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Bessie Ann Young,
Elizabeth Lin,
Michael Von Korff, Greg Simon,
Paul Ciechanowski,
Evette J Ludman,
Siobhan Everson-Stewart,
Leslie Kinder,
Malia Oliver,
Edward J Boyko,
Wayne J Katon
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ABSTRACT: To determine whether the number and severity of diabetes complications are associated with increased risk of mortality and hospitalizations.
Validation sample.
The Diabetes Complications Severity Index (DCSI) was developed from automated clinical baseline data of a primary care diabetes cohort and compared with a simple count of complications to predict mortality and hospitalizations. Cox proportional hazard and Poisson regression models were used to predict mortality and hospitalizations, respectively.
Of 4229 respondents, 356 deaths occurred during 4 years of follow-up. Those with 1 complication did not have an increased risk of mortality, whereas those with 2 complications (hazard ratio [HR] = 1.90, 95% confidence interval [CI] = 1.27, 2.83), 3 complications (HR = 2.66, 95% CI = 1.77, 4.01), 4 complications (HR = 3.41, 95% CI = 2.18, 5.33), and >5 complications (HR = 7.18, 95% CI = 4.39, 11.74) had greater risk of death. Replacing the complications count with the DCSI showed a similar mortality risk. Each level of the continuous DCSI was associated with a 1.34-fold (95% CI = 1.28, 1.41) greater risk of death. Similar results were obtained for the association of the DCSI with risk of hospitalization. Comparison of receiver operating characteristic curves verified that the DCSI was a slightly better predictor of mortality than a count of complications (P < .0001).
Compared with the complications count, the DCSI performed slightly better and appears to be a useful tool for prediction of mortality and risk of hospitalization.
The American journal of managed care 01/2008; 14(1):15-23. · 2.46 Impact Factor
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ABSTRACT: Depression is common in patients with diabetes, but it is often inadequately treated within primary care. Competing clinical demands and treatment resistance may make it especially difficult to improve depressive symptoms in patients with diabetes who have multiple complications.
To determine whether a collaborative care intervention for depression would be as effective in patients with diabetes who had 2 or more complications as in patients with diabetes who had fewer complications.
The Pathways Study was a randomized control trial comparing collaborative care case management for depression and usual primary care. This secondary analysis compared outcomes in patients with 2 or more complications to patients with fewer complications.
Three hundred and twenty-nine patients with diabetes and comorbid depression were recruited through primary care clinics of a large prepaid health plan.
Depression was assessed at baseline, 3, 6, and 12 months with the 20-item depression scale from the Hopkins Symptom Checklist. Diabetes complications were determined from automated patient records.
The Pathways collaborative care intervention was significantly more successful at reducing depressive symptoms than usual primary care in patients with diabetes who had 2 or more complications. Patients with fewer than 2 complications experienced similar reductions in depressive symptoms in both intervention and usual care.
Patients with depression and diabetes who have multiple complications may benefit most from collaborative care for depression. These findings suggest that with appropriate intervention depression can be successfully treated in patients with diabetes who have the highest severity of medical problems.
Journal of General Internal Medicine 11/2006; 21(10):1036-41. · 2.83 Impact Factor
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ABSTRACT: The authors compared the incremental cost-effectiveness of a stepped-care, multicomponent program with usual care for the treatment of depressed women in primary care in Santiago, Chile.
A cost-effectiveness study was conducted of a previous randomized controlled trial involving 240 eligible women with DSM-IV major depression who were selected from a consecutive sample of adult women attending primary care clinics. The patients were randomly allocated to usual care or a multicomponent stepped-care program led by a nonmedical health care worker. Depression-free days and health care costs derived from local sources were assessed after 3 and 6 months. A health service perspective was used in the economic analysis.
Complete data were determined for 80% of the randomly assigned patients. After we adjusted for initial severity, women receiving the stepped-care program had a mean of 50 additional depression-free days over 6 months relative to patients allocated to usual care. The stepped-care program was marginally more expensive than usual care (an extra 216 Chilean pesos per depression-free day). There was a 90% probability that the incremental cost of obtaining an extra depression-free day with the intervention would not exceed 300 pesos (1.04 US dollars).
