Integrated management of type 2 diabetes mellitus and depression treatment to improve medication adherence: a randomized controlled trial.

PURPOSE: Depression commonly accompanies diabetes, resulting in reduced adherence to medications and increased risk for morbidity and mortality. The objective of this study was to examine whether a simple, brief integrated approach to depression and type 2 diabetes mellitus (type 2 diabetes) treatment improved adherence to oral hypoglycemic agents and antidepressant medications, glycemic control, and depression among primary care patients. METHODS: We undertook a randomized controlled trial conducted from April 2010 through April 2011 of 180 patients prescribed pharmacotherapy for type 2 diabetes and depression in primary care. Patients were randomly assigned to an integrated care intervention or usual care. Integrated care managers collaborated with physicians to offer education and guideline-based treatment recommendations and to monitor adherence and clinical status. Adherence was assessed using the Medication Event Monitoring System (MEMS). We used glycated hemoglobin (HbA(1c)) assays to measure glycemic control and the 9-item Patient Health Questionnaire (PHQ-9) to assess depression. RESULTS: Intervention and usual care groups did not differ statistically on baseline measures. Patients who received the intervention were more likely to achieve HbA(1c) levels of less than 7% (intervention 60.9% vs. usual care 35.7%; P < .001) and remission of depression (PHQ-9 score of less than 5: intervention 58.7% vs. usual care 30.7%; P < .001) in comparison with patients in the usual care group at 12 weeks. CONCLUSIONS: A randomized controlled trial of a simple, brief intervention integrating treatment of type 2 diabetes and depression was successful in improving outcomes in primary care. An integrated approach to depression and type 2 diabetes treatment may facilitate its deployment in real-world practices with competing demands for limited resources.

Assessment of cost and health resource utilization for elderly patients with heart failure and diabetes mellitus.

BACKGROUND: Our aim was to examine the health resource utilization and cost of care associated with heart failure (HF) and diabetes mellitus (DM) for elderly Medicare enrollees. METHODS AND RESULTS: A retrospective case-control design was used to identify 4 groups of elderly patients with HF and DM (n = 498), HF only (n = 1089), DM only (n = 971), and no-HF and no-DM (n = 5438) using an administrative database of a large urban academic health care system. Demographic, diagnostic, health resource utilization, and cost (reimbursement) data were obtained from the Medicare claims database for the years 2000 and 2001. Disease states were identified by ICD-9 codes. Costs and health resource utilization were compared across the groups. The mean total costs were highest for the group with HF and DM ($32,676), and second highest for the HF only group ($22,230). In multivariable models that adjusted for potentially influential covariates, the group with HF and DM had a 3-fold increase in total cost compared with the group without DM and HF (relative total cost = 4.51, 95% confidence interval 3.82-5.31). CONCLUSIONS: The presence of DM has a substantial influence on the costs for managing older patients with HF. An integrated approach to management may be needed.

Depression, cognition, apolipoprotein e genotype: latent class approach to identifying subtype.

OBJECTIVES: Possessing the epsilon4 allele of apolipoprotein E (APOE-epsilon4) genotype is associated with cognitive impairment in nondemented older adults. The authors hypothesized that they might find a subtype of depression related to impaired cognitive performance associated with the APOE-epsilon4 allele. DESIGN: A survey conducted between 2001 and 2003 with APOE genotyping. SETTING: Primary care offices in the Baltimore area. PARTICIPANTS: The study sample consisted of 305 adults aged 65 or older with complete information on APOE genotyping and covariates. MEASUREMENTS: The authors used the latent class model to classify respondents according to symptom criteria of American Psychiatric Association's Diagnostic and Statistical Manual as assessed in the Composite International Diagnostic Interview and the following four measures of cognitive function: the Mini-Mental State Exam, Hopkins Verbal Learning Test, Controlled Oral Word Association Test, and the Brief Test of Attention. The authors examined the relationship between class membership and APOE genotype. RESULTS: The latent class model yielded three classes: a nondepressed class, a class with depressive symptoms and average cognitive functioning, and a class with depressive symptoms (particularly thoughts of death and suicide) and impaired cognitive functioning. Possessing at least one APOE-epsilon4 allele was not predictive of class membership. CONCLUSION: A subgroup of elderly patients with depressive symptoms, cognitive impairment, and a high likelihood of experiencing thoughts of death or suicide may exist that may not be related to APOE-epsilon4. Subgroups of older patients with depressive symptoms may be important to identify because of the association with thoughts of death or suicide and cognitive impairment.

