Depressive symptoms moderated the effect of chronic illness self-management training on self-efficacy

Assessing the Effect of Cancer Diagnosis on Beliefs about Comorbid Diabetes

OBJECTIVES

Increasingly, patients diagnosed with cancer also live with chronic comorbidities, and it is important to understand the impact of a new cancer diagnosis on perceptions about preexisting conditions. This study assessed the effect of cancer diagnosis on beliefs about comorbid diabetes mellitus and assessed changes in beliefs about cancer and diabetes over time.

DATA SOURCES

We recruited 75 patients with type 2 diabetes who were newly diagnosed with early-stage breast, prostate, lung, or colorectal cancer and 104 age-, sex-, and hemoglobin A1c-matched controls. Participants completed the Brief Illness Perception Questionnaire four times over 12 months. The authors examined within-patient and between-group differences in cancer and diabetes beliefs at baseline and over time.

RESULTS

Overall, diabetes beliefs did not differ between cancer patients and controls at baseline. Cancer patients' beliefs about diabetes varied significantly over time; they reported less concern about cancer, less emotional effect, and greater cancer knowledge over time. Participants without cancer were significantly more likely to report that diabetes affected their life across all time points, though this effect did not persist after adjustment for sociodemographic variables.

CONCLUSION

While all patients' diabetes beliefs were similar at baseline and 12 months, cancer patients' beliefs about both illnesses fluctuated during the months following cancer diagnosis.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses can play a key role in recognizing the effects of cancer diagnosis on beliefs about comorbid conditions and fluctuations in these beliefs during treatment. Assessing and communicating patient beliefs between oncology and other practitioners could produce more effective care plans based on patients' current outlook on their health.

Health-promoting behavior to enhance perceived meaning and control of life in chronic disease patients with role limitations and depressive symptoms: a network approach

The association between health-related role limitations in the mental and physical subdomains and clinical status (i.e., chronic disease and comorbid depressive symptoms) is mediated by health-promoting behaviors. To enhance health-promoting behaviors in adults with chronic disease, it is necessary to identify item-level associations among targets of health-related monitoring and management. Therefore, the current study used a network approach to examine associations among health-related role limitations, depressive symptoms, existential well-being, socioeconomic position, and health-promoting behavior in adults with chronic disease. A total of 535 adults (mean ± SD age = 62.9 ± 11.9 years; males, n = 231, females, n = 304) who were regularly visiting an outpatient clinic for chronic disease treatment participated in this cross-sectional study. Data on participant demographics, chronic disease diagnoses, socioeconomic status, health-related role limitations (12-item short form survey scores), depressive symptoms (patient health questionnaire-9 scores), existential well-being (scores for four items of the McGill quality of life questionnaire-Revised), and health-promoting behavior (Healthy Habits Questionnaire scores) were acquired. "Undirected regularized partial correlations" and "directional joint probability distributions" among these variables were calculated using a mixed graphical model (MGM) and directed acyclic graph (DAG). In the MGM, the most influential nodes were emotional well-being, feelings of failure, and health-related limitations affecting usual role and physical activities. According to both the MGM and DAG, the relationship between emotional well-being and feelings of failure mediated the relationships of health-related role limitations with concentration difficulty and suicidal ideation. A positive mindset was dependent on the probability distributions of suicidal ideation, controllability of life, and positive self-image. Both the meaning of life and a positive mindset had direct associations with proactive living. Specifically, proactive living was associated with a balanced diet, regular exercise, volunteering in the community, and nurturing intimacy in social interactions. The meaning and controllability of life in individuals with chronic diseases could mediate the relationships of health-promoting behavior with health-related limitations related to usual role activities, physical activities, and depressive symptoms. Thus, interventions targeting health-promoting behaviors should aim to enhance the meaning and controllability of life (as it pertains to limitations in usual role and physical activities), as well as promote proactive screening and timely psychiatric treatment of depressive symptoms including feelings of failure, concentration difficulties, and suicidal ideation.

A longitudinal study on the changes in the self‐efficacy of breast cancer patients during adjuvant chemotherapy

AIM

We aimed to investigate the changes in the self-efficacy of patients with breast cancer (BC) during adjuvant chemotherapy.

DESIGN

A longitudinal study was conducted.

METHODS

One hundred thirty patients with BC who underwent postoperative adjuvant chemotherapy at a medical centre in northern Taiwan were evaluated using self-efficacy survey tools before the first (T1), second (T2) and last (T3) cycles of adjuvant chemotherapy. The independent t-test, Kruskal-Wallis test, one-way analysis of variance, Pearson's correlation coefficient and generalized estimating equation were used for data analysis.

RESULTS

The self-efficacy measures of patients with BC were significantly higher at both T2 and T3 than at T1 (p < 0.001). Religious beliefs and changes in self-efficacy showed a significant correlation (p = 0.04). These findings will facilitate timely interventional measures to improve self-efficacy in patients with maladaptive behaviours, alleviate psychological distress and reduce the risk of future disease recurrence.

Experience of depression in older adults with and without a physical long-term condition: findings from a qualitative interview study

OBJECTIVE

To understand how the lived experience of depression differs among patients with a long-term condition (LTC) compared with those without an LTC, and how the experience differs across different types of LTC.

DESIGN

Face-to-face, semistructured interviews.

SETTING

Primary care; General Practitioner (GP) surgeries in and around North London.

PARTICIPANTS

41 primary care patients with depression were recruited. Our sample comprised participants aged 55-75 years with depression only (n=12), depression and coronary heart disease (n=5), depression and type 2 diabetes (n=10) and depression and arthritis (n=14).

RESULTS

Interviews were conducted, audio recorded, transcribed and analysed using thematic analysis. The results revealed that the cardinal diagnostic symptoms of depression (anhedonia, sadness) were experienced by all our participants regardless of LTC. However, the LTC did interact with depression by compounding somatic, cognitive and emotional symptoms, increasing disability and reducing independence, and hindering attempts at coping with mental illness. Our findings demonstrate common experiences across patients as well as key differences based on LTC.

CONCLUSIONS

We suggest four key implications for future care practices of these patients: (1) not all participants with depression and LTC view their mental and physical health as interconnected; there should be allowances in care plans for separate treatment pathways; (2) key features of depression that affect LTC management are social withdrawal and lack of motivation to self-manage or access healthcare; (3) key features of LTCs that worsen depression are pain, the unpredictability of future health and progressive disability; (4) positive self-management of LTC could improve self-efficacy and therefore mood, and should be encouraged.

Cross-sectional study of the effects of self-efficacy on fatigue and pain interference in black women with systemic lupus erythematosus: the role of depression, age and education

Objective

While fatigue and pain are pervasive symptoms in SLE, self-efficacy can mitigate their intensity and impact on patients’ daily activity. We examined the relationships of these domains and their interactions with demographics and depression in black women with SLE.

Methods

This is a cross-sectional analysis of data collected among 699 black women with SLE. We used validated, self-reported measures of fatigue, pain interference, symptom self-efficacy, treatment self-efficacy and depression. Linear regression analyses were conducted to examine the relationships between each outcome (fatigue and pain interference) and each predictor (symptom self-efficacy and treatment self-efficacy), and the interaction of demographics and depression.

