Diabetes, depression, and death: a randomized controlled trial of a depression treatment program for older adults based in primary care (PROSPECT)

Depression prevalence, screening, and treatment in adult outpatients with type 1 and type 2 diabetes: A nationally representative cross-sectional study (National Ambulatory Medical Care Survey 2014-2019)

BACKGROUND

Studies have shown that the presence of diabetes or depression may increase the risk for developing the other. The primary objective of this study is to describe the current prevalence of comorbid depression and the rate of screening and treatment for comorbid depression in US adult outpatients with diabetes compared to those without diabetes.

METHODS

We analyzed data from the 2014-2019 National Ambulatory Medical Care Survey. Descriptive statistics, univariate analyses, and multivariable regression models were developed with weighting factors applied.

RESULTS

Depression prevalence is higher in those with diabetes than without diabetes. Females with diabetes have higher rates of depression (15.4%) compared to females without diabetes (13.7%) or males with diabetes (9.1%). Screening rates for depression are extremely low (<6%) in patients with diabetes and without diabetes. Patients with diabetes and depression are less likely to be screened than those with depression alone.

LIMITATIONS

The cross-sectional design of the study cannot establish causality and has inherent limitations in capturing temporal relationships. The reliance on ICD codes limits the scope of diagnosis and underestimates rates of comorbidity if depression is not formally diagnosed. The NAMCS cohort only includes ambulatory visits to office-based physicians, so depression diagnoses and screening rates among patients who visit other health care settings or are not seeing physicians would be underestimated.

CONCLUSIONS

Depression is prevalent in people with diabetes. Screening rates are unacceptably low, indicating a gap in recommended care and underreporting of depression. More routine screening and treatment are necessary to align with guideline-recommended care.

Effectiveness of Psychotherapy for Community-Dwelling Vulnerable Older Adults with Depression and Care Needs: Findings from the PSY-CARE Trial

BACKGROUND

For older adults with care needs, evidence for the effectiveness of psychotherapy on depression is scarce.

METHODS

In PSY-CARE, a pragmatic randomized controlled trial, N = 197 home-living older adults with depression and care needs were randomized into outpatient psychotherapy or an active control condition. Residential psychotherapists offered age-sensitive cognitive-behavioral psychotherapy (at-home if needed). Control group participants received telephone counseling and a self-help guide. Outcomes were assessed at baseline (T1), after (T2), 3 months after (T3), and 12 months after the intervention (T4).

RESULTS

There was a significant decrease in depressive symptoms across both arms with Cohen's d T4-T1 = .52 in the psychotherapy and .55 in the control group. Mixed models revealed no statistically significant difference in primary and secondary outcomes between interventions. Posthoc, we found control group participants with greater ADL limitations experienced significantly increased depressive symptoms compared to those reporting lower limitations.

CONCLUSIONS

Interventions were successful in reducing depressive symptoms, even though treatment fidelity was decreased due to the COVID-19 pandemic. We could not demonstrate superior effectiveness of psychotherapy for older adults with care needs.

CLINICAL IMPLICATIONS

Findings suggest that psychotherapy may be an important and superior treatment to circumvent aggravation of depression in older patients with high functional limitations.

TRIAL REGISTRATION

The trial was prospectively registered with the ISRCTN registry (Trial registration number: ISRCTN55646265, February 15, 2019).

Review of the direct and indirect effects of hyperglycemia on the HPA axis in T2DM and the co-occurrence of depression

Type 2 diabetes mellitus (T2DM) is characterized by persistent hyperglycemia which is further associated with hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis. Several studies have shown that HPA axis hyperactivity is heightened in the chronic hyperglycemic state with severe hyperglycemic events more likely to result in a depressive disorder. The HPA axis is also regulated by the immune system. Upon stress, under homeostatic conditions, the immune system is activated via the sympatho-adrenal-medullary axis resulting in an immune response which secretes proinflammatory cytokines. These cytokines aid in the activation of the HPA axis during stress. However, in T2DM, where there is persistent hyperglycemia, the immune system is dysregulated resulting in the elevated concentrations of these cytokines. The HPA axis, already activated by the hyperglycemia, is further activated by the cytokines which all contribute to a diagnosis of depression in patients with T2DM. However, the onset of T2DM is often preceded by pre-diabetes, a reversible state of moderate hyperglycemia and insulin resistance. Complications often seen in T2DM have been reported to begin in the pre-diabetic state. While the current management strategies have been shown to ameliorate the moderate hyperglycemic state and decrease the risk of developing T2DM, research is necessary for clinical studies to profile these direct effects of moderate hyperglycemia in pre-diabetes on the HPA axis and the indirect effects moderate hyperglycemia may have on the HPA axis by investigating the components of the immune system that play a role in regulating this pathway.

Adapting psychotherapy in collaborative care for treating opioid use disorder and co-occurring psychiatric conditions in primary care

INTRODUCTION

Opioid use disorder (OUD) and psychiatric conditions commonly co-occur yet are infrequently treated with evidence-based therapeutic approaches, resulting in poor outcomes. These conditions, separately, present challenges to treatment initiation, retention, and success. These challenges are compounded when individuals have OUD and psychiatric conditions.

METHOD

Recognizing the complex needs of these individuals, gaps in care, and the potential for primary care to bridge these gaps, we developed a psychotherapy program that integrates brief, evidence-based psychotherapies for substance use, depression, and anxiety, building on traditional elements of the Collaborative Care Model (CoCM). In this article, we describe this psychotherapy program in a primary care setting as part of a compendium of collaborative services.

RESULTS

Patients receive up to 12 sessions of evidence-based psychotherapy and case management based on a structured treatment manual that guides treatment via Motivational Enhancement; Cognitive Behavioral Therapies for depression, anxiety, and/or substance use disorder; and/or Behavioral Activation components.

DISCUSSION

Novel, integrated treatments are needed to advance service delivery for individuals with OUD and psychiatric conditions and these programs must be rigorously evaluated. We describe our team's efforts to test our psychotherapy program in a large primary care network as part of an ongoing three-arm randomized controlled trial. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The evaluation of cognitive-behavioral therapy-based intervention on type 2 diabetes patients with comorbid metabolic syndrome: a randomized controlled trial

BACKGROUND

Cognitive behavior therapy (CBT) has been applied in intervention research in diabetes patients with satisfying results. However, there was no research on type 2 diabetes (T2DM) patients with comorbidities. This study aimed to investigate the effectiveness of CBT on psychological variables, behavior variables, quality of life, sleep quality, and physical variables among adult T2DM patients with comorbid metabolic syndrome (MS).

METHODS

281 patients aged 18-75 years were recruited from Ningbo First Hospital in China from October 2021 to March 2022. Patients were randomized to the intervention group (IG, N = 148) or control group (CG, N = 133). Patients in the IG received 12 CBT-based sessions during a six-month intervention time. Patients in the CG received the usual care only. Univariate General Linear Model was used to analyze the effect of CBT-based interventions. The analysis was conducted by SPSS Version 28.

RESULTS

Results indicated that CBT-based intervention was superior in the following aspects: relieving depression symptoms: IG (4.11 ± 4.35 vs. 1.99 ± 2.12), CG (3.40 ± 3.26 vs. 2.32 ± 1.88), interaction effect (F = 4.074, P = 0.044); enhancing diabetes self-care behaviors: IG (26.79 ± 12.18 vs. 37.49 ± 10.83), CG (25.82 ± 13.71 vs. 31.96 ± 11.72), interaction effect (F = 5.242, P = 0.022); promoting the efficacy of CBT: IG (47.45 ± 6.83 vs. 50.76 ± 4.98), CG (46.74 ± 6.94 vs. 47.87 ± 5.11), interaction effect (F = 5.198, P = 0.023); improving subjective sleep quality: IG (0.93 ± 0.68 vs. 0.69 ± 0.63), CG (1.03 ± 0.72 vs. 1.01 ± 0.68), interaction effect (F = 3.927, P = 0.048).

