East Carolina University – Depression, Distress, and Diabetes

Partners: Community Care Plan of Eastern Carolina, Greene County Healthcare, OIC Family Medical Health Center and other community partners.

The Need: The rate of major depression in patients with Type 2 diabetes mellitus (T2DM) is twice as high as those without T2DM, and depression is associated with poorer adherence to treatment regimen, worse glycemic control, and neuroendocrine changes, as well as a significantly higher risk of severe episodes of low blood-sugar resulting in emergency department visit or hospitalization. Similarly, poorly controlled diabetes may worsen depression and the relationship appears to be bi-directional. Diabetes-related distress, defined as “patient concerns about disease management, support, emotional burden, and access to care,” is related to symptoms of depression, but a separate and distinct construct. Similar to depression, distress is significantly and positively associated with HbA1c, and responds well to intervention.

According to the CDC, the highest prevalence rates are seen in the southeastern United States (“diabetes belt”) and specifically in communities with large minority populations and limited socioeconomic status. Behavioral Risk Fact Surveillance System data reveals that the prevalence of diabetes in eastern NC is higher than in NC overall (11.3% vs 9.8% respectively), and is higher in African Americans than in Caucasians (16.7% vs 10.2%). East Carolina University (ECU)’s EMPOWER trial (also supported by Together on Diabetes ®) demonstrated that more than 50% of diabetic patients have co-morbid diabetes-related-distress and/or depression, which often goes unrecognized.

The Project: Focusing on rural eastern North Carolina (Edgecombe County, Pitt County, and Greene County), East Carolina University (ECU) will pilot a unique stepped, collaborative care intervention for 100 patients with uncontrolled type-2 diabetes and co-morbid diabetes-related-distress and/or depression. ECU’s intervention will combine practice-based medical and cognitive behavioral care and treatment with strong community-based support to stratify patient needs, provide the right level of intervention and step-up treatment if the initial response is inadequate. The practice-based component will use a care manager linked to primary care and behavioral health colleagues, and the community based component will utilize community health workers to provide emotional and practical support to patients and facilitate access to resources.

Project Leader: Doyle Cummings, cummingsd@ecu.edu

East Carolina University EMPOWER Trial

Completed 2013

Partners: East Carolina University Health Disparities Center, Peers for Progress, North Carolina Office of Minority Health, North Carolina Department of Health & Human Services, Diabetes Control Program, Success Dynamics, Community Development Corp., Cornerstone Ministries, Lucille Gorham Intergenerational Center, Tillery Community Health Center, Greene County Healthcare, University Health Systems of Eastern Carolina and local health departments in four counties

The Need: The southeastern region of United States has the highest prevalence rate of diabetes among African Americans and profound disparities in diabetes morbidity and mortality, particularly among African American women. In North Carolina, the African American population is concentrated in the eastern rural counties: the historic plantation communities. Diabetes mortality among women in North Carolina increased in 2009, with African American women having a rate almost three times greater than white women.

The Project: East Carolina University and its partners will implement the first regional community-based and culturally tailored intervention to reduce disparities among 300 rural African American women with uncontrolled type 2 diabetes using a behaviorally centered "small changes" approach and navigation services delivered by teams of supervised lay health ambassadors and patient navigators. This approach avoids cyclical patterns of dieting and focuses on making small but sustainable changes in diet, physical activity and care management choices. Because many rural African Americans distrust the traditional health care delivery system, the East Carolina program will evaluate a culturally-concordant approach which team clinical teams with lay “health ambassadors” and “navigators who are trusted members of the African American community.

Project Leader: Doyle Cummings, cummingsd@ecu.edu