Results

We found inverse associations between fatigue and each of symptom self-efficacy (slope −0.556, p<0.001) and treatment self-efficacy (slope −0.282, p<0.001), as well as between pain interference and each of symptom self-efficacy (slope −0.394, p<0.001) and treatment self-efficacy (slope −0.152, p<0.001). After adjusting for confounders, symptom self-efficacy remained significantly associated with each outcome (adjusted slope −0.241 (p<0.001) and −0.103 (p=0.008) for fatigue and pain, respectively). The amount of decrease in fatigue and pain interference differed by depression severity (p<0.05 for the interaction of symptom self-efficacy and depression). The difference in fatigue by depression widened as symptom self-efficacy increased; the adjusted fatigue scores for moderate/severe depression compared with no depression were 6.8 and 8.7 points higher at mean and high symptom self-efficacy, respectively (p<0.001). Age and education significantly changed the relationship between outcomes and self-efficacy.

Conclusions

Symptom self-efficacy and treatment self-efficacy were inversely related to fatigue and pain interference in black women with SLE. Depression disproportionately increased the intensity of these outcomes. While older women with low symptom self-efficacy reported disproportionately higher pain interference, those with higher education and mean or high levels of symptom self-efficacy reported lower pain interference. These findings may help predict who might benefit most from self-efficacy-enhancing interventions.

Adults with type 2 diabetes benefit from self-management support intervention regardless of depressive symptoms

AIMS

Elevated depressive symptoms are common among adults with type 2 diabetes (T2D). In a secondary analysis from an RCT of a diabetes self-management support intervention that did not target depressive symptoms, we sought to determine if depressive symptoms were reduced by the intervention (i.e., depressive symptoms an outcome) or, alternatively, if intervention effects on hemoglobin A1c were lesser among persons with clinically elevated depressive symptoms (i.e., depressive symptoms an effect modifier).

METHODS

We evaluated a text messaging intervention, REACH, in a diverse (half non-white, half underinsured) sample of N = 506 adults with T2D. Participants completed the Patient Health Questionnaire-8 (PHQ) and A1c tests at baseline and 6 months. We conducted a factor analysis to identify somatic- and cognitive-affective symptoms on the PHQ. We tested our hypotheses with regression models, using interaction terms and subgroup analyses.

RESULTS

REACH improved depressive symptoms among participants with lower baseline A1c (<8.5%; β = -0.133, p = .007; cognitive β = -0.107, p = .038; somatic β = -0.131, p = .014) but not among participants with higher baseline A1c (≥8.5%; β = 0.040, p = .468). Baseline depressive symptoms did not modify the effect on A1c.

CONCLUSIONS

We found support for the hypothesis that depressive symptoms - both somatic- and cognitive-affective - may be an outcome, rather than an effect modifier, of effective diabetes self-management support interventions.

Improving Diabetes Management in Emerging Adulthood: An Intervention Development Study Using the Multiphase Optimization Strategy

Background

Poor diabetes self-management in emerging adulthood (age 18-25 years) is associated with poorer diabetes health and diabetes complications. Emerging adults’ focus on individuation and independence underlies their poor diabetes outcomes, offering a lever for behavior change. Self-determination theory (SDT) suggests that interventions leveraging emerging adults’ innate developmental need for autonomy may offer a route to improving diabetes outcomes by increasing feelings of responsibility for and control over diabetes self-management activities.

Objective

This research project will use the multiphase optimization strategy to test the efficacy of three autonomy-supportive intervention components to elicit a clinically significant improvement in metabolic control, assessed by a 0.5% improvement in hemoglobin A_1c (HbA_1c), among older adolescents and emerging adults (16-25 years) with poorly controlled type 1 diabetes (T1D; HbA_1c≥9.0%).

Methods

A question prompt list (QPL) is a tool to empower patients to assume a more active role during medical visits by asking questions and stating concerns. The motivation enhancement system (MES) is a brief counseling intervention that uses motivational interviewing communication strategies to build intrinsic motivation and self-efficacy for self-management. Text message reminders to complete diabetes care tasks may increase self-efficacy for diabetes self-management. After refining these intervention components for emerging adults, we will conduct a component selection experiment using an eight-arm full factorial design: 2 (QPL yes or no)×2 (MES yes or no)×2 (Text yes or no). Participants will complete 3 study visits: baseline, treatment end at 2 months, and a follow-up at 6 months. The primary outcome is metabolic control, which will be measured via HbA_1c. Secondary outcomes include diabetes management and diabetes clinic attendance. SDT constructs of intrinsic motivation, self-efficacy, and the quality of the patient-provider relationship (ie, relatedness) are hypothesized mediators. Depression symptoms and emerging adults’ gender are hypothesized moderators. We will use the mixed-effects linear model for the analysis of variance of a factorial design to analyze continuous longitudinal experimental data; the generalized linear model will be used with categorical outcomes (eg, treatment attendance). The experiment was powered to detect the main effects of the intervention on the primary outcome.

Results

A total of 20 participants have enrolled and completed a qualitative interview after reviewing one or more intervention components. Analysis of interview data are underway, with a report of these results anticipated in the fall of 2020. The clinical trial will be launched in the fall 2020, with participants enrolled through May 2023 and data collection continuing through November 2023.

Conclusions

At the end of this experiment, we will have empirical evidence to support a large-scale, multisite effectiveness trial of an intervention package that has been optimized for older adolescents and emerging adults with poorly controlled T1D.

Trial Registration

ClinicalTrials.gov NCT04066959; https://clinicaltrials.gov/ct2/show/NCT04066959

International Registered Report Identifier (IRRID)

DERR1-10.2196/20191

Depression but not frailty contributed to a higher risk for all-cause hospitalizations in male older veterans

INTRODUCTION

Frailty is a state of vulnerability to stressors resulting in higher morbidity, mortality, and utilization in older adults. Depression and frailty often coexist, suggesting a bidirectional relationship that may increase the effects of each individual condition on clinical outcomes and health-care utilization in older adults.

OBJECTIVE

To determine the effects of concurrent frailty and depression on all-cause hospitalizations.

METHODS/DESIGN

Prospective cohort study, conducted at a Veterans Affairs (VA) Medical Center. The participants were male, community-dwelling veterans 65 years and older. From 4 January through 30 December 2016, a 46-item frailty index was generated from data obtained from the VA electronic health record. Trained staff conducted in-depth reviews of electronic health records ascertaining depression status. Patients were followed through 31 December 2017 for all-cause hospitalizations following the initial assessment of frailty. After adjusting for covariates, the association of frailty and depression with all-cause hospitalizations was determined with the Andersen-Gill model, accounting for repeated hospitalizations.

RESULTS

Five hundred fifty-three male patients were part of the study, mean age 76.3 (SD = 8.2) years. One hundred eighty-one patients (32.7%) had depression diagnoses. During a median follow-up period of 530 days (interquartile range [IQR] = 245), 123 patients (22.2%) had 240 hospitalizations. Frailty status was not associated with future hospitalizations (adjusted hazard ratio [HR] = 1.61; 95% CI, 95-2.74; P > .05). Depression was associated with higher all-cause hospitalizations (adjusted HR = 1.57; 95% CI, 1.09-2.26); P = .0157).

CONCLUSIONS

Depression but not frailty was significantly associated with higher rates of all-cause hospitalization. Implementing interventions that target older adults with both frailty and depression may reduce the burden of both conditions and reduce hospitalizations.