CONCLUSIONS

The CBT-based intervention was beneficial in improving depression symptoms, diabetes self-care behaviors, the efficacy of CBT, and sleep quality in T2DM patients with comorbid MS. The downtrend of body mass index, systolic blood pressure, diastolic pressure, and glycated hemoglobin was larger in the intervention group but not to a significant level.

TRIAL REGISTRATION

This study has been prospectively registered at Australia New Zealand Clinical Trials Registry (Registration ID: ACTRN12621001348842 website: https://www.anzctr.org.au/trial/MyTrial.aspx ).

Depression and Suicide Risk Screening: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Depression is common and associated with substantial burden. Suicide rates have increased over the past decade, and both suicide attempts and deaths have devastating effects on individuals and families.

Objective

To review the benefits and harms of screening and treatment for depression and suicide risk and the accuracy of instruments to detect these conditions among primary care patients.

Data Sources

MEDLINE, PsychINFO, Cochrane library through September 7, 2022; references of existing reviews; ongoing surveillance for relevant literature through November 25, 2022.

Study Selection

English-language studies of screening or treatment compared with control conditions, or test accuracy of screening instruments (for depression, instruments were selected a priori; for suicide risk, all were included). Existing systematic reviews were used for treatment and test accuracy for depression.

Data Extraction and Synthesis

One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Findings were synthesized qualitatively, including reporting of meta-analysis results from existing systematic reviews; meta-analyses were conducted on original research when evidence was sufficient.

Main Outcomes and Measures

Depression outcomes; suicidal ideation, attempts, and deaths; sensitivity and specificity of screening tools.

Results

For depression, 105 studies were included: 32 original studies (N=385 607) and 73 systematic reviews (including ≈2138 studies [N ≈ 9.8 million]). Depression screening interventions, many of which included additional components beyond screening, were associated with a lower prevalence of depression or clinically important depressive symptomatology after 6 to 12 months (pooled odds ratio, 0.60 [95% CI, 0.50-0.73]; reported in 8 randomized clinical trials [n=10 244]; I2 = 0%). Several instruments demonstrated adequate test accuracy (eg, for the 9-item Patient Health Questionnaire at a cutoff of 10 or greater, the pooled sensitivity was 0.85 [95% CI, 0.79-0.89] and specificity was 0.85 [95% CI, 0.82-0.88]; reported in 47 studies [n = 11 234]). A large body of evidence supported benefits of psychological and pharmacologic treatment of depression. A pooled estimate from trials used for US Food and Drug Administration approval suggested a very small increase in the absolute risk of a suicide attempt with second-generation antidepressants (odds ratio, 1.53 [95% CI, 1.09-2.15]; n = 40 857; 0.7% of antidepressant users had a suicide attempt vs 0.3% of placebo users; median follow-up, 8 weeks). Twenty-seven studies (n = 24 826) addressed suicide risk. One randomized clinical trial (n=443) of a suicide risk screening intervention found no difference in suicidal ideation after 2 weeks between primary care patients who were and were not screened for suicide risk. Three studies of suicide risk test accuracy were included; none included replication of any instrument. The included suicide prevention studies generally did not demonstrate an improvement over usual care, which typically included specialty mental health treatment.

Conclusions and Relevance

Evidence supported depression screening in primary care settings, including during pregnancy and postpartum. There are numerous important gaps in the evidence for suicide risk screening in primary care settings.

Integrated Care for Complicated Patients: A Role for Combined Training and Practice

Patients with chronic medical disease frequently have comorbid psychiatric illness, yet mental and physical healthcare is frequently siloed in the United States. Integrated behavioral healthcare models, such as medicine-psychiatry services, are feasible, improve patient outcomes, and reduce costs. The Duke University Hospital medicine-psychiatry service provides holistic patient care and serves as a model for those interested in developing combined services or training programs elsewhere. Combined residency training in psychiatry is a way to provide a workforce of physician-scientist educators adept at providing coordinated, integrated care for complex patients with comorbid illness.

The increased prevalence of depression and anxiety in T2DM patients associated with blood glucose fluctuation and sleep quality

BACKGROUND

Current evidence demonstrates that blood glucose fluctuation can be associated with depression and anxiety. The association among blood glucose fluctuation, traditional risk factors and emotional disorders in T2DM should be studied and clarified.

METHODS

A total of 182 diabetic patients including 81 patients with depression or anxiety and 101 patients without emotional disorder were enrolled into this study. Data were obtained through medical history and questionnaire survey. Data were analyzed using appropriate statistical methods.

RESULTS

The comparison results of basic information between the two groups showed that the differences of the proportion of female were statistically significant (p = 0.002). There was no statistical difference in laboratory examination indexes between the two groups, however, standard deviation of blood glucose (SDBG) and postprandial glucose excursion (PPGE) of the comorbidity group were significantly higher than that of control group (p = 0.032 and p = 0.037). The results of questionnaire survey showed that there were statistically significant differences in sleep quality, PSQI and dietary habit between the two groups (p < 0.001, p < 0.001 and p < 0.001). Stratified analysis results according to gender showed that the percentage of cognitive disorder, anxiety and depression in female group was significantly higher than that in male group (p = 0.001, p < 0.001 and p < 0.001). Mini-mental state examination (MMSE), self-rating anxiety scale (SAS) and patient health questionnaire (PHQ-9) score in female group were also higher than male group (p = 0.001, p < 0.001 and p < 0.001). Logistic regression analysis results showed that SDBG and sleep quality were associated with emotional disorders in T2DM (p = 0.040 and p < 0.001) and the OR values of these factors were 7.588 (1.097-52.069) and 4.428 (2.649-7.401).

CONCLUSIONS

Blood glucose fluctuation and sleep quality are associated with the increased prevalence of depression and anxiety disorders in T2DM.

Depression, diabetes, comorbid depression and diabetes and risk of all-cause and cause-specific mortality: a prospective cohort study

AIMS/HYPOTHESIS

The aim of this study was to investigate the risks of all-cause and cause-specific mortality among participants with neither, one or both of diabetes and depression in a large prospective cohort study in the UK.

METHODS

Our study population included 499,830 UK Biobank participants without schizophrenia and bipolar disorder at baseline. Type 1 and type 2 diabetes and depression were identified using self-reported diagnoses, prescribed medication and hospital records. Mortality was identified from death records using the primary cause of death to define cause-specific mortality. We performed Cox proportional hazards models to estimate the risk of all-cause mortality and mortality from cancer, circulatory disease and causes of death other than circulatory disease or cancer among participants with either depression (n=41,791) or diabetes (n=22,677) alone and with comorbid diabetes and depression (n=3597) compared with the group with neither condition (n=431,765), adjusting for sociodemographic and lifestyle factors, comorbidities and history of CVD or cancer. We also investigated the interaction between diabetes and depression.

RESULTS

During a median of 6.8 (IQR 6.1-7.5) years of follow-up, there were 13,724 deaths (cancer, n=7976; circulatory disease, n=2827; other causes, n=2921). Adjusted HRs of all-cause mortality and mortality from cancer, circulatory disease and other causes were highest among people with comorbid depression and diabetes (HRs 2.16 [95% CI 1.94, 2.42]; 1.62 [95% CI 1.35, 1.93]; 2.22 [95% CI 1.80, 2.73]; and 3.60 [95% CI 2.93, 4.42], respectively). The risks of all-cause, cancer and other mortality among those with comorbid depression and diabetes exceeded the sum of the risks due to diabetes and depression alone.

CONCLUSIONS/INTERPRETATION

We confirmed that depression and diabetes individually are associated with an increased mortality risk and also identified that comorbid depression and diabetes have synergistic effects on the risk of all-cause mortality that are largely driven by deaths from cancer and causes other than circulatory disease and cancer.

