The impact of primary care behavioral health services on patient behaviors: A randomized controlled trial.

INTRODUCTION: Greater understanding of the impact of low intensity psychosocial interventions delivered by behavioral health clinicians (BHCs) working in an integrated care program (ICP) may promote better depression care. METHOD: In a randomized controlled trial, 153 participants identified as depressed by their primary care provider (PCP) were assigned to ICP or usual care (UC, management by PCP, including specialty referral). In the ICP condition, BHCs worked collaboratively with PCPs and liaison psychiatrists. RESULTS: ICP participants with lower and higher severity symptoms reported significantly greater use of coping strategies than UC participants at the 1-month follow up (lower: p = .002; higher: p = .016). ICP participants with lower severity continued to report significantly greater use of coping strategies than UC participants at the 4-month (p = .024), and 7-month (p = .012) follow ups. ICP participants were more likely to be following relapse preventions plans at the 4-month follow up (lower: 89.5% vs. 50%, p = .0.000; higher 74.1% vs. 33%, p = .0001). ICP participants also reported use of antidepressant medications on more days than UC participants at the 4-month follow up (lower: 21.27 vs. 14.49 days, p = .049; higher: 24.61 vs. 17.08 days, p = .035). Patient retention in the ICP was high, and ICP participants were significantly more satisfied with depression care than UC participants at follow-up assessments. DISCUSSION: Delivery of low intensity psychosocial interventions by BHCs was associated with improvements to behavior charge targets. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Medication Related Self- efficacy among Linguistically Diverse Patients with Chronic Illnesses.

This study examines medication-related self-efficacy in a linguistically diverse group of patients with diabetes, hypertension, and elevated cholesterol. A telephone survey of 509 adults conducted in six languages (English, Spanish, Korean, Vietnamese, Mandarin, and Cantonese) was analyzed. Self-efficacy was assessed with the overall Medication Understanding and Use Self-Efficacy (MUSE) score and its two subscale scores on taking medication and learning about medications. Compared with English proficient (EP) patients, patients with limited English proficiency (LEP) had a lower mean learning self-efficacy subscale score (LEP: 14.5, EP: 15.4; p<.001) and no difference in the mean taking self-efficacy subscale score (LEP: 14.4, EP: 14.6; p=.40). Receiving verbal medication information (VMI) from providers modified the relationship between LEP status and learning self-efficacy. In conclusion, among patients with chronic illnesses, LEP patients had lower medication-related self-efficacy scores than EP patients, which may put them at greater risk for medication taking errors and lower adherence.

Disparities in the Use of Internet and Telephone Medication Refills among Linguistically Diverse Patients.

BACKGROUND: Health systems are increasingly implementing remote telephone and Internet refill systems to enhance patient access to medication refills. Remote refill systems may provide an effective approach for improving medication non-adherence, but more research is needed among patients with limited English proficiency with poor access to remote refill systems. OBJECTIVE: To compare the use of remote medication refill systems among limited-English-proficiency (LEP) and English-proficient (EP) patients with chronic conditions. METHODS: Cross-sectional survey in six languages/dialects (English, Cantonese, Mandarin, Korean, Vietnamese, and Spanish) of 509 adults with diabetes, hypertension, or hyperlipidemia. Primary study outcomes were self-reported use of 1) Internet refills, 2) telephone refills, and 3) any remote refill system. LEP was measured by patient self-identification of a primary language other than English and a claims record of use of an interpreter. Other measures were age, gender, education, years in the U.S., insurance, health status, chronic conditions, and number of prescribed medications. Analyses included multivariable logistic regression weighted for survey non-response. RESULTS: Overall, 33.1 % of patients refilled their medications by telephone and 31.6 % by Internet. Among LEP patients (n = 328), 31.5 % refilled by telephone and 21.2 % by Internet, compared with 36.7 % by telephone and 52.7 % by Internet among EP patients (n = 181). Internet refill by language groups were as follows: English (52.7 %), Cantonese (34.9 %), Mandarin (17.4 %), Korean (16.7 %), Vietnamese (24.4 %), and Spanish (12.6 %). Compared to EP patients, LEP patients had lower use of any remote refill system (adjusted odds ratio [AOR] 0.18; p < 0.001), CONCLUSIONS: LEP patients are significantly less likely than EP patients to use any remote medication refill system. Increased reliance on current systems for remote medication refills may increase disparities in health outcomes affecting LEP patients with poor access to telephone and Internet medication refills.

