Screening, assessment and management of type 2 diabetes mellitus in children and adolescents: Australasian Paediatric Endocrine Group guidelines.

INTRODUCTION: The incidence of type 2 diabetes mellitus has increased in children and adolescents due largely to the obesity epidemic, particularly in high risk ethnic groups. ß-Cell function declines faster and diabetes complications develop earlier in paediatric type 2 diabetes compared with adult-onset type 2 diabetes. There are no consensus guidelines in Australasia for assessment and management of type 2 diabetes in paediatric populations and health professionals have had to refer to adult guidelines. Recent international paediatric guidelines did not address adaptations to care for patients from Indigenous backgrounds. MAIN RECOMMENDATIONS: This guideline provides advice on paediatric type 2 diabetes in relation to screening, diagnosis, diabetes education, monitoring including targets, multicomponent healthy lifestyle, pharmacotherapy, assessment and management of complications and comorbidities, and transition. There is also a dedicated section on considerations of care for children and adolescents from Indigenous background in Australia and New Zealand. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINES: Published international guidelines currently exist, but the challenges and specifics to care for children and adolescents with type 2 diabetes which should apply to Australasia have not been addressed to date. These include: recommendations regarding care of children and adolescents from Indigenous backgrounds in Australia and New Zealand including screening and management; tighter diabetes targets (glycated haemoglobin, ≤ 48 mmol/mol [≤ 6.5%]) for all children and adolescents; considering the use of newer medications approved for adults with type 2 diabetes under the guidance of a paediatric endocrinologist; and the need to transition adolescents with type 2 diabetes to a diabetes multidisciplinary care team including an adult endocrinologist for their ongoing care.

Clinical and Workplace Outcomes From a Virtually Delivered Cognitive Behavioral Therapy Program for Pain.

OBJECTIVES: To evaluate clinical and workplace outcomes from an evidence-based virtual behavioral therapy program for individuals with pain and behavioral health issues. METHODS: This was a retrospective de-identified data analysis among a cohort of 1,086 participants enrolled in a standardized, evidence-based telebehavioral therapy program between September 1, 2016, and August 31, 2017 (mean age 53 ± 11.5 years; 29% male). The program was delivered over approximately 8 weeks by licensed therapists and behavior coaches by telephone or video, and tailored to the pain management and behavioral health goals of each participant. Structured measurements were documented in the electronic clinical record, including demographics, comorbidities, pain severity (Pain Intensity, Enjoyment of Life, General Activity tool), behavioral health symptoms (Depression, Anxiety and Stress Scale short form), and productivity (Work Productivity and Activity Impairment survey). RESULTS: At baseline, participants had high average pain severity (5.8/10 points), high frequencies of behavioral health symptoms (68%), and activity impairment (90%); absenteeism (34%) and presenteeism (75%) were observed among employed individuals. Pain severity and pain interference improved by 17% and 27%, respectively, over 8 weeks (P < 0.0001). Reductions in depression, anxiety, and stress symptoms were significant and associated with reductions in pain interference (P < 0.0001). Absenteeism, presenteeism, and activity impairment ratings each improved by more than 25% (P < 0.0001). DISCUSSION: Participants in a virtually delivered behavioral therapy program for pain experienced significant improvements in pain intensity, pain interference, behavioral health symptoms, and work productivity.

A Nationally Scaled Telebehavioral Health Program for Chronic Pain: Characteristics, Goals, and Psychological Outcomes.

BACKGROUND: Millions of U.S. adults suffer from chronic pain with a high prevalence of comorbid mental health issues. Telehealth-delivered behavioral therapy for chronic pain has been evaluated in the research setting. The purpose of this study was 1) to describe a nationally scaled, standardized, telebehavioral therapy program for patients with chronic pain and behavioral comorbidities, and 2) evaluate characteristics, goals, and psychosocial outcomes among program participants. MATERIALS AND METHODS: This was mixed-methods retrospective cohort analysis among consecutive program graduates (mean age 53y; 24% male). The 8-week program was delivered by a licensed therapist and a behavior coach through telephone/secure video and tailored to each participant's behavioral health needs and goals. Participant chief complaints, behavioral goals, and mood triggers were abstracted by deidentified clinical record review using structured qualitative research methods. Depression, anxiety, and stress symptom data were collected at baseline and program graduation using the validated Depression Anxiety Stress Scales 21. RESULTS: Back pain (42%) and hip/leg/knee pain (28%) comprised the most common chief complaints. Pain management (44%) and weight loss (43%) were the most frequently cited goals. At baseline, approximately half of participants had elevated depression (59%), anxiety (54%), and/or stress (48%) scores. Triggers for depressed, anxious, or stressed mood included severe pain (47%), health concerns (46%), and interpersonal relationship challenges (45%). At graduation, significant improvement in median depression (-54%), anxiety (-50%), and stress (-33%) symptom scores was observed among those with non-normal baseline values (p < 0.001); degree of improvement did not vary by participant age or sex. CONCLUSIONS: Participants in a nationally scaled telebehavioral health program for chronic pain experienced significant improvement in depression, anxiety, and stress symptoms and shared several complaints, goals, and mood triggers.

