Diabetes and Depression

November 20, 2015 Dr. Michele R Guzmán and Kendal Tolle, LMSW

November is National Diabetes Month and is intended to increase awareness of the disease and its effects on millions of people in the U.S. Approximately 26 million children and adults in the U.S. have Type I or Type II diabetes, with most having Type II.¹ In addition to not being aware of the prevalence of the disease, many people may not realize that depression frequently co-occurs with diabetes, most frequently with Type II.² One out of every four people with Type II diabetes has clinically significant depression, with the prevalence of depression being double in people with Type II diabetes in comparison to the general population.³

Unfortunately, fewer than 25% of individuals with diabetes and depression receive adequate treatment.4 Untreated and poorly managed diabetes can lead to serious consequences. When patients with diabetes are also experiencing depression, physicians may have concerns that they may not take the correct dosage of medications or monitor blood sugar levels appropriately. This can lead to overall poor management of diabetes and result in serious health conditions (heart disease, blindness, amputations).5 Major depression also has adverse effects on diabetes outcomes, resulting in poorer quality of life and lowered self-care.6

There is a high prevalence of comorbid diabetes and depression in the Latino population, especially among low-income Latinos.7

Among Latinos, Mexican Americans experience higher rates of depression than other groups, and are further susceptible to comorbid diabetes and depression.8 Studies of Hispanic culture and health show some Hispanic individuals seek medical care from traditional healers or use home remedies and over-the-counter medications, often due to financial and cultural/linguistic barriers. Stigma associated with mental illness and depression may affect whether or not individuals choose to seek treatment for comorbid diabetes/depression.9

What do we know about how to best help individuals with co-occurring depression and diabetes?

Research tells us that Latinos with Type II diabetes experiencing depressive symptoms “may derive the greatest benefits from diabetes self-management interventions.”10 These types of educational programs provide people with skills that they can incorporate into their everyday lives. It almost goes without saying that improved eating habits support diabetes management, but a healthy dietary pattern has also been associated with a reduced likelihood of depressive symptoms, especially with Type II diabetes; healthy diet has been associated with a reduced likelihood of depression/depressive symptoms for those both with and without diabetes.11

In addition to self-care, there are models of care and approaches that physicians can take that result in better outcomes for individuals with these co-occurring conditions. First of all, early detection is key. It is recommended that primary care physicians screen for depression in diabetic patients.12 Besides screening, depression treatment provided by primary care providers has been shown to be effective for low-income, racial and ethnic minority populations.13 However, it should be noted that medication-only may not be the best route for all individuals with these co-occurring conditions. Counseling may provide the opportunity to not only address the symptoms and underlying issues related the depression, but also allow for conversations about changing behavior and lifestyle to better manage diabetes.

Integrated health care efforts, models in which behavioral and primary health care are not only co-located, but closely coordinated, are particularly well-suited to treating co-occurring diabetes and depression. The Diabetes-Depression Care-Management Adoption Trial conducted in Los Angeles explored the impact of the collaborative depression care model, which incorporates evidence-based diabetes care management components and utilizes structured tools such as patient education, care coordination, depression screening, electronic disease registry, and integrated clinical decision support systems. The model also includes integrated team-based care, an intensive care model with strict guidelines for follow-up and monitoring of diabetes symptoms and comorbid risks, such as depression. The quasi-experimental trial found that the implementation of collaborative depression care in a diabetes disease management program effectively improved depression outcomes along with patient satisfaction, specifically in safety-net care systems.14 An evaluation of integrated care programs in Texas utilizing the collaborative care model for the treatment of depression and anxiety found the odds of improvement for patients with depression were 54 percent higher among patients who preferred Spanish, compared to patients who preferred English, demonstrating that for this subset of Latinos, this type of coordinated care may be especially effective.15

The Meadows Mental Health Policy Institute (MMHPI) is a non-profit organization established in 2013 to provide policy research and development to improve mental health services in Texas. It analyzes and evaluates public policy through evidence-based research and data-driven assessment of outcomes. The mission of the institute is to support the implementation of policies and programs that help Texans obtain effective, efficient mental health care when and where they need it.