Evaluation of a self-management patient education programme for fibromyalgia-results of a cluster-RCT in inpatient rehabilitation

The objective was to evaluate the effectiveness of a self-management patient education programme for fibromyalgia syndrome (FMS) as compared with usual care education in inpatient rehabilitation. In a multicentre cluster-randomized controlled trial, 583 inpatients in 3 rehabilitation centres received an advanced self-management patient education programme or usual care education. Patients completed questionnaires at admission, discharge and after 6 and 12 months. Primary outcomes were disease- and treatment-specific knowledge at discharge, and self-management-competencies after 6 months. Secondary outcomes included satisfaction, attitudes, coping competencies, psychological distress and health impairment. We found a medium-sized effect on disease- and treatment-specific knowledge at discharge (P < 0.05, Cohen's d = 0.45, 95% CI = 0.27-0.63), and small effects for subjective knowledge, pain-related control, self-monitoring and insight, communication about disease, action planning for physical activity and treatment satisfaction (all P < 0.05). Only the effect on knowledge persisted for 6 and 12 months. This advanced education programme seemed to be more effective in the short term than usual education. However, intermediate- and long-term effects did not emerge. While superior long-term effects on knowledge as well as short-term effects on self-management skills may suggest implementation, additional long-term effects on other patient-relevant outcomes would be desirable. Trial registration: German Clinical Trials Register, DRKS00008782, Registered 8 July 2015.

Effects of the Chronic Disease Self-Management Program on medication adherence among older adults

Despite many interventions to promote medication adherence in older adults, we know little about how medication adherence has improved as a result of such interventions. The purpose of this study was to examine the long-term program impacts on medication adherence from participating in the Chronic Disease Self-Management Program (CDSMP). Secondary data used for this study included the CDSMP participants' sociodemographic characteristics and their baseline and 6- and 12-month follow-up assessments on health-related indicators, including medication adherence, self-rated health, depression, and patient communication skills. This study included those who were 65 years or older, had one or more chronic conditions, and attended at least the first or second session. Linear mixed models were used to analyze the impacts of short-term (6 months) changes in health-related indicators on long-term (12 months) changes in medication nonadherence. The subset analyses were performed among participants with self-rated major depression at baseline. This study included 687 participants. Self-reported medication adherence did not improve significantly at 6-month follow-up assessment but significantly improved at 12-month follow-up assessment. Among those with self-reported major depression at baseline assessment, the short-term improvements in depression and self-rated health were associated with long-term changes in medication adherence. The long-term impacts of the CDSMP on medication adherence were influenced by the short-term program impacts on health-related indicators. More targeted interventions are needed for patients with major depression, and programs such as the CDSMP can be particularly helpful among the population.

Do Depressive Symptoms Moderate the Effects of Exercise Self-efficacy on Physical Activity Among Patients With Coronary Heart Disease?

BACKGROUND

Exercise self-efficacy is an important predictor of physical activity. Patients with coronary heart disease are at risk of developing depressive symptoms that could further weaken their self-efficacy and interfere with their ability to engage in physical activity.

OBJECTIVE

The aim of this study was to examine the relationship between depressive symptoms, exercise self-efficacy, and physical activity among patients with coronary heart disease and how the efficacy-activity relationship is affected by the patient's level of depression.

METHODS

A survey was conducted on 149 participants at the time of discharge from the emergency and in-patient medical wards at 2 regional hospitals.

RESULTS

The sample was mostly male, married, living with families, and of lower socioeconomic status. The mean exercise self-efficacy was 4.26 ± 2.73, and the median physical activity was 12 (interquartile range, 6-21). Approximately 26% of participants had high depressive symptoms. Those with more depressive symptoms reported lower self-efficacy scores and lower physical activity. In multivariate regressions, self-efficacy was an independent predictor of physical activity (b = 1.48, P < .001). After including depressive symptoms as the interaction term, exercise self-efficacy had a significantly stronger and positive relationship with physical activity (b = 0.14, P = .043).

CONCLUSION

Exercise self-efficacy had a positive association with physical activity, and this relationship was stronger among coronary heart disease patients with depressive symptoms. This finding suggests that self-efficacy might be important in encouraging individuals with depressive symptoms to participate in physical activity. More efforts should target the development of effective strategies to improve exercise self-efficacy as a way of promoting physical activity among depressed coronary heart disease patients.

Preparing Home Health Aides to Serve as Health Coaches for Home Care Patients With Chronic Illness: Findings and Lessons Learned From a Mixed-Method Evaluation of Two Pilot Programs

This article highlights findings from a mixed-method evaluation of two pilot programs that utilized Home Health Aides (HHAs) as health coaches for home care patients with chronic illness, including (1) a dedicated health coaching program for patients with heart failure and (2) an integrated program for HHAs working with chronically ill patients. Interviews were conducted with HHAs and staff to understand their experiences implementing program activities. Data from clinical assessments and surveys were employed to examine the characteristics and outcomes of patients. HHAs viewed health coaching positively and described it as an informative process that is dependent on patient motivation and willingness to change. Patients in both programs reported improvement in self-care maintenance. Patients in the chronic illness program also reported improved quality-of-life.

Detecting the effects of physician training in self-care interviewing skills: Coding of standardized patient (SP) visit recordings versus SP post-visit ratings

OBJECTIVE

To compare how coder ratings of standardized patient (SP) visit recordings and SP ratings of the visits detect primary care physician (PCP) training in self-efficacy enhancing interviewing techniques (SEE IT).

METHODS

Analyses of data from 50 PCPs who participated in a randomized controlled trial of SEE IT training, which led to increased SEE IT use during three SP visits 1-3 months post-intervention. Untrained SPs rated SEE IT use post-visit. Subsequently, three trained coders generated a consensus SEE IT rating from visit audio recordings. SPs and coders were blinded to provider study arm, and coders to SP ratings.

RESULTS

SP and coder ratings were correlated (r=0.62). In detecting the intervention effect, the areas under the receiver operating characteristic curve were 0.80 (95% CI 0.74-0.87) and 0.76 (95% CI 0.69-0.84) for consensus coder and SP ratings, respectively (difference 0.04, 95% CI -0.04-0.11; z=1.04, p=0.30).

CONCLUSION

SP ratings were not significantly different from coder ratings of SP visit recordings in detecting PCP SEE IT training.

PRACTICE IMPLICATIONS

If similar findings are observed in larger studies, it would suggest a greater role for SP ratings in detecting provider interviewing skills training, given the relative simplicity, low cost, and non-intrusiveness of the approach.

Feasibility and Preliminary Efficacy of an Internet Support Group for Parents of a Child with Neurofibromatosis Type 1: a Pilot Study

This pilot study investigated the feasibility and preliminary efficacy of an Internet Support Group (ISG) for parents of children with NF1. Eligible parents were recruited by email and completed baseline questionnaires assessing social support, self-efficacy, depression, and anxiety. The ISG involved eight weekly 90-min chat sessions and a discussion forum open 24 h/day for 8 weeks. Follow-up measures were completed immediately post-intervention and 3 months later. Parents from 33 families (29 mothers, 4 fathers) completed baseline measures. Over half of parents (52 %) rated their child's disease severity as mild, 33 % moderate, and 15 % severe. Among 21 parents who completed post-intervention measures, ratings of perceived emotional (p = .0008) and informational (p = .0003) support increased. There were no significant changes in self-efficacy, depression, or anxiety (ps > .05). The mean satisfaction rating was moderately high (7.6/10; range 4-10). Some parents commented that the chat sessions were at inconvenient times, which may have limited participation. Preliminary evidence in this small sample of parents suggests that ISGs may be a feasible and potentially efficacious method of providing support to parents of children with NF1. Having multiple weekly chat sessions held at various days and times may improve accessibility and participation. Clinicians are encouraged to help parents access online support resources.