The efficacy of cognitive behavioral therapy-based intervention on patients with diabetes: A meta-analysis

AIMS

This meta-analysis aims to update former meta-analyses from randomized controlled trials (RCT) focused on the efficacy of CBT for diabetes.

METHODS

Five databases were searched for RCTs. Primary outcomes were glycated hemoglobin (HbA_1c), fasting blood glucose (FBS), systolic blood pressure (SBP), diastolic blood pressure (DBP), and body mass index (BMI). Secondary outcomes were depression, anxiety and distress symptoms, quality of life, sleep quality.

RESULTS

32 RCTs were included. Results revealed that CBT could reduce HbA_1c: -0.14% (95% CI: -0.25 to -0.02%, P = 0.020); FBS: -15.48 mg/dl (95% CI: -30.16 to -0.81 mg/dl, P = 0.040); DBP: -2.88 mmHg (95% CI: -4.08 to -1.69 mmHg, P < 0.001); depression symptoms: -0.90 (95% CI: -1.22 to -0.57, P < 0.001); anxiety symptoms: -0.28 (95% CI: -0.50 to -0.07, P = 0.009); improve sleep quality: -0.92 (95% CI: -1.77 to -0.07, P = 0.030). Subgroup analysis indicated that CBT has siginificantly reduced HbA_1c when delivered as a group-based and face-to-face method, and psycho-education, behavioral, cognitive, goal-setting, homework assignment strategies were applied as central strategies.

CONCLUSION

CBT was an effective treatment for diabetes patients, significantly reduced their HbA_1c, FBS, DBP, depression and anxiety symptoms, and improved sleep quality.

Depression and Associated Risk Factors Among Type 2 Diabetic Patients: A Cross Sectional Study on a Convenience Sample from the Diabetic Center, Khamis Mushait; Saudi Arabia

BACKGROUND

Studies had confirmed that diabetic patients have a greater risk for developing depression. Our objectives were to estimate the prevalence and predictors of depression among type 2 diabetic patients.

METHODS

A cross-sectional study at the Diabetic Center, Armed Forces Hospital-Southern Region (AFHSR), Khamis Mushait was conducted in the period from March to June 2017. The study includes a convenience sample of type 2 diabetic patients. Self-administered questionnaires were utilized. It consists of personal characteristics, diabetes-related information's, and the Arabic version of the Patient Health Questionnaire (PHQ-9). Proper statistical analyses were done to assess the significance of the correlates with p ≤ 0.05 considered significant.

RESULTS

The study included 350 diabetic patients out of 410 with a response rate of 85.4%. Their age ranged between 28 and 100 years with a mean ±SD of 61.4±13 years. The prevalence of depression among them was 36.6%. Logistic regression revealed that patients older than 50 years were at lower risk for developing depression as compared to those aged between 28 and 40 years OR and 95% CI were 0.21 (0.08-0.57), 0.30 (0.12-0.78) and 0.33 (0.12-0.91) for patients in the age groups 51-60, 61-70 and > 70 years, respectively. Diabetic patients with thyroid dysfunction, neuropathy, those treated with insulin, and noncompliant patients were at double risk for developing depression compared to their counterparts (OR = 2.26, 95% CI = 1.20-4.27, p = 0.012); (OR = 2.35, 95% CI = 1.22-4.53, p = 0.011); (OR = 1.92, 95% CI = 1.08-3.40, p = 0.026); (AOR = 2.14, 95% CI = 1.01-4.53, p = 0.047) respectively.

CONCLUSION

Almost one third of type 2 diabetic patients were depressed. Younger patients, having comorbid thyroid disorders or neuropathy, those treated with insulin and noncompliant patients were at higher risk for developing depression. Proper screening and treatment of depression is a crucial part of the health care management of diabetic people.

Effectiveness of intervention program on the change of glycaemic control in diabetes with depression patients: A meta-analysis of randomized controlled studies

AIM

The glycaemic control of diabetes with depression was inconsistent from randomized controlled studies. This meta-analysis aimed to explore the effectiveness of intervention methods in diabetes with depression.

METHODS

This study systematically searched electronic databases (PubMed, EBSCO, Elsevier, Springer, Wiley, and Cochrane) for studies published up to August 17, 2020. Standardized mean difference (SMD) and 95%CI were used to evaluate the effectiveness of interventions on HbA1c. Heterogeneity was estimated using the I² statistic. Begg's test was used to assess the possible publication bias among studies.

RESULTS

Twelve studies of 2444 cases were included in this study. The overall SMD is -0.22 and 95%CI -0.33 to -0.10 in 0-6 months of intervention group. The I² and P were 18.4% and 0.26. There are no publication bias tested (z = 0.37, P = 0.72).

CONCLUSION

Cognitive behavioral therapy and mindful self-compassion might be effective method to improve glycaemic control of diabetes with depression in 0-6 months.

Anxiety, depression and their associated risk factors among patients with diabetic foot ulcer: A two center cross-sectional study in Jordan and Saudi Arabia

BACKGROUND AND AIMS

To determine and analyze the factors related to anxiety and depression in patients having diabetic foot ulcer (DFU).

METHODS

This two-center, cross-sectional study was conducted among 250 patients with DFU, who were receiving treatment in the outpatient diabetes foot care clinic at Prince Sultan Military Medical City, Saudi Arabia and National Center for Diabetes, Endocrinology and Genetics, Jordan. Employing the Hospital Anxiety and Depression Scale (HADS), the anxiety and depression levels of the study population were measured. The demographic variables were also recorded.

RESULTS

Females displayed significantly higher anxiety (p = 0.032) and depression levels (p = 0.043); and those who were unmarried showed higher anxiety (p = 0.042). School educated patients showed reduced degrees of anxiety (p = 0.023) and depression (p = 0.003) and college educated showed reduced anxiety (p = 0.047) compared to uneducated. Compared to patients on treatment with diet, a significant decline was found in depression (p = 0.034) levels among orally treated patients. Compared to patients on oral medication, patients with oral and insulin treatments revealed higher depression (p = 0.026). Higher-income patients showed a significant decline for anxiety (p = 0.004). Patients who were past smokers had higher anxiety (p = 0.046) than current and never had been smokers. Higher anxiety (p = 0.017) was observed in patients having higher HbA1c levels, similarly, patients with three diabetes-related complications showed higher levels of anxiety (p = 0.001) and depression (p = 0.001).

CONCLUSION

Female gender, lower education levels, patients on oral and insulin treatments, low income, high HbA1c levels and patients experiencing a higher number of diabetes-related complications showed either higher anxiety or depression levels.

[Depressive disorders: An often underestimated comorbidity in diabetes]

People with diabetes often have a depressive disorder in addition to diabetes, which makes therapy more difficult and worsens the prognosis of the disease. Depression is an often underestimated risk factor in the context of diabetes. The aim of this article is to illustrate the significance of depression in diabetes for the course of the disease and to provide an overview of the most important diagnostic and therapeutic recommendations for practice.

People with diabetes need a lower cut-off than others for depression screening with PHQ-9

Aims

This study evaluated the psychometric characteristics of the Polish version of the PHQ-9 in detecting major depression (MDD) and ‘MDD and/or dysthymia’ in people with and without type 2 diabetes.

Methods

Participants were randomly selected from a diabetes outpatient facility (N = 216) and from among patients admitted to a medical center and psychiatric hospital (N = 99). The participants completed the PHQ-9. The Hamilton Depression Rating Scale and the Mini International Neuropsychiatric Interview were used to identify the presence of psychiatric symptoms. The optimal cut-offs for PHQ-9 in people with and without type 2 diabetes were investigated based on two methods: 1) Youden’s index which identifies cut-off points useful in scientific research; 2) a second method of two-stage screening for depressive disorders to provide guidance for clinical practice.

