Depression , Diabetes Depression , Diabetes andand

Quality of lifeQuality of life

Prof. Ahmed OkashaM.D., PhD, F.R.C.P., F.R.C., Psych., F.A.C.P (Hon.)

Founder and Director of WHO Collaborating CenterFor Research and Training in Mental Health

Okasha Institute of Psychiatry, Ain Shams University

President Egyptian Psychiatric Association Hon. President Arab Federation of PsychiatristsPresident World Psychiatric Association (2002 – 2005)

What Is Happening in The Middle East?What Is Happening in The Middle East?

EgyptTunis Libya

Bahrain

Yemen Morocco

Syria Jordan

• 60% of Arab World below 30 years

• Tunisia, Egypt, Yemen, Libya, Syria

• Common factors: Despotism, Security torture, Long standining in power, violation of human rights…etc

• No democracy, transparency, accountability.

• Revolutions of dignity to the Arab Citizens

• Democracy, providing physical and mental health are assets to wellbeing and happiness.

• In Egypt, first revolution by intellectual youth using the technology of social networking

Uprise in the Arab WorldUprise in the Arab World

Psychiatric Disorders in the Community

Out of every 100 citizens

30% are suffering from a mental problem that needs attention.

20% will seek traditional healers or general practitioner’s (GPs) help.

10% will be recognized by the GP to be psychiatric cases.

2.3% will be referred to the psychiatrist.0.5% will need inpatient treatment.

Ten leading causes of burden of diseases, world, Ten leading causes of burden of diseases, world, 2004 and 2030 2004 and 2030

2004

Disease or injury

As % of

total

DALYs

Rank Rank As % of

total

DALYs

2030

Disease or injury

Lower respiratory infections

6.2 1 1 6.2 Unipolar depressive disorders

Diarrhoeal diseases 4.8 2 2 5.5 Ischaemic heart disease

Unipolar depressive disorders

4.3 3 3 4.9 Road trafic accidents

Ischaemic heart disease 4.1 4 4 4.3 Cerebrovascular disease

HIV/AIDS 3.8 5 5 3.8 COPD

Cerebrovascular disease 3.1 6 6 3.2 Lower respiratory infections

Prematurity and low birth weight

2.9 7 7 2.9 Hearing loss, adult onset

Birth asphyxia and birth trauma

2.7 8 8 2.7 Refractive errors

Road trafic accidents 2.7 9 9 2.5 HIV/AIDS

Neonatal infections and other

2.7 10 10 2.3 Diabetes mellitus

COPD 2.0 13 11 1.9 Neonatal infections and others

Refractive errors 1.8 14 12 1.9 Prematurity and low birth weight

Hearing loss, adult onset 1.8 15 15 1.9 Birth asphyxia and birth trauma

Diabetes mellitus 1.3 19 18 1.6 Diarrhoeal diseasesCOPD , chronic obstructive pulmonary disease Global burden of disease WHO 2004

Prevalence*There is a range of percentages depending on the study.

39 %

45 %

47 %42 %

33 %36 %

33 %

9 %

6 %

0% 10% 20% 30% 40% 50%

Parkinson's disease

Stroke

Cancer outpatients

Hospitalized

General population

Prevalence of Depressive Prevalence of Depressive Disorders in Different Patient Disorders in Different Patient

Populations*Populations*

MI

Cancer.In-patients

Chronically ill

Geriatric

Two questions: During last month, have you often been

bothered by feeling down, depressed or hopeless? (Pleasure).

During the last month, have you been bothered by having little interest or pleasure in doing things? (Interest)

Diagnosis of DepressionDiagnosis of Depression

DepressionDepression

Main presentation:FatigueLack of concentration.Somatic symptoms (masked depression) e.g.

Headache, Backache, Paraesthesia.Sleep (EMW), appetite, sex, behaviorPsychomotor agitation or retardation.Malancholia.Psychosis: self depreciation, nihilism, guilt

Who gets depressed?Who gets depressed?

Knol MJ. Twisk JWR, Beekman ATF, Heine RJ, Snock FJ, Pouver F. Depression as a risk factor for the onset of type 2

diabetes meillitus. Ameta-analysis Diabetologia 2006:49,837-845

Prevalence of DMPrevalence of DM

World Wide 285 Millions expected in 2030 to be 439 Millions

Egypt 5 Millions 10% young.

