Randomized Trial of Communication Facilitators to Reduce Family Distress and Intensity of End-of-Life Care.

RATIONALE: Communication with family of critically ill patients is often poor and associated with family distress. OBJECTIVES: To determine if an intensive care unit (ICU) communication facilitator reduces family distress and intensity of end-of-life care. METHODS: We conducted a randomized trial at two hospitals. Eligible patients had a predicted mortality greater than or equal to 30% and a surrogate decision maker. Facilitators supported communication between clinicians and families, adapted communication to family needs, and mediated conflict. MEASUREMENTS AND MAIN RESULTS: Outcomes included depression, anxiety, and post-traumatic stress disorder (PTSD) among family 3 and 6 months after ICU and resource use. We identified 488 eligible patients and randomized 168. Of 352 eligible family members, 268 participated (76%). Family follow-up at 3 and 6 months ranged from 42 to 47%. The intervention was associated with decreased depressive symptoms at 6 months (P = 0.017), but there were no significant differences in psychological symptoms at 3 months or anxiety or PTSD at 6 months. The intervention was not associated with ICU mortality (25% control vs. 21% intervention; P = 0.615) but decreased ICU costs among all patients (per patient: $75,850 control, $51,060 intervention; P = 0.042) and particularly among decedents ($98,220 control, $22,690 intervention; P = 0.028). Among decedents, the intervention reduced ICU and hospital length of stay (28.5 vs. 7.7 d and 31.8 vs. 8.0 d, respectively; P < 0.001). CONCLUSIONS: Communication facilitators may be associated with decreased family depressive symptoms at 6 months, but we found no significant difference at 3 months or in anxiety or PTSD. The intervention reduced costs and length of stay, especially among decedents. This is the first study to find a reduction in intensity of end-of-life care with similar or improved family distress. Clinical trial registered with www.clinicaltrials.gov (NCT 00720200).

PACES in epilepsy: Results of a self-management randomized controlled trial.

OBJECTIVE: Self-management challenges facing adults with epilepsy include limited understanding of the condition and treatment, associated psychosocial issues, and lack of community integration. Self-management interventions improve patients' medical, life role, and emotional management. Previous interventions, developed from expert opinion, indicated issues with participant engagement/retention, and limited follow-up periods. PACES in Epilepsy addressed methodologic concerns by utilizing patient needs assessment data (n = 165) to derive self-management content and program features for evaluation via randomized controlled trial (RCT). METHODS: Participants were adults with chronic epilepsy (n = 83), without serious mental illness or substantive intellectual impairment, who were recruited from two epilepsy centers. Participants were assigned randomly to intervention or treatment-as-usual groups. Outcomes included the Epilepsy Self-Management Scale (ESMS), Epilepsy Self-Efficacy Scale (ESES), Quality of Life in Epilepsy-31 (QOLIE-31), Patient Health Questionnaire-9 (PHQ-9), and the Generalized Anxiety Disorder-7 (GAD-7), administered at baseline, postintervention (8 weeks), and 6 months postintervention. The intervention was an 8-week group of 6-8 adults co-led by a psychologist and trained peer with epilepsy that met one evening per week at a hospital for 75 min. Topics included medical, psychosocial, cognitive, and self-management aspects of epilepsy, in addition to community integration and optimizing epilepsy-related communication. The treatment group provided satisfaction ratings regarding program features. RESULTS: PACES participants (n = 38) improved relative to controls (n = 40) on the ESMS (p < 0.001) and subscales [Information (p < 0.001); Lifestyle (p < 0.002)]; ESES (p < 0.001); and QOLIE-31 (p = 0.002). At 6-month follow up, PACES participants remained improved on the ESMS (p = 0.004) and Information subscale (p = 0.009); and Energy/Fatigue (p = 0.032) and Medication Effects (p = 0.005) of the QOLIE-31. Attrition in both groups was low (8% in each group) and all program satisfaction ratings exceeded 4.0/5.0, with leadership (4.76), topics (4.53), and location (4.30) as the most highly rated aspects. SIGNIFICANCE: A consumer generated epilepsy self-management program appears to be a promising intervention from multiple perspectives, particularly in relation to disability management.

Depression among patients with diabetes attending a safety-net primary care clinic: relationship with disease control.

