide significant evidence of depressive disorder, evidence for subsyndromal features, and symptomatic presentation that is either atypical or has special characteristics. Since Mr. H.Y’s presentation has significant evidence to be classified as depressive disorder, both pharmacologic and non-pharmacologic therapy may yield significant results with an improved quality of life.
Most NOS classified patients exhibit a significant degree of dysfunction which if left untreated may lead to negative outcomes, such as suicide. Identifying this group of patients is important because pharmacological treatment needs to be initiated at an early stage to prevent such negative outcomes. These outcomes may also be inevitable for patients with sub-clinical symptoms classified as NOS and therefore, necessitate a detailed history, evaluation and follow-up with appropriate treatment even though they do not meet the diagnostic criteria for established disorders. (American Psychiatric Association, 2010)
Although Cognitive Behavioral Therapy, CBT, and Inter-Personal Therapy, IPT, may be equally effective for the treatment of depression, the experience and effectiveness of such therapy may vary amongst different therapist. This trial and error method may facilitate negative outcomes and therefore needs to be avoided. Pharmacological treatment should be the treatment of choice in such a circumstance. (Ellis & Smith, 2002) Moreover, evidence-based treatment does not support the sole role of CBT and IPT for Major Depressive Disorder, although not the case in this situation.
Treatment plans should always be based on a thorough assessment, duration of a depressive attack, frequency and factors that lead to such episodes. According to a meta-analysis, patients suffering from mild to moderate depression benefit less with a single course of treatment and continuation of therapy is the most important factor of benefit in such patients. In case of pharmacological intervention, treatment should continue for at least one year during the first attack and at least two years for relapse or when associated risk factors are present. (Ellis & Smith, 2002)
Based on this conclusion, the best mode of treatment for MR. H.Y. would be to initiate pharmacologic treatment and to continue it for at least 2 years along with follow ups. The treatment of choice should be an SSRI along with psychotherapy. TCAs are not used in diabetes and are avoided in obese individuals because of existing evidence of worsening glycemic control and its associated with an increased towards weight gain. Bupropion is a drug that can also be used in this patient due its effect on weight reduction. The rationale for using both modes of treatment is due to the un-established diagnosis of a primary disorder. Studies have also shown a benefit of combining pharmacological and psychotherapy in patients with interpersonal and psychosocial problems, as is the case in this scenario. (Gelenburg et al., 2010) This treatment regimen may help MR. H.Y. To adhere to his treatment plan for diabetes and obesity, deflect any negative outcome, and will also help him return to the quality of life that he would enjoy prior to diagnosis.
E) PATIENT / FAMILY TEACHING RECOMMENDATIONS
After establishing a diagnosis, counseling the patient, as well as their family members is an important step. The patient’s consent is required when sharing certain information with family members. The patient should be educated regarding the diagnosis of depressive disorder. This is important because most patients do not realize that they may have a problem. This attitude interferes with compliance of treatment and affects the general outcome of treatment. Patients should also be allowed to make informed decisions regarding treatment. They should be informed of side effects of drugs so that they may contact a physician on time if they experience any adverse reactions.