Physician training in self-efficacy enhancing interviewing techniques (SEE IT): Effects on patient psychological health behavior change mediators

OBJECTIVE

To explore how physician training in self-efficacy enhancing interviewing techniques (SEE IT) affects patient psychological health behavior change mediators (HBCMs).

METHODS

We analyzed data from 131 patients visiting primary care physicians ≥4 months after the physicians participated in a randomized controlled trial. Experimental arm physicians (N=27) received SEE IT training during three ≤20min standardized patient instructor (SPI) visits. Control physicians (N=23) viewed a diabetes medications video during one SPI visit. Physicians were blinded to patient participation. Outcomes were self-care self-efficacy, readiness, and health locus of control (Internal, Chance, Powerful Others), examined as a summary HBCM score (average of standardized means) and individually. Analyses adjusted for pre-visit values of the dependent variables.

RESULTS

Patients visiting SEE IT-trained physicians had higher summary HBCM scores (+0.42, 95% CI 0.07-0.77; p=0.021). They also had greater self-care readiness (AOR 3.04, 95% CI 1.02-9.03, p=0.046) and less Chance health locus of control (-0.27 points, 95% CI -0.50-0.04, p=0.023), with no significant differences in other HBCMs versus controls.

CONCLUSION

Improvement in psychological HBCMs occurred among patients visiting SEE IT-trained physicians, PRACTICE IMPLICATIONS: If further research shows the observed HBCM effects improve health behaviors and outcomes, SEE IT training might be offered widely to physicians.

Training Primary Care Physicians to Employ Self-Efficacy-Enhancing Interviewing Techniques: Randomized Controlled Trial of a Standardized Patient Intervention

BACKGROUND

Primary care providers (PCPs) have few tools for enhancing patient self-efficacy, a key mediator of myriad health-influencing behaviors.

OBJECTIVE

To examine whether brief standardized patient instructor (SPI)-delivered training increases PCPs' use of self-efficacy-enhancing interviewing techniques (SEE IT).

DESIGN

Randomized controlled trial.

PARTICIPANTS

Fifty-two family physicians and general internists from 12 primary care offices drawn from two health systems in Northern California.

INTERVENTIONS

Experimental arm PCPs received training in the use of SEE IT training during three outpatient SPI visits scheduled over a 1-month period. Control arm PCPs received a single SPI visit, during which they viewed a diabetes treatment video. All intervention visits (experimental and control) were timed to last 20 min. SPIs portrayed patients struggling with self-care of depression and diabetes in the first 7 min, then delivered the appropriate intervention content during the remaining 13 min.

MAIN MEASURES

The primary outcome was provider use of SEE IT (a count of ten behaviors), coded from three audio-recorded standardized patient visits at 1-3 months, again involving depression and diabetes self-care. Two five-point scales measured physician responses to training: Value (7 items: quality, helpfulness, understandability, relevance, feasibility, planned use, care impact), and Hassle (2 items: personal hassle, flow disruption).

KEY RESULTS

Pre-intervention, study PCPs used a mean of 0.7 behaviors/visit, with no significant between-arm difference (P = 0.23). Post-intervention, experimental arm PCPs used more of the behaviors than controls (mean 2.7 vs. 1.0 per visit; adjusted difference 1.7, 95 % CI 1.1-2.2; P < 0.001). Experimental arm PCPs had higher training Value scores than controls (mean difference 1.05, 95 % CI 0.68-1.42; P < 0.001), and similarly low Hassle scores.

CONCLUSIONS

Primary care physicians receiving brief SPI-delivered training increased their use of SEE IT and found the training to be of value. Whether patients visiting SEE IT-trained physicians experience improved health behaviors and outcomes warrants study. CLINICALTRIALS.

GOV IDENTIFIER

NCT01618552.

Describing Self-Care Self-Efficacy: Definition, Measurement, Outcomes, and Implications

PURPOSE

The pragmatic utility method of concept analysis was used to explore the usefulness of the concept self-care self-efficacy.

DATA SOURCES

Empirical studies across disciplines published between 1996 and 2015 were used as data.

DATA SYNTHESIS

A data matrix was developed. Analytical questions and responses were derived from the data to understand patterns, develop new knowledge and achieve synthesis.

CONCLUSION

Usefulness of the concept is contingent on how it is defined and measured. Self-care self-efficacy is associated with performance of self-care activities and positive health outcomes in diverse populations.

IMPLICATIONS

Research can guide development of targeted interventions to increase patients' self-care self-efficacy, thus reducing costs, and assisting people to achieve optimal health.

Multimorbidity, Depression, and Mortality in Primary Care: Randomized Clinical Trial of an Evidence-Based Depression Care Management Program on Mortality Risk

BACKGROUND

Two-thirds of older adults have two or more medical conditions that often take precedence over depression in primary care.

OBJECTIVE

We evaluated whether evidence-based depression care management would improve the long-term mortality risk among older adults with increasing levels of medical comorbidity.

DESIGN

Longitudinal analyses of the practice-randomized Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT). Twenty primary care practices randomized to intervention or usual care.

PATIENTS

The sample included 1204 older primary care patients completing the Charlson Comorbidity Index (CCI) and other interview questions at baseline.

INTERVENTION

For 2 years, a depression care manager worked with primary care physicians to provide algorithm-based care for depression, offering psychotherapy, increasing the antidepressant dose if indicated, and monitoring symptoms, medication adverse effects, and treatment adherence.

MAIN MEASURES

Depression status based on clinical interview, CCI to evaluate medical comorbidity, and vital status at 8 years (National Death Index).

KEY RESULTS

In the usual care condition, patients with the highest levels of medical comorbidity and depression were at increased risk of mortality over the course of the follow-up compared to depressed patients with minimal medical comorbidity [hazard ratio 3.02 (95% CI, 1.32 to 8.72)]. In contrast, in intervention practices, patients with the highest level of medical comorbidity and depression compared to depressed patients with minimal medical comorbidity were not at significantly increased risk [hazard ratio 1.73 (95% CI, 0.86 to 3.96)]. Nondepressed patients in intervention and usual care practices had similar mortality risk.

CONCLUSIONS

Depression management mitigated the combined effect of multimorbidity and depression on mortality. Depression management should be integral to optimal patient care, not a secondary focus.

Social determinants of health in adults with type 2 diabetes--Contribution of mutable and immutable factors

AIMS

Socioeconomic, psychosocial, and neighborhood factors influence clinical outcomes and self-care behaviors in diabetes; however, few studies simultaneously assessed the impact of multiple social determinant of health factors on glycemic control. We used an explanatory model to examine the differential contribution of social determinants and clinical factors on glycemic control. Secondarily, we examined the contribution of mutable and immutable factors to identify meaningful future interventions.

METHODS

Six hundred and fifteen adults with type 2 diabetes in the southeastern United States were recruited. A hierarchical model was run with HbA1c as the dependent variable and independent variables entered in blocks: demographics (block 1), socioeconomic (block 2), psychosocial (block 3), built environment (block 4), clinical (block 5), and knowledge/self-care (block 6).