Egypt rating among the World is number 10.

Life Time Prevalence of Depression in Diabetic Patients

Life Time Prevalence of Depression in Diabetic Patients

36%

DepressionFemale > Male

18%

Normal populationFemale > Male

Kaplan & Sadock, 2002Kaplan & Sadock, 2002

Face the FactsFace the FactsFace the FactsFace the Facts

The Stress CurveThe Stress Curve

Benefit- Vitality- Enthusiasm- Optimism- Mental alertness- High productivity and creativity

Benefit- Vitality- Enthusiasm- Optimism- Mental alertness- High productivity and creativity

Hazards- Fatigue- Irritability- Lack of concentration- Anxiety- Illness- Low productivity and creativity

Hazards- Fatigue- Irritability- Lack of concentration- Anxiety- Illness- Low productivity and creativity

Causes of Depression in Diabetic Causes of Depression in Diabetic PatientsPatients

Causes of Depression in Diabetic Causes of Depression in Diabetic PatientsPatients

1. Stress, dysregulation of HPA axis, dysregulation of blood glucose.

2. Reaction associated with having a chronic disease (e.g. denial, anger, depression, anxiety, acceptance).

3. Strict dietary regimen.

4. Concern over guilt of inappropriate following of dietary restriction.

1. Stress, dysregulation of HPA axis, dysregulation of blood glucose.

2. Reaction associated with having a chronic disease (e.g. denial, anger, depression, anxiety, acceptance).

3. Strict dietary regimen.

4. Concern over guilt of inappropriate following of dietary restriction.

5. Significant chronic pain secondary to neuropathy.

6. Effect on brain function {e.g. diabetes induces vascular (cerebral ischemia)}.

7. Coincidence (chance association).

8. Side effects or complications from medications.

5. Significant chronic pain secondary to neuropathy.

6. Effect on brain function {e.g. diabetes induces vascular (cerebral ischemia)}.

7. Coincidence (chance association).

8. Side effects or complications from medications.

Cont….

Cognitive Dysfunctions in Diabetic Cognitive Dysfunctions in Diabetic PatientsPatients

Impaired attention

Information processing

Memory (Short)

Problems solving

Language function

Visuo-constructional skills

Significant reduction of IQHolmes, 1990Holmes, 1990

Causes of Cognitive ImpairmentCauses of Cognitive Impairment

Metabolic dyscontrol.

Keto acidosis.

Hyperosmolar states.

Recurrent hypoglycemia.

Chronic hypoglycemia.

High prevalence of CVS.

Depression.

 Stress may produce:anxiety – depression – hostility – unexpressed anger - cynicism – mistrust

Stress, Diabetes and DepressionStress, Diabetes and Depression

1.    Reduction of vagal tone which is protective for the heart2.  Endothelial function is impaired → injured → thrombosis3.  Platelets more hyper-coagulable, more sticky,increases platelet aggregation and adhesion. 4.  Haemoconcentration → increased blood viscosity

Acute stress → Activation of Acute stress → Activation of sympathetic system :sympathetic system :

1.      Platelets2.      Endothelium3.      Vagal tone4.      Activating cortisol system (Lipids – Glucose, Hypertension)5.      Ovarian dysfunction, oestrogen is probably very protective → it raises HDL

Chronic StressChronic Stress

After an episode of major depression, the risk of myocardial infarction increased to fivefold.

Subsyndromal forms of depression had a twofold increased risk of myocardial infarction.

M.IM.I..

6 months after MI:Mortality rate : 17% in patients with depression , 3% without .

12 months after bypass: Those with depression had a higher incidence of subsequent cardiac events, angina , heart failure MI, repeat surgery.

MD is a significant risk factor for the development of coronary artery disease and stroke.

