Published studies have demonstrated that many patients with diabetes and cardiovascular disease (CVD) often have comorbid depression. In individuals with diabetes or CVD, depression has been linked to poor self-management of their physical health, an increased risk for complications, and higher morbidity. Due to feelings of helplessness and hopelessness that accompany depression, the management of these patients is often more complicated than for those who are not depressed. Compounding the problem is that complications of diabetes and CVD can exacerbate any previously existing depression.
Exploring a New Depression Intervention
In the December 30, 2010 New England Journal of Medicine, my colleagues and I published data from a randomized controlled trial in which we tested a primary care intervention called TEAMcare. In this intervention, nurses worked together with patients and healthcare teams to manage care using evidence-based guidelines for both depression and physical diseases together. The TEAMcare intervention involved having nurse care managers coach patients, monitor disease control and depression, and work with patients’ primary care physicians (PCPs) to make changes in medications and lifestyle when treatment goals were not reached. Nurses were supervised weekly by psychiatrists and PCPs who made recommendations about medication changes that nurses then communicated to patients’ PCPs.
“Patients who received the TEAMcare intervention were significantly less depressed, and also had improvements in blood glucose, LDL cholesterol, and systolic blood pressure levels.”
Working collaboratively, nurses and patients set realistic step-by-step goals for reducing depression as well as blood glucose, blood pressure, and cholesterol levels. To reach the goals set forth in the TEAMcare intervention, nurses regularly monitored patients’ mental and physical health and offered recommendations to patients’ PCPs to consider changes to the dosing or type of medications used for managing depression and blood glucose, blood pressure, and lipids. The purpose of taking a “treating to target” approach was to boost patients’ confidence as goals were accomplished.
Significant Findings of TEAMcare
Patients who received the TEAMcare intervention were significantly less depressed and also had improvements in blood glucose, LDL cholesterol, and systolic blood pressure levels at 1 year. Patients in the TEAMcare intervention arm were also more likely to have one or more timely adjustments of insulin, antihypertensive medications, and antidepressant medications. Furthermore, they reported having a better quality of life and greater satisfaction with care for diabetes, CVD, or both, as well as with care for depression.
We’re currently exploring the possible cost savings that can result from utilizing the TEAMcare intervention. We estimate that the 2-year TEAMcare intervention will cost about $1,224 per patient. It should be noted that the intervention is caring for patients whose medical care has been shown to cost healthcare systems about $10,000 per year.
Aiming for Patient-Centered Care
My colleagues and I feel that our TEAMcare intervention is a truly patient-centered approach that enhances the ability of PCPs to deliver optimal care for physical and mental health seamlessly. We hope to identify strategies that will make the intervention universally applicable to other academic medical centers and hospital systems throughout the United States. Ultimately, we’re trying to be proactive for people with diabetes and CVD to ensure that both their mental and physical health are managed simultaneously and aggressively to maximize outcomes.
Katon WJ, Lin EHB, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363:2611-2620. Available at:http://www.nejm.org/doi/full/10.1056/NEJMoa1003955.
American Diabetes Association. Standards of Medical Care in Diabetes—2011. Diabetes Care.2011;34:S11-S61. Available at: http://care.diabetesjournals.org/content/34/Supplement_1/S11.full.
Shojania KG, Ranji SR, McDonald KM, et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA. 2006;296:427-440.
Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006;166:2314-2321.