Veronica Cardenas, Ph.D. University of California, San Diego Elizabeth Lugo & Roberto Cervantes

1. Improved Depression and Diabetes Care Management among Elderly Latinos: Design, Implementation, and Preliminary Outcomes of a Culturally Tailored Strategy 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

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: “ManejoPersonal 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. Initial Tailoring for Target Population • 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

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 (Löweet al, 2004, Ell et al, 2009) • Hyper- & Hypoglycemia Symptom Scales • Each are 7-item scales of common related symptoms (Loringet 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 (Loriget 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)

23. Primary Indicators – Baseline & Change Scores ^p<.10; *p<.05; **p<.01; ***p<.001

24. Regression Results - 1 *p<.05; ***p<.001 Note: All models control for clinic, gender, age, & education (not sig.)

25. Regression Results - 2 **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 toboth 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. Additional Tailoring for Target Population • Culturally adapted Problem Solving Therapy includes: • Improved Spanish language • Improved terminology • Visual examples • Culturally relevant examples Aranda, Grant #5R21MH080624-02

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. MUCHISIMAS GRACIAS! 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