Mental Health and Diabetes , Stroke and Heart Disease

1. Mental Health and Diabetes, Stroke and Heart Disease Deborah Nelson, Psy.D. September 2013

2. Mental and Physical Health are Intricately Intertwined “Treat the Mind and Help the Heart” “Studies Try to Tease Apart the Links Between Depression and Heart Disease” “Blood Shortage in Heart Linked to Mental Stress” “Defective Warning System Tied to “Silent” Heart Disease” “The Heavy Cost Of Chronic Stress” “Chance of Heart Attack Increases For Those Who Suffer Depression” “Prognosis: Diabetes and Depression Track Each Other” “Which Comes First: Depression or Heart Disease?” “Of Hearts, Minds and Menopause” “Serious Depression Raises Risk of Heart Ailments” “For Some, Psychiatric Trouble May Start in Thyroid” “Risk of Adult Anxiety Seen in Children’s Stomachaches” “Can Strep Bring On an Anxiety Disorder?” “Depression and Anxiety Seen as Cause of Much Addiction” “People Haunted by Anxiety Appear to Be Short on a Gene” “Allergies Can Increase the Risk of Depression” “Depression Raises Stroke Risk in Younger Women” “Does Depression Contribute to Dementia?” “Depression May Raise Risk of Gut Infection” “Exploring the Links Between Depression and Weight Gain” “Dealing With Depression and the Perils of Pregnancy”

3. Mental and Physical Health are Intricately Intertwined “Inflammation Byproduct Linked to Stress” “Facing Up to Depression After a Bypass” “In Sleepless Nights, a Hope for Treating Depression” “Pregnancy, Depression and Acupuncture” “Concussions Tied to Depression in Ex-N.F.L. Players” “After Cancer, Ambushed by Depression” “Personal Health; Helping the depression-prone to quit smoking” “Depression May Slow Exercise Recovery” “Depression Is a Dilemma for Women in Pregnancy” “Mild Depression and Eroding Immunity” “Lack of Exercise Explains Depression-Heart Link” “Gene Link Seen in Drug Abuse and Depression” “Linking Anxiety, Depression and Strokes” “Coping With Depression During Pregnancy” “Probing depression and its ties to diabetes - Health & Science - International Herald Tribune” “Which Comes First: Depression or Heart Disease?” “Aging: Depression Tied to Alzheimer’s” “Virus May Be Linked to Depression” “Can Migraines Cause Mood Swings?” “Remedy for Sleep Apnea May Lift Depression's Veil” “Tracking Stress and Depression Back to the Womb” “Depression More Deadly for Diabetics”

4. Anxiety and Depression

5. Anxiety • Stress: Level and quality of challenge when weighed against our ability to manage • Stress can come from any event or thought that makes you feel frustrated, angry, or nervous. • Chronic stress is one of the major causes of anxiety • Anxiety is a feeling of fear, unease, and worryand you may not know the source of this fear

6. Anxiety Symptoms • Racing heart • Trouble sleeping • Digestive problems • Sense of impending danger/doom • Sweating, trembling

7. Prevalence of Anxiety nimh

8. Depression • Depression is not sadness or grief • Sadness and grief are normal, transitory feelings • Depression is an illness for which sadness may be one symptom among many others. • Depression is more of a constant experience that reacts less to what goes on and affects function.

9. Depression Symptoms • Low or irritable mood most of the time • Aloss of pleasure in usual activities • Trouble sleeping or sleeping too much • Significant change in appetite, often with weight gain or loss • Tiredness and lack of energy • Feelings of worthlessness, self-hate, and guilt • Difficulty concentrating • Lack of activity and avoiding usual activities • Feeling hopeless or helpless • Repeated thoughts of death or suicide, and low self-esteem

10. Prevalence of Depression http://www.cdc.gov/nchs/data/databriefs/db07.pdf

11. Co-Morbidity of Depression and Anxiety • More than 50% of primary care patients who present with anxiety or depression also suffer from a secondary depressive or anxiety disorder (Hirschfeld, 2001) • According to the National Comorbidity Survey, 51% of those with major depression also suffer from lifetime anxiety • Individuals with a high level of work-related stress are more than twice as likely to experience a major depressive episode, compared with people who are under less stress. • Depression shares some of the symptoms of stress, including changes in appetite, sleep patterns, and concentration • Research shows that worry precedes the onset of depression – you can literally worry yourself into a depression. (The Worry Cure)

