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In this trial, an intervention involving a medically supervised nurse providing guideline-based management, as compared with usual care, resulted in improved medical outcomes in patients who had depression and diabetes, coronary heart disease, or both. Evidence-based care management for single conditions improves outcomes among patients with diabetes, 1 coronary heart disease, 2 and depression, 3 but organizing diagnosis-specific programs is complex and costly, so such programs are not routinely available. 4 , 5 Care for patients with multiple chronic illnesses is expensive, and coordination of care among specialties can be inadequate. 5 , 6 In previous trials involving high-risk Medicare patients with diabetes, heart disease, or both, nurse care-management interventions did not improve patient outcomes. 7 However, these interventions were primarily delivered by telephone, had no physician supervision, did not include medication recommendations to primary care physicians, and were not integrated into primary . . .

OBJECTIVE: To prospectively examine the association of depression with risks for advanced macrovascular and microvascular complications among patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: A longitudinal cohort of 4,623 primary care patients with type 2 diabetes was enrolled in 2000-2002 and followed through 2005-2007. Advanced microvascular complications included blindness, end-stage renal disease, amputations, and renal failure deaths. Advanced macrovascular complications included myocardial infarction, stroke, cardiovascular procedures, and deaths. Medical record review, ICD-9 diagnostic and procedural codes, and death certificate data were used to ascertain outcomes in the 5-year follow-up. Proportional hazard models analyzed the association between baseline depression and risks of adverse outcomes. RESULTS: After adjustment for prior complications and demographic, clinical, and diabetes self-care variables, major depression was associated with significantly higher risks of adverse microvascular outcomes (hazard ratio 1.36 [95% CI 1.05-1.75]) and adverse macrovascular outcomes (1.24 [1.0-1.54]). CONCLUSIONS: Among people with type 2 diabetes, major depression is associated with an increased risk of clinically significant microvascular and macrovascular complications over the ensuing 5 years, even after adjusting for diabetes severity and self-care activities. Clinical and public health significance of these findings rises as the incidence of type 2 diabetes soars. Further research is needed to clarify the underlying mechanisms for this association and to test interventions to reduce the risk of diabetes complications among patients with comorbid depression.

OBJECTIVE:--We assessed whether patients with comorbid minor and major depression and type 2 diabetes had a higher mortality rate over a 3-year period compared with patients with diabetes alone. RESEARCH DESIGN AND METHODS--In a large health maintenance organization (HMO), 4,154 patients with type 2 diabetes were surveyed and followed for up to 3 years. Patients initially filled out a written questionnaire, and HMO-automated diagnostic, laboratory, and pharmacy data and Washington State mortality data were collected to assess diabetes complications and deaths. Cox proportional hazards regression models were used to calculate adjusted hazard ratios of death for each group compared with the reference group. RESULTS:--There were 275 (8.3%) deaths in 3,303 patients without depression compared with 48 (13.6%) deaths in 354 patients with minor depression and 59 (11.9%) deaths among 497 patients with major depression. A proportional hazards model with adjustment for age, sex, race/ethnicity, and educational attainment found that compared with the nondepressed group, minor depression was associated with a 1.67-fold increase in mortality (P = 0.003), and major depression was associated with a 2.30-fold increase (P < 0.0001). In a second model that controlled for multiple potential mediators, both minor and major depression remained significant predictors of mortality. CONCLUSIONS:--Among patients with diabetes, both minor and major depression are strongly associated with increased mortality. Further research will be necessary to disentangle causal relationships among depression, behavioral risk factors (adherence to medical regimens), diabetes complications, and mortality.

OBJECTIVE:--The purpose of this study was to examine the 5-year effects on total health care costs of the Pathways depression intervention program for patients with diabetes and comorbid depression compared with usual primary care. RESEARCH DESIGN AND METHODS--The Pathways Study was conducted in nine primary care practices of a large HMO and enrolled 329 patients with diabetes and comorbid major depression. The current study analyzed the differences in long-term medical costs between intervention and usual care patients. Participants were randomly assigned to a nurse depression intervention (n = 164) or to usual primary care (n = 165). The intervention included education about depression, behavioral activation, and a choice of either starting with support of antidepressant medication treatment by the primary care doctor or problem-solving therapy in primary care. Interventions were provided for up to 12 months, and the main outcome measures are health costs over a 5-year period. RESULTS:--Patients in the intervention arm of the study had improved depression outcomes and trends for reduced 5-year mean total medical costs of -$3,907 (95% CI -$15,454 less to $7,640 more) compared with usual care patients. A sensitivity analysis found that these cost differences were largely explained by the patients with depression and the most severe medical comorbidity. CONCLUSIONS:--The Pathways depression collaborative care program improved depression outcomes compared with usual care with no evidence of greater long-term costs and with trends for reduced costs among the more severely medically ill patients with diabetes.

