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publications

TEAMcare investigators have published their research in peer-reviewed medical journals. The following is a list of selected publications by TEAMcare investigators on topics which are relevant to and have been formative in development of the TEAMcare health approach. 

TEAMcare study [more]

TEAMcare study


Rosenberg D, Lin E, Peterson D et al. Integrated medical care management and behavioral risk reduction for multicondition patients: Behavioral outcomes of the TEAMcare trial. Gen Hosp Psychiatry. 2013. [epub].
  • This study explored behavioral outcomes that resulted from a multi-condition collaborative care intervention known as TEAMcare. Results are presented from a clinical trial comparing this intervention with usual care in 214 adults with depression and poorly controlled diabetes and/or coronary heart disease. Compared to patients in usual care, those receiving collaborative care were more likely to: follow a healthy eating plan and participate in physical activity, and more likely to meet physical activity guidelines.

Ludman EJ, Peterson D, Katon WJ et al. Improving confidence for self care in patients with depression and chronic illnesses. Behav Med. 2013. 39:1-6.
  • In this study, the authors examined whether patients who received a multi-condition collaborative care intervention for chronic illnesses and depression had greater improvement in self-care knowledge and efficacy. Results demonstrated that the group receiving the intervention had more confidence in ability to follow through with medical regimens important to managing their conditions and to maintain lifestyle changes even during times of stress. Improvements in self care-efficacy were related to improvements in depression.

Katon W et al. Integrating depression and chronic disease care among patients with diabetes and/or coronary heart disease: The design of the TEAMcare study. Contemp Clin Trials. 2010; Jul 31(4):312-22.
  • This paper describes the design and development of a new biopsychosocial intervention (TEAMcare) aimed at improving both medical disease control and depression in patients with poor control of diabetes and/or CHD who met the criteria for comorbid depression. A team approach is used with a nurse interventionist who receives weekly psychiatric and primary care physician caseload supervision in order to enhance treatment by the primary care physician. This intervention has been tested in an NIMH-funded randomized controlled trial in a large integrated health plan.

Katon W et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010; 363(27):2611-20.
  • This study randomized 214 patients with diabetes and/or coronary heart disease with evidence of poor medical disease control (HbA1c >8.5, SBP >140, LDL >130) and depression (PHQ-9 >10) to a nurse intervention versus usual care. The medically supervised nurse worked with each patient’s primary care physician, providing guideline-based collaborative care management with the goal of controlling multiple disease risk factors. Compared with the usual care group, intervention patients had greater overall 12-month improvement (p <0.001) across HbA1c, LDL, SBP and SCL-20 depression outcomes Intervention patients were more likely to have 1 or more adjustments of insulin (p <.01), antihypertensive (p <.001), and antidepressant medications (p <.001), and had greater overall medical improvement (p = 0.024), quality of life (p <0.001), and satisfaction with diabetes/coronary heart disease (p <0.001) and depression care (p <0.001).

Katon W et al. Cost-effectiveness of a multicondition collaborative care intervention: a randomized controlled trial. Archives of General Psychiatry 2012; 69(5):506-14.
  • Over a 24-month period, the TEAMcare intervention was associated with approximately four months more depression-free days compared to usual care. The TEAMcare intervention was also associated with a total 24-month outpatient cost savings of approximately $600 per patient compared to usual care in capitated populations and approximately $1100 savings in 24-month outpatient costs per patient in fee-for-service care compared to usual care

Lin EBH et al.Treatment adjustment and medication adherence for complex patients with diabetes, heart disease, and depression: a randomized controlled trial. Ann Fam Med 2012; 10(1):6-14.
  • Compared to usual primary care, the TEAMcare intervention was shown to improve depression, HbA1c, LDL and SBP control. This paper describes the improvements in quality of care and self care of patients who received the intervention. Intervention patients were found to have significantly higher rates of home monitoring of blood pressure and glucose compared to usual care controls. Intervention patients were found to have significantly higher rates of pharmacotherapy initiation rates across antidepressant and lipid lowering medications with similar trends in anti-hypertensive and insulin therapy. Compared to usual care controls, intervention patients had significantly higher adjustment rates for all five medication classes including antidepressants, oral hypoglycemics, antihypertensives, lipid lowering medications and insulin.

McGregor M et al. TEAMcare: An integrated Multicondition Collaborative Care Program for Chronic Illnesses and Depression. J Ambul Care Manage 2011; 34:152-162.
  • This article describes key components of the TEAMcare health services model that has been shown to improve quality of care, medical disease control (glycated hemoglobin, systolic blood pressure and LDL cholesterol) and depression outcomes in patients with poor controlled diabetes and or coronary heart disease with comorbid depression.

