Among patients with diabetes, major depression is associated with Outcome measures included the Summary of Diabetes Self-Care Activi …

Effects of Enhanced Depression Treatment on Diabetes Self-Care
Elizabeth H B Lin, MD, MPH1 Wayne Katon, MD2 Carolyn Rutter, PhD1 Greg E Simon, MD, MPH1 Evette J Ludman, PhD1 Michael Von Korff, ScD1 Bessie Young, MD, MPH3 Malia Oliver, BA1 Paul C Ciechanowski, MD, MPH2 Leslie Kinder, PhD3 Edward Walker, MD, MPH2
1

ABSTRACT
PURPOSE Among patients with diabetes, major depression is associated with more diabetic complications, lower medication adherence, and poorer self-care of diabetes We reported earlier that enhanced depression care reduces depression symptoms but not hemoglobin A1c level This study examined effects of depression interventions on self-management among depressed diabetic patients METHODS A total of 329 patients in 9 primary care clinics were randomized to an

evidence-based collaborative depression treatment pharmacotherapy, problemsolving treatment, or both in combination or usual primary care routine medical services Outcome measures included the Summary of Diabetes Self-Care Activities SDSCA, reported at baseline and 3, 6, and 12 months, and medication nonadherence as assessed by automated pharmacy refill data of oral hypoglycemic agents, lipid-lowering agents,
and angiotensin-converting enzyme inhibitors We used mixed regression models adjusted for baseline differences to compare the intervention with usual care groups at follow-up assessments
RESULTS During the 12-month intervention period, enhanced depression care and

Center for Health Studies, Group Health Cooperative, Seattle, Wash
2

Department of Psychiatry Behavioral Sciences, University of Washington School of Medicine, Seattle, Wash
3

Department of Medicine, Veterans Administration Hospital, and the University of Washington, Seattle, Wash

outcomes were not associated with improved diabetes self-care behaviors healthy nutrition, physical activity, or smoking cessation Relative to the usual care group, the intervention group reported a small decrease in body mass index mean difference 070 kg/m2, 95 CI, 017 to 124 kg/m2 and a higher rate of nonadherence to oral hypoglycemic agents mean difference 63, 95 CI, 1191 to 071 Adherence to lipid-lowering agents and to antihypertensive medicines was similar for the 2 groups
CONCLUSIONS In general, diabetes self-management did not improve among the

enhanced depression treatment group during a 12-month period, except for small
between-group differences of limited clinical importance Research needs to assess whether self-care interventions tailored for specific conditions, in addition to enhanced depression care, can achieve better diabetes and depression outcomes
Ann Fam Med 2006;4:46-53 DOI: 101370/afm423

INTRODUCTION
elf-care is a cornerstone of diabetes management Daily practice of healthy nutrition and physical activity can slow disease progression1-3 Adherence to medical regimens for diabetes can lessen the disease burden and reduce the morbidity and mortality associated with diabetic complications4 Poor self-management of diabetes is, however, the norm and intensifies the burden of this epidemic condition5-7 The prevalence of depression is roughly twice as high among diabetic patients as among the general population8 Depressed patients with diabetes have poorer glycemic control, more severe diabetes symptoms and disability, added complications, and higher health care use relative to patients with diabetes but no depression6,8-14 Self-management is even less adequate among diabetic patients with depression than among those without it Nonadherence to diabetes medications, physical inactivity, poor
nutrition, and smoking are highly correlated with depression, while self-monitoring

Conflicts of interest: none reported

CORRESPONDING AUTHOR

Elizabeth H B Lin, MD, MPH Center for Health Studies, Group Health Cooperative 1730 Minor Ave, Suite 1600 Seattle, WA 98101 line@ghcorg

