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.
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 thinking about, and that is you know we treat diseases; we treat pre-diseases. We know how to treat prediabetes with nutrition, physical activity. We pre-treat other diseases. Well depression is a disease. Do we wait until they get depression and then provide them treatment? Or can a family practitioner look at a patient, talk to a patient, maybe do a quiz or fill out a form or something to see this patient is on their way to becoming depressed or at greater risk for depression. Wouldn’t it be better to prevent depression rather than treat it; is that available?
Mary De Groot: The first step is to screen for depression. So whether it’s low levels of depression or whether it’s high levels of depression we can’t treat what we don’t know about. And so my advice to my primary care colleagues as well as my endocrine colleagues and nurse practitioners and everyone involved in diabetes care, diabetes educators and pharmacists, is to screen for depression. Screening alone is not the same as treatment for depression. But screening gives us good information to then be able to make decisions about whether there needs to be follow up assessment and referral to mental health providers who can do the effective treatment that we know works, and that might include antidepressant medication prescriptions but also behavioral treatments, and I can talk about that in a moment. So screening really matters. We also know that once people have received treatment for depression that that’s really important that we continue to monitor depressive symptoms over time even if they’ve dropped to a lower level; work that’s been done out of the University of Texas Southwestern Medical School has found that people who have even low levels of depressive symptoms, what otherwise we would consider to be minimal, levels are still at greater risk for developing depression again, having a relapse, then people who whose depressive symptoms go away entirely. So the more that we can reduce those depressive symptoms the better.
Now some of my own work in the past few years has looked at the course of depression in people with type 2 diabetes and two separate samples of adults with type 2 diabetes who were enrolled in a depression treatment program called program ACTIVE. ACTIVE is an acronym that stands for “Adults Coming Together to Increase Vital Exercise” which was a multifaceted approach to treating depression for people with type 2 diabetes. What we observed in a series of interviews, in-depth interviews, of people’s history of depression, and this is starting from birth to their time of enrollment into the study. First in a sample of 50 adults and then in a second separate sample of 176 adults we found that the average number of depressive episodes that people had coming into our study was one point eight, so that was for major depression, and two point one episodes over the course of their lifetime for any form of depression, whether that was at the top of the hierarchy, major depression or whether that was lower levels of depression that still have impact on people’s lives but that are not quite as severe as major depression would be. We found that the average duration of a major depressive episode was, rather than 22 weeks which is what we see in the general population, the average duration was beyond 92 weeks in our samples, and that was consistent in both our first sample and in our second sample.
So that’s an order of magnitude higher for people with diabetes than we see in the general population. We also then looked at how long, not only how long do episodes last but then how much time is there between. And do people have recurrent episodes, which we now know that they do. And what we found was that the the pattern that we saw in both studies was that the amount of time people spent in depression, with second episodes or third episodes or more, got longer over time and the periods between those episodes where people returned to their baseline level became shorter. And so what that means, beyond the jargon, is that people are spending more time living with depression. And the more time people spend living with depression that means that there’s more negative impacts. And I was just talking about whether that’s blood sugar management at risk of complications or functional disability or early mortality. So to your point of can we catch it early. The answer is yes, we should absolutely catch it early, and work with people effectively and assertively around treatment so that we can. Because when depression comes it stays and then it comes back, even once it’s treated. And so we need to be very effective and strategic about about screening and also about treating.
Steve Freed: Shouldn’t family practitioners screen their patients for depression, whether they have diabetes or not? It’s a simple test on a sheet of paper. You know, if you catch it early and treat it the person is going to have a much better quality of life. But is that something that is drilled into a medical professional from school, that this is something they should be providing in their care?
Mary De Groot: I think that’s improving and it’s improving because we’re getting messages out to both sides of the equation. So for providers of all stripes there’s more awareness now than I think there’s ever been about how important depression is in terms of overall health picture. There’s more decision support in electronic medical record systems. So for example we have two different medical records systems in our training environment at Indiana University School of Medicine, and one of those on the dashboard has a slot for what is the depression score using the PHQ9. So that’s helpful because then physicians see it. So that’s useful. On the other side of the equation are patients. And so we’re educating patients to, even if the provider doesn’t think to ask about depression or screen for depression, it’s really important that patients know that this is really important information for their provider. And so that’s something that needs to be offered by patients as well as inquired about by providers.
Steve Freed: Is there a web site that provides the actual test that you give to patients, how to reply to it; is that available, obviously via the Internet?
