Heather F. de Vries

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 (HbA1c) 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 HbA1c 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.

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.

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.

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.

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 (

Depression, Cognition, Apolipoprotein E Genotype: Latent Class Approach to Identifying Subtype

32,676), and second highest for the HF only group (

Disparity in Use of Psychotherapy Offered in Primary Care Between Older African-American and White Adults: Results from a Practice-Based Depression Intervention Trial

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.

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

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 Associations 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.

CHRONIC MEDICAL CONDITIONS AND REPRODUCIBILITY OF SELF-REPORTED AGE AT MENOPAUSE AMONG COMMUNITY DWELLING WOMEN

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, ≥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.

How Employment Helps Female Victims of Intimate Partner Violence: A Qualitative Study

ObjectiveThe 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. MethodsThe 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. ResultsAmong 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. ConclusionsPostmenopausal 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.