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ECHO 5: Diabetes, Depression, and Behavioral Health

Learning Objectives
1. Describe the most common psychosocial issues affecting people with diabetes
2. Differentiate depression and depressive symptoms from other psychosocial issues
3. Identify validated screening tools for psychosocial issues
4. Review evidence-based treatment guidelines for depression and other psychosocial issues in people with diabetes
1 Credit CME

This is part 5 of Project ECHO: Prevention and Management of Diabetes and Cardiometabolic Disorders in Community Health Centers. This series explores diabetes and cardiometabolic care from the endocrine perspective and the factors unique to the health center community, such as the need for clinical care integration and mindfulness towards health disparities. This 6-ECHO series will focus on approaches to cardiometabolic care and management in the primary care, and typically rural, setting and how to bring best practices to this unique arena. The ECHOs will incorporate endocrinologists and FQHC staff, such as certified diabetes educators, nurses, and behavioral health specialists, as they explore the many ways to manage diabetes and its comorbidities (such as depression, cardiovascular disease, hypertension, etc.) as well as considerations when working with the special populations FQHCs serve. This series will bridge the gap between specialty endocrine care and the primary care setting by focusing on FQHCs and their unique placement within these special populations.

This presentation includes a review of depression and other psychosocial issues prevalent in people with diabetes. This review distinguishes common features between psychosocial issues, and highlight brief, validated screening tools for clinical use. Finally, this session incorporates evidence-based interventions for the treatment of depression and other psychosocial issues in people with diabetes.

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Video Transcript

Andrea Quiles-Sanchez: [00:00] Hello, everyone, and thank you for joining us today. As you know, my name is Andrea and Endocrine Society and I are your host for this ECHO series, Project ECHO Prevention and Management of Diabetes in Cardiometabolic Disorders and Community Health Centers, which is funded by Abbott Diabetes Care. I'm so excited to welcome you to our fifth ECHO in the series, if you can believe it: Diabetes, Depression and Behavioral Health. As a reminder, we ask that, if possible, that you keep your cameras on and participate in the discussion with our facilitator. We invite you to share your experiences and expertise. Please try to remain muted if you're not actively speaking. Always feel free to unmute and speak directly. And you can also always send chats through the chat box.

In the interest of time today we ask that everyone introduce themselves in the chat, share your name, your role and where you're calling in from. Today I am pleased to welcome Dr Elizabeth Beverly. Dr Beverly is a professor in the Department of Primary Care—[cross talk] [Cross talk] Dr Beverly is a professor in the Department of Primary Care at the Ohio University Heritage College of Osteopathic Medicine and codirector of the Ohio University Diabetes Institute. Dr Beverly graduated from the Pennsylvania State University with a Doctor of Philosophy degree in bio-behavioral health in 2008. She completed a five-year postdoctoral fellowship in diabetes at Harvard Medical School with the Joslin Diabetes Center in 2013. Dr Beverly's research and diabetes focuses on understanding the linkages among cycle, psychosocial issues, self-care, and health outcomes. She employs mixed methodology to examine the culture and context of diabetes self-management. And with that, I will turn things over to Dr Beverly.

Liz A. Beverly, PhD: [02:02] Thank you so much, Andrea, I'm excited to talk today. I'm going to get my slides up and running. As she said, I have dedicated my life so far to studying the psychosocial impact on diabetes, and that's both Type 1 and Type 2. And so what I'm going to be doing today is just doing a review about that. All right. Are we good? We're good now. Yes, we're good. Okay, wonderful. I didn't give too long of a bio, but today we are going to be talking about diabetes, depression, and behavioral health. Some of the objectives we're going to be going over is: I'm going to talk about depression, but I'm also going to go over some of the most common other psychosocial issues that affect people with diabetes. And then I want to differentiate depression and depressive symptoms from those other psychosocial issues to help you all of you. I want to identify some of the most important validated screening tools to identify those psychosis, social issues, and then review some of the evidence-based treatment guidelines.

Let's first talk about diabetes and depression. We're all aware that people with Type 1 and Type 2 diabetes have elevated depressive symptoms and major depression to the point where the prevalence is actually one out of four or 25%. And you can see that compared to the general population without diabetes, which is about 11%, so it's a significantly higher risk. I also wanted to point out that there is an observed gender difference in the research: we can see it's 28% for people who identify as women compared to 18% who identify as men. I do want to put a little asterisk next to that: We're talking about this in the research realm. A lot of times in research study, you'll see that more people who identify as women tend to participate in research, as well as they might be more forthcoming about the depressive symptoms.

Why is this important? Well, people experiencing depressive symptoms, major depression, this all negatively impacts self-care, as well as a one C. And if you perform less self-care, you have a higher frequency, it increases your likelihood of developing diabetes complications, it decreases your physical functioning, increases rates of hospitalization, and then ultimately mortality. I do want to point out, research has shown that it's a bi-directional relationship: The lifetime history of depression will actually increase your risk of Type 2 diabetes, and that range is between 38 and 60%. It's believed to be through the activation of neuroendocrine and inflammatory responses, and that induces insulin resistance. But it's also important to note, again, it's bidirectional, that simply being diagnosed with diabetes—and we know how difficult it is to live with diabetes, the 24 hours, seven days a week of dealing with diabetes self-care, and the worries and frustrations you experience that can also lead to depressive symptoms as well as major depressive disorder.

