A nurse-directed, multidisciplinary intervention can improve quality of life and reduce hospital use and medical costs for elderly patients with congestive heart failure.

Hyperglycemia has been linked to the development of diabetic complications (1). Treatments that lower blood glucose levels reduce the risks of retinopathy, neuropathy, and nephropathy in patients with type 1 (2,3) or type 2 (4,5) diabetes. Accordingly, maintenance of good glycemic control is the focus of diabetes therapy, and the importance of other clinical factors is judged largely in relation to their effects on this parameter.Clinical and subclinical expressions of depression are present in Ͼ25% of patients with type 1 or type 2 diabetes (6-14) and have adverse effects on functioning and quality of life (15,16). The existing literature is not consistent and clear with regard to the association between depression and poor glycemic control. Such an association would suggest the possibility that depression treatment might have favorable effects on diabetic outcomes. We surveyed the scientific literature, identified studies that measured the association of depression (either by symptoms or the diagnosis) with glycemic control, and performed a metaanalysis to assess the reliability and strength of any association. RESEARCH DESIGN ANDMETHODS -Medline and PsycINFO were used to locate studies published in the last 25 years that reported the association of depression with glycemic control in adult diabetic subjects. The reference lists of these articles were examined to identify additional studies, and this led to the consideration of several unpublished papers and manuscripts. Inclusion and exclusion criteriaStudies were limited to adult participants (Ն18 years of age), to those that assessed glycemic control using a measure of glycohemoglobin (denoted as GHb within this article) (17,18), and to those that measured depression and GHb coincident to the study evaluation. Studies with Ͻ25 patients, those neither published nor available in English, and those that ascertained only a history of depression were excluded. Subjects in the included studies were patients diagnosed with type 1 or type 2 diabetes; studies of subjects with impaired glucose tolerance, borderline diabetes, or gestational diabetes were not considered. Studies were included without regard to the way the depression-glycemic control association was tested. In some studies, depression was the independent variable and glycemic control the dependent variable. Other studies used the reverse approach, and some reported only the correlation between the 2 variables.Study procedures and statistical analysis Study characteristics were recorded, and the studies were categorized by methodology. Type of diabetes and method of depression assessment were recorded, and effect sizes (ESs) were examined in relation to these factors. The diagnosis of depression (major depressive disorder) was established by using structured or semistructured clinical interviews and the diagnostic criteria in use at the time of the study (e.g., American Psychiatric Association' s Diagnostic and Statistical Manual of Mental Disorders [19,20] Depression and Poor Glycemic ControlA meta-an...

Despite the heterogeneity of published studies included in this review, the preponderance of evidence supports the recommendation that the American Heart Association should elevate depression to the status of a risk factor for adverse medical outcomes in patients with acute coronary syndrome.

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Context Depressive symptoms predict adverse cardiovascular outcomes in patients with coronary heart disease, but the mechanisms responsible for this association are unknown. Objective To determine why depressive symptoms are associated with an increased risk of cardiovascular events. Design and Participants The Heart and Soul Study is a prospective cohort study of 1017 outpatients with stable coronary heart disease followed up for a mean (SD) of 4.8 (1.4) years. Setting Participants were recruited between September 11, 2000, and December 20, 2002, from 12 outpatient clinics in the San Francisco Bay Area and were followed up to January 12, 2008. Main Outcome Measures Baseline depressive symptoms were assessed using the Patient Health Questionnaire (PHQ). We used proportional hazards models to evaluate the extent to which the association of depressive symptoms with subsequent cardiovascular events (heart failure, myocardial infarction, stroke, transient ischemic attack, or death) was explained by baseline disease severity and potential biological or behavioral mediators. Results A total of 341 cardiovascular events occurred during 4876 person-years of follow-up. The age-adjusted annual rate of cardiovascular events was 10.0% among the 199 participants with depressive symptoms (PHQ score ≥10) and 6.7% among the 818 participants without depressive symptoms (hazard ratio [HR], 1.50; 95% confidence interval, [CI], 1.16–1.95; P=.002). After adjustment for comorbid conditions and disease severity, depressive symptoms were associated with a 31% higher rate of cardiovascular events (HR, 1.31; 95% CI, 1.00–1.71; P=.04). Additional adjustment for potential biological mediators attenuated this association (HR, 1.24; 95% CI, 0.94–1.63; P=.12). After further adjustment for potential behavioral mediators, including physical inactivity, there was no significant association (HR, 1.05; 95% CI, 0.79–1.40; P=.75). Conclusion In this sample of outpatients with coronary heart disease, the association between depressive symptoms and adverse cardiovascular events was largely explained by behavioral factors, particularly physical inactivity.