Presented at Diabetes Workshop 2017 in conjunction with World Diabetes Day. Organized by Malaysian Endocrine & Metabolic Society and Hospital Putrajaya. 15th November 2017.

1. WDD2
World Diabetes Day
Women Diabetes Depression
Dr. Umi Adzlin Silim
Consultation-Liaison Psychiatrist HKL

2. Issues Unique to
Women with Diabetes
• Biologically
• Psychosocially
• Women’s multiple roles –
pregnant, mother, wife, work
• Women is vulnerable to
depression – twice more likely
than men

3. Overview
• Relationship Women, Diabetes & Depression &
Prevalences
• Diabetes Distress
• Practical Ways: How Healthcare Providers Can
Help Patients
• How to Listen So Patients Will Talk
• How to Talk So Patients Will Listen (and
change their health-related behaviour)

4. Women, Diabetes, Depression
Landmark Study 2010

5. Risk of Depression in
Diabetes
• A significant increased risk of developing
depression in the diabetic patients compared
to non-diabetic patients during the 10 years of
follow-up, which supports the previous notion
that diabetes is a “depressogenic” condition
and “stress-sensitive” disorder.
• Depression in Diabetes may result from:
• the biochemical changes directly caused
by diabetes or its treatment,
• the stresses and strains associated with
suffering from diabetes and its often
debilitating consequences

6. Risk of Diabetes in
Depression
• Depressed mood was moderately associated
with increase of developing type 2 diabetes
after adjustment for various covariates.
• These results are consistent with accumulating
evidence that depression is a significant risk
factor for developing type 2 diabetes.

7. Women, Diabetes, Depression
Landmark Study 2010: Bi-directional Effect
Diabetes Depression

9. Depression and diabetes are associated with significantly increased risk of all cause and CVD mortality

10. NORMAL
SADNESS OR
CLINICAL
DEPRESSION?

11. Recognizing Depression in Diabetes:
Whooley Screening (CPG MDD Malaysia)

12. Fig 1. Hypothesized model of the relationship between depression, diabetes distress and self –efficacy with
self-care practices.
Devarajooh C, Chinna K (2017) Depression, distress and self-efficacy: The impact on diabetes self-care practices. PLOS ONE 12(3): e0175096.
https://doi.org/10.1371/journal.pone.0175096
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0175096

13. Prevalence of Depression in Diabetes
• The prevalence rate of depression is more than three-times higher in
people with type 1 diabetes (12%, range 5.8-43.3% vs. 3.2%, range
2.7-11.4%) and nearly twice as high in people with type 2 diabetes
(19.1%, range 6.5-33% vs. 10.7%, range 3.8-19.4%) compared to
those without.
• Women with diabetes and also women without diabetes experience a
higher prevalence of depression than men.
Epidemiology of depression and diabetes: A systematic review. Available from:
https://www.researchgate.net/publication/232715188_Epidemiology_of_depression_and_diabetes_A_system
atic_review [accessed Nov 15 2017].

14. Prevalence of Diabetes Distress
• Type 1 DM: The prevalence and 9-month incidence of elevated
diabetes distress was 42.1% and 54.4%, respectively (Fisher et al,
2016)
• Type 2 DM: Systematic Review & meta-analysis of 55 studies (n = 36
998) demonstrated an overall prevalence of 36% for diabetes distress
in people with Type 2 diabetes. Significantly higher in samples with a
higher prevalence of comorbid depressive symptoms and a female
sample majority. (Perin et al, 2017)

15. Diabetes is one of
the Most Difficult
Chronic Diseases
• Living with diabetes is a challenge.
o Multiple medications, finger sticks,
physician visits, dietary restrictions
and the need to be physically
active.
o Complex and sometimes confusing
set of directives that may lead to
anger, frustration, and feeling
overwhelmed.
o Conflict with loved ones and
strained relationship with health
care providers.
• As a result motivation for self care
may be impaired.

16. Diabetes Distress (DD)
Diabetes distress (DD) refers to the unique,
often hidden, emotional burdens and worries
that a patient experiences when they are
managing a severe chronic disease like
diabetes. High levels of DD are common and
distinct from clinical depression
Gonzalez et al Diabetes Care 2011; 34:236-239

17. Diabetes
Distress Scale
(DDS17)
Validated in
Malay
Emotional Burden- personal reactions like
feeling scared, angry, or diabetes controls
my life
Physician Related Distress- doctor does
not give clear directions or take me
seriously
Regimen Related Distress- too many
meds and finger sticks-not confident in
my ability to care for my diabetes
Interpersonal Distress— Friends and
Family do not appreciate how difficult it is
and may not provide support

18. Understanding
Diabetes Distress
DD - THE PATIENT
Unsuccessful diabetes self
management over time
Downward spiral of poor
management and poor coping.
Reduced ability to gain new
knowledge/skills, development
of unrealistic goals and
expectations, inaccurate
personal beliefs and perceptions
that are self defeating.
Common reactions for a
distressed patient facing a
demanding chronic disease like
diabetes.
Fisher et al, Diabetes Care 2013;36:2551–2558

19. Life changes
dramatically when
THE PATIENT
receives a diagnosis
of Diabetes.
• Food choices are now changed and some of their
favorite food choices may be limited
• Physical activity is no longer an option but a requirement
for their health
• Multiple medications are required to sustain life
• Finger sticks are now required to guide their treatment
• Visits to the doctor and other health care providers is
now changed from an occasional to a frequent
occurrence.