Von Korff M et al. Functional outcomes of multi-condition collaborative care and successful ageing: results of a randomized trial. BMJ 343, 2011.
  • The TEAMcare intervention was found to significantly improve patient functioning and quality of life over a 12-month period compared to usual primary care among patients with comorbid depression and poorly controlled diabetes and/or coronary artery disease. Successful aging could be enhanced by integrated care of multiple chronic conditions that covers both physical and psychological illness

Cardiac risk in patients with depression and diabetes [more]

Cardiac risk in patients with depression and diabetes


Katon W et al. Cardiac risk factors in patients with diabetes mellitus and major depression. J Gen Intern Med. 2004; 19:1192-9.
  • In this population-based sample of 4225 patients with diabetes, those with major depression had almost twice the rate of having 3 or more of eight cardiovascular risk factors compared to non-depressed diabetics (62.5% vs 38.4%) in those without a history of cardiovascular disease (CVD) as well as those with a history of CVD (61.3% vs. 45%). Patients with diabetes without CVD who were depressed were significantly more likely to be smokers, have a BMI >30 kg/m2 and to have a more sedentary lifestyle that the non-depressed diabetics without CVD.

Depression and diabetes [more]

Depression and diabetes


Ciechanowski P et al. Where is the patient? The association of psychosocial factors and missed primary care appointments in patients with diabetes. Gen Hosp Psychiatry. 2006; 28:9-17.
  • Among 3923 primary care patients with diabetes, those with major depression had more scheduled office visits, same-day appointments and missed scheduled visits compared to non-depressed patients. Patients with preoccupied attachment style had more scheduled office visits and same-day appointments and patients with fearful attachment had more same-day appointments but less preventative care visits as compared to those with secure attachment. Among nondepressed patients, there were more missed scheduled office visits among those with dismissing versus secure attachment.

Heckbert SR et al. Depression in relation to long-term control of glycemia, blood pressure, and lipids in patients with diabetes. J Gen Intern Med. 2010; 25(6): 524-9.
  • In 3,762 patients with diabetes enrolled in the Pathways Epidemiologic Study who were followed for 5 years, among those who had an indication for drug treatment of glucose, blood pressure (SBP) or low density lipids (LDL), average long-term HbA1c, SBP and LCL did not differ in patients with diabetes and minor or major depression compared to those with diabetes alone.

Huang H et al. The effect of changes in depressive symptoms on disability status in patients with diabetes. Psychosomatics 2012; 53: 21-9.
  • In patients nondisabled at baseline (n=2155), the improved depression group had a risk of disability comparable to the no-depression reference group [relative risk (RR): 0.70, 95% CI (0.44-1.12)]. The development-of-depression and persistent-depression groups were significantly more likely to develop disability compared with the no-depression group [RR: 2.86, 95% CI (2.12-3.86) and RR: 2.16, 95% CI (1.47-3.18), respectively]. Among those who were disabled at baseline, there was no significant change in the disability status of the three depression groups compared to disabled patients with no depressive symptoms at either time point.

Katon W et al. Depression and diabetes: factors associated with major depression at 5-year follow-up. Psychosomatics. 2009; 50(9):570-9.
  • After controlling for baseline severity of depressive symptoms and history of depression in 2,759 primary care patients with diabetes having one or more cardiac procedures during follow-up and baseline severity of diabetes symptoms were strong predictors of having major depression at 5-year follow-up. Over 80% of patients with major depression at 5-year follow-up met DSM-IV criteria for either minor depression or major depression at baseline, showing the chronicity of depression in patients with diabetes.

Katon W et al. Behavioral and clinical factors associated with depression among individuals with diabetes. Diabetes Care. 2004; 27:914-20.
  • This population-based study surveyed approximately 4800 patients with diabetes enrolled in 9 primary care clinics of a Seattle HMO. 11.7% of patients were found to meet DSM IV criteria for major depression (14.2% of women, 9.2% of men). Demographic, behavioral and clinical risk factors that predicted meeting criteria for major depression included younger age, female gender, less education, single marital status, BMI >30,smoking, higher nondiabetic medical comorbidity, type 2 diabetes, higher number of diabetes complications, being treated with insulin and having higher HbA1c levels in patients less than age 65.

Ludman E et al. Depression and diabetes symptom burden. Gen Hosp Psychiatry. 2004; 26:430-6.
  • Patients with comorbid major depression and diabetes were 1.93 to 4.96 times more likely to report each of 10 diabetes symptoms compared to patients with diabetes who were not depressed after controlling for demographics, HbA1c, diabetes complications and medical comorbidity. Comorbid depression is a more robust predictor of a standard checklist of diabetic symptoms in patients with diabetes compared to metabolic control based on HbA1c or number of diabetes complications.