Results

The Polish version of the PHQ-9 is a reliable and valid screening tool for depression in people with and without type 2 diabetes. An optimal cut-off of ≥ 7 was indicated by Youden’s index and ≥ 5 by the two-stage method for screening for MDD and ‘MDD and/or dysthymia’ in the group with type 2 diabetes. A cut-off of ≥ 11 was optimal for screening for both MDD and ‘MDD and/or dysthymia’ among people without diabetes (Youden’s index). The two-stage approach suggested a ≥ 10 score for screening for MDD and ≥ 9 for screening for ‘MDD and/or dysthymia’ in people without diabetes.

Conclusions

A lower cut-off score of the PHQ-9 is recommended for people with type 2 diabetes as compared to the general population.

Efficacy of Depression Management in an Integrated Psychiatric-Diabetes Education Clinic for Comorbid Depression and Diabetes Mellitus Types 1 and 2

OBJECTIVES

Patients with type 1 and type 2 diabetes mellitus (DM) are 2 times as predisposed to developing mood disorders, such as major depressive disorder (MDD), compared with patients without diabetes. Management of comorbid MDD and DM remains a challenge because patients often suffer from poor medication compliance, lifestyle factors and refractory depression. Integration of psychiatric care into diabetes education clinics (DECs) has been suggested as an effective method of managing the comorbid conditions. As this strategy is being implemented into clinical care, its effectiveness in practice warrants further research.

METHODS

A retrospective chart review of 24 patients (10 men and 14 women) followed by an integrated psychiatry-DEC in Newmarket, Ontario, Canada, between April 2016 and July 2019 was performed. Depressive symptom severity at each appointment was assessed with the Patient Health Questionnaire-9 (PHQ-9) depression rating scale.

RESULTS

There was no significant change in PHQ-9 depression rating scale scoring between the first and most recent appointments (paired t test, p=0.356); however, patients who had improved PHQ-9 scoring were more likely to have more clinic visits (analysis of variance, p=0.0271). A significant negative correlation was found between both number of visits (Pearson coefficient, -0.56; p=0.005) and overall time the patients were followed by DEC (Pearson coefficient, -0.42; p=0.040) and PHQ-9 score changes between the first and most recent appointments. PHQ-9 change between individual appointments also displayed a positive correlation with time between appointments (Pearson coefficient, 0.26; p=0.027).

CONCLUSIONS

Regular follow up in a psychiatry-DEC service might be beneficial in managing MDD symptom severity for comorbid MDD and DM.

Patient and public involvement in integrated psychosocial care

Purpose

Recent models of care incorporate service user involvement within the development and sustainability of a quality improvement project. The purpose of this paper is to demonstrate the significance of working with patients and members of the public for the integration of psychosocial care into long-term condition (LTC) management.

Design/methodology/approach

Research shows that mental health difficulties are more prevalent in people with LTC. The three Dimensions for Long-term Conditions (3DLC) is a patient-centred multidisciplinary service which integrates psychological and social care into the usual physical care. Thematic analysis was conducted on the discussions of the two patient and public involvement workshops that were facilitated by the service. The workshops included healthcare professionals, patients with LTC and their carers.

Findings

Several themes and subthemes emerged which highlighted the importance of discussing and treating mental health in a physical health setting, the challenges that both the patients and healthcare professionals encounter and the ways in which an integrated care service may address these barriers. The findings show that there was an emphasis on patient-centeredness, accessibility of services and the need for better communication.

Practical implications

People with LTC can be empowered to better self-manage their condition, whilst having access to all types of care, physical, social and psychological. By involving service users in the implementation process of the 3DLC service, the components of an effective integrated service are delineated.

Originality/value

The service users have identified barriers and facilitators of integrating a biopsychosocial model in care pathways. This has helped the 3DLC team to further develop the model to ensure improvements in condition-specific outcomes, quality of life and healthcare utilisation.

Assessing rates and contextual predictors of 5-year mortality among HIV-infected and HIV-uninfected individuals following HIV testing in Durban, South Africa

Background

Little is known about contextual factors that predict long-term mortality following HIV testing in resource-limited settings. We evaluated the impact of contextual factors on 5-year mortality among HIV-infected and HIV-uninfected individuals in Durban, South Africa.

Methods

We used data from the Sizanani trial (NCT01188941) in which adults (≥18y) were enrolled prior to HIV testing at 4 outpatient sites. We ascertained vital status via the South African National Population Register. We used random survival forests to identify the most influential predictors of time to death and incorporated these into a Cox model that included age, gender, HIV status, CD4 count, healthcare usage, health facility type, mental health, and self-identified barriers to care (i.e., service delivery, financial, logistical, structural and perceived health).

Results

Among 4816 participants, 39% were HIV-infected. Median age was 31y and 49% were female. 380 of 2508 with survival information (15%) died during median follow-up of 5.8y. For both HIV-infected and HIV-uninfected participants, each additional barrier domain increased the HR of dying by 11% (HR 1.11, 95% CI 1.05–1.18). Every 10-point increase in mental health score decreased the HR by 7% (HR 0.93, 95% CI 0.89–0.97). The hazard ratio (HR) for death of HIV-infected versus HIV-uninfected varied by age: HR of 6.59 (95% CI: 4.79–9.06) at age 20 dropping to a HR of 1.13 (95% CI: 0.86–1.48) at age 60.

Conclusions

Independent of serostatus, more self-identified barrier domains and poorer mental health increased mortality risk. Additionally, the impact of HIV on mortality was most pronounced in younger persons. These factors may be used to identify high-risk individuals requiring intensive follow up, regardless of serostatus.

Trial registration

Clinical Trials.gov Identifier NCT01188941. Registered 26 August 2010.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4373-9) contains supplementary material, which is available to authorized users.

Depressive Symptoms and All-Cause Mortality in Older American Indians with Type 2 Diabetes Mellitus

OBJECTIVES

American Indians experience disproportionately high rates of poor mental health and type 2 diabetes mellitus (T2DM). We examined the association between depressive symptoms and all-cause mortality in older American Indians with T2DM.

DESIGN

We used the Native Elder Care Study survey data from community-dwelling American Indians aged 55 years or older, linked to data extracted from participants' electronic health records. We focused on those who had an International Classification of Diseases-Ninth Revision diagnosis of T2DM in their electronic health records.

SETTING

The study was conducted with a federally-recognized tribe with approximately 16,000 enrolled members, most of whom reside on or near tribally-owned lands that span several rural counties.

PARTICIPANTS

Participants were among the Native Elder Care Study participants with a final analytic sample of 222.

MEASUREMENTS

We measured depressive symptoms with the Centers for Epidemiologic Studies-Depression (CES-D) scale. We used Cox proportional hazard models to examine the association between depressive symptoms and all-cause mortality in the final analytic sample of 222 subjects.

RESULTS

Survival curves revealed that individuals in the third and fourth CES-D scale categories had higher mortality than those in the first and second categories. Mortality risk was significantly higher for participants with CES-D scale scores in the third highest compared with the lowest category (hazard ratio = 2.07; 95% confidence interval = 1.07-4.04), after adjustment for demographic characteristics, health behaviors, obesity, and prevalent T2DM complications. Analyses with the CES-D scale as a continuous variable also showed a positive association with mortality.

CONCLUSION

The impact of mental health on older American Indians with T2DM is often overlooked, yet it is vital to clinical and public health practice. Our findings underscore the importance of addressing the mental health needs of this population, particularly because depression in older patients is often undetected or inadequately treated. J Am Geriatr Soc 67:1940-1945, 2019.

Prevalence of comorbid major depressive disorder in Type 2 diabetes: a meta-analysis of comparative and epidemiological studies

AIMS

To examine the average point prevalence of major depressive disorder in people with Type 2 diabetes and its associated factors in a comprehensive meta-analysis.

