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).

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).

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.

Sertraline for prevention of depression recurrence in diabetes mellitus: a randomized, double-blind, placebo-controlled trial.

CONTEXT: In patients with diabetes mellitus, depression is a prevalent and recurrent problem that adversely affects the medical prognosis. OBJECTIVE: To determine whether maintenance therapy with sertraline hydrochloride prevents recurrence of major depression in patients with diabetes. DESIGN: A randomized, double-blind, placebo-controlled, maintenance treatment trial. Patients who recovered from depression during open-label sertraline treatment continued to receive sertraline (n = 79) or placebo (n = 73) and were followed up for up to 52 weeks or until depression recurred. SETTING: Outpatient clinics at Washington University, St Louis, MO, the University of Washington, Seattle, and the University of Arizona, Tucson. PATIENTS: One hundred fifty-two patients with diabetes (mean age, 52.8 years; 59.9% female; 82.9% with type 2 diabetes) who recovered from major depression (43.3% of those initially assigned) during 16 weeks of open-label treatment with sertraline (mean dose, 117.9 mg/d). INTERVENTION: Sertraline continued at recovery dose or identical-appearing placebo. MAIN OUTCOME MEASURES: The primary outcome was length of time (measured as the number of days after randomization) to recurrence of major depression as defined in DSM-IV. The secondary outcome was glycemic control, which was assessed via serial determinations of glycosylated hemoglobin levels. RESULTS: Sertraline conferred significantly greater prophylaxis against depression recurrence than did placebo (hazard ratio = 0.51; 95% confidence interval, 0.31-0.85; P = .02). Elapsed time before major depression recurred in one third of the patients increased from 57 days in patients who received placebo to 226 days in patients treated with sertraline. Glycosylated hemoglobin levels decreased during the open treatment phase (mean +/- SD glycosylated hemoglobin level reduction, -0.4% +/- 1.4%; P = .002). Glycosylated hemoglobin levels remained significantly lower than baseline during depression-free maintenance (P = .002) and did not differ between treatment groups (P = .90). CONCLUSIONS: In patients with diabetes, maintenance therapy with sertraline prolongs the depression-free interval following recovery from major depression. Depression recovery with sertraline as well as sustained remission with or without treatment are associated with improvements in glycosylated hemoglobin levels for at least 1 year.

Isn't this just bedtime snacking? The potential adverse effects of night-eating symptoms on treatment adherence and outcomes in patients with diabetes.

OBJECTIVE: Night-eating syndrome is characterized by excessive eating in the evening and nocturnal awakening with ingestion of food. Psychosocial variables and emotional triggers may be associated with these behaviors. In patients with diabetes, such behaviors may lead to glucose dysregulation and contribute to obesity and complications. RESEARCH DESIGN AND METHODS: In 714 tertiary care patients with type 1 and 2 diabetes, we determined the proportion of patients reporting eating >25% of their daily food intake after regular suppertime. We also screened patients for major depression, childhood maltreatment histories, nonsecure attachment styles, and emotional eating triggers. We examined whether patients reporting night-eating behaviors had greater psychosocial distress, higher HbA(1c) (A1C) levels, more obesity, and more diabetes complications compared with patients without night-eating behaviors. RESULTS: Night-eating behaviors were reported in 9.7% of patients. Compared with patients without night-eating behaviors, those with these behaviors were less adherent with diet, exercise, and glucose monitoring and more likely to be depressed, to report childhood maltreatment histories, to have nonsecure attachment styles, and to report eating in response to anger, sadness, loneliness, worry, and being upset. Controlling for age, sex, race, and major depression, patients with night-eating behaviors, compared with patients without night-eating behaviors, were more likely to be obese (odds ratio 2.6 [95% CI 1.5-4.5]), to have A1C values >7% (2.2 [1.1-4.1]) and to have two or more diabetes complications (2.6 [1.5-4.5]). CONCLUSIONS: Night-eating behaviors are associated with adverse outcomes in patients with diabetes. Use of clinical screening tools may help identify patients with night-eating behaviors.

Using relationship styles based on attachment theory to improve understanding of specialty choice in medicine.

