Relationships of hypoglycemia awareness, hypoglycemia beliefs, and continuous glucose monitoring glycemic profiles with anxiety and depression symptoms in adults with type 1 diabetes using continuous glucose monitoring systems

AIMS

To evaluate relationships of hypoglycemia awareness, hypoglycemia beliefs, and continuous glucose monitoring (CGM) glycemic profiles with anxiety and depression symptoms in adults with type 1 diabetes (T1D) who use CGM.

METHODS

A cross-sectional survey and data collections were completed with 196 T1D adults who used CGM (59% also used automated insulin delivery devices (AIDs)). We assessed hypoglycemia awareness (Gold instrument), hypoglycemia beliefs (Attitudes to Awareness of Hypoglycemia instrument), CGM glycemic profiles, demographics, and anxiety and depression symptoms (Hospital Anxiety and Depression Scale). Analysis included simple and multiple linear regression analyses.

RESULTS

Lower hypoglycemia awareness, weaker "hypoglycemia concerns minimized" beliefs, stronger "hyperglycemia avoidance prioritized" beliefs were independently associated with higher anxiety symptoms (P < 0.05), with similar trends in both subgroups using and not using AIDs. Lower hypoglycemia awareness were independently associated with greater depression symptoms (P < 0.05). In participants not using AIDs, more time in hypoglycemia was related to less anxiety and depression symptoms (P < 0.05). Being female and younger were independently associated with higher anxiety symptoms, while being younger was also independently associated with greater depression symptoms (P < 0.05).

CONCLUSION

Our findings revealed relationships of impaired hypoglycemia awareness, hypoglycemia beliefs, CGM-detected hypoglycemia with anxiety and depression symptoms in T1D adults who use CGMs.

Associations Between Hypoglycemia Awareness, Hypoglycemia Beliefs, and Continuous Glucose Monitoring Glycemic Profiles and Anxiety and Depression Symptoms in Adults with Type 1 Diabetes Using Advanced Diabetes Technologies

AIMS

To evaluate relationships between hypoglycemia awareness, hypoglycemia beliefs, and continuous glucose monitoring (CGM) glycemic profiles and anxiety and depression symptoms in adults with type 1 diabetes (T1D) who use CGM or automated insulin delivery devices.

METHODS

A cross-sectional survey and data collections were completed with 196 T1D adults who used advanced diabetes technologies. We assessed hypoglycemia awareness (Gold instrument), hypoglycemia beliefs (Attitudes to Awareness of Hypoglycemia instrument), CGM glycemic profiles, demographics, and anxiety and depression symptoms (Hospital Anxiety and Depression Scale). Data were processed via regression analyses and receiver operating characteristic analyses.

RESULTS

Lower hypoglycemia awareness, weaker "hypoglycemia concerns minimized" beliefs, stronger "hyperglycemia avoidance prioritized" beliefs, female, and younger age were independently associated with higher anxiety symptoms (P<0.05). Lower hypoglycemia awareness, less time in hypoglycemia, and younger age were independently associated with greater depression symptoms (P<0.05). Age of <50 years had 77.8% sensitivity and 48.8% specificity in detecting elevated anxiety symptoms. Spending ≥35% of time with glucose levels >180 mg/dL on CGMs had 85.7% sensitivity and 54.3% specificity in detecting elevated depression symptoms.

CONCLUSION

Our findings revealed relationships between impaired hypoglycemia awareness, hypoglycemia beliefs, CGM-detected hypoglycemia and anxiety and depression symptoms in T1D adults who use advanced diabetes technologies.

Glycemic outcomes of a family-focused intervention for adults with type 2 diabetes: Main, mediated, and subgroup effects from the FAMS 2.0 RCT

AIMS

Family/friend Activation to Motivate Self-care (FAMS) is a self-care support intervention delivered via mobile phones. We evaluated FAMS' effects on hemoglobin A1c (HbA1c) and intervention targets among adults with type 2 diabetes in a 15-month RCT.

METHODS

Persons with diabetes (PWDs) were randomized to FAMS or control with their support person (family/friend, optional). FAMS included monthly phone coaching and text messages for PWDs, and text messages for support persons over a 9-month intervention period.

RESULTS

PWDs (N = 329) were 52 % male, 39 % reported minoritized race or ethnicity, with mean HbA1c 8.6 ± 1.7 %. FAMS improved HbA1c among PWDs with a non-cohabitating support person (-0.64 %; 95 % CI [-1.22 %, -0.05 %]), but overall mean effects were not significant. FAMS improved intervention targets including self-efficacy, dietary behavior, and family/friend involvement during the intervention period; these improvements mediated post-intervention HbA1c improvements (total indirect effect -0.27 %; 95 % CI [-0.49 %, -0.09 %]) and sustained HbA1c improvements at 12 months (total indirect effect -0.19 %; 95 % CI [-0.40 %, -0.01 %]).

CONCLUSIONS

Despite improvements in most intervention targets, HbA1c improved only among PWDs engaging non-cohabitating support persons suggesting future family interventions should emphasize inclusion of these relationships. Future work should also seek to identify intervention targets that mediate improvements in HbA1c.

An mHealth Text Messaging Program Providing Symptom Detection Training and Psychoeducation to Improve Hypoglycemia Self-Management: Intervention Development Study

BACKGROUND

Hypoglycemia remains a challenge for roughly 25% of people with type 1 diabetes (T1D) despite using advanced technologies such as continuous glucose monitors (CGMs) or automated insulin delivery systems. Factors impacting hypoglycemia self-management behaviors (including reduced ability to detect hypoglycemia symptoms and unhelpful hypoglycemia beliefs) can lead to hypoglycemia development in people with T1D who use advanced diabetes technology.

OBJECTIVE

This study aims to develop a scalable, personalized mobile health (mHealth) behavioral intervention program to improve hypoglycemia self-management and ultimately reduce hypoglycemia in people with T1D who use advanced diabetes technology.

METHODS

We (a multidisciplinary team, including clinical and health psychologists, diabetes care and education specialists, endocrinologists, mHealth interventionists and computer engineers, qualitative researchers, and patient partners) jointly developed an mHealth text messaging hypoglycemia behavioral intervention program based on user-centered design principles. The following five iterative steps were taken: (1) conceptualization of hypoglycemia self-management processes and relevant interventions; (2) identification of text message themes and message content development; (3) message revision; (4) patient partner assessments for message readability, language acceptability, and trustworthiness; and (5) message finalization and integration with a CGM data-connected mHealth SMS text message delivery platform. An mHealth web-based SMS text message delivery platform that communicates with a CGM glucose information-sharing platform was also developed.

RESULTS

The mHealth SMS text messaging hypoglycemia behavioral intervention program HypoPals, directed by patients' own CGM data, delivers personalized intervention messages to (1) improve hypoglycemia symptom detection and (2) elicit self-reflection, provide fact-based education, and suggest practical health behaviors to address unhelpful hypoglycemia beliefs and promote hypoglycemia self-management. The program is designed to message patients up to 4 times per day over a 10-week period.

CONCLUSIONS

A rigorous conceptual framework, a multidisciplinary team (including patient partners), and behavior change techniques were incorporated to create a scalable, personalized mHealth SMS text messaging behavioral intervention. This program was systematically developed to improve hypoglycemia self-management in advanced diabetes technology users with T1D. A clinical trial is needed to evaluate the program's efficacy for future clinical implementation.

Well-being outcomes of a family-focused intervention for persons with type 2 diabetes and support persons: Main, mediated, and subgroup effects from the FAMS 2.0 RCT

AIMS

Type 2 diabetes self-management occurs within social contexts. We sought to test the effects of Family/friend Activation to Motivate Self-care (FAMS), a self-care support intervention delivered via mobile phones, on psychosocial outcomes for persons with diabetes (PWDs) and their support persons.

METHODS

PWDs had the option to enroll with a friend/family member as a support person in a 15-month RCT to evaluate FAMS versus enhanced usual care. FAMS included 9 months of monthly phone coaching and text message support for PWDs, and text message support for enrolled support persons.

RESULTS

PWDs (N = 329) were 52% male and 39% reported minoritized race or ethnicity ; 50% enrolled with elevated diabetes distress. Support persons (N = 294) were 26% male and 33% reported minoritized race or ethnicity. FAMS improved PWDs' diabetes distress (d = -0.19) and global well-being (d = 0.21) during the intervention, with patterns of larger effects among minoritized groups. Post-intervention (9-month) and sustained (15-month) improvements were driven by changes in PWDs' self-efficacy, self-care behaviors, and autonomy support. Among support persons, FAMS improved helpful involvement without increasing burden or harmful involvement.

CONCLUSIONS

FAMS improved PWDs' psychosocial well-being, with post-intervention and sustained improvements driven by improved self-efficacy, self-care, and autonomy support. Support persons increased helpful involvement without adverse effects.

Prerandomization withdrawals from a Type 2 diabetes self-care support intervention trial are associated with lack of available support person coparticipant

OBJECTIVES

Dyadic interventions, involving two persons with a preexisting close relationship, offer the opportunity to activate support persons (SPs) to improve health for adults with chronic conditions. Requiring SP coparticipation can challenge recruitment and bias samples; however, the associations between voluntary SP coparticipation and recruitment outcomes across patient characteristics are unknown.

METHODS

The Family/Friend Activation to Motivate Self-care 2.0 randomized controlled trial (RCT) enrolled adults with Type 2 diabetes (T2D) from an academic health system. Participants were asked-but not required-to invite an SP to coenroll. Using data from the electronic health record we sought to describe RCT enrollment in the setting of voluntary SP coparticipation.