Frasure-Smith et al 1993Connerney 2000 Nemeroff 2001

Aims of TreatmentAims of Treatment

R ed u ce / R em oves ig n s & sym p tom s

R es to rero le fu n c tion

M in im ize risk o fre lap se / recu rren ce

Trea tm en t

Treatment OptionsTreatment Options

Antidepressant medicationPsychotherapyElectro-convulsive therapy (ECT) (Brain synchronization treatment)

Antidepressant Medication ClassesAntidepressant Medication Classes

TCAs

Clomipramine

Imipramine

AmitryptilineMAOIs

Phenelzine

IsocarboxazideRIMA

Moclobemide

SSRIs

Fluoxetine, Sertraline, Escitalopram, Paroxetine, Fluvoxamine

SNRI

Venlafaxine, DuloxetineOthers

Mianserin, Tianeptine, Nefazodone, Trazodone, Mirtazapine, Maprotiline.

Use AD with the least Drug-Drug interaction e.g. Sertraline, Ecitalopram, Mianserin i.e. no induction

Or inhibition of liver enzymes

SSRI Bleeding, hyponitraerina

Drug: Drug InteractionDrug: Drug Interaction

Taking moderate to high daily doses of antidepressants for more than 2 years is associated with an 84% increased risk for diabetes, according to a large observational study.

The increased risk was particularly notable for (SSRI) paroxetine and the tricyclic antidepressant amitriptyline.

Weight gain might explain much of the relation between antidepressant use and diabetes

Andersohn 2009

AntidepressantsAntidepressants

The study found a 4-fold increased risk for diabetes associated with the long-term use of paroxetine in daily doses above 20 mg/day, but not of fluoxetine, citalopram, or sertraline

Depression itself might be some how connected to diabetes and pointed out that there is evidence that patients who treat their depression in ways other than with antidepressants ( for example, with cognitive behavior therapy) are also at high risk of developing diabetes.

Andersohn 2009

SSRISSRI

New research suggest that a combination of type 2 diabetes and smoking may place individuals with serious mental illness (SMI) at even greater risk for death than their counterparts with diabetes who smoke but who do not have SMI.

Norra MacReady 2009

SmokingSmoking

Consequences of Psychiatric Consequences of Psychiatric Morbidity in Diabetic PatientsMorbidity in Diabetic Patients

Poorer glucose control.Increase risk of complications.Affected medication adherence and self

care regimes.Impaired quality of life.Lethal dose of insulin.Poor outcome.High frequency of (smoking, alcohol).

MYTH

Depression is obvious

and easily recognized and expressed by the

patient

MYTH

Depression is obvious

and easily recognized and expressed by the

patient

REALITY

Depression disorders are overlapping, hardly

expressed by the patient and constitute a major problem in symptom

exaggeration

REALITY

Depression disorders are overlapping, hardly

expressed by the patient and constitute a major problem in symptom

exaggeration

MYTH

Depression is Secondary to GMD

activityTreatment of the medical

disorder will relief Depression.

MYTH

Depression is Secondary to GMD

activityTreatment of the medical

disorder will relief Depression.

REALITY

Depression Depression requires treatment intervention and does not remit with relieve

of symptoms

REALITY

Depression Depression requires treatment intervention and does not remit with relieve

of symptoms

What is Mental Health?What is Mental Health?

Mental health is more than the mere lack of mental disorders.

Mental health is a state of well-being whereby individuals recognize their abilities, are able to cope with normal stresses of life, work productively and fruitfully, and make a contribution to their communities

Quality of Life Versus Longevity of LifeQuality of Life Versus Longevity of Life

Quality of life describes an individual’s satisfaction with his or her general sense of wellbeing. It is often measured as physical , psychological and social wellbeing.

Longevity of life at the expense of quality of life is an empty prize.

1. Psychological factors may affect health-related behaviours such as smoking, diet, alcohol consumption, or physical activity, which in turn may influence the risk of CHD and diabetes.

2. Psychosocial factors may cause direct acute or chronic pathophysiological changes, possibly by their effect on neuroendocrine or immune systems.

3. Access to and content of medical care may be influenced by social factors.

Psychosocial FactorsPsychosocial Factors

Psychological traits ( type A behaviour, hostility, workaholic, time urgency)

Psychological states ( depression, anxiety)

Psychological work characteristics ( job control , demands, support)

Social networks and social supports.

Personality and Social NetworksPersonality and Social Networks

Evidence that high levels of social support are protective against CHD and diabetes, while social isolation is related to increased mortality risk.