1Semenkovich, K., Brown, M., Svrakic, D., & Lustman, P. (2015). Depression in Type 2 Diabetes Mellitus: Prevalence, Impact, and Treatment. Drugs, 75(6), 577-587.
2Dipnall, J., Pasco, J., Meyer, D., Berk, M., Williams, L., Dodd, S., & Jacka, F. (2015). The Association between Dietary Patterns, Diabetes and Depression. Journal of Affective Disorders, 174, 215-224.
3Semenkovich, K et. Al, “Depression in Type 2 Diabetes Mellitus” (see footnote 1)
4Colon, E., Giachello, A., McIver, L., Pacheco, G., & Vela, L. (2013). Diabetes and Depression in the Hispanic/Latino Community. Clinical Diabetes, 31(1), 43-45.
5CDC Explores the Relationship Between Diabetes and Depression. (2009, November 1). Retrieved from http://www.usmedicine.com/2009-issues/november-2009/cdc-explores-the-relationship-between-diabetes-and-depression/
6Ciechanowski, P.S. Katon, W.J., & Russo, J.E. (2000). Impact of depressive symptoms on adherence, function, and costs. JAMA Internal Medicine, 160(21).
7Wu, B., Jin, H., Vidyanti, I., Lee, P., Ell, K., & Wu, S. (2014). Collaborative Depression Care Among latino Patients in Diabetes Disease Management, Los Angeles, 2011-2013. Preventing Chronic Disease, 11.
8Nedungadi, T., Johnson, L., Edwards, M., Barber, R., Hall, J., D’Agostino, D., . . . O’Bryant, S. (2015). Comorbid Diabetes and Depression Impacts Diabetic, Cognitive and Affective Outcomes among Mexican Americans. The Journal of the Federation of American Societies for Experimental Biology, 29(1).
9Colon, E. et. al, “Diabetes and Depression in the Hispanic/Latino Community” (see footnote 4)
10Wang, M., Lemon, S., Whited, M., & Rosal, M. (2014). Who Benefits from Diabetes Self-Management Interventions? The Influence of Depression in the Latinos en Control Trial. Annals of Behavioral Medicine, 48(2), 256-264.
11Dipnall, J. et. al, “The Association between Dietary Patterns, Diabetes and Depression” (see footnote 2)
12CDC Explores the Relationship Between Diabetes and Depression (see footnote 5)
13Wu, B., Jin, H., Vidyanti, I., Lee, P., Ell, K., & Wu, S. (2014). Collaborative Depression Care Among latino Patients in Diabetes Disease Management, Los Angeles, 2011-2013. Preventing Chronic Disease, 11.
15An Evaluation of the Collaborative Care Model of Integrated Health Care in Texas: An Executive Summary. (n.d.). Retrieved from http://www.hogg.utexas.edu/uploads/documents/CollaborativeCareModel_EvaluationReport1.pdf

Executive Profile – Nicole Lievsay

November 19, 2015 Vashtai Kekich


“My work and roles have positioned me well to represent the Institute in Houston and to develop and maintain relationships with key stakeholders and create an environment of collaboration,” says Nicole Lievsay, the new Harris County Regional Director of the Meadows Mental Health Policy Institute. Nicole brings with her a diverse and robust background that is an excellent complement to the goals and objectives of Institute. Nicole joins us with over 20 years of experience in criminal justice, behavioral health, family services and health care. While collaboratively developing programs and policy at the federal, state and local levels, Nicole built partnerships across sectors while focusing on systems development and transformation.

“We look forward to her leadership in facilitating collaboration and support of improved outcomes for those with mental illness in the Houston community and strengthening our presence in the region with her strong background in both public policy and behavioral health care,” says Phil Ritter, Chief Operating Officer of the Meadows Mental Health Policy Institute.

Nicole was most recently the Director of Health Systems Strategies, Waiver Operations, at the Harris County Hospital District, which services the 3rd largest county and 5th largest city in the country, and also serves as the coordinating entity for Texas’ largest health care transformation system. Building on her prior experience in Harris County, Nicole led Harris Health System’s implementation of the 1115 Medicaid Transformation Waiver in a nine county region centered in Houston. In this role, she was responsible for ensuring the success of over $2 billion in health care transformation projects.