RESULTS

Significant associations for HbA1c included self-efficacy (β=-0.10, p<0.001), social support (β=0.01, p<0.05), comorbidity (β=-0.09, p<0.05), insulin use (β=0.95, p<0.001), medication adherence (β=-0.11, p<0.05), and being a former smoker (β=0.34, p<0.05); accounting for 24.4% of the variance.

CONCLUSIONS

Important factors that drive glycemic control are mutable, and amenable to health interventions. Greater attention should be given to interventions that increase self-efficacy and social support, reduce the burden of comorbidities, and enhance medication adherence and smoking cessation.

Integrative Medicine Patients Have High Stress, Pain, and Psychological Symptoms

CONTEXT

Integrative medicine (IM) is a rapidly growing field whose providers report clinical success in treating significant stress, chronic pain, and depressive and anxiety symptoms. While IM therapies have demonstrated efficacy for numerous medical conditions, IM for psychological symptoms has been slower to gain recognition in the medical community.

OBJECTIVE AND DESIGN

This large, cross-sectional study is the first of its kind to document the psychosocial profiles of 4182 patients at 9 IM clinics that form the BraveNet Practice-Based Research Network (PBRN).

RESULTS

IM patients reported higher levels of perceived stress, pain, and depressive symptoms, and lower levels of quality of life compared with national norms. Per provider reports, 60% of patients had at least one of the following: stress (9.3%), fatigue (10.2%), anxiety (7.7%), depression (7.2%), and/or sleep disorders (4.8%). Pain, having both physiological and psychological components, was also included and is the most common condition treated at IM clinics. Those with high stress, psychological conditions, and pain were most frequently treated with acupuncture, IM physician consultation, exercise, chiropractic services, diet/nutrition counseling, and massage.

CONCLUSION

With baseline information on clinical presentation and service utilization, future PBRN studies can examine promising interventions delivered at the clinic to treat stress and psychological conditions.

Towards tailoring of self-management for patients with chronic heart failure or chronic obstructive pulmonary disease: a protocol for an individual patient data meta-analysis

INTRODUCTION

Self-management interventions in patients with chronic conditions have received increasing attention over the past few years, yet the meta-analyses encountered considerable heterogeneity in results. This suggests that the effectiveness of self-management interventions must be assessed in the context of which components are responsible for eliciting the effect and in which subgroups of patients the intervention works best. The aim of the present study is to identify condition-transcending determinants of success of self-management interventions in two parallel individual patient data meta-analyses of self-management trials in patients with congestive heart failure (CHF) and in patients with chronic obstructive pulmonary disease (COPD).

METHODS AND ANALYSIS

Investigators of 53 randomised trials (32 in CHF and 21 in COPD) will be requested to share their de-identified individual patient data. Data will be analysed using random effects models, taking clustering within studies into account. Effect modification by age, sex, disease severity, symptom status, comorbid conditions and level of education will be assessed. Sensitivity analyses will be conducted to assess the robustness of the findings.

ETHICS AND DISSEMINATION

The de-identified individual patient data are used only for the purpose for which they were originally collected and for which ethical approval has been obtained by the original investigators. Knowledge on the effective ingredients of self-management programmes and identification of subgroups of patients in which those interventions are most effective will guide the development of evidence-based personalised self-management interventions for patients with CHF and COPD as well as with other chronic diseases.

TRIAL REGISTRATION NUMBER PROSPERO

CRD42013004698.

Psychiatric symptoms moderate the effects of mental illness self-management in a randomized controlled trial

Depression has been shown to moderate the effects of physical illness self-management (ISM) programs. We attempted to replicate these findings for a mental ISM intervention. Outpatients with serious mental illness (N = 428) from eight Tennessee communities were randomly assigned to receive a peer-led self-management intervention called Building Recovery of Individual Dreams and Goals Through Education and Support or services as usual. Psychiatric symptoms were assessed with the Brief Symptom Inventory; the outcome of personal empowerment was measured by the Empowerment Scale. Intent-to-treat analysis using mixed-effects random regression found significant interaction effects between study condition and three moderating symptom profiles. Empowerment was greater for the intervention participants with high levels of depressive symptoms, anxiety symptoms, and general symptom distress than for the experimental participants with low symptom levels and the control subjects with high or low levels of symptoms. These results shed light on how mental ISM programs operate and ways these can be improved.

Mediators of adherence among adults with comorbid diabetes and depression: The role of self-efficacy and social support

Depression and diabetes have been linked in a variety of ways, and the presence of depression in those with diabetes can negatively affect adherence to care recommendations. A sample of 201 participants with Type 2 Diabetes completed a cross-sectional survey that assessed depressive symptoms, adherence, self-efficacy, social support, and personal characteristics. Multiple regression analysis was used to test whether self-efficacy and social support mediate the relationship between depressive symptoms and adherence. The findings suggest complete mediation via self-efficacy and some types of social support. Intervening to bolster self-efficacy and social support may decrease the negative effect of depression on adherence.

Depression screening in uninsured patients in a primary care setting

There is a strong correlation between chronic disease and depression; however, screening patients for depression is not typical in the primary care setting due to factors such as time constraints and the provider's ability to diagnose and manage depression. This study sought to: (1) determine the prevalence of depression in uninsured or underinsured patients with chronic diseases using a screening instrument validated for use in the primary care setting, (2) provide a referral to the patient's primary care provider (PCP) for depression management prior to disease management as needed, and (3) enroll patients for chronic disease management services. The study utilized a cross-sectional design consisting of a self-administered survey and medical record review after physician and nursing appointments. Patients completed the Beck Depression Inventory for Primary Care (BDI-PC) upon program enrollment. Patients that screened positively for depression were referred to the PCP for follow-up services prior to entry into one of the disease management programs. After PCP appointments took place, medical records were reviewed to obtain medical and depression diagnoses, along with mediation recommendations. Forty-one patients were enrolled in the clinic program and completed the depression screening. Eight patients were found to have mild depression and two patients had moderate depression as determined by the BDI-PC, which accounted for 24% of the clinic patients. Four of the patients with mild depression and both patients with moderate depression initiated antidepressant therapy. Additionally, three patients with minimal scores on the screening began medication therapy based on symptoms reported to the PCP. The results of this study suggest that it is feasible to incorporate a depression-screening tool in a primary care setting with further evaluation and follow-up by primary care providers.

Decay of impact after self-management education for people with chronic illnesses: changes in anxiety and depression over one year

BACKGROUND

In people with chronic illnesses, self-management education can reduce anxiety and depression. Those benefits, however, decay over time. Efforts have been made to prevent or minimize that "decay of impact", but they have not been based on information about the decay's characteristics, and they have failed. Here we show how the decay's basic characteristics (prevalence, timing, and magnitude) can be quantified. Regarding anxiety and depression, we also report the prevalence, timing, and magnitude of the decay.

METHODS

Adults with various chronic conditions participated in a self-management educational program (n = 369). Data were collected with the Hospital Anxiety and Depression Scale four times over one year. Using within-person effect sizes, we defined decay of impact as a decline of ≥0.5 standard deviations after improvement by at least the same amount. We also interpret the results using previously-set criteria for non-cases, possible cases, and probable cases.

