Diabetes, Depression, and Overwhelm Peggy Odegard, PharmD, CDE (with helpful notes from Paul Ciechanowski, MD!)

You are in clinic today… You just completed a visit with Mr. James, a 72 year old male with type 2 DM. He attended this clinic visit with his wife, Sally, who seems to be a very attentive and helpful. Although his glucose control is not ideal, A1c is now improved from 9.4% to 8.2%. You recommend keeping up the good work and continue meds with metformin 1000 mg BID and glipizide 10 mg daily, in addition to his other 9 meds. He is to return to clinic (RTC) in 3 months…

A call from the front desk… Mr. James asks the front desk clerk at the clinic if he can have just a few more minutes of your time for a quick question. You are paged to the front desk while his wife handles scheduling his next appointment Upon taking Mr. James back to the exam room, he reports to you that he felt funny mentioning something in front of his wife. You invite his concern and he shares with you that he doesn’t feel it is worth it any longer and wonders if it would be easier to just call it quits, perhaps even end it all. He is tearful, expresses their joint overwhelm with the diabetes and all the responsibilities, and indicates he feels it might be easier to leave his wife without him as a burden.

Diabetes, depression, and overwhelm (not to mention anxiety) Pharmacist’s role Assessment, screening, triage The diabetes connection Symptoms and problems Approach to treatment & support

Managing DM in the face of stress Hypothetical situation…You have a therapeutics exam fast approaching on Monday… how will your life be different this week?

Depression Realities It exists – is actually twice as likely to occur in people with diabetes Depression can mimic and amplify DM sx Fatigue Impaired concentration Changes in appetite Changes in sleep Agitation or feeling slowed down Clin Diab 2011;29(2):43-9

Depression Realities Associated with poor self-management & poor adherence adverse lifestyle habits changes in health care utilization Reduced trust and satisfaction Clin Diab 2011;29(2):43-9

Assessment Depression Comorbid anxiety Eating disorder PHQ-9 Geriatric Depression Scale Comorbid anxiety GAD-7 Eating disorder

Treatment Options Cognitive Behavioral Therapy (CBT) Antecedents Behaviors Consequences Different behaviors As effective as antidepressant medication for mild to moderate depression, no physical side effects, helps with stereotypical thinking

Decisional balance and motivation interviewing Benefits (Pros) Costs (Cons) Change (e.g losing weight) No change (e.g not losing weight) acknowledgement: P Ciechanowski, MD, UW

Medication Efficacy Safety – match side effects to patient needs Onset Targeted symptoms Safety – match side effects to patient needs Consider ability to tx comorbid conditions Neuropathy Sleep disturbances Weight management

Medications http://accesspharmacy.mhmedical.com/ViewLarge.aspx?figid=45316430

Case Mrs. B is a 42 year old female who has had diabetes for 12 years. Current labs/vitals: BP 112/74 mmHg, Wt 328 lbs, Ht 5’6”, HR 72, A1c 8.1% (up from 6.2% 6 months ago), LDL 78 mg/dL. Medical problem list: cardiomyopathy (EF 41%), hyperlipidemia, allergic rhinitus, hypothyroidism, asthma. Meds Carvedilol 25 mg tablet twice daily as needed Furosemide 20 mg tablet daily to control peripheral edema As-needed 2 puffs very 4-6 hours, Albuterol inhaler Advair 250/50 inhaled daily Levothyroxine 0.1 mg tablet daily Losartan 25 mg tablet twice daily Orsythia 1 tablet daily Simvastatin 5 mg tablet in the evening NPH 42 units SC BID Novolog 10-15 units before meals (uses prn, has not used in 3 months) Liraglutide 1.8 mg SC daily Metformin 2 gm ER daily

Since last visit 6 months prior Insomnia and some neuropathic pain on walks, precluding exercise Fatigue Decreased concentration at work Increased isolation (hard to do things with her active group of friends) Grazing, admits to eating more carbs Work is stressful Denies depressed mood

The conundrum “I know what I am supposed to do and I what what I am not supposed to do, but I still can’t quite pull it together to get this controlled”

A bit more about Mrs. B Seeks care for help but cancels appointments frequently (9 out of last 10 except for 2 phone questions regarding concerns) Admits to reduced frequency of monitoring (now just a few times weekly) Ran out of metformin 2 weeks ago Concerned about med side effects History of poor adherence