This is just a quick review, if you're looking at the diagnosis of major depressive disorder in the DSM five, you have to either a criteria one or two for at least two weeks, and then for other associated features. My reason for showing this is I do a lot of research on depressive symptoms and depression and I use a lot of questionnaires. A lot of you are most likely using these questionnaires as well in your clinics, it's important to note that if you look at a lot of these features, they also overlap with hyperglycemia and hypoglycemia. If you do have a positive screen, also pay attention to someone's blood glucose values, or A1C, and if they do screen positive, refer for the clinical interview for proper diagnosis.

Talking about this, there's some new research that actually someone who is on our hub team has been a part of, and that's Dr Shubhra. This is coming out of the ACTIV Trials, ACTIV-1 and 2 for Program ACTIV. And this is about the number and duration of clinical depressive episodes: The mean number of lifetime episodes for major depression is about two, and the episode duration of how long they're experiencing that episode of depression is approximately two years. The mean lifetime exposure to all depression diagnoses is approximately three and a half years to five years—that's a lot. When you're thinking about this... some of the takeaways from this program act of these trials is the episode length becomes longer with each subsequent episode of depression and periods between episodes become shorter. If you're seeing a new patient, and they have a history of depression, you need to know that most likely they will have another episode of depression, it will be longer., and the period between the episodes of depression will be shorter. And it's just something to make note of.

So what is it that you do? Again, most clinics are already screening annually if not every visit and so there are great tools that you can use: Most of us are familiar with the patient health questionnaire. There are multiple versions, there's a PHQ-9, which is used, PHQ-8, too, we have the Beck Depression Inventory, and then the CESD, but there are numerous tools that you can use. If you get one of these screening tools, if someone screens positive based off of a cutoff score, the best thing to do is to refer to a mental health provider. It is preferable to refer to somebody who has experienced cognitive behavioral therapy, interpersonal therapy, or other evidence-based treatments, which I'm going to share in a minute. One of the other things—just to make note of and I'm going to talk about it—is if someone is physically able to, incorporate physical activity into their self care. And here's the reasoning: This Program ACTIV trial, which has been great, they actually compared four different arms.

The first arm was 10 sessions of CBT therapy, 12 weeks of community-based exercise, and then an arm that had both of them, and then usual care. You can see with the findings, all of the active interventions improved depression and depressive symptoms for 12 weeks. Then, when you looked at the combined arm with CBT and exercise, they showed an improvement in A1C by over a percent compared to usual care. This is the reason among with other research trials, it shows the benefit of incorporating physical activity. In a somewhat similar study, looking at Veteran Affairs, they also use CBT, but it was delivered via telephone counseling and it incorporated walking, and compared that to usual care. Their follow up at one year is that they showed reductions and depressive symptoms, and there was a reduction in both groups, but there was a significant difference with the treatment group receiving the telephone therapy as well as the walking. But they did not see a difference in A1C 12 months.

Another study that was actually conducted out of Germany with several different health care clinics: they looked at people with diabetes, people diagnosed with major depression, and they randomized them to 12 weeks of CBT or sertraline, and you can see that they had improvements in both groups, but there was a significant advantage for sertraline. Again, similar to the other trial we just discussed, there were no improvements in A1C. The take-home from that is: there are lots of available treatments out there for depression, and perhaps to include physical activity. One of the other common psychosocial issues that we are all familiar with is anxiety. You can see here at the top of the slide, that the lifetime prevalence for anxiety is quite high for people with diabetes, so it's about one in five people. Anxiety is something to take note of, because it increases the likelihood of unhealthy behaviors such as smoking, following an unhealthy diet, and physical inactivity. People can worry about a variety of different things living with diabetes, but they can express excessive worry about complications and hypoglycemia, and those things can then lead to generalized anxiety disorder.

I also want to make note: if there are individuals, depending on what type of medication that they're on, if they experienced a severe hypoglycemic event—and I mean a very severe one—that can be associated with post-traumatic stress disorder as well as panic disorder. What are the recommendations for this? It's to screen people for anxiety if they're showing this excessive worry—excessive worries about complications, insulin injections or infusions, or excessive worry about hypoglycemia. I picked out two different screening tools that are available for free online: The Generalized Anxiety Disorder Questionnaire 7—the GAD-7—and the Hamilton Rating Scale for Anxiety. Again, it's not recommended widely disagree and routinely for anxiety just yet in the diabetes community, but they recommend screening for those who show anxiety symptoms. Some of those symptoms would be someone's showing avoidance behavior, excessive repetitive behaviors, or social withdraw.