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of blood glucose is similar in depressed and nondepressed diabetic patients5 Poor medication adherence is related not only to worse clinical outcomes, but also to subsequent hospitalizations and increased health care costs15 This relationship of depression and poor self-management is consistent across different socioeconomic and cultural groups16,17 The clear association between depression, inadequate self-management, and adverse outcomes has led many to advocate for better identification and treatment of depression among diabetic patients Thus far, cross-sectional studies have provided most of the evidence regarding the association of depression with poor diabetes self-management and adverse outcomes Recently, McKellar and colleagues18 and Piette
and colleagues19 used structural equation modeling to test the relationship between depressive symptoms, poorer self-care, and subsequent glucose dysregulation These studies found that depression increased symptoms of glucose dysregulation through lower adherence to selfcare; however, depression did not significantly influence subsequent diabetes-related symptoms above and beyond their impact on patients self-care behaviors Randomized controlled trials to improve depression among diabetic patients have had mixed effects on diabetes outcomes20-24 Among patients with poorly controlled diabetes receiving specialty care, an earlier study of cognitive behavioral therapy and diabetes education showed a clinically significant reduction in hemoglobin A1c HbA1c level at the 6-month follow-up when compared with a control group receiving diabetes education only21 An unexpected finding was that intervention patients receiving cognitive behavioral therapy and diabetes education showed less self-monitoring of glucose levels relative to the education group during the intervention period Trials comparing antidepressant pharmacotherapy with placebo found that nortriptyline therapy did not change
the glycemic index among patients with diabetes and depression,20 while fluoxetine therapy was associated with a trend toward a lower HbA1c level22 Two recent randomized trials of systematic depression management in primary care both found a significant improvement in depression among patients with diabetes and depression, but no significant effect on glycemic control23,24 In a study of older adults with depression and diabetes, Williams and colleagues23 reported that the intervention patients increased their physical activity relative to usual care patients There was, however, no intervention effect on other self-management activities, and diabetic medication adherence was not assessed In a randomized trial of a mixed-age primary care population with diabetes, Katon and colleagues24 found that a systematic depression care proANNALS O F FAMILY MED ICINE

gram significantly increased quality of depression care and reduced depressive symptoms but did not have a significant impact on glycemic control24 We used data from this same trial to examine the impact of improved depression treatment on self-care behaviors, including adherence to diabetes medications

METHODS
Study Setting From
March 2001 to May 2002, 9 primary care clinics of Group Health Cooperative GHC, a prepaid health plan enrolling about 500,000 Washington State residents, participated in this study Demographic characteristics of GHC enrollees are representative of the Seattle-area population Board-certified family medicine physicians and internists provide the majority of medical services for GHC enrollees The Human Subjects Review Committees of Group Health Cooperative and the University of Washington approved the study procedures Sample Recruitment and Randomization Enrollees aged 18 years or older were recruited from the GHC diabetes registry that included individuals with any of the following: 1 at least 2 fasting plasma glucose levels of greater than 126 mg/dL or a random plasma glucose level of greater than 200 mg/dL, 2 current use of any diabetic medication, and 3 an inpatient or outpatient diagnosis of diabetes Exclusion criteria included the following: not having diabetes, having gestational diabetes, cognitive impairment, terminal illness, disenrollment or planned disenrollment from the health plan, language or hearing barrier, psychotic disorder, bipolar disorder, use of mood-stabilizing
or antipsychotic medication, and current care by a psychiatrist A questionnaire was sent to 7,841 eligible individuals with diabetes In all, 62 responded, and 4,839 were enrolled in the cohort epidemiologic study To be eligible for the randomized trial, participants were required to have a score of 10 or higher on the Patient Health Questionnaire-9 PHQ-925 at the initial screening and evidence of persistent depression as measured by a mean item score of 11 or higher on the Hopkins Symptom Checklist-20 SCL-2026 2 weeks later Patients were not excluded if they had taken antidepressants in the previous 3 months as long as they had persistent depressive symptoms Among the 375 patients eligible for the depression and diabetes clinical trial, 46 declined randomization A computer algorithm randomly assigned 164 patients to the intervention group and 165 patients to the usual care group A detailed description of sample recruitment is described in our earlier publication24