Population targeting and durability of multimorbidity collaborative care management.

OBJECTIVES: A patient-centered collaborative care program for depression and uncontrolled diabetes and/or coronary heart disease (CHD) demonstrated improved clinical outcomes relative to usual care. We report clinically stratified analyses of patient outcomes to inform the duration and targeting of care management services for complex patients with multimorbidity. METHODS: A 12-month randomized controlled trial of a multimorbidity collaborative care program followed patients at 6, 12, 18, and 24 months for diabetes (glycated hemoglobin [A1C]), blood pressure (systolic; SBP), low-density lipoprotein (LDL) cholesterol, and depression (Symptoms Check List-20 score). Depressed patients with less favorable medical control (Patient Health Questionnaire-9 score > 10, A1C > 8.0 %, SBP > 140 mm Hg, and LDL cholesterol > 120 mg/dL) were compared with depressed patients with more favorable medical control to describe differential intervention benefits over time. RESULTS: In contrast to patients with more favorable baseline control, patients with depression and unfavorable control of A1C, SBP, and LDL at baseline showed improved outcomes as early as the 6-month follow-up assessment. Clinical benefits in the intervention group were largely sustained over the 24-month follow-up, except for some deterioration of glycemic control in intervention patients and trends toward improvement among controls over time. Among patients with depression and more favorable medical control at baseline, there were minimal between-group differences in medical disease outcomes. CONCLUSIONS: Clinical benefits of a multimorbidity collaborative care management program occurred early, and were only found among patients with poor control of baseline diabetes and CHD risk factors. Targeting may maximize reach and improve affordability of complex care management.

What factors determine disclosure of suicide ideation in adults 60 and older to a treatment provider?

Correlates of patient disclosure of suicide ideation to a primary care or mental health provider were identified. Secondary analyses of IMPACT trial data were conducted. Of the 107 patients 60 years of age or older who endorsed thoughts of ending their life at least "a little bit" during the past month, 53 indicated they had disclosed these thoughts to a mental health or primary care provider during this period. Multiple logistic regression was used to identify predictors of disclosure to a provider. Significant predictors included poorer quality of life and prior mental health specialty treatment. Among participants endorsing thoughts of suicide, the likelihood of disclosing these thoughts to a provider was 2.96 times higher if they had a prior history of mental health specialty treatment and 1.56 times higher for every one-unit decrease in quality of life. Variation in disclosure of thoughts of suicide to a mental health or primary care provider depends, in part, on patient characteristics. Although the provision of evidence-based suicide risk assessment and guidelines could minimize unwanted variation and enhance disclosure, efforts to routinize the process of suicide risk assessment should also consider effective ways to lessen potential unintended consequences.

Association of depression with increased risk of severe hypoglycemic episodes in patients with diabetes.