20. DD – THE PATIENT
• All of these changes are coupled
with the knowledge that if the
disease is not controlled you may
face loss of vision, heart attack,
stroke, amputation and kidney
failure.
• Self management is the key to
success but the patients reaction
to self management directions
may lead to an inability to self
manage.

21. DD – THE PATIENT
• It is not unusual for patients with
diabetes to feel overwhelmed with the
demands of self management.
• Feelings of frustration, fatigue, anger,
burnout, poor mood and depression are
common.
• It is difficult to keep up with a
complicated routine when you have all
the above feelings
• Diabetes distress makes it difficult to self
manage and results in poor diabetes
control.

22. Understanding
Diabetes Distress
DD – FAMILY &
FRIEND
Families of patients with diabetes
may or may not understand all of
these issues and their lack of
understanding may place an
additional burden on the patient.
Family meals are an example. If
appropriate options are not
available the patient does not
want to inconvenience other
family members.

23. DD – FAMILY & FRIENDS
Patients with diabetes benefit by discussing their fears and
concerns with individuals and groups they can trust. Family and
friends are usually the patients most trusted associates.
But communication with family, friends and spouse about
diabetes is not easy for the patient, they may be embarrassed or
do not want to burden family and friends with their problems.

24. Understanding
Diabetes Distress
DD – Health care
providers
Diabetes creates significant challenges for all health care
providers (HCP) not just physicians.
HCP are driven by the fear of diabetes complications and
the knowledge that achieving goals for HbA1c, LDL B/P
reduces complications.
This fear produces behaviors in HCP that may interfere
with diabetes self-management.
HCP feel guilty if a patient is not achieving diabetes goals.
The guilt may lead to a culture of blame—where someone
has to be blamed and the patient is usually the target of
the blame.

25. DD – HEALTHCARE
PROVIDERS
• The common reaction to blame is labeling the patient non-
compliant.
• A more productive way to face this issue is to replace the
concept of compliance with the concept of barriers to
adherence:
– past emotional health,
– lack of support from family and friends
– misconceptions about their disease and its treatment
– inability to understand, purchase and use medications
– understanding and availability of appropriate food choices
– and an environment that is not conducive to physical activity

26. Tekanan Berkait Diabetes
Diabetes DistressD)
• Isu emosi yang unik kepada diabetes
• Berkait dengan bebanan dari diabetes
dan kerisauan kerana hidup dalam
keadaan mempunyai penyakit kronik
• Dilalui oleh sebahagian besar pesakit
diabetes

27. Tekanan akibat bebanan emosi
• Diabetes ambil terlalu banyak tenaga fizikal & mental setiap hari.
• Marah, takut, sedih memikirkan kehidupan dengan diabetes.
• Merasakan diabetes mengongkong kehidupan.
• Merasa akan dapat komplikasi jangkamasa panjang yang serius
(penyakit menjadi semakin teruk), walau apa pun yang dilakukan.
• Merasa tertekan dengan tuntutan hidup dengan diabetes

28. Tekanan berkaitan
doktor/anggota kesihatan
Tidak memahami secukupnya mengenai
diabetes dan penjagaan diabetes.
Tidak memberikan cukup panduan
tentang bagaimana mengendalikan
diabetes
Tidak cukup memandang serius
mengenai apa yang bimbangkan.
Tidak ada doktor/anggota kesihatan
yang dapat ditemui secara berkala
dengan secukupnya

29. Tekanan berkait dengan
penjagaan diabetes
• Rasa tidak cukup memantau gula dalam
darah.
• Rasa sering gagal memastikan rutin kawalan
diabetes.
• Rasa tidak yakin dengan keupayaan
mengendalikan diabetes
• Rasa tidak cukup mematuhi perancangan
pemakanan yang baik.
• Rasa tidak bermotivasi untuk meneruskan
pengurusan diri

30. Tekanan interpersonal/sokongan sekeliling
Kawan atau keluarga:
Tidak cukup memberi sokongan terhadap usaha
membuat penjagaan diri (seperti merancang aktiviti
yang tidak bersesuaian dengan jadual, menggalakkan
makan makanan yang salah
Tidak dapat memahami betapa sukarnya hidup dengan
diabetes boleh dilalui.
Tidak memberikan sokongan emosi yang diharapkan.