Mental health services use: Baltimore epidemiologic catchment area follow-up.

OBJECTIVE: To examine the patterns of previous and current mental health services use among older adults in the Baltimore Epidemiologic Catchment Area Follow-up. Examination of a recent cohort of older adults is important because patterns of utilization may have changed due to treatment advances, changes in mental healthcare services, and greater mental health awareness. DESIGN: A population-based longitudinal survey. SETTING: Continuing participants in a study of community-dwelling adults who were living in East Baltimore in 1981. PARTICIPANTS: In all, 1,067 adults for whom complete data were available. MEASUREMENTS: Separately, and before the mental health assessments were made, participants were asked about use of health services. Cognitive status and physical health were assessed using standardized instruments. Mental disorders were assessed using the Diagnostic Interview Schedule. RESULTS: Compared with adults aged 40-59 years in 2004, adults aged 60 years and older were less likely to report specialty mental health services versus general medical care without a mental health component (adjusted odds ratio = 0.28, 95% confidence interval [0.14-0.56]). Multivariate models controlled for potentially influential characteristics including major depression or depression associated with recent bereavement, anxiety disorders, and past use of mental health services. CONCLUSION: Adults aged 60 years and older are approximately one third as likely to consult a specialist in mental health compared with adults aged 40-59 years even accounting for other factors associated with differential use of services. Our study strengthens evidence that the primary care remains important for the treatment of psychiatric disorders in the elderly.

Integration of depression and hypertension treatment: a pilot, randomized controlled trial.

PURPOSE: We wanted to examine whether integrating depression treatment into care for hypertension improved adherence to antidepressant and antihypertensive medications, depression outcomes, and blood pressure control among older primary care patients. METHODS: Older adults prescribed pharmacotherapy for depression and hypertension from physicians at a large primary care practice in West Philadelphia were randomly assigned to an integrated care intervention or usual care. Outcomes were assessed at baseline, 2, 4, and 6 weeks using the Center for Epidemiologic Studies Depression Scale (CES-D) to assess depression, an electronic monitor to measure blood pressure, and the Medication Event Monitoring System to assess adherence. RESULTS: In all, 64 participants aged 50 to 80 years participated. Participants in the integrated care intervention had fewer depressive symptoms (CES-D mean scores, intervention 9.9 vs usual care 19.3; P <.01), lower systolic blood pressure (intervention 127.3 mm Hg vs usual care 141.3 mm Hg; P <.01), and lower diastolic blood pressure (intervention 75.8 mm Hg vs usual care 85.0 mm Hg; P <.01) compared with participants in the usual care group at 6 weeks. Compared with the usual care group, the proportion of participants in the intervention group who had 80% or greater adherence to an antidepressant medication (intervention 71.9% vs usual care 31.3%; P <.01) and to an antihypertensive medication (intervention 78.1% vs usual care 31.3%; P <.001) was greater at 6 weeks. CONCLUSION: A pilot, randomized controlled trial integrating depression and hypertension treatment was successful in improving patient outcomes. Integrated interventions may be more feasible and effective in real-world practices, where there are competing demands for limited resources.

Older patients' views on the relationship between depression and heart disease.

BACKGROUND AND OBJECTIVES: Longitudinal studies have found evidence of associations between coronary heart disease and clinical depression. We sought to understand older patients' views regarding relationships between depression and heart disease to facilitate patient-provider communication about heart disease and depression and to lay the groundwork for designing interventions. METHODS: The design was a qualitative study using semi-structured interviews. In all, 33 primary care patients 65 years and over with dysphoria, anhedonia, hopelessness, worthlessness, or sleep disturbance who were taking at least one medication targeting cardiovascular risk factors were interviewed in the office of their primary care clinician. Participants were asked open-ended questions about depression and heart disease and their treatment. A multidisciplinary research team coded the transcripts and identified key themes. RESULTS: Participants gave clear descriptions of how heart disease can lead to depression and depression can lead to heart disease. Participants supported treating depression immediately in the context of heart disease and generally preferred integrated care. CONCLUSIONS: Depression treatment may be more acceptable if discussed in terms of overall cardiovascular risk. Our results support the integration of depression management with management for risk factors for cardiovascular disease.

How employment helps female victims of intimate partner violence: a qualitative study.