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Main Outcome Measures Self-Care for Diabetes We used a recently revised version of the Summary
of Diabetes Self-Care Activities SDSCA27 to assess diabetes self-management behaviors for diet, exercise, blood glucose testing, foot checks, and smoking The SDSCA is a brief, reliable, valid, and multidimensional measure of diabetes self-care behaviors based on selfreport Patients reported how many days in the previous week they engaged in a certain activity Medication Adherence The GHC automated pharmacy database has recorded all prescriptions filled by enrollees since 1976 We used computerized records of pharmacy refills to derive measures of adherence to oral hypoglycemic agents, antihypertensive agents, and lipid-lowering medications for the year before each patients interview date For each prescription, the days of medication supply were added to the date that the prescription was filled This second date was considered the expected refill date If the next refill was obtained after the expected refill date, then the number of days between the expected refill date and the next refill date days during which a patient lacked oral hypoglycemic, lipid-lowering, or antihypertensive medicines were labeled as nonadherent days The percentage of days a patient was nonadherent was then
estimated by dividing the total number of nonadherent days in the previous year numerator by the total number of days the patient was prescribed oral hypoglycemic agents, including the nonadherent days denominator The percentage of days nonadherent allowed us to combine information across patients with varying lengths of follow-up The observation window, that is, the number of days a patient was prescribed oral hypoglycemic agents in the year, was estimated to be either 365 for patients already using these medications at the beginning of the year or the number of days between the first prescription and the interview date for patients started on these medications during the year Patients whose first oral hypoglycemic agent prescription had not been exhausted by the interview date were excluded A similar measure, using automated pharmacy data, was used in an earlier study to evaluate nonadherence with antihypertensive medications28 Study Groups Intervention: Collaborative Depression Care Management Our year-long intervention focused on enhancing depression treatment, not on diabetes management Nurses received training on depression diagnosis and pharmacotherapy, behavioral
activation, and problem-solving treatANNALS O F FAMILY MED ICINE

ment for primary care, similar to the intervention developed for the IMPACT study29 Nurses collaborated with behavioral health consultants and primary care physicians to provide individualized management of depression care according to patient preference and treatment response Patients were offered an initial choice of 2 evidencebased treatments: antidepressant medication or problem-solving treatment The goal of depressive symptom remission was achieved through a stepped care approach that augmented pharmacotherapy, problem-solving treatment, or both with psychiatric consultations and group and community services Nurse care managers supported depression self-management through behavioral activation, such as exercise, goal setting, and problem solving Neither diabetes education nor diabetes clinical management was a component of this depression intervention; however, patients could choose physical activity or healthy nutrition for behavioral activation, or could identify another diabetes self-care activity as a problem to tackle in a problem-solving treatment session Treatment included an initial hour-long visit
followed by twice-monthly, half-hour appointments telephone and in-person in the acute phase of treatment 0-12 weeks Once patients experienced a substantial at least 50 reduction in clinical symptoms, the nurse began continuation phase treatment, which consisted of monthly scheduled telephone contacts For patients who had persistent symptoms or who were socially isolated, nurses offered monthly continuation groups instead of monthly telephone calls Each nurse was supervised twice per month by a team of a psychiatrist WK, GES, or EW, psychologist EJL, and family physician EHBL in the review of new cases and patient progress Nurses interacted regularly via written notes and verbally with the primary care physician treating the patient Our earlier publication details the intervention design and procedures24 Usual Care Usual care patients were advised to consult their primary care physician regarding depression treatment Primary care physicians at GHC frequently prescribe antidepressant medication and can refer patients to the GHC Mental Health Services Both intervention and usual care patients could also self-refer to a GHC mental health clinician Primary care physicians provide most
of the diabetes care in GHC with occasional support from diabetes consultants for complex patients Statistical Analyses We used t tests to compare characteristics of intervention and usual care groups at baseline We used regression analysis to model outcomes as a function of intervention status while adjusting for potential con