31. Impak Tekanan Berkait Diabetes
•Menjejaskan
•Kawalan gula dalam darah
•Penjagaan diri
•Keupayaan diri mengawal diabetes
•Kualiti hidup

32. Menilai Tekanan
• Tahap Tekanan
• Tekanan (distress)
• Gejala kemurungan/gejala keresahan (depressive/anxiety symptoms)
• Penyakit kemurungan/penyakit keresahan (depressive/anxiety disorder)
• Punca Tekanan – adakah ia berkait dengan diabetes?
• Tekanan berkait diabetes (diabetes distress)

33. HOW CAN WE HELP
OUR PATIENTS WITH
DIABETES DISTRESS?
AASAP

34. How To Listen So The Patients Will Talk
How To Talk So The Patients Will Listen
(and Change Their Health-related
Behaviour)

35. AASAP
AA
• Anticipate and Acknowledge the distress
Reflect & name distress
• “Sounds like you are feeling guilty..”
Identify the Ambivalence.
• “On one hand you feel like you really want
to lose weight/change your diet/exercise
more but feel you might fail again”
Identify both feelings

36. AASAP
S=Standardize and normalize the feelings
• “You are not alone, many patients with Diabetes
feel they same way this is expected and does not
surprise me..”
Also standardize the ambivalence by
normalizing the desire to improve and
the road blocks that are preventing
improvement
• “Most people with diabetes feel this way; they want
to improve but they often feel that it is so hard..”

37. AASAP
A=Accept and Understand
• Understand where the distress comes from- an emotional
struggle experienced when change not successful.
Examples
• “Change is hard work and distress occurs when goals that
were anticipated are not achieved or harder than expected”
• “Why do you think these feelings are happening now?”
• “Some people tell us they feel guilty when they are not able
to control their diet”
Emotion and Behaviour are different things
• Distressed does not mean they have to respond to it in ways
that are harmful to change. Reframe it
Accept it
• Do not fight it or react blindly or discount it as not important

38. AASAP
P= Plan to incorporate distress
as part of the plan for
behavioral change. i.e how to
respond to distress if it should
come about
If distress is experienced by
discouragement with meal
planning or exercise and this
blocks performance use
anticipatory problem solving

40. AASAP
STRATEGIES PESAKIT:
Saya paling tak suka bila semua orang membebel suruh saya jaga makan,
lagi orang buat macam tu lagi saya makan semua benda..
REPEAT Saya dengar encik kata … (ulang semua)
REPHRASE Encik pantang kalau orang berleter menyuruh-nyuruh encik jaga makan,
menyebabkan encik lagi makan semua benda
PARAPHRASE Encik pantang kalau orang berleter menyuruh-nyuruh encik makan, dan
kerana itu encik bertindakbalas dengan buat sebaliknya walaupun perkara
itu berbahaya untuk encik sendiri…

41. AASAP:
Contoh
Menamakan
Emosi
“Mesti puan merasa sedih kerana kawalan gula masih
tidak baik walaupun telah berusaha sedaya upaya”
“Puan merasa kecewa kerana doktor seperti tidak
percaya puan”
“Puan rasa marah kerana selalu dipersalahkan”
“Boleh saya tahu apa perasaan anda bila kita perlu
tambahkan ubat anda? Adakah anda rasa sedih seolah-
olah apa yang anda buat untuk mengawal diabetes tidak
Berjaya?”

42. AASAP:
Contoh
Menormalkan
Emosi
Semua orang pun akan rasa
leceh bila terpaksa mengawal
makanan sebegini
Dalam keadaan begini, bila
gula dalam darah sentiasa
tinggi, siapalah yang tak risau..
Memang semua orang dalam
situasi begini akan rasa sukar
untuk laluinya…

43. AASAP:
Mengendalikan ‘Ambivalence’
(Rasa berbelah-bahagi)
• “Jadi sebahagian diri encik memang mahu
turunkan berat badan dan encik nampak
pentingnya untuk imej, kesihatan dan ingin
kembali aktif seperti dulu tapi sebahagian
dari diri encik rasa sukar mencari masa untuk
bersenam dan sukar menjaga makan kerana
makan di luar…..”

44. THANK YOU
umiadzlin@gmail.com
• “Reducing distress, may have less to do
with providing patients with programs
of action and behavioral change and
more to do with health care
professionals listening to,
understanding, acknowledging, and
normalizing DD so that patients
internal resources can become free of
internal distress–related constraints”

45. Acknowledgement & References
• A significant part of this presentation is from Edward Shahady MD FFAFP, ABCL,
Clinical Professor Family Medicine & Medical Director Diabetes Master Clinician
Program
• AASP protocol personal communication L. Fisher
• Fisher et al, AASAP protocol- Patient Education and Counseling 2012;86:372-377
• Fisher et al Diabetes Care 2007;30:542–548
• Fisher et al, Diabetes Care 2010;33:23–28
• Fisher L et al, Diabetes Care 2012;35(2):259-264
• Fisher et al, Diabetes Care 2013;36:2551–2558
• Fisher et al Diabe. Med 2009; 26: 622–627
• Fisher et al Diabe. Med 2014 ;31(7):764-72