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Depression, Diabetes and Quality of life Prof. Ahmed Okasha M.D., PhD, F.R.C.P., F.R.C., Psych., F.A.C.P (Hon.) Founder and Director of WHO Collaborating.

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Presentation on theme: "Depression, Diabetes and Quality of life Prof. Ahmed Okasha M.D., PhD, F.R.C.P., F.R.C., Psych., F.A.C.P (Hon.) Founder and Director of WHO Collaborating."— Presentation transcript:

1 Depression, Diabetes and Quality of life Prof. Ahmed Okasha M.D., PhD, F.R.C.P., F.R.C., Psych., F.A.C.P (Hon.) Founder and Director of WHO Collaborating Center For Research and Training in Mental Health Okasha Institute of Psychiatry, Ain Shams University President Egyptian Psychiatric Association Hon. President Arab Federation of Psychiatrists President World Psychiatric Association (2002 – 2005)

2 What Is Happening in The Middle East? Egypt Tunis Libya Bahrain Yemen Morocco Syria Jordan

3 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 World

4 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.

5 Ten leading causes of burden of diseases, world, 2004 and Disease or injury As % of total DALYs Rank As % of total DALYs 2004 Disease or injury Unipolar depressive disorders Lower respiratory infections Ischaemic heart disease Diarrhoeal diseases Road trafic accidents Unipolar depressive disorders Cerebrovascular disease Ischaemic heart disease COPD HIV/AIDS Lower respiratory infections Cerebrovascular disease Hearing loss, adult onset Prematurity and low birth weight Refractive errors Birth asphyxia and birth trauma HIV/AIDS Road trafic accidents Diabetes mellitus Neonatal infections and other Neonatal infections and others COPD Prematurity and low birth weight Refractive errors Birth asphyxia and birth trauma Hearing loss, adult onset Diarrhoeal diseases Diabetes mellitus COPD, chronic obstructive pulmonary disease Global burden of disease WHO 2004

6 Prevalence *There is a range of percentages depending on the study. Prevalence of Depressive Disorders in Different Patient Populations* MI Cancer.In-patients Chronically ill Geriatric

7 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 Depression

8 Depression Main presentation: Fatigue Lack of concentration. Somatic symptoms (masked depression) e.g. Headache, Backache, Paraesthesia. Sleep (EMW), appetite, sex, behavior Psychomotor agitation or retardation. Malancholia. Psychosis: self depreciation, nihilism, guilt

9 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,

10 Prevalence 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.

11 Life Time Prevalence of Depression in Diabetic Patients 36% Depression Female > Male 18% Normal population Female > Male Kaplan & Sadock, 2002 Face the Facts

12 The 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

13 Causes of Depression in Diabetic Patients 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.

14 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….

15 Cognitive Dysfunctions in Diabetic Patients Impaired attention Information processing Memory (Short) Problems solving Language function Visuo-constructional skills Significant reduction of IQ Holmes, 1990

16 Causes of Cognitive Impairment Metabolic dyscontrol. Keto acidosis. Hyperosmolar states. Recurrent hypoglycemia. Chronic hypoglycemia. High prevalence of CVS. Depression.

17 Stress may produce: anxiety – depression – hostility – unexpressed anger - cynicism – mistrust Stress, Diabetes and Depression

18 1. Reduction of vagal tone which is protective for the heart 2. Endothelial function is impaired → injured → thrombosis 3. Platelets more hyper-coagulable, more sticky,increases platelet aggregation and adhesion. 4. Haemoconcentration → increased blood viscosity Acute stress → Activation of sympathetic system :

19 1. Platelets 2. Endothelium 3. Vagal tone 4. Activating cortisol system (Lipids – Glucose, Hypertension) 5. Ovarian dysfunction, oestrogen is probably very protective → it raises HDL Chronic Stress

20 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.I.

21 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 1993 Connerney 2000 Nemeroff 2001

22 Aims of Treatment

23 Treatment Options Antidepressant medication Psychotherapy Electro-convulsive therapy (ECT) (Brain synchronization treatment)

24 Antidepressant Medication Classes TCAs Clomipramine Imipramine Amitryptiline MAOIs Phenelzine Isocarboxazide RIMA Moclobemide SSRIs Fluoxetine, Sertraline, Escitalopram, Paroxetine, Fluvoxamine SNRI Venlafaxine, Duloxetine Others Mianserin, Tianeptine, Nefazodone, Trazodone, Mirtazapine, Maprotiline.

25 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 Interaction

26 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 2009Antidepressants

27 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 SSRI

28 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 Smoking

29 Consequences of Psychiatric Morbidity 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).

30 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

31 MYTH  Depression is Secondary to GMD activity Treatment of the medical disorder will relief Depression. MYTH  Depression is Secondary to GMD activity Treatment 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

32 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

33 Quality 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.

34 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 Factors

35 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 Networks

36 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 Support

37 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 interaction

38 Temperaments (Genetic ) 1.Depressiveالمزاج الإكتئابى 2.Cyclothymicالمزاج النوابى 3.Irritable المزاج العصبى 4.Anxious المزاج القلق 5.Hyperthymic المزاج النشط Akiskal 2003

39 Characters (Environmental) مصداقية الذات 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. تجاوز الذات Self-transcendence: a part of the universe as a whole.

40 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-being

41 “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.

42 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.

43 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.

44 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.

45 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.

46 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.

47 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

48 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.

49 Happy 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.

50 Positive Steps for Mental Health (WHO) 1.Accepting who you are 2.Talking about it 3.Keeping active 4.Learning new skills 5.Keeping in touch with friends 6.Doing something creative 7.Getting involved 8.Asking for help 9.Relaxing 10.Surviving Conclusion

51 Make Your Choice. Be successful, competitive, workaholic and die younger. OR. Be less ambitious, lower income, more relaxed and live longer.


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