METHODS

Two researchers independently conducted a systematic literature search of PubMed, EMBASE, PsycINFO and Cochrane databases. Studies reporting the prevalence of major depressive disorder in people with Type 2 diabetes were identified and analysed using a random-effects model.

RESULTS

A total of 26 studies meeting the inclusion criteria were included in the study. The point prevalence of major depressive disorder was 14.5% (95% CI 7.9-25.3; I²=99.65). People with Type 2 diabetes were more likely to have major depressive disorder compared with the general population (odds ratio 1.73, 95% CI 1.38-2.16). Subgroup and meta-regression analyses showed that study site, study type, diagnostic criteria and age significantly moderated the prevalence of major depressive disorder.

CONCLUSIONS

In this meta-analysis, the average point prevalence of major depressive disorder in people with Type 2 diabetes was high. Routine screening and more effective interventions should be implemented for this population.

Assessment of Long-term Follow-up of Randomized Trial Participants by Linkage to Routinely Collected Data: A Scoping Review and Analysis

Importance

Follow-up of participants in randomized trials may be limited by logistic and financial factors. Some important randomized trials have been extended well beyond their original follow-up period by linkage of individual participant information to routinely collected data held in administrative records and registries.

Objective

To perform a scoping review of randomized clinical trials extended by record linkage to characterize this literature and explore any additional insights into treatment effectiveness provided by long-term follow-up using record linkage.

Data Sources

A literature search in Embase, CINAHL, MEDLINE, and the Cochrane Register of Controlled Trials was performed for the period January 1, 1945, through November 25, 2016.

Study Selection

Various combinations of search terms were used, as there is no accepted terminology. Determination of study eligibility and extraction of information about trial characteristics and outcomes, for both original and extended trial reports, were performed in duplicate.

Data Extraction and Synthesis

Assessment of study eligibility and data extraction were performed independently by 2 reviewers. All analyses were descriptive.

Main Outcomes and Measures

Outcomes in the pairs of original and extended trials were categorized according to whether any benefits or harms from interventions were sustained, were lost, or emerged during long-term follow-up.

Results

A total of 113 extended trials were included in the study. Linkage to administrative and registry data extended follow-up by between 1 and 55 years. The most common interventions were pharmaceuticals (47 [41.6%]), surgery (19 [16.8%]), and disease screening (19 [16.8%]). End points most frequently studied through record linkage included mortality (88 [77.9%]), cancer (41 [36.3%]), and cardiovascular events (37 [32.7%]). One hundred four trial extensions (92.0%) were analyzed according to the original trial randomization. The reports provided details of 155 analyses of study outcomes. Seventy-four analyses (47.7%) identified statistically significant benefits in the trial extension phase. In 21 of these (28.4%), benefits were significant only in this period. Null results in both the original and extended trials were seen in 34 of the analyses (21.9%). Loss of significant benefits of an intervention were seen in 12 analyses (7.7%). Statistically significant harms were seen in 16 trial extension analyses (10.3%), and in 14 of these (87.5%), the harms were significant only in the trial extension phase.

Conclusions and Relevance

Trial extension by linkage to routinely collected data is a versatile underused approach that may add critical insights beyond those of the original trial. Some beneficial and harmful outcomes of interventions are captured only in the extension phase of randomized trials.

Is Depression a Modifiable Risk Factor for Diabetes Burden?

The purpose of this review article was to examine the empirical evidence supporting depression as a risk factor for diabetes complications and associated burden. A database search using keywords located recent clinical and population studies addressing the association between depression and type 2 diabetes. Both cross-sectional and cohort studies were reviewed. Depression appears to exacerbate the progression of type 2 diabetes. The evidence is strong supporting the hypothesis that depression in persons with diabetes increases the risk of diabetes-related burden, including suboptimal glycemic control, complications, functionality, mortality, and health care utilization. Screening for depression among patients with diabetes should be increased in primary care. Newer approaches to diabetes care management may help to slow the progression of diabetes.

Depressive Symptoms, Co-Morbidities, and Glycemic Control in Hong Kong Chinese Elderly Patients With Type 2 Diabetes Mellitus

BACKGROUND AND OBJECTIVES

Undiagnosed depression is an important comorbidity in type 2 diabetes (T2D) which can be detected using the Geriatric Depression Scale (GDS-15) questionnaire. In this cross-sectional study, we examined the associations of depression using GDS score with control of cardiometabolic risk factors and health status in elderly patients with T2D.

SETTING AND PARTICIPANTS

Between February and December 2013, patients aged ≥65 years who underwent structured comprehensive assessment as a quality improvement program at the Diabetes Center of a teaching hospital were invited to complete the GDS-15 questionnaire.

MAIN OUTCOME MEASURES

Depression was defined as a GDS score ≥7. Demographic data, prior history of co-morbidities, frequency of self-reported hypoglycemia, and attainment of treatment targets defined as HbA_1c, <7%, blood pressure <130/80 mmHg, and LDL-C <2.6 mmol/L were documented.

RESULTS

Among 325 participants (65% male, median [interquartile range] age: 69 [8] years), 42 (13%) had depression. Patients with depression had longer disease durations (mean ± SD: 15.1 ± 9.1 vs. 11.6 ± 8.1 years, P = 0.02), more frequent self-reported hypoglycemic events (17 vs. 6%, P = 0.03) and were less likely to attain all three treatment targets (0 vs. 16%, P = 0.004) than those without depression. On multivariable analysis, patients with depression had an odds ratio of 2.84 (95% confidence intervals: 1.35-6.00, P = 0.006) of reporting prior history of co-morbidities.

CONCLUSION

In elderly patients with T2D, depression was not uncommon especially in those with poor control of risk factors, hypoglycemia, and co-morbidities. Inclusion of GDS-15 questionnaire during structured assessment for complications and risk factors can identify these high-risk patients for more holistic management of their physical and mental health.

Serious Mental Illness and Its Impact on Diabetes Care in a VA Nurse/ Pharmacist-Managed Population

Collaboration between a registered nurse-certified diabetes educator and clinical pharmacy specialist improved access to care and glycemic control in veterans with diabetes and mental illness.

MANAGEMENT OF ENDOCRINE DISEASE: Suicide risk in patients with diabetes: a systematic review and meta-analysis

BACKGROUND

Previous studies investigating the risk of suicide in diabetes patients reported controversial findings. We did a systematic review and meta-analysis to comprehensively estimate the risk and incidence rate of suicide in diabetic patients.

METHODS

PubMed, EMBASE and PsycINFO were searched for eligible studies. Random-effects meta-analysis was used to calculate the relative risk (RR) and the incidence rate of suicide in diabetes patients. We also calculated the proportion of deaths attributable to suicide among diabetes patients.

RESULTS

54 studies were finally included, including 28 studies on the suicide risk associated with diabetes, 47 studies on the incidence rate of suicide and 45 studies on the proportion of deaths attributable to suicide. Meta-analysis showed that diabetes could significantly increase the risk of suicide (RR = 1.56; 95% CI: 1.29-1.89; P < 0.001). Subgroup analysis showed that the RR of suicide associated with type 1 diabetes was 2.25 (95% CI: 1.50-3.38; P < 0.001). The pooled incidence rate of suicide in patients with diabetes was 2.35 per 10 000 person-years (95% CI: 1.51-3.64). The pooled proportions of long-term deaths attributable to suicide in type 1 diabetes patients and type 2 diabetes patients were 7.7% (95% CI: 6.0-9.8) and 1.3% (95% CI: 0.6-2.6), respectively.

CONCLUSION

This meta-analysis suggests that diabetes can significantly increase the risk of suicide. Suicide has an obvious contribution to mortality in diabetic patients, especially among type 1 diabetes patients. Effective strategies to decrease suicide risk and improve mental health outcomes in diabetes patients are needed.

