by Anoushka Kulikowski
A lifelong condition like diabetes takes a toll on mental health. “If you talk to patients, they’ll say living with a chronic illness is very challenging,” says Georgetown University clinical psychologist Stacey Kaltman, PhD.
Depression, in turn, makes it harder to find the motivation to care for diabetes: Getting exercise, eating right, and completing other basic tasks are difficult when you’re struggling just to get out of bed in the morning. “When [individuals] with diabetes [have] depression, their outcomes are much worse,” says Kaltman. “They’re at risk for poor outcomes.”
Yet when Kaltman began talking to health care workers at clinics in the Washington, D.C., area, she realized that some of the ways health care providers approach depression and diabetes are flawed. Even though the two conditions often occur together, they are treated separately. “People used to think if you address one, maybe the other will get better,” she says. She disagrees. “If you have one person with multiple conditions, it doesn’t make sense to fracture care.”
With the help of a grant from the American Diabetes Association, Kaltman decided to develop a behavioral treatment program, or intervention, that targets diabetes and depression at the same time. This was easier than it sounds, she says: Many of the lifestyle changes recommended for diabetes can also help lift mood. “Exercise is a clear one—it’s good for both depression and diabetes,” she says. “People who are out and active in the world feel better about themselves and manage their diabetes better.”
For her first group of patients, she focused on the Central American immigrant community living in and around Washington. “Latinos have an increased risk of diabetes and disparities in their access to health care,” she says. “When it comes to treating depression, they have very little access to mental health care.”
Zeroing in on those patients who “just weren’t getting better,” Kaltman turned to techniques proven to work on people with depression and looked for ways to tailor an intervention program to address the needs of people with diabetes.
Using several techniques, including “motivational interviewing” in 45-minute counseling sessions, Kaltman and her team encouraged the patients they worked with to set attainable goals for healthy lifestyle changes. For example, they asked participants about the activities they enjoyed and the challenges they faced in caring for their diabetes. “Instead of a lecture, we tried to make it a conversation, pulling out what the patient already knew and establishing goals that were patient-centered,” she says.
The more they listened, the more Kaltman and her team realized cultural factors played a big role in both diƒabetes and depression. For instance, the epidemic of diabetes among Latinos is often blamed in part on a poor diet.
But encouraging people to switch to salads overnight is unrealistic, too. Central American cuisine may be heavy on carbs and the fatty and fried, but after talking to patients, Kaltman realized it’s also a refuge for lonely immigrants. “Food is a really important connection to home, not just a preference,” she says. She encourages step-by-step substitutions that her patients want to try, such as eating whole-wheat tortillas instead of white flour varieties.
The pilot study involved 18 patients, all of whom were given six counseling sessions over the course of several months. “Patients really liked the intervention,” Kaltman says. “They felt like someone was listening to them and cared about them, and they made changes.”
After the sessions, patients were given two booster sessions at one-month intervals. They were also monitored for three months to see if they managed to improve measures of health and sustain the progress after counseling ended. On average, participants’ A1C, a measure of average blood glucose, dropped, and their depression symptoms lifted. (Getting more exercise was one of the few lifestyle changes people didn’t make.)
Kaltman’s next step is to set up an experiment that compares people who get counseling with people who don’t to see how big a difference the counseling makes. In the meantime, she’s optimistic that her approach can help people make changes that last. “The big focus is to make it sustainable,” she says. “The problem with diabetes is you have to sustain changes over a lifetime.”