Telephone Counseling Aids Vets With Diabetes and Depression

Miriam E. Tucker

August 08, 2019

An individualized telephone-based intervention reduced depressive symptoms among US veterans with type 2 diabetes and depression, a new study found.

The results were published online yesterday in JAMA Network Open by Aanand D. Naik, MD, of the Houston Center for Innovations in Quality, Effectiveness, and Safety, Debakey VA Medical Center in Texas, and colleagues. 

The intervention, consisting of nine telephone sessions focusing on addressing patient-centered behavioral goals targeting both diabetes control and depression symptoms, reduced depression at 1 year but did not significantly improve glycemic control compared with "enhanced usual care." However, glycemic control improved in both groups, suggesting that in the control group merely informing the patient's providers about the patient's non-optimally controlled diabetes and/or depression had an effect, Naik told Medscape Medical News

"The average hemoglobin A1c came down significantly in both arms…If I tell [the] provider who cares about them that this person is at risk, it's not surprising to me that the control group did as well as they did." 

The "patient-centered" focus is key to the intervention, Naik explained. "Identifying what's most important to the patient in their life and health and walking them through the steps…is certainly effective in improving depression — and the diabetes didn't get worse. It matched the improvement in usual care." 

Such an intervention is possible in many clinical settings by providing behavioral health training to a nurse or other allied health professional and having them call patients to conduct the counseling in between office visits. Medicare covers such sessions under "chronic care management" calls, Naik said.

"There are many of these evidence-based approaches. You can probably get much better results than we did if the person delivering the intervention is actually in your office and can communicate directly with you," he noted. 

"Identifying What Matters Most"

The trial took place within an integrated regional Veterans Affairs healthcare system involving 225 patients who lived at least 20 miles from the medical center, had hemoglobin A1c values of higher than 7.5%, and clinically significant depression as assessed with the 9-item Patient Health Questionnaire (PHQ-9).

The researchers randomly assigned 136 participants to the nine-session blended diabetes and depression behavioral health telephone coaching program over 6 months;  89 others received "enhanced usual care," in which participants were informed of their high-risk status, encouraged to share the information with their providers, and were sent educational materials. 

The telephone interventions, delivered by trained health professionals (psychologists, nurses, pharmacists, or social workers), were biweekly for the first 3 months for 30 to 40 minutes each, then monthly for about 15 minutes for the next 3 months. 

The first two sessions focused on building rapport, collaboratively setting goals, identifying potential skill sets to address the goals, and "empowering patients to advocate for their health through active communication with their clinicians."   

"We started with identifying what matters most to patients," Naik said. "This isn't typically done in usual medical care. What really matters to you? What gives your life purpose? What's most meaningful to you? What makes you happy, and what's getting in the way? Then we create very specific, measurable outcome goals."

Such goals, he explained, range from simply being able to walk 30 minutes a day and increasing fruit and vegetable intake, to "things that aren't easy to capture in a typical medical visit, like being able to play with [the] grandkids for 30 minutes without getting too tired."   

Sessions three to six focused on customized behavior goals around daily activities, diet, physical activity, medication management, and relaxation. The final three sessions involved maintenance skills. The program prioritizes skills aimed at improving both diabetes control and depression at the same time, such as stress reduction and exercise.

All subjects received their usual primary care for months 7 through 12.

Most of the participants were older (mean age 62 years), male (90%), and married (64%). They had a mean HbA1c of 9.3% and mean PHQ-9 score of 15.9 (moderately severe depression symptoms). 

In the intervention group, mean PHQ-9 scores dropped from 15.8 at baseline to 10.9 at 6 months and 10.1 at 12 months, compared with 12.4 and 12.6, respectively, from baseline 16.2, in the control group. The difference between the two groups was statistically significant at both 6 and 12 months (both P = .03).

Hemoglobin A1c levels improved from 9.2% at baseline to 9.1% at 6 months and 8.7% at 12 months in the intervention group, compared with an initial improvement in the control group (from 9.3% at baseline to 8.7% at 6 months), followed then by a rise to 8.9% at 12 months. The difference between the two groups was not significant at either time point (P = .08 and P = .83, respectively).

The number of mental health and primary care visits was comparable between the two groups throughout the study.

The study was funded by the Veterans Health Administration Health Services Research and Development Office and the National Institute of Diabetes and Digestive and Kidney Diseases. The authors have disclosed no relevant financial relationships.

JAMA Network Open. Published online August 7, 2019. Full text

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