BACKGROUND Both depression and diabetes have been found to be risk factors for dementia. This study examined whether comorbid depression in patients with diabetes increases the risk for dementia compared to those with diabetes alone. METHODS We conducted a prospective cohort study of 3,837 primary care patients with diabetes (mean age 63.2 ± 13.2 years) enrolled in an HMO in Washington State. The Patient Health Questionnaire (PHQ-9) was used to assess depression at baseline, and ICD-9 diagnoses for dementia were used to identify cases of dementia. Cohort members with no previous ICD-9 diagnosis of dementia prior to baseline were followed for a 5-year period. The risk of dementia for patients with both major depression and diabetes at baseline relative to patients with diabetes alone was estimated using cause-specific Cox proportional hazard regression models that adjusted for age, gender, education, race/ethnicity, diabetes duration, treatment with insulin, diabetes complications, nondiabetes-related medical comorbidity, hypertension, BMI, physical inactivity, smoking, HbA 1c , and number of primary care visits per month. RESULTS Over the 5-year period, 36 of 455 (7.9%) patients with major depression and diabetes (incidence rate of 21.5 per 1,000 person-years) versus 163 of 3,382 (4.8%) patients with diabetes alone (incidence rate of 11.8 per 1,000 person-years) had one or more ICD-9 diagnoses of dementia. Patients with comorbid major depression had an increased risk of dementia (fully adjusted hazard ratio 2.69, 95% CI 1.77, 4.07). CONCLUSIONS Patients with major depression and diabetes had an increased risk of development of dementia compared to those with diabetes alone. These data add to recent findings showing that depression was associated with an increased risk of macrovascular and microvascular complications in patients with diabetes.

Relationship of Depression and Diabetes Self-Care, Medication Adherence, and Preventive Care Elizabeth H.B. Lin , MD, MPH 1 , Wayne Katon , MD 2 , Michael Von Korff , SCD 1 , Carolyn Rutter , PHD 1 , Greg E. Simon , MD, MPH 1 , Malia Oliver , BA 1 , Paul Ciechanowski , MD, MPH 2 , Evette J. Ludman , PHD 1 , Terry Bush , PHD 1 and Bessie Young , MD 3 1 Center for Health Studies, Group Health Cooperative, Seattle, Washington 2 Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington 3 Department of Medicine, Veterans Administration Hospital, University of Washington, Seattle, Washington Address correspondence and reprint requests to Elizabeth H.B. Lin, MD, MPH, Center for Health Studies, Group Health Cooperative, 1730 Minor Ave., Suite 1600, Seattle, WA 98101. E-mail: lin.e{at}ghc.org Abstract OBJECTIVE —We assessed whether diabetes self-care, medication adherence, and use of preventive services were associated with depressive illness. RESEARCH DESIGN AND METHODS —In a large health maintenance organization, 4,463 patients with diabetes completed a questionnaire assessing self-care, diabetes monitoring, and depression. Automated diagnostic, laboratory, and pharmacy data were used to assess glycemic control, medication adherence, and preventive services. RESULTS —This predominantly type 2 diabetic population had a mean HbA 1c level of 7.8 ± 1.6%. Three-quarters of the patients received hypoglycemic agents (oral or insulin) and reported at least weekly self-monitoring of glucose and foot checks. The mean number of HbA 1c tests was 2.2 ± 1.3 per year and was only slightly higher among patients with poorly controlled diabetes. Almost one-half (48.9%) had a BMI >30 kg/m 2 , and 47.8% of patients exercised once a week or less. Pharmacy refill data showed a 19.5% nonadherence rate to oral hypoglycemic medicines (mean 67.4 ± 74.1 days) in the prior year. Major depression was associated with less physical activity, unhealthy diet, and lower adherence to oral hypoglycemic, antihypertensive, and lipid-lowering medications. In contrast, preventive care of diabetes, including home-glucose tests, foot checks, screening for microalbuminuria, and retinopathy was similar among depressed and nondepressed patients. CONCLUSIONS —In a primary care population, diabetes self-care was suboptimal across a continuum from home-based activities, such as healthy eating, exercise, and medication adherence, to use of preventive care. Major depression was mainly associated with patient-initiated behaviors that are difficult to maintain (e.g., exercise, diet, medication adherence) but not with preventive services for diabetes. GHC, Group Health Cooperative SDSCA, summary of diabetes self-care activity Footnotes A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Accepted May 27, 2004. Received February 12, 2004. DIABETES CARE

Urbanizing global populations spend over 90% of their time indoors where microbiome abundance and diversity are low. Chronic exposure to microbiomes with low abundance and diversity have demonstrated negative long-term impacts on human health. Sequencing-based analyses of environmental nucleic acids are critical to understanding the impact of the indoor microbiome on human health, however low DNA yields indoors, alongside sample collection and processing inconsistencies, currently challenge study replicability. This study presents a comparative assessment of a novel, passive, easily replicable sampling strategy using polydimethylsiloxane (PDMS) sheets alongside a representative swab-based collection protocol. Deployable, customizable PDMS films designed for whole-sample insertion into standardized extraction kits demonstrated 43% higher DNA yields per sample, and 76% higher yields per cm 2 of sampler over swab-based protocols. These results indicate that this accessible, scalable method enables sufficient DNA collection to comprehensively evaluate indoor microbiome exposures and potential human health impacts using smaller, more space efficient samplers, representing an attractive alternative to swab-based collection. In addition, this process reduces the manual steps required for microbiome sampling which could address inter-study variability, transform the current microbiome sampling paradigm, and ultimately benefit the replicability and accessibility of microbiome exposure studies.

