1. VERONICA CARDENAS, PH.D. UNIVERSITY OF CALIFORNIA, SAN DIEGO ELIZABETH LUGO & ROBERTO CERVANTES SAN 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

2. 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.

3. 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)

4. 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

5. 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

6. 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

7. Tailoring for Target Population Conducted in Spanish Developed 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 leaders Consistent with peer approach –age appropriate staff

8. Interactive MPD/DSMP Activity Brainstorming:

9. Interactive MPD/DSMP Activity Problem-solving:

10. Interactive MPD/DSMP Activity Action Planning:

11. 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.

12. 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

13. Primary Goals of Problem Solving Therapy Establish a cooperative relationship with patient Symptoms are due to depression Explain link between problems, depression and PST Problem Solving Orientation Teach problem solving skills – PST Activity scheduling

14. Problem Solving Steps 1.- Identify a Problem 2.- Establish a Goal 3.- Brain storm solutions 4.- Pros vs Cons of each solution 5.- Select a solution to implement 6.- Develop an action plan 7.- Review progress on next visit

15. Structure of PST 6 visits Visit 1 60min, 2-6 30-45min Bi-weekly visits Teach problem solving skills each time you meet Work through a problem at each visit Work on homework between appointments

16. 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

17. PST Activity

18. SALUD Study Preliminary Results

19. 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

20. 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)

21. 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)

22. Participant Characteristics (n=95) %n Gender Female 66.363 Male 33.732 Education 6 th grade or less 72.669 6 th Grade + 27.426 Clinic DSMP 50.548 DSMP+PST 49.547 Age (mean /s.d.) 65.8 / 5.2

23. Primary Indicators – Baseline & Change Scores BaselineChange (6 month) Change Sig. MeanS.D.MeanS.D. PHQ-9 (0-24) 10.34.5-4.15.3*** Hyperglycemia Symptoms (0-7) 2.21.7-0.51.8* Hypoglycemia Symptoms (0-7) 2.11.7-0.31.6^ Nutrition (0-4) 2.60.60.20.8** Exercise (0-7) 2.82.40.92.9** Self-Efficacy (0-10) 7.21.60.91.9*** ^p<.10; *p<.05; **p<.01; ***p<.001

24. Regression Results - 1 Change: Nutrition Change: Exercise Change: Diabetes Self-Efficacy Std. BSig.Std. BSig.Std. BSig. Baseline value -.697***-.676***-.769*** Baseline PHQ-9 -.193*-.088 Change: PHQ-9.194*.093.193* *p<.05; ***p<.001 Note: All models control for clinic, gender, age, & education (not sig.)

25. Regression Results - 2 Change: Hyper- glycemia Change: Hypo- glycemia Std. BSig.Std. BSig. 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.)

26. Summary of Findings Bivariate results indicate: Changes post-DSMP/MPD completion were in desired direction Regression 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

27. 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

28. 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

29. Limitations Relatively small sample size identified from two (2) clinics in one (1) county No randomization or control condition for comparison

30. 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

32. New Exploratory Questions Does culturally adapted PST Increase treatment adherence Improve therapeutic alliance Lowers stigma

33. 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

34. VERONICA CARDENAS, PH.D. UNIVERSITY OF CALIFORNIA, SAN DIEGO VCARDENAS@UCSD.EDU ELIZABETH LUGO & ROBERTO CERVANTES SAN YSIDRO HEALTH CLINIC, SAN DIEGO CONSUELO RAZO, R.N. NORTH COUNTY HEALTH SERVICES, SAN MARCOS MUCHISIMAS GRACIAS!