PURPOSE: Although psychosocial and clinical factors have been found to be associated with hypoglycemic episodes in patients with diabetes, few studies have examined the association of depression with severe hypoglycemic episodes. This study examined the prospective association of depression with risk of hypoglycemic episodes requiring either an emergency department visit or hospitalization. METHODS: In a longitudinal cohort study, a sample of 4,117 patients with diabetes enrolled between 2000 and 2002 were observed from 2005 to 2007. Meeting major depression criteria on the Patient Health Questionnaire-9 was the exposure of interest, and the outcome of interest was an International Classification of Disease, Ninth Revision code for a hypoglycemic episode requiring an emergency department visit or hospitalization. Proportional hazard models were used to analyze the association of baseline depression and risk of one or more severe hypoglycemic episodes. Poisson regression was used to determine whether depression status was associated with the number of hypoglycemic episodes. RESULTS: After adjusting for sociodemographic, clinical measures of diabetes severity, non-diabetes-related medical comorbidity, prior hypoglycemic episodes, and health risk behaviors, depressed compared with nondepressed patients who had diabetes had a significantly higher risk of a severe hypoglycemic episode (hazard ratio = 1.42, 95% CI, 1.03-1.96) and a greater number of hypoglycemic episodes (odds ratio = 1.34, 95% CI, 1.03-1.74). CONCLUSION: Depression was significantly associated with time to first severe hypoglycemic episode and number of hypoglycemic episodes. Research assessing whether recognition and effective treatment of depression among persons with diabetes prevents severe hypoglycemic episodes is needed.

Improving confidence for self care in patients with depression and chronic illnesses.

The aim of this study was to examine whether patients who received a multicondition collaborative care intervention for chronic illnesses and depression had greater improvement in self-care knowledge and efficacy, and whether greater knowledge and self-efficacy was positively associated with improved target outcomes. A randomized controlled trial with 214 patients with comorbid depression and poorly controlled diabetes and/or coronary heart disease tested a 12-month team-based intervention that combined self-management support and collaborative care management. At 6 and 12 month outcomes the intervention group showed significant improvements over the usual care group in confidence in ability to follow through with medical regimens important to managing their conditions and to maintain lifestyle changes even during times of stress. Improvements in self care-efficacy were significantly related to improvements in depression, and early improvements in confidence to maintain lifestyle changes even during times of stress explained part of the observed subsequent improvements in depression.

Depression and risk of hospitalizations for ambulatory care-sensitive conditions in patients with diabetes.

BACKGROUND: Hospitalizations for ambulatory care-sensitive conditions (ACSCs), conditions that should not require inpatient treatment if timely and appropriate ambulatory care is provided, may be an important contributor to rising healthcare costs and public health burden. OBJECTIVE: To examine if probable major depression is independently associated with hospitalization for an ACSC in patients with diabetes. DESIGN: Secondary analysis of data from a prospective cohort study. PARTICIPANTS: Population-based cohort of 4,128 patients with diabetes ≥ 18 years old seen in primary care, who were enrolled between 2000 and 2002 and followed for 5 years (through 2007). MAIN MEASURES: Depressive symptoms were assessed with the Patient Health Questionnaire-9. Outcomes of interest included time to initial hospitalization for an ACSC and total number of ACSC-related hospitalizations. We used Cox proportional hazards regression models to ascertain an association between probable major depression and time to ACSC-related hospitalization, as well as Poisson regression for models examining probable major depression and number of ACSC-related hospitalizations. KEY RESULTS: Patients' mean age at study enrollment was 63.4 years (Standard Deviation: 13.4 years). Over the 5-year follow-up period, 981 patients in the study were hospitalized a total of 1,721 times for an ACSC, comprising 45.1 % of all hospitalizations. After adjusting for baseline demographic, clinical and health-risk behavioral factors, probable major depression was associated with initial ACSC-related hospitalization (Hazard Ratio: 1.41, 95 % Confidence Interval [95 % CI]: 1.15, 1.72) and number of ACSC-related hospitalizations (Relative Risk: 1.37, 95 % CI: 1.12, 1.68). CONCLUSIONS: Probable major depression in patients with diabetes is independently associated with hospitalization for an ACSC. Additional research is warranted to ascertain if effective interventions for depression in patients with diabetes could reduce the risk of hospitalizations for ACSCs and their associated adverse outcomes.

A Review of Potential Adverse Effects of Long-Term Opioid Therapy: A Practitioner's Guide.