The stepped-care program was significantly more effective and marginally more expensive than usual care for the treatment of depressed women in primary care. Small investments to improve depression appear to yield larger gains in poorer environments. Simple and inexpensive treatment programs tested in developing countries might provide good study models for developed countries.
American Journal of Psychiatry 09/2006; 163(8):1379-87. · 12.54 Impact Factor
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ABSTRACT: We assessed whether patients with comorbid minor and major depression and type 2 diabetes had a higher mortality rate over a 3-year period compared with patients with diabetes alone.
In a large health maintenance organization (HMO), 4,154 patients with type 2 diabetes were surveyed and followed for up to 3 years. Patients initially filled out a written questionnaire, and HMO-automated diagnostic, laboratory, and pharmacy data and Washington State mortality data were collected to assess diabetes complications and deaths. Cox proportional hazards regression models were used to calculate adjusted hazard ratios of death for each group compared with the reference group.
There were 275 (8.3%) deaths in 3,303 patients without depression compared with 48 (13.6%) deaths in 354 patients with minor depression and 59 (11.9%) deaths among 497 patients with major depression. A proportional hazards model with adjustment for age, sex, race/ethnicity, and educational attainment found that compared with the nondepressed group, minor depression was associated with a 1.67-fold increase in mortality (P = 0.003), and major depression was associated with a 2.30-fold increase (P < 0.0001). In a second model that controlled for multiple potential mediators, both minor and major depression remained significant predictors of mortality.
Among patients with diabetes, both minor and major depression are strongly associated with increased mortality. Further research will be necessary to disentangle causal relationships among depression, behavioral risk factors (adherence to medical regimens), diabetes complications, and mortality.
Diabetes Care 12/2005; 28(11):2668-72. · 8.09 Impact Factor
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Psychiatric Services 04/2005; 56(3):357. · 2.38 Impact Factor
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ABSTRACT: This paper investigates comorbidity between chronic back and neck pain and other physical and mental disorders in the US population, and assesses the contributions of chronic spinal pain and comorbid conditions to role disability. A probability sample of US adults (n=5692) was interviewed. Chronic spinal pain, other chronic pain conditions and selected chronic physical conditions were ascertained by self-report. Mood, anxiety and substance use disorders were ascertained with the Composite International Diagnostic Interview (CIDI). Role disability was assessed with questions about days out of role and with impaired role functioning. The 1 year prevalence of chronic spinal pain was 19.0%. The vast majority (87.1%) of people with chronic spinal pain reported at least one other comorbid condition, including other chronic pain conditions (68.6%), chronic physical conditions (55.3%), and mental disorders (35.0%). Anxiety disorders showed as strong an association with chronic spinal pain as did mood disorders. Common conditions not significantly comorbid with chronic spinal pain were diabetes, heart disease, cancer, and drug abuse. Chronic spinal pain was significantly associated with role disability after controlling for demographic variables and for comorbidities. However, comorbid conditions explained about one-third of the gross association of chronic spinal pain with role disability. We conclude that chronic spinal pain is highly comorbid with other pain conditions, chronic diseases, and mental disorders, and that comorbidity plays a significant role in role disability associated with chronic spinal pain. The societal burdens of chronic spinal pain need to be understood and managed within the context of comorbid conditions.
Pain 03/2005; 113(3):331-9. · 5.78 Impact Factor
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ABSTRACT: The prevalence of major depression is approximately 2-fold higher in patients with diabetes mellitus compared to medical controls. We explored the association of major depression with 8 cardiac risk factors in diabetic patients with and without evidence of cardiovascular disease (CVD).
A mail survey questionnaire was administered to a population-based sample of 4,225 patients with diabetes to obtain data on depression status, diabetes self-care (diet, exercise, and smoking), diabetes history, and demographics. On the basis of automated data we measured diabetes complications, glycosylated hemoglobin, medical comorbidity, low-density lipid levels, triglyceride levels, diagnosis of hypertension, and evidence of microalbuminuria. Separate analyses were conducted for subgroups according to the presence or absence of CVD.
Nine primary care clinics of a nonprofit health maintenance organization.
