Addressing the Needs of Patients With Multiple Chronic Illnesses

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The American Journal of Managed Care, February 2004 - Part 2, Volume 10, Issue 2 Pt 2

Objective: To review the literature on comorbid depression and diabetes (DM/D) and present a conceptual framework for integrating depression management with diabetes care in a managed care environment.

Study Design: Literature review.

Results: Depression affects diabetes management by 1) directly affecting patients’ health-related quality of life, 2) reducing physical activity levels, 3) limiting adherence to self-care regimens, and 4) impairing patients’ ability to communicate effectively with clinicians. Small randomized trials suggest that both antidepressant medication and cognitive behavioral therapies (CBTs) or related approaches may improve not only DM/D patients’ depressive symptoms, but their physical health as well.

Conclusions: An effective DM/D management strategy should include the following elements: 1) systematic identification of DM/D patients and quality-of-care reviews, 2) proactive patient monitoring between outpatient encounters, 3) intensive efforts to coordinate treatment across providers, 4) increased access to CBT or related therapies addressing patients’ depressive symptoms and diabetes self care, and 5) an emphasis on promoting physical activity to address both depressive symptoms and physiologic dysregulation. The conceptual framework developed for the care of DM/D patients offers general insights into the management of patients with multiple chronic medical disorders

(Am J Manag Care. 2004;10(part 2):152-162)

Medical care for diabetes is improving in many health systems. The Department of Veterans Affairs,1 the Indian Health Service,2 and private managed care organizations 3 have reorganized some diabetes services to reflect principles of effective chronic disease management. As a result, they have increased the provision of recommended care processes and improved patients' glycosylated hemoglobin (HbA1C) levels–an important intermediate outcome linked to long-term complications such as blindness, limb amputation, and kidney failure.4,5

Nevertheless, nationwide studies report that many diabetes patients continue to have difficulty with self care and experience suboptimal outcomes.6 Comorbid medical problems such as depression may be key barriers to achieving treatment gains. Unfortunately, most diabetes management algorithms provide only a limited framework for considering the treatment of comorbid medical conditions. Rather, comorbid conditions usually are addressed under the broad rubric of "tailoring" guidelines to patients' unique needs–a strategy that often fails to conceptually integrate care, prioritize interventions, and identify treatment synergies (ie, treatments that impact more than 1 of the patient‛s comorbid conditions and thus increase treatment value). A more explicit method of identifying priorities for treatment planning could lead to more effective and rational care for patients with comorbid conditions, especially in the context of limited healthcare resources.

Patients with diabetes and depression (DM/D) comprise a large, costly, and vulnerable subgroup of diabetes patients. The purpose of this paper is to review the literature on comorbid depression and diabetes, and present a conceptual framework for integrating depression management with diabetes care. We discuss the ways in which depression might affect diabetes patients' self-care activities and outcomes, even when health systems offer excellent diabetes-specific treatment. Given the state-of-the-science in DM/D research, an exhaustive quantitative summary of studies addressing specific dimensions of DM/D care (eg, the relative effectiveness of interventions focusing on exercise promotion vs intensive pharmacologic management) is not possible. Nevertheless, we highlight some of the most important literature from relevant fields, examine the treatment implications suggested by the links between these 2 conditions, and suggest ways in which DM/D care may offer general insights into how to conceptualize treatment and manage patients with multiple chronic disorders.

DEPRESSION AMONG DIABETES PATIENTS

Epidemiology

Like diabetes, major depressive disorder is a common and debilitating illness. Among patients in primary care, 4% to 15% meet criteria for major depression and another 9% to 16% meet criteria for other depressive disorders.7,8 Elderly and poor individuals have particularly high rates of depression, and these groups also are at greatest risk for diabetes and diabetes-related complications.

