1. Diabetes and Mental Health Chapter 18 David J. Robinson, Meera Luthra, Michael Vallis Canadian Diabetes Association 2013 Clinical Practice Guidelines

2. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

3. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 1.Psychiatric disorders, particularly depression, anxiety and eating disorders, are prevalent in diabetes 2.Mental illness increases risk of diabetes and diabetic complications 3.Patients taking psychiatric medications need metabolic screening 4.Screening for depression and anxiety is important in patients with diabetes 2013 Key Points

4. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 1. Psychiatric disorders, particularly depression, anxiety and eating disorders, are prevalent in diabetes

5. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2. Mental illness increases risk of diabetes and diabetic complications Non-adherence to medication and self-care Functional impairment Risk of complications Healthcare costs Risk of early mortality Mental Illness Diabetes Depression increases risk of DM by 60%!

6. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Psychoactive Medications May Predispose to Diabetes Especially second-generation antipsychotics (olanzapine, clozapine, risperidone, quetiapine, aripiprazole, ziprasidone) Biochemical and lifestyle factors may also contribute Co-morbid mental illness can worsen diabetes control

7. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 3. Patients taking high-risk psychiatric medications need metabolic screening ParameterBase- line 1 mo2 mos3 mosEvery 3-6 mos Annually Weight (BMI)XXXXX Waist circumferenceXXX Blood pressureXXX Fasting glucose and/or A1C XXX Fasting lipidsXXX Personal history of alcohol, tobacco, recreational drugs XXX Family historyXX

8. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Depressive symptoms in 30% of patients with diabetes Major depressive disorder in 10% Co-morbid depression worsens clinical outcomes in DM – Lower physical fitness? – Poor medication adherence?

9. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diabetes Distress Despondency and emotional turmoil related to diabetes, the need for monitoring and treatment, preoccupation with complications, and loss of relationships Related to poorer outcomes

10. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Websites with psychological / psychiatric scales: www.phqscreeners.com www.outcometracker.org/scales_library.phpwww.outcometracker.org/scales_library.php. 4. Screening for depression and anxiety is important in patients with diabetes PurposeTools Diabetes-specificProblem Areas in Diabetes (PAID) Scale Diabetes Distress Scale (DDS) Quality of LifeWHO-5 Depression/AnxietyHospital Anxiety and Depression Scale (HADS) Patient Health Questionnaire (PHQ-9) Beck Depression Inventory (BDI)

11. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Treatment Cognitive-behavioural therapy Other psychotherapy Antidepressant medication

12. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Other Psychiatric Associations Bipolar disorder Anxiety Eating disorders Schizophrenia and other psychotic disorders

13. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 1 1.Individuals with diabetes should be regularly screened for subclinical psychological distress and psychiatric disorders (eg. Depressive and anxiety disorders) by interview [Grade D, Consensus] or with a standardized questionnaire [Grade B, Level 2]

14. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 2 2.Psychosocial interventions should be integrated into diabetes care plans [Grade B, Level 2], including – Motivational interventions [Grade B, Level 2] – Stress management strategies [Grade B, Level 2] – Coping skills training [Grade A, Level 1A for type 2 diabetes; Grade B, Level 2, for type 1 diabetes] – Family therapy [Grade A, Level 1B] – Case management [Grade B, Level 2] 2013

15. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 3 3.Antidepressant medication should be used to treat acute depression [Grade A, Level 1A] and for maintenance/prophylactic treatment of depression [Grade A, Level 1A]. Cognitive-behaviour therapy (CBT) alone [Grade B, Level 2] or in combination with antidepressant medication [Grade A, Level 2] may be used to treat people with depression in diabetes.

16. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 4 4.Antipsychotic medications (especially atypical/second generation) can cause adverse metabolic changes [Grade A, Level 1]. Regular metabolic monitoring is recommended for patients with and without diabetes who are treated with such medications [Grade D, Consensus] 2013

17. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association CDA Clinical Practice Guidelines http://guidelines.diabetes.cahttp://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca http://diabetes.ca – for patients