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.)

OBJECTIVE -We assessed whether diabetes self-care, medication adherence, and use of preventive services were associated with depressive illness. RESEARCH DESIGN AND METHODS -In a large health maintenance organization, 4,463 patients with diabetes completed a questionnaire assessing self-care, diabetes monitoring, and depression. Automated diagnostic, laboratory, and pharmacy data were used to assess glycemic control, medication adherence, and preventive services.RESULTS -This predominantly type 2 diabetic population had a mean HbA 1c level of 7.8 Ϯ 1.6%. Three-quarters of the patients received hypoglycemic agents (oral or insulin) and reported at least weekly self-monitoring of glucose and foot checks. The mean number of HbA 1c tests was 2.2 Ϯ 1.3 per year and was only slightly higher among patients with poorly controlled diabetes. Almost one-half (48.9%) had a BMI Ͼ30 kg/m 2 , and 47.8% of patients exercised once a week or less. Pharmacy refill data showed a 19.5% nonadherence rate to oral hypoglycemic medicines (mean 67.4 Ϯ 74.1 days) in the prior year. Major depression was associated with less physical activity, unhealthy diet, and lower adherence to oral hypoglycemic, antihypertensive, and lipidlowering medications. In contrast, preventive care of diabetes, including home-glucose tests, foot checks, screening for microalbuminuria, and retinopathy was similar among depressed and nondepressed patients.CONCLUSIONS -In a primary care population, diabetes self-care was suboptimal across a continuum from home-based activities, such as healthy eating, exercise, and medication adherence, to use of preventive care. Major depression was mainly associated with patient-initiated behaviors that are difficult to maintain (e.g., exercise, diet, medication adherence) but not with preventive services for diabetes. Diabetes Care 27:2154 -2160, 2004T he World Health Organization estimates that at least 170 million individuals suffer from diabetes globally, and this figure is likely to double by 2030 (1). Diabetes-related complications are major causes of morbidity and mortality. Optimal outcomes in diabetes require diligent and daily self-management, including eating a healthy diet, exercising, and regular glucose monitoring (2-4). The American Diabetes Association publishes standards of medical care yearly to promote the importance of achieving optimal glycemic control (HbA 1c Ͻ7%) (2). Comprehensive treatment includes lifestyle modifications; pharmacological control of hyperglycemia, hypertension, and hyperlipidemia; and preventive care such as monitoring for glycemic control or retinopathy. Depression not only affects mood but compromises functioning as well (5,6). Among diabetic patients, depression is twice as common as compared with matched control subjects without diabetes (7,8). When depression accompanies diabetes, there is evidence of poorer glycemic control, decreased physical activity, higher obesity, and potentially more diabetes end-organ complications and impaired function (9 -14). There is also evidence that de...

OBJECTIVE -We assessed whether patients with comorbid minor and major depression and type 2 diabetes had a higher mortality rate over a 3-year period compared with patients with diabetes alone.RESEARCH DESIGN AND METHODS -In a large health maintenance organization (HMO), 4,154 patients with type 2 diabetes were surveyed and followed for up to 3 years. Patients initially filled out a written questionnaire, and HMO-automated diagnostic, laboratory, and pharmacy data and Washington State mortality data were collected to assess diabetes complications and deaths. Cox proportional hazards regression models were used to calculate adjusted hazard ratios of death for each group compared with the reference group.RESULTS -There were 275 (8.3%) deaths in 3,303 patients without depression compared with 48 (13.6%) deaths in 354 patients with minor depression and 59 (11.9%) deaths among 497 patients with major depression. A proportional hazards model with adjustment for age, sex, race/ethnicity, and educational attainment found that compared with the nondepressed group, minor depression was associated with a 1.67-fold increase in mortality (P ϭ 0.003), and major depression was associated with a 2.30-fold increase (P Ͻ 0.0001). In a second model that controlled for multiple potential mediators, both minor and major depression remained significant predictors of mortality.CONCLUSIONS -Among patients with diabetes, both minor and major depression are strongly associated with increased mortality. Further research will be necessary to disentangle causal relationships among depression, behavioral risk factors (adherence to medical regimens), diabetes complications, and mortality. Diabetes Care 28:2668 -2672, 2005P atients with type 2 diabetes have a high prevalence of affective illness, with ϳ11-15% meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for major depression (1). Major depression has been found to be a chronic or recurrent illness in most patients with type 2 diabetes (2). As many as two-thirds of patients with diabetes and major depression have been ill with depression for Ն2 years (2). Over a 5-year period, ϳ80% of patients with major depression and diabetes were found to have had one or more relapses (3).Compared with patients with diabetes alone, patients with depression and diabetes have been shown to have poorer self-management (i.e., following diet, exercise regimens, and checking blood glucose) (4,5) and to have significantly more lapses in refilling oral hypoglycemic, lipid-lowering, and antihypertensive medications (4). Depressed patients with diabetes are also significantly more likely to have three or more cardiac risk factors (i.e., smoking, obesity, sedentary lifestyle, HbA 1c [AIC] Ͼ8.0%) compared with those with diabetes alone (6).A meta-analysis of 27 cross-sectional studies showed that patients with depression and diabetes were significantly more likely to have macrovascular and microvascular complications (7). This association between complications and depression ...

OBJECTIVETo prospectively examine the association of depression with risks for advanced macrovascular and microvascular complications among patients with type 2 diabetes.RESEARCH DESIGN AND METHODSA longitudinal cohort of 4,623 primary care patients with type 2 diabetes was enrolled in 2000–2002 and followed through 2005–2007. Advanced microvascular complications included blindness, end-stage renal disease, amputations, and renal failure deaths. Advanced macrovascular complications included myocardial infarction, stroke, cardiovascular procedures, and deaths. Medical record review, ICD-9 diagnostic and procedural codes, and death certificate data were used to ascertain outcomes in the 5-year follow-up. Proportional hazard models analyzed the association between baseline depression and risks of adverse outcomes.RESULTSAfter adjustment for prior complications and demographic, clinical, and diabetes self-care variables, major depression was associated with significantly higher risks of adverse microvascular outcomes (hazard ratio 1.36 [95% CI 1.05–1.75]) and adverse macrovascular outcomes (1.24 [1.0–1.54]).CONCLUSIONSAmong people with type 2 diabetes, major depression is associated with an increased risk of clinically significant microvascular and macrovascular complications over the ensuing 5 years, even after adjusting for diabetes severity and self-care activities. Clinical and public health significance of these findings rises as the incidence of type 2 diabetes soars. Further research is needed to clarify the underlying mechanisms for this association and to test interventions to reduce the risk of diabetes complications among patients with comorbid depression.

Dismissing attachment in the setting of poor patient-provider communication is associated with poorer treatment adherence in patients with diabetes.