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Beating the Blues: Pharmacists can play an integral role in helping people with diabetes manage depression

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No one knows more than Donnetta that diabetes and depression too often go hand in hand. The two diseases, she says, have wrecked her life.

Several years ago, she had prediabetes and was depressed. She found herself coming home from work on a Friday afternoon and not leaving the house until Monday morning when she dragged herself back to her job.

“I stopped exercising, stopped even moving,” Donnetta said. “I had been participating in society, but quit.”

She gained 50 pounds in four months and it wasn’t long before she had full-fledged type 2 diabetes.

Tawny Bettinger
Depression can strike anyone, but people with diabetes, a serious disorder that affects an estimated 16 million Americans, may be at greater risk. Dr. Tawny Bettinger, assistant professor of pharmacy, is conducting a study designed to improve the health of patients with both diseases.

“If I had tapped into my depression earlier, this wouldn’t have happened,” she said.

Yes, if you can’t control depression and diabetes, they will control you, says a University of Texas at Austin faculty member who is studying how pharmacists can play an integral role in helping patients who suffer from both illnesses.

Dr. Tawny Bettinger, assistant professor in the Division of Pharmacy Practice, believes education—both of the diseases and medications—is one solution. She received funding from the National Alliance for Research in Schizophrenia and Depression and the PhRMA Foundation for her study on “Depression and Diabetes: Improving Patient Outcomes in Primary Care.”

“The co-occurrence of depression and diabetes is increasingly being recognized as a significant problem,” said Bettinger. “Although the exact relationship between depression and diabetes is poorly understood, studies strongly suggest that depression is more common in adults with diabetes than the general population.”

It is estimated that 25 percent of patients with type I or type II diabetes have some form of depression.

According to the National Institute of Mental Health, some research suggests that diabetes doubles the risk of depression and that the chances of becoming depressed increase as the diabetes complications worsen.

There also is some thought that depression can lead to diabetes.

“It is unclear whether the presence of depression increases the risk of diabetes or whether having diabetes increases the risk of developing depression,” Bettinger said.

Depressed patients, for example, tend to eat more and exercise less, which could result in weight gain and interfere with efforts at controlling blood sugar levels.

Donnetta is convinced that her depression led to her diabetes.

Signs of Depression
  • Little interest or pleasure in doing things
  • Feeling down, depressed or hopeless
  • Trouble falling or staying asleep, or sleeping too much
  • Feeling tired or having little energy
  • Poor appetite or overeating
  • Feeling bad about yourself—or that you are a failure or have let yourself or your family down
  • Trouble concentrating on things, such as reading the newspaper or watching television
  • Moving or speaking so slowly that other people have notice. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual
  • Thoughts that you would be better off dead, or of hurting yourself in some way

“If a person is depressed, they won’t exercise, they won’t interact with people, they’ll overeat, they’ll undereat, they’ll oversleep, they’ll undersleep,” she said.

Bettinger is conducting her research at the Blackstock Family Practice Clinic in Austin. Those who enter the study are screened for depression. She developed a treatment adherence program. In the second part of the study, a clinical pharmacist provides extensive patient education on the disorders, medication management and follow-up contact. Another group of patients have treatment as usual (no pharmacist intervention).

“Clinical pharmacists have played an integral role in implementing disease management programs,” said Bettinger. “They are able to provide patient education, assist in monitoring treatment effectiveness, enhance medication adherence and identify and manage side effects.”

Placebo-controlled trials have shown that the use of antidepressants can improve depressive systems in diabetic patients, suggesting that when depression is treated properly, better glycemic control can be achieved.

Bettinger said the family clinic is a perfect setting for the study because both illnesses are generally treated in primary care. A big issue in primary care is the lack of detection of depression and, consequently, a failure to treat it, she said.

“Despite the high prevalence of major depression and the fact that effective treatments have been available for 35 years—extensive documentation shows that underdiagnosis and undertreatment remain the norm,” said Bettinger.

Statistics have shown that only one-third to one-half of individuals with depression are properly recognized by practitioners and, even of those who are, many do not receive the correct dose of antidepressant or for a long enough period of time.

It is estimated, she said, that anywhere from 30 to 60 percent of all patients don’t take medications as prescribed, regardless of the disease.