Von Korff M et al. Work disability among persons with diabetes. Diabetes Care. 2005; 28:1326-32. 
  • Among persons with diabetes (N=1642) enrolled in a large HMO, excluding homemakers and retirees, we assessed the relationship of diabetes severity, chronic disease comorbidity, depressive illness and behavioral risk factors with work disability. Depressive illness and diabetic symptoms were associated with significantly greater work disability, including missing 5 or more days of work in the prior month and severe difficulty performing work tasks. Depressive illness, diabetes symptoms, medical comorbidity, diabetes complications, poor glycemic control and type 1 status were all significantly associated with unemployment.

Von Korff M et al. Potentially modificable risk factors for disability among persons with diabetes. Psychosom Med. 2005; 67:233-40. 
  • Among 4357 patients with diabetes, comorbid major depression was associated with a 10-fold increase in risk of elevated WHO-DAS-I1 scores and low SF-36 social function scores and a 4-fold increase in the risk of having 20 or more days of reduced ability to do housework in the last 30 days after controlling for medical comorbidity. The number of diabetic complications and the number of ten diabetes symptoms were also independently associated with increased disability risks, but had less impact compared to comorbid depression. An increased frequency of exercise was protective, i.e. it was associated with decreased risk of disability.

Depression, diabetes and high health care costs [more]

Depression, diabetes and high health care costs


Simon G et al. Diabetes complications and depression as a predictors of health care costs. Gen Hosp Psychiatry. 2005; 27:344-55.
  • Among 4398 patients with diabetes, total health care services were approximately 70% higher in those with major depression compared to those without depression ($5361 over 6 months versus $3120, p < .001) and this difference was consistent across all categories of health services costs. Diabetes complications was the strongest predictor of costs, but depression remained strongly associated with increased costs at all levels of diabetes severity.

Simon G et al. Cost-effectiveness of systematic depression treatment among people with diabetes. Arch Gen Psychiatry. 2007; 64:65-72.
  • Depression co-occurring with diabetes is associated with higher health services costs, suggesting that more effective depression treatment might reduce the use of other medical services. Among 329 depressed patients with diabetes, a collaborative care intervention was associated with a mean of 61 additional depression-free days (95% CI 11 to 82) and had outpatient costs that averaged $314 less (95% CI -$1007 to $379) compared to usual care patients. Thus, improvement of depression outcomes in patients with diabetes is associated with a high likelihood of cost-offset effect.

Katon W et al. Long-term effects on medical costs of improving depression outcomes in patients with depression and diabetes. Diabetes Care. 2008; 31(6) 1155-9. 
  • Patients in the collaborative care group of the PATHWAYS interventional study had improved depression outcomes and trends for reduced 5 year mean total medical costs compared to usual care patients. Thus the Pathways depression collaborative care program improved depression outcomes compared to usual care with no evidence of greater long-term costs, and with trends for reduced costs among the more severely medically ill patients with diabetes.

Katon W et al. Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression. Diabetes Care. 2006; 29 (2): 265-70. 
  • This article describes a preplanned subgroup analysis of patients with diabetes from the Improving Mood-Promoting Access to Collaborative (IMPACT) randomized controlled trial. The setting for the study included 18 primary care clinics from eight health care organizations in five states. A total of 418 of 1,801 patients randomized to the IMPACT intervention (n = 204) versus usual care (n = 214) had coexisting diabetes. A depression care manager offered education, behavioral activation, and a choice of problem-solving treatment or support of antidepressant management by the primary care physician. Relative to usual care, intervention patients experienced 115 (95% CI 72-159) more depression-free days over 24 months. Total outpatient costs were 25 dollars (95% CI -1,638 to 1,689) higher during this same period. The incremental cost per depression-free day was 25 cents (-14 dollars to 15 dollars) and the incremental cost per quality-adjusted life year ranged from 198 dollars (144-316) to 397 dollars (287-641). An incremental net benefit of 1,129 dollars (692-1,572) was found.

Young B et al. Diabetes Complications Severity lndex (DCSI) and risk of mortality, hospitalization and health care utilization. Am J Managed Care. 2008; 14 (1): 15-23. 
  • An 11-point Diabetes Complication Severity Index (DCSI) was developed from automated clinical data from over 4000 patients with diabetes. Each level of the DCSl was associated with a 1.34 (95% CI1.28-1.41) greater risk of death over 4 years as well as a greater risk of hospitalization and time to first hospitalization. This new diabetes complication measure is an important new measure of diabetes severity that can be used by health services researchers as a case mix adjuster.

