A symposium that focused on the relationship between behavioral health and diabetes examined how the challenges of living with the disease wear on patients over time, ahead of results presented Sunday showing that much of what is diagnosed as "depression" in diabetes may not be. Presenters offered 3 models for better coordination of care.
Diabetes is medical condition that not only damages the body, it can also crush the spirit of those who have it. A lifetime of following diets, counting carbohydrates, sticking with medication schedules, managing insulin injections, and visiting a fleet of doctors can wear diabetics down, even if they are doing everything right.
So, how should doctors serve those who suffer depression alongside the disease, both type 1 (T1DM) and type 2 diabetes mellitus (T2DM)? Tackling both conditions at once was the theme of a Saturday symposium at the 74th Scientific Sessions of the American Diabetes Association (ADA), being held at the Moscone Center in San Francisco, California.
“Bending the Curve: Behavioral Health Efforts in Diabetes and Healthcare Reform,” featured 3 examples of efforts to better coordinate care, especially for those whose symptoms or history suggest they are most likely to land in hospital. But first attendees heard from William Polonsky, PhD, CDE, who is associate clinical professor at the University of California at San Diego and head of its Behavioral Diabetes Institute.
Dr Polonsky delivered the Richard R. Rubin Award Lecture, which he titled, “Important Lessons My Patients Have Taught Me.” His premise: Decades’ worth of papers, studies, and efforts force lifestyle changes have gone overboard. In Polonsky’s view, if patients aren’t responding, it might be time to stop blaming them, and for doctors to “look in the mirror.”
“Does behavior matter? Yes, it matters a lot,” he said. But “evidence of the power of collaborative action planning,” in which doctors and patients agree on diet and exercise goals, is sorely lacking. “Why is it so hard?” Dr Polonsky asked. “Habits are hard to change.”
“Diabetes is a lot of work. The day someone is diagnosed, they’ve just been given a new job for the rest of their life,” that doesn’t pay and has “no days off,” he said. It’s time for doctors to “step back and think differently” about what they expect from persons with diabetes.
Real change, he said, requires 3 steps, which Dr Polonsky called:
Taking time, he said, requires doctors to gradually warm up their patients to the idea of change, to get their buy-in, to not push so hard that patients don’t come back. When patients don’t meet goals, “We have been focusing on the behavior rather than what’s behind the behavior.”
Motivational interviewing, for example, is getting lots of attention. But a review of 4 studies on its effects since 2010 showed 0.1% difference in A1C among the patients studied. Setting goals patients won’t buy into may be worse than doing nothing, Polonsky said.
Looking at “the mundane” asks doctors to isolate obstacles to meeting goals. Many patients who take antidepressants, he said, may show symptoms that are really “diabetes fatigue,” or “burnout,” from handling the disease every day. He hinted at data that was formally presented Sunday, which showed that overall rates of depression in T1DM and T2DM may not be as high as previously believed. (On Sunday, the ADA released a study co-authored by Dr Polonsky and led by Lawrence Fisher, PhD, ABPP, of the University of California, San Francisco. In the study, persons with diabetes whose scores on a standard questionnaire showed they were suffering depressive symptoms were prescribed 1 of 3 interventions. None of these interventions treated depression per se, but instead helped them manage their diabetes. After 12 months, participants in all 3 intervention groups were able to lower their scores on the questionnaire.)1
Change can come in small steps. Dr Polonsky showed data from a patient who was asked to take his blood glucose right before and right after a 45 minute walk for 7 days. The average drop each day was 35 mg/dL, and the results were a revelation to the patient. Seeing that exercise is worth it did more convincing than another lecture, Polonsky said.
“Actions that matter” are recommendations that give both doctor and patient “bang for your buck,” he said. Instead of giving the patient a list of a dozen things to change, focus on one that’s really important, like taking medication properly.
Two other speakers, Paul Ciechanowski, MD, MPH, of the University of Washington, and Mark Williams, MD, of the Mayo Clinic, presented related approaches to collaborative care, in which primary care physicians (PCPs) and psychiatrists work in teams, along with care coordinators and diabetic educators. The key element of this approach is the systemic case review, usually once a week, in which the team reviews individual patients’ progress. Team members are given assignments for the following week, and Dr Ciechanowksi said everyone is held accountable — not just the patient. The TEAMcare approach, featured in the New England Journal of Medicine, saved an average of $594 per patient.2
Dr Ciechanowski said the collaborative model has several advantages: It addresses comorbid conditions, and patients with diabetes and mental health issues often have 4 or more diagnoses; it catches the need for “treatment intensification,” by taking on “clinical inertia,” the phenomenon of putting patients on antidepressants but not adjusting the dose as needed; and it offers psychic benefits to the providers, who get support from each other and feel less strained.
Dr Williams noted that this “population management” approach, so different from the “disease-based” approach in which so many were trained, really requires a different way of thinking. This method forces the providers to look for those patients who are not well but simply aren’t “noisy” and demanding someone’s attention. Those quiet patients are the ones who are often missed, he said.
Saving Lives, Costs in Type 1. Michael Harris, PhD, of the Oregon Health and Sciences University, presented a model to reduce hospitalization days among youth with T1DM. Even with strong family support, teenagers may struggle with regimens as they begin managing their disease on their own. But among the Medicaid population that Harris’ group treats, high rates of parental unemployment, single parenthood, or even homelessness makes staying on insulin or diets more perilous.
The program, Novel Interventions in Children’s Healthcare (NICH), pairs youth who have had multiple hospitalizations with “interventionists,” who do everything from coordinating medical care to attending meetings with school officials to making home visits. Early success stories included eliminating hospital stays for youth who had been admitted 9 times in 8 months for diabetic ketoacidosis (DKA), which can mean the teenager or a parent has failed to keep adequate insulin or supplies on hand.3
These life-threatening episodes tax both the patient and the hospitals that serve them; as Harris noted, Medicaid reimbursement rates often mean such incidents are a money-loser for the provider. Youth that NICH targeted made up 4.5% of the diabetic population, but were consuming 50% of the healthcare resources, Harris said.
Success starts with understanding what Harris called “the context” of behavior. “If you don’t know the context in which the behavior is occurring, you can’t change it,” Dr Harris said.
NICH’s first patient was a 15-year-old female who previously had 2 DKA episodes over 4 years. Then, in 2012, she had 12 in a year. The NICH interventionist uncovered upheaval in her home and a mother unwilling to provide supervision. “We moved her into a great aunt’s home, where she has stayed and thrived,” Dr Harris said.
Hospitalization has not been eliminated among this group, but it has been dramatically reduced. “Every single person (enrolled” reduced hospital stays,” he said. NICH saved Oregon Medicaid $116,814 in a year, cutting hospitalization costs from $158,616 to $41,702. And that’s just what Medicaid was paying—savings to the hospitals is likely higher.
Being an “interventionist” is a 24/7 job, so duties rotate among a dozen staff, who are actively encouraged to take down time said. But the interventionists often push back. “There’s so much ownership of this,” Dr Harris said. “You can effect change that no one else can do.”
1. Fisher L, Polonsky W, Hessler D. A new validated measure of diabetes distress for adults with type 1 diabetes. Diabetes. 2014;63(suppl 1): Abstract 67-LB.
2. Katon WJ, Lin EHB, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363:2611-2620.
3. Filling a NICH. Oregon Health and Sciences University website. http://www.ohsu.edu/blogs/doernbecher/2012/08/22/filling-a-nich/. Accessed June 15, 2014.