Diagnostic and Statistical Manual for Mental Disorders

Depression is twice as common among diabetes patients than in the general population, with 15% to 30% of diabetes patients meeting criteria for depression, depending on whether criteria or high scores on standard depression scales are used to define clinically significant illness.9 Evidence is conflicting with regard to whether depression is an independent risk factor for diabetes.10,11 However, depression clearly is more common among diabetes patients–especially those with comorbid conditions.12 After an initial episode of depression, patients with diabetes relapse more frequently than other patients.13

Pathophysiologic Impacts

Depression is a risk factor for hypertension,14 hyperlipidemia, 15 and heart failure;16 and each of these illnesses increases the rate of cardiovascular events among diabetes patients. Although the relationship is complex and may differ for patients with type 1 and type 2 diabetes,17 it is clear that depression among diabetes patients is associated with poor glycemic control. 18 Patients with DM/D also have higher rates of retinopathy19 and macrovascular complications such as stroke and myocardial infarction (MI) than do nondepressed diabetes patients,20 and they report more diabetes- related symptoms.17

Effectiveness of Depression Treatment

Patients with major depression respond to antidepressants, depression-specific psychotherapies, or both. Meta-analyses report absolute increases in remission rates of 17% to 39% among patients randomized to receive antidepressants compared with patients receiving placebo.21,22 Antidepressants are as effective among patients with comorbid medical illnesses as they are among patients with major depression alone.23 Numerous randomized trials have demonstrated the efficacy of psychotherapies such as cognitive behavioral therapy (CBT) or related approaches (eg, problem- solving therapy) for patients with depression.24 Cognitive behavioral therapists work with patients to interrupt self-perpetuating cycles of negative thoughts, low mood, decreased motivation, and inactivity. They also use behavioral techniques to increase pleasurable and productive activities. Depressed patients who receive CBT appear less likely to relapse after treatment is discontinued than patients receiving only antidepressant medication.25

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In randomized trials, Lustman and colleagues demonstrated that both antidepressant medication and CBT are efficacious for patients with DM/D. In one study, they found that 67% of DM/D patients receiving fluoxetine showed improvement on the Beck Depression Inventory after 8 weeks of treatment compared with 37% of patients receiving placebo.26 In a second study, a conservative intent-to-treat analysis showed that 71% of DM/D patients randomized to a 10- week CBT intervention achieved remission, compared with 22% of patients randomized to diabetes education alone ( < .001); 58% of the CBT patients were in remission at the 6-month follow-up, compared with 26% of controls (= .03).27

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Although there are no large studies indicating that depression treatments for DM/D patients improve medical outcomes, studies by Lustman and colleagues suggest that the treatments may have this important effect. In their CBT study,27 these investigators found that patients receiving CBT had substantially better HbA1C levels 6 months after the intervention than did control patients (9.5% vs 10.9%; = .03).

Despite the potential efficacy of depression treatment, DM/D patients are likely to experience significant gaps in their depression care. Providers often fail to detect depression among their patients,8,28,29 and when depression is identified, depression-specific therapies often are not initiated.28 Primary care physicians may be uncomfortable managing depression because they lack treatment expertise or because of time constraints and competing clinical demands. Patients may be unwilling to accept or continue antidepressant treatment because of concerns about stigma or side effects.30 Effective CBT therapy often is unavailable because of the lack of adequately trained therapists or limitations on patients' mental health benefits.31,32 Among patients who initiate a course of antidepressant medication, long-term adherence is poor. In a large managed care organization, 28% of patients discontinued their antidepressants within the first month of treatment and 44% discontinued these medications by the third month.33 Pharmaceutical claims databases suggest that 30% of patients with private insurance and 70% of patients with Medicaid coverage fill fewer than 4 30-day prescriptions in the 6 months after initiation of antidepressant therapy and thus do not receive an adequate antidepressant trial.34,35

A potential barrier to effective depression management among diabetes patients is the lack of a coherent view of patients' clinical problems that encompasses both disorders. At the system level, this often is reflected by a structural lack of integration between medical and mental health services, with mental health and general medical providers often treating patients in different locations, maintaining separate medical records, and communicating infrequently.36,37 Primary care providers often do not appreciate the importance of aggressive depression management for patients' overall health, and patients often do not draw connections between their depressive symptoms and their ability to manage their diabetes. Despite a good deal of descriptive epidemiology about the confluence of diabetes and depression as well as the availability of effective treatments, there is little consensus regarding the mechanisms linking these 2 conditions or how the care of DM/D patients might be most effectively managed.

