Case Study: Care Coordination and Case Finding of Undetected Depression in a 72-Year-Old Man With Type 2 Diabetes Free

In 2001, M.G., a 72-year-old white man, enrolled in a diabetes management program sponsored through his health benefits program. This is a voluntary program that includes periodic telephone assessment of diabetes self-management. In addition to self-reported information, the program also utilizes claims and lab data made available through the health plan. After each assessment, the program mails summary reports to participating patients and their physicians. These reports support better communication between patients and physicians regarding information gathered during program assessments that falls outside the recommendations of the American Diabetes Association (ADA).

In addition to asking the assessment survey questions, the program staff also provides patient education materials based on the ADA’s current clinical practice recommendations and support patients and their practitioners with care coordination and diabetes management supplies. Between assessments, participants can access the program staff through a toll-free telephone number 24 hours a day, 365 days a year.

At enrollment, M.G. provided demographic information and medical history indicating that he is single, elderly, living alone, and responsible for his own self-care. M.G.’s type 2 diabetes was diagnosed 5 years before he enrolled in the program and is controlled by diet and activity alone.

In addition to diabetes, he has been treated for other conditions, including chronic back pain, hyperlipidemia, coronary artery disease, neuropathy, arthritis, and cancer. Several physicians share responsibility for his medical care; some are from a large multi-physician group, and others are from a Veterans Affairs clinic. M.G. complains that his care is fragmented and that the advice and recommendations of his doctors frequently clash. He often feels caught in the middle of these disagreements and sometimes does not know whose advice to follow. This has frustrated him tremendously and caused him to lose faith and trust in the health care system.

Lab data confirm that M.G. has been successful in maintaining his blood glucose levels within the targets set forth in the ADA’s clinical practice guidelines (hemoglobin A_1c [A1C] < 7%). Additionally, all of his assessments and lab results have been consistent with the program’s clinical goals for diabetes control (A1C results < 7%, blood pressure < 130/80 mmHg, LDL cholesterol < 100 mg/dl, HDL cholesterol > 40 mg/dl, and triglycerides < 150 mg/dl). M.G. has kept his routine physician appointments, and in turn, his physicians have performed the screening tests recommended in the ADA guidelines (dilated eye examination, thorough foot exam, and screening for urine protein). M.G. has not required any emergent or inpatient care since enrolling in the program.

About a year after his enrollment in the program, during a routine assessment, M.G.’s nurse detected that he was not acting like himself. Although his responses to most of the assessment questions were well within diabetes care guidelines, he appeared to be somewhat upset and agitated. He reported that over the past 90 days he had lost considerable weight, ∼23 lb. He said he had not been attempting to lose weight, but had lost his appetite and did not have the energy or desire to prepare meals. Additionally, the assessment of M.G.’s functional health status indicated that over the past 4 weeks, he had been feeling down, had less energy, and had not been able to attend to his normal activities of daily living.

The nurse asked if he had spoken with his doctors about the changes he had noted in his health. M.G. indicated that he had not and stated emphatically in an agitated tone that he would not. When asked why, M.G. stated that he did not trust his physicians and felt that they really did not care about him. He talked again about his fragmented care and his frustration with getting different recommendations from different providers. Upon further discussion, the nurse determined that there was one physician with whom M.G. still had a good working relationship.

Before completing the assessment, M.G. volunteered that he was also upset about a letter that he had recently written to his children. He had not received any response and said that this deeply hurt him and that he felt his children did not care about him anymore. M.G. went on to say that he felt terrible, that he was tired, and that he sometimes felt like he just wanted to give up. When the nurse asked if he had any thoughts of hurting himself or of suicide, M.G. said no.

After completing the assessment, the nurse decided that, in addition to mailing out the routine report, she needed to contact a physician and report her concerns about M.G.’s state of mind and recent weight loss. The physician she contacted was the one in whom M.G. said he still had confidence. The physician called M.G. after hearing from the nurse and made arrangements for an office visit that same day. Subsequently, the physician diagnosed clinical depression and started M.G. on an antidepressant medication.

M.G. accepted the treatment recommended by his physician for depression. About 8 weeks after initiation of his antidepressant therapy, M.G. called the program nurse to let her know that he had not been completely truthful during his earlier assessment and that, in fact, he had actually been planning a suicide attempt. Now that he felt better, he said he wanted her to know and that he felt he owed her his life. He thanked her for listening to him and caring enough to make sure he got the medical care he needed. He reported that his appetite had returned, that he had regained his weight, and that he had been able to resume his activities of daily living.