BACKGROUND: Patient-provider relationships in primary care are characterized by greater continuity and depth than in non-primary care specialties. We hypothesized that relationship styles of medical students based on attachment theory are associated with specialty choice factors and that such factors will mediate the association between relationship style and ultimately matching in a primary care specialty. METHODS: We determined the relationship styles, demographic characteristics and resident specialty match of 106 fourth-year medical students. We assessed the associations between 1) relationship style and specialty choice factors; 2) specialty choice factors and specialty match, and 3) relationship style and specialty match. We also conducted mediation analyses to determine if factors examined in a specialty choice questionnaire mediate the association between relationship style and ultimately matching in a primary care specialty. RESULTS: Prevalence of attachment styles was similar to that found in the general population and other medical school settings with 59% of students rating themselves as having a secure relationship style. Patient centeredness was directly associated, and career rewards inversely associated with matching in a primary care specialty. Students with a self-reliant relationship style were significantly more likely to match in a non-primary care specialty as compared to students with secure relationship style (OR = 5.3, 95% CI 1.8, 15.6). There was full mediation of the association between relationship style and specialty match by the specialty choice factor characterized by patient centeredness. CONCLUSION: Assessing relationship styles based on attachment theory may be a potentially useful way to improve understanding and counsel medical students about specialty choice.

Depression-related hyperglycemia in type 1 diabetes: a mediational approach.

OBJECTIVE: Depression is linked with hyperglycemia and with an increased risk for diabetes complications, but the mechanisms underlying these relationships have not been established. In this study, we applied mediational analysis methods to determine whether the hyperglycemic effect of depression could be mediated by poor diabetes self-care. METHODS: Depression symptoms and diabetes self-care activity were assessed in a primary care sample of 188 patients with type 1 diabetes by using the Hopkins Symptom Checklist-90 (SCL-90) and the Summary of Diabetes Self-Care Activities (SDSCA). A composite score of self-care activity was formed from SDSCA ratings for diet amount, exercise, and glucose testing. Degree of hyperglycemia (level of glycosylated hemoglobin [HbA1c]), weight, insulin dose, and other clinical characteristics were obtained from electronic medical records. Ordinary least-squares regression was used to determine the effect of depression on HbA1c level controlling for weight and insulin dose. The SDSCA score was then added to the regression model to determine whether it attenuated the effect of depression symptoms on HbA1c level, thus providing suggestive evidence of mediation from these cross-sectional data. RESULTS: Depression symptoms, poor diabetes self-care, and hyperglycemia were correlated with one another in univariate analyses (p <.05). Depression symptoms were associated with higher HbA1c after controlling for weight and insulin dose (parameter estimate for depression 0.53, t = 3.6, p <.001). Inclusion of SDSCA in the model minimally attenuated the effect of depression symptoms (adjusted parameter estimate for depression 0.50, t = 3.3, p = .001). CONCLUSIONS: These findings do not support mediation of the depression-hyperglycemia relationship by diabetes self-care behavior. Other pathways, including psychophysiological mechanisms, should be investigated.

The association of depression and perceptions of interpersonal relationships in patients with diabetes.

OBJECTIVE: Using an instrument assessing interpersonal relationships in patients with diabetes, we hypothesized that a change in depression would be associated with a change in patients' perceptions of themselves and others in relationships. METHODS: Instruments assessing attachment, depression, and demographics were administered twice to 367 patients with diabetes in an HMO primary care setting, 10 months apart. We assessed change in capacity to rely on others (model of other) and to feel worthy of attention (model of self) according to depression change categories (unchanged, decreased, and increased depression). RESULTS: The degree to which patients reported being able to rely on others increased with a reduction in depressive symptoms (P = .02). The degree to which patients endorsed a sense that they were not worthy of attention in relationships increased with an increase in depressive symptoms (P = .02). CONCLUSION: A change in depressive symptoms is associated with a change in perception of interpersonal relationships in patients with diabetes.

Interpersonal predictors of HbA(1c) in patients with type 1 diabetes.

