samepage blog

Diabetes + Depression = Diapression

Dr. Paul — Tue, 11 May 2010 00:00:00 GMT

On May 1st, the Samepage team participated in this year’s highly successful Diabetes Expo at the Washington State Convention & Trade Center in Seattle. The Expo drew over 5,400 participants – a 6% increase over last year’s attendance! Congratulations to the American Diabetes Associationand the hard-working Expo organizers who showed, once again, that they are masters at running a practical and highly relevant program that helps individuals with diabetes and their families in dealing with the daily challenges of living with diabetes.

At the Samepage exhibit booth, Marianne, Ben, Emma, and Sabine did a terrific job demonstrating freely available on-line tools, including VisitPrep and Ask and Tell Gallery, while I took a few breaks to give a couple of scheduled presentations. Here are the main points from one of my talks entitled ‘Diapression’.

What is diapression?

Based on clinical and research work, I coined the term ‘diapression’ as a way of better understanding the lived experience of people with both a medical and behavioral condition – like diabetes and depression.

One of the main ideas behind diapression is to help patients and healthcare providers communicate better. Clinicians can get a clearer understanding of the daily experience of patients who have both conditions. Patients can better understand and accept the questions and clinical tasks of the healthcare provider trying to diagnose and/or treat a behavioral and medical condition.

Which comes first, depression or diabetes?

Diabetes leads to a greater likelihood of having depression. In fact, depression is twice as common in people with diabetes compared to the general population.

On the other hand, research is showing that untreated depression is associated with onset of diabetes. In people already diagnosed with diabetes, depression leads to worse clinical outcomes.

Some key features of diapression:

Individuals with diabetes and depression can have confusing symptoms.

Depression can worsen diabetes symptoms like neuropathy pain and fatigue.
Persisting diabetes symptoms can make people with depression feel even more down and can lead to difficulties with concentration and motivation.
People with both conditions can experience bewilderment and frustration about a decreasing ability to control diabetes, often leading to a mounting sense of giving up.
At healthcare visits patients often don’t know what is going on and they may feel they are doing something wrong as their diabetes spirals more and more out of control.

In individuals with diabetes and depression, emotions can seem to temporarily take charge of daily behaviors.

Almost weekly in my clinical work, I hear patients who are struggling with depression say something like this about their diabetes self-care:

“I know what I am supposed to do and I know what I am not supposed to do, but I still do the wrong things and I don’t know why.”

I often say that some of my patients could write a best-selling book about what to do to effectively manage diabetes. Yet, when they are depressed they may be barely able to manage their weight, glucose numbers, blood pressure or make regular healthcare visits.

Depression “turns up the volume” on physical symptoms!

For years, clinicians and researchers have recognized that depression is a “symptom amplifier” of emotional and physical symptoms.
This was shown most recently in a study of 4,000 primary care patients with diabetes at Group Health in Seattle. Ludman and colleagues showed that, compared to patients without depression, those who were depressed were:
- Twice as likely to report neuropathy pain
- Three times as likely to report excessive hunger or thirst
- Almost four times as likely to report shakiness, blurred vision or feeling faint
- Five times as likely to report daytime sleepiness

Depression can lead to difficulties with diabetes self-management, with taking medications, and with glucose control.

Symptoms of depression – like lower motivation, poorer concentration, difficulties with sleep and less hope for the future – can all lead to challenges in taking care of oneself.
Stress and depression can also increase glucose levels and blood pressure through biological mechanisms.

Depression can lead to isolation and reduce one’s ability to trust or to be satisfied with healthcare.

In a prior study, we followed individuals with diabetes for 10 months and showed that those whose depression worsened over time were less able to trust others in their social environment while those whose depression improved were more able to reach out and trust others.
In other words, depression can have a negative impact on the ability of individuals with diabetes to reach out to family, friends and healthcare providers in taking care of their condition.

The good news

There are effective treatments for depression, including psychotherapy and antidepressant medications. Effective treatments for depression and diabetes also include “collaborative care” models where nurse care managers, primary care providers, behavioral health and internal medicine specialists all work together in an efficient way to deliver tailored, evidence-based care for depression.

Regardless of type of care one receives for depression, treatment can start by understanding and discussing “diapression” challenges such as having confusing symptoms, symptom amplification, difficulties with self-management, and reductions in trust level. For more on diapression, go to diapression.com.

Dr. Paul

The Downside of Self-Reliance

Dr. Paul — Tue, 06 Apr 2010 00:00:00 GMT

Does self-reliance really help in getting more done?

It depends.

Occasionally taking a self-reliant stance can help break through inaction and 'make things happen', as the examples below show.

Jenna has always been a ‘self-starter’. When a new project proposal was being prepared in her organization, Jenna took initiative after office hours to write her section and a co-worker’s section to meet the submission deadline. Even though her co-worker was upset Jenna didn’t first ask permission to write her section, Jenna’s boss was pleased the proposal was submitted ahead of schedule.