12. The Body’s Reaction to Stress

13. Links between Anxiety, Depression and Heart Disease • In one 2013 study, for middle- aged women, new onset of heart disease is associated with a history of comorbid depression and anxiety. (Berecki-Gisolf, J et al 2013) • There is growing evidence that depression, anxiety, social isolation, anger, mental stress, are risk factors for cardiovascular morbidity, mortality, or both, in patients with established CHD (e.g., Ahern et al., 1990; Berkman, Leo–Summer, & Horwitz, 1992; Carney, Freedland, & Jaffe, 2001; Carney et al., 1988; Frasure–Smith, Lespérance, & Talajic, 1993, 1995; Penninx et al., 2001). (as quoted in Day, Freedland & Carney, 2005) • Cardiac patients who are anxious or depressed are more likely to attribute their heart disease, to negative emotions such as stress, anger, fear, anxiety, or depression, than are their less anxious or depressed counterparts. Anxiety is an independent correlate of heart disease attributions after adjusting for the effects of gender and age. (Day, Freedland, & Carney, 2005).

14. Links between Anxiety, Depression and Stroke • In some people, prolonged or frequent mental stress causes an exaggerated increase in blood pressure, a risk factor for stroke. • Some studies have shown that depression increases the risk of first stroke and recurrent stroke by 45% to 80% (Wassertheil, Shumaker, Ockene, Talaver, Greenland, 2004 in Yuan 2012) • Being depressed nearly doubled the risk for stroke, even after the researchers accounted for other risk factors like age, education, high blood pressure, diabetes, heart disease, smoking, alcohol intake, physical activity and body mass index.

15. Links Between Anxiety and Depression and Diabetes • A prospective population-based study (N=37,291) investigating the associations between symptoms of depression/anxiety and diabetes was conducted. Individuals reporting symptoms of depression and anxiety at baseline had increased risk of onset of type 2 diabetes at 10-year follow-up. (Engum, 2007) • Emotional stress can increase the risk for the development of type 2 diabetes through different pathways. • The first pathway is via behavioral mechanisms. Emotional stress was found to be associated with unhealthy lifestyle behaviors, (Bonnet et al., 2005; Rod et al., 2009). • The second pathway is via physiological mechanisms. Chronic stress reactions and depression are often characterized by long term activation of the hypothalamic-pituitary-adrenal axis and sympathetic nervous system which were found to be associated with the development of abdominal obesity, and this may explain why depression or chronic stress increases the risk of diabetes (Bjorntorp, 2001; Vogelzangs et al., 2008)

16. But what if you already have diabetes, heart disease or have had a stroke?

17. Mental Health and Diabetes • Rates of depression among individuals with diabetes are estimated to be approximately two to four times that of adults without diabetes [2,3]. • Depression is associated with poorer adherence to treatment regimens, greater symptom burden, poorer glyceamic control, more diabetes-related complications, exacerbations of health problems relating to diabetes, higher hospitalization rates and higher mortality (Poulsen & Pachana, 2010) • Aggressive treatment of depression can prolong the lives of diabetic patients. (NY Times, http://well.blogs.nytimes.com/2007/12/05/depression-more-deadly-for-diabetics/)

18. Mental Health and Stroke • Post stroke depression is associated with a higher risk of recurrent stroke at 1 year. (Yuan et al, 2012) • Post stroke depression is the most common psychological disorder among stroke survivors (Hacakett, Yapa, Parag, Anderson 2005 in Yuan et al, 2012) • 37% of older stroke survivors reported depressive symptoms (Klinedinst, Clark, 2013) • Middle-aged men who suffer from psychological problems like depression and anxiety are much more likely to die of strokes than men who do not, a study reports. But they are no more likely to suffer nonfatal strokes . (NY Times, http://www.nytimes.com/2002/01/29/health/vital-signs-at-risk-linking-anxiety-depression-and-strokes.html) • Neurocognitive changes can include personality changes, mood changes/fluctuations, increased anxiety and depression re: changes

19. Mental Health and Heart Disease • People with heart disease are more likely to suffer from depression than otherwise healthy people. Angina and heart attacks are closely linked with depression. • Up to 15 percent of patients with cardiovascular disease and up to 20 percent of patients who have undergone coronary artery bypass graft (CABG) surgery experience major depression.1 (http://my.clevelandclinic.org/heart/prevention/stress/depressionandheart.aspx) • For people with heart disease, depression can increase the risk of an adverse cardiac event such as a heart attack or blood clots and increase the risk of death • During recovery from cardiac surgery, depression can intensify pain, worsen fatigue and sluggishness, or cause a person to withdraw into social isolation.