OBJECTIVE: Research suggests that increased collaboration and satisfaction in the patient-provider relationship is associated with better outcomes in patients with diabetes. In adults, an interpersonal style characterized by low trust of others and excessive self-reliance is known as "dismissing attachment style." We hypothesized that diabetic patients with dismissing attachment style, due to a decreased ability to collaborate with providers and others, would have significantly higher HbA(1c) levels than patients with secure attachment style. RESEARCH DESIGN AND METHODS: From 276 adult tertiary care patients with type 1 diabetes, we obtained mean HbA(1c) levels over the prior year and assessed patient attachment style, demographics, and clinical characteristics. We used chi(2) tests and logistic regression to determine whether attachment style was associated with HbA(1c) levels. RESULTS: We found that 62% of patients with dismissing attachment style had mean HbA(1c) levels >or=8% compared with 34% of patients with secure attachment style (P = 0.002). After adjusting for demographics, diabetes severity, medical comorbidity, and depression, dismissing attachment style remained significantly associated with HbA(1c) levels >or=8%, compared with secure attachment style (odds ratio 2.5, 95% CI 1.1-6.0). CONCLUSIONS: We have found that dismissing attachment style is associated with a higher risk for poor glycemic control. This has relevance from a population-based perspective because approximately 25% of the general population has a dismissing attachment style. Attachment style is easily measured using self-report instruments and may inform clinicians how to work with patients who are less engaged in the health care relationship.

Adult health status of women HMO members with posttraumatic stress disorder symptoms.

Posttraumatic stress disorder (PTSD) is associated with high numbers of self-reported physical symptoms and functional disability in clinical samples, but little is known about the magnitude of these associations in population samples and using actual physician-coded diagnoses. We administered a 22-page survey to 1225 female HMO enrollees randomly selected from the current membership of a large, staff model HMO in Seattle, Washington. Using the PTSD Checklist (internally validated against a subset of clinical interviews) we compared women with low, moderate, and high scores with respect to differences in self-reported physical health status, functional disability (36-item short form health survey), numbers and types of self-reported health risk behaviors, common physical symptoms, and physician-coded ICD-9 diagnoses. Compared to women with low PTSD symptom severity, those with moderate or high severity reported significantly higher functional disability (P<.001), rates of abuse and neglect (P<.01 to P<.001), health risk behavior scores (P<0.05), as well as higher mean numbers of common physical symptoms (P<.05). Compared to women with low PTSD symptom severity those with moderate or high severity had significantly higher adjusted odds ratios for aversive physical symptoms (range, 1.7-10.1). The mean number of physician-coded ICD-9 diagnoses was also significantly higher in the both the moderate and high severity groups. Among female HMO members, PTSD symptoms are associated with a wide range of both self-reported and physician-coded adverse physical health outcomes.

The relationship of depressive symptoms to symptom reporting, self-care and glucose control in diabetes.

Depressive symptoms are common among patients with diabetes and may have a significant impact on self-management and health outcomes. In this study we predicted that: 1) there would be a significant association between depressive symptoms and diabetes symptom burden, physical functioning, diabetes self-care, and HbA1c levels; and, 2) that the association between depressive symptoms and HbA1c levels would be significantly greater in type 1, as compared to type 2 diabetic patients. This cross-sectional observational study of 276 type 1 and 199 type 2 diabetes patients took place in a tertiary care specialty clinic. We collected self-reported data on depressive symptoms, complications, medical comorbidity, diabetes symptoms, diabetes self-care behaviors, physical functioning, and demographics. From automated data we determined mean HbA1c levels over the prior year. We performed linear regression analyses to assess the association between depressive symptoms and diabetes symptom perception, diabetes self-care behaviors, physical functioning, and glycemic control. Among patients with type 1 and 2 diabetes, depressive symptoms were associated with greater diabetes symptom reporting, poorer physical functioning, and less adherence to exercise regimens and diet. There was a significant association between depressive symptoms and HbA1c levels in type 1, but not type 2 diabetic patients. Because of their association with clinical aspects of diabetes care such as diabetes symptom reporting and adherence to diabetes self-care, depressive symptoms are important to recognize in treating patients with diabetes.

Development and evaluation of an interprofessional communication intervention to improve family outcomes in the ICU.

The intensive care unit (ICU), where death is common and even survivors of an ICU stay face the risk of long-term morbidity and re-admissions to the ICU, represents an important setting for improving communication about palliative and end-of-life care. Communication about the goals of care in this setting should be a high priority since studies suggest that the current quality of ICU communication is often poor and is associated with psychological distress among family members of critically ill patients. This paper describes the development and evaluation of an intervention designed to improve the quality of care in the ICU by improving communication among the ICU team and with family members of critically ill patients. We developed a multi-faceted, interprofessional intervention based on self-efficacy theory. The intervention involves a "communication facilitator" - a nurse or social worker - trained to facilitate communication among the interprofessional ICU team and with the critically ill patient's family. The facilitators are trained using three specific content areas: a) evidence-based approaches to improving clinician-family communication in the ICU, b) attachment theory allowing clinicians to adapt communication to meet individual family member's communication needs, and c) mediation to facilitate identification and resolution of conflict including clinician-family, clinician-clinician, and intra-family conflict. The outcomes assessed in this randomized trial focus on psychological distress among family members including anxiety, depression, and post-traumatic stress disorder at 3 and 6 months after the ICU stay. This manuscript also reports some of the lessons that we have learned early in this study.