Davydow DS et al. The association between intensive care unit admission and subsequent depression in patients with diabetes. Int J Geriatr Psychiatry 2011 Feb 9 [Epub ahead of print].  
  • ICU admission in patients with diabetes is independently associated with subsequent probable major depression. Additional research is needed to identify at-risk patients and potentially modifiable ICU exposures in order to inform future interventional studies with the goal of decreasing the burden of comorbid depression in older patients with diabetes who survive critical illnesses.

Depression, diabetes and poor outcomes [more]

Depression, diabetes and poor outcomes



Lin HB, Von Korff M, Peterson D, Ludman E, Ciechanowksi P, Katon W: Population Targeting and Durability of Multimorbidity Collaborative Care Management: Am J Managed Care (in press).
  • This secondary analysis of the TEAMcare study examined whether the better outcomes associated with the intervention versus usual care occurred in two stratified groups ie those with depression and unfavorable control at baseline (PHQ-9 of 10 or more, HbA1c of 8.0% or more, SBP of 140 or greater, LDL of 120 or greater) versus those with high PHQ-9 scores but better control of these three medical disease control measures. Better outcomes in depression occurred in both groups but in the group with poor medical disease control improvements occurred early and continued over two years./li>

Katon WJ, Young BA, Russo J et al. Association of depression with increased risk of severe hypoglycemic episodes in patients with diabetes. Ann Fam Med. 2013: 11: 245-250.
  • In this prospective study of over 4,000 primary care patients with diabetes, depression was found to be a significant risk factor for severe hypoglycemic episodes confirmed with ICD codes and requiring an emergency room or hospital visit. Specifically, those individuals with diabetes who met major depression criteria were approximately 40% more likely to have a severe hypoglycemic episode and had a greater number of hypoglycemic episodes over two years, as compared to non-depressed individuals with diabetes.

Davydow DS, Katon WJ, Lin EH, Ciechanowski P, Ludman E, Oliver M, Von Korff M. Depression and risk of hospitalizations for ambulatory care-sensitive conditions in patients with diabetes. J Gen Intern Med. 2013 28:921-929.
  • Ambulatory care-sensitive conditions (ACSCs) are conditions where provision of timely and high quality outpatient care would decrease chance of these type of inpatient hospitalizations. In this prospective cohort study of over 4,000 primary care patients with diabetes, patients with comorbid major depression had a 40% greater risk of having a hospitalization for an ACSC and a greater number of such hospitalizations, as compared to diabetes patients without depression.

Coleman SM, Katon W, Lin E, Von Korff M. Depression and death in diabetes: 10-year follow-up of all-cause mortality and cause-specific mortality in a diabetic cohort. Psychosomatics. 2013. 54:428-436.
  • Previous trials that have followed populations for two to five years have shown that patients who have depression and co-morbid diabetes have increased all-cause mortality compared with those with depression or diabetes alone. In this study of over 4,000 primary care patients with diabetes followed longitudinally for 10 years, investigators found a significant association between depression and greater all-cause as well as non-cardiovascular and non-cancer mortality.

Yu MK, Katon W, Young BA. Diabetes self-care, major depression, and chronic kidney disease in an outpatient diabetic population. Nephron Clin Pract. 2013. 124: 106-112.
  • This study explored the association of major depression and incident chronic kidney disease and specifically examined the potential mediating role of poor diabetes self-care in this association. Among ~4,000 primary care patients with diabetes, clinically significant depressive symptoms were associated with a greater risk of microalbuminuria - an association that was not entirely explained by differences in diabetes self-care.

Huang H, Russo J, Von Korff M et al. The effect of changes in depressive symptoms on disability status in patients with diabetes. Psychosomatics. 2013. 53:21-29.
  • In this longitudinal study examining 2,733 individuals with diabetes, improvements in depression from baseline to five year follow-up were associated with improvements in functional outcomes based on activities of daily living. Individuals who developed depression or had persistent depression over a five year period were more likely to experience disability at five years, as compared to non-depressed individuals.

Katon W, Lyles CR, Parker MM et al. Association of depression with increased risk of dementia in patients with type 2 diabetes: the Diabetes and Aging Study. Arch Gen Psychiatry. 2012. 69: 410-417.
  • This cohort investigation of 19,239 patients with type 2 diabetes explored whether individuals with comorbid depression and diabetes were at higher risk of developing dementia over a five year period, as compared to individuals with diabetes alone.. We elected to study incident depression both in years one to five and years three to five because depression may be a prodromal symptom of dementia. Twenty percent of the sample was identified as having depression based on ICD-9 codes, PHQ scores or use of antidepressant medications. Individuals with comorbid depression and diabetes had an approximately 2-fold increased risk of dementia as compared to individuals with diabetes alone over the five year observation period. Leaving out cases of dementia over the first two years had a minimal effect on risk.