OBJECTIVE: Review, synthesize, and summarize recent evidence on adverse effects of long-term opioid treatment for noncancer pain and present an organ system-based guide for primary care physicians in initiating and monitoring patients receiving chronic opioid therapy. DATA SOURCES: A search for studies published in peer-reviewed journals from 2005 to 2011 was conducted using MEDLINE, Agency for Healthcare Research and Quality Clinical Guidelines and Evidence Reports, and the Cochrane Database of Systematic Reviews. Related citations and expert recommendations were included. DATA EXTRACTION: Studies were selected if the search terms opioid and the organ system of interest were in the article's title, abstract, or text. Systems considered were gastrointestinal, respiratory, cardiovascular, central nervous, musculoskeletal, endocrine, and immune. Of 1,974 initially reviewed articles, 74 were selected for evidence regarding effects of chronic opioid use on that organ system. Of these articles, 43 were included on the basis of direct relevance to opioid prescriptions in the primary care setting. DATA SYNTHESIS: A qualitative review was performed because the number of articles pertaining to specific adverse effects of opioids was typically small, and the diversity of adverse effects across systems precluded a quantitative analysis. RESULTS: Through a variety of mechanisms, opioids cause adverse events in several organ systems. Evidence shows that chronic opioid therapy is associated with constipation, sleep-disordered breathing, fractures, hypothalamic-pituitary-adrenal dysregulation, and overdose. However, significant gaps remain regarding the spectrum of potentially opioid-related adverse effects. Opioid-related adverse effects can cause significant declines in health-related quality of life and increased health care costs. CONCLUSIONS: The diverse adverse effects potentially caused by chronic opioid therapy support recommendations for judicious and selective opioid prescribing for chronic noncancer pain by primary care physicians. Additional research clarifying the risks and management of potential adverse effects of chronic opioid therapy is needed to guide clinical practice.

Cost-effectiveness of a multicondition collaborative care intervention: a randomized controlled trial.

CONTEXT: Patients with depression and poorly controlled diabetes mellitus, coronary heart disease (CHD), or both have higher medical complication rates and higher health care costs, suggesting that more effective care management of psychiatric and medical disease control might also reduce medical service use and enhance quality of life. OBJECTIVE: To evaluate the cost-effectiveness of a multicondition collaborative treatment program (TEAMcare) compared with usual primary care (UC) in outpatients with depression and poorly controlled diabetes or CHD. DESIGN: Randomized controlled trial of a systematic care management program aimed at improving depression scores and hemoglobin A(1c) (HbA(1c)), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) levels. SETTING: Fourteen primary care clinics of an integrated health care system. PATIENTS: Population-based screening identified 214 adults with depressive disorder and poorly controlled diabetes or CHD. INTERVENTION: Physician-supervised nurses collaborated with primary care physicians to provide treatment of multiple disease risk factors. MAIN OUTCOME MEASURES: Blinded assessments evaluated depressive symptoms, SBP, and HbA(1c) at baseline and at 6, 12, 18, and 24 months. Fasting LDL-C concentration was assessed at baseline and at 12 and 24 months. Health plan accounting records were used to assess medical service costs. Quality-adjusted life-years (QALYs) were assessed using a previously developed regression model based on intervention vs UC differences in HbA(1c), LDL-C, and SBP levels over 24 months. RESULTS: Over 24 months, compared with UC controls, intervention patients had a mean of 114 (95% CI, 79 to 149) additional depression-free days and an estimated 0.335 (95% CI, -0.18 to 0.85) additional QALYs. Intervention patients also had lower mean outpatient health costs of $594 per patient (95% CI, -$3241 to $2053) relative to UC patients. CONCLUSIONS: For adults with depression and poorly controlled diabetes, CHD, or both, a systematic intervention program aimed at improving depression scores and HbA(1c), SBP, and LDL-C levels seemed to be a high-value program that for no or modest additional cost markedly improved QALYs. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00468676

Treatment adjustment and medication adherence for complex patients with diabetes, heart disease, and depression: a randomized controlled trial.

