The Mental Health Issues of Diabetes, A National Conference

October 8, 2013; Philadelphia, PA; Top Ten Highlights - Draft

Executive Highlights

Yesterday, we attended The Mental Health Issues of Diabetes, A National Conference in Philadelphia’s Rittenhouse Hotel. The discussion surrounding how to best address the mental health issues associated with diabetes – especially how to pay for effective interventions – was heated and lively. Certainly, much of the candid commentary offered by many of the “who’s who” in type 1 diabetes care and behavioral medicine was facilitated by the conference’s intimate size of ~100 people. We thank the JDRF and Universal Health Services for co-sponsoring this important event. Below are just some of the highlights from yesterday’s presentations and panel discussions. Tomorrow will feature a series of closed-door workshops for KOLs to debate and hopefully decide upon a paradigm for the diagnosis and treatment of the mental health issues for people with type 1 diabetes.

We think this is such an important area, and yet it is often widely under-recognized in mainstream diabetes care. We hope to see substantially increased awareness of this issue over time, since mental health and diabetes control are so bi-directionally linked (i.e., depression can lead to worse diabetes control, and worse diabetes control also leads to depression). We believe it’s particularly critical to change medical education curricula, as better education of future doctors (both specialists and generalists) could go a long way towards improving mental health disease recognition.

  1. Depressingly, NIDDK Director Dr. Griffin Rodgers (Bethesda, MD) delivered the keynote address, “Research at NIDDK: Type 1 Diabetes and Psychosocial Factors” by phone due to forced furlough related to the government shutdown. In fact, Dr. Arthur Rubenstein (University of Pennsylvania, Philadelphia, PA) was initially uncertain Dr. Rodgers would even be allowed to call in. The teleconference was a stark reminder of the current depressing political situation and that medical research is certainly not spared from the wider implications of budgetary constraints and politics.

  2. That said, we were very encouraged to hear Dr. Rodgers repeatedly refer to the development of an artificial pancreas as one of the NIDDK’s “primary goals.” Though government funding is certainly not what it once was, the NIDDK’s support is absolutely critical, especially because the Agency can engage the FDA from a more neutral perspective.

  3. Funding was identified as a major challenge in addressing the mental health issues associated with diabetes – a broad panel of leaders from well regarded academic diabetes centers (e.g., Barbara Davis Center, Penn, Pittsburgh) all seemed to agree on this front. Without coordinating their presentations, all but the presentations on Joslin and the DRI (which did not detail either’s overall model for addressing mental health issues), noted that they required endowments or outside funding in order to staff a full-time psychologist. This is particularly concerning when one considers that only 5% of people with diabetes receive treatment at such leading institutions (according to Dr. Mark Schutta [University of Pennsylvania, Philadelphia, PA]). The subsequent panel discussion became heated over how to best address this problem; one proposal, put forward by Dr. Georgeanna Klingensmith (Barbara Davis Center, Aurora, CO), was to code visits with a psychologist as diabetes care. An attendee warned, however, that this represented insurance fraud. Jokingly, an attendee suggested taking a page from “Breaking Bad” (i.e., making and selling crystal meth). All jokes aside, it quickly became clear that funding acquisition will be a key focus at tomorrow’s closed-door workshops on how to address mental health issues in diabetes. Hopefully, the NIH/NIDDK and JDRF can step up in a big way on this front.

  4. Kicking off a session on innovative treatments, Dr. Garry Welch (Tufts University School of Medicine, Boston, MA) gave two interesting examples to illustrate the advantages of telehealth. The first, a virtual diabetes nurse program, provided 330 patients with weekly phone calls, as well as home blood pressure and blood glucose monitors that electronically uploaded their data to the nurses. After eight months, investigators saw an impressive A1c drop of 3.3% (!) in patients who met the A1c and blood pressure goals (n=35; goals were <7% and ≤130/80 mmHg, respectively), as well as large A1c declines in patients who were still enrolled (1.9%; n=126), who quit the study (1.4%; n=75), and who discontinued the study due to a lack of phone access (1.3%; n=94). We did not catch the baseline A1c in the study, but assume it was ~10%. A second smaller study (n=30) leveraged electronic data collection from home blood glucose , home blood pressure monitoring devices, and an electronic pillbox – patients experienced a modest A1c decline of 0.6%. We are very curious whether these telehealth approaches are scalable and reimbursable, and if so, whether they will catch the eye of insurers and HCPs.

