Recommendations for Alcohol and Other Substance Use
Screen for use of alcohol and other substances periodically. Utilize motivational interviewing when appropriate.
Be alert for behaviors, symptoms, signs, and laboratory test results suggestive of substance abuse.
Refer patients for behavioral health care and substance abuse treatment as appropriate.
Counsel patients on the appropriate use of alcohol:
Recognize and support that some AI/AN people and communities have chosen to be alcohol-free;
Advise abstention from alcohol for women planning a pregnancy and during pregnancy, and for people with medical problems such as liver disease, pancreatitis, advanced neuropathy, severe hypertriglyceridemia, or alcohol abuse;
For those who choose to use alcohol, recommend limiting alcoholic beverages to 1 serving per day for adult women and 2 servings per day for adult men. (1 serving = 12 oz. beer, 5 oz. glass of wine, or 1.5 oz. distilled spirits [e.g., vodka, whiskey, gin, etc.]).
For patients unwilling or unable to limit/abstain from alcohol or substance use, adjust medication choices and dosing schedules to minimize patient safety risks.
Rates of alcohol-related deaths in AI/ANs were 519% higher than the rate for U.S. all races from 2003-2005. AI/AN people are more likely than any other racial group to have either an alcohol or drug abuse disorder in the past year. Substance abuse disorders frequently coexist with and complicate the course of diabetes.
The toll these conditions take on AI/AN people, their families, and their communities is significant. Yet, while the risk of substance abuse is high, so is the rate of remission in AI/AN people.
Recommendations for Depression Screening and Follow-up
Screen adult patients with diabetes for depression at regular intervals.
Providers investigate positive screening results with patients to determine if depression is present and, if so, the severity.
A collaborative care team for the treatment and follow-up of patients with depression is established and accessible.
If depression is diagnosed, the collaborative care team develops and implements a treatment plan that includes routine monitoring using a standardized depression survey, stepped treatment intensification, and follow-up.
Depression is closely intertwined with type 2 diabetes, and the association between the two conditions is “bidirectional” – the presence of one increases the risk that the other will develop. Individuals with depression are at increased risk of developing diabetes, and as many as one-third of patients with diabetes will develop depression at some point. In the 2006 Behavioral Risk Factor Surveillance System (BRFSS), the overall rate of depression in people with diabetes was 8.3% but in American Indians and Alaska Natives (AI/ANs) it was 27.8%.
Depression not only affects patient self-management tasks such as medication adherence or lifestyle behaviors, but it also affects patient outcomes. Major depression is associated with a 25% increased risk of macrovascular complications and a 36% increased risk of microvascular complications in patients with type 2 diabetes. In a study of AI/AN patients with both diabetes and depression, A1C levels were found to be 1.2% higher (9.3% versus 8.1%). Effective treatment of depression and diabetes using collaborative care that emphasizes stepped treatment intensification has been shown to improve both conditions as well as quality of life and a number of functional outcomes.
To screen for depression, use a screening tool that is simple to administer and assess such as the Patient Health Questionnaire (PHQ-2). Other screening tools may be used, however, the PHQ has been validated in many populations, is relatively short and simple to use, and is designed for use in the primary care setting. Its’ longer version, the PHQ-9, can be used to track depression severity over time and supports appropriate treatment intensification. Routine use of the PHQ-9 at protocol-defined follow-up points in a manner similar to blood pressure tracking for hypertension is recommended. Even in higher risk populations, such as those with diabetes, the optimal frequency for depression screening is unknown.
→ Note: Depression screening alone has not been shown to improve outcomes. Screening must be incorporated into an effective collaborative care system that provides ongoing treatment, appropriate treatment intensification at timely intervals, care coordination and assertive follow-up, patient self-management support, psychoeducation, and monitoring to ensure resolution of depressive symptoms. Collaborative care teams (primary care provider, nurse care manager or other case manager, and consulting psychiatrist) have been shown to be particularly effective, though protocol-driven case management even without ongoing psychiatric oversight can also be effective.
This guide provides health educators and community health workers with the information, skills, and tools needed to conduct screening and brief intervention to help at-risk drinkers reduce their alcohol use to a safe amount or to stop drinking.