RESULTS

In a diverse sample of adults with (T2D) (48% female, 44% minoritized race/ethnicity), most participants (91%) invited SPs and (89%) enrolled with SPs. However, prerandomization withdrawal was significantly higher among participants who did not have consenting SPs than those who did. Females were less likely to invite SPs than males and more Black PWD were prerandomization withdrawals than randomized.

DISCUSSION

Voluntary SP coenrollment may benefit recruitment for dyadic sampling; however, more research is needed to understand if these methods systematically bias sampling and to prevent these unintended biases.

Well-being outcomes of a family-focused intervention for persons with type 2 diabetes and support persons: Main, mediated, and subgroup effects from the FAMS 2.0 RCT

Aims

Type 2 diabetes self-management occurs within social contexts. We sought to test the effects of Family/friends Activation to Motivate Self-care (FAMS), a self-care support intervention delivered via mobile phones, on psychosocial outcomes for persons with diabetes (PWDs) and their support persons.

Methods

PWDs had the option to enroll with a friend/family member as a support person in a 15-month RCT to evaluate FAMS versus enhanced usual care. FAMS included 9-months of monthly phone coaching and text message support for PWDs, and text message support for enrolled support persons.

Results

PWDs (N=329) were 52% male and 39% from minoritized racial or ethnic groups; 50% enrolled with elevated diabetes distress. Support persons (N=294) were 26% male and 33% minoritized racial or ethnic groups. FAMS improved PWDs' diabetes distress ( d =-0.19) and global well-being ( d =0.21) during the intervention, with patterns of larger effects among minoritized groups. Post-intervention and sustained (15-month) improvements were driven by changes in PWDs' self-efficacy, self-care behaviors, and autonomy support. Among support persons, FAMS improved helpful involvement without increasing burden or harmful involvement.

Conclusions

FAMS improved PWDs' psychosocial well-being, with post-intervention and sustained improvements driven by improved self-efficacy, self-care, and autonomy support. Support persons increased helpful involvement without adverse effects.

Glycemic outcomes of a family-focused intervention for adults with type 2 diabetes: Main, mediated, and subgroup effects from the FAMS 2.0 RCT

Aims

Family/friends Activation to Motivate Self-care (FAMS) is a self-care support intervention delivered via mobile phones. We evaluated FAMS effects on hemoglobin A1c (HbA1c) and intervention targets among adults with type 2 diabetes in a 15-month RCT.

Methods

Persons with diabetes (PWDs) and their support persons (family/friend, optional) were randomized to FAMS or control. FAMS included monthly phone coaching and text messages for PWDs, and text messages for support persons over a 9-month intervention period.

Results

PWDs (N=329) were 52% male, 39% from minoritized racial or ethnic groups, with mean HbA1c 8.6±1.7%. FAMS improved HbA1c among PWDs with a non-cohabitating support person (-0.64%; 95% CI [-1.22%, -0.05%]), but overall effects were not significant. FAMS improved intervention targets including self-efficacy, dietary behavior, and family/friend involvement during the intervention period; these improvements mediated post-intervention HbA1c improvements (total indirect effect -0.27%; 95% CI [-0.49%, -0.09%]) and sustained HbA1c improvements at 12 months (total indirect effect -0.19%; 95% CI [-0.40%, -0.01%]).

Conclusions

Despite improvements in most intervention targets, HbA1c improved only among PWDs engaging non-cohabitating support persons suggesting future family interventions should emphasize inclusion of these relationships. Future work should also seek to identify intervention targets that mediate improvements in HbA1c.

Psychological Support Strategies for Adults With Type 2 Diabetes in a Very Low-Carbohydrate Web-Based Program: Randomized Controlled Trial

BACKGROUND

A very low-carbohydrate (VLC) nutritional strategy may improve glycemic control and weight loss in adults with type 2 diabetes (T2D). However, the supplementary behavioral strategies that might be able to improve outcomes using this nutritional strategy are uncertain.

OBJECTIVE

This study aims to compare the impact of adding 3 different supplementary behavioral strategies to a web-based VLC diet intervention. To our knowledge, this is the first trial to randomize participants to different frequencies of dietary self-monitoring.

METHODS

The study included 112 overweight adults with T2D (hemoglobin A_1c ≥6.5%) taking no antiglycemic medications or only metformin. They received a remotely delivered 12-month VLC diet intervention. Participants were randomly assigned through a full factorial 2×2×2 design to supplementary strategies: either daily or monthly dietary self-monitoring, either mindful eating training or not, and either positive affect skills training or not. Our research goal was to determine whether 3 different supplemental strategies had at least a medium effect size (Cohen d=0.5).

RESULTS

Overall, the VLC intervention led to statistically significant improvements in glycemic control (-0.70%, 95% CI -1.04% to -0.35%; P<.001), weight loss (-6.82%, 95% CI -8.57% to -5.08%; P<.001), and depressive symptom severity (Cohen d -0.67, 95% CI -0.92 to -0.41; P<.001). Furthermore, 30% (25/83) of the participants taking metformin at baseline reduced or discontinued their metformin. Only 1 Cohen d point estimate reached 0.5; daily (vs monthly) dietary self-monitoring had a worse impact on depressive symptoms severity (Cohen d=0.47, 95% CI -0.02 to 0.95; P=.06). None of the strategies had a statistically significant effect on outcomes. For changes in our primary outcome, hemoglobin A_1c, the daily (vs monthly) dietary self-monitoring impact was 0.42% (95% CI -0.28% to 1.12%); for mindful eating, it was -0.47% (95% CI -1.15% to 0.22%); and for positive affect, it was 0.12% (95% CI -0.57% to 0.82%). Other results for daily (vs monthly) dietary self-monitoring were mixed, suggesting an increase in weight (0.98%) and depressive symptoms (Cohen d=0.47), less intervention satisfaction (Cohen d=-0.20), more sessions viewed (3.02), and greater dietary adherence (Cohen d=0.24). For mindful eating, the results suggested a benefit for dietary adherence (Cohen d=0.24) and intervention satisfaction (Cohen d=0.30). For positive affect, the results suggested a benefit for depressive symptoms (Cohen d=-0.32), the number of sessions viewed (3.68), dietary adherence (Cohen d=0.16), and intervention satisfaction (Cohen d=0.25).

CONCLUSIONS

Overall, our results support the use of a VLC diet intervention in adults with T2D. The addition of monthly (not daily) dietary self-monitoring, mindful eating, and positive affect skills training did not show a definitive benefit, but it is worth further testing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03037528; https://clinicaltrials.gov/ct2/show/NCT03037528.

Readmission Rates and Episode Costs for Alzheimer Disease and Related Dementias Across Hospitals in a Statewide Collaborative

IMPORTANCE

There has been a paucity of research examining the risk and cost of readmission among patients with Alzheimer disease and related dementias (ADRD) after a planned hospitalization for a broad set of medical and surgical procedures.

OBJECTIVE

To examine 30-day readmission rates and episode costs, including readmission costs, for patients with ADRD compared with their counterparts without ADRD across Michigan hospitals.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used 2012 to 2017 Michigan Value Collaborative data across different medical and surgical services stratified by ADRD diagnosis. A total of 66 676 admission episodes of care that occurred between January 1, 2012, and June 31, 2017, were identified for patients with ADRD using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic codes for ADRD, along with 656 235 admission episodes in patients without ADRD. Using a generalized linear model framework, this study risk adjusted, price standardized, and performed episode payment winsorization. Payments were risk adjusted for age, sex, Hierarchical Condition Categories, insurance type, and prior 6-month payments. Selection bias was accounted for using multivariable logistic regression with propensity score matching without replacement using calipers. Data analysis was performed from January to December 2019.

EXPOSURE

Presence of ADRD.

MAIN OUTCOMES AND MEASURES

Main outcomes were 30-day readmission rate at the patient and county levels, 30-day readmission cost, and 30-day total episode cost across 28 medical and surgical services.

RESULTS

The study included 722 911 hospitalization episodes, of which 66 676 were related to patients with ADRD (mean [SD] age, 83.4 [8.6] years; 42 439 [63.6%] female) and 656 235 were related to patients without ADRD (mean [SD] age, 66.0 [15.4] years; 351 246 [53.5%] female). After propensity score matching, 58 629 hospitalization episodes were included for each group. Readmission rates were 21.5% (95% CI, 21.2%-21.8%) for patients with ADRD and 14.7% (95% CI, 14.4%-15.0%) for patients without ADRD (difference, 6.75 percentage points; 95% CI, 6.31-7.19 percentage points). Cost of 30-day readmission was $467 higher (95% CI of difference, $289-$645) among patients with ADRD ($8378; 95% CI, $8263-$8494) than those without ($7912; 95% CI, $7776-$8047). Across all 28 service lines examined, total 30-day episode costs were $2794 higher for patients with ADRD vs patients without ADRD ($22 371 vs $19 578; 95% CI of difference, $2668-$2919).

CONCLUSIONS AND RELEVANCE

In this cohort study, patients with ADRD had higher readmission rates and overall readmission and episode costs than their counterparts without ADRD. Hospitals may need to be better equipped to care for patients with ADRD, especially in the postdischarge period. Considering that any type of hospitalization may put patients with ADRD at a high risk of 30-day readmission, judicious preoperative assessment, postoperative discharge, and care planning are strongly advised for this vulnerable patient population.

