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Lisa Nainggolan

ORLANDO, Florida — New research shows that diabetes educators assessing patients for signs of depression and anxiety and referring them on to mental-health coaching if they require it is a beneficial strategy.

Such a stepped-level approach resulted in improved symptoms and lower blood glucose in a pilot study in a rural, low-income area with a high rate of type 2 diabetes, researchers reported this week at the American Association of Diabetes Educators (AADE) Annual Meeting.

Melissa Herman, RD, CDE, program director of the Diabetes & Nutrition Education Center of FirstHealth of the Carolinas, Pinehurst, North Carolina, presented the findings during a poster session.

She told Medscape Medical News: "The most important thing is [for diabetes educators or physicians] to ask patients with diabetes about depression."

Once her team established who had such symptoms, they got 80% participation in the next stage, which was for patients feeling this way to see a social worker, trained to give them behavioral coaching, she explained. As well as the benefits in terms of better blood sugar control and reduced depression and anxiety, the social worker also negotiated 11 "life contracts," she said.

These were patients whom the social worker felt might harm themselves or others, and they were referred to psychiatry services. "These were potentially 11 suicides, or [at least] suicide attempts, averted," said Ms. Herman.

Advice on How to Adjust and Cope With Diabetes

Ms. Herman explained that a significant number of people with diabetes suffer from depression, which can interfere with their ability to participate in self-care activities, which are key to managing this chronic, progressive disease.

But doctors have almost given up asking patients about depressive symptoms altogether, she noted, often because the resources to deal with this are limited, so they don't feel there is much they can do.

She and her colleagues developed a program to identify and provide resources for depression among people with diabetes in central North Carolina, an area where nearly 16% of the population has diabetes (vs 10% nationally): 30% of them have depression, and 65% live below the poverty level.

Patients with type 2 diabetes were referred to 1 of 5 diabetes educators for self-management education. All patients were taught how to manage their disease and be as healthy as possible by focusing on the AADE7 Self-Care Behaviors: healthy eating, being active, monitoring, taking medication, problem solving, healthy coping, and reducing risks.

In this program, the educators also incorporated a Patient Health Questionnaire-2 (PHQ2) assessment tool for behavioral/depression/anxiety issues into the electronic medical record. This was used to refer patients with abnormal readings on this scale to the behavioral-health coach.

In this instance, this was a social worker who was well-versed in diabetes, Ms. Herman explained. But this is not a common finding, she acknowledged, noting that more training of such individuals with regard to diabetes is sorely needed.

In the poster, Ms. Herman reported on 1164 patients assessed by diabetes educators from June 2011 to June 2013; 152 patients scored abnormally on the PHQ2 tool and were referred on to the social worker.

Of the 152, 126 kept their initial appointments, an 82% "show rate."

This indicates that "these folks wanted help; they were just not sure how to go about it," Ms. Herman stressed. "It's about teaching folks how to adjust and cope better with their diabetes."

The individuals who displayed depressive symptoms had an average of 3 visits with the social worker, approximately once a month, lasting for an hour. "They felt like this was sufficient to help them," she said.

Following the mental-health coaching, 53% of patients displayed improved depressive symptoms — the average precounseling PHQ2 score was 13 (indicating moderate severity of depressive symptoms). At the end of the sessions, this average score had fallen to 5.

In addition, 54% of the patients seen by the mental-health coach had a reduction in HbA1c levels, from an average of 8.8% before the sessions to 7.7% afterward.

"The program was to be piloted for a two-year period but has been so powerful we have continued it," Ms. Herman noted.
 
While healthy coping is an essential part of diabetes education, mental-health coaching takes it to another level for people who struggle with depression.
 
"While healthy coping is an essential part of diabetes education, mental-health coaching takes it to another level for people who struggle with depression. Those who had mental-health coaching said it was life-changing and lifesaving and helped them feel better and happier than they had in a long time," she explained.

Avoiding Potentially Disastrous Consequences

Importantly, the mental-health coaching helped identify 5 patients at risk of harming themselves or others, as reported in the poster, said Ms. Herman. But with the continuation of the pilot program, this total now stands at 11 people, she told Medscape Medical News.

These patients were referred for higher-level psychiatric services, with the social worker providing the mental-health coaching being mentored by a psychiatrist, she explained.

"We did not anticipate this level of stress, depression, and anxiety, and we were very grateful to have that social worker available."

Asked to comment on the cost of this program, M. Herman said it is "pretty small. The tools are there, they are free, it's just about training the staff, and the clinical social worker's time. It's a step forward to establish this type of referral program."

Ms. Herman has reported no relevant financial relationship.

American Association of Diabetes Educators Annual Meeting. Poster P23, presented August 6, 2014.