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founders age, sex, race, education, comorbid disease severity, diabetic complications, and insulin use and the corresponding baseline measure For example, models describing physical activity at follow-up adjusted for physical activity at baseline in addition to potential confounders We estimated regression models using generalized estimating equations GEE with robust covariance estimation to adjust variance estimates for the clustering of patients within primary care physician and of physicians within clinics Models for outcomes measured at 3, 6, and 12 months used all available data and adjusted for repeated measures within patients over time We used logistic regression for dichotomous outcomes and linear regression for ordinal
outcomes and continuous outcomes ie, adherence measures

problem-solving treatment As reported previously, relative to usual care patients, intervention patients had more adequate antidepressant pharmacotherapy over a 1-year period and less severe depression over time24 Diabetes Self-Care There were gaps in quality of self-care activities at baseline for both treatment groups Table 2 Practicing healthy nutrition or following a recommended diet was reported for about one half the number of days in the preceding week This largely sedentary and overweight population reported that they engaged in at least 30 minutes of continuous activity for only 2 to 3 days in the previous week Specific exercise sessions were carried out on fewer than 2 days in the previous week The proportion of cigarette smokers was lower but not significantly so in the intervention group 18, SD 111 than in the usual care group 28, SD 173 The only significant baseline differences in diabetes self-care found between usual care and intervention groups were a slightly higher number of days with exercise sessions P 005 and a slightly lower body mass index BMI P 03 among intervention patients relative to usual care
patients Overall, there was no difference between intervention and usual care in diabetes self-management during the 12-month period Table 2 When controlling for baseline differences, the intervention group maintained a lower BMI at the 1-year follow-up P 01 No difference was observed between the 2 groups in healthy

RESULTS
Sample Among the 329 randomized patients–164 in the intervention group and 165 in the usual care group–respective rates of completion of assessments were 91 and 933 at 3 months, 878 and 909 at 6 months, and 885 and 861 at 12 months In all, 805 of intervention patients and 794 of usual care patients completed all assessments during 1 year of follow-up

Baseline Characteristics The intervention and usual care groups were demographically similar and clinically balanced at baseline with respect to diabetes and depression measures Table 1 This primary care population Table 1 Demographic and Baseline Clinical Characteristics with diabetes and coexisting depression had a mean age of 585 years; two thirds were Usual Care Intervention n 165 n 164 women, and one fifth were racial or ethnic Characteristic No No minorities Patients predominantly had type Dichotomous
characteristics 2 diabetes, with a mean HbA1c value of 80, Female 648 107 652 107 and 15 diabetic complications About 40 Married 549 90 548 94 required insulin treatment A majority of the Employed full- or part-time 452 71 542 84 sample had chronic or recurrent depression White 811 133 752 115 dysthymia or 3 or more previous episodes of Type 2 diabetes 958 158 963 157 depression Approximately two thirds met Taking insulin 430 71 384 63 criteria for major depression and had moderMajor depression 691 114 626 102 ate depression severity as measured by SCLLifetime dysthymia 703 116 675 110 2026 One half of patients had been treated 3 previous episodes of depression 605 92 686 107 with an antidepressant medication in the preAntidepressant use in previous 3 months 540 101 460 86 ceding 3 months Mean SD Mean SD Intervention Participation and Depression Outcomes Almost all of the intervention patients 976 completed the initial visit; among the intervention group, only 14 patients 85 received neither antidepressant nor
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Continuous characteristics Age, y HbA1c, Number of diabetic complications Baseline SCL-20 score 581 120 80 15 15 14 16 05 586 118 80 16 15 13
17 05

HbA1c hemoglobin A1c; SCL-20 Hopkins Symptom Checklist-20

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Table 2 Self-Care Activities of Patients With Diabetes and Depression in the Past 7 Days at Baseline and at Various Follow-up Times
Usual Care n 165 Mean SD Intervention n 164 Mean SD Adjusted Mean Difference 95 CI