This exploratory, qualitative study documents ways in which being employed is helpful to victims of intimate partner violence (IPV). The authors conducted in-depth interviews with 21 women employed by a large health care organization in a major U.S. city. Through content analysis, the authors identified six ways in which employment was helpful to participants: by (1) improving their finances, (2) promoting physical safety, (3) increasing self-esteem, (4) improving social connectedness, (5) providing mental respite, and (6) providing motivation or a "purpose in life." Findings suggest that employment can play a critically important, positive role in the lives of IPV victims. The importance of flexible leave-time policies and employer assistance to IPV victims is discussed.

Pilot trial of a licensed practical nurse intervention for hypertension and depression.

BACKGROUND AND OBJECTIVES: Depression is a risk factor for hypertension, and risk of depression is increased substantially in patients with hypertension. Our objective was to examine whether an intervention carried out by Licensed Practical Nurses (LPNs) integrating depression treatment into care for hypertension improved blood pressure control and depressive symptoms. METHODS: In all, 60 patients ages 41 to 92 years with hypertension and depressive symptoms at a large primary care practice in Philadelphia were randomly assigned to an integrated care intervention carried out by LPNs (n=30) or usual care (n=30). Intervention and control groups did not differ statistically on baseline measures. Outcomes assessed at baseline and 12 weeks included standard laboratory procedures to measure blood pressure control and the Patient Health Questionnaire (PHQ-9) to assess depression. RESULTS: Patients in the integrated care intervention had lower diastolic blood pressure (intervention 74.2 mmHg versus usual care 82.0 mmHg) and fewer depressive symptoms (PHQ-9 mean scores, intervention 2.4 versus usual care 7.1) compared with patients in the usual care group at 12 weeks after adjustment for baseline values. Patients in the integrated care intervention also had lower systolic blood pressure (intervention 130.0 mmHg versus usual care 140.6 mmHg) compared with patients in the usual care group at 12 weeks although the results approached but did not reach conventional levels of statistical significance. CONCLUSION: Training existing primary care practice office staff will facilitate implementation in real world practices with limited resources and competing demands.

Measuring concurrent oral hypoglycemic and antidepressant adherence and clinical outcomes.

OBJECTIVES: Many patients experience difficulty in adhering to medication for both physical and mental health. Our objective was to compare selfreported adherence and electronic monitoring of adherence to oral hypoglycemic agents and antidepressants and to examine the relationship of adherence with clinical outcomes. STUDY DESIGN: Primary care-based longitudinal study. METHODS: Adherence was assessed in 180 patients prescribed pharmacotherapy for type 2 diabetes mellitus (T2DM) and depression enrolled in a randomized controlled trial of an integrated intervention for depression and T2DM. Adherence data were collected using self report and electronic monitoring. Glycated hemoglobin (A1C) assays were used to measure glycemic control, and the 9-item patient health questionnaire assessed depression. RESULTS: At 12 weeks, self-reported adherence and electronic monitoring of adherence showed fair agreement (kappa = 0.213, P = .004 for oral hypoglycemic agents and kappa = 0.380, P < .001 for antidepressants). Patients who achieved >80% adherence to oral hypoglycemic agents measured with electronic monitoring were more likely to achieve A1C < 7% compared with patients who did not achieve > 80% adherence at 12 weeks (adjusted odds ratio = 3.52, 95% confidence interval 1.07-11.57). Self-reported adherence to oral hypoglycemic agents was not associated with diabetes outcomes. Measures of adherence for antidepressants were not associated with depression outcomes in models adjusted for potentially influential covariates. CONCLUSIONS: Compared with electronic monitoring of adherence, self-reported adherence tended to overestimate medication adherence. Electronic monitoring of adherence to oral hypoglycemic agents predicted glycemic control, but self-reported adherence did not predict clinical outcomes.

Urinary incontinence (UI) and new psychological distress among community dwelling older adults.

This study aimed at determining whether UI is associated with increased risk for the onset of psychological distress. This was a population based longitudinal survey of adults aged 50 and older who did not report psychological distress in 1993 and for whom complete data were available. Participants were classified as having UI if they reported uncontrolled urine loss within 12 months of the 1993 interview. Condition-specific functional loss secondary to UI was assessed by questions on participants' ability to engage in certain activities due to UI. Psychological distress was assessed using the General Health Questionnaire (GHQ) in 2004. The continuing participants were living in East Baltimore, Maryland in 1981. Persons with UI in 1993 were more likely to experience new psychological distress in 2004 than were persons without UI in 1993 adjusting for potentially influential covariates (relative odds (RO)=2.18, 95% confidence interval (CI)=1.19-4.01). Persons with condition-specific functional loss secondary to UI were more likely to experience new psychological distress than were persons without UI adjusting for potentially influential covariates (RO=7.57, 95%CI=2.92-19.62). We conclude that UI, especially when associated with condition-specific functional loss, predicted the onset of psychological distress among community dwelling older adults.