Patients with major depression and diabetes were 1.5- to 2-fold more likely to have 3 or more cardiovascular risk factors as patients with diabetes without depression (62.5% vs 38.4% in those without CVD, and 61.3% vs 45% in those with CVD). Patients with diabetes without CVD who met criteria for major depression were significantly more likely to be smokers, to have a body mass index (BMI) > or = 30 kg/m2, to lead a more sedentary lifestyle, and to have HbA1c levels of >8.0% compared to nondepressed patients with diabetes without heart disease. Patients with major depression, diabetes, and evidence of heart disease were significantly more likely to have a BMI > or = 30 kg/m2, a more sedentary lifestyle, and triglyceride levels > 400 mg/dl than nondepressed diabetic patients with evidence of heart disease.
Patients with major depression and diabetes with or without evidence of heart disease have a higher number of CVD risk factors. Interventions aimed at decreasing these risk factors may need to address treatment for major depression in order to be effective.
Journal of General Internal Medicine 01/2005; 19(12):1192-9. · 2.83 Impact Factor
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ABSTRACT: There is a high prevalence of depression in patients with diabetes mellitus. Depression has been shown to be associated with poor self-management (adherence to diet, exercise, checking blood glucose levels) and high hemoglobin A1c (HbA1c) levels in patients with diabetes.
To determine whether enhancing quality of care for depression improves both depression and diabetes outcomes in patients with depression and diabetes.
Randomized controlled trial with recruitment from March 1, 2001, to May 31, 2002.
Nine primary care clinics from a large health maintenance organization.
A total of 329 patients with diabetes mellitus and comorbid major depression and/or dysthymia. Intervention Patients were randomly assigned to the Pathways case management intervention (n = 164) or usual care (n = 165). The intervention provided enhanced education and support of antidepressant medication treatment prescribed by the primary care physician or problem-solving therapy delivered in primary care.
Independent blinded assessments at baseline and 3, 6, and 12 months of depression (Hopkins Symptom Checklist 90), global improvement, and satisfaction with care. Automated clinical data were used to evaluate adherence to antidepressant regimens, percentage receiving specialty mental health visits, and HbA1c levels.
When compared with usual care patients, intervention patients showed greater improvement in adequacy of dosage of antidepressant medication treatment in the first 6-month period (odds ratio [OR], 4.15; 95% confidence interval [CI], 2.28-7.55) and the second 6-month period (OR, 2.90; 95% CI, 1.69-4.98), less depression severity over time (z = 2.84, P = .004), a higher rating of patient-rated global improvement at 6 months (intervention 69.4% vs usual care 39.3%; OR, 3.50; 95% CI, 2.16-5.68) and 12 months (intervention 71.9% vs usual care 42.3%; OR, 3.50; 95% CI, 2.14-5.72), and higher satisfaction with care at 6 months (OR, 2.01; 95% CI, 1.18-3.43) and 12 months (OR, 2.88; 95% CI, 1.67-4.97). Although depressive outcomes were improved, no differences in HbA1c outcomes were observed.
The Pathways collaborative care model improved depression care and outcomes in patients with comorbid major depression and/or dysthymia and diabetes mellitus, but improved depression care alone did not result in improved glycemic control.
Archives of General Psychiatry 11/2004; 61(10):1042-9. · 12.02 Impact Factor
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ABSTRACT: This article uses data from two studies that have demonstrated the overall effectiveness of Collaborative Care interventions to evaluate factors associated with poor outcomes overall (general prognostic factors) and factors associated with greater or lesser effects of treatment (differential treatment effects).
Adult primary care patients initiating antidepressant treatment for major depression were randomized to usual care or to Collaborative Care, a structured depression treatment program that included planned, proactive and coordinated care with a health care team and informed, activated patients (n = 156, mean age = 43, 85% white). Response to treatment was defined as a 50% or greater reduction in depression at four months.
High neuroticism and a history of recurrent major depression (3+ episodes) or dysthymia predicted poor outcomes in general. While the magnitude of the intervention effects differed, frequently cited predictors of persistence of depression (age, gender, depression severity, medical and psychiatric comorbidity) were not significantly associated with greater or lesser benefit from Collaborative Care (no differential treatment effects). Results demonstrate the robustness of intervention effects across numerous groups at risk for persistence of depression.
