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

2. 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…

3. 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.

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

6. 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?

7. 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

8. 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

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

10. 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

11. 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

12. 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

13. Medications

14. 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 units before meals (uses prn, has not used in 3 months)
Liraglutide 1.8 mg SC daily
Metformin 2 gm ER daily

15. 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

16. 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”

17. 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