Rationale, design, and recruitment outcomes for the Family/Friend Activation to Motivate Self-care (FAMS) 2.0 randomized controlled trial among adults with type 2 diabetes and their support persons

BACKGROUND

Self-care behaviors help reduce hemoglobin A1c (HbA1c) and prevent or delay type 2 diabetes (T2D) complications. Individualized interventions that support goal setting and self-monitoring improve self-care and HbA1c in the short-term; engaging family and friends may enhance and/or sustain effects. Family/Friend Activation to Motivate Self-care (FAMS) is a mobile phone-delivered intervention (i.e., phone coaching and text message support) based on Family Systems Theory which was successfully piloted among diverse adults with T2D.

METHODS

We made improvements to FAMS and conducted iterative usability testing to finalize FAMS 2.0 before evaluation in a randomized controlled trial (RCT). Adult persons with diabetes (PWDs) who enrolled were asked to invite a support person (friend or family member) to participate alongside them. For the RCT, dyads were randomly assigned to FAMS 2.0 or enhanced treatment as usual (control) for the first 9 months of the 15-month trial. Outcomes include PWDs' HbA1c and psychosocial well-being (including diabetes distress) and support persons' own diabetes distress and support burden.

RESULTS

We recruited RCT participants from April 2020 through October 2021 (N = 338 PWDs with T2D; 89% [n = 300] with a support person). PWDs were 52% male, 62% non-Hispanic White, aged 56.9 ± 11.0 years with HbA1c 8.7% ± 1.7% at enrollment; 73% cohabitated with their enrolled support person. Data collection is ongoing through January 2023.

CONCLUSION

Findings will inform the utility of engaging family/friends in self-care behaviors for both PWD and support person outcomes. Using widely available mobile phone technology, FAMS 2.0, if successful, has potential for scalability.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04347291 posted April 15, 2020.

Technology-Facilitated Depression Self-Management Linked with Lay Supporters and Primary Care Clinics: Randomized Controlled Trial in a Low-Income Sample

Purpose: To test whether technology-facilitated self-management support improves depression in primary care settings. Methods: We randomized 204 low-income primary care patients who had at least moderate depressive symptoms to intervention or control. Intervention participants received 12 months of weekly automated interactive voice response telephone calls that assessed their symptom severity and provided self-management strategies. Their patient-nominated supporter (CarePartner) received corresponding guidance on self-management support, and their primary care team received urgent notifications. Those randomized to enhanced usual care received printed generic self-management instructions. Results: One-year attrition rate was 14%. By month 6, symptom severity on the Patient Health Questionnaire-9 (PHQ-9) decreased 2.5 points more in the intervention arm than in the control arm (95% CI -4.2 to -0.8, p = 0.003). This benefit was similar at month 12 (p = 0.004). Intervention was also over twice as likely to lead to ≥50% reduction in symptom severity by month 6 (OR = 2.2 (1.1, 4.7)) and a decrease of ≥5 PHQ-9 points by month 12 (OR = 2.3 (1.2, 4.4)). Conclusions: Technology-facilitated self-management guidance with lay support and clinician notifications improves depression for primary care patients. Subsequent research should examine implementation and generalization to other chronic conditions. clinicaltrials.gov, identifier NCT01834534.

Beliefs Around Hypoglycemia and Their Impacts on Hypoglycemia Outcomes in Individuals with Type 1 Diabetes and High Risks for Hypoglycemia Despite Using Advanced Diabetes Technologies

OBJECTIVE

This study aimed to 1) identify the frequency of severe and level 2 hypoglycemia presenting in individuals with type 1 diabetes using continuous glucose monitoring systems (CGMs), including those with concomitant closed-loop insulin pumps, in a clinical practice setting and 2) evaluate the impact of beliefs around hypoglycemia in the development of severe and level 2 hypoglycemia in this population.

RESEARCH DESIGN AND METHODS

A cross-sectional survey study in adults with type 1 diabetes using CGMs >6 months was conducted at a large tertiary academic center. Participant demographics, 6-month severe hypoglycemia history, hypoglycemia beliefs (with the Attitude to Awareness of Hypoglycemia questionnaire), and 4-week CGM glucose data were collected. Statistical analysis was performed to assess the presentation of severe and level 2 hypoglycemia and identify associated risk factors.

RESULTS

A total of 289 participants were recruited (including 257 participants with CGM data within the last 3 months). Of these, 25.6% experienced at least one severe hypoglycemic episode in the last 6 months, and 13.6% presented with ≥1% of time in level 2 hypoglycemia on CGMs. Reporting beliefs about prioritizing hyperglycemia avoidance was associated with severe hypoglycemia development (P < 0.001), while having beliefs of minimal concerns for hypoglycemia was associated with spending ≥1% of time in level 2 hypoglycemia (P = 0.038).

CONCLUSIONS

Despite the use of advanced diabetes technologies, severe and level 2 hypoglycemia continues to occur in individuals with type 1 diabetes and high hypoglycemia risks. Human factors, including beliefs around hypoglycemia, may continue to impact the effectiveness of glucose self-management.

Impact of an online multicomponent very-low-carbohydrate program in women with polycystic ovary syndrome: a pilot study

OBJECTIVE

To study the impact of a very-low-carbohydrate (VLC) diet for 16 weeks in overweight or obese women with polycystic ovary syndrome (PCOS).

DESIGN

Single-arm prospective pilot study.

SETTING

We recruited participants using medical records from an academic medical center.

PATIENTS

Twenty-nine overweight or obese women (body mass index, 25-50 kg/m2) with PCOS.

INTERVENTIONS

We taught participants to follow a VLC diet and provided information about a variety of behavioral skills including mindfulness and positive affect using an online 16-week intervention.

MAIN OUTCOME MEASURES

Changes in body weight, glycated hemoglobin, and PCOS-related quality of life.

RESULTS

The intervention led to positive health outcomes including decreases in percent weight (mean difference = -7.67, SD = 6.10) and glycated hemoglobin level (mean difference = -0.21%, SD = 0.27), an increase in sex hormone binding globulin level (mean difference = 9.24 nmol/L, SD = 16.34), and increases in PCOS-related quality of life measures, including menstrual predictability (mean difference = 2.10, SD = 2.76) and body hair (mean difference = 1.14, SD = 1.04). The low-density lipoprotein cholesterol level increased (mean difference = 0.23 mmol/L, SD = 0.49).

CONCLUSIONS

The results suggest that a VLC dietary intervention has potential to promote both weight loss and glycemic control in overweight and obese adults with PCOS, two key components in the prevention of type 2 diabetes.

TRIAL REGISTRATION NUMBER

NCT03987854.

Impacts of Post-Hospitalization Accessible Health Technology and Caregiver Support on 90-Day Acute Care Use and Self-Care Assistance: A Randomized Clinical Trial

Hospitalized patients often are readmitted soon after discharge, with many hospitalizations being potentially preventable. The authors evaluated a mobile health intervention designed to improve post-hospitalization support for older adults with common chronic conditions. All participants enrolled with an informal caregiver or "CarePartner" (CP). Intervention patients received automated assessment and behavior change calls. CPs received automated, structured feedback following each assessment. Clinicians received alerts about serious problems identified during patient calls. Controls had a 65% greater risk of hospitalization within 90 days post discharge than intervention patients (P = .041). For every 6.8 enrollees, the intervention prevented 1 rehospitalization or emergency department encounter. The intervention improved physical functioning at 90 days (P = .012). The intervention also improved medication adherence and indicators of the quality of communication with CPs (all P < .01). Automated telephone patient monitoring and self-care advice with feedback to primary care teams and CPs reduces readmission rates over 90 days.

Intervention Enhancement Strategies Among Adults With Type 2 Diabetes in a Very Low-Carbohydrate Web-Based Program: Evaluating the Impact With a Randomized Trial

BACKGROUND

Adults with type 2 diabetes may experience health benefits, including glycemic control and weight loss, from following a very low-carbohydrate, ketogenic (VLC) diet. However, it is unclear which ancillary strategies may enhance these effects.

OBJECTIVE

This pilot study aims to estimate the effect sizes of 3 intervention enhancement strategies (text messages, gifts, and breath vs urine ketone self-monitoring) that may improve outcomes of a 12-month web-based ad libitum VLC diet and lifestyle intervention for adults with type 2 diabetes. The primary intervention also included other components to improve adherence and well-being, including positive affect and mindfulness as well as coaching.

METHODS

Overweight or obese adults (n=44; BMI 25-45 kg/m²) with type 2 diabetes (glycated hemoglobin [HbA_1c] ≥6.5%), who had been prescribed either no glucose-lowering medications or metformin alone, participated in a 12-month web-based intervention. Using a 2×2×2 randomized factorial design, we compared 3 enhancement strategies: (1) near-daily text messages about the intervention's recommended behaviors (texts n=22 vs no texts n=22), (2) mailed gifts of diet-relevant foods and cookbooks (6 rounds of mailed gifts n=21 vs no gifts n=23), and (3) urine- or breath-based ketone self-monitoring (urine n=21 vs breath n=23). We assessed HbA_1c and weight at baseline and at 4, 8, and 12 months. We evaluated whether each strategy exerted a differential impact on HbA_1c and weight at 12 months against an a priori threshold of Cohen d of 0.5 or greater.

RESULTS

We retained 73% (32/44) of the participants at 12 months. The intervention, across all conditions, led to improvements in glucose control and reductions in body weight at the 12-month follow-up. In intent-to-treat (ITT) analyses, the mean HbA_1c reduction was 1.0% (SD 1.6) and the mean weight reduction was 5.3% (SD 6.0), whereas among study completers, these reductions were 1.2% (SD 1.7) and 6.3% (SD 6.4), respectively, all with a P value of less than .001. In ITT analyses, no enhancement strategy met the effect size threshold. Considering only study completers, 2 strategies showed a differential effect size of at least a d value of 0.5 or greater.