A Tele-Behavioral Health Intervention to Reduce Depression, Anxiety, and Stress and Improve Diabetes Self-Management.

BACKGROUND: Depression is prevalent among individuals with diabetes and associated with suboptimal self-management. Little is known about the feasibility and potential impact of tele-behavioral therapy to improve depressive symptoms and self-management among diabetes patients. METHODS: This was a retrospective observational study of consecutive graduates enrolled in a national 8-week diabetes behavioral telehealth program between August 1, 2014, and January 31, 2015 (N = 466; mean age 56.8 ± 5.0 years; 56% female). Participant characteristics (demographics, comorbidities) were obtained by standardized questionnaire. Depression, anxiety, and stress symptoms (DASS; validated Depression Anxiety and Stress Scale 21 survey), and glucose self-testing frequency and values (point-of-care monitor) were measured at program start and completion. Changes in DASS severity and glucose self-testing frequency were assessed by chi-square tests. Changes in DASS and blood glucose levels were evaluated by paired t-tests. RESULTS: At baseline, approximately one in three participants had elevated depression (32%), anxiety (33%), or stress (31%) scores. Significant reductions in average DASS, depression (-8.8), anxiety (-6.9), and stress (-9.9), scores were observed at graduation among those with elevated baseline scores (p < 0.0001); most (≥80%) improved to less severe depression, anxiety, or stress categories. Improved glucose self-testing frequency (69% vs. 60% tested ≥once per week; p = 0.0005) and significant reductions in mean morning glucose levels (-12.3 mg/dL; p = 0.0002) were observed from baseline to graduation. Participants with normal versus non-normal depression scores were more likely to have lower (

Neurocognitive and Symptom Validity Testing for Post-COVID-19 Condition in a Workers Compensation Context.

OBJECTIVE: Efficacy of a neurocognitive screening evaluation (NCSE) in assessing symptoms and disability associated with post-COVID-19 condition (PCC) and facilitating employee recovery and return to work was evaluated. METHODS: An NCSE was administered to 64 employees off work because of neurocognitive complaints attributed to post-COVID-19 condition. Neurocognitive and symptom validity data were analyzed along with recovery and return-to-work timelines. RESULTS: A large percentage of the employees gave invalid responses and noncredible effort on psychological and cognitive tests (48%). The NCSEs with invalid profiles suggested more severe cognitive and psychiatric symptoms than valid profiles. Both valid and invalid groups had significant reductions in illness duration and lost workdays after the NCSE. CONCLUSIONS: Post-COVID-19 condition resulted in reports of mild to moderate cognitive and psychiatric symptoms with extensive mean work leave of 11 months before mental health assessment. Regardless of symptom validity, after the NCSE, the employees were released to work at an average of 3 weeks.

Addressing Mental Health Factors to Improve Outcomes in Work-Related COVID-19: A Retrospective Study of Frontline Workers.

OBJECTIVE: This retrospective study investigated the benefits of adding psychological services for frontline workers with delayed recovery from COVID-19 due to psychosocial stressors and/or mental disorders. METHODS: Both standardized psychological evaluation and at least 3 sessions of work-focused cognitive behavioral therapy were provided to 103 participants. Benefits were assessed by comparing the pretreatment and posttreatment recovery, work status, and self-ratings of work-related and adaptive daily functioning. RESULTS: Duration of recovery and return to work were reduced along with improvements in work relevant (40%) and adaptive functioning (31%). The majority (80%) returned to work within 12 weeks despite variable presenting problems, course of illness, demographic, and job factors. CONCLUSIONS: Brief work-focused cognitive behavioral therapy seems to be an effective adjunct to customary outpatient medical care for COVID-19 in frontline essential workers for whom the return-to-work process may be negatively affected by stress, anxiety, and depressed mood.

Improving Outcomes for Work-Related Concussions: A Mental Health Screening and Brief Therapy Model.

