In this Exclusive Interview transcript, Mary de Groot talks with Diabetes in Control Publisher Steve Freed during the ADA 2018 convention in Orlando about why people with diabetes have higher rates of depression, how depression differs from diabetes distress, and the effect of depression on diabetes management.
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Steve Freed: This is Steve Freed. We’re here at the American Diabetes Association 78th Scientific Sessions. It is probably close to maybe 20,000 people coming here to learn more about diabetes, mostly medical professionals and researchers, but there’s a lot of information coming out of these presentations. Probably over a hundred presentations and probably five or six hundred abstracts. So there’s just actually too much information to absorb in a short period of time. So we have with us to help those people that couldn’t attend a very special person, Mary de Groot, PhD. and associate professor of medicine and actually director of the diabetes Translational Research Center at Indiana University. So why don’t we just start out with, tell us a little bit about yourself and what you do.
Mary De Groot: Thank you for the opportunity for this interview. I am a clinical health psychologist which means I work with people around the emotional and behavioral aspects of managing diabetes. I work with adults who have either type 1 diabetes or type 2 diabetes. And so I wear many hats. One of those is as a clinician so I work with patients who are referred by their endocrinologist or diabetes educator to my health psychology practice which is embedded in adult endocrinology in the IU Health System in Indianapolis. The other five days a week I am a researcher and my particular area of interest is diabetes and depression. I’m interested in the mechanisms that linked the two disorders. They go hand-in-hand and I’m even more interested in how we leverage community resources to address this comorbidity and its negative impacts, to make access to treatment more available to people in all areas whether that’s rural areas or urban areas and have more resources to be able to address and support diabetes self care.
Steve Freed: So the title of your presentation is “Mental Health Disorders and Diabetes distress Among Adults with Diabetes: The Epidemiology and Impact of Mental Health Disorders among Adults with Diabetes.” Being a diabetes educator I am depressed just thinking about diabetes; I can’t imagine how a patient with diabetes feels, whether it be type 1 or type 2. And we had the occasion to do another interview today with Katherine Kreider and her topic was on diabetes distress; so yours is on diabetes depression. So obviously there’s a difference between the two and if you can start off with this and tell us. You know I would assume that every patient with diabetes is somehow a little bit depressed, because of just being diagnosed with diabetes but when they understand that they have to count carbs, they have to check their blood sugars and they have to do all these other things. They’re just set up to be depressed. So how do you deal with it?
Mary De Groot: It used to be our clinical assumption that that if you had diabetes, because there is so much for people to manage, that depression is a natural consequence of that. And we’ve actually learned a lot more about that territory or that emotional landscape as I like to refer to it. So we now understand that depression is different from diabetes related distress. Depression can have many sources; it can come from life events, it can come from genetics, it can come from stress, chronic stress, and that affects one in four people with diabetes, whether that’s people with type 1 diabetes or type 2 diabetes. That’s a separate construct from diabetes related distress, which is specific to the experience of living with diabetes as a chronic condition. And so as Larry Fisher, who is one of the originators of the concept of diabetes distress, just described in a symposium session in the last hour, that we expect that everyone at some point may experience diabetes related distress because managing diet, exercise and multiple medications is very difficult to do.
Depression on the other hand we wouldn’t necessarily expect everyone to have, but we also know that both conditions have a negative impact on quality of life and on health outcomes, so we care about both conditions, but we consider them to be separately now and they’re along a continuum, diabetes distress being on one end of that continuum, clinical depression being on the other.
So what have we learned about the depression and diabetes? So I’ll speak to it to depression and Katherine can speak to diabetes related distress as she did eloquently yesterday. We have learned that as I said one in four people with diabetes have experienced depression at some point in their life. The studies that we’ve accumulated over time are a mixture of studies that have asked people surveys about depression, or diabetes depression questionnaires I should say, as well as studies that have had people engaged in more in-depth interviews or psychiatric interview protocols where we can be much more specific about the symptoms and to make sure that they are different from the experience of managing diabetes. And so how we ask the question makes a difference in what we see in terms of the prevalence rates of depression; when it comes to depressive symptoms it’s about one in four, one in four people with type 1 or type 2 diabetes will experience elevated depressive symptoms at some point in their life. When we look at clinical depression, so that is feeling depressed or down most of the day nearly every day; a lack of interest in things that people might otherwise enjoy doing; changes in sleep, appetite, weight, concentration; feelings of worthlessness and decreased energy; when we have that constellation of symptoms, at least five of those, we know that the rates of depression are are between 11 and 15 percent of people with diabetes.
We compare that to other chronic illnesses and those rates are pretty comparable. But when we compare that to the general population of people without diabetes those rates are elevated. And so we care about that because those rates are high. When we think about that proportion, whether it’s 1 in 4 or whether it’s 11 to 15 percent, we know that we have a growing population of people with diabetes. Our current estimate is thirty point three million people in the U.S. with another 87 million people waiting in the wings, and that the cost of diabetes generally in 2017 alone was to the tune of 327 billion dollars, with a B. And so that’s a large denominator. So any proportion of that large group are too many people who are experiencing depression.
There’s lots of good reasons to care about depression and diabetes and when I talk about depression, I always give the caveat that talking about depression does not induce depression, and that there is in fact good news about diabetes and depression. And so I can speak to that in a moment. But in terms of impacts, what impacts does depression have for people with diabetes, it’s important that patients know about this as well as providers. We know that there are changes in glycemic control, so glycemic management is much more difficult when you have diabetes and depression happening at the same time, that that trends in the direction of worsened glycemic control and so higher blood sugars.
It also has been shown to have more glycemic excursions, that is more variability in blood sugars over time when depression is present. We know that there’s changes in adherence. When you have diabetes it’s hard; when you have depression on top of that it’s even harder, so it’s harder to manage exercise and food and all of the medications and self care behaviors that go hand in hand with diabetes. We know that medical costs go up. If that were in the service of really good diabetes care and really good depression management those dollars may be well spent but we know in fact that those are not typically the outcomes. And so we have just higher costs overall. There’s greater severity of diabetes complications, there’s greater functional disability — the ability to engage in activities of daily living and meaningful activities in life. And then if all of that weren’t impactful enough, we also know that people are at risk for early mortality, and that that is not only attributable to cardiovascular disease but also attributable to all causes. And so we have a great deal of concern that when we have diabetes and depression together that we have much more risk for negative outcomes for folks who have both conditions than either condition alone.
Steve Freed : Let me ask you a question I was just […]
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