VERONICA CARDENAS, PH.D. UNIVERSITY OF CALIFORNIA , SAN DIEGO

ELIZABETH LUGO & ROBERTO CERVANTESSAN YSIDRO HEALTH CLINIC, SAN DIEGO

CONSUELO RAZO, R .N.NORTH COUNTY HEALTH SERVICES, SAN

MARCOS

DECEMBER 6 , 2012

Improved Depression and Diabetes Care Management among Elderly Latinos:

Design, Implementation, and Preliminary Outcomes of a Culturally Tailored Strategy

Background & Study Context

Depression is common among primary care patients, although often undiagnosed

Chronic health care conditions, such as diabetes, increase the prevalence of depression

Latino populations are particularly at risk Prevalence of diabetes is approximately twice non-Latino whites Comorbidity with depression is also greater than non-Latino whites

Within San Diego County, 41.4% of Latinos age 65 and older have been diagnosed with type 2 diabetes.

Salud Program – San Diego County

Funded by Mental Health Services Act, Prevention and Early Intervention

Target population: Latinos age 60 and older with diabetes who are

depressed or at risk of developing depression

Salud Program evaluation aims to evaluate patient, program and systems outcomes Clinic A - Diabetes Self Management Program (DSMP) Clinic B – DSMP plus Problem-Solving Therapy (PST)

Diabetes Self-Management Program (DSMP)

An evidence-based practice developed at Stanford University (Lorig et al, 2008; Lorig et al, 2009)

http://patienteducation.stanford.edu/

We have been using the version for Spanish-speaking persons: “Manejo Personal de la Diabetes (MPD)”

MPD is not a direct translation of DSMP

Primary Goals of MPD/DSMP

Provide patient with: knowledge, skills, and motivation needed to effectively

self- manage their diabetes

Help patient: identify the behavioral changes needed to control

diabetes

In order to: minimize, delay, or avoid complication associated with

long-term disease process

Description MPD/DSMP

DSMP/MPD intervention structure: 6 weekly ~2.5 hour sessions with 10-15 participants

2 leaders (at least one leader w/personal diabetes connection)

Education about diabetes management (+ some emotional health information)

Action/problem-solving orientation

Tailoring for Target Population

Conducted in SpanishDeveloped specifically for Latinos

Emphasizes the specific nutritional habits of the population and what/how changes are needed and can be made (example: portion control and salt intake)

Culturally adapted music for exercise activities Effective communication with providers of care

(example: language barrier or method of learning)Use bilingual-bicultural leadersConsistent with peer approach –age

appropriate staff

Interactive MPD/DSMP Activity

Brainstorming:

Interactive MPD/DSMP Activity

Problem-solving:

Interactive MPD/DSMP Activity

Action Planning:

Depression Treatment in Primary Care

Most cases of depression are identified and treated in primary care.

Current depression treatment consists of 1) medication, 2) reassurance and/or 3) brief counseling.

Challenges for successful treatment in primary care Non-compliance to meds due to side effects Beliefs regarding drug dependence or interactions between

meds Length of time between visits and follow-up Lack of effective mental health counseling strategies Patients unwilling to accept specialty mental health Rx

Clear need to develop an effective treatment strategy for primary care settings.

Problem Solving Therapy (PST)

An evidence-based practice developed by Arean and colleagues (Arean et al 2008)

PST is a cognitive behavioral therapy that treats depression by teaching patients how to systematically solve psychosocial problems

http://impact-uw.org/training/problem_solving.html

Primary Goals of Problem Solving Therapy

Establish a cooperative relationship with patient

Symptoms are due to depressionExplain link between problems, depression

and PSTProblem Solving OrientationTeach problem solving skills – PSTActivity scheduling

Problem Solving Steps

1.- Identify a Problem2.- Establish a Goal3.- Brain storm solutions4.- Pros vs Cons of each solution5.- Select a solution to implement6.- Develop an action plan7.- Review progress on next visit

Structure of PST

6 visitsVisit 1 60min, 2-6 30-45min Bi-weekly visitsTeach problem solving skills each time you

meetWork through a problem at each visitWork on homework between appointments

Adopting an EBP previously used with older adult and Spanish populations

PST sessions conducted in Spanish with bi-cultural/bi-lingual staff

Provided greater assistance with PST form completion

Allowed PST sessions to be slightly longer than standard protocol

Initial Tailoring for Target Population

PST Activity

SALUD Study Preliminary Results

Additional Salud Study Results

Part of an ongoing study of the implementation and effectiveness of the Salud Program strategies

Specific analytical focus: Change in key depression and diabetes-related

outcomes measured at baseline and 6-month follow-up Intersection of depression and diabetes change

outcomes

Primary Measures

Personal Health Questionnaire-9 (PHQ-9) 9-item depression diagnostic measure (Löwe et al,

2004, Ell et al, 2009) Hyper- & Hypoglycemia Symptom Scales

Each are 7-item scales of common related symptoms (Loring et al, 2008; Piette, 1999).