Barriers to metabolic care for adults with serious mental illness: provider perspectives.

This study assessed barriers to metabolic care for persons with serious mental illness (SMI) by surveying experienced healthcare providers. Sixty-eight medical, mental health, and other stakeholders who care for patients with SMI attended a CME conference focused on medical management of SMI patients in 2007. They completed a 27-item survey assessing barriers to and systemic responsibility for metabolic care. The top three ranked barriers were: "separate mental health and primary care systems," "patient's lack of resources," and "[mental health] providers are not trained to do basic primary care." Results indicated that ratings of CMHC responsibility for SMI metabolic care (M = 5.2, SD = 1.5) were significantly lower than ratings of public health (M = 5.7, SD = 1.4), t(66) = 2.3, p = 0.027, and primary care providers (M = 6.3, SD = 1.1), t(67) = 4.7,p <0.001. Experienced providers identified a lack of integrated care and patient characteristics as important barriers to metabolic care and concluded that the primary care and public health systems are primarily responsible for metabolic treatment.

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.

Understanding why patients delay seeking care for acute coronary syndromes.

BACKGROUND: Better insight into the psychosocial factors associated with prehospital delays in seeking care for acute coronary syndromes is needed to inform the design of future interventions. Delay in presenting for care after the onset of symptoms is common, limits the potential benefit of acute reperfusion, and has not been reduced by interventions tested thus far. METHODS AND RESULTS: Seven hundred ninety-six patients with suspected ischemic heart disease scheduled for clinically indicated imaging stress tests completed questionnaires concerning psychological distress and attachment styles (worthiness to receive care, trustworthiness of others to provide care). The primary dependent variable for this study was response to a question from the rapid early action for coronary treatment trial concerning intention to "wait until very sure" before seeking care for a possible "heart attack." Responses to this question were strongly associated with actual emergency department-reported and self-reported care delay in the rapid early action for coronary treatment trial. In multivariable ordinal regression models, a more negative view of the trustworthiness of others, greater physical limitations from angina, and no previous revascularization were independently associated with increased intention to wait to seek care for a myocardial infarction. Intention to wait was not associated with inducible ischemia or self-perceived risk of myocardial infarction. CONCLUSIONS: Intention to delay seeking care for acute coronary syndromes is associated with a patient's view of the trustworthiness of others, previous experience with revascularization, and functional limitations, even after adjustment for objective and perceived acute coronary syndromes risk. These findings provide insight into novel factors contributing to longer delay times and may inform future interventions to reduce delay time.

Long-term effects on medical costs of improving depression outcomes in patients with depression and diabetes.

OBJECTIVE: The purpose of this study was to examine the 5-year effects on total health care costs of the Pathways depression intervention program for patients with diabetes and comorbid depression compared with usual primary care. RESEARCH DESIGN AND METHODS: The Pathways Study was conducted in nine primary care practices of a large HMO and enrolled 329 patients with diabetes and comorbid major depression. The current study analyzed the differences in long-term medical costs between intervention and usual care patients. Participants were randomly assigned to a nurse depression intervention (n = 164) or to usual primary care (n = 165). The intervention included education about depression, behavioral activation, and a choice of either starting with support of antidepressant medication treatment by the primary care doctor or problem-solving therapy in primary care. Interventions were provided for up to 12 months, and the main outcome measures are health costs over a 5-year period. RESULTS: Patients in the intervention arm of the study had improved depression outcomes and trends for reduced 5-year mean total medical costs of -$3,907 (95% CI -$15,454 less to $7,640 more) compared with usual care patients. A sensitivity analysis found that these cost differences were largely explained by the patients with depression and the most severe medical comorbidity. CONCLUSIONS: The Pathways depression collaborative care program improved depression outcomes compared with usual care with no evidence of greater long-term costs and with trends for reduced costs among the more severely medically ill patients with diabetes.

