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The Effectiveness of Depression Care Management on Diabetes-Related Outcomes in Older Patients
- John W. Williams, Jr., MD, MHSc;
- Wayne Katon, MD;
- Elizabeth H.B. Lin, MD;
- Polly H. Nöel, PhD;
- Jason Worchel, MD;
- John Cornell, PhD;
- Linda Harpole, MD, MPH;
- Bridget A. Fultz, MA;
- Enid Hunkeler, MA;
- Virginia S. Mika, MPH;
- Jürgen Unützer, MD; and
- the IMPACT Investigators*
- From Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, and Duke University School of Medicine, Durham, North Carolina; University of Washington School of Medicine and Group Health Cooperative of Puget Sound, Seattle, Washington; South Texas Veterans Health Care System and University of Texas Health Science Center, San Antonio, Texas; Central Texas Veterans Health Care System, Austin, Texas; Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana; Kaiser Permanente of Northern California, Oakland, California; and University of California, Los Angeles, Los Angeles, California.
Abstract
Background: Depression frequently occurs in combination with diabetes mellitus, adversely affecting the course of illness.
Objective: To determine whether enhancing care for depression improves affective and diabetic outcomes in older adults with diabetes and depression.
Design: Preplanned subgroup analysis of the Improving Mood–Promoting Access to Collaborative Treatment (IMPACT) randomized, controlled trial.
Setting: 18 primary care clinics from 8 health care organizations in 5 states.
Patients: 1801 patients 60 years of age or older with depression; 417 had coexisting diabetes mellitus.
Intervention: A care manager offered education, problem-solving treatment, or support for antidepressant management by the patient's primary care physician; diabetes care was not specifically enhanced.
Measurements: Assessments at baseline and at 3, 6, and 12 months for depression, functional impairment, and diabetes self-care behaviors. Hemoglobin A1c levels were obtained for 293 patients at baseline and at 6 and 12 months.
Results: At 12 months, diabetic patients who were assigned to intervention had less severe depression (range, 0 to 4 on a checklist of 20 depression items; between-group difference, −0.43 [95% CI, −0.57 to −0.29]; P < 0.001) and greater improvement in overall functioning (range, 0 [none] to 10 [unable to perform activities]; between-group difference, −0.89 [CI, −1.46 to −0.32]) than did participants who received usual care. In the intervention group, weekly exercise days increased (between-group difference, 0.50 day [CI, 0.12 to 0.89 day]; P = 0.001); other self-care behaviors were not affected. At baseline, mean (±SD) hemoglobin A1c levels were 7.28% ± 1.43%; follow-up values were unaffected by the intervention (P > 0.2).
Limitations: Because patients had good glycemic control at baseline, power to detect small but clinically important improvements in glycemic control was limited.
Conclusions: Collaborative care improves affective and functional status in older patients with depression and diabetes; however, among patients with good glycemic control, such care minimally affects diabetes-specific outcomes.
*For a list of the IMPACT investigators, see the Appendix.
Article and Author Information
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Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
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Acknowledgments: The authors thank the contributions of the IMPACT study advisory board (Lydia Lewis; Lisa Goodale, ACSW; Howard Goldman, MD, PhD; Thomas Oxman, MD; Lisa Rubenstein, MD, MSPH; Cathy Sherbourne, PhD; Kenneth Wells, MD, MPH); statistical consultation from Lingqi Tang, PhD; and outstanding programming support by Tonya Marmon, MS. The authors also acknowledge the contributions and support of patients, providers, and staff and the use of resources and facilities at the study coordinating center and at all participating study sites.
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Grant Support: By grants from the Robert Wood Johnson Foundation, the John A. Hartford Foundation, the California Healthcare Foundation, and the Hogg Foundation.
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Potential Financial Conflicts of Interest:Consultancies: J.W. Williams Jr. (GlaxoSmithKline, Pfizer), E.H.B. Lin (Pfizer, Wyeth); Honoraria: J.S. Williams Jr. (Pfizer, Wyeth-Ayerst), E.H.B. Lin (Pfizer, Wyeth); Grants received: J.W. Williams Jr. (Eli Lilly, Pfizer), E.M. Hunkeler (Eli Lilly, Merck & Co., Solvay).
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Requests for Single Reprints: John W. Williams, MD, MHSc, Durham Veterans Affairs Medical Center (152), Center for Health Services Research in Primary Care, 508 Fulton Street, Durham, NC 27705.
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Current Author Addresses: Dr. Williams: Center for Health Services Research in Primary Care, HSR&D (Building 6), 508 Fulton Street, Durham, NC 27705.
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Drs. Katon and Unützer: Department of Psychiatry, University of Washington, Box 356560, 1959 NE Pacific, Seattle, WA 98195.
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Dr. Lin: Center for Health Studies, Group Health Cooperative, 1730 Minor Avenue #1600, Seattle, WA 98101.
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Drs. Nöel and Cornell: South Texas Veterans Health Care System, 7400 Merton Minter Boulevard, San Antonio, TX 78229.
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Dr. Worchel: Central Texas Veterans Health Care System, 2901 Montopolis, Austin, TX 78741.
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Dr. Harpole: Duke University Medical Center, 3024 Pickett Road, Durham, NC 27705.
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Ms. Fultz: Regenstrief Institute, Inc., 1050 Wishard Boulevard, RG 6, Indianapolis, IN 46202.
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Ms. Hunkeler: Division of Research, Kaiser Permanente–Northern California, 3505 Broadway, 7th Floor, Oakland, CA 94611.
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Ms. Mika: University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX 78229.
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