Activity
Generally healthy diet, number of days Baseline 3 mo 6 mo 12 mo Recommended diet, number of days Baseline 3 mo 6 mo 12 mo Physical activity 30 min, number of days Baseline 3 mo 6 mo 12 mo

37 21 43 20 44 19 45 21

37 21 41 19 42 20 45 19

– 015 015 to 045 007 021 to 035 001 056 to 054

32 16 36 17 38 17 38 18

35 17 38 18 39 18 41 19

– 007 034 to 020 001 022 to 020 005 042 to 032

about 2-1/2 to 3-1/2 months At baseline, there were no significant differences in adherence between intervention and usual care groups After controlling for baseline status, the depression care intervention group had a slightly higher rate of nonadherence to oral hypoglycemic agents compared with the usual care group during the 12-month period P 03 We did not find significant differences in
adherence to ACE inhibitors or lipidlowering medication in intervention group patients relative to their usual care counterparts

23 22 27 24 24 23 26 25

26 24 27 25 23 23 27 24

– 008 043 to 059 019 021 to 060 012 050 to 026

DISCUSSION

In an earlier study, we found that enhancing depression care among Exercise session, patients with diabetes and depresnumber of days Baseline 12 18 19 22 — sion increased adherence to anti3 mo 17 24 19 23 012 084 to 059 depressant pharmacotherapy and 6 mo 17 22 16 22 019 037 to 076 problem-solving treatment, and 12 mo 16 21 19 23 019 057 to 019 reduced depressive symptoms,24 BMI, kg/m2 but glycemic control in the interBaseline 363 111 339 86 — vention and usual care groups 12 mo 361 100 330 79 070 017 to 124 was similar Examining the effects CI confidence interval; BMI body mass index of the intervention on diabetes Means and SDs are unadjusted self-care behaviors showed that Adjusted mean differences and 95 CIs are based on regression models that adjusted for the baseline value, improved quality of depression age, sex, race, education, comorbid conditions other than diabetes and depression, complications, and use of insulin, with variance
estimates that accounted for clustering of measurements within patients, patients within phycare and depression outcomes sicians, and physicians within clinics were not associated with increases Intervention and usual care groups differ significantly, with adjustment, P 005 Intervention and usual care groups differ significantly, without adjustment, P 05 in healthy nutrition, physical Intervention and usual care groups differ significantly, with adjustment, P 01 activity, or smoking cessation, or increased adherence to ACE nutrition, following a recommended diet, days with 30 inhibitors or lipid-lowering agents Small but statistior more minutes of continuous physical activity, days cally significant between-group differences were seen with specific exercise sessions, or smoking status 18, in adherence to oral hypoglycemic agents and in BMI SD 123 for the intervention group vs 24, SD during the 12-month period Compared with patients 169 for the usual care group; 95 confidence interreceiving usual care, intervention patients reported val for the odds ratio 04-49 lower BMI but poorer adherence to oral hypoglycemic agents; however, these findings were small and of Medication
Adherence uncertain clinical importance The rate of nonadherence to oral hypoglycemic and Limitations of our study include unknown generalizability of a sample consenting to a randomized lipid-lowering agents and angiotensin-converting controlled trial to other patients with diabetes and enzyme ACE inhibitors was quite high among both depression Pharmacy refill records were used to measure intervention and usual care patients, ranging from adherence; these data indicate only prescriptions that roughly 20 to 30 Table 3 During the 12-month were filled, not medications actually taken30 Our meaintervention postrandomization period, diabetic patients with depression did not have medication sure may even underestimate actual patient adherence to control diabetes or to prevent complications for Nonadherence rates of 20 or higher, as reported in this
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2 hours each day is required for performing the American Diabetes Associationrecommended self-care tasks among Usual Care Intervention Adjusted Mean patients taking oral hypo of Days of