Angina pectoris during daily activities and exercise stress testing: The role of inducible myocardial ischemia and psychological distress.

Physicians often consider angina pectoris to be synonymous with myocardial ischemia. However, the relationship between angina and myocardial ischemia is highly variable and we have little insight into the sources of this variability. We investigated the relationship of inducible myocardial ischemia on SPECT stress perfusion imaging to angina reported with routine daily activities during the previous four weeks (N=788) and to angina reported during an exercise stress test (N=371) in individuals with confirmed or suspected coronary disease referred for clinical testing. We found that angina experienced during daily life is more strongly and consistently associated with psychological distress and the personal threat associated with angina than with inducible myocardial ischemia. In multivariable models, the presence of any angina during routine activities over the prior month was significantly associated with age, perceived risk of myocardial infarction, and anxiety when compared to those with no reported angina in the past month. Angina during daily life was not significantly associated with inducible myocardial ischemia on stress perfusion imaging in bivariate or multivariable models. In contrast, angina experienced during exercise stress testing was significantly related to image and ECG ischemia, though it was also significantly associated with anxiety. These results suggest that angina frequency over the previous four weeks is more strongly associated with personal threat and psychosocial distress than with inducible myocardial ischemia. These results lend support to angina treatment strategies that aim to reduce threat and distress as well as to reduce myocardial ischemia.

Efficacy of sertraline in prevention of depression recurrence in older versus younger adults with diabetes.

OBJECTIVE: Sertraline maintenance therapy effectively delays recurrence of major depressive disorder in adult diabetic patients when data are examined across all age-groups. A secondary analysis was performed to assess this effect in younger and older subsets of patients. RESEARCH DESIGN AND METHODS: Younger (aged <55 years, n = 85) and older (aged > or =55 years, n = 67) subsets were identified from a multicenter, double-blind, placebo-controlled, maintenance treatment trial of sertraline in diabetic participants who achieved depression recovery with open-label sertraline treatment. Cox proportional hazards models were used to determine differences in time to depression recurrence between treatment arms (sertraline or placebo) for each age subset and between age subsets for each treatment. RESULTS: In younger subjects, sertraline conferred significantly greater prophylaxis against depression recurrence than placebo (hazard ratio 0.37 [95% CI 0.20-0.71]; P = 0.003). Benefits of sertraline maintenance therapy were lost in older participants (0.94 [0.39-2.29]; P = 0.89). There was no difference in time to recurrence for sertraline-treated subjects between age subsets (P = 0.65), but older subjects had a significantly longer time to recurrence on placebo than younger subjects (P = 0.03). CONCLUSIONS: While sertraline significantly increased the time to depression recurrence in the younger diabetic participants, there was no treatment effect in those aged > or =55 years because of a high placebo response rate. Further research is necessary to determine the mechanisms responsible for this effect and whether depression maintenance strategies specific for older patients with diabetes should be developed.

The association of patient relationship style and outcomes in collaborative care treatment for depression in patients with diabetes.

PURPOSE: We sought to determine whether relationship style in patients with diabetes receiving depression treatment is associated with differential quality of care and depression outcomes. METHODS: From 9 health maintenance organization clinics, 324 primary care patients with diabetes and comorbid major depression and/or dysthymia participated in the Pathways randomized controlled trial of collaborative care for depression (n = 160) versus usual care (n = 164). The intervention provided outreach, enhanced support of antidepressant medication use, and problem-solving treatment delivered by nurse case managers. Using attachment theory principles, we categorized patients as having an independent (n = 190) or interactive (n = 134) relationship style. We assessed whether patient relationship style moderated treatment group differences in quality of care and depression outcomes. RESULTS: Among independent relationship style patients, the intervention resulted in significantly greater satisfaction with depression care in the first 6 months and 47 more depression-free days (P < 0.0003) based on the Hopkins Symptom Checklist at 12 months, compared with usual care. There were no significant treatment group differences in satisfaction with care or depression outcomes among patients with interactive relationship style. Among patients receiving the intervention, those with an independent relationship style received significantly more problem-solving treatment sessions as compared with patients with an interactive relationship style. CONCLUSION: Among depressed patients with diabetes, the Pathways collaborative care intervention improved quality of care for depression compared with usual care in both relationship style groups but was associated with significantly better depressive outcomes and greater satisfaction with care compared with usual care in patients with independent but not interactive relationship style.