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Mindfulness-based Diabetes Management


A targeted intervention for depression, anxiety and diabetes-distress OHSU Psychiatry Grand Rounds Sept. 20th, 2011

Jeff Horacek M.D./ Steven Alper L.C.S.W.

A personal and professional journey

My journey brings me here with more questions than answers Diabetes support group (depression/stress/isolation/shame/self-criticism) Oprah Winfrey podcast "moment" with Jon KabatZinn Meditation in the desert

Discuss confusion about prevalence of Major Depressive Disorder (MDD) in diabetes.


Distinguish between MDD and Diabetes-distress. Identify Diabetes-distress as normal part of DM. (Non-psychiatric distress).

Discuss broader approaches to treating Diabetesrelated distress as opposed to standard treatment approaches for MDD.

Introduce a Mindfulness-based approach to

International Diabetes Federation stats

366 million people worldwide with diabetes

4.6 million deaths annually due to DM 1 person dies every 7 seconds Health care spending 465 billion annually UN Summit on non-communicable dz's today

Diabetes will be an ever-growing part of ALL practices!

What is Prevalence of depression (MDD) in Diabetes?

Previous estimates of MDD prevalence 2-3 times greater than general population. CESD-Center for Epidem. Studies Depress. Scale (self-report questionnaire may over diagnose)

Diabetes Care 2001, Anderson RJ et al. (meta-analysis)

MDD only 60% more common than general pop. CIDI-Composite International Diag. Interview (structured clinical interviews are gold standard)

Diabetes Med 2008, Fisher L et al

Distressed or Depressed?

Self-report measures more reflective of general emotional distress than MDD.

Coyne JC, Psychol. Bull. 1994

Self-report measures may inappropriately pathologize Diabetes-distress and depressive symptoms. Adequate sensitivity for MDD but high % of false positives.

Thombs BD, JAMA 2008

70% of diabetic patients with elev. self-reported depressive symptom scores did not meet diagnostic criteria for MDD on structure clinical interview. Fisher L, Diabetes Care 2007

MDD more common with DM but not as high as previously thought.

Diabetes-distress is a part of having diabetes and is non-psychiatric distress. (in other words.....self-care for people with diabetes can be very hard work)

What is Diabetes Distress Scale?

Questionnaire for measurement of 4 domains: -Emotional burden -Physician-related distress (yes, we can add to burden!) -Regimenrelated distress Diabetes-related interpersonal distress

Polonsky WH, et al, Diabetes Care 2005;28:626-631.

Overapplication of MDD conceptual model to Diabetes-distress may be linked to fact that diagnostic system for MDD is based only on symptom assessment and ignores life context. (great book for residents!)

(Horowitz/Wakefield, "The Loss of Sadness:How Psychiatry Transformed Normal Sorrow into Depressive Disorder." 2007)

If we miss Diabetes-distress then we increase risk of treatment failure.

Even if dx is MDD, it is still important to address self-

management of diabetes and Diabetes-distress.

Which approach for treatment in Diabetes?

Meta-analysis of antidepressant use may be no more effective than placebo for mild to mod. severity MDD. (this used to be my practice!)

Fournier JC, et al, JAMA 2010

Improving MDD with psychotherapy and antidepressants fail to show compelling improvement of glycemic control in diabetes.

Markowitz S, et al, Psychosomatics Jan 2011

Over-application of MDD-model to address Diabetesdistress is not appropriate.

Diabetes Distress vs MDD

Addressing Diabetes-distress improves both self-care and glycemic control. -negative emotional reactions to dx of DM -threat of complications -self-management demands -unresponsive providers -unsupportive interpersonal relationships

Fisher L et al Diabet. Med. 2008, Diabetes Care 2007, Diabetes Care 2010

Novel approaches addressing diabetes management and MDD

Nurse-led self-management support

Gonazalez JS,et al, J Cogn Psychother 2010

Psychological treatment with exercise training

Katon W, et al, Contemp Clin trials 2010

Nurse-, dietitian- and mental health specialistdelivered self-management interventions.

Amsberg S, et al, Patient Educ Couns 2009

Novel approaches addressing Diabetes-distress

CBT adapted to address DM-relevant behavior improved both glycemic control and diabetes distress.

Lorig K, et al, Diabetes Care 2008

Peer-delivered self-management intervention with Spanish speaking type 2 patients: both glycemic control and diabetes-related distress improved.

Carver CS, et al, Pers Soc Psychol Rev 2011

Mindfulness-based approach!

Mindfulness-based Stress Reduction (MBSR)

MBSR pilot study (observational) n=14, improvement in glycemic control, blood pressure and measurement of general psychological distress.

Rosenzweig S, et al, Altern Ther Health Med. Sept-Oct 2007

DiaMind- Dutch study testing effectiveness of MBSR to reduce emotional distress in outpatients with diabetes. Outcomes to be measured: measures of distress, quality of life, dispositional mindfulness, self-esteem, self-care, bp, and glycemic control.



· Prevalence of depression is approx. 60% higher than

general population.

· Distinguishing between MDD and Diabetes-distress

is crucial. They can co-exist!

· Diabetes-distress can be a normal part of diabetes

and is non-psychiatric distress.

· When treating MDD in diabetes, it is also important

to address Diabetes-distress and diabetes selfmanagement.

Joshua Tree Sunset


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