CONCLUSIONS

Text messages, gifts of food and cookbooks, and urine-based ketone self-monitoring may potentially enhance the glycemic or weight loss benefits of a web-based VLC diet and lifestyle intervention for individuals with type 2 diabetes. Future research could investigate other enhancement strategies to help create even more effective solutions for the treatment of type 2 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02676648; http://clinicaltrials.gov/ct2/show/NCT02676648.

Lifestyle Interventions for Polycystic Ovary Syndrome: Cross-Sectional Survey to Assess Women's Treatment and Outcome Preferences

Background

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age. Diet and lifestyle programs improve health, but women’s preferences for these programs have not been formally explored.

Objective

The aim of our study was to examine diet and lifestyle program preferences among women with PCOS.

Methods

We conducted a cross-sectional online survey of women with PCOS.

Results

At least half of the 197 respondents expressed strong interest in programs addressing energy level, anxiety, depression, weight, diabetes prevention, menstrual period regulation, and hirsutism. Similarly, at least half reported willingness to modify their sleep, stress, and physical activity; and slightly less than half reported willingness to adopt a very low-carbohydrate, paleo, or low–glycemic index diet. At least half reported interest in online or mobile programs and email-based mentoring. Younger age was associated with interest in help with acne and fertility; higher body mass index was associated with wanting help with weight loss, energy, and anxiety; and greater stress eating was associated with wanting help with depression, anxiety, and menstrual period regulation.

Conclusions

To our knowledge, this is the first study to examine attitudes and preferences of women with PCOS toward such programs. Future online and mobile diet and lifestyle programs may be able to capitalize on this information to better target this population’s expressed preferences.

Functional support and burden among out-of-home supporters of heart failure patients with and without depression

OBJECTIVE

Over 20% of patients with heart failure (HF) experience clinical depression, which is associated with higher rates of mortality, morbidity, and hospitalization. Support from family members or friends (whom we refer to as care partners [CPs]) can lower the risk of these outcomes. We examined whether HF patients with depression received assistance from CPs living outside of their homes. Further, we examined whether patient depression was associated with support-related strain among out-of-home CPs.

METHOD

We analyzed baseline survey data from 348 HF patients with reduced ejection fraction and their CPs. Patients with scores on the Center for Epidemiological Studies Depression Scale-10 (Kohout, Berkman, Evans, & Cornoni-Huntley, 1993) of ≥10 were classified as having clinically significant depressive symptoms (i.e., depression). Outcomes included CP-reported hr per week helping with health care and talking with patients via telephone and scores on the Modified Caregiver Strain Index. Negative binomial regression models examined differences in the amount of in-person and telephone support for patients with and without depression, controlling for patients' comorbidities, living alone, CP geographic distance, and CP emotional closeness to the patient.

RESULTS

CPs provided more in-person support to HF patients with depression (M = 3.64 hr) compared with those without depression (M = 2.60 hr per week, incident rate ratio [IRR] = 1.40, p = .019). CPs provided more telephone support to patients with depression (M = 3.02 hr) compared with those without depression (M = 2.09 hr per week, IRR = 1.42, p < .001). Patient depression had no effect on caregiver burden (IRR = 1.00, p = .843).

CONCLUSION

Patients with clinically significant depressive symptoms receive more in-person assistance and telephonic support from CPs. Despite that additional contact, caregiver burden was not greater among the supporters of depressed patients. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Effects of Accessible Health Technology and Caregiver Support Posthospitalization on 30-Day Readmission Risk: A Randomized Trial

INTRODUCTION

Patients with chronic illness often require ongoing support postdischarge. This study evaluated a simple-to-use, mobile health-based program designed to improve postdischarge follow-up via (1) tailored communication to patients using automated calls, (2) structured feedback to informal caregivers, and (3) automated alerts to clinicians about urgent problems.

METHODS

A total of 283 patients with common medical diagnoses, including chronic obstructive pulmonary disease, coronary artery disease, pneumonia, and diabetes, were recruited from a university hospital, a community hospital, and a US Department of Veterans Affairs hospital. All patients identified an informal caregiver or "care partner" (CP) to participate in their postdischarge support. Patient-CP dyads were randomized to the intervention or usual care. Intervention patients received weekly automated assessment and behavior change calls. CPs received structured e-mail feedback. Outpatient clinicians received fax alerts about serious problems. Primary outcomes were 30-day readmission rate and the combined outcome of readmission/emergency department (ED) use. Information about postdischarge outpatient visits, rehospitalizations, and ED encounters was obtained from medical records.

RESULTS

Overall, 11.4% of intervention patients and 17.9% of controls were rehospitalized within 30 days postdischarge (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.31-1.11; p = 0.102). Compared to intervention patients with other illnesses, those with pulmonary diagnoses generated the most clinical alerts (p = 0.004). Pulmonary patients in the intervention group showed significantly reduced 30-day risk of rehospitalization relative to controls (HR: 0.31; 95% CI: 0.11-0.87; p = 0.026).

CONCLUSION

The CP intervention did not improve 30-day readmission rates overall, although post hoc analyses suggested that it may be promising among patients with pulmonary diagnoses.

Feasibility study of automated interactive voice response telephone calls with community health nurse follow-up to improve glycaemic control in patients with type 2 diabetes

BACKGROUND

Thailand has a shortage of community health nurses for supporting the self-management of type 2 diabetes, which is prevalent and poorly controlled.

AIM

This study examined the feasibility and acceptability of a self-care assistance programme for poorly controlled type 2 diabetes mellitus. The SukapapNet programme consisted of automated interactive voice response calls to patients and automated follow-up email notifications to their nurses.

DESIGN

Single-arm pre-post trial.

METHODS

Six nurses and 35 type 2 diabetes patients were recruited from primary care settings in suburban provinces in Thailand. The study was conducted from June 2017 to November 2017. We assessed patients before and after 12 weeks of the SukapapNet intervention.

RESULTS

Mean glycated haemoglobin decreased by 0.9%. Patients reported reduced carbohydrate consumption, increased physical activity, increased medication adherence, improved sleep quality, and more frequent foot care. Patients and nurses both recommended using the intervention, although nurses expressed concerns regarding increased workload.

CONCLUSIONS

The study programme could improve outcomes in Thai type 2 diabetes patients. Further study of the impact of technology upon nurses' workload is warranted.

Relationship and communication characteristics associated with agreement between heart failure patients and their Carepartners on patient depressive symptoms

Objectives: Informal caregivers who recognize patients' depressive symptoms can better support self-care and encourage patients to seek treatment. We examined patient-caregiver agreement among patients with heart failure (HF). Our objectives were to (1) identify distinct groups of HF patients and their out-of-home informal caregivers (CarePartners) based on their relationship and communication characteristics, and (2) compare how these groups agree on the patients' depressive symptoms. Method: We used baseline data from a comparative effectiveness trial of a self-care support program for veterans with HF treated in outpatient clinics from 2009-2012. We used a cross-sectional design and latent class analysis (LCA) approach to identify distinct groups of patient-CarePartner dyads (n = 201) based on relationship and communication characteristics then evaluated agreement on patients' depressive symptoms within these groups. Results: The LCA analysis identified four groups: Collaborative (n = 102 dyads, 51%), Avoidant (n = 33 dyads, 16%), Distant (n = 35 dyads, 17%), and Antagonistic (n = 31 dyads, 15%). Dyadic agreement on the patients' depressive symptoms was highest in the Distant (Kappa (κ) = 0.44, r = 0.39) and Collaborative groups (κ = 0.19, r = 0.32), and relatively poor in the Avoidant (κ = -0.20, r = 0.17) and Antagonistic (κ =-0.01, r = 0.004) groups. Patients in Avoidant (61%) and Antagonistic groups (74%) more frequently had depression based on self-report than patients in Collaborative (46%) and Distant (34%) groups. Conclusion: Caregiver relationships in HF tend to be either Collaborative, Avoidant, Distant, or Antagonistic. Patients' depressive symptoms may negatively affect how they communicate with their caregivers. At the same time, improved patient-caregiver communication could enhance dyadic consensus about the patient's depressive symptoms.

Impact of using a broad-based multi-institutional approach to build capacity for non-communicable disease research in Thailand

Thailand's transition to high middle-income country status has been accompanied by demographic changes and associated shifts in the nation's public health challenges. These changes have necessitated a significant shift in public health focus from the treatment of infectious diseases to the more expensive and protracted management of non-communicable diseases (NCDs) in older adults.In 2010, in response to this shift in focus, the University of Michigan and colleagues at the Praboromarajchanok Institute for Health Workforce Development in Thailand began work on a broad-based multi-institutional programme for NCD research capacity-building in Thailand.To begin to build a base of intervention research we paired our programme's funded Thai postdoctoral fellows with United States mentors who have strong programmes of intervention research. One direct impact of the programme was the development of research 'hubs' focused upon similar areas of investigative focus such as self-management of cancer symptoms, self-management of HIV/AIDS and health technology information applications for use in community settings. Within these hubs, interventions with proven efficacy in the United States were used as a foundation for culturally relevant interventions in Thailand. The programme also aimed to develop the research support structures necessary within departments and colleges for grant writing and management, dissemination of new knowledge, and ethical conduct of human subject research.In an effort to capitalise on large national health datasets and big data now available in Thailand, several of the programme's postdoctoral fellows began projects that use data science methods to mine this asset. The investigators involved in these ground-breaking projects form the core of a network of research hubs that will be able to capitalise on the availability of lifespan health data from across Thailand and provide a robust working foundation for expansion of research using data science approaches.Going forward, it is vitally important to leverage this groundwork in order to continue fostering rapid growth in NCD research and training as well as to capitalise upon these early gains to create a sustaining influence for Thailand to lead in NCD research, improve the health of its citizens, and provide ongoing leadership in Southeast Asia.