Depression: a common and burdensome complication of diabetes that warrants the continued attention of clinicians, researchers and healthcare policy makers

There is ample evidence that depression is a common comorbid health issue in people with type 1 or type 2 diabetes. Reviews have also concluded that depression in diabetes is associated with higher HbA_1c levels, less optimal self-care behaviours, lower quality of life, incident vascular complications and higher mortality rates. However, longitudinal studies into the course of depression in people with type 1 diabetes remain scarce. In this issue of Diabetologia, Kampling and colleagues (doi: 10.1007/s00125-016-4123-0 ) report the 5 year trajectories of depression in adults with newly diagnosed type 1 diabetes (mean age, 28 years). Their baseline results showed that shortly after the diagnosis of type 1 diabetes a major depressive episode was diagnosed in approximately 6% of participants, while 8% suffered from an anxiety disorder. The longitudinal depression data showed that, in a 5 year period, 79% reported no depressive symptoms at any time, while 7% had a high depression score that improved and 14% reported worsening of depressive symptoms. Here, the clinical relevance of these findings is discussed and areas for further research are described.

Role of depression in diabetes management in an ethnic minority population: a case of Korean Americans with type 2 diabetes

BACKGROUND

Comorbid depression and diabetes mellitus (DM) compound challenges to disease management such as low health literacy, insufficient access to care, and social or linguistic isolation. Korean Americans (KAs), predominantly first-generation immigrants, suffer from a high prevalence of type 2 DM and depression. Limited research on KAs has prevented the development of effective interventions.

OBJECTIVES

To compare the prevalence of depression in KAs with DM and all Americans with/without DM, and to explore correlates of comorbid DM and depression and strategies to address KAs' DM and depression.

METHODS

KAs' data were from a clinical trial of a community-based self-help intervention to improve KAs' DM and mental health outcomes. National Health and Nutrition Examination Survey data sets enabled comparison. Clinical indicators included hemoglobin A1C, lipid panel, and body mass index. Psychobehavioral indicators included self-efficacy for DM management, quality of life, and depression (Patient Health Questionnaire-9 (PHQ-9)).

RESULTS

More KAs with DM had depression (44.2%) than did all Americans with DM (28.7%) or without DM (20.1%). Significantly more KAs with DM had mild (29.3%) or clinical (14.9%) depression than did Americans with DM (mild, 17.2%; clinical, 11.5%) or without (mild, 13.8%; clinical, 6.3%). One of six KAs with DM (16.9%) thought of suicide or self-harm (Americans with/without =5.0%, 2.8%). The self-help intervention reduced the mean PHQ-9 from 5.4 at baseline to 4.1 at 12 months.

LIMITATIONS

External validity might be limited; KAs' data were from one study site.

CONCLUSIONS

The prevalence of depression and DM among KAs warrants the development of efficacious interventions.

TRIAL REGISTRATION NUMBER

NCT01264796.

Understanding the body-mind in primary care

Patients' experience of symptoms does not follow the body-mind divide that characterizes the classification of disease in the health care system. Therefore, understanding patients in their entirety rather than in parts demands a different theoretical approach. Attempts have been made to formulate such approaches but many of these, such as the biopsychosocial model, are still basically dualistic or methodologically reductionist. In primary care, patients often present with diffuse symptoms, making primary care the ideal environment for understanding patients' undifferentiated symptoms and disease patterns which could readily fit both bodily and mental categories. In this article we discuss theoretical models that have attempted to overcome this challenge: The psychosomatic approach could be called holistic in the sense of taking an anti-dualistic stance. Primary care theorists have formulated integrative views but these have not gained a foothold in primary care medicine. McWhinney introduced a new metaphor, 'the body-mind', and Rudebeck advocated cultivating 'bodily empathy'. These views have much in common with both phenomenological thinking and mentalization, a psychological concept for understanding others. In the process of understanding patients there is a need for the physician to enter an intersubjectivity that aims at understanding the patient's experiences and sensations without initially jumping to diagnostic conclusions or into a division into mental and physical phenomena. Mentalization theory could form the basis of an approach to a more comprehensive understanding of patients. The success of such an approach is, however, dependent upon structural and organizational conditions that do not counteract it.

Psychosocial Factors in Diabetes and Cardiovascular Risk

Type 2 diabetes is a chronic disease that is increasing in prevalence globally. Cardiovascular disease is a major cause of mortality and morbidity in diabetes, and lifestyle and clinical risk factors do not fully account for the link between the conditions. This article provides an overview of the evidence concerning the role of psychosocial stress factors in diabetes risk, as well as in cardiovascular complications in people with existing diabetes. Several types of psychosocial factors are discussed including depression, other types of emotional distress, exposure to stressful conditions, and personality traits. The potential behavioral and biological pathways linking psychosocial factors to diabetes are presented and implications for patient care are highlighted.

Impact of lifestyle interventions on depressive symptoms in individuals at-risk of, or with, type 2 diabetes mellitus: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND AIM

Depression affects one in four individuals with type 2 diabetes mellitus (T2DM). The impact of T2DM lifestyle interventions on depression is unclear. The aim of this analysis was to examine the influence of lifestyle interventions on depressive symptoms scores in individuals at-risk of or with T2DM.

METHOD AND RESULTS

Major bibliographic databases were searched for studies published in English from 1990 to 2015. Meta-analysis was conducted by random-effects model. Nineteen studies were included in the meta-analyses. A significant reduction in depression scores was shown for lifestyle interventions in the pooled analysis (Standardized Mean Difference (SMD): -0.165; 95%CI: -0.265, -0.064; I(2):67.9%) and when limited to individuals with T2DM (SMD: -0.202; 95%CI: -0.288, -0.079; I(2):72.5%). In subgroup analyses the most effective intervention methods were face-to-face individual consultations (SMD: -0.241; 95%CI: -0.403, -0.078, I(2): 50.8%) with a duration of ≤6 months (SMD: -0.203; 95%CI: -0.381, -0.026, I(2):59.9%). Interventions were most effective when delivered four times a month (SMD: -0.247; 95%CI: -0.441, -0.053, I(2):76.3%).

CONCLUSIONS

Lifestyle interventions were effective in improving depression among people with T2DM.

Anxiety and diabetes: Innovative approaches to management in primary care

Type 2 diabetes mellitus is a chief concern for patients, healthcare providers, and health care systems in America, and around the globe. Individuals with type 2 diabetes mellitus exhibit clinical and subclinical symptoms of anxiety more frequently than people without diabetes. Anxiety is traditionally associated with poor metabolic outcomes and increased medical complications among those with type 2 diabetes mellitus. Collaborative care models have been utilized in the multidisciplinary treatment of mental health problems and chronic disease, and have demonstrated success in managing the pathology of depression which often accompanies diabetes. However, no specific treatment model has been published that links the treatment of anxiety to the treatment of type 2 diabetes mellitus. Given the success of collaborative care models in treating depression associated with diabetes, and anxiety unrelated to chronic disease, it is possible that the collaborative care treatment of primary care patients who suffer from both anxiety and diabetes could be met with the same success. The key issue is determining how to implement and sustain these models in practice. This review summarizes the proposed link between anxiety and diabetes, and offers an innovative and evidence-based collaborative care model for anxiety and diabetes in primary care.

Does a Depression Management Program Decrease Mortality in Older Adults with Specific Medical Conditions in Primary Care? An Exploratory Analysis

OBJECTIVES

To determine whether treating depression decreases mortality from various chronic medical conditions.

DESIGN

Long-term follow-up of multisite-practice randomized controlled trial (Prevention of Suicide in Primary Care Elderly: Collaborative Trial).

SETTING

Twenty primary care practices randomized to intervention or usual care.