PURPOSE: Medication nonadherence, inconsistent patient self-monitoring, and inadequate treatment adjustment exacerbate poor disease control. In a collaborative, team-based, care management program for complex patients (TEAMcare), we assessed patient and physician behaviors (medication adherence, self-monitoring, and treatment adjustment) in achieving better outcomes for diabetes, coronary heart disease, and depression. METHODS: A randomized controlled trial was conducted (2007-2009) in 14 primary care clinics among 214 patients with poorly controlled diabetes (glycated hemoglobin [HbA(1c)] ≥8.5%) or coronary heart disease (blood pressure >140/90 mm Hg or low-density lipoprotein cholesterol >130 mg/dL) with coexisting depression (Patient Health Questionnaire-9 score ≥10). In the TEAMcare program, a nurse care manager collaborated closely with primary care physicians, patients, and consultants to deliver a treat-to-target approach across multiple conditions. Measures included medication initiation, adjustment, adherence, and disease self-monitoring. RESULTS: Pharmacotherapy initiation and adjustment rates were sixfold higher for antidepressants (relative rate [RR] = 6.20; P <.001), threefold higher for insulin (RR = 2.97; P <.001), and nearly twofold higher for antihypertensive medications (RR = 1.86, P <.001) among TEAMcare relative to usual care patients. Medication adherence did not differ between the 2 groups in any of the 5 therapeutic classes examined at 12 months. TEAMcare patients monitored blood pressure (RR = 3.20; P <.001) and glucose more frequently (RR = 1.28; P = .006). CONCLUSIONS: Frequent and timely treatment adjustment by primary care physicians, along with increased patient self-monitoring, improved control of diabetes, depression, and heart disease, with no change in medication adherence rates. High baseline adherence rates may have exerted a ceiling effect on potential improvements in medication adherence.

The association between intensive care unit admission and subsequent depression in patients with diabetes.

OBJECTIVE: To examine whether intensive care unit (ICU) admission is independently associated with increased risk of major depression in patients with diabetes. METHODS: This prospective cohort study included 3596 patients with diabetes enrolled in the Pathways Epidemiologic Follow-Up Study, of whom 193 had at least one ICU admission over a 3-year period. We controlled for baseline depressive symptoms, demographics, and clinical characteristics. We examined associations between ICU admission and subsequent major depression using logistic regression. RESULTS: There were 2624 eligible patients who survived to complete follow-up; 98 had at least one ICU admission. Follow-up assessments occurred at a mean of 16.4 months post-ICU for those who had an ICU admission. At baseline, patients who had an ICU admission tended to be depressed, older, had greater medical comorbidity, and had more diabetic complications. At follow-up, the point prevalence of probable major depression among patients who had an ICU admission was 14% versus 6% among patients without an ICU admission. After multivariate adjustment, ICU admission was independently associated with subsequent probable major depression (Odds Ratio 2.07, 95% confidence interval (1.06-4.06)). Additionally, baseline probable major depression was significantly associated with post-ICU probable major depression. CONCLUSIONS: ICU admission in patients with diabetes is independently associated with subsequent probable major depression. Additional research is needed to identify at-risk patients and potentially modifiable ICU exposures in order to inform future interventional studies with the goal of decreasing the burden of comorbid depression in older patients with diabetes who survive critical illnesses.

Functional outcomes of multi-condition collaborative care and successful ageing: results of randomised trial.