CONCEPTUAL FRAMEWORK FOR THE RELATIONSHIP BETWEEN DIABETES AND DEPRESSION

Based on an extensive review of the literature, we developed a framework for better understanding the impact of depression on diabetes care and treatment outcomes in managed care settings (Figure). This model specifies 4 main pathways through which depression may affect outcomes among patients with DM/D: 1) by directly impacting their health-related quality of life, 2) by affecting their physical activity levels, 3) by affecting their self efficacy for diabetes management and self care, and 4) by affecting their ability to communicate effectively with healthcare providers. The Figure also suggests the theoretical impact of treatment with antidepressants or behaviorally focused counseling such as CBT.

First Pathway: Depression Directly Affects DM/D Patients' Quality of Life and Functioning

Depression directly affects the health-related quality of life of patients with many chronic disorders, including diabetes.20,38 Depression is associated with increased mortality rates among patients with heart failure,39 MI,40 and stroke.41 Physical, social, and role functioning are compromised more by depressive symptoms than by most other chronic medical conditions, including hypertension, chronic lung diseases, gastrointestinal conditions, and arthritis.42,43 Patients who have both depression and a comorbid medical condition, including patients with DM/D, experience additive disability.44 Thus, addressing depressive symptoms among DM/D patients is likely to improve their health-related quality of life, even if diabetes-related pathophysiology and outcomes remain unchanged.

Second Pathway: Depression Affects DM/D Patients' Level of Physical Activity

Diabetes patients who are depressed are more likely to report limited physical functioning,17,45 and increasing physical activity may be one of the most important behavioral changes for DM/D patients. Epidemiologic studies have repeatedly found cross-sectional associations between low levels of physical activity, diabetes, and depression.46,47 Longitudinal studies indicate that patients who are more physically active have better diabetesrelated outcomes, and most studies indicate that individuals who are less physically active are more likely to develop depression.46,48,49 In a prospective study, Lampinen and colleagues found that subjects who decreased their level of physical activity over time were particularly prone to depression.50

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Interventions that promote physical activity can improve both diabetes-related and depression-related outcomes. In a meta-analysis of 14 studies examining interventions to increase physical activity among diabetes patients,51 individuals receiving these interventions had a mean poststudy HbA1C level of 7.7% compared with 8.3% among comparison group patients ( < .001). In addition to affecting glycemic control, moderate physical activity improved other cardiovascular risk factors such as high-density lipoprotein cholesterol and blood pressure. Blumenthal and colleagues found good therapeutic benefit and comparable outcomes for patients with major depression who were randomized to a 4-month intervention of either aerobic exercise, antidepressant medication, or a combination of exercise and antidepressants.52 At 10 months, those in the exercise group were less likely to have had a depressive relapse than those in the medication group (30% vs 52%; = .03).53 Singh and colleagues found that elderly depressed patients randomized to an exercise intervention were less than half as likely to be depressed after 5 months than control patients (27% vs 64%; = .02).54 Finally, Mather and colleagues found exercise to be a useful adjunct to antidepressant treatment. 55 All of these studies suggest that promoting physical activity may be a treatment approach that improves both patients' physiologic risk factors for diabetes-related complications and their mental health.

Third Pathway: Depression Affects DM/D Patients' Self-Care Behaviors

Depressed patients may be less likely than nondepressed patients to optimally manage their diabetes self care because of their lack of energy and motivation, negative patterns of cognition, internalizing and pessimistic attributional styles, and passive coping strategies. 16,56,57 Depressed patients are more likely to use emotion-focused coping rather than problem-focused coping and to attribute negative events to their own actions rather than the actions of other people or external factors (internal vs external attribution). Depressed patients also are more likely to believe that negative events that they have experienced will be repeated in the future (stable vs unstable attribution), and expect the same negative results in a variety of life situations (global vs specific attribution). If DM/D patients have doubts about their abilities to be effective in various life domains, they may be less likely to take positive action regarding their health and place less importance on following through with self-management plans.