PARTICIPANTS

Individuals aged 60 and older identified through depression screening of random patients (N=1,226).

INTERVENTION

For 2 years, a depression care manager worked with primary care physicians in intervention practices to provide algorithm-based care for depression.

MEASUREMENTS

Mortality risk based on a median follow-up of 98 months (range 0.8-116.4 months) through 2008; chronic medical conditions ascertained through self-report.

RESULTS

For heart disease, persons with major depression were at greater risk of death, whether in usual-care or intervention practices. Older adults with major depression and diabetes mellitus in practices randomized to the intervention condition (hazard ratio=0.47, 95% confidence interval=0.24-0.91) were less likely to die. For other medical conditions, the point estimates for risk of death in persons with major depression were all in the direction of indicating lower risk in intervention practices but did not reach statistical significance.

CONCLUSION

Older adults with depression and medical comorbidity pose a significant clinical and public health challenge. Evidence was found of a statistically significant intervention effect on mortality for diabetes mellitus in persons with major depression.

Blood glucose regulation mechanism in depressive disorder animal model during hyperglycemic states

Depression is more common among diabetes people than in the general population. In the present study, blood glucose change in depression animal model was characterized by various types of hyperglycemia models such as d-glucose-fed-, immobilization stress-, and drug-induced hyperglycemia models. First, the ICR mice were enforced into chronic restraint stress for 2h daily for 2 weeks to produce depression animal model. The animals were fed with d-glucose (2g/kg), forced into restraint stress for 30min, or administered with clonidine (5μg/5μl) supraspinally or spinally to produce hyperglycemia. The blood glucose level in depression group was down-regulated compared to that observed in the normal group in d-glucose-fed-, restraint stress-, and clonidine-induced hyperglycemia models. The up-regulated corticosterone level induced by d-glucose feeding or restraint stress was reduced in the depression group while the up-regulation of plasma corticosterone level is further elevated after i.t. or i.c.v. clonidine administration in the depression group. The up-regulated insulin level induced by d-glucose feeding or restraint stress was reduced in the depression group. On the other hand, blood corticosterone level in depression group was up-regulated compared to the normal group after i.t. or i.c.v. clonidine administration. Whereas the insulin level in depression group was not altered when mice were administered clonidine i.t. or i.c.v. Our results suggest that the blood glucose level in depression group is down-regulated compared to the normal group during d-glucose-fed-, immobilization stress-, and clonidine-induced hyperglycemia in mice. The down-regulation of the blood glucose level might be one of the important pathophysiologic changes in depression.

Input of stakeholders on reducing depressive symptoms and improving diabetes outcomes in India: Formative work for the INDEPENDENT Study

AIMS

Depression and diabetes are highly comorbid, adversely affecting treatment adherence and resulting in poor outcomes. To improve treatment and outcomes for people dually-affected by diabetes and depression in India, we aimed to develop and test an integrated care model. In the formative phase of this INtegrated DEPrEssioN and Diabetes TreatmENT (INDEPENDENT) study, we sought stakeholder perspectives to inform culturally-sensitive adaptations of the intervention.

METHODS

At our Delhi, Chennai, and Vishakhapatnam sites, we conducted focus groups for patients with diabetes and depression and interviewed healthcare workers, family members, and patients. These key informants were asked about experiences with diabetes and depression and for feedback on intervention materials. Data were analyzed using a grounded theory approach.

RESULTS

Three major themes emerged that have bearing on adaptation of the proposed intervention: importance of family assistance, concerns regarding patient/family understanding of diabetes, and feedback regarding the proposed intervention (e.g. adequate time needed for implementation; training program and intervention should address stigma).

CONCLUSIONS

Based on our findings, the following components would add value when incorporated into the intervention: 1) engaging families in the treatment process, 2) clear/simple written information, 3) clear non-jargon verbal explanations, and 4) coaching to help patients cope with stigma.

The excess mortality of patients with diabetes and concurrent psychiatric illness is markedly reduced by structured personal diabetes care: A 19-year follow up of the randomized controlled study Diabetes Care in General Practice (DCGP)

OBJECTIVE

To assess the effectiveness of an intervention in Type 2 diabetic patients with concurrent psychiatric illness (PI) and compare this with the effectiveness in patients without PI.

METHOD

In the Diabetes Care in General Practice trial, 1381 patients newly diagnosed with Type 2 diabetes were randomized to 6 years of structured personal diabetes care or routine diabetes care (ClinicalTrials.gov NCT01074762). In this observational post-hoc analysis, the effectiveness of the intervention for diabetes in 179 patients with concurrent PI was analyzed.

RESULTS

During the 19-year follow-up period, patients with PI in the structured personal care group experienced a lower risk for all-cause mortality [105.3 vs. 140.4 events per 1000 patient-years; hazard ratio (HR): 0.63, P=0.023, multivariably adjusted], diabetes-related death (66.0 vs. 95.1; HR: 0.57, P=0.015), any diabetes-related endpoint (169.5 vs. 417.5; HR: 0.47, P=0.0009) and myocardial infarction (54.1 vs. 104.4; HR: 0.48, P=0.013), compared to patients with PI in the routine care group. This translates into a number needed to treat over 10 years of three or lower for these outcomes.

CONCLUSION

These findings suggest that in primary care, structured diabetes care allowing for individualization was highly effective among diabetic patients with co-occurring PI.

Association between guideline recommended drugs and death in older adults with multiple chronic conditions: population based cohort study

OBJECTIVE

To estimate the association between guideline recommended drugs and death in older adults with multiple chronic conditions.

DESIGN

Population based cohort study.

SETTING

Medicare Current Beneficiary Survey cohort, a nationally representative sample of Americans aged 65 years or more.

PARTICIPANTS

8578 older adults with two or more study chronic conditions (atrial fibrillation, coronary artery disease, chronic kidney disease, depression, diabetes, heart failure, hyperlipidemia, hypertension, and thromboembolic disease), followed through 2011.

EXPOSURES

Drugs included β blockers, calcium channel blockers, clopidogrel, metformin, renin-angiotensin system (RAS) blockers; selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs); statins; thiazides; and warfarin.

MAIN OUTCOME MEASURE

Adjusted hazard ratios for death among participants with a condition and taking a guideline recommended drug relative to participants with the condition not taking the drug and among participants with the most common combinations of four conditions.

RESULTS

Over 50% of participants with each condition received the recommended drugs regardless of coexisting conditions; 1287/8578 (15%) participants died during the three years of follow-up. Among cardiovascular drugs, β blockers, calcium channel blockers, RAS blockers, and statins were associated with reduced mortality for indicated conditions. For example, the adjusted hazard ratio for β blockers was 0.59 (95% confidence interval 0.48 to 0.72) for people with atrial fibrillation and 0.68 (0.57 to 0.81) for those with heart failure. The adjusted hazard ratios for cardiovascular drugs were similar to those with common combinations of four coexisting conditions, with trends toward variable effects for β blockers. None of clopidogrel, metformin, or SSRIs/SNRIs was associated with reduced mortality. Warfarin was associated with a reduced risk of death among those with atrial fibrillation (adjusted hazard ratio 0.69, 95% confidence interval 0.56 to 0.85) and thromboembolic disease (0.44, 0.30 to 0.62). Attenuation in the association with reduced risk of death was found with warfarin in participants with some combinations of coexisting conditions.

CONCLUSIONS

Average effects on survival, particularly for cardiovascular study drugs, were comparable to those reported in randomized controlled trials but varied for some drugs according to coexisting conditions. Determining treatment effects in combinations of conditions may guide prescribing in people with multiple chronic conditions.