BACKGROUND: Depression and diabetes are highly comorbid, with depression increasing risk of diabetes-related complications and mortality. Few studies have examined the relationship between depression and diabetes in safety-net populations with high rates of trauma exposure, anxiety, and substance use disorders. METHODS: Using a cross-sectional survey of 261 patients with diabetes attending safety-net clinics, associations between depression and key diabetes control parameters were examined in bivariate and multivariable analyses adjusting for relevant confounders and significant interactions. RESULTS: Among the participants, 57% were men, 51% were white, and the average age was 57 years. Most respondents were unemployed (81%) and earned less than $10,000 per year (51%). Overall, 28% screened positive for depression, with a high overlap of posttraumatic stress (58%) and generalized anxiety (77%) symptoms. After adjustment for socioeconomic and clinical variables, depression was associated with higher mean body mass index (p = 0.01), severe obesity (body mass index ≥ 35kg/m(2)) (odds ratio = 2.34, 95% CI: 1.09-5.04, p = 0.03) and uncontrolled diastolic blood pressure (odds ratio = 2.49, 95% CI: 1.15-5.39, p = 0.02). There was a nonsignificant trend for those with depression to have worse control of blood glucose. Associations with depression and diabetes clinical outcomes were not significantly worsened in the presence of comorbid anxiety disorders. CONCLUSIONS: Within a highly comorbid safety-net population, significant associations between depression and key diabetes outcomes remained after accounting for relevant covariates. Further research will help elucidate the relationship between depression and diabetes control measures in safety-net populations.

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 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.

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.

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 effect of changes in depressive symptoms on disability status in patients with diabetes.

OBJECTIVE: To examine the association between changes in depressive symptoms and disability status in patients with diabetes. METHODS: This 5-year prospective cohort study included 2733 patients with diabetes enrolled in the Pathways Epidemiologic Follow-Up Study who had completed depression and activities of daily living questionnaires at baseline and 5 years. Four depression groups were created using changes in depression scores over 5 years: no depression, improved depression, persistent depression, and development of depression. After controlling for sociodemographic and clinical characteristics, we examined the association between changes in depressive symptoms and incident disability at 5 years using Poisson regression. RESULTS: In patients nondisabled at baseline (n = 2155), the improved depression group had a risk of disability comparable to the no depression reference group [relative risk (RR): 0.70, 95% CI (0.44-1.12)]. The development of depression and persistent depression groups were significantly more likely to develop disability compared with the no depression group [RR: 2.86, 95% CI (2.12-3.86) and RR: 2.16, 95% CI (1.47-3.18), respectively]. Among those who were disabled at baseline, there was no significant change in the disability status of the three depression groups compared with disabled patients with no depressive symptoms at either time point. CONCLUSIONS: Among initially nondisabled patients with diabetes, those whose depression improved had functional outcomes comparable to those who were nondepressed at baseline and 5 years. Patients who developed depression and had persistent depression were more likely to experience disability at 5 years than those who were nondepressed at baseline and 5 years.

A comparison of epilepsy self-management needs: provider and patient perspectives.

A consistent and serious empirical issue in the epilepsy self-management literature involves dropout and attrition in intervention studies. One explanation for this issue revolves around "top-down" intervention designs (i.e., interventions generated by epilepsy clinicians and researchers) and the potential for disparity with patient interests, capabilities, and perceived needs. The purpose of this study was to extend the work of Fraser et al. (2011) [19] by comparing perceptions regarding self-management problems, topics, and program design, between two subgroups of adult patients with epilepsy (n=165) and epilepsy clinicians (n=20). Results indicate differences in problem severity ratings, program emphasis (i.e., goal-setting, coping, education), and program leadership between clinicians and each patient subgroup to varying degrees. These findings highlight some of the differences in opinion between patients and clinicians and emphasize the need for patient-involved planning with regard to self-management programs. Implications and explanations are offered as points for consideration in self-management program development.

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.

Somatic symptoms and the association between hepatitis C infection and depression in HIV-infected patients.

Studies of depression and hepatitis C virus (HCV) infection in HIV-infected patients have been contradictory and often not addressed key differences between HCV-infected and uninfected individuals including substance use. This cross-sectional observational study from the University of Washington HIV cohort examined associations between HCV, symptoms, and depression in HIV-infected patients in routine clinical care. Patients completed instruments measuring depression, symptoms, and substance use. We generated depression severity scores and used linear regression to examine the relationship with HCV accounting for demographic and clinical characteristics. We conducted sensitivity analyses in which we removed depression somatic symptom items (e.g., fatigue) from depression scores, and sensitivity analyses in which we also adjusted for nondepression somatic symptom items to examine the role of somatic and nonsomatic symptoms in the association between depression and HCV. Of 764 HIV-infected patients, 160 (21%) were HCV-infected. In adjusted analysis, HCV-infected patients had worse depression severity (p =0.01) even after adjusting for differences in substance use. HCV remained associated with depression severity in secondary analyses that omitted the depression somatic patient health questionnaire-9 (PHQ-9) items (p=0.01). However, when nondepression somatic symptoms were included as covariates in multivariate analyses, HCV was no longer associated with depression (p=0.09).