Mary De Groot: It is. There are several measures that can be used. One of those measures is called the PHQ9 or the Prime Health Questionnaire for depression. It’s publicly available; it was designed for primary care practice setting; it has literally nine items on it, and then one extra one to ask about the impact of those symptoms. It can be scored very easily by adding up the numbers that you circle and it asks about the frequency of depressive symptoms and how how much they get in the way. And so that’s an easy test that people could take to help them put into numbers that experience of depressed mood.
Steve Freed: What do we have for them, how do we treat depression?
It’s a great question. So the good news about depression and diabetes is that we have effective treatments for this, so people don’t need to live with depression. Depression can be insidious and so people don’t always realize that they’re working harder and harder or moving through molasses to get through their day. But when we do recognize that we have great tools. There are a host of antidepressant medications that are available. We’re still learning about brain chemistry and what which medications are the right fit for which people. And so, it’s not uncommon to try one medication, maybe to try several doses of that medication and maybe even try a second or third medication in order to to reach effectiveness. That’s a process that unfortunately right now takes time, but very important to be persistent about, in order to get good effectiveness if medication is an option for that person, and that’s a conversation to have with one’s provider.
In addition to medication or in place of medication for folks who don’t prefer that option we now know that both counseling, or talk therapy as I like to refer to it, in the form of cognitive behavioral therapy, which is a skills based approach to counseling, can be very effective in treating depression. And that can be delivered in multiple forms. There are counselors who work with people individually, some in private practices, some within the primary care setting, so-called integrated care. Nurse case managers can work with patients around problem solving therapy which is a variation of this type of counseling. There are also web sites now, web based care, such as Beating the Blues, and that is available. The work that I’ve done made use of a diabetes-specific approach called Program ACTIVE, where we had patients work with individual counselors who were trained both in CBT, cognitive behavioral therapy, and diabetes, and met with patients individually using a manualized approach so that it was similar kinds of interventions for people across across the study. People could choose their own goals. Some of those might have been diabetes related and some may not, but they had a wide range.
The third category of interventions is exercise. And so we have known for a while that in the general population exercise works as well as antidepressant medications, and like antidepressant medications it only works if you take advantage of it. So if you’re doing exercise it helps you; if you stop doing exercise it stops helping you. And so that’s kind of a simple truth that applies to this approach as well. In our studies we found that the exercise intervention, when it was combined with the counseling intervention not only was effective in treating depression at this highest level, major depressive disorder, it was also effective in improving overall A1c, and by a significant margin compared to people who were randomly assigned to a usual care condition. We are presenting here at these meetings not only information about diabetes and depression generally, but we have a poster in our poster session where we’re presenting the six and twelve month outcomes of our Program ACTIVE 2 study, where we’ve demonstrated that we have a sustained effect of A1c improvement over 6 and 12 months beyond treatment for people who receive both the counseling and the exercise. So this is a bit we have observed that has a synergistic effect, that one intervention actually boosts the other and back and forth with the ultimate improvement in both depression and A1c.
Steve Freed: Can we know for a fact that treating depression — we know that physical activity can improve your A1c; that’s a given. What I’m trying to get from you, can we say treating depression, maybe without the physical activity, just treating it medically with the treatment, whether it be Prozac or one of the hundreds that are out there — do we see a lowering of A1c, just making a person happier?
Mary De Groot: That’s a great question. And the literature is quite mixed. So some antidepressant medications have been associated with a slightly hyperglycemic effect, some of the tricyclic antidepressant medications, TCA’s, who are the older generation of medications. Others such as the selective serotonin reuptake inhibitors, the SSRIs, have been shown to have either no effect on blood sugar control, or a slightly lowering effect of blood sugars, not hypoglycemia but lowered effect, but anti depressants by themselves don’t appear to have a dramatic effect on A1c. They can improve symptoms, so they can be very helpful improving depressive symptoms, but it appears that that physical activity piece is very important in lowering A1c. If antidepressants are delivered in conjunction with other medications such as diabetes medications, and hypertensive medications and statins and so forth, you can see improvements across the board on all of those markers, but typically what’s driving that are the diabetes medications, they’re driving the A1c effect, not necessarily the antidepressants.
So that was one of the reasons why we’ve been so pleased with the Program ACTIVE 2 findings, because we’ve been able to demonstrate that without those antidepressant medications being actively managed, for some people they didn’t have them at all, for other people they were just maintained at their current level but still met for depression, that when we gave people behavioral interventions, and particularly the combination behavioral intervention, we saw effects both on depression and A1c. And so that was, this is landmark and we’re thrilled, for our patients.
Steve Freed: I recently learned about genetic testing to determine the best depressive drug to give to a patient, and it tells you which ones you shouldn’t give, would have greater side effects and so forth. Because there’s so many out there, it’s very difficult to know which one has the least side effects, is going to be the most effective. Have you learned about that?