  5. We were particularly impressed with Dr. Michael Harris’ (Oregon Health and Science University, Portland, OR) behavioral health program NICH (Novel Interventions in Children’s Healthcare), which supports type 1 patients who repeatedly enter the hospital for DKA. In its first year, the program saved the OHSU Children’s Hospital an impressive $116,000 by lowering the readmission rates for 10-12 patients. Dr. Harris explained that the program’s model focuses on care coordination (e.g., team members accompany patients to their doctor visits and help interpret the medical language), case management (e.g., the program helps patients’ families solve issues such as homelessness), and behavioral and family systems therapy. The hands-on care model uses quite an arsenal of delivery techniques, including inpatient visits, extensive telehealth (weekly Skype chats, daily text messaging, and daily phone conversations), weekly home visits, and even school visits. The quandary, of course, is that such intensive care delivery is expensive, though very much worth it if it reduces hospital admissions.

  6. Dr. Howard Wolpert, MD (Harvard University, Boston, MA) opened his presentation explaining that the current approach to medical training and practice is negatively impacting the care people with diabetes receive from their physicians. First, he painted a picture of how physicians’ training and socialization in the acute care hospital environment shapes them to view a patient as a passive object and themselves as the directors of care. This is the antithesis of the “coach” approach Dr. Wolpert and many KOLs are proponents for. Additionally, he pressed that an underappreciated difference exists between endocrinology and diabetology. He characterized endocrinology as an essentially diagnostic and prescriptive practice; whereas, in diabetology the patient-provider relationship is the foundation for treatment effectiveness. Thus, he pressed, “Diabetology is not just an exercise in optimizing hormone replacement and/or correcting a pathophysiology.” From a patient perspective, we hope to see this knowledge reach every medical school in America, every clinical practice guidelines document, and every patient visit.

  7. A moving panel of people with type 1 diabetes and family members ensured that later discussion around the issue of mental health and diabetes was grounded in the patient and family experience. We were particularly disturbed to hear a high school sophomore describe the misinformation and bullying abounding in schools: “friends” complained that she talked about diabetes too often; people made “jokes” about eating 20 candy bars triggering diabetes; and teachers yelled at her for eating food in class or having her alarm go off. We hope that this conference will lead to initiatives to address this depressing reality – fortunately, other panel members (i.e., JDRF founder Ms. Lee Ducat) and attendees (i.e., Nicole Johnson, Miss America 1999) expressed a desire to address this problem.

  8. Discussion expanded beyond the patient during an afternoon session on the mental health burden of family members. In a departure from typical conference topics, Dr. Paula Trief (SUNY Upstate Medical University, Syracuse, NY) outlined the emotional challenges of partners of adult type 1 patients – a subject that has so far yielded “miniscule data.” Dr. Trief explored the subject using two small focus groups (n=14) and found that by far, the biggest issue for partners and spouses of type 1 patients was the fear of hypoglycemia. Other issues included anxiety and anger about the risk of future complications, concerns about childbearing and child rearing, and anxiety about the use of new diabetes technology. In addition, Drs. Ake Lernmark (Lund University, Lund, Sweden) and Suzanne Bennett Johnson (Florida State University College of Medicine, Tallahassee, FL) discussed the TEDDY study and how childhood genetic screening can affect the emotional status of mothers and fathers (TEDDY one-year results are currently in press). 

  9. Several speakers highlighted the importance of family-oriented models of care. Dr. Jill Weissberg-Benchell (Northwestern University, Evanston, IL) emphasized that diabetes-specific family conflict is clearly and consistently associated with worse medication adherence, lower health-related quality of life, and increased risk of depression. Dr. John Rolland (University of Chicago Pritzker School of Medicine, Chicago, IL) highlighted the need for a family psychosocial map and noted that physicians should introduce psychosocial components of care to a family within the first month of a diabetes diagnosis. Dr. Rolland underscored the need to track the entire family’s development in response to an illness, and offered techniques to better incorporate families into diabetes care (e.g., using “we” statements to define challenges in diabetes).

  10. Joslin CMO Dr. Robert Gabbay (Joslin Diabetes Center, Boston, MA) closed the conference with a brief yet compelling talk on the changing healthcare landscape and the prospect of better mental health therapy. He noted that future healthcare reimbursement will likely depend on the quality of health outcomes, a shift that will incentivize comprehensive care and create new opportunities for diabetes advocates. Dr. Gabbay reminded the audience that treatment for type 1 diabetes is expensive ($15 billion annually) and that diabetes patients are more likely to suffer from depression, which itself is associated with higher medical costs – a strong rationale for insurers to invest in mental health therapy for diabetes patients. In ending, he encouraged listeners to reposition mental health as a “cost saver” for insurers by focusing on three things: 1) using research to demonstrate the health and economic value of mental health therapy; 2) focusing on high-risk individuals; and 3) tackling high-cost items such as depression and adherence, and showing cost-effectiveness.

-- by Hannah Deming, Nina Ran, Adam Brown, and Kelly Close