Commentary

Commentary: Shifting the care delivery paradigm to diabetes-depression collaborative care models


 

Significant depressive symptoms affect approximately one in four adults with type 1 and type 2 diabetes while a formal diagnosis of depressive disorders is made in approximately 10%-15% of individuals with diabetes.1 The combination of diabetes and depression presents a major clinical challenge because the outcomes of each condition is worsened by the presence of the other, which results in worsened quality of life, impaired diabetes self-management, and poor clinical outcomes.1 While the costs of treatment are high for both individual patients and health economies, these costs do not necessarily result in significant improvements in disease or quality of life outcomes.1 This raises the question, “What is the best approach to managing patients with comorbid depression and diabetes?”

Dr. Sherita Hill Golden, the Hugh P. McCormick Family Professor of Endocrinology and Metabolism, and executive vice-chair, department of medicine, Johns Hopkins University, Baltimore

Dr. Sherita Hill Golden

Effective strategies for improving outcomes in patients with diabetes target several areas – health systems (case management, team changes, electronic patient registry, facilitated relay of information to clinicians, continuous quality improvement), health care providers (audit and feedback, clinician education, clinician reminders, financial incentives), and patients (patient education, promotion of self-management, reminder systems).2

Strategies associated with at least a 0.5% reduction in hemoglobin A1c include team changes (–0.67%) and case management (–0.52%).2 The most effective team changes were those that included multidisciplinary, interactive teams with shared care between specialists and primary care providers.2 Such a collaborative care model that integrates specialty psychiatric care into primary care has been successfully demonstrated for patients with depression and poorly controlled type 2 diabetes or coronary heart disease.3

In this study, patients at 14 primary care clinics in an integrated health care system in Washington State received either a multidisciplinary, team-based intervention or usual care.3 Components of the intervention in these clinics included the following:

  • Three part-time registered nurses who had diabetes education training (certified diabetes educators), as well as training on depression management, behavioral strategies, and glycemic, hypertension, and lipid control.
  • Combined support for self-care with pharmacotherapy to control depression, hyperglycemia, hypertension, and hyperlipidemia with algorithm guidance.
  • Motivational and encouraging coaching for problem-solving and adherence to self-care.
  • Weekly nurse supervision with a psychiatrist, primary care physician, and psychologist, with a nurse communicating recommendations back to the primary care team.

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