Self-reported estrogen use and newly incident urinary incontinence among postmenopausal community-dwelling women.

OBJECTIVE: The aim of this study was to examine the relationship between self-reported estrogen use and newly incident urinary incontinence (UI) among community-dwelling postmenopausal women. METHODS: The study was a population-based longitudinal survey of postmenopausal women who did not report UI in 1993 and for whom complete data were available. Women were classified as having newly incident UI if they reported uncontrolled urine loss within 12 months of the 2004 interview. Condition-specific functional loss secondary to UI was assessed using questions on the participants' inability to engage in certain activities because of UI. The duration of hormone therapy containing estrogen was obtained in 1993 using a structured questionnaire. RESULTS: Among the 167 postmenopausal women who did not report UI in 1993, 47 (28.1%) reported newly incident UI, and 31 (18.6%) reported newly incident UI with condition-specific functional loss in 2004. Of the 167 postmenopausal women, 46 (27.5%) reported using hormone therapy containing estrogen ever, and 14 (8.3%) women reported using hormone therapy containing estrogen for 5 years or more in 1993. Estrogen use for 5 years or more was significantly associated with newly incident UI with condition-specific functional loss compared with estrogen use for less than 5 years or having no reported history of estrogen (adjusted relative odds, 3.97; 95% CI, 1.02-15.43) in multivariate models controlling for potentially influential characteristics. CONCLUSIONS: Postmenopausal community-dwelling women with a history of estrogen use for 5 years or more were more likely to report newly incident UI with condition-specific functional loss after 10 years of follow-up.

Chronic medical conditions and reproducibility of self-reported age at menopause among community-dwelling women.

OBJECTIVE: The aim of this study was to examine the association between chronic medical conditions and reproducibility of self-reported age at menopause among community-dwelling women. METHODS: Age at menopause was assessed in a population-based longitudinal survey of 240 women twice, in 1993 and 2004. Women who recalled age at menopause in 2004 within 1 year or less of age at menopause recalled in 1993 (concordant) were compared with women who did not recall age at menopause in 2004 within 1 year of age at menopause recalled in 1993 (discordant). Type of menopause (surgical or natural) and chronic medical conditions were assessed by self-report. RESULTS: One hundred forty-three women (59.6%) reported surgical menopause, and 97 (40.4%) reported natural menopause. In all, 130 (54.2%) women recalled age at menopause in 2004 within 1 year or less of recalled age at menopause in 1994, whereas 110 (45.8%) women did not recall age at menopause in 2004 within 1 year or less of recalled age at menopause in 1994. Among the women with surgical menopause, the women with three or more medical conditions were less likely to have concordant recall of age at menopause than the women with less than three chronic medical conditions (adjusted odds ratio, 0.36; 95% CI, 0.15-0.91) in multivariate models controlling for potentially influential characteristics including cognition and years since menopause. CONCLUSIONS: Among women who underwent surgical menopause, the presence of three or more medical conditions is associated with decreased reproducibility of self-reported age at menopause.

The temporal relationship between anxiety disorders and urinary incontinence among community-dwelling adults.

OBJECTIVE: The purpose of this paper was to carefully examine the temporal relationships between anxiety disorders and urinary incontinence among community-dwelling adults. METHOD: In all, 1071 persons aged 30 and over were the continuing participants in a population-based longitudinal study of community-dwelling adults. Participants were classified as incontinent if any uncontrolled urine loss within the 12 months prior to the interview was reported. Condition-specific functional loss secondary to urinary incontinence was further assessed based on a series of questions relating directly to participants' inability to engage in certain activities due to their urinary incontinence. Anxiety disorders were assessed with standardized interviews keyed to the diagnostic criteria. RESULTS: In multivariate models that controlled for potentially influential characteristics the association between urinary incontinence with condition-specific functional loss and newly-incident anxiety disorders was statistically significant (adjusted relative odds (RO)=2.55, 95% confidence interval (CI) [1.05, 6.20]). CONCLUSIONS: Urinary incontinence with condition-specific functional loss predicted onset of newly-incident anxiety disorders among community-dwelling adults.