Katon W et al. Comorbid depression is associated with an increased risk of dementia diagnosis in patients with diabetes: a prospective cohort study. J Gen Intern Med. 2010; 25: 423-9.
  • In 3,837 primary care patients with diabetes, comorbid major depression was associated with a 2.69-fold (95%CI 1.77 – 4.07) increased risk of dementia over a 5-year period compared to those with diabetes alone after controlling for socioeconomic, clinical and health-risk behaviors.

Ciechanowski P et al. Relationship styles and mortality in patients with diabetes. Diabetes Care. 2010; 33: 539-44.
  • The rate of death in the independent and interactive relationship style groups was 39 and 29 per 1,000 individuals, respectively. Unadjusted RR of death was 1.33 (95% CI 1.12-1.58), indicating an increased risk of death among individuals with an independent relationship style. After adjustment for demographic and clinical covariates, those with an independent relationship style still had a greater risk of death compared with those with an interactive relationship style (hazard ratio 1.20 [95% CI 1.01-1.43]).

Katon W et al. Diabetes and poor disease control: Is comorbid depression associated with poor medication adherence or lack of treatment intensification? Psychosom Med. 2009; 71: 965-72. 
  • In a cohort of 4,117 patients with diabetes, among those with poor disease control (HbA1c >8.0%, LDL >130, systolic blood pressure >140), major depression was associated with poor adherence to diabetes glucose control medications (OR = 1.98, 95% CI 1.31, 2.98), antihypertensives (OR = 2.06, 95% CI 1.47, 2.88) and LDL control medications (OR = 2.43, 95% CI 1.19, 4.97). Among those with poor disease control but adequate adherence to disease control medication, depression was not associated with lack of physician intensification of treatment.

Katon W et al. The association of comorbid depression with mortality in patients with type 2 diabetes. Diabetes Care. 2005; 28:2668-72.
  • Over a 3-year period, there were 277 (8.3%) deaths in the 3344 patients without depression compared to 48 (13.4%) deaths in the 350 patients with minor depression and 59 (11.2%) deaths among the 505 patients with major depression. A proportional hazards model with adjustment for age, gender and educational attainment found that, compared to the non-depressed group, minor depression was associated with a 1.66-fold and major depression with a 2.26-fold increase in mortality. A second model that controlled for potentially behavioral (obesity, smoking, sedentary lifestyle) and clinical (diabetes complications, HbA1c, other nondiabetes medical comorbidity, insulin treatment) mediators found that both major and minor depression continued to be significant predictors of mortality.

Lin EHB et al. Depression and advanced complications of diabetes: a prospective cohort study. Diabetes Care. 2010; 33(2):264-9.
  • A longitudinal cohort of 4,623 primary care patients with type 2 diabetes was enrolled in 2000-2002 and followed through 2005-2007. After adjustment for prior complications and demographic, clinical, and diabetes self-care variables, major depression was associated with significantly higher risks of adverse microvascular outcomes and adverse macrovascular outcomes Among people with type 2 diabetes, major depression is associated with an increased risk of clinically significant microvascular and macrovascular complications over the ensuing 5 years, even after adjusting for diabetes severity and self-care activities.

Lin EHB et al. Depression and increased mortality in diabetes: unexpected causes of death. Ann Fam Med. 2009; 7:414-21. 
  • Among 4,184 primary care patients with diabetes, after adjusting for baseline sociodemographic and clinical characteristics, major depression was associated with an increased risk of all-cause mortality (HR 1.52, 95% CI 1.19 – 1.95), and with death not due to cancer or atherosclerotic cardiovascular disease (HR 2.15, 95% CI 1.43 – 3.24), but not other causes of mortality.

Young BA et al. Association of major depression and mortality in stage 5 diabetic chronic kidney disease. Gen Hosp Psychiatry. 2010; 32:119-24. 
  • Among 4,128 enrollees with diabetes, 110 were identified with stage 5 chronic kidney disease. Of those, 34 (22%) met criteria for comorbid major depression. Over a 5-year period, comorbid major depression was associated with a 2.95-fold greater risk of mortality compared to patients with stage 5 chronic kidney disease with no or few depressive symptoms.