Development and validation of the 25-item Hikikomori Questionnaire (HQ-25)

AIM

Hikikomori, a form of severe social withdrawal, is an emerging issue in mental health, for which validated measurement tools are lacking. The object was to develop a self-report scale of hikikomori, and assess its psychometric properties and diagnostic accuracy.

METHODS

A sample of 399 participants from clinical and community settings completed measures. Psychometric properties were assessed with factor analysis; diagnostic accuracy was compared against a semi-structured diagnostic interview.

RESULTS

The Hikikomori Questionnaire contained 25 items across three subscales representing socialization, isolation, and emotional support. Internal consistency, test-retest reliability, and convergent validity were all satisfactory. The area under the curve was 0.86 (95% confidence interval, 0.80-0.92). A cut-off score of 42 (out of 100) was associated with a sensitivity of 94%, specificity of 61%, and positive predictive value of 17%.

CONCLUSION

The 25-item Hikikomori Questionnaire (HQ-25) possesses robust psychometric properties and diagnostic accuracy in an initial sample of Japanese adults. Additional research on its psychometric properties and ability to support clinical assessment of hikikomori is warranted.

Outcomes of a Digitally Delivered Low-Carbohydrate Type 2 Diabetes Self-Management Program: 1-Year Results of a Single-Arm Longitudinal Study

Background

Type 2 diabetes mellitus has serious health consequences, including blindness, amputation, stroke, and dementia, and its annual global costs are more than US $800 billion. Although typically considered a progressive, nonreversible disease, some researchers and clinicians now argue that type 2 diabetes may be effectively treated with a carbohydrate-reduced diet.

Objective

Our objective was to evaluate the 1-year outcomes of the digitally delivered Low-Carb Program, a nutritionally focused, 10-session educational intervention for glycemic control and weight loss for adults with type 2 diabetes. The program reinforces carbohydrate restriction using behavioral techniques including goal setting, peer support, and behavioral self-monitoring.

Methods

The study used a quasi-experimental research design comprised of an open-label, single-arm, pre-post intervention using a sample of convenience. From adults with type 2 diabetes who had joined the program and had a complete baseline dataset, we randomly selected participants to be followed for 1 year (N=1000; mean age 56.1, SD 15.7 years; 59.30% (593/1000) women; mean glycated hemoglobin A_1c (HbA_1c) 7.8%, SD 2.1%; mean body weight 89.6 kg, SD 23.1 kg; taking mean 1.2, SD 1.01 diabetes medications).

Results

Of the 1000 study participants, 708 (70.80%) individuals reported outcomes at 12 months, 672 (67.20%) completed at least 40% of the lessons, and 528 (52.80%) completed all lessons of the program. Of the 743 participants with a starting HbA_1c at or above the type 2 diabetes threshold of 6.5%, 195 (26.2%) reduced their HbA_1c to below the threshold while taking no glucose-lowering medications or just metformin. Of the participants who were taking at least one hypoglycemic medication at baseline, 40.4% (289/714) reduced one or more of these medications. Almost half (46.40%, 464/1000) of all participants lost at least 5% of their body weight. Overall, glycemic control and weight loss improved, especially for participants who completed all 10 modules of the program. For example, participants with elevated baseline HbA_1c (≥7.5%) who engaged with all 10 weekly modules reduced their HbA_1c from 9.2% to 7.1% (P<.001) and lost an average of 6.9% of their body weight (P<.001).

Conclusions

Especially for participants who fully engage, an online program that teaches a carbohydrate-reduced diet to adults with type 2 diabetes can be effective for glycemic control, weight loss, and reducing hypoglycemic medications.

Self-Rated Health and Glycemic Control in Type 2 Diabetes: Race by Gender Differences

BACKGROUND

Although some studies have shown a link between self-rated health (SRH) and glycemic control in type 2 diabetes (DM), other studies have failed to support this association. The purpose of this study was to determine whether these equivocal findings can be explained by specific interactions between gender, race, and SRH, as suggested by the intersectionality literature.

METHODS

This cross-sectional study included 287 patients with DM (85 Black men, 78 Black women, 64 White men, and 60 White women). After adjusting for demographic and medical factors, we regressed HbA1c on SRH with and without interactions between gender, race, and SRH. We conducted additional subgroup analyses to further characterize gender by race group differences.

RESULTS

Although there was no main effect of SRH upon HbA1c (b = .16, 95% CI: .08-.39), we found a significant interaction between gender and SRH on HbA1c (b = -.50, 95% CI: -.97 to -.03). In race by gender-stratified models, SRH (b = .53, 95% CI: .00-1.07) was associated with HbA1c in Black men. SRH was not associated with HbA1c in White men, White women, or Black women.

CONCLUSION

Combined race and gender differences may exist in the link between SRH and glycemic control in DM. Specifically, Black men with DM may be more attuned to the relationship between their overall health and their glycemic control.

Socioeconomic Status and Glycemic Control in Type 2 Diabetes; Race by Gender Differences

Background: This study aimed to investigate differences in the association between socioeconomic status (SES) and glycemic control in type 2 diabetes mellitus (DM) across race by gender groups. Methods: Using a convenient sampling strategy, participants were 112 patients with type 2 DM who were prescribed insulin (ns = 38 Black women, 34 Black men, 14 White women, and 26 White men, respectively). Linear regression was used to test the associations between sociodemographic variables (race, gender, SES, governmental insurance) and Hemoglobin A1c (HbA1c) in the pooled sample and within subgroups defined by race and gender. Results: In the pooled sample, neither SES nor governmental insurance were associated with HbA1c. However, the race by gender interaction approached statistical significance (B = 0.34, 95% CI = −0.24–3.00, p =0.094), suggesting higher HbA1c in Black women, compared to other race by gender groups. In stratified models, SES (B = −0.33, 95% CI = −0.10–0.00, p = 0.050), and governmental insurance (B = 0.35, 95% CI = 0.05–2.42, p = 0.042) were associated with HbA1c for Black men, but not for any of the other race by gender subgroups. Conclusion: Socioeconomic factors may relate to health outcomes differently across race by gender subgroups. In particular, SES may be uniquely important for glycemic control of Black men. Due to lack of generalizability of the findings, additional research is needed.

Developing a typology of patient-generated behavioral goals for cognitive behavioral therapy for chronic pain (CBT-CP): classification and predicting outcomes

Patient-generated treatment goals describe what patients value, yet the content of these goals, and the relationship among goal types, goal accomplishment, and treatment outcomes has received little examination. We used inductive sorting to categorize patient-generated goals made by 147 adults receiving cognitive-behavioral therapy for chronic pain. The resulting goal categories were: Physical Activity (29.0%), Functional Status (24.6%), Wellness (16.3%), Recreational Activities (11.3%), House/Yard Work (9.7%), Socializing (7.1%), and Work/School (2.0%). Next, we examined associations between number of goals by category, goal accomplishment, and clinically meaningful improvements in pain-related interference, pain intensity and depressive symptoms. Improvement in all outcome domains was related to goal accomplishment. Additionally, depressive symptoms were related to number of Physical Activity, House/Yard Work, Recreational Activities, and Wellness goals, whereas improved pain-intensity was significantly related to House/Yard Work. Classifying patient-generated goals facilitates investigation of the relationships among goal type, goal accomplishment and treatment outcomes.

Racial Discrimination in Health Care Is Associated with Worse Glycemic Control among Black Men but Not Black Women with Type 2 Diabetes

Background

A growing body of research suggests that racial discrimination may affect the health of Black men and Black women differently.

Aims

This study examined Black patients with diabetes mellitus (DM) in order to test gender differences in (1) levels of perceived racial discrimination in health care and (2) how perceived discrimination relates to glycemic control.

Methods

A total of 163 Black patients with type 2 DM (78 women and 85 men) provided data on demographics (age and gender), socioeconomic status, perceived racial discrimination in health care, self-rated health, and hemoglobin A1c (HbA1c). Data were analyzed using linear regression.

Results

Black men reported more racial discrimination in health care than Black women. Although racial discrimination in health care was not significantly associated with HbA1c in the pooled sample (b = 0.20, 95% CI = −0.41 −0.80), gender-stratified analysis indicated an association between perceived discrimination and higher HbA1c levels for Black men (b = 0.86, 95% confidence intervals (CI) = 0.01–1.73) but not Black women (b = −0.31, 95% CI = −1.17 to −0.54).

Conclusion

Perceived racial discrimination in diabetes care may be more salient for glycemic control of Black men than Black women. Scholars and clinicians should take gender into account when considering the impacts of race-related discrimination experiences on health outcomes. Policies should reduce racial discrimination in the health care.

Screening for depression in Andean Latin America: Factor structure and reliability of the CES-D short form and the PHQ-8 among Bolivian public hospital patients

Objective We assessed the validity and reliability of the Center for Epidemiologic Studies-Depression scale (CES-D) short form and the Patient Health Questionnaire-8 (PHQ-8) (two measures of depressive symptoms) among urban, low-income patients from a heavily indigenous area of Andean Latin America. This is a patient population that is in many ways culturally distinct from the populations that have been included in previous Spanish language validation studies of these instruments. Methods We administered the CES-D Yale version short form and the PHQ-8 to 107 outpatients at public hospitals in La Paz and El Alto, Bolivia. We conducted exploratory factor analysis, checked internal reliability, and examined concordance between the two measures in identifying patients with clinically significant depressive symptoms. Results Internal reliability was high for both scales: PHQ-8 (Cronbach's α = 0.808) and CES-D (α  = 0.825). A one-factor solution for the PHQ-8 was maintained after the removal of one poorly loading item. The CES-D showed a two-factor solution, with items for somatic symptoms and interpersonal problems loading on the same factor as negative affect. Using both the cutoff for depression recommended in prior studies and a sample specific cutoff of ≥1 standard deviation above the mean, the two scales demonstrated only moderate agreement (κ = 0.481-0.486). Conclusions The PHQ may be more appropriate for clinical use in the Andean region, given its greater specificity; however, lower than expected agreement between the scales suggests that they also measure different elements of depression. Irregularities with the factor structure of both scales suggest that further research with this population is needed to better understand depressive symptomology and improve screening in the region.

