Integrating depression and chronic disease care among patients with diabetes and/or coronary heart disease: The design of the TEAMcare study

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Abstract

Diabetes and coronary heart disease (CHD) are two of the most prevalent medical illnesses in the US population and comorbid depression occurs in up to 20% of these patients. Guidelines for management of diabetes and CHD overlap for healthy lifestyle and disease-control recommendations. However, the majority of patients with these medical illnesses have been shown to have inadequate control of key risk factors such as blood pressure, LDL cholesterol, or blood sugar. Comorbid depression has been shown to adversely affect self-care of diabetes and CHD, and is associated with an increased risk of complications and mortality. Interventions that have improved quality and outcomes of depression care alone in patients with diabetes and CHD have not demonstrated benefits in self-care, improved disease control or morbidity and mortality. 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 is being tested in an NIMH-funded randomized controlled trial in a large integrated health plan.

Introduction

Complex patients are characterized by multiple, poorly controlled chronic diseases complicated by psychological and behavioral impairments including depression, unhealthy lifestyles, and poor adherence to medication regimens [1]. Complex patients account for a disproportionate share of U.S. health care costs [2]. How to improve care for complex patients is one of the major challenges facing medicine today [3]. Recent evaluations of case-management services for patients with complex chronic disease have not yielded anticipated improvements in disease control or cost reductions [4]. While disease management interventions for single conditions, including congestive heart failure [5], diabetes,[6] and depression [7], have been shown to improve control of these chronic conditions, it remains unclear how to improve outcomes in complex patients who have multiple poorly controlled physical and psychological conditions [4].

Among patients with coronary heart disease (CHD) and/or diabetes with comorbid depressive illness, recent research has assessed whether overall health outcomes can be improved by effectively treating depression [8], [9], [10], [11]. The rationale for this approach is that in patients with diabetes and CHD, there is a high prevalence of co-existing depression [12], [13] and this comorbidity is associated with increased medical symptom burden [14], [15], additive functional impairment [16], poor self-care (adherence to diet, exercise, cessation of smoking or taking disease-control medications as prescribed) [17], higher medical utilization, costs [16], [18], macrovascular and microvascular complication rates, and mortality [19], [20], [21]. However, three trials of collaborative depression care versus usual primary care among patients with diabetes and comorbid depression have shown that improving quality of depression care and depressive outcomes has not resulted in improvements in diabetes self-care or HbA1c levels [8], [9], [10]. Similarly, the largest depression effectiveness trial in patients with CHD and comorbid depression has shown that improving depressive outcomes was not associated with decreased cardiac events or mortality [11]. One possible interpretation of these results is that management of multi-condition patients with comorbid physical and psychosocial impairments requires an integrated biopsychosocial approach that simultaneously addresses their physical and psychological problems. Optimal care of complex patients may also need to target behavioral risk factors such as exercise and medication adherence.

Despite evidence that team approaches (such as collaborative care) integrated with primary care improve quality of care and disease outcomes of single chronic conditions such as depression [20], CHF [5] and diabetes [6] most systems of care are struggling with how to improve quality and reduce costs of care for complex patients with multiple chronic diseases and psychological impairments [4]. An integrated medical and psychological care management model that improved quality and outcomes of care for these complex patients might be a more cost-effective approach to organizing health care as it could be implemented for a broad range of patients, as opposed to disease management programs that target patients with particular chronic diseases. Since over 90% of Medicare beneficiaries have more than one chronic condition and 71% of Medicare beneficiaries with depression have 4 or more chronic conditions [2], the potential significance of an effective approach to caring for these complex patients is compelling.