OBJECTIVE: To evaluate the effectiveness of integrated care for chronic physical diseases and depression in reducing disability and improving quality of life. DESIGN: A randomised controlled trial of multi-condition collaborative care for depression and poorly controlled diabetes and/or risk factors for coronary heart disease compared with usual care among middle aged and elderly people SETTING: Fourteen primary care clinics in Seattle, Washington. PARTICIPANTS: Patients with diabetes or coronary heart disease, or both, and blood pressure above 140/90 mm Hg, low density lipoprotein concentration >3.37 mmol/L, or glycated haemoglobin 8.5% or higher, and PHQ-9 depression scores of ≥ 10. INTERVENTION: A 12 month intervention to improve depression, glycaemic control, blood pressure, and lipid control by integrating a "treat to target" programme for diabetes and risk factors for coronary heart disease with collaborative care for depression. The intervention combined self management support, monitoring of disease control, and pharmacotherapy to control depression, hyperglycaemia, hypertension, and hyperlipidaemia. MAIN OUTCOME MEASURES: Social role disability (Sheehan disability scale), global quality of life rating, and World Health Organization disability assessment schedule (WHODAS-2) scales to measure disabilities in activities of daily living (mobility, self care, household maintenance). RESULTS: Of 214 patients enrolled (106 intervention and 108 usual care), disability and quality of life measures were obtained for 97 intervention patients at six months (92%) and 92 at 12 months (87%), and for 96 usual care patients at six months (89%) and 92 at 12 months (85%). Improvements from baseline on the Sheehan disability scale (-0.9, 95% confidence interval -1.5 to -0.2; P = 0.006) and global quality of life rating (0.7, 0.2 to 1.2; P = 0.005) were significantly greater at six and 12 months in patients in the intervention group. There was a trend toward greater improvement in disabilities in activities of daily living (-1.5, -3.3 to 0.4; P = 0.10). CONCLUSIONS: Integrated care that covers chronic physical disease and comorbid depression can reduce social role disability and enhance global quality of life. Trial registration Clinical Trials NCT00468676.

Depression and incident diabetic retinopathy: a prospective cohort study.

OBJECTIVE: This study examined whether depression is associated with a higher incidence of diabetic retinopathy among adults with type 2 diabetes after controlling for sociodemographic factors, health risk behaviors and clinical characteristics. METHOD: This study included 2359 patients enrolled in Pathways Epidemiologic Follow-Up Study, a prospective cohort study investigating the impact of depression in primary care patients with type 2 diabetes. The predictor of interest was baseline severity of depressive symptoms assessed with the Patient Health Questionnaire-9 (PHQ-9). The outcome was incident diabetic retinopathy. Risk of diabetic retinopathy was assessed using logistic regression, and time to incident diabetic retinopathy was examined using Cox proportional hazard models. RESULTS: Over a 5-year follow-up period, severity of depression was associated with an increased risk of incident retinopathy [odds ratio =1.026; 95% confidence interval (CI) 1.002-1.051] as well as time to incident retinopathy (hazard ratio=1.025; 95% CI 1.009-1.041). The risk of incident diabetic retinopathy was estimated to increase by up to 15% for every significant increase in depressive symptoms severity (5-point increase on the PHQ-9 score). CONCLUSION: Diabetic patients with comorbid depression have a significantly higher risk of developing diabetic retinopathy. Improving depression treatment in patients with diabetes could contribute to diabetic retinopathy prevention.

TEAMcare: an integrated multicondition collaborative care program for chronic illnesses and depression.

Patients with poorly controlled diabetes, coronary heart disease, and depression have an increased risk of adverse outcomes. In a randomized, controlled trial, we tested an intervention designed to improve disease control outcomes for diabetes and/or heart disease and coexisting depression. Patients with one or more parameters of poor medical disease control (ie, HbA1c ≥8.5, or SBP >140, or LDL >130) and a Patient Health Questionnaire-9 (PHQ-9) ≥10 were randomized to the TEAMcare intervention or usual care (N = 214). This article will describe the TEAMcare health services model that has been shown to improve quality of care and medical and psychiatric outcomes.

The association of comorbid depression with intensive care unit admission in patients with diabetes: a prospective cohort study.