1. How significant is depression as a comorbidity of diabetes?

2. What are common barriers to identifying depression in the primary care setting?

3. What disease management tools can be applied in the primary care setting to aid in depression case identification?

This case provides the backdrop for some important lessons. First, it addresses the fundamental importance of coordinated care. Most patients want to have a physician oversee and coordinate their overall health care plan. Unfortunately, the reality of today’s health care system is that too many physicians find themselves overloaded by the volume of patients they are expected to see. They have difficulty finding the time to provide a satisfactory level of care coordination. They do the best they can, but many feel that they are forever attempting to squeeze more and more from office visits in which they must address not only patients’ presenting chief complaint, but also their ongoing health management.1,2 

Second, this case illustrates how a program such as M.G.’s diabetes management program can provide valuable and timely alerts to physicians when their patients experience a significant decline in health status. In this case, the patient had not communicated with his health care provider and said he had no intention of doing so in the future. The program’s post-assessment referral brought his situation to the physician’s attention and opened an opportunity for him to reach out to M.G. and get him to come in for evaluation, diagnosis, and treatment. Although there is no way to know what would have happened to M.G. if he had not been participating in the program, or if his nurse had not contacted the physician after her assessment, the patient’s feedback indicates that for him it was indeed the right action to take.

Depression is a prevalent, serious, and costly comorbidity of diabetes. The literature indicates that the prevalence of depression in diabetes is probably twice that of the general population.3,4 There is also evidence that the costs of care escalate for depressed diabetic patients. One recent study reported that total annual costs were 4.5 times higher for depressed diabetic patients than for their nondepressed diabetic counterparts.4 

The prevalence of diabetes is disproportionately high among senior citizens. Elderly patients are at higher risk for depression and suicide. Risks are highest when seniors become socially isolated, lose the contact and/or support of family and friends, or are widowed or divorced.5 As health care providers, we need to educate our patients and their families about depression, its signs and symptoms, and the benefits and availability of early identification and treatment.

Undetected depression can interfere with metabolic control. Patients who are depressed are robbed of the energy and motivation they need to follow their treatment plan. Studies have shown that even mildly depressed patients are more likely to have problems maintaining blood glucose control and much less likely to attend to positive lifestyle behaviors.4 Without detection and appropriate treatment, depressed diabetic patients are likely to find themselves on a path that leads to isolation, hopelessness, and potentially serious deterioration of their health and well-being.

There are many barriers to early diagnosis of depression as a comorbidity of diabetes. Some of the more common barriers include:

• The social stigma associated with the diagnosis of a mental health problem.

• The complex comorbid nature of diabetes and the expectation that it may be normal for diabetic patients to feel burdened by their diabetes and its management.

• Lack of access to providers for coordination of care. Many patients and providers feel constrained by the limited amount of time routinely available for care management.

• People may not recognize emotional symptoms as health related. They may instead see them as “personal issues” and feel that they should be capable of handling them on their own, without the involvement of the health care team.6 

• Depression screening can improve the identification of depressed adult patients in the primary care setting. A 2002 report from the Agency of Healthcare Research and Quality’s U.S. Preventive Services Task Force (USPSTF)7 supported the importance of depression screening in adults, but noted that there is as yet insufficient evidence regarding the accuracy and reliability of such screening in children.

• Commonly used depression screening tools include the Beck Depression Inventory, the Zung Self-Depression Scale, the General Health Questionnaire, the 2-Whooley Questions, and others. The USPSTF report concluded that evidence is currently insufficient to determine which of these tools perform better than others and encouraged providers to select tools that are validated and work best for their practice setting and patients.

• Follow-up of a depression diagnosis is essential. The USPSTF report encouraged providers to develop structured processes and systems for ensuring adequate follow-up.

• It is important for patients to learn about depression and other mental health issues as part of their ongoing diabetes self-management program. In addition to formal instruction, exam room posters can play a valuable role in educating and reminding patients and medical personnel about the signs, symptoms, and treatment options for depression. As part of a suicide prevention program, the former U.S. Surgeon General and the National Institute of Mental Health (NIMH) created information that can be downloaded and used on exam room flyers at no charge.5