An Inside Look at Depression Training for Diabetes Educators

Ever wonder who trains the trainers? We did, so we sent off our resident expert to take part in an official CDE (certified diabetes educator) training session. Here is his report, unfortunately with some unsightly results:

By D’Mine Columnist / Correspondent Wil Dubois

Thirty-three percent of people with diabetes (PWDs) have sufficient “clinical symptoms” for a diagnosis of depression. But in the chaos of a complicated disease, and with short office visits, depression is often overlooked or ignored in medical settings. In fact, only 20% of PWDs who have depression are identified and diagnosed.

And of that 20%, only a quarter of them are getting the appropriate treatment.

If you work your way through the maze of math you’ll find that only 5 in 100 depressed PWDs are receiving the right help.

I don’t know which depresses me more: these well-published facts; or that fact the American Association of Diabetes Educators (AADE) apparently feels that many CDEs don’t know them yet. Or worse, the demeaning manner in which the AADE refers to patients in its training sessions for members.

Not kidding.

Last week, I was able to sit in on a training webinar for CDEs on recognizing and treating depression.  Note that CDEs are generally nurses, dietitians, or pharmacists. All three of these professions require their members to log a certain number of continuing medical education (so-called CME) hours to maintain their licenses. To assist with this, the AADE offers a variety of CME training options, including self-study programs, seminars in various cities, and live webinars like the one I attended, led by Joseph Nelson, a.k.a. “Mindful Joe,” a masters-level licensed psychologist. Oh, right. And he’s also a board certified sex therapist.

Nelson, at first glance, seems an odd choice to teach diabetes educators about PWDs and depression. But Nelson spent 19 years in our trenches working at the International Diabetes Center in Minneapolis, from 1984 until 2003, when he went into private practice. Since that time he has worked with PWDs on both sex issues and garden variety depression, been a speaker at many TCOYD events, and has written for the Diabetes Self-Management blog.

While not a PWD or a CDE, it’s pretty clear he knows his way around diabetes.

Yet almost half (44%) of Nelson’s Depression and Diabetes: Unraveling the Interaction webinar for CDEs was spent on just trying to sell his audience on those widely-accepted medical statistics about how widespread depression is among PWDs, and how often it’s overlooked.

Are CDEs that out of touch with their field, not to mention their patients?

Or is the AADE that out of touch with its membership?

The rest of Nelson’s webinar? About a quarter of it was spent on recognizing symptoms and assessing the level of depression using various “tools” such as the PHQ9, or Patient Health Questionnaire, a “multipurpose instrument for screening, diagnosing, monitoring and measuring the level of severity of depression.” He encouraged CDEs to: 1) look for visual cues such as not making eye contact, stooped body language, low level of energy, 2) have an “assessment conversation,” asking questions like, “How do you feel about diabetes? How burdened are you by diabetes management tasks?,” 3) use “quick tests” like the PHQ-9, and 4) make a better effort to follow up on no-shows, even if only making a phone call.

Then there was a brief overview of depression treatments available ranging from just-give-it-some-time on one end of the spectrum to electric shock therapy on the other.

So, is this training designed to help PWDs? Probably not.

I felt the information was so basic that any CDE should already know it. Gee… depression is common among people with diabetes, really? That’s so widely published and observed you’d have to be living under a rock not to know it. Anyone working with patients in the field should have known this for at least the last 15 years!

As to the “positive steps” educators should take, I thought they were shallow and should be things CDEs are doing anyway. Be aware of the mental health resources in your community. Recognize there is a problem and do something about it. Are you kidding?

Nelson didn’t really give CDEs any tools for intervention, as resources for mental health are highly variable nationwide. He mainly urged the CDEs to access for depression, and to make sure that when depression is discovered it’s followed up on. He also went to pains to be sure the audience would be able to recognize and understand how depression effects diabetes control.

While Nelson encouraged CDEs to be good listeners and not to be judgmental of patients, consider this slide from his webinar:

Do you find this respectful of PWDs? Or judgmental? Does it strike you as “mindful?”

Aren’t these webinars supposed to help CDEs to better understand us, rather than poke fun at how awfully hard the poor educators have to work to deal with us “difficult” patients?

Those images made me angry. I found it typical of the demeaning regard in which many CDEs seem to hold PWDs. I think there is a very anti-patient culture in medicine in general, but especially I see a lot of prejudice against PWDs both from the white coats and the CDEs. I think they don’t like to recognize the difficulties patients face and like to pass the blame—i.e. “the patient didn’t do what I told them to do.”

I think the AADE does PWDs no favors when they perpetuate this negative culture. I also think someone who calls himself “Mindful Joe” should be more sensitive. Probably never occurred to him there might be a spy in the crowd he’s playing to.

Nelson did caution educators that the classic “bad patient” is likely suffering from crippling depression, and that major depression usually results in “horrible control.” In fact, he says he’s “rarely” seen a PWD with depression who can keep their diabetes in control. By Nelson’s numbers, a third of us won’t be able to control our diabetes much at all.

Interestingly, while it’s most effective to treat both depression and diabetes at the same time, Nelson says research shows that if you can treat only one, the other will improve. Treating depression, not surprisingly, helps improve diabetes control; but improving diabetes control also improves depression as well. And one of the most effective treatments for depression, according to Nelson, is actually exercise—which is “good medicine” for diabetes, too.

Were the CDEs themselves listening? I have no way of knowing how many attended the webinar, but only ten bothered to ask a question at the end.  The questions were empty and lame, IMHO. I got the feeling the participants weren’t well engaged, but I could be wrong, since there was no way to observe them.

Overall, I found the content to be hollow and I didn’t learn much of anything new. It’s true that I’m probably not typical. We DOCers (patients who are active in the online community) are pretty well informed compared either to the typical CDE or the typical PWD. But I still felt the content was shallow, and could have offered much more – certainly in the way of empathy with patients and what to do with folks who are really in a bad way.

The AADE runs live webinars between one and three times per month. Quoting the AADE website, the webinars “provide up-to-the-minute, in-depth understanding of diabetes educator trends and topics.” They are already scheduled through December of 2012, so apparently up-to-the-minute is a relative concept.

Upcoming webinars include medical topics like diabetes management after gastric bypass surgery, policy topics like including community health workers in diabetes education programs, to technology topics like continuous glucose monitoring.

Are AADE webinars just a way for CDEs to check off the right boxes to keep their paychecks coming, or do they provide useful information to help educators improve their work?

Part of the answer comes, again, from the AADE website, where the live webinars are billed as “an outstanding value.” That sounds more like the marketing of a product in a mail-order catalog than a course description in a college catalog. But the answer is probably both, and no doubt it varies from CDE to CDE. Let’s hope some of them out there are able to think beyond these clichés about the best ways they can help real patients with real problems.