Collaborative care may improve diabetes, depression management in resource-limited settings
medwireNews: A collaborative care intervention delivered at urban diabetes clinics improves depressive symptoms and cardiometabolic outcomes among people with comorbid diabetes and depression in India, shows the INDEPENDENT trial.
“These findings may have implications for sustainable management of comorbid diabetes and depression in diverse, low-resource, fragmented health care settings in which care is often inconsistent,” write the study authors in JAMA.
The trial included 378 individuals aged 35 years or older with type 2 diabetes, moderate-to-severe depressive symptoms, and at least one inadequately controlled cardiometabolic parameter (glycated hemoglobin [HbA1c] ≥8%, systolic blood pressure (SBP) ≥140 mmHg, or low-density lipoprotein [LDL] cholesterol ≥130 mg/dL). Participants were randomly assigned to receive a 1-year collaborative care intervention – involving self-management support from nonphysician care coordinators, decision support through electronic health records, and specialist case reviews – or to receive usual care.
At the 2-year follow-up, 71.6% of 185 participants in the intervention arm achieved the primary composite outcome of a 50% or greater reduction in Symptom Checklist Depression Scale (SCL-20) score and a decrease of at least 0.5 percentage points in HbA1c, 10 mg/dL in LDL cholesterol, or 5 mmHg in SBP.
This was significantly higher than the 54.7% of 193 patients in the usual care arm who met the primary endpoint, with a between-group risk difference of 16.9% at 2 years.
Mohammed Ali (Emory University, Atlanta, Georgia, USA) and co-investigators also found that a significantly higher proportion of participants in the collaborative care versus the control arm achieved a reduction in HbA1c of at least 0.5 percentage points at the 1-year follow-up (62.2 vs 44.7%). However, this was not maintained at the 2-year follow-up, which highlights “the need for more intensive patient self-management support and/or for ongoing use of decision support tools,” they say.
Conversely, average depressive symptom scores, measured by both the SCL-20 and PHQ-9 scores, improved over the first year of the study and “continued to improve over months 13 through 24 despite no intervention,” report the researchers.
They note that “[t]his may reflect sustained effects of the intervention,” or other factors such as “the fluctuating nature of depressive symptoms or the subjective nature of measurement tools for depression.”
Taken together, the findings from the INDEPENDENT trial provide “evidence that diabetes clinicians can be supported to manage depression effectively,” and suggest that integrated care models have “potential to strengthen care delivery worldwide and address a wide range of converging multiple morbidities,” believe Ali et al.
And they conclude: “Further research is needed to understand the generalizability of the findings to other low- and middle-income health care settings.”
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