In terms of the evidence-based treatment, there is a lot less research on diabetes and anxiety, so there are very few interventions to draw from. But there was a systematic review that looked at mindful-based interventions, and they did have a study in there that showed deep breathing exercise can show improvement for anxiety and people with diabetes. And I also put in parentheses, it also helps for people with depression and diabetes distress, and I'm going to talk about diabetes distress in a minute. I also looked at a Cochrane Review—Cochrane Reviews are great, they're all evidence based—and this showed in terms of general treatments for anxiety, so this is for general adults, the general population. Any adult with anxiety, who receives collaborative care treatment shows statistically and clinically significant improvements in their anxiety. This showed improvements that can last up to two years, it improves medication taking and improves their quality of life, and they also show better patient satisfaction.

I had mentioned before on the previous slide diabetes distress. We're all familiar with depression, we're also familiar with anxiety, but maybe not everyone here is familiar with diabetes distress. This is something that I put a lot of my research time into. Diabetes distress refers to the emotional stress of living with diabetes. And there's a lot of things to worry about when you have diabetes: You worry about complications, you worry about cost of care, you worry about whether or not you have support from your family and friends and loved ones. That's what this diabetes distress is measuring: your worries, concerns, frustrations and fears about living with a demanding progressive chronic illness.

[12:42] I do want to make a point about this: Diabetes distress is distinct from depression, it is distinct from anxiety, but you can also be overlapping, so you can have diabetes distress, and depression, or you can have diabetes distress and anxiety, but it is not a proxy for major depression or for anxiety. In terms of the research and the prevalence? Well, in the research literature, there have been two recent meta-analyses that show an average for diabetes distress—and this is high levels of distress—there's a prevalence about 22 to 36%, so we're talking about a significant proportion of people with diabetes. The reason why we need to pay attention to diabetes distress is compared to all other psychosocial issues. Diabetes distress is more closely associated with decreased diabetes, self-efficacy, fewer self-care behaviors, higher A1C levels, increased complications and decreased quality of life.

So recommendations are that we should monitor routinely with screening measures, and there are some great screening measures out there for diabetes distress. The first one is the problem areas and diabetes that actually came out in 1995. And they do have it's a 20-question survey, but they do have two short forms. So there's the paid five, which is five questions, and then there's the paid one, and the sensitive specificity is pretty good for that. Then there are two more recent US screening measures. There's the diabetes distress scale, which is predominantly used for people with Type 2, and they also have a short version, which is a DDS two. And then there's one specific for people with Type 1 diabetes, which is the Type 1 diabetes distress scale. And what's recommended is if anybody screens high, you know, moderate to high for diabetes distress, it's to refer them first as a first line treatment to diabetes education. And then if after they've received their diabetes education, and after you've monitored them for a couple of months, and they haven't shown any reduction in their diabetes distress. The second line treatment is to refer to a behavioral health provider.

So I did want to point this out that there is a website out there that is actually from behavioral healthcare providers who created these surveys. and you go to this website, they are free to use for free for you to use. And you can see that they provide these screening tools in different languages, you can administer these screening tools online, and they score them automatically so that you don't have to score it on your own. And again, they are free to use. So it's a fantastic resource for all of us. So in terms of interventions I've mentioned, first line of treatment is diabetes, self-care. So when you are going through and if you take a moment to look at some of those screening tools, you can actually find the source of frustration. So it could be about checking our monitoring someone's blood glucose levels, it could be specific to food and meal preparation. And if you identify those things, targeted diabetes education can be quite helpful. Research has also shown that lay lead education, so support from peers and community health workers is also very helpful, and it can reduce diabetes distress. But if diabetes education does not work, the second line of treatment is referring to behavioral health care.

And so there have been several interventions already focusing on diabetes distress. And what they've shown works is cognitive behavioral therapy, which I feel is a theme throughout this entire talk. So cognitive behavioral therapy is: reduce diabetes distress, motivational interviewing, and then emotion regulation. And it's important to know emotion regulation also incorporates part of CBT. And so if you are looking, I know several people on this call in rural regions, like myself, if you are looking for who to refer to, there is a directory of mental health professionals who are qualified to treat people with diabetes who are experienced, experiencing psychosocial issues. And this is the website right here, if you wanted to look that up, you could also just go into your web browser and type in, you know, mental health provider directory listing, and it will pop up, you can type in where you're located your zip code your city, and it'll tell you who's closest living to you. And what's great about that now is teletherapy is quite accept, accessible. And so you can have people even if they're far away.

And then on the note that I wanted to close on, is if we're going to be talking about psychosocial issues, we should also talk about diabetes stigma. And so diabetes, stigma refers to negative feelings, so excluding people rejecting them, or blaming them because of their diabetes. And both people with Type 1 and Type 2 experienced stigma and talk about having stigma. The stigma that's most commonly reported for both people, is the perception that people with diabetes are responsible for developing their own diabetes. And the reason I'm bringing this up is people with diabetes perceive this from their family members, their friends, their loved ones, but they also talked about receiving this from their health care providers. And so people who perceive stigma, report higher levels of psychological distress, more depressive symptoms, less social support, and lower quality of life. So feeling stigma does turn into psychosocial issues. So what are something that we can do? Well, there's some simple things that I think that we can focus on. And one of those things is just changing the language that we use. So there are a lot of international guidelines out there and stuff in the United States, about swapping different words. And that can have a major difference and reducing stigma. We can also do contact based education with family members and peers, or students if we're at a university. And that's just giving people contact with people with diabetes so that they can learn about diabetes. And then just a way of raising awareness or promoting any kind of advocacy work to address stigma. And so that's the end of my talk and happy to see if there any questions in the chat.

