Making an IMPACT: Behavioral Activation & Depression Care for Persons Living with Type 2 Diabetes

Background: This retrospective outcome study examined an adaptation of the evidence based Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) Care Model of depression mental/behavioral health collaborative care in a primary care health setting with a very small sample of medically indigent African American and Latinx outpatient adults (N=3), from the southern sector of Dallas, Texas, USA, who are living with type 2 diabetes and depressive disorders.

Research indicates the benefits of diabetes education strategies and general guidelines for providing interprofessional, collaborative primary care with adults who have type 2 diabetes. However, there has been limited research evidence on how these adults with type 2 diabetes come to understand their diabetes distress, and their mood dysregulating depressive disorders. Additionally, there is a lack of research on how mental/behavioral health services are delivered with these outpatients and the effectiveness of these intervention strategies.

The paper helps to fill this gap by examining the retrospective accounts of these adults who are living with both type 2 diabetes, diabetes distress, and depression, to explore their utilization of specialized mental/behavioral health services, specifically regarding depression severity, functional impairment and depression related quality of life.

Methods: A mixed methods approach and adaptation of the IMPACT Care Model was utilized. The IMPACT Care Model consists of behavioral activation, problem solving, and stepped care. This model was measured by the 9 item depression symptom screening instrument, the Patient Health Questionnaire-9 (PHQ-9), which was self-administered at baseline, during and post individual, face to face clinical interviews, as related to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The variables included:

• Independent variables ("treatment"): the number of behavioral intervention sessions provided
• Dependent variables ("outcome"): the PHQ-9 depression screening scores
• Intervening variables ("mediators"): religious involvement and survivorship
• Intervening variables ("moderators"): psychosocial factors -supportive family and friends; health care access; religious involvement and living in the southern geographic region
• Exogenous variables: grief, loss and other life crises

Results: The data analysis indicated that behavioral activation and problem solving made a difference in decreasing the PHQ-9 scores, and decreased the depressive symptoms, even though bereavement impacted two of the three patient participants. Thus, there was evidence of lessened depression severity, improved functional impairment and improved quality of life outcomes.

Implications: Though not generalizable because of the very small sample size, these findings suggested that this adaptation of the evidence based Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) Care Model of depression mental/behavioral health collaborative care in primary health settings, i.e., behavioral activation, problem solving and stepped care, was very beneficial to these medically indigent African American and Latinx outpatients, who were living with both type 2 diabetes, diabetes distress, and depressive disorders.

Further research is needed to examine how mood promoting access to collaborative primary care, including mental/behavioral health care services, impacts the overall health care outcomes, biometrics (i.e.,metabolics and body mass index), health disparities, and psychosocial determinants of health.