Patients should be told not to expect drastic changes immediately following treatment. This is important because patients often become impatient and easily discouraged, since an initial response to treatment may take three to six weeks to develop. It is the job of a psychiatrist to encourage and educate patients to differentiate between the hopelessness that occurs as a symptom of depression from the relatively hopeful actual prognosis. Most psychiatrists choose to discuss the predicted outcome and progression of treatment which may be in the following order: initially, side effects may develop, then neuro-vegetative symptoms disappear and finally a significant improvement in mood may develop. (Gelenburg et al., 2010)
Depressive disorders have a significant risk of relapse. Patients and their family members should be educated about the chances of relapse, especially with non-compliance. Patients should be instructed not to stop medications on their own, even if they fail to observe results. Frequent follow-ups may help develop patient motivation. Patients should also be educated to identify early signs and symptoms of depressive disorder and the risk factors that may precipitate it. They should be counseled about ways that may eliminate or reduce the stressors that cause depression. (Gelenburg et al., 2010)
Patient and family counseling also includes promotion of healthy habits, such as good sleep, hygiene, decreased use of stimulants, such as coffee or tea, abstinence from alcohol or tobacco and other modes of substance abuse. Research has shown that exercise holds potential benefit in the treatment of mild-moderate depression. Regular exercise helps improve stress and anxiety as well as improves the quality of sleep. It is also has specific benefits in older adults and individuals with co-morbid conditions. (Gelenburg et al., 2010)
Patients with depressive disorder can be effectively managed at a primary care facility. However, referral to a psychiatric service is indicated if there is a risk of suicide, psychotic symptoms or a history of bipolar affective disorder. Consultation with, or referral to a psychiatrist is also appropriate when the practitioner is in-experienced with such cases or if two or more attempts to treat the patient have already been unsuccessful or have resulted in only a partial response. (NICE clinical guideline, 2009) Psychiatrists may also need to collaborate with the patient’s primary care physician, if the patient is a known diabetic. This is because initiating antidepressant therapy or making changes in treatment regimens or dosages, fluctuations in fasting blood sugar may occur. (Gelenburg et al., 2010)
Mr. H.Y. suffers from moderate depression that is associated with comorbidities, that is diabetes and obesity. He also drinks alcohol. Each condition has a set goal of treatment plan. Recently, Mr. H.Y. has been unable to adhere to his treatment regimens for diabetes and obesity due to the depressive symptoms he experiences. The goal is to treat all three conditions in such a way that neither condition complicates the other.
F) POTENTIAL OUTCOMES
The outlook of Mr. H.Y. is fairly good. Proper counseling of the patient and his family is an essential part of the treatment. Patient compliance can be assured through frequent follow ups. Exercise is a mode of therapy that will help the patient in all three conditions. This regimen will also help Mr. H.Y. form the bond, with his children, which he had previously through basketball.
It may be possible that the first line of treatment may fail causing Mr. H.Y. To lose hope. Support from his physician, family and social groups may help the patient regain motivation. Mr. H.Y. should be told of the new modes of treatment and should be counseled regarding prognosis, which is fairly good. His family should be told of warning signs of his condition and when he should return.
REFERENCES:
American Psychiatric Association. (2000). Depressive disorder coding and diagnostic criteria. Retrieved from http://www.cqaimh.org/pdf/tool_assist_ddcdc.pdf
American Psychiatric Association. (2010, January 2). Recommended changes in ‘depressive disorder not otherwise specified’ (code 311). Retrieved from http://www.dsm5.org/Documents/Mood Disorders Work Group/Subdividing the NOS Depressive Dx.2JAN2010.pdf
CDC. (2011). National diabetes fact sheet, 2011. Retrieved from http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
Ellis, P.M., & Smith, D.A.R. (2002). Treating depression: the beyondblue guidelines for treating depression in primary care. The Medical Journal of Australia, 176(10), 77.
Gelenburg, A.J., Freeman, M.P., Markowitz, J.C., Rossenbaum, J.F., Thase, M.E., & Trivedi, M.H. (2010, May). Practice guidelines for the treatment of patients with major depressive disorder. Retrieved from http://www.psych.org/guidelines/mdd2010
NANDA nursing. (2012). Nursing diagnosis and nursing interventions for depression . Retrieved from http://nanda-nursing.blogspot.com/2011/04/nursing-diagnosis-and-nursing_29.html
NICE clinical guideline. (2009, October). The treatment and management of depression in adults . Retrieved from http://www.nice.org.uk/nicemedia/pdf/CG90NICEguideline.pdf
Williams, M.M., Clouse, R.E., & Lustman, P.J. (2006). Treating depression to prevent diabetes and its complications: Understanding depression as a medical risk factor. American Diabetes Association, 24(2), 79-86.
Wood, J.C., & Wood, M. (2008). A brief look at modern psychotherapy techniques and how they can help. (1st ed.). Oakland: New Harbinger publication.
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