Rayhan A. Lal, MD: [18:40] Liz, I was monitoring and nothing came up so far. But I'm sure there are questions so I can turn it over to the group.

Shirley Wong, PharmD: [19:12] Hi, this is Shirly. I don't have a question per se, but I do have comments. I loved that you mentioned the (PAID)-5. We actually do use that in our patients a lot, And the P20 was a little bit long, so we did resort to the five. We ask the patient to explain why they feel "This is not a problem," or "This is a serious problem," because sometimes they are in denial or maybe they just recently got diagnosed and feels like nothing's a problem, so the more you have them open up to share stories, that can help in addition to using that questionnaire.

Beverly: [19:47] Thank you so much. Thanks for sharing that. Does anyone else use any of these screening tools?

Lal: [20:03] Liz, we did have a couple of questions pop up in the chat about who should be giving the screening? And what would be your approach to someone who is afraid of injecting insulin?

Beverly: [20:15] Sure. In terms of the screening, I see that as... we have a lot of providers here, who are on this call, who can give their recommendations. I would even ask Shirley based off of what you just said. But it's really a practice decision. If you want to have a nurse do it or a medical assistant or you yourself want to do it, a lot of it has to do with the resources that you have at your clinic. Some of us are in very rural areas that we don't have those resources. So you might have to do that yourself. So for example, Dr Shubrook, I know that you work with Shirley correct? Who administers the screening tools at your office?

Jay H. Shubrook, DO: [21:00] So in the farm to home, it would be surely in the team in the office, it's actually often the MA that does it as part of the check in at least annually.

Lal: [21:17] Liz, we had a request in the screenshare, as well, I'm sorry, thank you.

Beverly: [21:30] Oh, that's great, I see that people are using the GAD as well as the PHQ. That's wonderful. In terms of the approach for someone who is afraid to injecting insulin, Dr Shubrook gave a talk two months ago, and he was talking about the insulin, and one of the things that he mentioned is demonstrating in the office. Because a lot of the times, whether it's a fear of the needle and not knowing the needle size or the length. But also, it's a fear of some different component. So doing it in that office, and you demonstrating it with him would be very helpful, but I also want to ask the hub team: Is there anyone here who has had individuals who've expressed that fear? And then what is it that you've done?

Lal: [22:22] I tried to normalize a little bit because I always hear this term "needle-phobia," and I'm like "It would be strange if you weren't scared of sharp, pokey things. I mean, that should be the normal reactions." But the thing is, these are designed to be so thin, that if they were any thinner, they would bend upon insertion into the skin. So yes, we should all have that concern, but it's something that we can overcome.

Cyd Bernstein, LCSW: [22:58] I have a question for you if we have time. I was just I was reading the National Clinical Care Commission Report, the one about leveraging federal agencies to improve diabetes care in the country, and I think a large takeaway is something people say often in these calls: That diabetes is really a system failure, not an individual failure. I think we all understand that, and we talk about that, but I find that really difficult to convey to patients, particularly patients with Type 2, who aren't thinking about systems that interact with their lives. I'm just curious if you even like if you encounter that, if you try to tackle that on an individual level with patients, how you actually work with that, aside from the destigmatizing language, which is obviously important.

Beverly: [23:57] Thank you for sharing that, Cyd, I think that is a fantastic point. I do want to disclose that I do not see patients, so when I do talk about this, I do see people all the time at our institute, and I do work with people. One of the things is actually something I learned from Dr Shubrook, who used to be where I am now, and what he shares with us patients—I'm guessing he still does this—is he talks about how hard diabetes is, and just talking about how hard it is can be something that can break the ice, but it can also be so meaningful. I'll let Dr Schubert elaborate on that, but one of the things that I do for individuals is when you learn a little bit about them, it's just stressing: "Diabetes... you did not bring this on yourself. There are so many factors that come into play." Just doing it on a certain level while not using scientific terms—I don't need to talk about genetics and specific genes or anything—but just getting to them that this this is not your fault. Where I am—it's a rural region in Appalachia—the rates of diabetes being passed on from generation to generation, just talking about it, you can say, "This is something that is passed on in your family. This is not your fault." Then we talk about, you know, you, you know, other barriers that get in the way and how that interferes— the cost of prescriptions—you can say things that relate to them. We know we're talking about the systematic failures in the system, and it really has to do with the healthcare system, but we're talking about things that they would understand. So I don't know, Dr Shubrook, if you wanted to elaborate on your point.

Shubrook: [25:41] I love your question, because it is hard to communicate something that's abstract without making them feel helpless. What I say is, "It's already hard enough to have diabetes, but it's not a level playing field. Look at your neighborhood, do you have access to fresh fruits and vegetables? Can you afford a safe place to live? Is it really easy for you to get your supplies. Those things are not your fault. Those things we could be doing better as a nation. While I can't fix all those things, we have to find strategies to make it work." Sometimes, I think, recognizing that that work is harder for some people, because they have less privilege or less access, and saying that "I'll be your ally to help you find an answer. Albeit, that I can't fix a lot of those things individually."