BACKGROUND: It is unknown if comorbid depression in patients with diabetes mellitus increases the risk of intensive care unit (ICU) admission. OBJECTIVE: This study examined whether comorbid depression in patients with diabetes increased risk of ICU admission, coronary care unit (CCU) admission, and general medical-surgical unit hospitalization, as well as total days hospitalized, after controlling for demographics, clinical characteristics, and health risk behaviors. METHOD: This prospective cohort study included 3,596 patients with diabetes enrolled in the Pathways Epidemiologic Follow-Up Study. We assessed baseline depression with the Patient Health Questionnaire-9. We controlled for baseline demographics, smoking, BMI, exercise, hemoglobin A(1c), medical comorbidities, diabetes complications, type 1 diabetes, diabetes duration, and insulin treatment. We assessed time to any ICU, CCU, and/or general medical-surgical unit admission using Cox proportional-hazards regression. We used Poisson regression with robust standard errors to examine associations between depression and total days hospitalized. RESULTS: Unadjusted analyses revealed that baseline probable major depression was associated with increased risk of ICU admission [hazard ratio (HR) 1.94, 95% confidence interval (95% CI)(1.34-2.81)], but was not associated with CCU or general medical-surgical unit admission. Fully adjusted analyses revealed probable major depression remained associated with increased risk of ICU admission [HR 2.23, 95% CI(1.45-3.45)]. Probable major depression was also associated with more total days hospitalized (Incremental Relative Risk 1.64, 95%CI(1.26-2.12)). CONCLUSIONS: Patients with diabetes and comorbid depression have a greater risk of ICU admission. Improving depression treatment in patients with diabetes could potentially prevent hospitalizations for critical illnesses and lower healthcare costs.

Collaborative care for patients with depression and chronic illnesses.

BACKGROUND: Patients with depression and poorly controlled diabetes, coronary heart disease, or both have an increased risk of adverse outcomes and high health care costs. We conducted a study to determine whether coordinated care management of multiple conditions improves disease control in these patients. METHODS: We conducted a single-blind, randomized, controlled trial in 14 primary care clinics in an integrated health care system in Washington State, involving 214 participants with poorly controlled diabetes, coronary heart disease, or both and coexisting depression. Patients were randomly assigned to the usual-care group or to the intervention group, in which a medically supervised nurse, working with each patient's primary care physician, provided guideline-based, collaborative care management, with the goal of controlling risk factors associated with multiple diseases. The primary outcome was based on simultaneous modeling of glycated hemoglobin, low-density lipoprotein (LDL) cholesterol, and systolic blood-pressure levels and Symptom Checklist-20 (SCL-20) depression outcomes at 12 months; this modeling allowed estimation of a single overall treatment effect. RESULTS: As compared with controls, patients in the intervention group had greater overall 12-month improvement across glycated hemoglobin levels (difference, 0.58%), LDL cholesterol levels (difference, 6.9 mg per deciliter [0.2 mmol per liter]), systolic blood pressure (difference, 5.1 mm Hg), and SCL-20 depression scores (difference, 0.40 points) (P<0.001). Patients in the intervention group also were more likely to have one or more adjustments of insulin (P=0.006), antihypertensive medications (P<0.001), and antidepressant medications (P<0.001), and they had better quality of life (P<0.001) and greater satisfaction with care for diabetes, coronary heart disease, or both (P<0.001) and with care for depression (P<0.001). CONCLUSIONS: As compared with usual care, an intervention involving nurses who provided guideline-based, patient-centered management of depression and chronic disease significantly improved control of medical disease and depression. (Funded by the National Institute of Mental Health; ClinicalTrials.gov number, NCT00468676.).

Depression and incident diabetic foot ulcers: a prospective cohort study.

