PURPOSE Depression commonly accompanies diabetes, resulting in reduced adherence to medications and increased risk for morbidity and mortality. The objective of this study was to examine whether a simple, brief integrated approach to depression and type 2 diabetes mellitus (type 2 diabetes) treatment improved adherence to oral hypoglycemic agents and antidepressant medications, glycemic control, and depression among primary care patients. METHODSWe undertook a randomized controlled trial conducted from April 2010 through April 2011 of 180 patients prescribed pharmacotherapy for type 2 diabetes and depression in primary care. Patients were randomly assigned to an integrated care intervention or usual care. Integrated care managers collaborated with physicians to offer education and guideline-based treatment recommendations and to monitor adherence and clinical status. Adherence was assessed using the Medication Event Monitoring System (MEMS). We used glycated hemoglobin (HbA 1c ) assays to measure glycemic control and the 9-item Patient Health Questionnaire (PHQ-9) to assess depression. RESULTSIntervention and usual care groups did not differ statistically on baseline measures. Patients who received the intervention were more likely to achieve HbA 1c levels of less than 7% (intervention 60.9% vs usual care 35.7%; P <.001) and remission of depression (PHQ-9 score of less than 5: intervention 58.7% vs usual care 30.7%; P <.001) in comparison with patients in the usual care group at 12 weeks.CONCLUSIONS A randomized controlled trial of a simple, brief intervention integrating treatment of type 2 diabetes and depression was successful in improving outcomes in primary care. An integrated approach to depression and type 2 diabetes treatment may facilitate its deployment in real-world practices with competing demands for limited resources. INTRODUCTIONA bidirectional association has been found between depression and diabetes mellitus.1 Depression is a risk factor for diabetes, 2 and diabetes increases risk for the onset of depression.3 Not only is depression common in patients with diabetes, it also contributes to poor adherence to medication and dietary regimens, physical inactivity, poor glycemic control, reduced quality of life, disability, and increased health care expenditures. 4-9The purpose of this study was to carry out a randomized controlled trial to test the effectiveness of integrated care management of type 2 diabetes mellitus (type 2 diabetes) and depression in comparison with usual

An improved understanding of how older adults view loneliness in relation to depression, derived from multiple methods, may inform clinical practice.

Purpose The purpose of this study was to examine whether integrating depression treatment into care for Type 2 diabetes mellitus among older African-Americans improved medication adherence, glycemic control, and depression outcomes. Methods Older African-Americans prescribed pharmacotherapy for Type 2 diabetes mellitus and depression from physicians at a large primary care practice in West Philadelphia were randomly assigned to an integrated care intervention or usual care. Adherence was assessed at baseline, 2, 4, and 6 weeks using the Medication Event Monitoring System (MEMS) to assess adherence. Outcomes assessed at baseline and 12 weeks included standard laboratory tests to measure glycemic control and the Center Epidemiologic Studies Depression Scale (CES-D) to assess depression. Results In all, 58 participants aged 50 to 80 years participated. The proportion of participants who had 80% or greater adherence to an oral hypoglycemic (intervention 62.1% vs. usual care 24.1%) and an antidepressant (intervention 62.1% vs. usual care 10.3%) was greater in the intervention group in comparison with the usual care group at 6 weeks. Participants in the integrated care intervention had lower levels of glycosylated hemoglobin (intervention 6.7% vs. usual care 7.9%) and fewer depressive symptoms (CES-D mean scores, intervention 9.6 vs. usual care 16.6) compared with participants in the usual care group at 12 weeks. Conclusion A pilot randomized controlled trial integrating Type 2 diabetes mellitus treatment and depression was successful in improving outcomes among older African-Americans. Integrated interventions may be more feasible and effective in real world practices with competing demands for limited resources.

Longitudinal assessment of depression, hopelessness, anxiety, and physical and emotional functional limitations in depressed older primary care patients is critical. Patients with prominent symptoms or impairment in these areas may be candidates for care management or mental health care, since they are at risk for remaining depressed and disabled.

PURPOSE We wanted to examine whether integrating depression treatment into care for hypertension improved adherence to antidepressant and antihypertensive medications, depression outcomes, and blood pressure control among older primary care patients. METHODSOlder adults prescribed pharmacotherapy for depression and hypertension from physicians at a large primary care practice in West Philadelphia were randomly assigned to an integrated care intervention or usual care. Outcomes were assessed at baseline, 2, 4, and 6 weeks using the Center for Epidemiologic Studies Depression Scale (CES-D) to assess depression, an electronic monitor to measure blood pressure, and the Medication Event Monitoring System to assess adherence. RESULTSIn all, 64 participants aged 50 to 80 years participated. Participants in the integrated care intervention had fewer depressive symptoms (CES-D mean scores, intervention 9.9 vs usual care 19.3; P <.01), lower systolic blood pressure (intervention 127.3 mm Hg vs usual care 141.3 mm Hg; P <.01), and lower diastolic blood pressure (intervention 75.8 mm Hg vs usual care 85.0 mm Hg; P <.01) compared with participants in the usual care group at 6 weeks. Compared with the usual care group, the proportion of participants in the intervention group who had 80% or greater adherence to an antidepressant medication (intervention 71.9% vs usual care 31.3%; P <.01) and to an antihypertensive medication (intervention 78.1% vs usual care 31.3%; P <.001) was greater at 6 weeks.CONCLUSION A pilot, randomized controlled trial integrating depression and hypertension treatment was successful in improving patient outcomes. Integrated interventions may be more feasible and effective in real-world practices, where there are competing demands for limited resources. Ann Fam Med 2008;6:295-301. DOI: 10.1370/afm.843. INTRODUCTIONP rimary care occupies a strategic position in the evaluation and treatment of depression among older adults, 1 and enhancing depression management in primary care appears to be a promising use of health care resources.2 To have an impact on public health, advances in the treatment of depression must be realized in primary care. Although recent studies have shown that a variety of primary care interventions can improve depression outcomes among older adults, 3,4 these interventions are not being widely implemented in practice. Some evidence indicates that addressing medical comorbidity, especially cardiovascular disease (CVD), may be essential in managing depression. [5][6][7] In addition, managing depression in the context of medical comorbidity may be more acceptable to patients than managing depression alone. DEPR ES SION A ND HY PER T ENSION T R E AT MEN Tmanagement of depression with management of medical comorbidity.In this trial, we focused on integrating depression management into care for hypertension. Hypertension affects between 20% to 50% of adults in most countries 9 and is a major risk factor for cardiovascular morbidity and mortality, 10 representing two-thirds of all s...

