This is a case study on a 58-year-old male, Mr. H.Y. who worked at a supermarket and is now retired. He has a supportive wife who works full time and children who are all independent .He has a history of smoking, but quit 10 years ago and drinks alcohol twice a week. He is obese and a known case of diabetes for one year. He has gained 8 kg over the past four months, his blood glucose levels are uncontrolled. He denies feeling sad but doesn't like to take part in activities he once enjoyed, he feels tired and lethargic after doing any work, his sleep pattern is also disturbed. His drug history reveals that he is taking glyburide and multi-vitamins. He has scored 14 on his PHQ-9 score which indicates moderate depression. The patient has been diagnosed with depressive disorder not otherwise specified (DSM IV 311).
Mr H.Y has type 2 diabetes which is also known as non-insulin dependent diabetes. It is a metabolic disorder in which the beta cells of the pancreas do not produce enough insulin or there is resistance to the action of insulin on the cells of the body. (Kumar, et al., 2010). It affects 8.3% of the U.S. population. (CDC, 2011) . He has not been taking his medications for diabetes regularly. This increases his chances of developing complications of diabetes. He is also obese which is caused by various factors such as environmental, genetic, cultural, dietary habits, socioeconomic status, endocrine abnormalities, sedentary lifestyle, etc. In Mr. H. Y's case it is most likely due to his sedentary lifestyle, his lack of exercise, and depression. Obesity is prevalent amongst 35.7% of the U.S. population and one-fourth of obese patients are likely to develop depression (CDC, 2011) .Obesity can lead to the development of certain cancers, diabetes, coronary heart disease and may even lead to death.
The social and lifestyle determinants responsible for Mr. H.Y's condition are most likely him retiring from work at an early age due to his co-morbid conditions, more free time at hand, alcohol consumption, past history of smoking, full-time working wife and a chronic illness (diabetes).
According to the DSM IV, this patient has been diagnosed with Depressive Disorder Not Otherwise Specified as it does not meet the category of Major Depressive Disorder, Dysthymic Disorder, Adjustment Disorder With Depressed Mood, or Adjustment Disorder With Mixed Anxiety and Depressed Mood. It includes premenstrual dysphoric disorder, minor depressive disorder in which 2 to 5 of the symptoms of major depressive disorder are present for more than two weeks, recurrent brief depressive disorder, depressive disorder due to any underlying medical condition or substance abuse, post-psychotic depressive disorder of schizophrenia. (American Psychiatric Association, 2000)
To be able to be categorized as major depressive disorder, the patient must have more than one episode of at least five of the following symptoms for more than two weeks. These symptoms include feeling of emptiness, sadness, decreased pleasure in activities once enjoyed, significant weight loss or weight gain, disturbance in sleep pattern (insomnia or hypersomnia), fatigue, suicidal thoughts, feeling of guilt for no valid reason and slowing down of neurologic function and inability to concentrate. (American Psychiatric Association, 2000). Mr. H.Y. has denied feeling sad, has no feeling of guilt and does not have suicidal thoughts, but is suffering from all the other symptoms of depression.
Depression occurs in about 1 in 10 adults in the United States and is influenced by biological factors as studies show that there is a high incidence of depression amongst first degree relatives even if they have not been raised together. It is also influenced by environmental facts. Lack of support from family members, stress, financial problems, occupational problems are all situational factors that worsen a depressive disorder. (NANDA nursing, 2012).