Seeing the Person, Not the Illness: Promoting Diabetes Medication Adherence Through Patient-Centered Collaboration

IN BRIEF Nonadherence to diabetes medications is a primary contributor to health complications and avoidable hospitalizations. This article discusses the evidence for taking a person-centered (as opposed to illness-centered) approach to promoting medication adherence among diabetes patients, provides suggestions for ways in which diabetes clinicians can best promote medication adherence, and argues for needed changes in how health care systems support providers in their efforts at adherence promotion.

Feasibility of an interactive voice response system for monitoring depressive symptoms in a lower-middle income Latin American country

Background

Innovative, scalable solutions are needed to address the vast unmet need for mental health care in low- and middle-income countries (LMICs).

Methods

We conducted a feasibility study of a 14-week automated telephonic interactive voice response (IVR) depression self-care service among Bolivian primary care patients with at least moderately severe depressive symptoms. We analyzed IVR call completion rates, the reliability and validity of IVR-collected data, and participant satisfaction.

Results

Of the 32 participants, the majority were women (78 % or 25/32) and non-indigenous (75 % or 24/32). Participants had moderate depressive symptoms at baseline (PHQ-8 score mean 13.3, SD = 3.5) and reported good or fair general health status (88 % or 28/32). Fifty-four percent of weekly IVR calls (approximately 7 out of 13 active call-weeks) were completed. Neither PHQ-8 scores nor IVR call completion differed significantly by ethnicity, education, self-reported depression diagnosis, self-reported overall health, number of chronic conditions, or health literacy. The reliability for IVR-collected PHQ-8 scores was good (Cronbach’s alpha = 0.83). Virtually every participant (97 %) was “mostly” or “very” satisfied with the program. Many described the program as beneficial for their mood and self-care, albeit limited by some technological difficulties and the lack of human interaction.

Conclusion

Findings suggest that IVR could feasibly be used to provide monitoring and self-care education to depressed patients in Bolivia. An expanded stepped-care service offering contact with lay health workers for more depressed individuals and expanded mHealth content may foster greater patient engagement and enhance its therapeutic value while remaining cost-effective.

Trial registration ISRCTN ISRCTN 18403214. Registered 14 September 2016. Retrospectively registered

Structured Caregiver Feedback Enhances Engagement and Impact of Mobile Health Support: A Randomized Trial in a Lower-Middle-Income Country

BACKGROUND

Patients' engagement in mobile health (m-health) interventions using interactive voice response (IVR) calls is less in low- and middle-income countries (LMICs) than in industrialized ones. We conducted a study to determine whether automated telephone feedback to informal caregivers ("CarePartners") increased engagement in m-health support among diabetes and hypertension patients in Bolivia.

MATERIALS AND METHODS

Patients with diabetes and/or hypertension were identified through ambulatory clinics affiliated with four hospitals. All patients enrolled with a CarePartner. Patients were randomized to weekly IVR calls including self-management questions and self-care education either alone ("standard m-health") or with automated feedback about health and self-care needs sent to their CarePartner after each IVR call ("m-health+CP").

RESULTS

The 72 participants included 39 with diabetes and 53 with hypertension, of whom 19 had ≤6 years of education. After 1,225 patient-weeks of attempted IVR assessments, the call completion rate was higher among patients randomized to m-health+CP compared with standard m-health (62.0% versus 44.9%; p < 0.047). CarePartner feedback more than tripled call completion rates among indigenous patients and patients with low literacy (p < 0.001 for both). M-health+CP patients were more likely to report excellent health via IVR (adjusted odds ratio [AOR] = 2.60; 95% confidence interval [CI], 1.07, 6.32) and less likely to report days in bed due to illness (AOR = 0.42; 95% CI, 0.19, 0.91).

CONCLUSIONS

In this study we found that caregiver feedback increased engagement in m-health and may improve patients' health status relative to standard approaches. M-health+CP represents a scalable strategy for increasing the reach of self-management support in LMICs.

Improving the assessment of depression remission with the Remission Evaluation and Mood Inventory Tool

OBJECTIVE

The Remission Evaluation and Mood Inventory Tool (REMIT) is a practical 5-item self-report measure of key positive mood states associated with recovering from depression, as distinct from depressive symptoms per se. The study goal was to identify a clinically useful threshold for interpreting REMIT responses in the context of mild to moderate depressive symptoms.

METHODS

This was a secondary analysis of a cross-sectional dataset initially used to develop and validate the REMIT. Primary care patients being treated for depressive symptoms of either mild or moderate severity (n = 247 and 240, respectively) rated their perceived degree of depression remission prior to completing the Patient Health Questionnaire-8 (PHQ-8) and the REMIT. We summed the totals of the latter two measures to form the PHQ + REMIT index.

RESULTS

Receiver Operating Characteristics analysis indicated that the PHQ + REMIT threshold ≥ 13 was associated with good sensitivity (92%) and acceptable specificity (43%) to the absence of patient-perceived remission. In contrast, the PHQ had only 21% specificity at this sensitivity level. Area under the curve was 0.815 (95% C.I.: 0.765-0.865), which was significantly greater than that of the PHQ-8 alone (area under the curve = 0.745, 95% C.I.: 0.691-0.805, p(diff) = 0.0002). Threshold performance was unaffected by adjustment for demographic characteristics and variation in remission percentage. Compared with standard symptom-based classification, using the REMIT reclassified 27% of mildly symptomatic patients as remitted.

CONCLUSIONS

Using the REMIT with patients who have mild to moderate depressive symptoms improves the assessment of patient-perceived remission, which is indicated by a summed PHQ + REMIT index of less than 13. Longitudinal research is needed to test whether this broadened patient-centered approach to assessing remission improves clinical decision making and long-term outcomes.

Improving Post-Hospitalization Transition Outcomes through Accessible Health Information Technology and Caregiver Support: Protocol for a Randomized Controlled Trial

Objective

The goal of this trial is to evaluate a novel intervention designed to improve post-hospitalization support for older adults with chronic conditions via: (a) direct tailored communication to patients using regular automated calls post discharge, (b) support for informal caregivers outside of the patient’s household via structured automated feedback about the patient’s status plus advice about how caregivers can help, and (c) support for care management including a web-based disease management tool and alerts about potential problems.

Methods

846 older adults with common chronic conditions are being identified upon hospital admission. Patients are asked to identify a “CarePartner” (CP) living outside their household, i.e., an adult child or other social network member willing to play an active role in their post-discharge transition support. Patient-CP pairs are randomized to the intervention or usual care. Intervention patients receive automated assessment and behavior change calls, and their CPs receives structured feedback and advice via email and automated calls following each assessment. Clinical teams have access to assessment results via the web and receive automated reports about urgent health problems. Patients complete surveys at baseline, 30 days, and 90 days post discharge; utilization data is obtained from hospital records. CPs, other caregivers, and clinicians are interviewed to evaluate intervention effects on processes of self-care support, caregiver stress and communication, and the intervention’s potential for broader implementation. The primary outcome is 30-day readmission rates; other outcomes measured at 30 days and 90 days include functional status, self-care behaviors, and mortality risk.

Conclusion

This trial uses accessible health technologies and coordinated communication among informal caregivers and clinicians to fill the growing gap between what discharged patients need and available resources. A unique feature of the intervention is the provision of transition support not only for patients but also for their informal caregivers.

A Mobile Health Intervention Supporting Heart Failure Patients and Their Informal Caregivers: A Randomized Comparative Effectiveness Trial

Background

Mobile health (mHealth) interventions may improve heart failure (HF) self-care, but standard models do not address informal caregivers’ needs for information about the patient’s status or how the caregiver can help.

Objective

We evaluated mHealth support for caregivers of HF patients over and above the impact of a standard mHealth approach.

Methods

We identified 331 HF patients from Department of Veterans Affairs outpatient clinics. All patients identified a “CarePartner” outside their household. Patients randomized to “standard mHealth” (n=165) received 12 months of weekly interactive voice response (IVR) calls including questions about their health and self-management. Based on patients’ responses, they received tailored self-management advice, and their clinical team received structured fax alerts regarding serious health concerns. Patients randomized to “mHealth+CP” (n=166) received an identical intervention, but with automated emails sent to their CarePartner after each IVR call, including feedback about the patient’s status and suggestions for how the CarePartner could support disease care. Self-care and symptoms were measured via 6- and 12-month telephone surveys with a research associate. Self-care and symptom data also were collected through the weekly IVR assessments.