Bernstein: [26:32] Do you guys use the PRAPARE tool or another kind of screening for social determinants?

Shubrook: [26:41] We have the PRAPARE tool in our EMR, and we've used the PREPARE tool for social determinants of health at our EMR, and we've used the PREPARE tool in some of our research. I don't know about anyone else.

Nicolas Cuttriss, MD, MPH, FAAP: [26:58] This is Nick, I think it's also a matter of, even if PREPARE is there, it's about who's putting things in and communicating it because it can get into the system, but if you're not aware of something that just got updated, that's pertinent to your visit, it's challenging. One other comment on the system failure part: I think things that we can do as individuals of the health system, like addressing the social determinants of health, where it's already difficult with them of having a job, taking time off work, and just have: "When's your day off? When can you come back to follow up with this injection training and not realizing how difficult it is for them to get to a pharmacy, so picking up a prescription might take a couple of weeks, and you bring them back for a visit they haven't even started. Some of that practical stuff that we don't really think about that we say, "Go check out with our MA and we'll find something for you," and they just give them a date to follow up. Sometimes that can be more burdensome, and I think that happens more in specialty centers than where many of you practice, but it's still an issue.

Quiles-Sanchez: [28:07] I love the lively discussion that we're having. But I want to make sure that we have time for our case because we have an excellent case for today. Liz you want to go ahead and reshare the screen for the summary?

Beverly: [28:24] Sure I can do that. Quick reminder, please share your case and present. We love hearing about your cases and they bring forth great discussion, like the one we're going to hear today. So here is the case, today we have Ana presenting which is going to be very great, so thank you.

Anastasia Coutinho, MD: [29:15] Okay, so this is my patient and I work east of the East Bay, California, at a federally qualified health center. This is a this is a 62-year-old Hispanic that I have known since I've working here about five years ago, and who has insulin-dependent Type 2 diabetes for at least the last seven or eight years based on records that we have, complicated by cardiovascular disease, suspected sleep apnea—which he hasn't gotten an adequate workup for—fatty liver disease, reflux, constipation, and a lot of headaches, which might be separate from her OSA, that maybe related. She has frequent e-visits and multiple no-shows to our office, has a really hard to time completing at her labs, and so will come to the office without having had any lab work or without having any medication changes from time. There's a lot of physical stuff going on. She, multiple times, has been to the emergency room and had blood pressure that are greater than 100, came to the clinic once and then had one episode [unclear] She is from Mexico and has lived here with her daughter and granddaughter. They rent out a bunch of rooms in their house for extra money, cleaning houses when she feels capable are doing so, has a little bit of a food insecurity, not really a lot of exercise in her life. Very low health literacy when discussing her diagnosis and then the implications of her diagnosis, and then the relevant piece for today is that she has definitely extreme long term physical and emotional domestic violence with her ex-husband. She grew up in Mexico, her father died when she was about 11 and then it was raised by two older brothers and reports that there was a lot of abuse from them to her. She was married to, to this man 15 and left her house and then was with him for over 40 years before she got divorced. In that relationship, there was a lot of emotional abuse as well. Then she moved to the US with her daughter and granddaughter and then left her house in Mexico.

Her A1Cs have been moderately well controlled, and she fluctuates a lot. She has never been under seven for as long as I've known her, but can get fairly close to 7.5 or 7.8, but then have these periods where she just goes all the way up, and three months she'll go from seven to 10. In March of this year, she went to 13. Then her most recent A1C, which is from the summer, went back down to nine and a lot of that is due to when she's taking her medications or what she understands about her insulin use. Of note when we talk about her anxiety: it starting to get a little bit worse last fall, actually started seeing our in-house counselor, and that was when her A1C started going up. After being well-controlled at eight for almost a whole year and then a shot up to 13 after she started going to see him and then talking about all of the things that have been going on for her in her life and just this summer has started to be under control. Other labs are not really significant other than her random sugars that can often be very high. Oh! About two years ago she had triglycerides of 1700 in an emergency room visit after she had stopped all of her diabetes meds and her cholesterol medication and all of those things. In that visit, she had gone into the emergency room for chest pain and went down to have those labs which are now much better controlled.

As we have increased her medication doses, she's now on metformin, pegapamodutide, and 30 units of insulin, as well as medications and blood pressure and in terms of her support, we had been trying to get her into behavioral health for a long time before she agreed to do it, and she's found it really helpful in terms of in-the-moment relaxation techniques for when she has anxiety. She is not very excited about doing any sort of exercise, and it's really hard to have her go for a walk at night. She is now going to our health classes that are led by health education and a registered dietician. She's now involved in that but doesn't always attend. Her health literacy is pretty low, so her knowledge about diabetes is pretty low despite having had multiple conversations about it. We've had her family—her granddaughter—come to visit so we can include the family in treatment plans so they can make sure she's taking her medication at home, but a lot of time that doesn't follow through into actual practice, even though we're discussing it. She has headaches every day and overall tiredness. We referred her to pulmonology but she doesn't go. "They don't speak Spanish; I'm not going to go," "Can we help make you an appointment?" and she'll know she has an appointment.