RESULTS

Prevalence: On anxiety, decay occurred in 19% of the participants (70/369), and on depression it occurred in 24% (90/369). Timing: In about one third of those with decay, it began 3 months after the baseline measurement (6 weeks after the educational program ended). Magnitude: The median magnitudes of decay on anxiety and on depression were both 4 points, which was about 1 standard deviation. Early in the follow-up year, many participants with decay moved into less severe clinical categories (e.g., becoming non-cases). Later, many of them moved into more severe categories (e.g., becoming probable cases).

CONCLUSIONS

Decay of impact can be identified and quantified from within-person effect sizes. This decay occurs in about one fifth or more of this program's participants. It can start soon after the program ends, and it is large enough to be clinically important. These findings can be used to plan interventions aimed at preventing or minimizing the decay of impact.

Integrating nurse-led Self-Management Support (SMS) in routine primary care: design of a hybrid effectiveness-implementation study among type 2 diabetes patients with problems of daily functioning and emotional distress: a study protocol

Background

Psychosocial problems are more prevalent among patients with chronic diseases than among the general population. They may lead to a downward spiral of poor adherence, deterioration of the condition and decline in daily functioning. In addition to medical management, systematic attention to emotional and role management tasks during routine chronic care seems mandatory. We intend to integrate an existing nurse-led minimal psychological intervention to support patients’ self-management, which appeared to be effective and cost-effective, in routine care by primary care nurses, so we adjusted it to fit the host setting. The resulting Self-Management Support (SMS) programme involves early detection of patients with emotional distress and problems of daily functioning, as well as self-management support through problem solving and reattribution techniques. Strategies to embed SMS in daily practice include training and booster sessions for practice nurses as well as organisational and financial arrangements. This study aims to simultaneously evaluate the implementation process and effects of SMS in routine care, using a hybrid effectiveness–implementation design.

Methods/Design

Registration data, questionnaires and interviews will be used to explore the facilitators, barriers and costs regarding successful implementation of SMS. The effects of SMS will be evaluated in a pragmatic cluster-randomised controlled trial with a baseline measurement and follow-up measurements after 4 and 12 months. The population will consist of 46 practice nurses and their type 2 diabetes patients (N = 460; 10 per practice nurse). The practice nurses will be randomly assigned to the intervention or control group. Practice nurses of the intervention group will receive SMS training. Patients for the intervention and control groups will be recruited by a researcher-led self-administered screening procedure to decide which patients of those scheduled for routine consultation are likely to be detected by the practice nurses as eligible for the self-management support. Primary outcome measure is patients’ daily functioning. Secondary measures include emotional well-being, participation, autonomy and control over the disease.

Discussion

Our hybrid study design is complicated by the detection method used by the practice nurses. This method is an implementation issue in itself that has consequences for the realisation and power of the effect evaluation.

Trial registration

Current Controlled Trials, NTR2764

Depression and diabetes: the role and impact of models of health care systems

OBJECTIVES

Depression and diabetes often occur together and their comorbidity has a significant and detrimental impact on health outcomes. The aims of this paper are to review the existing international literature on approaches to health care for comorbid depression and diabetes and draw out the key conclusions for both research and future development in health care delivery.

METHODS

Narrative review of the literature with synthesis by an international team of authors.

RESULTS

The synthesized findings are discussed under four main headings: specialty and generalist care; models for co-ordinating and integrating care; community approaches to service delivery; and the role of health policy.

LIMITATIONS

The review only included literature published in English.

CONCLUSIONS

Translating basic and clinical research findings into improved treatment and outcomes of those with depression and diabetes remains a substantial challenge. There is little research on the difficulties of identifying and implementing best practice into routine health care. Systems need to be designed so that evidence-based interventions are provided in a timely way, with appropriate professional expertise where required.

Components of heart failure management in home care; a literature review

BACKGROUND

Patients with heart failure (HF) need long-term and complex care delivered by healthcare professionals in primary and secondary care. Although guidelines on optimal HF care exist, no specific description of components that are applied for optimal HF care at home exist. The objective of this review was to describe which components of HF (home) care are found in research studies addressing homecare interventions in the HF population.

METHODS

The Pubmed, Embase, Cinahl, and Cochrane databases were searched using HF-, homecare services-, and clinical trial-related search terms.

RESULTS

The literature search identified 703 potentially relevant publications, out of which 70 articles were included. All articles described interventions with two or more of the following components: multidisciplinary team, continuity of care and care plans, optimized treatment according to guidelines, educational and counselling of patients and caregivers, and increased accessibility to care. Most studies (n=65, 93%) tested interventions with three components or more and 20 studies (29%) used interventions including all five components.

CONCLUSIONS

There a several studies on HF care at home, testing interventions with a variety in number of components. Comparing the results to current standards, aspects such as collaboration between primary care and hospital care, titration of medication, and patient education can be improved.

Randomized controlled trial of peer-led recovery education using Building Recovery of Individual Dreams and Goals through Education and Support (BRIDGES)

OBJECTIVE

The purpose of this study was to test the efficacy of a peer-led, mental illness education intervention called Building Recovery of Individual Dreams and Goals through Education and Support (BRIDGES).

METHOD

Subjects were recruited from outpatient community mental health settings in eight Tennessee communities. Using a single-blind, randomized controlled trial design, 428 individuals with serious mental illness (SMI) were interviewed at baseline and assigned to BRIDGES or to a services as usual wait list control condition. Two-and-one-half hour classes were taught once a week for 8 weeks by peers who were certified BRIDGES instructors. Subjects were followed-up at immediate post-intervention and 6-months later. The primary outcome was self-perceived recovery, measured by the Recovery Assessment Scale (RAS). A secondary outcome was hopefulness as assessed by the State Hope Scale (SHS). An exploratory hypothesis examined the impact of depressive symptoms on both recovery outcomes.

RESULTS

Eighty six percent of participants were followed up. On average, participants attended five sessions. Intent-to-treat analysis using mixed-effects random regression found that, compared to controls, intervention participants reported: 1) significantly greater improvement in total RAS scores as well as subscales measuring personal confidence and tolerable symptoms; and 2) significantly greater improvement in hopefulness as assessed by the agency subscale of the SHS. While study subjects with high levels of depressive symptoms had significantly poorer outcomes, outcomes were superior for BRIDGES participants regardless of depressive symptoms.

CONCLUSIONS

Peer-led mental illness education improves participants' self-perceived recovery and hopefulness over time, even controlling for severity of depressive symptoms.

A secondary analysis of the moderating effects of depression and multimorbidity on the effectiveness of a chronic disease self-management programme

OBJECTIVE

Patients accessing the chronic disease self-management programme (CDSMP) often report multiple long-term conditions (multimorbidity). Although multimorbidity often predicts poor outcomes, CDSMP effectiveness may be enhanced in multimorbidity via synergies between self-management for different conditions. This study assessed whether CDSMP benefits varied by patterns of multimorbidity.

METHODS

The study was based on a secondary analysis of an RCT. Patients with long-term conditions (n=629) were randomised to CDSMP or wait-list and completed baseline and 6 month assessments. We identified four multimorbidity groups: (1) single physical condition; (2) multiple physical conditions; (3) single physical condition plus 'probable depression'; (4) multiple physical conditions plus 'probable depression'.

RESULTS

Multimorbidity group significantly moderated the effect of CDSMP on vitality, health-related quality of life, and mental well-being, with the greatest benefit found for patients with multiple physical conditions plus 'probable depression'.

CONCLUSION

The coexistence of depression and multiple physical conditions is associated with increased illness burden, but such patients benefit more from the CDSMP. The mechanisms underlying this effect are unclear, but it does not appear to be through self-management or self-efficacy.

