Treatment for Depression Reduces Mortality by Half in Older Diabetics

Pauline Anderson

November 29, 2007

November 29, 2007 — Older depressed patients with diabetes who receive additional intervention for their depression are half as likely to die within 5 years as similar patients who not provided this intervention, according to a new study appearing in the December issue of Diabetes Care, published by the American Diabetes Association.

"These results indicate that a depression care management intervention can significantly reduce all-cause mortality among depressed patients with diabetes," the authors conclude.

"There's a policy statement here," lead author Hillary R. Bogner, MD, assistant professor in the department of family practice and community medicine at the University of Pennsylvania, in Philadelphia, told Medscape Psychiatry. "We need more resources in primary care settings to treat depression."

A Daunting PROSPECT

The researchers used data from the randomized Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), which included a mix of 20 primary care practices from New York City, Philadelphia, and Pittsburgh and compared a primary care-based intervention with usual care in improving the outcome of depression.

This latest study sample included 599 depressed patients, of whom 396 (66.1%) met Diagnostic and Statistical Manual of Mental Disorders, 4th ed ( DSM-IV) criteria for major depression. Because of missing data on 15 of these patients, the sample size for analysis was reduced to 584 patients, whose mean age was 70.3 years. Of these participants, 123 (21.2%) reported a history of diabetes.

The intervention group had access to trained depression care managers, who collaborated with physicians by offering guidelines-based treatment recommendations, monitoring clinical status of patients, and providing appropriate follow-up, said Dr. Bogner. "These managers met with the patients in person or talked with them over the phone when clinically necessary or at scheduled intervals, in some cases as often as once a week. "

The depression care managers asked the patients questions regarding depressive symptoms, medication adverse effects, and adherence to medications, Dr. Bogner said. "Basically, they found out how the patient was feeling and whether their symptoms had improved. They also assessed whether the patient was having any trouble taking medications. For some patients, the depression care managers provided interpersonal therapy."

The fact that a person trained in depression management was available to address any problems or concerns that arose likely made a difference to the outcome for those in the intervention group, said Dr. Bogner. "It was an extra resource."

In the usual-care group, physicians were informed of a patient's depression diagnosis but did not receive specific treatment recommendations, said Dr. Bogner. "We know that patients in the usual-care group were often receiving depression treatment; the difference was that there was nobody in the practice who could make recommendations to the physician, such as increasing the dose" of medication, she said.

Mortality Cut By Half

After 5 years, 110 patients had died. Depressed patients with diabetes in the intervention group were about half as likely to die during that 5-year follow-up as were depressed patients with diabetes receiving usual care (adjusted hazard ratio, 0.49). Although researchers have not completed an analysis of the exact causes of these deaths, they do know that suicide was not a major contributor; there was only 1 suicide — a depressed patient with diabetes who was in the intervention group. According to Dr. Bogner, cardiovascular disease appears to be a likely cause of many of the other deaths.

In contrast to the patients with diabetes, depressed patients without diabetes in the intervention group had about the same risk of dying as similar patients in the usual-care group.

Although there has been much research on depression and diabetes, they write, "To our knowledge, this is the first study to report on the relationship between diabetes and mortality in a depression intervention trial."

The study suggests more attention should be paid to treating depression in patients with diabetes, they conclude. The need is all the more pressing due to the prevalence of depression and diabetes. These conditions represent 2 of the most common problems seen in primary care settings today, the authors note. The 2 are intimately related; depression is a risk factor for diabetes, and depression is increased by a factor of 2 in patients with diabetes, they write. Depression also contributes to poor adherence to medication and dietary regimens.

 

PROSPECT was funded by the National Institute of Mental Health (NIMH). Participation of Drs. Bogner, Post, and Bruce was supported by NIMH awards. The authors report no potential conflicts of Interest.

Diabetes Care. 2007;30:3005-3010. Abstract

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