OBJECTIVE: This study assessed the efficacy of a neurocognitive screening evaluation and brief therapy model to improve RTW outcomes for workers who experienced mild head injuries. METHODS: Patients referred were evaluated using a neurocognitive and psychological screening battery. Work-focused cognitive behavioral therapy was provided when appropriate, addressing the role of negative emotional adjustment and functional sleep disturbance in prolonging recovery. RESULTS: Average time to RTW was 7 weeks post-evaluation, despite workers being off an average of 10 months between injury and referral dates. Overall, 99% were released to full-duty work without restrictions or accommodations. CONCLUSIONS: This study demonstrates the favorable outcomes achieved via a structured, clinically driven program for workers who experience head-involved injuries, validating previous research on the importance of recognizing the role of psychological factors in prolonging concussion recovery.

Comparison of DASS-21, PHQ-8, and GAD-7 in a virtual behavioral health care setting.

BACKGROUND: Validated depression and anxiety symptom screeners are commonly used in clinical settings. How results from different brief depression and anxiety symptom assessment tools compare to each other is not well established, especially in real world healthcare settings. This study aimed to compare the Depression Anxiety Stress Scales 21 Depression scale (DASS-Depression) and Anxiety (DASS-Anxiety) scale to the Patient Health Questionnaire 8 (PHQ-8) and Generalized Anxiety Disorder 7 (GAD-7) respectively, in a real-world virtual behavioral healthcare setting. METHODS: This was a retrospective comparison study of clinical data from a population of adults who completed a consultation via telephone or secure video with a licensed therapist as part of a standardized, evidence-based, virtual behavioral therapy program for individuals with comorbid medical and behavioral health conditions. The joint distributions and correlations between scores yielded by each depression and anxiety scale were assessed using descriptive and Spearman correlation statistics. RESULTS: The DASS-Depression and PHQ-8 were highly correlated (r = .71; p=<.001); the DASS-Anxiety and GAD-7 correlation was also high (r = .61; p=<.001). The PHQ-8 categorized more individuals as having above-threshold depression scores versus the DASS-Depression (71.5% vs. 43.5%; p < .001). The GAD-7 categorized more individuals as having above-threshold anxiety scores versus the DASS-Anxiety (59.0% vs. 45.0%; p < .001). LIMITATIONS: This study compared results yielded by validated screeners, precluding conclusions related to the validity of screener results. CONCLUSIONS: The DASS-Depression and PHQ-8 and the DASS-Anxiety and GAD-7 similarly ranked symptom severity. The PHQ-8 and GAD-7 were more likely than the DASS-21 Depression or Anxiety scales to classify individuals as having above-threshold symptom severity.

Using Telehealth to Implement Cognitive-Behavioral Therapy.

Behavioral health issues are common among patients with comorbid medical conditions but often go unrecognized or untreated, resulting in worse clinical outcomes and avoidable medical expenditures. This column describes an innovative telehealth solution that includes proactive and targeted patient identification and engagement and nationwide delivery of a technology-enabled, standardized, and evidence-based behavioral health program delivered via phone or video. A retrospective before-after evaluation of the program demonstrated national reach, high patient satisfaction, and significant reductions in symptoms of depression, anxiety, and stress.

Leveraging remote behavioral health interventions to improve medical outcomes and reduce costs.

OBJECTIVE: The dramatic rise in healthcare expenditures calls for innovative and scalable strategies to achieve measurable, near-term improvements in health. Our objective was to determine whether a remotely delivered behavioral health intervention could improve medical health, reduce hospital admissions, and lower cost of care for individuals with a recent cardiovascular event. STUDY DESIGN: This retrospective observational cohort study included members of a commercial health plan referred to participate in AbilTo's Cardiac Health Program. AbilTo is a national provider of telehealth, behavioral change programs for high risk medical populations. METHODS: The program is an 8-week behavioral health intervention delivered by a licensed clinical social worker and a behavioral coach via phone or secure video. RESULTS: Among the 201 intervention and 180 comparison subjects, the study found that program participants had significantly fewer all-cause hospital admissions in 6 months (293 per 1000 persons/year vs 493 per 1000 persons/year in the comparison group) resulting in an adjusted percent reduction of 31% (P = .03), and significantly fewer total hospital days (1455 days per 1000 persons/year vs 3933 per 1000 persons/year) with an adjusted percent decline of 48% (P = .01). This resulted in an overall savings in the cost of care even after accounting for total program costs. CONCLUSIONS: Successful patient engagement in a national, remotely delivered behavioral health intervention can reduce medical utilization in a targeted cardiac population. A restored focus on tackling barriers to behavior change in order to improve medical health is an effective, achievable population health strategy for reducing health costs in the United States.