PRACTICE IMPLICATIONS

The presence of multimorbidity in combination with depression may be a useful criteria for referral to the CDSMP.

The perception of meaningfulness and performance of instrumental activities of daily living from the perspectives of the medically at-risk older adults and their caregivers

The purpose of the study was to understand the impact of chronic disability on the functional ability of older adults. Thirty older adult participants and their caregivers were asked to identify which instrumental activities of daily living (IADL) are most meaningful and how their disability affected performance. Data collected through individual analysis indicated that the most important IADL tasks were driving and managing medication. Both older adult participants and their caregivers similarly perceived the health condition as significantly affecting the performance of all of the IADLs. However, there was a difference in the perception of the prior level of functioning for managing medication (z = 2.45, p = .024) and phone use (z = 2.26, p = .014). Results arrived at, and to be discussed, were in agreement with previous research findings indicating that complex tasks of daily living, particularly driving, are significant to the older adult's quality of life.

The effectiveness of a minimal psychological intervention on self-management beliefs and behaviors in depressed chronically ill elderly persons: a randomized trial

BACKGROUND

Chronically ill patients often develop symptoms of depression. They run the risk of sliding into a downward spiral because of the interaction between depression and chronic illness. A minimal psychological intervention (MPI) has been developed to break through the spiral by applying principles of self-management and cognitive behavioral therapy. This study examines the effects of the MPI on self-efficacy, anxiety, daily functioning and social participation.

METHODS

A randomized controlled trial compared the MPI with usual care in 361 primary care patients. Nurses visited patients at home over a period of three months. Patients were aged 60 years and older, had minor depression or mild to moderate major depression and either type 2 diabetes mellitus (DM) or chronic obstructive pulmonary disease (COPD). Outcomes were measured at baseline and at one week, three months, and nine months after the intervention period.

RESULTS

At nine months after treatment, the MPI was associated with less anxiety (mean difference 2.5; 95% CI 0.7-4.2) and better self efficacy skills (mean difference 1.8; 95% CI 3.4-0.2), daily functioning (mean difference 1.7; 95% CI 0.6-2.7), and social participation (mean difference 1.3; 95% CI 0.4-2.2). Effect sizes for these outcomes were small to medium (0.29-0.40). Differences were primarily due to a stabilization of outcomes in the intervention group and deterioration in the control group. No major differences were observed between DM and COPD patients.

CONCLUSIONS

The intervention appears to be reasonably effective in improving care for chronically ill elderly people. We recommend further evaluation of the MPI, including emphasis on detection and watchful waiting.

Predicting complete loss to follow-up after a health-education program: number of absences and face-to-face contact with a researcher

Background

Research on health-education programs requires longitudinal data. Loss to follow-up can lead to imprecision and bias, and complete loss to follow-up is particularly damaging. If that loss is predictable, then efforts to prevent it can be focused on those program participants who are at the highest risk. We identified predictors of complete loss to follow-up in a longitudinal cohort study.

Methods

Data were collected over 1 year in a study of adults with chronic illnesses who were in a program to learn self-management skills. Following baseline measurements, the program had one group-discussion session each week for six weeks. Follow-up questionnaires were sent 3, 6, and 12 months after the baseline measurement. A person was classified as completely lost to follow-up if none of those three follow-up questionnaires had been returned by two months after the last one was sent.

We tested two hypotheses: that complete loss to follow-up was directly associated with the number of absences from the program sessions, and that it was less common among people who had had face-to-face contact with one of the researchers. We also tested predictors of data loss identified previously and examined associations with specific diagnoses.

Using the unpaired t-test, the U test, Fisher's exact test, and logistic regression, we identified good predictors of complete loss to follow-up.

Results

The prevalence of complete loss to follow-up was 12.2% (50/409). Complete loss to follow-up was directly related to the number of absences (odds ratio; 95% confidence interval: 1.78; 1.49-2.12), and it was inversely related to age (0.97; 0.95-0.99). Complete loss to follow-up was less common among people who had met one of the researchers (0.51; 0.28-0.95) and among those with connective tissue disease (0.29; 0.09-0.98). For the multivariate logistic model the area under the ROC curve was 0.77.

Conclusions

Complete loss to follow-up after this health-education program can be predicted to some extent from data that are easy to collect (age, number of absences, and diagnosis). Also, face-to-face contact with a researcher deserves further study as a way of increasing participation in follow-up, and health-education programs should include it.

Delineation of self-care and associated concepts

PURPOSE

The purpose of this paper is to delineate five concepts that are often used synonymously in the nursing and related literature: self-care, self-management, self-monitoring, symptom management, and self-efficacy for self-care.

METHOD

Concepts were delineated based on a review of literature, identification of relationships, and examination of commonalities and differences.

FINDINGS

More commonalities than differences exist among self-care, self-management, and self-monitoring. Symptom management extends beyond the self-care concepts to include healthcare provider activities. Self-efficacy can mediate or moderate the four other concepts. Relationships among the concepts are depicted in a model.

CONCLUSIONS

A clearer understanding of the overlap, differences, and relationships among the five concepts can provide clarity, direction and specificity to nurse researchers, policy makers, and clinicians in addressing their goals for health delivery.

CLINICAL RELEVANCE

Concept clarity enables nurses to use evidence that targets specific interventions to individualize care toward achieving the most relevant goals.

Maintenance of Risk Factor Control in Diabetic Patients with and Without Mental Health Conditions After Discharge from a Cardiovascular Risk Reduction Clinic

Background:

Diabetes and hypertension can be challenging to manage in patients with mental health conditions. While the effectiveness of a cardiovascular risk reduction clinic (CRRC) has been shown not to differ between those with and without mental health conditions, it is unknown whether patients with mental health conditions would differ in durability of success following discharge from the CRRC.

Objective:

To determine the effect of mental health conditions on the maintenance of glycemic control and blood pressure control in patients with diabetes following successful completion of a CRRC program.

Methods:

Patients were discharged from the CRRC when therapeutic goals of hemoglobin A1c (A1C) <7% and blood pressure <130/80 mm Hg were achieved. We performed a retrospective chart review of a cohort of 231 patients by quarterly intervals for A1C and systolic blood pressure (SBP), providing up to 3 years of data following discharge from the CRRC. We assessed the time to failure to maintain goal A1C and SBP following CRRC discharge for patients with diagnosed mental health conditions versus patients without mental health conditions.

Results:

For patients with and without mental health conditions, 50% of those who had been discharged from the CRRC with an SBP goal of <130 mm Hg failed to maintain SBP by 1 quarter. The hazard ratio for failure to maintain SBP, with those without mental health conditions as the reference group, was 0.96 (95% CI 0.68 to 1.35). Overall, for patients with an A1C goal of <7%, the combined median time to failure was 3 quarters. Among patients without mental health conditions, 25% failed in 3 quarters, and of those with mental health conditions, 25% failed in 4 quarters (HR 0.91; 95% CI 0.50 to 1.66).

Conclusions:

There was no significant difference between diabetic patients with and without mental health conditions in maintenance of A1C and SBP after discharge from a CRRC. This provides further evidence that a CRRC is a viable approach to cardiovascular risk reduction in individuals with mental health conditions.