“Patients with depression are three times more likely not to take their medications as compared to the general population,” said Bettinger. “This is unfortunate because when treated adequately, depressive symptoms usually respond well to antidepressant medications.”

Elida Olivarri, second-year pharmacy student; Dr. Debbie Lopez, clinical assistant professor of pharmacy; Dr. Tawny Bettinger, assistant professor of pharmacy; Dr. Aaron Gibson, psychiatric pharmacy practice resident; Dr. Margie Perez, primary care pharmacy resident
Working on the depression and diabetes research are Elida Olivarri, second-year pharmacy student; Dr. Debbie Lopez, clinical assistant professor of pharmacy; Dr. Tawny Bettinger, assistant professor of pharmacy; Dr. Aaron Gibson, psychiatric pharmacy practice resident and Dr. Margie Perez, primary care pharmacy resident.

Debra Lopez, also a clinical assistant professor in the College of Pharmacy, has worked at the Blackstock Family Practice Clinic for several years as a clinical pharmacist, managing patients with diabetes. She has assisted with recruitment for Bettinger’s study.

“Depression and diabetes are very important diseases and you can’t fix one without the other,” said Lopez. “Many of our patients have really poor glucose control and depression. Once the depression is treated, the glucose control seems to improve significantly.”

It is phenomenal how many patients don’t understand why they are taking medications, said Aaron Gibson, a graduate student in pharmacy who has worked on Bettinger’s study for more than a year.

The first major hurdle to clear with every patient in the study is to establish what baseline knowledge he or she has about both depression and diabetes. After that has been accomplished, the task of filling in the gaps begins. The researchers have put together a complete information packet that explains both diseases and spend nearly an hour with the patients going over the information.

“We want to make sure patients have all the specific information—benefits, side effects and how the medications actually work,” said Gibson. The second component is to explain the underlying disease processes of both diabetes and depression so that they know why they are being treated.

“One of the first things I discuss with the patients is that depression is a chronic illness just like diabetes or hypertension,” said Gibson. “Unfortunately, there is a sigma in our society today that patients with depression just need to ‘pull themselves out of it.’ That is simply not true.”

The researchers work to disprove any misconception about mental illness, then explain treatments and the benefits of medications.

“I’ve found that there is often a huge disconnect between patients taking medications simply because their physician prescribed them and actually understanding why they are taking them,” said Gibson.

It also is a challenge, he said, to explain these complex disease processes in ways that patients can understand.

HbA1c--or glycosylated hemoglobin A1c--measures how well glucose has been controlled over three months. It can be done at home with this device
HbA1c—or glycosylated hemoglobin A1cmeasures how well glucose has been controlled over three months. It can be done at home with this device. 

“The medical profession uses a great deal of jargon,” he said, “and cutting through that and explaining things in lay language is a central component of the education process in the clinic.”

Another patient, who completed the study, took what she learned home to her five siblings who also have diabetes.

“Diabetes didn’t skip anyone in our family—from great grandparents on down,” Sara said.

The consequences of the disease have included strokes and amputations among family members.

“I learned how important it is to take not only the diabetes medications, but also the depression pills,” she said. “Now—in our house—we all holler at each other a lot. ‘Did you take your pills? Did you take yours?’”

Gibson agrees with Bettinger that there is a significant increase in the co-occurrence of depression and diabetes.

“Until recently, there has been some disconnect between medical and psychiatric diagnoses,” he said. “They were treated as separate entities.”

The medical community is now starting to understand there may be some very significant connections and relationships between psychiatric illness and medical illness, he said.

“I think this research is going to help further that understanding and hopefully begin to change our thinking towards a more global clinical picture of each patient,” said Gibson.

Gibson said he has found patients in the study to be genuinely appreciative that a health care professional is taking time to listen and address their questions and needs.

“Unfortunately, our health care system puts pressure on physicians to see patients as quickly as possible,” he said. “This study provides patients with an environment to ask questions and an opportunity to gain insight into the disease process.”

Participation in the study has made pharmacy student Elida Olivarri more aware of the many diverse opportunities clinical pharmacists have in improving patients’ health in primary care settings.

“I have found that most patients are interested in improving the states of their diseases and in contributing to the research,” she said. “Through the nine months of the study, you build personal relationships with your patients and share genuine concerns for their health.”

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  Updated 31 May 2006
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