Mary De Groot: This is a promising area and I’ve been very pleased to see personalized medicine take this turn and be applied to depression in this way. I think there’s a lot more we need to know about that personalization for people with diabetes, that we do do not have good outcomes data yet for that kind of personalized medicine for depression and diabetes, but it’s a very encouraging development. So that’s one of the the next steps in our area in our field.
Steve Freed: And are treatments for depression effective for other outcomes? Because I would imagine a lot of people when they’re depressed eat more, gain weight, and if they’re happier they eat less, so can we see other benefits to treating depression rather than just depression?
Mary De Groot: That’s a great question. In our study — I’m just going to speak from our own experience and Program ACTIVE — we were not particularly focused on weight loss, so that was not part of the goals of the interventions. And in fact we did not see any changes in body mass index, which was our primary measure of of weight, or waist to hip ratio was another measure. So the way I think about that is that we’re starting with layers of addressing health concerns. If we don’t address depression we really can’t get traction on those other behavioral goals. But once we’ve addressed depression, then we can address diabetes distress, then we can address weight loss, and we can address other kinds of health concerns and health promotion in people. So it’s really these are multiple layers of the pyramid. And we really need to treat one layer at a time, because that’s really all people can do.
Steve Freed: What should providers and patients do when depression is part of the clinical picture?
Mary De Groot: Talk about it. The first step is take to communicate. To providers I advise that they ask about depression, and not be shy about asking about that, because asking about it does not induce it. For patients, if that’s part of the picture, to share that with your provider because that’s important information for them to know about how to manage the overall picture; it’s highly relevant. From there, then it’s about making decisions together about what makes the best, what’s the best choice for the patient and their whole medical picture, whether that’s a behavioral approach, counseling, exercise or an antidepressant medication. But that’s really a joint conversation that needs to happen. And then once that recommendation, that decision has been reached and a recommendation has been made, then on the provider side it’s all about followup, following up whether that’s a medication or whether that’s connecting to other services. One resource that providers now have which is very exciting is the American Diabetes Association has partnered with the American Psychological Association to create a mental health directory. And so that’s a resource that’s available nationwide of therapists, psychologists, in this case who have all been trained in a rigorous diabetes training program and who are available to be contacted by patients who would like to work on mental health concerns. So this is a resource for both physicians and for patients.
Steve Freed: There’s a lot of diabetes burnout in younger patients; they just get fed up with it and they wind up in the hospital. Is that considered depression?
Mary De Groot: It is separate from depression but it overlaps, so it’s really kind of a Venn diagram of overlapping circles for diabetes and depression. What our study has found is that when we’ve successfully treated depression, we successfully treat depression and we also lower diabetes distress, but it doesn’t go completely away. So we start first with the depression and then what remaining diabetes distress there is, we can then treat that too. But they are separate entities; they they interact with one another but they remain separate entities.
Steve Freed: Has the use of the CGM brought up more depression because people see what is actually happening that they’re not aware of? Not so much for — well maybe for type 1 and type 2. I would think that the more knowledge you have about where your blood sugars are. obviously if they’re in the higher ranges it’s going to cause depression.
Mary De Groot: So it’s interesting, I have not seen any literature that suggested that the use of CGM sensors is associated with increased depressive symptoms or clinical depression. What I have seen on the other hand is a real difference between how people interpret the data that they receive, and then what effect that has on diabetes distress and quality of life. For some people the sensor is a game changer because it gives people the context for individual blood sugar numbers that they didn’t have when they were using their meter as their primary source of information. For other people it can feel like information overload, or it can feel like they put more pressure on themselves; we have a tendency to put more pressure on themselves to try to increase their amount of time in target. So it’s really a matter of interpretation and that’s an important area that providers can be sensitive to, is how is a patient thinking about themselves, how are they thinking about their diabetes, how are they interpreting their numbers; we know as providers that they’re just numbers, they’re not a badge of identity, and we hope that people don’t have experiences of shame associated with their numbers, but for people who do, which is a telltale sign of diabetes distress, that that’s a conversation that needs to take place. And as Larry Fisher just recommended in a session, that we want to take care of the person and their relationship with their diabetes as much as we want to take care of their blood sugars. And so that’s a conversation starter that any provider can have.
Steve Freed: If there was just one message that you wanted medical professionals take away from your talk, or just depression in general, what would that be?
Mary De Groot: Depression exists. It is persistent and it can be treated. And if we give it the attention that it deserves, we can make great headway that will improve our patients’ lives, but it will also improve the provider’s experience. So it’s a message of hope.
Steve Freed: I want to thank you for your time. I thought it was very interesting. Enjoy the rest of your stay here while you’re in Orlando. Thank you.