In the 18 months we've been trying to get a sleep study to see if she needs a CPAP. You can see from the emergency room visit her triglycerides—she ran out of her medications, didn't call us for refills. She gets to points in her life where everything seems to become too much and she gets really flustered, and then anxious, and stop taking her medications, and then we'll call her in for an appointment and she'll no-show, then we keep calling her because she's such a high-risk patient. I think that's probably it. Her PHQ-9 on there was six in the fall. I think her GAD-7 was a little bit higher—it might have been 10 at that time—which, as of this summer, are now both zero since she's been seeing behavioral. I think that's all of my information.

Beverly: [37:41] Thank you so much for presenting the case! Do we have any hub team members who would like to give any input? [pause] Is there anyone here who wants to share any thoughts or feedback?

Colleen Hough, RDN: [38:18] Well, I can't help but notice the food insecurity. Is she able to get CalFresh, or I'm wondering about the granddaughter—I don't know how old that one is—maybe the daughter might be eligible for WIC.

Coutinho: [38:37] I believe they have food stamps, and her granddaughter is over the age of 21. None of them have WIC.

Beverly: [38:59] I think this is a fantastic case and it has so many layers to it. I think we could talk about this for hours. The history of intimate partner violence and domestic violence is key, and I think it's fantastic that she is talking to a behavioral health professional, and you mentioned since seeing the professional—I think you mentioned her AAMC went up? Is that correct? Yeah.

[39:25] Individuals who do experience that type of trauma, if she is now talking about the trauma, is going to be retraumatized. When you when you do go into counseling, you don't immediately get better, you know, you have to live through it, and you know, she's probably reliving some of that, and it could potentially explain that and it does not help that we have gone through a pandemic as well. My first thought would be trauma-informed care, and I'm curious if we have anyone here who would like to share anything on the trauma informed care approach, but my first thought is just making sure that she knows that your clinic is a safe place for her and she can trust you. Anything that can establish that trust and safety would be, I would think would be key.

Coutinho: [40:20] Yeah, I think she really liked along with the counselor that we have, which is great. She has indicated her, which is wonderful, because I think a lot of people go and they're like "Eh, whatever," I totally agree with you, I think she became more traumatized in reliving, and then has moved through that and has found it really helpful. I'm hoping that by us reaching out every time she misses an appointment or doesn't follow up, we can help her navigate through these things, and that we're being attentive to her needs.

Christopher West, PhD: [41:02] I'm curious how she is as far as attendance with the counselor, and if that's different than her attendance for regular medical appointments? And if that seems to be better, is there any way to see if the counselor can help with some CBT regarding her diabetes?

Coutinho: [41:20] I think our behavioral counselor, because of our volume, sees her about every six weeks, but she shows up all the time. She definitely does not have any missed visits with him as she does with me. That's a great way to loop him in and make sure that he is aware that she is not always following up with me.

Bernstein: [41:53] I'm seeing a couple of questions, comments in the chat. Leah noted, "It's difficult when you don't know if she's taking meds consistently in terms of her glycemic control. Is she going to the diabetes support group consistently?"

Coutinho: [42:08] Not consistently.

Kate Kirley, MD, MS: [42:10] And then James had a suggestion about would it be an option to coschedule visits with a nurse?

Coutinho: [42:15] That would be great but we have no nurses at our clinic at this very moment. We have made, with our medical assistant, an effort to say "Come in and we'll teach you how to use your insulin pen or someone can review your insulin log." But it's been hard, with those appointments, to get her to come in. We've gone through whether it's a transportation issue, is it a reminder issue? She says, there's not really any barriers that she can identify, but clearly something going on, whether it's just something that she hasn't actually recognized or is afraid of telling us or embarrassed of telling us.

Shubrook: [43:11] Anastasia, when you talk to the patient about glucose goals, do you have a shared goal with her of what you're trying to shoot for?

Coutinho: [43:23] Most of my goals are for her to just take her medicine. Without adding extra things, we will make goals that are unrelated to her diabetes, like "I want you to call the pulmonologist, and my medical assistant is going to call them for you and do a three way call to make you an appointment,” and then she won't pick up the phone or something like that. She did see the pulmonologist once this summer and I told him that her issue was asthma, so she went to the pulmonologyst and did not get worked up for sleep apnea but worked up for asthma. Which was maybe good, but not useful to what I needed. And sometimes just taking your medication every day, or let's get your mammogram. She is someone that I see at least every three months if not sooner. Not necessarily always for the diabetes, but to coordinate other parts of her care. Onto Leah's question, "Does she answer the phone?" Yes. Sometimes. It's hit or miss. I think part of it is that she has an inconsistent job where she cleans houses, so sometimes there's work and sometimes there's not and then there's no schedule and so she'll forget that she was supposed to have a phone call and so just won't answer.