The Affordable Care Act, Accountable Care Organizations, and Mental Health Care for Older Adults: Implications and Opportunities

The Patient Protection and Affordable Care Act (ACA) represents the most significant legislative change in the United States health care system in nearly half a century. Key elements of the ACA include reforms aimed at addressing high-cost, complex, vulnerable patient populations. Older adults with mental health disorders are a rapidly growing segment of the population and are among the most challenging subgroups within health care, and they account for a disproportionate amount of costs. What does the ACA mean for geriatric mental health? We address this question by highlighting opportunities for reaching older adults with mental health disorders by leveraging the diverse elements of the ACA. We describe nine relevant initiatives: (1) accountable care organizations, (2) patient-centered medical homes, (3) Medicaid-financed specialty health homes, (4) hospital readmission and health care transitions initiatives, (5) Medicare annual wellness visit, (6) quality standards and associated incentives, (7) support for health information technology and telehealth, (8) Independence at Home and 1915(i) State Plan Home and Community-Based Services program, and (9) Medicare-Medicaid Coordination Office, Center for Medicare and Medicaid Innovation, and the Patient-Centered Outcomes Research Institute. We also consider potential challenges to full implementation of the ACA and discuss novel solutions for advancing geriatric mental health in the context of projected workforce shortages and the opportunities afforded by the ACA.

[Differential characteristics of type 2 diabetes in the elderly. Role of dipeptidyl peptidase 4 inhibitors]

The prevalence of type 2 diabetes mellitus increases with age, reaching rates around 30% in those over 75 years. The type 2 diabetes mellitus in the elderly has different pathophysiological and clinical characteristics from those of the younger diabetic patient. Some differential aspects in this population are the lower life expectancy and the frequent comorbidity, frailty and associated disability. Avoiding hypoglycemia is a therapeutic priority, given their increased risk of severe hypoglycemia. It is a situation in which the benefits of intensive glycemic control are virtually non-existent, thus prevention of side effects of treatments becomes a priority. Therefore, the goals of glycemic control should be less stringent than in the general population (glycated hemoglobin>7%), and the drugs of choice should be those with a low risk of side effects (especially hypoglycemia) and well tolerated. Dipeptidyl peptidase 4 inhibitors (iDPP4) are particularly useful in this age group, either as a second drug added to metformin monotherapy, or as first line when metformin is contraindicated or not tolerated. In this article the evidence available on the efficacy and tolerance of different pharmacological options available in population over 70 years is reviewed.

Diabetes in older people: new insights and remaining challenges

Diabetes in ageing communities imposes a substantial personal and public health burden by virtue of its high prevalence, its capacity to cause disabling vascular complications, the emergence of new non-vascular complications, and the effects of frailty. In this Review, we examine the current state of knowledge about diabetes in older people (aged ≥ 75 years) and discuss how recognition of the effect of frailty and disability is beginning to lead to new management approaches. A multidimensional and multidisciplinary assessment process is essential to obtain information on medical, psychosocial, and functional capabilities, and also on how impairments of these functions could limit activities. Major aims of diabetes care include maintenance of independence, functional status, and quality of life by reduction of symptom and medicine burden, and active identification of risks. Linking of therapeutic targets to individual functional status is mandatory and very tight glucose control is often not necessary. Hypoglycaemia remains an important avoidable iatrogenic event. Quality diabetes care in older people remains an important challenge for health professionals.

Influence of depression on cardiometabolic responses to a lifestyle intervention in at-risk individuals

BACKGROUND

Cardiometabolic diseases and depression are public health problems that are often related. The benefits of behavioral interventions on lifestyle are well documented. However, the influence of depression in these interventions is unclear.

OBJECTIVE

To evaluate whether depression affects the impact of a lifestyle intervention on cardiometabolic response in an at-risk sample.

METHODS

129 individuals identified by the public health system to be at risk for cardiometabolic disease were allocated to 18-month interventions on diet and physical activity. Socio-demographic and clinical data were obtained. Depressive symptoms were assessed by the Beck Depression Inventory. Changes by at least 10% in each of 6 cardiometabolic risk factors were used to define responses to intervention. Logistic regression models were employed for each gender.

RESULTS

Approximately 42% of individuals had depressive symptoms. They had higher adiposity, cholesterol, and blood pressure levels and lower quality of life and physical activity levels than non-depressed individuals. In adjusted models, only women with depression at baseline had lower chance of improving plasma glucose (OR: 0.32) and lower chance of improving mean blood pressure (OR: 0.29) after the follow-up, compared with non-depressed women.

LIMITATIONS

The small sample size may have diminished the power of the results and the instrument used to measure depression does not provide clinical diagnosis according to DSM criteria.

CONCLUSION

Depression at baseline of lifestyle interventions predicted a lower chance of improving long-term cardiometabolic risk, particularly in women, suggesting that screening and management of depression as part of lifestyle interventions can potentially improve cardiometabolic risk profile.

Prevalence of depressive symptoms and factors associated with it in type 2 diabetic patients: a cross-sectional study in China

Background

Depressive symptoms in patients with type 2 diabetes mellitus (T2DM) have attracted much attention in recent years, and negatively affect the health of diabetic patients in numerous ways. This study evaluated the prevalence rate of depressive symptoms in T2DM patients in Shanghai, and the potential factors that may be associated with depressive symptoms in this select population.

Methods

A total of 865 T2DM patients were recruited from Longhua Street, Xuhui, Shanghai by simple random sampling, and all the patients were assessed with the Zung Self-rating Depression Scale to screen for depressive symptoms. Factors associated with depressive symptoms were analyzed by logistic regression.

Results

Among the 865 patients (403 were male, 462 were female, average age 70.13 ± 20.33 years), 304 (35.1%) patients were categorized as having depressive symptoms. Rates of myocardial infarction and stress in one month were higher in the depressive symptoms group than in the non-depressive symptoms group by the X² test. Rates of patients having a job, having a college education or above, and sleeping less than 7 h/24 h day were also higher in the depressive symptoms group by the X² test. Body mass index, and levels of total cholesterol, triglyceride, urea, creatinine, uric acid, and homocysteine were higher in the depressive symptoms group by the independent samples t test and non-parametric test. Sleeping hours, history of myocardial infarction, stress in one month, working status, and total cholesterol were significantly associated with depressive symptoms (p < 0.05).

Conclusions

In the Chinese population analyzed in this study, the prevalence rate of depressive symptoms in patients with T2DM was high. Further research on the relationship between diabetes and depressive symptoms is necessary in a wider Chinese population.

Sample size and robust marginal methods for cluster-randomized trials with censored event times

In cluster-randomized trials, intervention effects are often formulated by specifying marginal models, fitting them under a working independence assumption, and using robust variance estimates to address the association in the responses within clusters. We develop sample size criteria within this framework, with analyses based on semiparametric Cox regression models fitted with event times subject to right censoring. At the design stage, copula models are specified to enable derivation of the asymptotic variance of estimators from a marginal Cox regression model and to compute the number of clusters necessary to satisfy power requirements. Simulation studies demonstrate the validity of the sample size formula in finite samples for a range of cluster sizes, censoring rates, and degrees of within-cluster association among event times. The power and relative efficiency implications of copula misspecification is studied, as well as the effect of within-cluster dependence in the censoring times. Sample size criteria and other design issues are also addressed for the setting where the event status is only ascertained at periodic assessments and times are interval censored.

Depression among older adults with diabetes mellitus

Older adults with Diabetes Mellitus (DM) experience greater risk for comorbid depression compared to those who do not have DM. Undetected, untreated or under-treated depression impinges an individual's ability to manage their DM successfully, hinders their adherence to treatment regime, and undermines provider-patient relationships. Thus, in the context of caring for older adults with DM, comorbid depression presents special challenges and opportunities for clinicians. In this article, we summarize the clinical presentation of late-life depression, potential mechanisms of comorbidity of depression and DM, importance of depression in the successful management of DM, and available best practice models for depression treatment.