Williams LH et al. Depression and Incident diabetic foot ulcers: a prospective cohort study. Am J Med. 2010; 123 (8):748-54. 
  • The Pathways Epidemiologic Study included 3474 adults with type 2 diabetes and no prior diabetic foot ulcers or amputations. Mean follow-up was 4.1 years. We computed the hazard ratio and 95% confidence interval (CI) for incident diabetic foot ulcers, comparing patients with major and minor depression with those without depression and adjusting for sociodemographic characteristics, medical comorbidity, glycosylated hemoglobin, diabetes duration, insulin use, number of diabetes complications, body mass index, smoking status, and foot self-care. Compared with patients without depression, patients with major depression by PHQ-9 had a 2-fold increase in the risk of incident diabetic foot ulcers (adjusted hazard ratio 2.00; 95% CI, 1.24-3.25). There was no statistically significant association between minor depression by Patient Health Questionnaire-9 and incident diabetic foot ulcers (adjusted hazard ratio 1.37; 95% CI, 0.77-2.44).

Davydow DS et al. The association of comorbid depression with intensive care unit admission in patients with diabetes: a prospective cohort study. Psychosom 2011; 52:117-26. 
  • Unadjusted analyses revealed that baseline probable major depression was associated with increased risk of ICU admission [hazard ratio (HR) 1.94, 95% confidence interval (95% CI)(1.34-2.81)], but was not associated with CCU or general medical-surgical unit admission. Fully adjusted analyses revealed probable major depression remained associated with increased risk of ICU admission [HR 2.23, 95% CI(1.45-3.45)]. Probable major depression was also associated with more total days hospitalized (Incremental Relative Risk 1.64, 95% CI(1.26-2.12)).

Sieu N et al. Depression and incident diabetic retinopathy: A prospective cohort study. Gen Hosp Psy 2011; 33:429-35. 
  • Over a five-year follow-up period, severity of depression was associated with an increased risk of incident retinopathy [odds ratio=1.026; 95% confidence interval (CI) 1.002-1.051], as well as time to incident retinopathy (hazard ration=1.025; 95% CI 1.009-1.041). The risk of incident diabetic retinopathy was estimated to increase by up to 15% for every significant increase in depressive symptom severity (five-point increase on the PHQ-9 score).

Glycemic control [more]

Glycemic control


Morse SA et al. Isn't this just bedtime snacking? The potential adverse effects of night-eating symptoms on treatment adherence and outcomes in patients with diabetes. Diabetes Care. 2006; 29:1800-4.
  • Night-eating syndrome is characterized by excessive eating in the evening and nocturnal awakening with ingestion of food. In patients with diabetes, such behaviors may lead to glucose dysregulation and contribute to obesity and complications. In 714 tertiary care patients with type 1 and 2 diabetes, night-eating behaviors were reported in 9.7% of patients. Compared to patients without night-eating behaviors, those with these behaviors were less adherent to diet, exercise and glucose monitoring and more likely to be depressed, to report childhood maltreatment histories, to have insecure attachment styles and to report eating in response to anger, sadness, loneliness, worry and being upset. Controlling for age, sex, race and major depression, patients with night-eating behaviors compared to patients without night-eating behaviors were more likely to be obese, to have HbA1c values >7% and to have 2 or more diabetes complications.

Heckbert SR et al. Depression in relation to long-term control of glycemia, blood pressure, and lipids in patients with diabetes. J Gen Intern Med. 2010; 25(6): 524-9. 
  • In 3,762 patients with diabetes enrolled in the Pathways Epidemiologic Study who were followed for 5 years, among those who had an indication for drug treatment of glucose, blood pressure (SBP) or low density lipids (LDL), average long-term HbA1c, SBP and LCL did not differ in patients with diabetes and minor or major depression compared to those with diabetes alone.

Katon W et al. Diabetes and poor disease control: Is comorbid depression associated with poor medication adherence or lack of treatment intensification? Psychosom Med. 2009; 71:965-72. 
  • In a cohort of 4,117 patients with diabetes, in those with poor disease control (HbA1c >8.0%, LDL >130, systolic blood pressure >140), major depression was associated with poor adherence to diabetes glucose control medications (OR = 1.98, 95% CI 1.31, 2.98), antihypertensives (OR = 2.06, 95% CI 1.47, 2.88) and LDL control medications (OR = 2.43, 95% CI 1.19, 4.97). Among those with poor disease control but adequate adherence to disease control medication, depression was not associated with lack of physician intensification of treatment.

Katon W et al. Association of depression with increased risk of hypoglycemia in patients with diabetes. Ann Fam Med. (in press). 
  • In a population base sample of adults with diabetes (N=4,119), after controlling for sociodemographic, clinical measures of severity, non-diabetes related medical comorbidity, prior hypoglycemic episodes, and health risk behaviors, depressed compared to non-depressed patients with diabetes had a significantly higher risk of a severe hypoglycemic episode (HR=1.42, 95% CI 1.03, 1.96) and a greater number of hypoglycemic episodes (OR =1.34, 95% CI 1.03, 1.75).