It has been proposed that social supports may act to buffer the effect of various environmental stereos and hence increase susceptibility to disease.

Alloway 1987

Social SupportSocial Support

Social interaction leads to neurogenesis and proliferation of dendrites in cells of the hippocampus and increased dopamine in the dopaminergic reward pathways.

Lack of social interaction leads to atrophy in cells of the hippocampus, decreased dopamine together with hopelessness and helplessness.

Spitzer, 2002

Social interactionSocial interaction

TemperamentsTemperaments(Genetic(Genetic))

1. Depressive اإلكتئابى المزاج2. Cyclothymic النوابى المزاج3. Irritable العصبى المزاج4. Anxious القلق المزاج5. Hyperthymic النشط المزاج

Akiskal 2003

Characters (Environmental) Characters (Environmental) الذات مصداقية

• Self- directedness: how well is a person, responsible, reliable, goal oriented and self confident.

التعاون • Cooperativeness: how a person is considered

a part of human society. (i.e., tolerant, helpful, compassionate), and self-transcendence.

الذات تجاوز• Self-transcendence: a part of the universe as a

whole.

• Well-being is not enhanced by wealth, power, or fame, despite many people acting as if such accomplishments could bring lasting satisfaction.

• Character development does bring about greater self-awareness and hence greater happiness.

• The most effective methods of intervention all focus on the development of positive emotions and the character traits that underlie well-being.

Well-beingWell-being

“Social Capital" is defined as the ties that bind families, neighborhoods , workplaces, communities, and religious groups together and find that it correlates strongly with subjective wellbeing.

In fact the breadth and depth of individuals' social connections are the best predictors of their happiness.

Money can buy you happiness, but not much. and above a modest threshold, more money does not mean more happiness.

Individuals usually get richer during their lifetimes—but not happier.

As for individuals, so for countries. Ghana, Mexico, Sweden, the United Kingdom , and the United States all share similar life satisfaction scores despite per capita income varying 10-fold between the richest and poorest country.

If money does not buy happiness, what does?

In all 44 countries surveyed in 2002 by the Pew Research center, family life provided the greatest sources of satisfaction.

Married people live on average three years longer and enjoy greater physical and psychological health than the unmarried.

Having a family enhances wellbeing, and spending more time with one's family helps even more.

In fact the breadth and depth of individuals' social connections are the best predictors of their happiness.

Work is central to wellbeing, and certain features correlate highly with happiness. These include autonomy over how, where, and at what pace work is done.

Trust between employer and employee.

Procedural fairness.

The more that governments recognize individual references, the happier their citizens will be.

Free choice, and citizens' belief that they can affect the political process, increase subjective wellbeing.

An association between unhappiness and poor health:

Be happy with what you have got, “look outwards—not to compare yourself unfavorably with others, but to develop your relationship! with them.

It is a surer route to happiness than the pursuit of wealth.

• Embark on a loving relationship with another adult, and work hard to sustain it.

• Plan frequent interactions with friends, family, and neighbours (in that order).

• Make sure you are not working so hard that you have no time left for personal relationships, and leisure.

Get Happy … It Is Good For You Get Happy … It Is Good For You

• In your spare time, join a club, volunteer for community service or take up religion.

• Happiness should become the goal of public policy and the progress of national happiness should be measured and analyzed as closely as the growth of gross national product.

• This means that public policy should be judged by how it increases human happiness and reduces human misery.

Happy LivesHappy Lives

Pleasant life:

• Where you experience a succession of pleasures that lose their effect with repetition.

Good life:

• Where you play your strengths and are engaged.

Meaningful life :

• Where you put your strengths at the services of something higher than yourself.

Positive Steps for Mental Health Positive Steps for Mental Health (WHO)(WHO)

1. Accepting who you are 2. Talking about it 3. Keeping active4. Learning new skills 5. Keeping in touch with friends6. Doing something creative 7. Getting involved 8. Asking for help 9. Relaxing 10.Surviving

ConclusionConclusion

Make Your Choice Make Your Choice

Be successful, competitive, workaholic and die younger. .

OR

Be less ambitious, lower income, more relaxed and live longer. .