20. Depression versus Disease Symptoms • Many symptoms of diabetes, heart disease and stroke overlap with symptoms of depression • Look at cognitive symptoms of depression: anxious rumination and worry, thoughts of guillt and regret, feeling like a burden, feeling worthless, sadness, subjective distress, tearfulness, suicidal thougths,

21. What we can do

22. Knowledge is Power Knowledge + Action = Power

23. Anxiety and Depression Impact on Health Anxious and depressed moods lead to poor health behaviors Decrease in health increases anxious and depressive experiences Poor health behaviors lead to physiological changes over time

24. Anxiety and Depression’s Impact on Health Lack of exercise Poor Diet Depression Anxiety Decreased Socialization Poor Health Habits (e.g. smoking, alcohol consumption)

25. THOUGHTS PHYSICAL HEALTH EMOTIONS BEHAVIORS

26. What We Can Do - Behaviors • Exercise • Diet • Socialization • Work / hobbies • Create structure in day • Practice deep breathing • Mindfulness • See a mental health care provider • Maintain regular check ups with your primary care practitioner

27. What we can do - Thoughts • Ruminative thoughts • Notice • Accept • Let go • Work to understand triggers • Work to understand how connected to behaviors and feelings and physical sensations

28. What we can do - Feelings • Awareness of / Acknowledge • Accept / be gentle • Learn triggers for feelings • Work to understand how connected to behaviors and thoughts and physical sensations • Share with someone you trust

29. What we can do - Physical • Know your body • Be aware of changes • Become aware of triggers • Become aware of connections to thoughts, feelings and behaviors

30. Questions?

31. Know Thyself And Live Well Deborah Nelson, Psy.D. 2013

32. References • Scherrer, J.F., Xian, H., Lustman, P.J., Franz, C.E., McCaffery, J., Lyons, M.J., Jacobson, K.C., Kremen, W.S. (2011). A test for common genetic and environmental vulnerability to depression and diabetes. Twin Research and Human Genetics, 14, 2, 169-172. • Poulsen, K. & Pachana, N.A. (2010). Depression and anxiety in older and middle-aged adults with diabetes. Australian Psychologist, 47, 90-97. • Yuan, H.W., Wang, C.X., Zhang, N., Bai, Y., Shi, Y.Z., Zhou, Y., Wang, Y.L., Zhang, T., Zhou, J., Yu, X., Sun, X.Y., Liu, Z.R., Zhao, X.Q., Wang, Y.,J. (2012). Poststroke depression and risk of recurrent stroke at 1 year in a Chinese Cohort Study. Plos One, 7(10), 1-7. • McDade-Montez, E.A. (2011). Examining the potential influence of diabetes and anxiety symptoms via multiple sample confirmatory factor analysis. Annals of Behavioral Medicine, 42, 341-351. • Klinedinst, N.J. & Clark, P.C. (20130). Adult stroke survivors discussing poststroke depressive symptoms with a healthcare provider: a preliminary analysis. Rehabilitation Psychology. Advance online publication. Doi: 10.1037/a0033005.

33. References • Mezuk, B., Lee, H., Abdou, C.M., Johnson-Lawrence, V., Rafferty, J.A., Uzogara, E.E., Jackson, J.S. (2013). Ignorance Bliss? Depression, antidepressants, and the diagnosis of prediabetes and Type 2 diabetes. Health Psychology, 32(3), 254-263 • Engum, A. (2007) The role of depression and anxiety in onset of diabetes in a large population-based study. Journal of Psychosomatic Research, 62(1), 31-39. • Berecki-Gisolf, J., McKenzie, S.J., Dobson, A.J., McFarlane, A., McLaughlin, D. (2013). A history of comorbid depression and anxiety predicts new onset of heart disease. Journal of Behavioral Medicine. 36, 347-353. • Day, R.C., Freedland, K.E., Carney, R.M. (2005). Effects of anxiety and depression on heart disease attributions. International Journal of Behavioral Medicine. 12(1), 24-29. • http://www.nimh.nih.gov/statistics/1anyanx_adult.shtml • http://www.nimh.nih.gov/statistics/1mdd_adult.shtml • Hirschfeld, R.M.A. (2001). The comorbidity of major depression and anxiety disorders: recognition and management in primary care. Journal of Clinical Psychiatry. 3(6), 244-254. • The Worry Cure • National CoMorbidity survey • http://www.cdc.gov/nchs/data/databriefs/db07.pdf • . (NY Times http://health.nytimes.com/health/guides/symptoms/stress-and-anxiety/print.html)