Medication adherence [more]

Medication adherence


Katon W et al. Diabetes and poor disease control: Is comorbid depression associated with poor medication adherence or lack of treatment intensification? Psychosom Med. 2009; 71:965-72. 
  • In a cohort of 4,117 patients with diabetes, in those with poor disease control (HbA1c >8.0%, LDL >130, systolic blood pressure >140), major depression was associated with poor adherence to diabetes glucose control medications (OR = 1.98, 95% CI 1.31, 2.98), antihypertensives (OR = 2.06, 95% CI 1.47, 2.88) and LDL control medications (OR = 2.43, 95% CI 1.19, 4.97). Among those with poor disease control but adequate adherence to disease control medication, depression was not associated with lack of physician intensification of treatment.

Lin EHB et al. Relationship of depression and diabetes self-care, medication adherence and preventive care. Diabetes Care. 2004; 27:2154-60. 
  • In this sample of 4,463 primary care patients with diabetes, major depression was associated with a higher likelihood compared to nondepressed patients of less than two days a week of healthy eating and eating 5 servings of fruits and vegetables, eating high fat foods 6 or more days per week , less than two days a week of physical activity or specific exercise session and being a smoker. Depression was also associated with significantly more lapses in taking oral hypoglycemic, lipid lowering and antihypertensive medications.

Panic episodes and diabetes [more]

Panic episodes and diabetes


Ludman E et al. Panic episodes among patients with diabetes. Gen Hosp Psychiatry. 2006; 28:475-81. 
  • Panic disorder is a frequent primary care disorder as well as a common comorbid illness in patients with major depression. Approximately 4% of patients with diabetes met criteria for panic disorder, and after controlling for depression, panic was associated with higher HbA1c, greater number of diabetes complications and diabetes symptoms, increased disability and poorer self-rated health.

Pathways study [more]

Pathways study


Katon W et al. Improving primary care treatment of depression among patients with diabetes mellitus: the design of the Pathways Study. Gen Hosp Psychiatry. 2003, 25:158-68. 
  • This paper described the methodology involved in developing: 1) a mail survey that was sent to a population-based sample of approximately 9,000 primary care patients with diabetes; and 2) the methodology involved in the large treatment trial that randomized 330 patients with depression and diabetes to test a nurse collaborative care intervention versus usual care in improving quality of care and depression outcomes for patients with depression and diabetes.

Katon W et al. The Pathways Study: A randomized trial of collaborative care in patients with diabetes and depression. Arch Gen Psychiatry. 2004; 61:1042-9. 
  • A total of 329 primary care patients with diabetes and major depression and/or dysthymia were randomized to a nurse collaborative care intervention versus usual care. Patients in the intervention group were provided enhanced education and support of antidepressant medication prescribed by the primary care physician or problem-solving treatment delivered in primary care by a nurse. When compared to usual care patients, intervention patients showed greater improvement in adequacy of dosage of antidepressant medication treatment in the first 6-month and second 6-month periods, less depression severity over time, a higher rate of patient-rated global improvement at 6 months and 12 months, and higher satisfaction with care at 6 months and 12 months. Although depressive outcomes improved, no differences in HbA1c, outcomes were observed between intervention and usual care patients. The lack of effect on HbA1c, despite improvement in depression, suggests that further trials need to focus on a multi-modal intervention that addresses depression, behavioral risk factors and diabetes disease control.

Kinder L et al. Improving depression care in patients with diabetes and multiple complications. J Gen Intern Med. 2006; 21:1036-41. 
  • This secondary analysis compared outcomes of collaborative care versus usual care in patients with diabetes with 2 or more diabetes complications compared to those with 0 to 1 complication. The Pathways collaborative care intervention was more successful in reducing depressive symptoms compared to usual primary care in patients with 2 or more diabetes complications. Patients with less than 2 diabetes complications experienced similar reductions in depressive symptoms in both intervention and usual care groups. These data suggest that collaborative care is most effective in patients with the greatest severity of diabetes (and other medical comorbidity) where competing priorities may make it difficult for the primary care doctor to focus on effective treatment for depression.

  1. Ciechanowski P et al. The association of patient relationship style and outcomes in collaborative care treatment for depression in patients with diabetes. Medical Care. 2006; 44:283-91. 
  • Patients in the Pathways intervention trial were divided into the two attachment groups based on a standardized attachment scale: those with an independent style who often have more problems collaborating with physicians and the medical system and those with a more interactive style. Among independent-style patients, those receiving the intervention had 47 more depression-free days and greater satisfaction with depression care compared to those receiving usual care. There were no significant differences in depression outcomes or satisfaction with care between intervention and usual care groups in patients with a more interactive style. These data suggest that collaborative care is most effective in patients with maladaptive attachment styles who have problems partnering with their primary care physician and medical system.