Results

Participants were on average 67.8 years of age, 99% were male (329/331), 77% where white (255/331), and 59% were married (195/331). During 15,709 call-weeks of attempted IVR assessments, patients completed 90% of their calls with no difference in completion rates between arms. At both endpoints, composite quality of life scores were similar across arms. However, more mHealth+CP patients reported taking medications as prescribed at 6 months (8.8% more, 95% CI 1.2-16.5, P=.02) and 12 months (13.8% more, CI 3.7-23.8, P<.01), and 10.2% more mHealth+CP patients reported talking with their CarePartner at least twice per week at the 6-month follow-up (P=.048). mHealth+CP patients were less likely to report negative emotions during those interactions at both endpoints (both P<.05), were consistently more likely to report taking medications as prescribed during weekly IVR assessments, and also were less likely to report breathing problems or weight gains (all P<.05). Among patients with more depressive symptoms at enrollment, those randomized to mHealth+CP were more likely than standard mHealth patients to report excellent or very good general health during weekly IVR calls.

Conclusions

Compared to a relatively intensive model of IVR monitoring, self-management assistance, and clinician alerts, a model including automated feedback to an informal caregiver outside the household improved HF patients’ medication adherence and caregiver communication. mHealth+CP may also decrease patients’ risk of HF exacerbations related to shortness of breath and sudden weight gains. mHealth+CP may improve quality of life among patients with greater depressive symptoms. Weekly health and self-care monitoring via mHealth tools may identify intervention effects in mHealth trials that go undetected using typical, infrequent retrospective surveys.

Trial Registration

ClinicalTrials.gov NCT00555360; https://clinicaltrials.gov/ct2/show/NCT00555360 (Archived by WebCite at http://www.webcitation.org/6Z4Tsk78B).

Potential Impact of Incorporating a Patient-Selected Support Person into mHealth for Depression

BACKGROUND

Although telephone care management improves depression outcomes, its implementation as a standalone strategy is often not feasible in resource-constrained settings. Moreover, little research has examined the potential role of self-management support from patients' trusted confidants.

OBJECTIVE

To investigate the potential benefits of integrating a patient-selected support person into automated mobile health (mHealth) for depression.

DESIGN

Patient preference trial.

PARTICIPANTS

Depressed primary care patients who were at risk for antidepressant nonadherence (i.e., Morisky Medication Adherence Scale total score > 1).

INTERVENTION

Patients received weekly interactive voice response (IVR) telephone calls for depression that included self-management guidance. They could opt to designate a lay support person from outside their home to receive guidance on supporting their self-management. Patients' clinicians were automatically notified of urgent patient issues.

MAIN MEASURES

Each week over a period of 6 months, we used IVR calls to monitor depression with the Patient Health Questionnaire-9 (PHQ-9; with total < 5 classified as remission), adherence (single item reflecting perfect adherence over the past week), and functional impairment (any bed days due to mental health).

KEY RESULTS

Of 221 at-risk patients, 61% participated with a support person. Analyses were adjusted for race, medical comorbidity, and baseline levels of symptom severity and adherence. Significant interaction effects indicated that during the initial phase of the program, only patients who participated with a support person improved significantly in their likelihood of either adhering to antidepressant medication (AOR = 1.31, 95% CI: 1.16-1.47, p < 0.001) or achieving remission of depression symptoms (AOR = 1.24, 95% CI: 1.14-1.34, p < 0.001). These benefits were maintained throughout the 6-month observation period.

CONCLUSIONS

Incorporating the "human factor" of a patient-selected support person into automated mHealth for depression self-management may yield sustained improvements in antidepressant adherence and depression symptom remission. However, this needs to be confirmed in a subsequent randomized controlled trial.

Improvements in illness self-management and psychological distress associated with telemonitoring support for adults with diabetes

OBJECTIVE

The objective of this observational open label trial was to characterize changes in diabetes self-management and psychological distress associated with a mobile health (mHealth) interactive voice response (IVR) self-management support program.

METHODS

For 3-6 months, 301 patients with diabetes received weekly IVR calls assessing health status and self-care and providing tailored pre-recorded self-management support messages. Patients could participate together with an informal caregiver who received suggestions on self-management support, and patients' clinicians were notified automatically when patients reported significant problems.

RESULTS

Patients completed 84% of weekly calls, providing 5682 patient-weeks of data. Thirty-nine percent participated with an informal caregiver. Outcome analyses adjusted for study design factors and sociodemographics indicated significant pre-post improvement in medication adherence, physical functioning, depressive symptoms, and diabetes-related distress (all p values <0.001). Analyses of self-management problems indicated that as the intervention proceeded, there were significant improvements in patients' IVR-reported frequency of weekly medication adherence, SMBG performance, checking feet, and frequency of abnormal self-monitored blood glucose readings (all p values <0.001).

CONCLUSIONS

We conclude that the combined program of automated telemonitoring, clinician notification, and informal caregiver involvement was associated with consistent improvements in medication adherence, diabetes self-management behaviors, physical functioning, and psychological distress. A randomized controlled trial is needed to verify these encouraging findings.

Mobile health monitoring to characterize depression symptom trajectories in primary care

BACKGROUND

Classification of depression severity can guide treatment decisions. This study examined whether using repeated mobile health assessments to determine symptom trajectories is a potentially useful method for classifying depression severity.

METHODS

344 primary care patients with depression were identified and recruited as part of a program of mobile health symptom monitoring and self-management support. Depression symptoms were measured weekly via interactive voice response (IVR) calls using the Patient Health Questionnaire (PHQ-9). Trajectory analysis of weekly IVR PHQ-9 scores from baseline through week 6 was used to subgroup patients according to similar trajectories. Multivariable linear regression was used to determine whether the trajectories predicted 12-week PHQ-9 scores after adjusting for baseline and 6-week PHQ-9 scores.

RESULTS

The optimal trajectory analysis model included 5 non-intersecting trajectories. The subgroups of patients assigned to each trajectory had mean baseline PHQ-9s of 19.7, 14.5, 9.5, 5.0, and 2.0, and respective mean decreases in PHQ-9s over six weeks of .3, 2.0, 3.6, 2.3, and 1.9. In regression analyses, each trajectory significantly predicted 12-week PHQ-9 scores (using the modal trajectory as a reference) after adjusting for both baseline and 6-week PHQ-9 scores.

LIMITATIONS

Treatment history was unknown, findings may not be generalizable to new episodes of treatment.

CONCLUSIONS

Depression symptom trajectories based on mobile health assessments are predictive of future depression outcomes, even after accounting for typical assessments at baseline and a single follow-up time point. Approaches to classify patients׳ disease status that involve multiple repeated assessments may provide more accurate and useful information for depression management compared to lower frequency monitoring.

Integrating support persons into diabetes telemonitoring to improve self-management and medication adherence

OBJECTIVE

The purpose of this study was to investigate the potential benefits for medication adherence of integrating a patient-selected support person into an automated diabetes telemonitoring and self-management program, and to determine whether these benefits vary by patients' baseline level of psychological distress.

STUDY DESIGN

The study was a quasi-experimental patient preference trial.

METHODS

The study included patients with type 2 diabetes who participated in three to six months of weekly automated telemonitoring via interactive voice response (IVR) calls, with the option of designating a supportive relative or friend to receive automated updates on the patient's health and self-management, along with guidance regarding potential patient assistance. We measured long-term medication adherence using the four-point Morisky Medication Adherence Scale (MMAS-4, possible range 0-4), weekly adherence with an IVR item, and psychological distress at baseline with the Mental Composite Summary (MCS) of the SF-12.

RESULTS

Of 98 initially nonadherent patients, 42% opted to involve a support person. Participants with a support person demonstrated significantly greater improvement in long-term adherence than those who participated alone (linear regression slopes: -1.17 vs. -0.57, respectively, p =0.001). Among distressed patients in particular, the odds of weekly nonadherence tended to decrease 25% per week for those with a support person (p =0.030), yet remained high for those who participated alone (p =0.820).

CONCLUSIONS

Despite their multiple challenges in illness self-management, patients with diabetes who are both nonadherent and psychologically distressed may benefit by the incorporation of a support person when they receive assistance via automated telemonitoring.

Rationale and Methods of a Trial to Evaluate a Depression Telemonitoring Program that Includes a Patient-Selected Support Person

Objective

To test the effectiveness of an automated telemonitoring program for patients with depression that includes feedback to clinicians and support for a family member or friend serving as a non-professional caregiver.

Methods

Prior to being randomized to receive one year of either the Care Partners for Depression (CP-D) intervention or usual care alone, depressed patients from primary care clinics serving primarily low-income populations in rural and urban Michigan select a supportive adult from outside their home (their "Care Partner;" CP) to assist them in their depression self-management. In the CP-D arm, patients receive weekly automated telephone calls that provide monitoring and self-management guidance, CPs receive emailed guidance on supporting the patient's self-management based on patient-reported information, and primary care providers receive notifications about any urgent issues. At Baseline, Month 6, and Month 12, we assess depressive symptom severity (primary outcome) and several secondary outcomes.

Conclusion

To date, this is the only mHealth intervention for any psychiatric condition that involves a patient-selected support person. If it proves effective and cost-efficient, a new sustainable intervention would be available to patients with significant depressive symptoms, providing new management alternatives for patients who are medically underserved or socially isolated.

Diabetes self-management support using mHealth and enhanced informal caregiving

OBJECTIVE

To characterize diabetes patient engagement and clinician notifications for an mHealth interactive voice response (IVR) service.

DESIGN

Observational study.

METHODS

For three to six months, VA patients with diabetes received weekly IVR calls assessing health status and self-care along with tailored education. Patients could enroll with an informal caregiver who received suggestions on self-management support. Notifications were issued to clinicians when patients reported significant problems.

