Paul Ciechanowski

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 patients 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.).

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.

IMPACT OF MAJOR DEPRESSION ON CHRONIC MEDICAL ILLNESS

The study by Walker et al. 111 emphasizes the profound impact that current depressive and anxiety disorders may have in patients with chronic medical illness. Walker et al. found that patients with inflammatory bowel disease (IBD) and current DSM-III-R depressive and anxiety disorders, compared with patients with IBD without current psychiatric illness, suffered from significantly more gastrointestinal symptoms, nongastrointestinal medically unexplained symptoms such as headache or dizziness, and perceived themselves as significantly more disabled by their emotional symptoms, controlling for severity of inflammatory bowel disease. This editorial will initially review the expanding research database that has shown that patients with acute medical illness have a high incidence rate of major depression and patients with chronic medical illness have a high prevalence rate of comorbid major depression. Evidence will also be reviewed which shows that patients with comorbid affective disorder and chronic medical illness have 1) increased ambulatory visits and medical costs; 2) increased functional impairment and decreased quality of life; 3) increased somatic symptoms and problems habituating to chronic aversive symptoms of medical illness; 4) more problems following self-care regimens (such as adherence to medications, diet, and quitting smoking); and 5) increased rates of mortality.

Depression and Advanced Complications of Diabetes A prospective cohort study

OBJECTIVE To prospectively examine the association of depression with risks for advanced macrovascular and microvascular complications among patients with type 2 diabetes. RESEARCH DESIGN AND METHODS A 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. RESULTS After 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]). CONCLUSIONS Among 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.

Depression, fatigue, and functional disability in patients with chronic hepatitis C

OBJECTIVE To examine the extent to which fatigue and functional disability correlate with severity of depressive symptoms in patients with chronic hepatitis C. METHODS Fifty patients with chronic hepatitis C were evaluated using structured psychiatric interviews and standardized rating instruments. RESULTS Fourteen (28%) of patients had current depressive disorders. Depressed and nondepressed patients did not differ with regard to demographics or hepatic disease severity. Severity of depressive symptoms was highly correlated with fatigue severity while measures of hepatic disease severity, interferon treatment, and severity of comorbid medical illness were not. Severity of depressive symptoms was associated with functional disability and somatization. CONCLUSIONS Disability and fatigue are more closely related to depression severity than to hepatic disease severity. Antidepressant treatment trials in patients with hepatitis C are indicated to determine whether improvement in depressive symptoms leads to improvement in fatigue and functioning.

The relationship of attachment style to depression, catastrophizing and health care utilization in patients with chronic pain

Attachment theory and research suggest that patterns of interpersonal relationships may be important determinants of illness behavior, care seeking, and treatment response in individuals with chronic health problems, including chronic pain. Attachment styles have been shown to be associated with psychological adjustment in the context of chronic illness, but little research has been conducted so far examining these relationships in patients with chronic pain. We assessed 111 patients with chronic pain participating in a multidisciplinary pain treatment program to determine if attachment style is associated with pain, depression, catastrophizing and physical disability at pre‐treatment and 12‐month follow‐up, and with change in health care utilization pre‐treatment to follow‐up. At both pre‐treatment and follow‐up, fearful attachment style was associated with significantly greater depression and catastrophizing, and secure attachment was associated with significantly lower levels of depression. Preoccupied attachment style was associated with greater than weekly pain‐related visits at 12 months follow‐up, even after controlling for depression, catastrophizing and pre‐treatment pain‐related health care utilization. The findings suggest that attachment style may be a useful construct for examining factors affecting adjustment and treatment response of patients with chronic pain.

Cost-effectiveness of a Multicondition Collaborative Care Intervention: A Randomized Controlled Trial

CONTEXT Patients with depression and poorly controlled diabetes mellitus, coronary heart disease (CHD), or both have higher medical complication rates and higher health care costs, suggesting that more effective care management of psychiatric and medical disease control might also reduce medical service use and enhance quality of life. OBJECTIVE To evaluate the cost-effectiveness of a multicondition collaborative treatment program (TEAMcare) compared with usual primary care (UC) in outpatients with depression and poorly controlled diabetes or CHD. DESIGN Randomized controlled trial of a systematic care management program aimed at improving depression scores and hemoglobin A(1c) (HbA(1c)), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) levels. SETTING Fourteen primary care clinics of an integrated health care system. PATIENTS Population-based screening identified 214 adults with depressive disorder and poorly controlled diabetes or CHD. INTERVENTION Physician-supervised nurses collaborated with primary care physicians to provide treatment of multiple disease risk factors. MAIN OUTCOME MEASURES Blinded assessments evaluated depressive symptoms, SBP, and HbA(1c) at baseline and at 6, 12, 18, and 24 months. Fasting LDL-C concentration was assessed at baseline and at 12 and 24 months. Health plan accounting records were used to assess medical service costs. Quality-adjusted life-years (QALYs) were assessed using a previously developed regression model based on intervention vs UC differences in HbA(1c), LDL-C, and SBP levels over 24 months. RESULTS Over 24 months, compared with UC controls, intervention patients had a mean of 114 (95% CI, 79 to 149) additional depression-free days and an estimated 0.335 (95% CI, -0.18 to 0.85) additional QALYs. Intervention patients also had lower mean outpatient health costs of

Depression and Increased Mortality in Diabetes: Unexpected Causes of Death

594 per patient (95% CI, -

Quality of Depression Care in a Population-based Sample of Patients With Diabetes and Major Depression

3241 to

Validation of the PTSD checklist in an HMO sample of women

2053) relative to UC patients. CONCLUSIONS For adults with depression and poorly controlled diabetes, CHD, or both, a systematic intervention program aimed at improving depression scores and HbA(1c), SBP, and LDL-C levels seemed to be a high-value program that for no or modest additional cost markedly improved QALYs. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00468676