These findings suggest that at the time of diagnosis it is not possible to predict who is most likely to benefit from Collaborative Care. Instead, outcomes of treatment should be routinely monitored among depressed patients to ensure optimal response.
The International Journal of Psychiatry in Medicine 02/2004; 34(3):247-58. · 1.03 Impact Factor
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ABSTRACT: Depression in women is one of the commonest problems encountered in primary care. We aimed to compare the effectiveness of a stepped-care programme with usual care in primary-care management of depression in low-income women in Santiago, Chile.
In a randomised controlled trial, in three primary-care clinics in Chile, 240 adult female primary-care patients with major depression were allocated stepped care or usual care. Stepped care was a 3-month, multicomponent intervention led by a non-medical health worker, which included a psychoeducational group intervention, structured and systematic follow-up, and drug treatment for patients with severe depression. Data were analysed on an intention-to-treat basis. The primary outcome measure was the Hamilton depression rating scale (HDRS) administered at baseline and at 3 and 6 months after randomisation.
About 90% of randomised patients completed outcome assessments. There was a substantial between-group difference in all outcome measures in favour of the stepped-care programme. The adjusted difference in mean HDRS score between the groups was -8.89 (95% CI -11.15 to -6.76; p<0.0001). At 6-months' follow-up, 70% (60-79) of the stepped-care compared with 30% (21-40) of the usual-care group had recovered (HDRS score <8).
Despite few resources and marked deprivation, women with major depression responded well to a structured, stepped-care treatment programme, which is being introduced across Chile. Socially disadvantaged patients might gain the most from systematic improvements in treatment of depression.
The Lancet 03/2003; 361(9362):995-1000. · 38.28 Impact Factor
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ABSTRACT: A previous study described the effect of a collaborative care intervention on improving adherence to antidepressant medications and depressive and functional outcomes of patients with persistent depressive symptoms 8 weeks after the primary care physician initiated treatment. This paper examined the 28-month effect of this intervention on adherence, depressive symptoms, functioning, and health care costs.
Randomized trial of stepped collaborative care intervention versus usual care.
HMO in Seattle, Wash.
Patients with major depression were stratified into severe and moderate depression groups prior to randomization.
A multifaceted intervention targeting patient, physician, and process of care, using collaborative management by a psychiatrist and a primary care physician.
The collaborative care intervention was associated with continued improvement in depressive symptoms at 28 months in patients in the moderate-severity group (F1,87 = 8.65; P =.004), but not in patients in the high-severity group (F1,51 = 0.02; P =.88) Improvements in the intervention group in antidepressant adherence were found to occur for the first 6 months (chi2(1) = 8.23; P <.01) and second 6-month period (chi2(1) = 5.98; P <.05) after randomization in the high-severity group and for 6 months after randomization in the moderate-severity group(chi2(1) = 6.10; P <.05). There were no significant differences in total ambulatory costs between intervention and control patients over the 28-month period (F1,180 = 0.77; P =.40).
A collaborative care intervention was associated with sustained improvement in depressive outcomes without additional health care costs in approximately two thirds of primary care patients with persistent depressive symptoms.
Journal of General Internal Medicine 10/2002; 17(10):741-8. · 2.83 Impact Factor
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ABSTRACT: Behavioral factors may play a role in heart failure (HF) care costs by increasing hospital readmission rates. This study sought to estimate the effect of depression on health care costs for patients hospitalized for HF.
A 3-year retrospective cohort study of a staff-model health maintenance organization. Following a first hospitalization with a primary diagnosis of HF, 1098 health maintenance organization patients were evaluated. Median annualized health care costs for 3 depression groups were identified: (1) no depression (n = 672; cost, $7474), (2) antidepressant prescription only (n = 312; cost, $11 012), and (3) antidepressant prescription and depression diagnosis recorded (n = 114; cost, $9550). Depression and HF status were determined through diagnostic, laboratory, and pharmacy records. Actual utilization and cost values were derived from administrative data.
After adjusting for age, sex, medical comorbidity, and length of stay at index hospitalization (as proxy for HF severity), costs were 26% higher in the antidepressant prescription only group and 29% higher in the antidepressant prescription and depression diagnosis recorded group when compared with the no depression group (both P<.001). Increased inpatient and outpatient utilization contributed to the increased costs.