RESULTS

Patients (n = 303) participated for a total of 5684 patient-weeks, during which 84% of calls were completed. The odds of call completion decreased over time (AOR = 0.96, p < 0.001), and were lower among unmarried patients (AOR = 0.67, p = 0.038) and those who had difficulties with health literacy (AOR = 0.67, p = 0.039), diabetes-related distress (AOR = 0.30, p = 0.018), or medication nonadherence (AOR = 0.57, p = 0.002). Twenty-one clinician notifications were triggered per 100 patient-weeks. The odds of notification were higher during the early weeks of the program (AOR = 0.95, p < 0.001) and among patients who were older (AOR = 1.03, p = 0.004) or more physically impaired (AOR = 0.97, p < 0.001).

CONCLUSIONS

By providing information that is reliable, valid, and actionable, IVR-based mHealth services may increase access to between-visit monitoring and diabetes self-management support. The system detects abnormal glycemia and blood pressure levels that might otherwise go unreported, although thresholds for clinician notifications might require adjustment to avoid overloading clinicians. Patient engagement might be enhanced by addressing health literacy and psychological distress.

Depression self-management assistance using automated telephonic assessments and social support

OBJECTIVE

To understand patient participation in interactive voice response (IVR) depression monitoring and self-management support calls and estimate the workload from clinical alerts based on patients' IVR reports.

STUDY DESIGN

Observational study from program implementation in 13 community- and university-based primary care practices.

METHODS

Patients with depression were identified using electronic records and enrolled by telephone. Patients were asked to complete IVR assessments weekly; those with significantly improved symptoms had the option of completing assessments monthly. Patients could enroll with an informal caregiver who received automated feedback based on patients' IVR reports. Clinicians received alerts regarding significant changes in the scores on the Patient Health Questionnaire 9-item depression measure, antidepressant adherence problems, or suicidal ideation.

RESULTS

A total of 387 patients were followed for 12,042 weeks. More than half (59%) opted to participate with a caregiver. Patients completed 68% of 7912 attempted IVR assessments. Assessment completion was unrelated to patients' depressive symptoms and was higher among those who participated with a caregiver, were married, had more comorbidities, or reported missing a prior appointment. Assessment completion was lower when patients received monthly versus weekly assessment attempts. Clinical alerts were generated during 4.9% of follow-up weeks; most represented medication adherence problems (2.8%). Alerts indicating suicidal ideation were rare (0.2% of patient-weeks).

CONCLUSIONS

IVR support calls represent a viable strategy for increasing access to depression monitoring and self-management assistance in primary care. These programs generate a manageable number of alerts, most of which can be triaged with limited physician involvement.

Longitudinal association between medication adherence and glycaemic control in Type 2 diabetes

AIM

Despite the widespread assumption that adherence drives glycaemic control, there is little published support for this in Type 2 diabetes. The study objective was to determine whether self-reported medication adherence predicts future glycaemic control in Type 2 diabetes, after accounting for baseline control.

METHODS

Medication adherence (4-item Morisky scale), glycaemic control (HbA(1c)%), and other variables were assessed in 287 adult primary care patients prescribed oral medication (40% also on insulin) for Type 2 diabetes. Glycaemic control was reassessed 6 months later. Regression analyses examined concurrent and future glycaemic control as a function of baseline medication adherence after adjustment for baseline glycaemia and other potential confounders.

RESULTS

Only half of patients reported high adherence. Cross-sectional adjusted analysis replicated prior reports of an adherence-HbA(1c) association (P = 0.011). Even after adjusting for baseline HbA(1c), each one-point increase in baseline Morisky total score was associated with a 1.8 mmol/mol (or 0.16%) increase in HbA(1c) measured 6 months later. Additionally, baseline endorsement of forgetting to take medication was associated with a 4.7 mmol/mol (or 0.43%) increase in 6-month HbA(1c) (P = 0.005). This effect persisted after adjusting for psychological distress and did not vary by key demographic and medical features.

CONCLUSIONS

Even after stringent adjustment for baseline glycaemic control, self-reported adherence to diabetes medication predicts long-term glycaemic control. The Morisky scale is an easy-to-use clinical tool to identify patients whose glycaemic control will subsequently worsen, regardless of age, gender and psychological distress.

Prospective associations between emotional distress and poor outcomes in type 2 diabetes

OBJECTIVE

Cross-sectional studies link both depressive symptoms (DS) and diabetes-related distress (DRD) to diabetes self-management and/or glycemic control. However, longitudinal studies of these variables are rare, and their results are somewhat conflicting. The study objective was to compare DS and DRD as longitudinal predictors of medication adherence, self-care behavior, and glycemic control in type 2 diabetes.

RESEARCH DESIGN AND METHODS

Primary care patients with type 2 diabetes reported DS, DRD, and other variables at baseline were studied. Medication adherence, self-care behaviors (diet, physical activity, and glucose testing), and glycemic control (HbA(1c)) were assessed 6 months later (n = 253). Cross-sectional and longitudinal regression analyses were used to model behavioral and medical outcomes as a function of baseline confounders, DS, and DRD.

RESULTS

Adjusted cross-sectional and longitudinal analyses yielded very similar results. In the latter, only DS were significantly associated with future diet behavior (P = 0.049), physical activity (P = 0.001), and glucose testing (P = 0.018). In contrast, only DRD predicted future glycemic control (P < 0.001) and medication adherence (P = 0.011).

CONCLUSIONS

Distress-outcome associations seem to vary by type of distress under consideration. Only DS predicts future lifestyle-oriented self-management behaviors. In contrast, only DRD predicts glycemic control, perhaps by decreasing medication adherence. Clinical assessment and intervention should encompass both types of distress, unless the goal is to narrowly target a highly specific outcome.

Toward a more comprehensive assessment of depression remission: the Remission Evaluation and Mood Inventory Tool (REMIT)

OBJECTIVE

Depression remission continues to be defined in terms of resolution of the Diagnostic and Statistical Manual of Mental Disorders criteria symptoms. However, it may be useful to assess additional symptoms as part of a more complete evaluation of remission. We sought to develop an adjunct self-report measure that can be used with commonly used depression measures when assessing remission.

METHODS

Secondary data analysis and expert input were used to develop candidate items that were evaluated cross-sectionally in 1003 primary care clinician-identified depressed patients from two practice-based research networks. Multivariable regression analysis, with self-assessed recovery as the dependent variable, identified five symptoms that contributed significantly beyond the Patient Health Questionnaire (PHQ)-8. Further analysis was performed in selected subsamples.

RESULTS

Emotional control, contentedness, future seeming dark, ability to bounce back and happiness yielded an 11% increase in R(2) beyond 60% yielded by the PHQ-8. The summed Remission Evaluation and Mood Inventory Tool (REMIT) 5 items have a mean=9.6 (S.D.=4.5), range 0-20 and reliability of 0.86. Subsample analysis showed incremental R(2) ranging from 9% in men to 15% in African-Americans.

CONCLUSION

Depression remission is a multidimensional concept that includes important nondepressive symptom dimensions. These important dimensions can be measured using a self-report instrument feasible for routine primary care. Pending longitudinal validation, REMIT5 is a promising tool for depression management.

Racial differences in the discussion and treatment of depressive symptoms accompanying type 2 diabetes

OBJECTIVE

To compare rates of discussion of and treatment for depression among African Americans and Whites with diabetes.

METHODS

Measures of diabetes status, depressive symptoms, and history of discussing and being treated for depression were collected from 56 adults with elevated depressive symptoms accompanying diabetes who were drawn from a larger study of type 2 diabetes.

RESULTS

Analyses adjusted for confounders and multiple tests indicated that relative to Whites, African Americans were 6-12 times less likely to have ever: discussed depression with anyone (p=.007), discussed depression with their primary care physician (p=.008), been prescribed an antidepressant (p=.002), and they were 25 times less likely to have seen a psychiatrist (p=.003). There were no significant differences in discussing depression with clergypersons, or family members/friends.

CONCLUSIONS

Compared to their White counterparts, African Americans with depressive symptoms accompanying diabetes are unlikely to discuss depression with healthcare professionals, be prescribed antidepressant medication, or be seen by a psychiatrist. Minority diabetes patients' medical and psychiatric outcomes may improve if healthcare providers more actively initiate these discussions, provide culturally tailored education about the nature of depression and its management, incorporate patient preferences into treatment plans, and establish relationships with persons more likely to learn about African American patient symptoms.

Longitudinal analysis of depressive symptoms and glycemic control in type 2 diabetes

OBJECTIVE

To compare whether depressive symptoms are more strongly related to subsequent or prior glycemic control in type 2 diabetes and to test whether patient characteristics modify these longitudinal associations.

RESEARCH DESIGN AND METHODS

On two occasions separated by 6 months, depressive symptoms and glycemic control were assessed in 253 adults with type 2 diabetes. Regression analyses examined depressive symptoms as both a predictor and outcome of glycemic control and tested whether medication regimen (e.g., insulin versus oral drugs) was an effect modifier before and after adjusting for baseline levels of the outcome being predicted.

RESULTS

Depressive symptom severity predicted poor glycemic control 6 months later (P = 0.018) but not after baseline glycemic control was taken into account (P = 0.361). Although baseline glycemic control did not generally predict depressive symptoms 6 months later (P = 0.558), it significantly interacted with regimen (P = 0.008). Specifically, glycemic control predicted depressive symptoms among patients prescribed insulin (beta = 0.31, P = 0.002) but not among those prescribed oral medication alone (beta = -0.10, P = 0.210). Classifying depression dichotomously produced similar but weaker findings.

CONCLUSIONS

Depressive symptoms do not necessarily lead to worsened glycemic control. In contrast, insulin-treated patients in poor glycemic control are at moderate risk for worsening of depressive symptoms. These patients should be carefully monitored to determine whether depression treatment should be initiated or intensified.