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Just as there is no “one-size-fits-all” insulin dosing regimen in type 1 diabetes, there are an endless variety of ways this demanding condition can impact every individual’s mental health, too.
With over 25 participating clinics across the United States, the T1D Exchange’s Quality Improvement Collaborative (QIC) strives to improve the overall care and treatment available to people with type 1 diabetes using data benchmarking. The most recent round of data benchmarking included a focus on increasing CGM sensor use, insulin pump use, and depression screening.
Over the last two years, the QIC has increased the frequency of mental health screenings from 15 to 65 percent at their participating clinics. Research estimates that people with type 1 diabetes are 5 times more likely to develop depression and anxiety. The impact this inevitably will have on a patient’s self-care is undeniable, making mental health screening a critical part of patient care.
By joining the T1D Exchange’s QIC, Janine Sanchez, MD, and Director of Pediatric Diabetes at the University of Miami, is eager not only to learn from others’ research but to contribute research from the her own clinic where they’ve made significant changes in how they screen patients for challenges in their mental health.
“I’ve been involved in diabetes care and research for over 20 years,” explained Sanchez, who is also an Associate Professor of Pediatrics.
Over the years, her research involvement has included studies around immunity, psychology, medications, genetics in neonatal diabetes, and most recently — thanks to joining the T1D Exchange — the incidence of COVID-19 and diabetic ketoacidosis (DKA) in people with type 1 diabetes due to the high number of cases in the state of Florida.
“When the T1D Exchange’s QIC first began, I had been hoping to be involved but we just didn’t have the staff in our clinic,” explained Sanchez. “We joined now because it means working together to see what different clinics are doing to improve clinical care and making sure we are offering our patients the best care we can.”
How the University of Miami Changed T1D Mental Health Screenings
Every three months, at routine quarterly appointments with children and teenagers living with type 1 diabetes, Sanchez knows she has a finite amount of time to grasp which patients need more support and which patients are thriving.
While living with diabetes isn’t easy at any age, the challenges that young people face inevitably come with additional psychosocial obstacles: managing diabetes with parent involvement, wearing visible diabetes technology at an age when being “different” isn’t usually valued, being expected to rise to the high-maintenance demands and responsibilities of a condition that never takes a vacation, and so much more.
“We didn’t used to screen every single patient for depression and anxiety,” explained Sanchez.
Sanchez’s clinic set out to change their approach to mental health screenings much like the QIC’s own process: through a trial study.
“We started it as a trial and we saw how much we were picking up cases of depression and anxiety that we were not picking up in routine visits. Sometimes not directly related to their diabetes but definitely affecting their diabetes.”
Based on their research, Sanchez’s clinic has actually designed their own mental health screener, and every patient 12 years or older is screened at every appointment.
“We designed it by taking a combination of different screeners and chose the ones we thought were most specific to pediatric diabetes and mental health.”
While many clinics only use the “PhQ9” (patient health questionnaire) or “GAD7” (general anxiety disorder) screening tests, Sanchez has learned over the years that these screeners let too many patients in need of support slip through the cracks.
“In the screens like PhQ9, we discovered that older teenagers would learn very quickly how to answer questions so they wouldn’t raise any concerns and have to talk to a psychologist.”
Usually, Sanchez said teenage patients figured out how to answer questions after only one time taking the screening test.
“Now, it’s much harder for them to rig their answers with our new mental health screener,” added Sanchez. “And patients can do it via iPad in the clinic or via email for telemedicine appointments.”
Sanchez’s clinic has made two other changes to their patients’ routine appointments that she knows could be significant to share with the QIC:
- They’ve changed the way they interview their patients.
- Patients can meet with a psychologist at any clinic appointment, and those who raise concerns on the screening test are required to do so.
“We were finding that patients were telling psychologists important information about their mental health that they weren’t telling us during clinic appointments,” explained Sanchez.
By making a psychologist easily available to every patient before, during, or after their clinic appointments, the results have been invaluable.
“Even if their screening results are fine, we ask if they want to see psychology after their appointment,” added Sanchez. “Sometimes they say yes, and we had no idea there was an issue before then. I wouldn’t have thought to refer them, but patients share things with the psychologist they weren’t sharing with us.”
Sanchez is eager to participate in the many opportunities provided by the QIC that could further their approach to diabetes care.
“We’re always asking ourselves, ‘what can we do to make our care better and more efficient? A lot of times it’s easy to figure out what patients need, but how do you do that in the most efficient manner? We look forward to being part of the QIC to help us continue to provide good care for our patients in the most efficient manner.”
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