Cost-Effectiveness and Net Benefit of Enhanced Treatment of Depression for Older Adults With Diabetes and Depression Wayne Katon , MD 1 , Jürgen Unützer , MD, MPH 1 , Ming-Yu Fan , PHD 1 , John W. Williams, Jr , MD, MHS 2 , Michael Schoenbaum , PHD 3 , Elizabeth H.B. Lin , MD, MPH 4 and Enid M. Hunkeler , MA 5 1 Department of Psychiatry, University of Washington School of Medicine, Seattle, Washington 2 Department of Medicine, Durham Veterans Administration Medical Hospital, Durham, North Carolina 3 RAND, Arlington, Virginia 4 Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle, Washington 5 Kaiser Permanente, Oakland, California Address correspondence and reprint requests to Wayne Katon, MD, Department of PsychiatryBehavioral Sciences, Box 356560, University of Washington School of Medicine, 1959 NE Pacific St., Seattle, WA 98195-6560. E-mail: wkaton{at}u.washington.edu Abstract OBJECTIVE —To determine the incremental cost-effectiveness and net benefit of a depression collaborative care program compared with usual care for patients with diabetes and depression. RESEARCH DESIGN AND METHODS —This article describes a preplanned subgroup analysis of patients with diabetes from the Improving Mood-Promoting Access to Collaborative (IMPACT) randomized controlled trial. The setting for the study included 18 primary care clinics from eight health care organizations in five states. A total of 418 of 1,801 patients randomized to the IMPACT intervention ( n = 204) versus usual care ( n = 214) had coexisting diabetes. A depression care manager offered education, behavioral activation, and a choice of problem-solving treatment or support of antidepressant management by the primary care physician. The main outcomes were incremental cost-effectiveness and net benefit of the program compared with usual care. RESULTS —Relative to usual care, intervention patients experienced 115 (95% CI 72–159) more depression-free days over 24 months. Total outpatient costs were $25 (95% CI −1,638 to 1,689) higher during this same period. The incremental cost per depression-free day was 25 cents (−$14 to $15) and the incremental cost per quality-adjusted life year ranged from $198 (144–316) to $397 (287–641). An incremental net benefit of $1,129 (692–1,572) was found. CONCLUSIONS —The IMPACT intervention is a high-value investment for older adults with diabetes; it is associated with high clinical benefits at no greater cost than usual care. DCM, depression care manager HSCL-20, Hopkins Symptom Checklist 20 Depression Scale IMPACT, Improving Mood-Promoting Access to Collaborative PST-PC, problem-solving treatment developed for primary care QALY, quality-adjusted life year Footnotes E.M.H. has received grant/research support from Eli Lilly, Wyeth, Solvay, Merck, and GlaxoSmithKline. A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Accepted October 15, 2005. Received August 22, 2005. DIABETES CARE

ABSTRACT BACKGROUND Hospitalizations for ambulatory care-sensitive conditions (ACSCs), conditions that should not require inpatient treatment if timely and appropriate ambulatory care is provided, may be an important contributor to rising healthcare costs and public health burden. OBJECTIVE To examine if probable major depression is independently associated with hospitalization for an ACSC in patients with diabetes. DESIGN Secondary analysis of data from a prospective cohort study. PARTICIPANTS Population-based cohort of 4,128 patients with diabetes ≥ 18 years old seen in primary care, who were enrolled between 2000 and 2002 and followed for 5 years (through 2007). MAIN MEASURES Depressive symptoms were assessed with the Patient Health Questionnaire-9. Outcomes of interest included time to initial hospitalization for an ACSC and total number of ACSC-related hospitalizations. We used Cox proportional hazards regression models to ascertain an association between probable major depression and time to ACSC-related hospitalization, as well as Poisson regression for models examining probable major depression and number of ACSC-related hospitalizations. KEY RESULTS Patients’ mean age at study enrollment was 63.4 years (Standard Deviation: 13.4 years). Over the 5-year follow-up period, 981 patients in the study were hospitalized a total of 1,721 times for an ACSC, comprising 45.1 % of all hospitalizations. After adjusting for baseline demographic, clinical and health-risk behavioral factors, probable major depression was associated with initial ACSC-related hospitalization (Hazard Ratio: 1.41, 95 % Confidence Interval [95 % CI]: 1.15, 1.72) and number of ACSC-related hospitalizations (Relative Risk: 1.37, 95 % CI: 1.12, 1.68). CONCLUSIONS Probable major depression in patients with diabetes is independently associated with hospitalization for an ACSC. Additional research is warranted to ascertain if effective interventions for depression in patients with diabetes could reduce the risk of hospitalizations for ACSCs and their associated adverse outcomes.