Days Difference glycemic agents34 Physical Mean SD Mean SD of Days activity and healthy nutrition Medication [No of Patients] [No of Patients] 95 CI are the most time-consuming Oral hypoglycemic agent daily tasks This challenge was Prerandomization 229 240 198 213 suggested by the unexpected [103] [103] 240 247 282 289 63 Postrandomization results of Lustman and col[103] [103] 1191 to 071 leagues21 that adding cognitive ACE inhibitor behavioral therapy to diabetes Prerandomization 297 293 274 271 education had a significantly [65] [54] Postrandomization 189 174 242 227 25 deleterious effect on self-moni[52] [59] 869 to 370 toring of blood glucose during Lipid-lowering agent the 10-week treatment period Prerandomization 245 230 293 267 They postulated that perhaps [52] [50] Postrandomization 277 240 288 271 02 cognitive behavioral therapy [63] [54] 723 to 676 homework, such as recognizing CI confidence interval; ACE angiotensin-converting enzyme maladaptive thought patterns Means and SDs are unadjusted on top of an already complex Estimated differences and 95 CIs are based on regression models that adjusted for the baseline value, age, sex, diabetes education regimen race,
education, comorbid conditions other than diabetes and depression, complications, and use of insulin, with variance estimates that account for clustering of measurements within patients, patients within physicians, and physicians for self-management, was within clinics more than the patients could Intervention and usual care groups differ significantly, P 03 handle Our finding that, during enhancement of depression management, intervention patients showed lower study, are clinically important and found to predict subadherence to oral hypoglycemic medicines also highsequent hospitalization rate15 Diabetes-specific self-care lights the complexity and challenge patients face in behaviors, such as foot checks and self-monitoring of managing multiple medical conditions on a daily basis blood glucose, were not examined in this study because Competing demands is also a challenging realthose activities levels were similar for depressed and ity for primary care physicians37 Coexisting physical nondepressed patients in our earlier survey Contrary to the clinical hypothesis that improving conditions compete with and overshadow the needs of depression treatment and outcomes would enhance
depression care in brief primary care encounters38 One diabetes self-care activities and medication adherence, must therefore be vigilant to limit the number of new these results show no increase in healthy nutrition or interventions physicians are recommended to provide; physical activity and lower adherence to oral antidiaotherwise, successful management of one chronic illness betic medications among intervention participants Our eg, antidepressant medication adherence may occur hypothesis was based on cross-sectional findings show- at the expense of another clinically important behavior ing the association of depression with lower adherence eg, antidiabetic medication adherence Encouraging to diabetes self-care and medication regimens Perhaps patients to identify 1 top-priority self-care behavior of this seemingly logical assumption reflects too simplistic their preference that they feel is most feasible may be an understanding of the relation between depression more effective than expecting physicians and patients to and behavior changes, such as improving levels of adopt multiple behavior changes simultaneously healthy nutrition, physical activity, and medication Findings of
this study do not imply that depression adherence Increasing these behaviors is achievable but care is not useful for improving diabetes self-manageoften requires fairly intensive interventions specific to ment or outcomes Better identification and care of each behavior31-36 A second possibility is that the mod- depression among diabetic patients may be the first step est effects of the intervention on depression outcomes toward more effective diabetes self-management Piette may not have been powerful enough to increase optiand colleagues19 proposed a schema of pathways linking mism and motivation, prerequisites for good self-care major depression to adverse physiologic and quality-ofFrom a patients perspective, diabetes self-managelife outcomes for diabetes, mediated by poor self-manment is no small task It has been estimated that about agement Perhaps major depression, poor self-care, and
Table 3 Nonadherence to Prescribed Medications Percentage of Days Nonadherent During the 12-Month Prerandomization and Postrandomization Periods
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N

