Older depressed patients with diabetes in primary care practices that
implement depression care management were less likely to die over a five-year
period than were depressed patients with diabetes who received usual care.
That was the finding from a multisite, randomized, controlled trial of a
depression care management strategy for primary care patients with and without
diabetes. The study appeared in the December 2007 Diabetes Care.
"To our knowledge, this is the first study to report on the
relationship between diabetes and mortality in a depression intervention
trial," wrote lead author Hillary Bogner, M.D., of the Department of
Family Medicine and Community Health at the University of Pennsylvania, and
colleagues. "We believe these findings support the integration of
depression evaluation and treatment with diabetes management in primary
The study was part of the Prevention of Suicide in Primary Care Elderly:
Collaborative Trial (PROSPECT). Twenty primary care practices in the New York,
Philadelphia, and Pittsburgh metropolitan areas participated in the study.
During patient recruitment from May 1999 to August 2001, 584 participants
were identified though a two-stage, age-stratified, depression screening of
randomly sampled patients and classified as depressed. Of those, 123 (21.2
percent) reported a history of diabetes.
The 20 primary care practices were paired by region (urban versus
suburban/sparsely populated), affiliation, size, and population type. Within
the 10 pairs, practices were randomly assigned by coin flip to the depression
care management intervention or usual care.
The researchers found that depressed patients with diabetes in the
intervention practices were significantly less likely to have died during the
five-year follow-up than were depressed patients with diabetes who received
usual care. Specifically, depressed patients with diabetes in the intervention
practices experienced a mortality rate of 68.2/1,000 person-years, whereas
depressed patients with diabetes in usual care experienced a mortality rate of
In contrast, individuals without diabetes experienced no difference in
mortality rates between intervention and usual-care practices, suggesting that
the intervention attenuates the influence of diabetes on mortality risk among
older adults with depression.
The intervention consisted of trained depression care managers offering
guideline-concordant recommendations to the primary care physicians and
helping patients with treatment adherence. The care managers monitored
psychopathology, treatment adherence, response, and side effects and provided
follow-up care at predetermined intervals or when clinically necessary.
Patients who refused antidepressants were offered interpersonal
psychotherapy by the depression care managers. In the intervention, a
first-line antidepressant (citalopram, a selective serotonin reuptake
inhibitor) and the interpersonal psychotherapy were provided at no cost.
In usual care, physicians were informed of patients' depression diagnoses.
Physicians also received informational materials and treatment guidelines for
geriatric depression. No specific recommendations were given to these
physicians regarding individual patients except for handling psychiatric
Past APA President Michelle Riba, M.D., a professor of psychiatry and
associate chair for integrated medicine and psychiatric services at the
University of Michigan, called the results "profound" and said
they underscore the importance of involvement by psychiatrists in the care of
chronic medical conditions.
"We have known for a long time that depression impacts adherence to
medications for diabetes and that diabetes impacts on depression," she
told Psychiatric News. "And we have also known that some
psychiatric medications impact glycemic control and can modulate diabetes.
"What we haven't known is if you can make a difference by treating
the depression using something like a case-management strategy," Riba
said. "This is an important, very well done study in a very high risk
group of patients. It makes it clear that treating depression makes a
difference in mortality and that it is important for psychiatrists to be
involved in the care of patients with chronic medical conditions, such as
Riba said further research on the effect of early intervention with
patients at risk for diabetes and depression is needed. "[The current
study] looked at a group of elderly patients," Riba said, "but we
know that diabetes starts much earlier, as does depression."
In the report, Bogner and colleagues say the precise mechanism by which
depression may increase mortality in diabetes remains a matter of speculation."
Both physiologic factors, such as increased inflammation [and] poor
glucose regulation, and behavioral processes, such as poor adherence, may link
depression with increased mortality in patients with diabetes," they
noted. "The potential mediators between treatment assignment and
outcomes for patients with diabetes deserve further study."
"Diabetes, Depression, and Death: A Randomized Controlled
Trial of a Depression Treatment Program for Older Adults Based in Primary Care
(PROSPECT)" is posted at<http://care.diabetesjournals.org/cgi/content/full/30/12/3005>.▪