ORLANDO – Asking just a few questions about mental health from patients with type 2 diabetes helped identify underlying depression, and a consequent referral to a behavioral coach improved the patients’ mental health status and diabetes self-management skills, according to a pilot study in rural North Carolina.
The patients who had depression received three coaching sessions with a social worker over a 3- to 6-month period, and their hemoglobin A1c dropped by 1%, while their depression scores were cut in half. "We also may have prevented 11 suicides," said Melissa Herman, who presented the poster at the American Academy of Diabetes Educators.
The findings could also mean that behavioral coaching may "improve diabetes self-management among those who do not present with depressive symptoms ... as an array of other tangible and intangible barriers may impede the patient’s ability to proper self-management," Ms. Herman and her colleagues wrote in their study.
The mental health aspect of diabetes care can go unnoticed and untreated if providers don’t open the conversation because of a lack of training, comfort, or resources. This could especially affect patients in rural areas where access to care is limited and many are uninsured and underinsured.
The FirstHealth Diabetes Self-Management Program began screening all patients for depression and anxiety in three rural counties in North Carolina where more than 60% of the population is below the poverty level, and the diabetes prevalence is 16%, compared with 9% statewide, Ms. Herman said. In addition, roughly 30% of patients with diabetes have depression.
"We realized that there really were no resources for patients who had underlying depression or other mental health issues," said Ms. Herman, a registered dietitian and certified diabetes educator who is the director of the diabetes program at FirstHealth of Carolinas.
"Folks were not asking or screening these individuals about depression, and we really felt like the depression interfered with their ability to take care of their diabetes, because the lack of jobs, lack of access to care, medication, and social issues trumped the diabetes care."
Five diabetes educators were trained to screen every patient for depression and anxiety with a Patient Health Questionnaire–2 tool or – PHQ-2. The tool was built into the electronic medical record.
Out of 2,233 patients screened from June 2011 to July 2013, a total of 222 were referred for behavioral health coaching with a social worker, and 181 kept their initial appointment. Those patients were further assessed with the PHQ-9, a more advanced questionnaire, and saw their coach an average of three times over a 3-month period.
Researchers found that in roughly 60% of the patients, the PHQ-9 scores improved by average of 50%, hinting at improvement in depressive symptoms.
Also, more than half of the patients had a 1% drop in the HbA1c levels, from an average of 8.9% to an average of 7.8%.
The behavioral health coaches also negotiated 11 life contracts, which were used when there was a suspicion of self-harm. Those patients were also referred to psychiatric services.
Another important factor in success of the program was having a mental health coach who had a background in social work, health education, and diabetes knowledge. "This proved key to linking the behavior change to the influence of disease management," Ms. Herman and her colleagues wrote in their poster.
The team continues the program, even though the grant that initially funded the project has ended, "because it’s been phenomenal," said Ms. Herman. "It’s not time intensive, it’s just a matter of telling people that it’s okay to vent, and then give them some coping skills."
Ms. Herman had no disclosures.
On Twitter @naseemmiller