West: [44:53] Have you had a chance to discuss with her about what her goals are, like what does she want from life? What would make life better for her, and trying to work on things more that way?

Coutinho: [45:06] I feel like I have not discussed those things with her that way. Yeah, I could reframe it. I have definitely come at it like, "What are the barriers you're facing?" "How do you think we can keep the treatment plan?" but not "Is your diabetes important to you? What is important to you?"

Bernstein: [45:38] I had the exact same thought, and I feel like when you have a complicated patient like this—like many of the ones that we've talked about—every time you see them you're reassessing priorities and making this new list of things to do and from both the care team side and the patient side feels like it's constantly shifting and getting rearranged by "What's the burning thing right now?" I think sometimes it is helpful to like have that higher order like "What are your health goals here, overall, your life goals overall? And how do we keep working towards those things?" But it's messy. I empathize. I'm curious if you sense that she has a resistance to taking her medication, or if it's more life circumstances all of the challenges around work and supplies and getting to the pharmacy? You see what I mean? Like, is it more of like an emotional barrier? Or is it more of just a kind of social barrier?

Coutinho: [46:54] It's more of a social barrier. She doesn't have an issue giving herself injections, she doesn't have adversity to taking pills, but she'll say, "Oh, I didn't realize that there are refiles. I didn't realize when it ran out I should go back to the pharmacy. She didn't call us and they didn't call the pharmacy. Now we're going on three years or four years, where we're having the same discussion. When we talk about medication, we gave her a pill box. I called the pharmacy to give her three months at a time. Bringing in her granddaughter to make sure that they know what she's supposed to be taking and try and help support her. I think it's just that she forgets, you know? It's clearly not her priority. I explain to her the risks of uncontrolled diabetes, and she does. She is very well aware of it and wants to have her sugar more control, and then when it comes down to actually doing each activity, she doesn't always follow through.

Bernstein: [48:23] Do you think that she's a good candidate for a CGM? Or do you think that would just be another thing that would stress her out, and she might not interact with that productively?

Coutinho: [48:34] Yeah, I think it would be too much information for her.

[48:56] Also, her granddaughter is usually the person who comes to her appointments. I haven't totally probed about her daughter and how her daughter is engaged or not engaged in caretaking with her or living with her, my sense is that she works a lot.

Beverly: [49:22] That might also be something to build off of with the granddaughter. I don't remember who mentioned the point about understanding values and preferences and finding out, but the granddaughter might be that motivation as well, to build off of. I also just want to say it is clear how much you care about her and her well-being and it's very clear to me that you have done so many things. I just want to commend you on this.

West: [49:56] Somebody had mentioned before the idea of doing a shared visit with a nurse, I'm wondering about doing a shared visit with the behavioral health provider.

Coutinho: [50:09] That's a great idea! I've never done those—I more have talked behind the scenes. What does that look like in practice? For all of us, just because I know I have never been in it and I think maybe other people have too.

West: [50:26] I've seen it done in a couple different ways. One way can be a visit where there's two people there—unfortunately, you can only really have one person billing out at that visit, usually. Another way would be to schedule with one person and then the other one, kind of a warm handoff immediately afterwards.

Coutinho: [50:53] If you were to do it together, is it kind of like working with a behavioral counselor prior to try and get at why she's not taking her medicine or what are her goals, and then letting them lead the visit while we're just trying to add medical pieces.

West: [51:17] You could even consider something where you kind of go in, frame it a little bit, and have them have a conversation, and then come back in 40 minutes later or half an hour later, and kind of let them do that processing in the meantime.

Coutinho: [51:34] I like that idea.

Bernstein: [51:38] I have a question. Is there potentially a role for pharmacotherapy for potential mood disorder? She's seeing a therapist for I think, what you described as anxiety? I think you mentioned that her PHQ-9 score had improved, but is her sort of mental health related? Psychiatric state adequately treated?

Coutinho: [52:07] Yeah, initially, she didn't want medications but I haven't checked in with her in a couple of months. I think as she started going to the behavioral health person, and she's getting more anxious, and her A1C went up, we talked about it, but since then, I haven't necessarily been there, from a motivational standpoint, maybe the medications can be helpful.

Wong: [52:40] I had a question too. For the behavioral health, do you know what type of therapy it is? Is it more like talking where they share their problems, and then they kind of walk them through it? Or is it like a specific other...?

Coutinho: [52:54] I think our therapist does a lot of ACT—acceptance commitment therapy—and teaches CBT principles. Yeah, it's just talk therapy, there's no EMDR or other modality.

Wong: [53:11] Okay. Yeah, I was curious, because I remember having a patient who also has some like trauma, and they went through EMDR recently, and they said, it's helped significantly, they felt like the previous type of talk therapy didn't really treat their underlying problem, but EMDR walked them through that whole process. Of course, it's very traumatizing in those weeks, but I don't know if your area offers that or no? Okay.

Coutinho: [53:36] I think EMDR for trauma can be super amazing, but unfortunately there are not tons of providers that insurance will cover.