adverse outcomes are linked in a bidirectional and reciprocal manner, thus resulting in adverse outcomes Just as effective diabetes management may be compromised by depression and associated characteristics, such as pessimism and fatigue, effective depression management may also be undermined by symptoms of poor diabetes control, such as neuropathic pain and functional disability Maximal benefit of treating depression for improving broader outcomes is likely to require direct targeting of specific behaviors most relevant to the patients role in managing their coexisting chronic illness Because the population is aging, most patients seeking care from primary care physicians will have more than 1 chronic illness A coordinated therapeutic approach that considers coexisting chronic diseases will be essential Patients with depression and co-occurring medical illnesses require interventions that advance beyond single-disease case management, such as nurse case managers trained to manage care for related chronic conditions eg, diabetes and heart disease and coexisting depression in general medical settings39 Focusing patients on disease management of 1 chronic illness can have
unintended adverse effects on management of other important disorders Further research is needed to determine whether integrated diabetes and depression care management, including specific support for diabetes medication adherence and self-care activities, as well as systematic depression care, can help patients achieve better psychological and diabetes outcomes
To read or post commentaries in response to this article, see it online at http://wwwannfammedorg/cgi/content/full/4/1/46 Key words: Diabetes mellitus; depression; self-care; exercise; patient nonadherence; mental health; health care delivery; health services research; primary care Submitted March 24, 2005; submitted, revised, August 22, 2005; accepted September 13, 2005 Presented at the 63rd Annual Scientific Meeting of the American Psychosomatic Society, March 4, 2005, Vancouver, British Columbia Funding support: Supported by grants MH 41739 and MH 01643 from the National Institute of Mental Health, Services Division, Bethesda, Md

5 Lin EH, Katon W, Von Korff M, et al Relationship of depression and diabetes self-care, medication adherence, and preventive care Diabetes Care 2004;27:2154-2160 6 Ciechanowski PS, Katon WJ,
Russo JE, Hirsch IB The relationship of depressive symptoms to symptom reporting, self-care and glucose control in diabetes Gen Hosp Psychiatry 2003;25:246-252 7 Cramer JA A systematic review of adherence with medications for diabetes Diabetes Care 2004;27:1218-1224 8 Katon W, von Korff M, Ciechanowski P, et al Behavioral and clinical factors associated with depression among individuals with diabetes Diabetes Care 2004;27:914-920 9 Gary TL, Crum RM, Cooper-Patrick L, Ford D, Brancati FL Depressive symptoms and metabolic control in African-Americans with type 2 diabetes Diabetes Care 2000;23:23-29 10 de Groot M, Anderson R, Freedland KE, Clouse RE, Lustman PJ Association of depression and diabetes complications: a meta-analysis Psychosom Med 2001;63:619-630 11 Lustman PJ, Anderson RJ, Freedland KE, et al Depression and poor glycemic control: a meta-analytic review of the literature Diabetes Care 2000;23:934-942 12 Ludman E, Katon W, Bush T, et al Behavioural factors associated with symptom outcomes in a primary care-based depression prevention intervention trial Psychol Med 2003;33:1061-1070 13 Von Korff M, Katon W, Lin EH, et al Work disability among individuals with diabetes
Diabetes Care 2005;28:1326-1332 14 Simon GE, Katon WJ, Lin EH, et al Diabetes complications and depression as predictors of health service costs Gen Hosp Psychiatry 2005;27:344-351 15 Lau DT, Nau DP Oral antihyperglycemic medication nonadherence and subsequent hospitalization among individuals with type 2 diabetes Diabetes Care 2004;27:2149-2153 16 Park H, Hong Y, Lee H, Ha E, Sung Y Individuals with type 2 diabetes and depressive symptoms exhibited lower adherence with selfcare J Clin Epidemiol 2004;57:978-984 17 Lerman I, Lozano L, Villa AR, et al Psychosocial factors associated with poor diabetes self-care management in a specialized center in Mexico City Biomed Pharmacother 2004;58:566-570 18 McKellar JD, Humphreys K, Piette JD Depression increases diabetes symptoms by complicating patients self-care adherence Diabetes Educ 2004;30:485-492 19 Piette JD, Richardson C, Valenstein M Addressing the needs of patients with multiple chronic illnesses: the case of diabetes and depression Am J Manag Care 2004;10:152-162 20 Lustman PJ, Griffith LS, Clouse RE, et al Effects of nortriptyline on depression and glycemic control in diabetes: results of a doubleblind, placebo-controlled trial
Psychosom Med 1997;59:241-250 21 Lustman PJ, Griffith LS, Freedland KE, Kissel SS, Clouse RE Cognitive behavior therapy for depression in type 2 diabetes mellitus: a randomized, controlled trial Ann Intern Med 1998;129:613-621 22 Lustman PJ, Freedland KE, Griffith LS, Clouse RE Fluoxetine for depression in diabetes: a randomized double-blind placebo-controlled trial Diabetes Care 2000;23:618-623 23 Williams JW Jr, Katon W, Lin EH, et al The effectiveness of depression care management on diabetes-related outcomes in older patients Ann Intern Med 2004;140:1015-1024 24 Katon WJ, Von Korff M, Lin EH, et al The Pathways Study: a randomized trial of collaborative care in patients with diabetes and depression Arch Gen Psychiatry 2004;61:1042-1049 25 Spitzer RL, Kroenke K, Williams JB Validation and utility of a selfreport version of PRIME-MD: the PHQ primary care study Primary Care Evaluation of Mental Disorders Patient Health Questionnaire JAMA 1999;282:1737-1744

