Depression, Diabetes Distress, and a 20-Minute Visit
A 48-year-old man with type 2 diabetes has an HbA1c of 10.4%. He has missed four of his last five clinic appointments and has not started the insulin recommended 6 months ago. PHQ-9 score is 17. He says, 'I don't see the point-my father lost his foot.' He drinks three to four beers nightly and reports waking at 3 a.m. with worry. He fears needles and hypoglycemia. The clinic visit is 20 minutes, and the resident wants to intensify his insulin regimen today.
1. What is the most likely barrier to glycemic control, and how should the resident prioritize the 20-minute visit? Include a safety assessment.
Read the worked answer
His PHQ-9 of 17 indicates moderate-to-severe depression, and his statements suggest diabetes distress, hopelessness, and fear of insulin. The 20-minute visit should prioritize safety and engagement, not insulin intensification. First assess suicide risk: ask directly about thoughts, plan, intent, and means, especially because he says 'I don't see the point.' Assess alcohol use (3–4 beers nightly), hypoglycemia history, and social supports. Then use a brief motivational-interviewing frame: ask permission, explore his fears about needles and lows, and reflect his experience of his father's amputation. Refer to integrated behavioral health and consider depression treatment. Intensifying insulin without addressing depression and fear risks nonadherence, hypoglycemia, and dropout.
2. Design a brief behavioral intervention and a measurable follow-up plan. Explain why this is preferable to immediate insulin intensification.
Read the worked answer
Set one or two collaborative, measurable goals: for example, check fasting glucose on 3 days per week, take his current medications with breakfast, and attend a 2-week follow-up visit. Use behavioral activation by scheduling one valued activity and linking it to his goal of avoiding his father's outcome. Provide concrete insulin education and consider a trial of an insulin pen or pen trainer to address needle fear; involve a diabetes educator. Brief alcohol intervention: advise reduction and offer follow-up. Arrange a phone check in 1–2 weeks and a full visit in 4 weeks. This is preferable to immediate intensification because depression lowers self-efficacy and adherence; a small success improves engagement and makes later medication changes more likely to succeed.