OBJECTIVE: To test whether depression is associated with an increased risk of incident diabetic foot ulcers. METHODS: The Pathways Epidemiologic Study is a population-based prospective cohort study of 4839 patients with diabetes in 2000-2007. The present analysis included 3474 adults with type 2 diabetes and no prior diabetic foot ulcers or amputations. Mean follow-up was 4.1 years. Major and minor depression assessed by the Patient Health Questionnaire-9 were the exposures of interest. The outcome of interest was incident diabetic foot ulcers. We computed the hazard ratio and 95% confidence interval (CI) for incident diabetic foot ulcers, comparing patients with major and minor depression with those without depression and adjusting for sociodemographic characteristics, medical comorbidity, glycosylated hemoglobin, diabetes duration, insulin use, number of diabetes complications, body mass index, smoking status, and foot self-care. Sensitivity analyses also adjusted for peripheral neuropathy and peripheral arterial disease as defined by diagnosis codes. RESULTS: Compared with patients without depression, patients with major depression by Patient Health Questionnaire-9 had a 2-fold increase in the risk of incident diabetic foot ulcers (adjusted hazard ratio 2.00; 95% CI, 1.24-3.25). There was no statistically significant association between minor depression by Patient Health Questionnaire-9 and incident diabetic foot ulcers (adjusted hazard ratio 1.37; 95% CI, 0.77-2.44). CONCLUSION: Major depression by Patient Health Questionnaire-9 is associated with a 2-fold higher risk of incident diabetic foot ulcers. Future studies of this association should include better measures of peripheral neuropathy and peripheral arterial disease, which are possible confounders or mediators.

Association of major depression and mortality in Stage 5 diabetic chronic kidney disease.

OBJECTIVES: Depression is the most common psychiatric disorder in patients with chronic kidney disease (CKD). We sought to determine the association of major depression with mortality among diabetic patients with late stage CKD. METHOD: The Pathways Study is a longitudinal, prospective cohort study initiated to determine the impact of depression on outcomes among primary care diabetic patients. Subjects were followed from 2001 until 2007 for a mean duration of 4.4 years. Major depression, identified by the Patient Health Questionnaire-9, was the primary exposure of interest. Stage 5 CKD was determined by dialysis codes and estimated glomerular filtration rate (<15 ml/min). An adjusted Cox proportional hazards multivariable model was used to determine the association of baseline major depression with mortality. RESULTS: Of the 4128 enrolled subjects, 110 were identified with stage 5 CKD at baseline. Of those, 34 (22.1%) had major depression. Over a period of 5 years, major depression was associated with 2.95-fold greater risk of death (95% CI=1.24-7.02) compared to those with no or few depressive symptoms. CONCLUSION: Major depression at baseline was associated with a 2.95-fold greater risk of mortality among stage 5 CKD diabetic patients. Given the high mortality risk, further testing of targeted depression interventions should be considered in this population.

Integrating depression and chronic disease care among patients with diabetes and/or coronary heart disease: the design of the TEAMcare study.

Diabetes and coronary heart disease (CHD) are two of the most prevalent medical illnesses in the US population and comorbid depression occurs in up to 20% of these patients. Guidelines for management of diabetes and CHD overlap for healthy lifestyle and disease-control recommendations. However, the majority of patients with these medical illnesses have been shown to have inadequate control of key risk factors such as blood pressure, LDL cholesterol, or blood sugar. Comorbid depression has been shown to adversely affect self-care of diabetes and CHD, and is associated with an increased risk of complications and mortality. Interventions that have improved quality and outcomes of depression care alone in patients with diabetes and CHD have not demonstrated benefits in self-care, improved disease control or morbidity and mortality. This paper describes the design and development of a new biopsychosocial intervention (TEAMcare) aimed at improving both medical disease control and depression in patients with poor control of diabetes and/or CHD who met the criteria for comorbid depression. A team approach is used with a nurse interventionist who receives weekly psychiatric and primary care physician caseload supervision in order to enhance treatment by the primary care physician. This intervention is being tested in an NIMH-funded randomized controlled trial in a large integrated health plan.