Standards of Care and Clinical Practice
Recommendations: Type 2 Diabetes
Clinical Practice Recommendations
Alcohol and Other Substance Abuse
Last updated: July 2012
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.
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Last updated: August 2012
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.
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Tools for Clinicians and Educators
Patient Education Materials
National Institute of Alcohol Abuse and Alcoholism. Rethinking Drinking: Alcohol and Your Health.
NIH Publication No. 10-3770, 2010.
- Online version of 16-page booklet with interactive features and additional resources.
National Institute of Mental Health. Depression and Diabetes.
NIH Publication No. 11–5003. 2011.
- This brochure describes the signs and symptoms of depression and how it is linked to diabetes.
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Bantle JP, Wylie-Rosett J, Albright AL, Apovian CM, Clark NG, Franz MJ, et al. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association.
[PDF] Diabetes Care. 2008;31 Suppl 1:S61-78. (See p. S67 for alcohol recommendations)
Boyd DR, Milman K, Stuart P, Dekker A, Flaherty J. Alcohol screening and brief intervention (ASBI) program implementation and operations manual. [PDF] Rockville (MD): Indian Health Service, Office of Clinical and Preventive Services, Emergency Services; 2008 Mar. 36 p.
Guard A, Rosenblum L. Alcohol screening and brief intervention: a guide for public health practitioners.
Produced by the American Public Health Association under contract to the National Highway Traffic Safety Administration, U.S. Department of Transportation. Washington (DC): American Public Health Association and Education Development Center, Inc.; 2008. 28 p.
Indian Health Service National Tribal Advisory Committee on Behavioral Health (NTAC) and the Behavioral Health Work Group. [PDF - 2.7MB] American Indian/Alaska Native behavioral health briefing book.Rockville (MD): U.S. Department of Health and Human Services, Indian Health Service, Division of Behavioral Health, Office of Clinical and Preventive Services; 2011 Aug.
Kim SJ, Kim DJ. Alcoholism and diabetes mellitus.
Diabetes Metab J. 2012 Apr;36(2):108-15.
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The national survey on drug use and health (NSDUH) report: substance use among American Indian or Alaska Native adults.
Rockville (MD); 2010 Jun 24.
Beck, AT, Steer, RA, Brown, GK. Manual for the Beck Depression Inventory–II. San Antonio (TX): Psychological Corporation; 1996.
Ell K, Katon W, Xie B, Lee P-J, Kapetanovic S, Guterman J, et al. Collaborative care management of major depression among low-income, predominantly Hispanic subjects with diabetes.
[PDF] Diabetes Care. 2010 Apr;33(4):706-13. http://care.diabetesjournals.org/content/33/4/706.full.pdf+html
Fisher L, Glasgow RE, Mullan JT, Skaff MM, Polonsky WH. Development of a brief diabetes distress screening instrument.
[PDF] Ann Fam Med. 2008 May/Jun;6(3):246-52.
Fisher L, Skaff MM, Mullan JT, Arean P, Mohr D, Masharani U, et al. Clinical depression versus distress among patients with type 2 diabetes: not just a question of semantics.
[PDF] Diabetes Care. 2007 Mar;30(3):542-8.
Gonzalez JS, Safren SA, Cagliero E, Wexler DJ, Delahanty L, Wittenberg E, et al. Depression, self-care, and medication adherence in type 2 diabetes: relationships across the full range of symptom severity.
[PDF] Diabetes Care. 2007 Sep;30(9):2222–7.
Hartmann M, Kopf S, Kircher C, Faude-Lang V, Djuric Z, Augstein F, et al. Sustained effects of a mindfulness-based stress-reduction intervention in type 2 diabetic patients: design and first results of a randomized controlled trial (the Heidelberger Diabetes and Stress-Study.
Diabetes Care. 2012 May;35(5):45-8.
Jiang L, Beals J, Whitesell NR, Roubideaux Y, Manson SM; the AISUPERPFP Team. Stress burden and diabetes in two American Indian reservation communities.
[PDF] Diabetes Care. 2008 Mar;31(3):427-9.
Katon WJ, Lin EHB, Von Korff M, Ciechanowski P, Ludman EJ, Young B, et al. Collaborative care for patients with depression and chronic illnesses.
N Engl J Med. 2010 Dec 30;363(27):2611-20.
Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener.
Med Care. 2003 Nov;41(11):1284-92.
Li C, Ford ES, Strine TW, Mokdad AH. Prevalence of depression among U.S. adults with diabetes: findings from the 2006 Behavioral Risk Factor Surveillance System.
[PDF] Diabetes Care. 2008 Jan;31(1): 105-7.
Lin EHB, Rutter CM, Katon W, Heckbert SR, Ciechanowski P, Oliver MM, et al. Depression and advanced complications of diabetes: a prospective cohort study.
[PDF] Diabetes Care. 2010 Feb;33(2):264-9.
Manson SM, Beals J, Klein SA, Croy CD; AISUPERPFP Team. Social epidemiology of trauma among 2 American Indian reservation populations.
Am J Public Health. 2005;95:851-9.
Pan A, Lucas M, Sun Q, van Dam RM, Franco OH, Manson JE, et al. Bidirectional association between depression and type 2 diabetes mellitus in women.
Arch Intern Med. 2010(21);170:1884-91.
Sahota PKC, Knowler WC, Looker HC. Depression, diabetes, and glycemic control in an American Indian community.
J Clin Psychiatry. 2008;69:800-9.
Singh PK, Looker HC, Hanson RL, Krafoff J, Bennett PH, Knowler WC. Depression, diabetes, and glycemic control in Pima Indians.
Diabetes Care. 2004;27(2):618-9.
Whooley MA. Diagnosis and treatment of depression in adults with comorbid medical conditions: a 52-year-old man with depression.
JAMA. 2012 May;307(17):1848-57.