She has worked at all levels of the government and says through her work “she gained an appreciation for the importance local mental health systems play in effective behavioral health care.” Nicole has expertise in a vast array of areas, both in public and private sector, including public policy, strategic planning, policy and procedure development, behavioral health care and community affairs.

As the Harris County Regional Director, Nicole will build important relationships and further the Institute’s mission in her hometown, “I hope to continue contributing to this progressive and dynamic community.”

Nicole is a graduate of the University of Texas at Austin. We are excited to have her join the Meadows Mental Health Policy Institute team and to strengthen our presence in the important and diverse Houston community.

Leader Spotlight – Dr. Tony Fabelo

November 12, 2015 Vashtai Kekich


Dr. Tony Fabelo is the Director of the Research Division of the Council of State Governments and is helping provide the momentum needed to make necessary changes in the justice system for individuals with mental illness. Working from the Austin office of the Counsel of State Government’s Justice Center, he provides technical assistance to state and local governments to help make more efficient use of state and local taxpayer dollars. The Justice Center serves all states to promote data-driven practices in the justice system and manages major national justice projects with state, federal and foundation funding support. Dr. Fabelo believes it is these data-driven practices that make the most significant strides towards decreasing the prison population by treating those with mental illness.

Dr. Fabelo’s successful career has found him assisting every Texas legislature since 1985 to develop criminal justice policies, including crafting the Justice Reinvestment Initiative adopted by Texas in 2007. In his previous work at the Texas Criminal Justice Policy Council he managed the production of over 200 research reports. Throughout his career he has used his highly specialized knowledge and charisma to create community partnership and legislative momentum to reform the justice system. Although he is known for his no-holds-barred, realistic approach to justice reform, he still expresses hope and passion in his belief that local systems can still make smart justice reforms to the benefit of their communities.

For Tony, the groundbreaking laws passed 22 years ago that address the need to identify and divert individuals with mental illness who become justice-involved are finally being addressed at the local level, allowing local systems to link these individuals to community care and decrease recidivism. “I am glad to have a new opportunity to tackle the system and am excited to work with the Meadows Mental Health Policy Institute. Now we can concentrate on helping people get done what should have been done years ago.”

Tony’s impactful work includes the MMHPI and CSGJC partnership with Bexar County officials to transform the county’s local justice system to achieve the goals of the Smart Justice Initiative. In 2013, the CSGJC team completed a data-driven in-depth review of Bexar County’s pretrial processes and mental health diversion practices. MMHPI/CSGJC worked with county officials to revamp interagency processes to allow for better identification of mentally ill persons at intake at the Central Magistrate Facility (CMAG) and some of these processes are already implemented.

Dr. Fabelo will continue his work in Bexar County partnering with local officials and MMHPI to assist in the implementation and monitoring of outcomes for strategies they have outlined for the county. The goal is to develop Bexar County as a demonstration site for best practices related to the identification and treatment of justice involved mentally ill persons.

If you ask Tony what he is most proud of his immediate answer is “My kids. I have done my part for Texas by raising kids that are good citizens.” But in terms of his work he is most proud of having a clear mindset, realistic approach and good understanding of what he is capable of doing. “The numbers, the data, it is more important than the ideology. Those with the ideological frames are the architects. But architects need good engineers and my job is to be an engineer. To build things based on numbers and data.” We thank Dr. Fabelo for being an engineer to these projects, as they are truly creating positive change in our state and setting an example nationwide.

Networking Groups

November 11, 2015 Kendal Tolle, LMSW

During the first year of its inception, the Institute held the “Texas State of Mind” tour, hosting community conversations in a number of Texas cities to discuss the state of mental health services across Texas. While the events and conversations at each stop along the tour were uniquely designed and led by each community, a common theme arose from a number of the stops: individuals with expertise and interest in behavioral health wanted a way to connect and network with professional peers in their field across the state. One result of these conversations was the development of two networking groups.

Both groups are facilitated by the Institute and each are co-chaired by professionals working within the groups’ respective focus areas. Networking group calls are held during the third week of each month and host a guest speaker who presents on particularly noteworthy work or innovations in the field, including best practices in the field, workforce issues and opportunities, systems change, and shared learning. The majority of time on the networking calls are left for robust discussion amongst the networking group participants, allowing members from across Texas to share and learn from their peers in an engaging and informative conversation.