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.

Long-term outcomes from the PEARLS randomized trial for the treatment of depression in patients with epilepsy.

Depression is associated with higher rates of suicide and lower quality of life in individuals with epilepsy. We previously published the 12-month outcome from our randomized clinical trial of PEARLS (Ciechanowski P, Chaytor N, Miller J, et al. Epilepsy Behav. Epub 5 July 2010). The purpose of this study was to determine the long-term effectiveness of PEARLS, a home-based collaborative care intervention consisting of problem-solving treatment, behavioral activation, and psychiatric consultation, in individuals with epilepsy. Patients were randomly assigned to PEARLS (N=40) or usual care (N=40), and assessed at baseline and 6, 12, and 18 months. Patients assigned to PEARLS achieved lower depression severity (P<0.05) (Hopkins Symptoms Checklist-20), lower suicidal ideation (P<0.02), and better emotional well being (QOLIE-31) (P<0.02) over 18 months, compared with patients given the usual care. The PEARLS program significantly reduces depressive symptoms in adults with epilepsy, and this effect is maintained for 18 months after baseline and for more than 1 year after completion of home visits.

Managing epilepsy well: self-management needs assessment.

Epilepsy self-management interventions have been investigated with respect to health care needs, medical adherence, depression, anxiety, employment, and sleep problems. Studies have been limited in terms of representative samples and inconsistent or restricted findings. The direct needs assessment of patients with epilepsy as a basis for program design has not been well used as an approach to improving program participation and outcomes. This study investigated the perceived medical and psychosocial problems of adults with epilepsy, as well as their preferences for self-management program design and delivery format. Results indicated a more psychosocially challenged subgroup of individuals with significant depressive and cognitive complaints. A self-management program that involves face-to-face individual or group meetings led by an epilepsy professional and trained peer leader for 60 minutes weekly was preferred. Six to eight sessions focused on diverse education sessions (e.g., managing disability and medical care, socializing on a budget, and leading a healthy lifestyle) and emotional coping strategies delivered on weeknights or Saturday afternoons were most highly endorsed. Emotional self-management and cognitive compensatory strategies require special emphasis given the challenges of a large subgroup.

Psychosocial modulators of angina response to myocardial ischemia.

BACKGROUND: Although angina is often caused by atherosclerotic obstruction of the coronary arteries, patients with similar amounts of myocardial ischemia may vary widely in their symptoms. We sought to compare clinical and psychosocial characteristics associated with more frequent angina after adjusting for the amount of inducible ischemia. METHODS AND RESULTS: From 2004 to 2006, 788 consecutive patients undergoing single-photon emission computed tomography stress perfusion imaging at 2 Seattle hospitals were assessed for their frequency of angina over the previous 4 weeks with the Seattle Angina Questionnaire and for a broad range of psychosocial characteristics. Among patients with demonstrable ischemia on single-photon emission computed tomography (summed difference score >or=2; n=191), angina frequency was categorized as none (Seattle Angina Questionnaire score=100; n=68), monthly (score=61 to 99; n=66), and weekly or daily (score=0 to 60; n=57). Using multivariable ordinal logistic regression, increasing angina was significantly associated with a history of coronary revascularization (odds ratio 2.24, 95% confidence interval 1.19 to 4.19), anxiety (odds ratio 4.72, 95% confidence interval 1.91 to 11.66), and depression (odds ratio 3.12, 95% confidence interval 1.45 to 6.69) after adjustment for the amount of inducible ischemia. CONCLUSIONS: Among patients with a similar burden of inducible ischemia, a history of coronary revascularization and current anxiety and depressive symptoms were associated with more frequent angina. These results support the study of angina treatment strategies that aim to reduce psychosocial distress in conjunction with efforts to lessen myocardial ischemia.

Comorbid depression is associated with an increased risk of dementia diagnosis in patients with diabetes: a prospective cohort study.

