veronica cardenas, ph.d. university of california, san diego elizabeth lugo & roberto cervantes...
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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
ELIZABETH LUGO & ROBERTO CERVANTESSAN YSIDRO HEALTH CLINIC, SAN DIEGO
CONSUELO RAZO, R .N.NORTH COUNTY HEALTH SERVICES, SAN
MARCOS
MUCHISIMAS GRACIAS!