The Physical Health/Behavioral Health Integration (PHBHI) Networking Group provides an opportunity for individuals across the state with interest and/or expertise in the integration of primary and behavioral health care services to connect, network and share ideas with other professionals in the PHBHI field.

In this networking group, previous speakers have included Dr. Octavio Martinez, Jr. (Hogg Foundation for Mental Health) and Melissa Rowan (Texas Council of Community Centers) presenting on the work of the Behavioral Health Integration Advisory Committee (BHIAC), and Dr. Rebecca Wells of UT-School of Public Health sharing preliminary findings from the evaluation of an 1115 Waiver integrated behavioral healthcare (IBH) project. The next PHBHI Networking Group call, scheduled for Friday, November 20th from 11:00-12:00pm CST, will have guest presenter Dr. Jim Zahniser of Meadows Mental Health Policy Institute speaking on best practices and emerging trends in IBH.

Interested in Joining the PHBHI Networking Group?

For more information on how to join the PHBHI Networking Group, please contact the PHBHI Planning Team at PHBHI@texasstateofmind.org.

      The Peer/Recovery-Oriented Systems of Care (Peer/ROSC) Networking Group provides a platform for individuals with interest and/or expertise in recovery-oriented behavioral health services and related fields to network and share ideas, and keeps with an overall focus on recovery services that integrate substance use and mental health.

Previous Peer/ROSC Networking Group calls have had presentations from Lori Ashcraft, Executive Director of the Recovery Innovations Recovery Opportunity Center discussing the services provided by the Center, and Dr. Linda Holloway of the University of North Texas who shared findings from an environmental scan of addiction counseling professionals across Texas as part of a Recovery to Practice grant from the Hogg Foundation for Mental Health. Our next Peer/ROSC call, on Thursday, November 19th from 1:00-2:00pm CST, will have guest presenter Dr. Stacey Manser of the UT-Austin School of Social Work to speak about advancements and opportunities in the peer workforce in Texas.

  Interested in Joining the Peer/ROSC Networking Group?

For more information on how to join the Peer/ROSC Networking Group, please contact the Peer/ROSC Planning Team at PeerROSC@texasstateofmind.org.  

Strengthening the Safety Net: The Intersection of Mental Health Clinicians and Law Enforcement

November 10, 2015 Brittany Lash, LPC

In recent years, the nation has seen a significant increase in attention drawn to the issues of mental illness and law enforcement. Typically, the media coverage of these two issues trigger feelings of sorrow, outrage, and resignation as U.S. citizens have watched the number of casualties rise in mass shootings, law enforcement officer fatalities, and civilian deaths due to an officer’s use of force. Even more striking is the story of the families who quietly watch the lives of their loved ones decline as they struggle to cope with their symptoms, feeling lost as they attempt to navigate a complicated care system. They suffer silently when their family member or friend is one of the 40,000 Americans each year to complete suicide[1] or are hurt or killed as the result of a cry for help that escalated and required law enforcement use of force. (Twenty-five percent of the time, citizens who are fatally wounded during a law enforcement response are found to have been mentally ill)

Despite media attention that, at times, has correlated individuals with mental illness and law enforcement as a purely negative interaction, there is a hidden truth in our current mental health safety net: law enforcement are often the first response to cries for help from individuals with mental illness and their families, and responses to these calls are often the most time consuming and dangerous for officers. Knowing this, many states have legislated increased training for their officers using a nationally recognized best-practice called Crisis Intervention Training (CIT) that started in 1988 but only recently began to gain traction and national attention. At this time, over 2,700 communities in the U.S. have adopted required CIT training for their officers.[3] Texas is currently leading the nation with its exemplary CIT programs in Houston and San Antonio.[4] However, even with great training, officers are not equipped to act as mental health clinicians and at times may need additional resources when they address mental health related calls, especially when these calls may take hours to resolve.

An even less recognized resource for psychiatric crisis assistance is a mobile crisis outreach team (MCOT). While there are multiple variances of an MCOT, in its purest form it is a two-person team of mental health clinicians, usually master’s degree level, who respond with or without law enforcement to address psychiatric crisis wherever a person needs it, whether it be in their home or under a bridge. These teams usually respond to calls from a crisis hotline rather than 911 dispatch. An MCOT also has the capability to more easily link a client to appropriate community resources and support the individual as they begin the journey of mental health recovery.