Costs of care for patients hospitalized for HF are significantly higher for patients with evidence of depression.
Archives of Internal Medicine 10/2002; 162(16):1860-6. · 11.46 Impact Factor
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ABSTRACT: This paper reviews the concepts of population-based care and disease management of major depression. Populationbased care and disease management strategies motivated by health care reform provide approaches for organizing health services to lower the prevalence of common medical and psychiatric illnesses in primary care populations. We apply these concepts to the organization of services for patients with major depression.
General Hospital Psychiatry.
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ABSTRACT: This paper describes the methodology of a population based study of primary care patients with diabetes mellitus enrolled in a health maintenance organization. The first goal was to determine the prevalence and impact of depression in patients with diabetes. The second goal was to randomize approximately 300 patients with diabetes and major depression and/or dysthymia in a trial to test the effectiveness of a collaborative care intervention in improving quality of care and health outcomes among patients with diabetes and depression.
General Hospital Psychiatry 25(3):158-68. · 2.74 Impact Factor
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ABSTRACT: Telephone psychotherapy is an emerging model of care that appears feasible for extending the reach of evidence-based psychotherapy treatment without accruing the full costs of traditional office-based, mental health care. This manuscript describes the development, implementation and acceptance of a 12-month telephone psychotherapy program (TPP) for depressed adults not fully responding to standard antidepressant treatment in primary care.
The TPP combined a population-based medication monitoring and information system with a structured cognitive-behavioral treatment (CBT) program. The TPP included 8-12 telephone sessions (eight core CBT sessions and three to four clinical booster sessions) delivered by a master-level therapist working in tandem with each patient's primary care physician (PCP).
The TPP was well accepted (i.e., 80% completed the core program) by a population-based sample of adult primary care patients initiating antidepressant treatment. The mean duration of core telephone psychotherapy sessions was approximately 31 min during acute-phase treatment (0-6 months). Eighty-two percent of TPP patients maintained contact with their therapist during maintenance-phase treatment (6-12 months).
The practical and efficient nature of this TPP appears to sidestep many of the treatment barriers encountered in traditional office-based care. Implementation of this TPP program in other primary care settings may be valuable for enhancing standard pharmacotherapy treatment of adult depression, especially among populations facing greater barriers of care.
General Hospital Psychiatry 27(6):400-10. · 2.74 Impact Factor
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ABSTRACT: This report evaluates the effects of a depression relapse prevention program on disability outcomes among patients treated for depression at high risk for relapse.
Primary care patients initiating antidepressant treatment for depression were assessed 6 to 8 weeks after the initial prescription. Patients responding to initial treatment but at high risk for relapse were randomized to usual care or a relapse prevention intervention (N= 386). The 12-month relapse prevention program included systematic patient education, two psycho-educational visits with a depression prevention specialist, shared decision-making regarding maintenance pharmacotherapy, and ongoing monitoring of medication adherence and depressive symptoms via telephone and mail. Disability outcomes were assessed via blinded telephone assessments at 3, 6, 9, and 12 months using SF-36 and Sheehan Disability scales.
Usual care patients and relapse prevention program patients had high rates of use of maintenance pharmacotherapy. Both relapse prevention and usual care patients showed improved functioning over the 12-month follow-up period. One of the three disability measures (the SF-36 Social Function scale) showed a significant intervention effect because of continuing improvement at 9 and 12 month follow-up, whereas the Sheehan Disability Scale showed a nonsignificant trend toward greater improvements in disability among relapse prevention patients than among usual care controls.
Moderate effects of a relapse prevention intervention on depressive symptoms were associated with modest and variable effects on disability outcomes. Inconsistent effects of the intervention for disability outcomes may be because of the high rates of maintenance pharmacotherapy among usual care patients, relatively mild levels of depressive symptoms among both intervention and control patients at baseline, the absence of a specific relapse prevention effect of the intervention, and the resultant modest differences in depressive symptoms between intervention and control patients in this trial.
Psychosomatic Medicine 65(6):938-43. · 3.97 Impact Factor
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ABSTRACT: Objective.
—To examine whether depressive symptoms in older adults contribute to increased cost of general medical services.
JAMA The Journal of the American Medical Association 277(20):1618-1623. · 30.03 Impact Factor