Self-care [more]

Self-care


Ciechanowski P et al. The influence of patient collaborative style on self-care and outcomes in diabetes. Psychosom Med. 2004; 66:720-8. 
  • Patients with insecure attachment styles, particularly fearful and dismissing attachment, have been shown to have problems trusting and collaborating with physicians. In this population-based sample of patients with diabetes, dismissing attachment style was show to be associated with lower levels of exercise, foot care, adherence to diet, adherence to oral hypoglycemic medications and higher rates of smoking. These relationships were mediated by the doctor patient relationship. Greater patient-physician collaboration mediated the relationship of dismissing and fearful attachment to poor adherence. No differences in HbA1c levels were found between those with insecure and secure attachment after controlling for demographic factors, diabetes severity and medical comorbidity and depression.

Katon W et al. The relationship between changes in depression symptoms and changes in health risk behaviors in patients with diabetes. Intern J Geriatr Psychiatry. 2010; 25:466-75. 
  • In the Pathways epidemiologic study, at 5-year follow-up, patients with diabetes with either persistent or worsening depressive symptoms compared to those in the never depressed had significantly fewer days per week of following a healthy diet or participating in >30 minutes of exercise. At 5-year follow-up, patients with clinical improvement in depression symptoms showed no differences compared to the no depression group on number of days per week of adherence to diet but showed deterioration in adherence to exercise on some, but not all, measures.

Lin EHB et al. Effects of enhanced depression treatment on diabetes self-care. Ann Fam Med. 2006; 4:46-53. 
  • The Pathways collaborative care intervention was associated with a significant improvement in quality of depression care and improvement in depressive outcomes and a decrease in BMI over a 2-year period compared to usual care. This paper found that, despite improvements in depressive outcomes in intervention compared to usual care patients, there was no evidence of improvement in healthy nutrition, physical activity, or smoking cessation.

Lin EHB et al. Relationship of depression and diabetes self-care, medication adherence and preventive care. Diabetes Care. 2004; 27:2154-60. 
  • In this sample of 4,463 primary care patients with diabetes, major depression was associated with a higher likelihood compared to nondepressed patients of less than two days a week of healthy eating and eating 5 servings of fruits and vegetables, eating high fat foods 6 or more days per week , less than two days a week of physical activity or specific exercise session and being a smoker. Depression was also associated with significantly more lapses in taking oral hypoglycemic, lipid lowering and antihypertensive medications.

Ludman EJ et al. How does changes in depressive symptomology influence weight change in patients with diabetes? Observational results from the Pathways Longitudinal Cohort. J Gerontol. 2010; 65:93-8. 
  • In the Pathways epidemiologic study, patients who became more depressed at 5 years compared to baseline in comparison to those with persistently low depression symptoms did not differ in their pattern of weight change. Both groups weighed approximately 92 kg at baseline and lost approximately 2 kg. A significantly different pattern of changes over time was observed for those with persistently high depression symptoms in comparison to those whose depression improved at 5-year follow-up. Although the groups had almost identical weight at baseline (approximately 100 kg), at the 5-year assessment, those with persistently high depression symptoms had about half the weight loss in comparison to those whose depression improved.

Depression in primary care [more]

Depression in primary care


Gensichen J et al. Physician support for diabetes patients and clinical outcomes in primary care. BMC Public Health. 2009; 9:367. 
  • Approximately 4000 patients with diabetes, empowerment and practical support subscales were used to measure providers’ mean levels of support (the between-physician or practice-variation effect) and patients’ deviation from their physician’s mean (the within-physician effect). Glycemic control was assessed at baseline and follow-up (an average of 23 months apart) by glycosylated hemoglobin levels (HbA1c). Patients' ratings of physicians’ average level of practical support (the between-physician effect) was associated with more favorable HbA1c outcome at follow-up after controlling for baseline HbA1c. Empowerment support did not predict differences in HbA1c outcome.

Katon W et al. Quality of depression care in a population-based sample of patients with diabetes and major depression. Med Care. 2004; 42:1222-9. 
  • A total of 524 (12%) of our sample of patients met DSM IV criteria for major depression. Of those with depression, only 36.3% received a depression diagnosis in the previous 12-month period and 43% filled one or more prescriptions for antidepressant medication. However, only 31.3% receive adequate dosage and duration of antidepressant medication for 90 days or more. A much smaller percentage (13.5%) had a mental health visit in the 12-month period and only 6.7% had 4 or more psychotherapy visits.