Integrating type 2 diabetes mellitus and depression treatment among African Americans: a randomized controlled pilot trial.

PURPOSE: The purpose of this study was to examine whether integrating depression treatment into care for type 2 diabetes mellitus among older African Americans improved medication adherence, glycemic control, and depression outcomes. METHODS: Older African Americans prescribed pharmacotherapy for type 2 diabetes mellitus and depression from physicians at a large primary care practice in west Philadelphia were randomly assigned to an integrated care intervention or usual care. Adherence was assessed at baseline, 2, 4, and 6 weeks using the Medication Event Monitoring System to assess adherence. Outcomes assessed at baseline and 12 weeks included standard laboratory tests to measure glycemic control and the Center for Epidemiologic Studies Depression Scale (CES-D) to assess depression. RESULTS: In all, 58 participants aged 50 to 80 years participated. The proportion of participants who had 80% or greater adherence to an oral hypoglycemic (intervention 62.1% vs usual care 24.1%) and an antidepressant (intervention 62.1% vs usual care 10.3%) was greater in the intervention group in comparison with the usual care group at 6 weeks. Participants in the integrated care intervention had lower levels of glycosylated hemoglobin (intervention 6.7% vs usual care 7.9%) and fewer depressive symptoms (CES-D mean scores: intervention 9.6 vs usual care 16.6) compared with participants in the usual care group at 12 weeks. CONCLUSION: A pilot randomized controlled trial integrating type 2 diabetes mellitus treatment and depression was successful in improving outcomes among older African Americans. Integrated interventions may be more feasible and effective in real-world practices with competing demands for limited resources.

Disparity in use of psychotherapy offered in primary care between older african-american and white adults: results from a practice-based depression intervention trial.

The purpose of this study was to assess ethnic differences in use of psychotherapy (having met at least once with a psychotherapist) for late-life depression in primary care. Participants were identified through a two-stage, age-stratified (60-74, > or =75) depression screening of randomly sampled patients from 20 practices in New York City, Philadelphia, and Pittsburgh in a practice-randomized trial. Practices were randomly assigned to usual care or to an intervention with a depression care manager who worked with primary care physicians to provide algorithm-based care. Depression status based on clinical interview and any use of psychotherapy within the 2-year follow-up interval were the primary dependent variables under study. The focus was on 582 persons with complete data. Participants were sorted into major depression (n=385, 112 African American and 273 white) and clinically significant minor depression (n=197, 51 African American and 146 white) based on clinical diagnostic assessment. Persons who self-identified as African American were less likely than whites to use interpersonal therapy (IPT) if they had minor depression, even after adjusting for potentially influential variables including age, cognitive functioning, and whether the dose of antidepressant was adequate (adjusted odds ratio (AOR)=0.22, 95% confidence interval (CI)=0.06-0.80). Ethnicity was not significantly associated with IPT use in persons with major depression (AOR=0.71, 95% CI=0.37-1.37). Older African Americans with minor depression were less likely than whites to use psychotherapy. Targeted strategies are needed to mitigate the disparity in use of psychotherapy.

A cross-sectional study of somatic symptoms and the identification of depression among elderly primary care patients.

OBJECTIVE: To examine the relationship between somatization and depression as rated by primary care physicians. METHOD: This study was a cross-sectional survey of 355 older adults with and without significant depressive symptoms. Physicians' ratings of somatization and depression were obtained for 341 of the 355 patients. Patients were sorted into 4 groups on the basis of physician ratings (no depression/no somatization, somatization only, depression only, and both somatization and depression). Data were collected from 2001-2003. RESULTS: Patients who were rated as somatizing were 4.03 (95% CI, 2.52-6.45) times as likely to be rated as depressed as well as somatizing. A comparison of the 4 groups defined by physicians' ratings found that functional status, ethnicity, number of medical conditions, depressive symptoms, and anxiety were statistically significantly different (P < .05). Primary care physicians were 3.95 (95% CI, 1.53-10.16) times more likely to identify older black patients as somatizing only versus depressed and somatizing compared to older white patients among patients above a threshold on a standard depression instrument. CONCLUSIONS: Our study fills a gap in the literature by focusing on the primary care physician ratings of depression and somatization, and also specifically on older primary care patients. Blacks are less likely to be rated as depressed, but this may reflect the tendency of doctors to rate them as somatizing.