References
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Feil EG, Barrera M Jr The D-Net diabetes self-management program: long-term implementation, outcomes, and generalization results Prev Med 2003;36:410-419 3 Newman S, Steed L, Mulligan K Self-management interventions for chronic illness Lancet 2004;364:1523-1537 4 American Diabetes Association Standards of medical care in diabetes Diabetes Care 2005;28Suppl 1:S4-S36

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26 Derogatis L, Rickels K, Uhlenhuth E, Covi L The Hopkins Symptom Checklist: a measure of primary symptom dimensions In: Pinchot P, ed Psychological Measurements in Psychopharmacology: Problems in Pharmacopsychiatry Basil, Switzerland: Kargerman; 1974 27 Toobert DJ, Hampson SE, Glasgow RE The Summary of Diabetes Self-Care Activities measure: results from 7 studies and a revised scale Diabetes Care 2000;23:943-950 28 Wang PS, Bohn RL, Knight E, et al Noncompliance with antihypertensive medications: the impact of depressive symptoms and psychosocial factors J Gen Intern Med 2002;17:504-511 29 Unutzer J, Katon W, Callahan CM, et al Collaborative care management of
late-life depression in the primary care setting: a randomized controlled trial JAMA 2002;288:2836-2845 30 Pladevall M, Williams LK, Potts LA, et al Clinical outcomes and adherence to medications measured by claims data in patients with diabetes Diabetes Care 2004;27:2800-2805 31 Gaede P, Vedel P, Larsen N, et al Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes N Engl J Med 2003;348:383-393 32 Knowler WC, Barrett-Connor E, Fowler SE, et al Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin N Engl J Med 2002;346:393-403

33 Diabetes Prevention Program DPP Research Group The Diabetes Prevention Program DPP: description of lifestyle intervention Diabetes Care 2002;25:2165-2171 34 Russell LB, Suh DC, Safford MA Time requirements for diabetes selfmanagement: too much for many? J Fam Pract 2005;54:52-56 35 Herman WH, Hoerger TJ, Brandle M, et al The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance Ann Intern Med 2005;142:323-332 36 Diabetes Prevention Program Research Group Within-trial cost-effectiveness of lifestyle intervention or
metformin for the primary prevention of type 2 diabetes Diabetes Care 2003;26:2518-2523 37 Klinkman MS Competing demands in psychosocial care: a model for the identification and treatment of depressive disorders in primary care Gen Hosp Psychiatry 1997;19:98-111 38 Rost K, Nutting P, Smith J, et al The role of competing demands in the treatment provided primary care patients with major depression Arch Fam Med 2000;9:150-154 39 de Gruy F 3rd Depression research in primary care: pushing the field forward Ann Fam Med 2005;3:3-6

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