This paper reports the development of a TEAMcare intervention to assist primary care management of complex patients with comorbid depression and poorly controlled diabetes and/or CHD that is currently being tested in a randomized controlled trial. There is considerable overlap in guidelines for management of diabetes [22] and CHD [23], and major depression is found in up to 20% of patients with these diseases [24]. Therefore, a collaborative care intervention for multiple illnesses would target a meaningful and commonly occurring cluster of chronic conditions. This paper also considers design issues encountered in developing an experimental evaluation of an integrated intervention for poorly controlled diabetes and/or heart disease patients who also had major depression and/or dysthymia.

Section snippets

Methods

The TEAMcare study was developed by a multidisciplinary team from the University of Washington and the Group Health (GH) Research Institute, and was implemented in GH primary care clinics. GH is a non-profit mixed model health care organization with 30 primary care clinics in Western Washington State. Fourteen GH primary care clinics in a 90-mile geographic region of Western Washington State were included in this study.

The study was funded by the National Institute of Mental Health (NIMH)

Discussion

The research team has successfully recruited over 200 patients with depression and poorly controlled diabetes and/or CHD, developed a nurse treatment manual, trained diabetes nurses in the TEAMcare approach, developed an electronic disease register to track patient progress, developed electronic templates for initial visit, progress and relapse prevention notes, and utilized efficient one- to two-hour weekly physician caseload supervision sessions with nurses. The feasibility of recruitment,

Acknowledgement

This research was supported by grants from the National Institute of Mental Health to Dr. Katon (MH41739 and K24 MH069741).

References (61)

  • Partnership for Solutions National Program Office. Chronic Conditions: Making the Case for Ongoing Care. Robert Wood...
  • K.B. Weiss

    Managing complexity in chronic care: an overview of the VA state-of-the-art (SOTA) conference

    J Gen Intern Med

    (2007)
  • J.L. Wolff et al.

    Moving beyond round pegs and square holes: restructuring Medicare to improve chronic care

    Ann Intern Med

    (2005)
  • C.O. Phillips et al.

    Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis

    JAMA

    (2004)
  • C.M. Renders et al.

    Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review

    Diabetes Care

    (2001)
  • S. Gilbody et al.

    Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes

    Arch Intern Med

    (2006)
  • K. Ell et al.

    Collaborative care management of major depression among low-income, predominantly Hispanics with diabetes: a randomized controlled trial

    Diabetes Care

    (2010)
  • J.W. Williams et al.

    The effectiveness of depression care management on diabetes-related outcomes in older patients

    Ann Intern Med

    (2004)
  • W.J. Katon et al.

    The Pathways Study: a randomized trial of collaborative care in patients with diabetes and depression

    Arch Gen Psychiatry

    (2004)
  • L.F. Berkman et al.

    Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) randomized trial

    JAMA

    (2003)
  • R.J. Anderson et al.

    The prevalence of comorbid depression in adults with diabetes: a meta-analysis

    Diabetes Care

    (2001)
  • P.S. Ciechanowski et al.

    Depression and diabetes: impact of depressive symptoms on adherence, function, and costs

    Arch Intern Med

    (2000)
  • E.H. Lin et al.

    Relationship of depression and diabetes self-care, medication adherence, and preventive care

    Diabetes Care

    (2004)
  • S.A. Black et al.

    Depression predicts increased incidence of adverse health outcomes in older Mexican Americans with type 2 diabetes

    Diabetes Care

    (2003)
  • W.J. Katon et al.

    The association of comorbid depression with mortality in patients with type 2 diabetes

    Diabetes Care

    (2005)
  • E.H. Lin et al.

    Depression and increased mortality in diabetes: unexpected causes of death

    Ann Fam Med

    (2009)
  • American Diabetes Association

    Standards of medical care in diabetes

    Diabetes Care

    (2007)
  • S.C. Smith et al.

    AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute

    Circulation

    (2006)
  • K. Kroenke et al.

    The PHQ-9: validity of a brief depression severity measure

    J Gen Intern Med

    (2001)
  • K. Kroenke et al.

    The Patient Health Questionnaire-2: validity of a two-item depression screener

    Med Care

    (2003)
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