OBJECTIVE—We sought to test our a priori hypothesis that depressed patients with diabetes in practices implementing a depression management program would have a decreased risk of mortality compared with depressed patients with diabetes in usual-care practices. RESEARCH DESIGN AND METHODS—We used data from the multisite, practice-randomized, controlled Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), with patient recruitment from May 1999 to August 2001, supplemented with a search of the National Death Index. Twenty primary care practices participated from the greater metropolitan areas of New York City, New York; Philadelphia, Pennsylvania; and Pittsburgh, Pennsylvania. In all, 584 participants identified though a two-stage, age-stratified (aged 60–74 or ≥75 years) depression screening of randomly sampled patients and classified as depressed with complete information on diabetes status are included in these analyses. Of the 584 participants, 123 (21.2%) reported a history of diabetes. A depression care manager worked with primary care physicians to provide algorithm-based care. Vital status was assessed at 5 years. RESULTS—After a median follow-up of 52.0 months, 110 depressed patients had died. Depressed patients with diabetes in the intervention category were less likely to have died during the 5-year follow-up interval than depressed diabetic patients in usual care after accounting for baseline differences among patients (adjusted hazard ratio 0.49 [95% CI 0.24–0.98]). CONCLUSIONS—Older depressed primary care patients with diabetes in practices implementing depression care management were less likely to die over the course of a 5-year interval than depressed patients with diabetes in usual-care practices.

Objective To investigate whether an intervention to improve treatment of depression in older adults in primary care modified the increased risk of death associated with depression.Design Long term follow-up of multi-site practice randomized controlled trial (PROSPECT-Prevention of Suicide in Primary Care Elderly: Collaborative Trial).Setting 20 primary care practices in New York City, Philadelphia, and Pittsburgh, USA, randomized to intervention or usual care.Participants 1226 participants identified between May 1999 and August 2001 through a two stage, age stratified (60-74; ≥75 years) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of patients who screened negative.Intervention For two years, a depression care manager worked with primary care physicians in intervention practices to provide algorithm based care for depression, offering psychotherapy, increasing antidepressant dose if indicated, and monitoring symptoms, adverse effects of drugs, and adherence to treatment. This paper reports the long term follow-up. Main outcome measure ResultsIn baseline clinical interviews, 396 people were classified as having major depression, 203 had clinically significant minor depression, and 627 did not meet criteria for depression. At follow-up, 405 patients had died. Patients with major depression in usual care were more likely to die than were those without depression (hazard ratio 1.90, 95% confidence interval 1.57 to 2.31). In contrast, patients with major depression in intervention practices were at no greater risk than were people without depression (hazard ratio 1.09, 0.83 to 1.44). Patients with major depression in intervention practices, relative to usual care, were 24% less likely to have died (hazard ratio 0.76, 0.57 to 1.00; P=0.05). Preliminary data on cause of death are provided. No significant effect on mortality was found for minor depression. ConclusionsOlder adults with major depression in practices provided with additional resources to intensively manage depression had a IntroductionProspective studies have consistently shown an association between depression and increased mortality in older adults.1 2The biological, social, psychological, and behavioral mechanisms that mediate the effect of depression on mortality have only recently begun to be elucidated. 3 4 A strong association exists between depression in late life and factors that increase mortality risk, such as poor adherence to medical treatment and self care for diabetes and cardiovascular disease, 5 health behaviors such as smoking and lack of physical activity, 6 cognitive impairment, 7 and disability. 8 Investigators seeking to understand the biological mechanisms linking depression and medical conditions have drawn attention to cardiovascular, immunologic, inflammatory, metabolic, and neuroendocrine pathways. Randomized trials testing models of service delivery have shown that treatment of depression in later life in primary care settings can lead to remis...

Objective To determine whether subjective memory complaints (SMCs) are associated with performance on objective cognitive measures and psychological factors in healthy, community-dwelling older adults. Method The cohort was composed of adults, 65 years and older with no clinical evidence of cognitive impairment (n = 125). Participants were administered: CogState computerized neurocognitive battery, Prospective Retrospective Memory Questionnaire, personality and meaning-in-life measures. Results SMCs were associated with poorer performance on measures of executive function (p = 0.001). SMCs were also associated with impaired delayed recall (p = 0.006) but this did not remain significant after statistical adjustment for multiple comparisons. SMCs were inversely associated with conscientiousness (p = 0.004) and directly associated with neuroticism (p < 0.001). Higher scores on SMCs were associated with higher perceived stress (p = 0.001), and ineffective coping styles (p = 0.001). Factors contributing to meaning-in-life were associated with fewer SMCs (p < 0.05). Conclusions SMCs may reflect early, subtle cognitive changes and are associated with personality traits and meaning-in-life in healthy, older adults.