Diabetes distress but not clinical depression or depressive symptoms is associated with glycemic control in both cross-sectional and longitudinal analyses

OBJECTIVE

To determine the concurrent, prospective, and time-concordant relationships among major depressive disorder (MDD), depressive symptoms, and diabetes distress with glycemic control.

RESEARCH DESIGN AND METHODS

In a noninterventional study, we assessed 506 type 2 diabetic patients for MDD (Composite International Diagnostic Interview), for depressive symptoms (Center for Epidemiological Studies-Depression), and for diabetes distress (Diabetes Distress Scale), along with self-management, stress, demographics, and diabetes status, at baseline and 9 and 18 months later. Using multilevel modeling (MLM), we explored the cross-sectional relationships of the three affective variables with A1C, the prospective relationships of baseline variables with change in A1C over time, and the time-concordant relationships with A1C.

RESULTS

All three affective variables were moderately intercorrelated, although the relationship between depressive symptoms and diabetes distress was greater than the relationship of either with MDD. In the cross-sectional MLM, only diabetes distress but not MDD or depressive symptoms was significantly associated with A1C. None of the three affective variables were linked with A1C in prospective analyses. Only diabetes distress displayed significant time-concordant relationships with A1C.

CONCLUSIONS

We found no concurrent or longitudinal association between MDD or depressive symptoms with A1C, whereas both concurrent and time-concordant relationships were found between diabetes distress and A1C. What has been called "depression" among type 2 diabetic patients may really be two conditions, MDD and diabetes distress, with only the latter displaying significant associations with A1C. Ongoing evaluation of both diabetes distress and MDD may be helpful in clinical settings.

A systematic review of community-based health interventions on depression for older adults with heart disease

PURPOSE

This systematic review examined the effectiveness of community-based heart-health interventions on depression outcomes among homebound elderly (64 years and older) with heart disease.

DESIGN AND METHODS

A comprehensive literature search and meta analysis was performed to evaluate randomized controlled trials examining outpatient or home-based interventions. Methodological quality was assessed by standard criteria developed by the Cochrane Collaborative Initiative.

RESULTS

Fifteen studies met our inclusion criteria and all measured depression outcomes. Studies differed in scope and methodological rigor and sample sizes varied widely. Problems in treatment fidelity and masking of group assignment were noted. Great variability was found in depression outcomes due to the differences in methodology and intervention. Five studies reported significant treatment effect on depression; three of those employed home-based interventions and two were outpatient-clinic interventions. Ten studies were included in the meta analysis and the effect sizes (ESs) ranged from -0.39 (in favor of control group) to 0.65 (in favor of treatment group). The mean weighted ES was 0.11 and six studies showed positive ESs.

IMPLICATIONS

Mixed evidence for community-based heart disease interventions on depression outcomes was found. Future research should include sub-analysis of ESs of interventions on depression outcomes by different demographic characteristics of the study sample, common depression outcome measures, and different follow-up periods.

'Extra information a bit further down the line': rheumatoid arthritis patients' perceptions of developing educational material about the cardiovascular disease risk

OBJECTIVE

There are no patient education programmes addressing the increased risk of cardiovascular disease (CVD) associated with rheumatoid arthritis (RA). This is the second in a pair of studies exploring stakeholder perceptions of developing such educational material. Healthcare professionals' perceptions were explored in the first study; here, we explore the perceptions of people with RA.

METHODS

Semi-structured interviews were held individually with 18 people with RA, purposively sampled to include participants with no co-morbid history of CVD, those with CVD risk factors and those who had experienced a CVD event. The interview transcripts were analysed using interpretative phenomenological analysis.

RESULTS

Four superordinate themes were identified: experiences of living with RA; reactions to learning about co-morbid CVD; implementing lifestyle changes; and expectations of education. Participants found being diagnosed with RA a devastating experience and were mostly unaware of their increased risk of CVD co-morbidity. They explained how information about CVD would be overwhelming and irrelevant at diagnosis, but they would have coped with 'extra information a bit further down the line'.

CONCLUSION

There is a need to develop educational material or programmes. Their design must consider factors which facilitate lifestyle change, such as motivation or receiving personalized advice, and factors that inhibit change, such as depression or fatalism. Emphasizing the positive effects that some CVD lifestyle changes may have on RA symptom control may be particularly persuasive. Group education would be a popular format. These findings can be directly translated into clinical practice.

Home-based, peer-led chronic illness self-management training: findings from a 1-year randomized controlled trial

PURPOSE

Studies suggest peer-led self-management training improves chronic illness outcomes by enhancing illness management self-efficacy. Limitations of most studies, however, include use of multiple outcome measures without predesignated primary outcomes and lack of randomized follow-up beyond 6 months. We conducted a 1-year randomized controlled trial of Homing in on Health (HIOH), a Chronic Disease Self-Management Program variant, addressing these limitations.

METHODS

We randomized outpatients (N = 415) aged 40 years and older and who had 1 or more of 6 common chronic illnesses, plus functional impairment, to HIOH delivered in homes or by telephone for 6 weeks or to usual care. Primary outcomes were the Medical Outcomes Study 36-ltem short-form health survey's physical component (PCS-36) and mental component (MCS-36) summary scores. Secondary outcomes included the EuroQol EQ-5D and visual analog scale (EQ VAS), hospitalizations, and health care expenditures.

RESULTS

Compared with usual care, HIOH delivered in the home led to significantly higher illness management self-efficacy at 6 weeks (effect size = 0.27; 95% CI, 0.10-0.43) and at 6 months (0.17; 95% CI, 0.01-0.33), but not at 1 year. In-home HIOH had no significant effects on PCS-36 or MCS-36 scores and led to improvement in only 1 secondary outcome, the EQ VAS (1-year effect size = 0.40; CI, 0.14-0.66). HIOH delivered by telephone had no significant effects on any outcomes.

CONCLUSIONS

Despite leading to improvements in self-efficacy comparable to those in other CDSMP studies, in-home HIOH had a limited sustained effect on only 1 secondary health status measure and no effect on utilization. These findings question the cost-effectiveness of peer-led illness self-management training from the health system perspective.

Urinary incontinence and overactive bladder in patients with heart failure

PURPOSE

We explored the nature of the relationship between heart failure and urinary symptoms, specifically urinary incontinence and overactive bladder.

MATERIALS AND METHODS

An 81-item written survey about urinary incontinence, urgency, frequency, nocturia and other symptoms was administered to hospitalized and clinic patients with heart failure. A medical records review was also conducted to determine types of medications, body mass index and documentation of the New York Heart Association Classification of heart failure.

RESULTS

Of 408 respondents 296 (average age 62.2 years) had information about heart failure stage and urinary symptoms. Of these respondents 45% and 57% reported urinary incontinence and overactive bladder, respectively. Adjusted odds ratio for having overactive bladder over no symptoms for respondents with New York Heart Association Class III or Class IV heart failure was 2.9 (95% CI 1.344-6.250) and for higher fatigue-depression composite was 2.155 (95% CI 1.206-3.860). Adjusted odds ratio for having overactive bladder over frequency/nocturia for respondents with higher body mass index was 1.458 (95% CI 1.087-1.953) and for higher fatigue-depression composite was 1.629 (95% CI 1.038-2.550).

CONCLUSIONS

Urinary incontinence and overactive bladder are prevalent in patients with heart failure. Evidence of late stage heart failure, higher fatigue-depression composite and higher body mass index were associated with overactive bladder. Sex, age and diuretic use were not associated with urinary incontinence and overactive bladder.