Some communities partner specific law enforcement officers (usually CIT specialized) with MCOT clinicians as part of an organized unit. Others allow officers and MCOT to contact one another and request assistance on calls as needed. No matter how a community pairs their officers and MCOT clinicians, communities benefit from this alliance.

On many calls for assistance, the individual or their family is seeking resources, not hospitalization. In these instances, MCOT can take the call from officers and allow the officer to respond to other, more emergent calls and focus on their role of maintaining public safety. MCOT then can provide an on-site clinical risk assessment as well as the support and connection to resources that the individual desperately needs. In some communities, MCOT professionals are also able to provide follow-up over a seven to 30-day period of time, allowing the MCOT to confirm that the person’s crisis is resolved and the person is linked to appropriate ongoing care. This decreases the likelihood that the person will make another call for law enforcement services, get admitted to a psychiatric facility, or become incarcerated.

Due to the unpredictable nature of many mental health related calls, officer presence is often needed to maintain safety for the MCOT, family, and client on location. In instances where an individual is deemed to be a danger to themselves or those around them, officers may also assist in transport to the nearest appropriate emergency department or psychiatric hospital. Even when MCOT and officers address calls requiring hospitalization together, the overall time an officer is off the street on a mental health call is often decreased. MCOT clinicians can assist the family and client in understanding the hospitalization process, obtain appropriate hospital resource placement for the client, and stay at the hospital emergency department (ED) with the patient to advocate for care and communicate with providers. Without an MCOT, officers may have to sit in an ED for hours waiting to transfer custody and speak to a medical professional about the client’s needs. In communities that are consistently understaffed in their law enforcement jurisdications, the wait time in an ED can be costly in not only overtime but also in overall public safety.

Officers often hold a significant amount of information about the lives and needs of the citizens in their service area. In many communities, officers have made at least one call for service to the homes of the individuals with mental illness in their communities and may have established relationships with them over repeated contacts. Because of this increased rapport and knowledge, officers can find themselves frustrated when they feel they are not able to get someone to care who is not currently meeting hospitalization or emergency detention criteria. These individuals are on the cusp of a crisis that could either result in hospitalization or detention in jail, but due to the reactionary nature of most mental health and justice systems, the person may not be able to get urgent care at that time. MCOT can bridge this gap, working with officers to identify and serve these individuals prior to the point of crisis, also diverting individuals from potential incarceration or hospitalization. Officers may also find that addressing these individuals “pre-crisis” could improve rapport with citizens in their districts and decrease overall instances requiring use of force.

The partnership between law enforcement and mental health clinicians is imperative as law enforcement find themselves addressing increasing calls that are mental health related. The relationship is often a symbiotic one, with officers and MCOT working together to meet all the needs of the individual. However, most communities find that limited capacity in both law enforcement and mental health resources is a barrier to providing this level of care, despite the long-term cost savings to the community. Thankfully, legislators have begun to recognize the need for expanded resources and improved access to care, and they are working to pass legislation to improve the overall structure of the mental health safety net. Pennsylvania congressman Tim Murphy is one such legislator, submitting bill H.R. 3717 to the house floor in 2013. The “Helping Families in Mental Health Crisis Act” pledges to increase training for law enforcement officers and add crisis and outpatient capacity for the mentally ill and is gaining support in the House.[5] Hopefully, with added resources and legislative support, law enforcement and mental health clinicians will be able to advance their budding partnerships to increase public safety and quality of life for individuals with mental illness and their families.

[1] American Association for Suicide Prevention: https://www.afsp.org/understanding-suicide/facts-and-figures
[2] National Alliance for Mental Illness: http://www.nami.org/cit
[3] National Alliance for Mental Illness: http://www.nami.org/cit
[4] Mental Health Channel: http://mentalhealthchannel.tv/episode/the-right-response
[5] Helping Families in Mental Health Crisis Act: http://murphy.house.gov/helpingfamiliesinmentalhealthcrisisact#Bill%20Information