Objective
There is a disconnect between how the healthcare system addresses individuals' physical and mental health needs. This project intends to help enhance the reach and implementation of evidence-based interventions that can improve the health outcomes and quality of life for people living with physical and mental co-morbidities. Adapting the proposed coordinated care model for people with type 1 diabetes would serve to address a gap in diabetes care, which largely focus on improving quality of care for people with type 2 diabetes and increase access to depression treatment in a state that ranks second to last in accessibility of mental health care.
Background Rationale
It is common for people living with Type 1 diabetes to experience depression or anxiety, which can in turn lead to worsening mental and physical health. Medical guidelines advice that physicians screen patients with diabetes for depression and anxiety, but these screenings are often not performed and follow-up with patients is difficult. This study seeks to adapt and test an integrated mental health and diabetes care model that has previously been shown to lower anxiety and depressive symptoms and blood sugar levels in adults with Type 2 diabetes for use with patients with Type 1 diabetes. This study will assess whether the adapted integrated care model can improve health outcomes better than usual care for patients seeking care in a diabetes clinic. In the first phase of the study, the study team will speak with patients, clinic staff, and clinicians to understand their perspectives on integrating diabetes and mental health treatment and potential barriers to care integration. The study team will develop a community advisory board, including patients with Type 1 diabetes, to understand whether depression and anxiety are priorities, guide adaptation of the care components, and to identify the key barriers and facilitators to care building on findings from the formative data. Then the final care model will be tested in a clinical trial where 80 individuals are randomly assigned to receive either usual care or the intervention care model. The care model has three parts that work together: self-management support from a non-specialized care coordinator, clinician-directed treatment decision support, and specialist case reviews. Patients assigned to the intervention group will receive the integrated care model for 12 months and both groups will be monitored for a total of 18 months to examine differences in health outcomes over time. The main outcome of interest for this study is changes in depressive, anxiety, and sugar levels in patients that received the integrated care model for 12-months, and
whether those changes are better than what is documented in usual care patients. People will be eligible to participate in this study if they are 18+ years of age, have been diagnosed with Type 1 diabetes by a physician, and have clinically significant depressive symptoms as assessed by a validated mental health screener. Eligible patients who consent to additional testing, the intervention, and follow-up will be enrolled. The study team’s diverse training and research experience will allow us to transform care for people with Type 1 diabetes and mental illness. Institutional ethics approval will be applied for to conduct this study. We anticipate the risks from involvement in this trial to be minimal. No invasive
procedures will be performed, except for collection of blood samples, which poses a risk of bruising and discomfort. It is unlikely, but study mental health questionnaires could cause distress. Appropriate precautions will be taken to avoid inflicting harm to participants. We anticipate that this care model will empower patient self-management and improve detection of depression and anxiety, access to mental health treatment, and quality of diabetes care.
Description of Project
It is common for people living with Type 1 diabetes to experience depression or anxiety, which can in turn lead to worsening mental and physical health. Medical guidelines advice that physicians screen patients with diabetes for depression and anxiety, but these screenings are often not performed and follow-up with patients is difficult. This study seeks to adapt and test an integrated mental health and diabetes care model that has previously been shown to lower anxiety and depressive symptoms and blood sugar levels in adults with Type 2 diabetes for use with patients with Type 1 diabetes. This study will assess whether the adapted integrated care model can improve health outcomes better than usual care for patients seeking care in a diabetes clinic. In the first phase of the study, the study team will speak with patients, clinic staff, and clinicians to understand their perspectives on integrating diabetes and mental health treatment and potential barriers to care integration. The study team will develop a community advisory board, including patients with Type 1 diabetes, to understand whether depression and anxiety are priorities, guide adaptation of the care components, and to identify the key barriers and facilitators to care building on findings from the formative data. Then the final care model will be tested in a clinical trial where 80 individuals are randomly assigned to receive either usual care or the intervention care model. The care model has three parts that work together: self-management support from a non-specialized care coordinator, clinician-directed treatment decision support, and specialist case reviews. Patients assigned to the intervention group will receive the integrated care model for 12 months and both groups will be monitored for a total of 18 months to examine differences in health outcomes over time. The main outcome of interest for this study is changes in depressive, anxiety, and sugar levels in patients that received the integrated care model for 12-months, and
whether those changes are better than what is documented in usual care patients. People will be eligible to participate in this study if they are 18+ years of age, have been diagnosed with Type 1 diabetes by a physician, and have clinically significant depressive symptoms as assessed by a validated mental health screener. Eligible patients who consent to additional testing, the intervention, and follow-up will be enrolled. The study team’s diverse training and research experience will allow us to transform care for people with Type 1 diabetes and mental illness. Institutional ethics approval will be applied for to conduct this study. We anticipate the risks from involvement in this trial to be minimal. No invasive
procedures will be performed, except for collection of blood samples, which poses a risk of bruising and discomfort. It is unlikely, but study mental health questionnaires could cause distress. Appropriate precautions will be taken to avoid inflicting harm to participants. We anticipate that this care model will empower patient self-management and improve detection of depression and anxiety, access to mental health treatment, and quality of diabetes care.
Anticipated Outcome
The proposed research will have an immediate impact for patients engaged in the testing of the care model as those randomized to the integrated care model will receive extra support from a care coordinator. This project will produce an integrated care model that meets the mental health treatment needs of patients with type 1 diabetes.
In the long-term, this project will demonstrate the acceptability, feasibility, and effectiveness of using a coordinated care model to improve mental health and diabetes care for patients with type 1 diabetes. Findings from this research will be used to advocate for institutionalization of effective care components in the local health care system, with disseminated findings serving as a model for other health systems to adopt.
Relevance to T1D
This project builds on an extensive literature base supporting the use of collaborative care models to improve health
outcomes for patients with type 2 diabetes. The model that we propose to adapt had a 1.6 times greater likelihood of
reducing depressive symptoms by 50% than use care. A detailed mixed methods evaluation of this care model identified
how the care model empowered patients to self-manage their depression and diabetes, with further recommendations on
how to improve the care components in future iterations. We plan to refine this care model using feedback and input from
patient and clinical actors within a local diabetes care clinic to be relevant for people with T1D.