The treatment of diabetes entails tight glycemic control and lifestyle modifications such as exercise and a diet which is low in carbohydrates and high in protein. Pharmacologic treatment is essential in maintaining blood glucose levels. Sulfonylureas are drugs that stimulate the release of insulin from the beta cells of the pancreas. Meglitinides also stimulate their release of insulin from the pancreas, but they are short acting compared to sulfonylureas. Biguanides reduce the production of glucose by the liver and increase utilization of glucose in the peripheries thereby controlling blood glucose levels. Alpha glucosidase inhibitors delay the absorption of glucose and prevent a rise in glucose levels after a meal. Glitazones work by increasing insulin sensitivity of cells. Incretin mimetic agents reduce glucagon and stimulate the release of insulin. If all therapy fails insulin can be added to the diabetes drug regimen. Mr. H.Y should aim to drop his weight by regularly exercising, reducing intake of alcohol, behavioural changes by joining support groups. Diet pills and liposuction or other weight reducing surgeries can help reduce weight . (NANDA nursing, 2012)
Depression is effectively treated with pharmacologic therapy along with cognitive behavioural and interpersonal therapy. There is a wide range of drugs used to treat depression. Selective serotonin reuptake inhibitors such as citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline are the best drugs offered to treat depression. They act by inhibiting the uptake of 5 HT and stimulating 5 HT-1 receptors thus causing antidepressant and anxiolytic effects. They have a good safety profile, are easy to administer and they don't require a dose adjustment. They may however cause depression, nausea, anxiety and insomnia, sexual dysfunction. Serotonin modulators such as trazodone,, nefazodone, mirtazipine block 5 HT -2 receptors and prevent reuptake of 5 HT and norepinephrine. Nefazodone does not cause sexual dysfunction and produce peaceful sleep without suppression of rapid eye movement sleep, however it may cause liver toxicity. Mirtazapine causes the blockage of 5HT 2 and 3 receptors. It increases the function of serotonin and does not cause nausea and sexual dysfunction. It causes weight gain and sedation. Selective norepinephrine reuptake inhibitors such as duloxetine and venlafaxine have the same action as 5HT and norepinephrine. They have the same toxicity as SSRI's. They may cause loss of appetite, dizziness, fatigue, weight loss, nausea, sexual dysfunction, urinary retention and elevated blood pressure. Norepinephrine dopamine reuptake inhibitors such as bupropion do not effect on the 5- HT system, rather they effect the catecholaminergic, nonadrenergic and dopaminergic function. They can cause agitation and hypertension. Monoamine oxidase inhibitors act by increasing the availability of norepinephrine, dopamine and other phenylamphetamines. They are used as a last resort when depression is refractory to all other antidepressants and even electroconvulsive therapy. They should never be taken with a tyramine diet or along with other sypathomimetic drugs. Heterocyclic antidepressants act by increasing availability of 5HT and norepinephrine. They are very effective but rarely used due to the overdose toxicity and have more adverse effects than other antidepressants. (Mycek, Harvey & Champe, 2010)
There are also several non-pharmacologic modes of treatment for patients with depressive disorder; out of which psychotherapy is the most studied. The sole role of psychotherapy is beneficial for treatment of patients with mild to moderate depression. However, psychotherapy is often combined with pharmacologic drugs for the treatment of severe depressive disorder. Out of all the forms of psychotherapy, Cognitive Behavioral Therapy, CBT, and Inter-Personal Therapy have yielded the most positive results. (Gelenburg et al., 2010)
Cognitive behavioral therapy is a combination of two techniques, that is, cognitive therapy and behavioral therapy. Cognitive therapy focuses on a person's thoughts and beliefs, and how they affect a person's mood and actions. It analyzes a person's perception of certain situations. The combination of cognitive therapy with behavioral therapy allows a person to change the way they think and to be more adaptive and healthy. It helps patients get rid of unhealthy behavior patterns. (Wood & Wood, 2008)
In CBT, the therapist facilitates the patient in identifying healthy behaviors from those that are harmful. The patient is then allowed to identify ways to change such negative behavior into positive ones. The role of CBT in treating depressive disorder with type 2 diabetes is significant and is associated with improved glycemic control. According to a study, eighty five percent of patients who received CBT achieved remission of moderate depressive disorder after ten weeks of therapy. About seventy percent of patients remained symptom free at the six-month follow-up period. (Williams, Clouse & Lustman, 2006)
Inter-Personal Therapy is another mode of therapy that is useful for the treatment of mild and moderate depression. This mode of therapy focuses on the interpersonal context and on building such skills. This mode of therapy stems from the universal belief that mood disorders are related to three components and should be treated in regards to these components. This model is called the behavioral-psycho-social model. IPT plays a significant role in establishing such a model of care. The major emphasis of this mode of therapy is on interpersonal processes and it aims on changing a person's interpersonal behavior by helping the patient adapt to current interpersonal roles and situations. (Wood & Wood, 2008)