Dennis was just diagnosed with diabetes. His doctor was surprised that within days, Dennis had taken extra time on his own to research and understand how to operate his glucose meter so he could download and print his glucose readings at home. His doctor praised him for being a ‘go-getter’ in managing his diabetes.

Limits of a ‘go-it-alone’ approach

Jenna and Dennis were very comfortable taking a ‘go-it-alone’ approach to complete their required tasks. In fact, they generally prefer to independently make decisions and carry out tasks without reaching out to others.

“I have learned that the best person to rely on is me,” confided Jenna to an acquaintance, “I once had this fantasy that others would be there for me and after being wrong one too many times, being independent is very, very important for me.”

Dennis takes pride in his self-reliance: “As long as I remember, I have always wanted to do things myself. I get things done. It has never been like me to ask people for help. Why should I?”

Many situations or tasks in life, however, require productive interactions with others for their successful resolution or completion.

After becoming a division head, Jenna and her staff were faced with a significant organizational expansion. Upper management strongly encouraged greater emphasis on teamwork, effective communication between divisions, and streamlined delegation of tasks among employees in order to meet sales targets. Not accustomed to working closely with others, Jenna chose to skip a number of key administrative meetings, preferring to work on her own. Unfortunately, her team’s performance over the next two quarters dipped well below their previous benchmark. At her annual performance review, her lack of team effort was a primary discussion point and Jenna was asked to step down as division head.

Several years after being diagnosed with diabetes, Dennis developed his first complication of diabetes – a small hemorrhage in his left eye. His healthcare provider encouraged him to attend health visits more frequently, begin to see an eye specialist, develop a new nutritional plan with the hospital dietician, and work with the healthcare team in learning how to use his glucose readings to better adjust his insulin around meals. Dennis was feeling overwhelmed and was frightened about his threatened eyesight. However, he told his healthcare provider that he was doing okay and that he would do his best to follow up with these recommendations. Three months later he still hadn’t called to set up any of the recommended appointments.

High levels of self-reliance or an inflexible self-reliant stance can paradoxically lead to less success in accomplishing goals and tasks, especially complex ones.

Comment

It is time to recognize the degree to which highly self-reliant people potentially struggle from day-to-day, often because of an inability to network effectively with others in work, home, or healthcare settings. Taking a (protective) self-reliant stance has often served them well in many domains of their lives. As a result, they may rarely have needed to flex their “reaching out to others” muscle. However, when life hands them a complex situation or task, they may be ill prepared to deal with it.

Over the past decade, I have had the privilege to conduct research with a team at the University of Washington’s Department of Psychiatry and Behavioral Sciences and Group Health Research Institute. Our findings have shown that individuals with diabetes who are more highly independent are less likely to schedule health visits, more likely to miss appointments, have higher glucose levels, and are less likely to adhere with foot care, exercise, diet, oral hypoglycemic medications and with quitting smoking compared to their more collaborative counterparts.

The cumulative effect of an inability to engage with others can have drastic consequences. Last month, we published study results in Diabetes Care showing that among 3,535 non-depressed patients with diabetes, those with an independent relationship style were 33% more likely to die over a five-year period compared to their counterparts who were more able to reach out to others.

These results are often surprising to clinicians. Yet, almost half of our sample of patients with diabetes had an independent relationship style. Despite the high prevalence of “go-it-alone” patients, it is not always clear to busy clinicians what is going on. It may be that individuals with a self-reliant predisposition often send out a very strong signal that says “I’m okay – I’m taking care of it” even when this may not be the case. This is compounded by the common experience any of us can have that a self-reliant stance is, indeed, often associated with success in getting things done.

Those working in healthcare settings may benefit from recognizing that our healthcare system does a better job of serving those who reach out, who schedule regular appointments and who actively engaging in the patient-provider interaction compared to those who have more difficulty with collaboration, as was pointed out in the Institute of Medicine’s well-regarded report Crossing the quality chasm: a new health system for the 21st century.

Unlike tough strategies in corporate settings, healthcare systems can’t or shouldn’t “replace” or demote highly independent patients who struggle to manage daily medical tasks. Unfortunately, labeling a self-reliant person as a “difficult patient” may effectively do the same thing because such labels often follow them and may affect their future care.

Of course, there are other differences between organizational and healthcare settings. Patients’ daily tasks are of a significantly different nature compared to tasks in organizational settings. People with chronic conditions have to potentially worry about and take care of self-management tasks “24/7”. These tasks and related symptoms can directly affect their personal lives. Furthermore, chronic conditions and related treatments can physiologically affect one's capacity to think, to be motivated, and to have energy to complete tasks.

With healthcare reform in the U.S. and demographic shifts favoring proportionately greater numbers of older individuals, we will see more patients with one or more chronic conditions, many of whom have not flexed their “reaching out to others” muscle for years. Is our healthcare system ready?

In future posts, we will explore the roots of interpersonal self-reliance and review strategies for working with self-reliance in organizations and healthcare settings.

Dr. Paul