BACKGROUND: Both depression and diabetes have been found to be risk factors for dementia. This study examined whether comorbid depression in patients with diabetes increases the risk for dementia compared to those with diabetes alone. METHODS: We conducted a prospective cohort study of 3,837 primary care patients with diabetes (mean age 63.2 +/- 13.2 years) enrolled in an HMO in Washington State. The Patient Health Questionnaire (PHQ-9) was used to assess depression at baseline, and ICD-9 diagnoses for dementia were used to identify cases of dementia. Cohort members with no previous ICD-9 diagnosis of dementia prior to baseline were followed for a 5-year period. The risk of dementia for patients with both major depression and diabetes at baseline relative to patients with diabetes alone was estimated using cause-specific Cox proportional hazard regression models that adjusted for age, gender, education, race/ethnicity, diabetes duration, treatment with insulin, diabetes complications, nondiabetes-related medical comorbidity, hypertension, BMI, physical inactivity, smoking, HbA(1c), and number of primary care visits per month. RESULTS: Over the 5-year period, 36 of 455 (7.9%) patients with major depression and diabetes (incidence rate of 21.5 per 1,000 person-years) versus 163 of 3,382 (4.8%) patients with diabetes alone (incidence rate of 11.8 per 1,000 person-years) had one or more ICD-9 diagnoses of dementia. Patients with comorbid major depression had an increased risk of dementia (fully adjusted hazard ratio 2.69, 95% CI 1.77, 4.07). CONCLUSIONS: Patients with major depression and diabetes had an increased risk of development of dementia compared to those with diabetes alone. These data add to recent findings showing that depression was associated with an increased risk of macrovascular and microvascular complications in patients with diabetes.

Depression in relation to long-term control of glycemia, blood pressure, and lipids in patients with diabetes.

BACKGROUND: Little information is available about the association of depression with long-term control of glycemia, blood pressure, or lipid levels in patients with diabetes. OBJECTIVE: To determine whether minor and major depression at study enrollment compared with no depression are associated with higher average HbA(1c), systolic blood pressure (SBP) and LDL cholesterol over the long term in patients with an indication for or receiving drug treatment. DESIGN: Cohort study. PATIENTS: A total of 3,762 patients with type 2 diabetes mellitus enrolled in the Pathways Epidemiologic Study in 2001-2002 and followed for 5 years. MAIN MEASURES: Depression was assessed at study enrollment using the Patient Health Questionnaire-9 (PHQ-9). SBP and information on cardiovascular co-morbidity were abstracted from medical records, and LDL cholesterol and HbA(1c) measured during clinical care were obtained from computerized laboratory data during a median of 4.8 years' follow-up. KEY RESULTS: Among those with an indication for or receiving drug treatment, after adjustment for demographic and clinical characteristics, average long-term HbA(1c), SBP, and LDL cholesterol did not differ in patients with comorbid diabetes and minor or major depression compared with those with diabetes alone. CONCLUSIONS: The adverse effect of depression on outcomes in patients with diabetes may not be mediated in large part by poorer glycemic, blood pressure, or lipid control. Further study is needed of the biologic effects of depression on patients with diabetes and their relation to adverse outcomes.

PEARLS depression treatment for individuals with epilepsy: a randomized controlled trial.

OBJECTIVE: Depression is associated with higher rates of suicide and lower levels of functioning and quality of life in individuals with epilepsy. The objective of this randomized controlled trial was to determine the effectiveness of PEARLS, a home-based program for managing depression in adult individuals with epilepsy and clinically significant acute and chronic depression. METHODS: Delivered by masters-level counselors, PEARLS is a collaborative care intervention consisting of problem solving treatment, behavioral activation, and psychiatric consultation. Patients were randomly assigned to the PEARLS intervention (N = 40) or usual care (N = 40), and assessed at baseline, 6 months, and 12 months. RESULTS: Compared with patients who received usual care, patients assigned to the PEARLS intervention achieved lower depression severity (P<0.005) (Hopkins Symptoms Checklist-20) and lower suicidal ideation (P = 0.025) over 12 months. CONCLUSIONS: The PEARLS program, a community-integrated, home-based treatment for depression, effectively reduces depressive symptoms in adults with epilepsy and comorbid depression.

The prevention research centers' managing epilepsy well network.

The Managing Epilepsy Well (MEW) Network was created in 2007 by the Centers for Disease Control and Prevention's (CDC) Prevention Research Centers and Epilepsy Program to promote epilepsy self-management research and to improve the quality of life for people with epilepsy. MEW Network membership comprises four collaborating centers (Emory University, University of Texas Health Science Center at Houston, University of Michigan, and University of Washington), representatives from CDC, affiliate members, and community stakeholders. This article describes the MEW Network's background, mission statement, research agenda, and structure. Exploratory and intervention studies conducted by individual collaborating centers are described, as are Network collaborative projects, including a multisite depression prevention intervention and the development of a standard measure of epilepsy self-management. Communication strategies and examples of research translation programs are discussed. The conclusion outlines the Network's role in the future development and dissemination of evidence-based epilepsy self-management programs.