Treat Depression and Diabetes for Best Results

Hillary R. Bogner, MD, MSCE, of the University of Pennsylvania in Philadelphia, and colleagues reported that, an intervention for integrated care in primary care practices got 60.9% of patients with both conditions to the hemoglobin A1c goal compared with just 35.7% of those in usual care (P<0.001).

Depression went into remission for 58.7% of the integrated care group compared with 30.7% cared for as usual (P<0.001) in the randomized trial.

Boosting medication adherence was the main target of the three-month intervention and appeared to largely account for its benefits.

Depression often drags down adherence and commonly complicates diabetes, the investigators noted. But the benefits of adding a care manager as a liaison for the patient, as done in the trial, aren't likely limited to comorbid diabetes and depression, an accompanying editorial pointed out.

Elizabeth A. Bayliss, MD, MSPH, of the Kaiser Permanente Institute for Health Research in Denver wrote that, "Any complex patient would stand to gain from such continuous, cohesive care management." She suggested that the key is likely communication and continuity between patients and clinicians.

The trial included 180 patients prescribed medication for type 2 diabetes and depression at three community primary care practices in Philadelphia. They were randomized to either usual care or the integrated care intervention. For the intervention, trained care managers collaborated with physicians and monitored clinical status and adherence. Depression treatment was integrated into diabetes management.
Intervention-group patients received individualized programs, education, and help to improve adherence with three 30-minute sessions in person with a trained care manager, and also participated in another two 15-minute telephone conversations over the three-month trial. During that period, adherence -- monitored electronically by medication bottle caps -- jumped for intervention versus usual care. By week 12, the proportion of patients taking their oral diabetes medication at least 80% of the time had improved from less than 40% to more than 60% in the intervention group, whereas that proportion progressively fell from 42% at baseline to 30% with usual care (P<0.001 for difference).

The proportion adherent to antidepressants showed the same patterns such that at 12 weeks, the intervention group reached 60% adherence compared with around 20% in the usual care group (P<0.001). The mean hemoglobin A1c, as might be expected from better adherence, dropped by 0.7 percentage points with integrated care, whereas it rose by 0.5 percentage points with usual care (P<0.001).

Likewise, depression scores on the nine-item Patient Health Questionnaire dropped by 2.42 points on average with the intervention over 12 weeks, but rose by 0.29 with usual care (P=0.007). The researchers cautioned that the primary care sites involved in the study, though diverse and varied in size, may not have been nationally representative.

Another limitation was that the usual care group didn't have the same number of total in-person contacts with a clinician as those in the intervention group, which may have impacted the results through differences in attention. Yet the intervention may be a "sustainable" solution for many practices because it is brief, doesn't require a high level of expertise, and can be adapted to community primary care, Bogner and colleagues pointed out.

"Ancillary health personnel who are already working in primary care practices could be trained to carry out the intervention," they suggested.

Practice Pearls:

• This study suggests that the use of integration care managers is associated with improved medication adherence and disease outcomes for persons with depression and diabetes.
• Depression is a risk factor for diabetes and contributes to poor adherence, physical inactivity, poor glycemic control, reduced quality of life, and disability.

Bogner HR, et al "Integrated management of type 2 diabetes mellitus and depression treatment to improve medication adherence: A randomized controlled trial" Ann Fam Med 2012; 10: 15-22.