Summary of Diabetes Self-Care Activities 5-item Nutrition & 3-item Exercise subscales

(Toobert & Glasgow, 1994); Self-Efficacy for Diabetes

8-item scale regarding diabetes management confidence (Lorig et al, 2005)

Data & Methods

Analyses conducted with Salud program participants who: Completed program & reached their 6-month follow-up data

collection Had baseline PHQ-9 scores of 5 or greater (at least minor depression)

Descriptive analyses of primary variables Paired-sample t-tests assessing change from baseline

Linear regression analyses of T1-T2 change in five (5) primary diabetes-related outcomes variables Where needed, change outcomes have been reverse coded so that

positive coefficients always equate to desired change outcomes (e.g., a greater reduction in symptoms or a greater increase in positive health behaviors)

Participant Characteristics (n=95)

% n

Gender

Female 66.3 63Male 33.7 32

Education

6th grade or less

72.6 69

6th Grade + 27.4 26Clinic

DSMP 50.5 48

DSMP+PST 49.5 47

Age (mean /s.d.) 65.8 / 5.2

Primary Indicators – Baseline & Change Scores

Baseline Change (6 month)

Change Sig.

Mean S.D. Mean S.D.

PHQ-9 (0-24) ↓ 10.3 4.5 -4.1 5.3 ***

Hyperglycemia Symptoms (0-7) ↓

2.2 1.7 -0.5 1.8 *

Hypoglycemia Symptoms (0-7) ↓

2.1 1.7 -0.3 1.6 ^

Nutrition (0-4) ↑ 2.6 0.6 0.2 0.8 **

Exercise (0-7) ↑ 2.8 2.4 0.9 2.9 **Self-Efficacy (0-10) ↑

7.2 1.6 0.9 1.9 ***

^p<.10; *p<.05; **p<.01; ***p<.001

Regression Results - 1

Change: Nutrition

Change:Exercise

Change: Diabetes

Self-Efficacy

Std. B

Sig. Std. B Sig. Std. B Sig.

Baseline value -.697 *** -.676 *** -.769 ***

Baseline PHQ-9 -.193 * -.088 -.088

Change: PHQ-9 .194

* .093 .193 **p<.05; ***p<.001

Note: All models control for clinic, gender, age, & education (not sig.)

Regression Results - 2

Change: Hyper-

glycemia

Change: Hypo-

glycemia

Std. B

Sig. Std. B Sig.

Baseline value .652 *** .634 ***

Baseline PHQ-9 -.300 ** -.303 **

Change: PHQ-9 .461 *** .394 *****p<.01; ***p<.001

Note: All models control for clinic, gender, age, & education (not sig.)

Summary of Findings

Bivariate results indicate: Changes post-DSMP/MPD completion were in desired

directionRegression results indicate:

Changes post-DSMP/MPD completion were strongly related to baseline values

Higher baseline depression was frequently associated with a reduction in “desired/positive” change values

Greater reduction in depression was frequently associated with an increase in “desired/positive” change values

Clinic, gender, age, and education not related to change values

Discussion & Conclusions - 1

The findings suggest that the Salud Program for elder Latinos is achieving the primary goals of: Reducing/preventing depression Improving diabetes self-management activities Reducing diabetes related symptoms

Discussion & Conclusions - 2

Depression at baseline negatively impacts achievement of desired diabetes related change outcomes

However, reductions in depression were associated with improved diabetes related change outcomes

Since the specific order/timing of changes is unknown: Reductions in depression may contribute to improved diabetes

outcomes Improved diabetes outcomes may contribute to reductions in

depression

Either mechanism highlights the importance of attending to both diabetes and depression simultaneously to promote better well-being and reduced symptomology

Limitations

Relatively small sample size identified from two (2) clinics in one (1) county

No randomization or control condition for comparison

Culturally adapted Problem Solving Therapy includes:

Improved Spanish language

Improved terminology

Visual examples

Culturally relevant examples

Aranda, Grant #5R21MH080624-02

Additional Tailoring for Target Population

New Exploratory Questions

Does culturally adapted PST Increase treatment adherence Improve therapeutic allianceLowers stigma

Implementation Considerations

Sufficient demand to regularly form groups of 10-15 interested & eligible participants

Capacity to handle emotional & physical health crises that may occur during interventions

Good participant & staff “fit” (e.g., bi-cultural/bi-lingual, age appropriateness/awareness)

Training plan to ensure that new staff can complete the (relatively intensive) training requirements

Fidelity plan to promote high quality adherence to interventions

Adequate transportation and facilities to allow regular and comfortable participation in multi-week intervention

VERONICA CARDENAS, PH.D. UNIVERSITY OF CALIFORNIA, SAN DIEGO

VCARDENAS@UCSD.EDU

ELIZABETH LUGO & ROBERTO CERVANTESSAN YSIDRO HEALTH CLINIC, SAN DIEGO

CONSUELO RAZO, R .N.NORTH COUNTY HEALTH SERVICES, SAN

MARCOS

MUCHISIMAS GRACIAS!