West: [54:30] I guess any last thoughts? Or I can begin to summarize the case and the recommendations here. We have a challenging and complex case of a 62-year-old Hispanic female, who has a history of prior trauma along with multiple medical issues. She has been fairly engaged with her mental health treatment lately, but has been in and out of engagement with her medical treatment. It's questionable how well she's adhering to medications, she seems to kind of fluctuate up and down. We identified strengths as our adherence with her therapist and also her relationship with her granddaughter.

[55:13] Some of the recommendations here to consider is that she's being retraumatized as she's going through treatment for her trauma right now, and so that may be impacting her ability to adhere with things, so we're trying to focus on trauma informed care. Thinking about the possibility of doing covisits with behavioral health or with other providers to try to engage her surround her with care as much as possible so that when she's there, she can get what she needs. Looking into trying to do some goal setting, really trying to understand what her values are and what her preferences are, and trying to work from that point of view. Thinking if there's any ways to engage her granddaughter, thinking about her granddaughter, possibly remaining healthy to be around for her as part of her motivation. Asking a little bit more questions about her family and what's happened with her daughter, other people that don't seem to be involved. And then also consideration for possibly looking at medications for either some kind of mood disorder or anxiety treatment if she's now open to that since it's been a while.

Beverly: [56:23] Thank you for that summary. And thanks for the opportunity to speak today about something I'm so passionate about, which is behavioral diabetes. So today we reviewed, you know, the most common psychosocial issues: depression, anxiety, diabetes distress, and even the discussion about how diabetes stigma factors in. We can see through this case, a history of domestic violence and intimate partner violence is associated with the psychosocial issues. She's definitely experiencing anxiety, perhaps other, and the literature shows that people who actually experienced intimate partner violence are at increased risk for diabetes, as well as a whole slew of other health conditions—you can see in the case that a lot of the complaints that she has, are somatic complaints that can be associated with psychosocial issues. I think this just shows how complicated it is to live with diabetes. It is one of the most difficult conditions not only for all of you to be treating, but for people to live with. That's why addressing the psychosocial issues—while very challenging—it's so important that we give time to focus on those things, so I think it was great that we had the opportunity to do that today. And again, Ana, thank you so much for presenting this case.

Coutinho: [57:50] Thanks for all of your recommendations, guys.

Quiles-Sanchez: [57:55] Thank you so much, Dr Beverly, for that fantastic presentation. Anyone has any additional questions, please feel free to reach out. And thank you everyone for joining today's ECHO and again, a special thank you for Ana for submitting this case. You've done a great job so far, and I hope you were able to get a lot from today. A recording of today's session will be made available next week. Be on the lookout for emails regarding our final session on November 16, where Dr Rayhan Lal will be discussing the role of technology and managing diabetes in rural communities. This will be a great way to close out the series. So I really do hope I get to see you all there. Have a great day. Bye everyone.

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The faculty, committee members, and staff who are in position to control the content of this activity are required to disclose to the Endocrine Society and to learners any relevant financial relationship(s) of the individual or spouse/partner that have occurred within the last 24 months with any commercial interest(s) whose products or services are related to the content. Financial relationships are defined by remuneration in any amount from the commercial interest(s) in the form of grants; research support; consulting fees; salary; ownership interest (e.g., stocks, stock options, or ownership interest excluding diversified mutual funds); honoraria or other payments for participation in speakers' bureaus, advisory boards, or boards of directors; or other financial benefits. The intent of this disclosure is not to prevent planners with relevant financial relationships from planning or delivery of content, but rather to provide learners with information that allows them to make their own judgments of whether these financial relationships may have influenced the educational activity with regard to exposition or conclusion.

The Endocrine Society has reviewed these relationships to determine which are relevant to the content of this activity and resolved any identified conflicts of interest for these individuals.

The following faculty reported relevant financial relationships: Elizabeth Beverly, PhD - Journal of Osteopathic Medicine, Section Editor. Nicolas Cuttriss, MD - ENDO Diabetes & Wellness, Employer; ECHO Diabetes Action Network, Employer; The Leona M. and Harry B. Helmsley Charitable Trust, Consultant; Cecelia Health; Consultant; American Youth Understanding Diabetes Abroad, Board. Kate Kirley, MD - American Medical Association, Employer. Rayhan Lal, MD - Abbott Diabetes Care, Consultant; Biolinq, Consultant; Capillary Biomedical, DSMB; Deep Valley Labs, Consultant; Gluroo, Consultant; Provention Bio, Advisory Board; Tidepool, Consultant. Jay Shubrook, DO - Abbott Diabetes Care, Consultant and Advisor; NovoNordisk, Consultant; Astra Zeneca, Advisor; Bayer, Advisor; Eli Lilly, Advisor; Nevro and Nevro, Advisor.

The following faculty reported no relevant financial relationships: Christopher E. West, PhD, A-GNP-C

Endocrine Society staff associated with the development of content for this activity reported no relevant financial relationships.

The Endocrine Society has reviewed all disclosures and resolved or managed all identified conflicts of interest, as applicable.


This educational activity is supported by an independent medical educational grant from Abbott Diabetes Care Inc.

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