Studies support a causal link between depression and chronically ill patients' ability to adhere to self-care regimens. 17,58 A study by Ziegelstein and colleagues of cardiac rehabilitation patients showed that patients with depression were less likely to follow treatment recommendations after an MI and were less likely to take their cardiac medications as prescribed.59 One study found that diabetes patients with high levels of depressive symptoms did not take their hypoglycemic agents as prescribed twice as often as patients with fewer depressive symptoms.60 In a recent trial of a telephone case management intervention, diabetes patients with depressive symptoms at baseline experienced increased diabetes-related physical symptoms 1 year later, and this association appeared to be entirely mediated by poorer self-care behaviors.61

Successful depression treatment may modify patients' attributional style and decrease the intensity of the dysfunctional beliefs that pose obstacles to self care. Patients with a more optimistic attributional style are more likely to perceive themselves as being able to prevent health problems.62 Patients whose depression has remitted experience increased energy and motivation, and they also may experience greater self efficacy in a variety of life situations.63 Greater self efficacy for diabetes care is associated with improved glycemic control64 and functioning.65

Fourth Pathway: Depression Affects DM/D Patients' Communication with Providers

Patient-provider communication is a critical element of healthcare and may be especially important for patients with DM/D. The quality of patient-provider communication predicts patients' treatment satisfaction, comprehension of and adherence to care plans, and physical outcomes.66 Patients who believe that their treatment agenda has not been addressed are less satisfied with their medical care, are less likely to follow through on treatment plans, and have poorer outcomes. 67 Among diabetes patients, both high-quality general communication and diabetes-specific communication are independently associated with better self care.68

Depression may lead to less satisfactory encounters between diabetes patients and providers, perhaps because of poorer communication.69 Depressed patients are more likely to have unmet expectations after their visits.70 They also are less satisfied with their medical care 71 and their health plans.72 Primary care providers are more likely to consider patients with depressive or anxiety disorders to be "difficult,"73 and to consider diabetes patients who are depressed and anxious as "less able to cope with their diabetes"–a perception that may influence their communication and management style.74 Diabetes patients with a "dismissive" interpersonal style and poor communication with their providers have poorer adherence with medications and higher HbA1C levels.75

Healthcare Use

Perhaps because of problems with self care, poor adherence, and difficult interactions with providers, depressed patients use more health services than nondepressed patients and have higher healthcare costs.76 Ciechanowski and colleagues found that diabetes patients treated in an HMO who scored in the highest tertile for depressive symptoms on the Hopkins Symptom Checklist-20 had healthcare costs 86% higher than those of patients scoring in the lowest tertile.60 A recent study found that total healthcare expenditures for DM/D patients were 4.5 times higher than those for nondepressed diabetes patients, and that the groups differed in treatment costs even after adjusting for patients' demographic characteristics, health insurance, and coexisting illnesses.77

THERAPEUTIC AND HEALTH SERVICES IMPLICATIONS

The Table summarizes some of the most important findings from recent research on the linkage between depression and diabetes. Overall, evidence is mounting that these 2 chronic illnesses are interrelated on multiple levels, complicating patients' care and leading to worse outcomes than those of individuals with only 1 of the conditions. Nevertheless, a variety of randomized trials suggest that DM/D patients can be effectively treated in a managed care environment. Unfortunately, health systems and their case management programs often fail to explicitly consider 1) the ways in which diabetes and depression interact to affect patients' functioning, health, and service use; and 2) the ways in which treatment strategies might change when both conditions are present. From our literature review, the following principles appear important.

Systematic Patient Identification and Quality-of-Care Review

Because depression often is underdiagnosed among patients with diabetes, healthcare systems might consider instituting systematic screening of diabetes patients for depression–realizing that screening will most likely be of benefit and cost effective if a comprehensive follow-up program for depression is in place.78

Healthcare systems also might consider systematically identifying patients who have received a diagnosis of both depression and diabetes to exam- ine the quality of their care and evaluate the need for more intensive services. For many years, the Health Plan Employer Data and Information Set (HEDIS) has included performance measures for diabetes care to encourage routine monitoring of treatment quality. A performance measure for antidepressant management was recently added to HEDIS. Because the National Committee for Quality Assurance considers performance on HEDIS measures in its accreditation processes, managed care organizations routinely collect these measures. Using them to monitor care specifically for DM/D patients may be a manageable way to increase adherence to guideline practices for these vulnerable patients. However, DM/D management reviews must go beyond ensuring that depression and diabetes treatment standards are met, and evaluate the level of depression and types of linkages between patients' depression care and management of their diabetes.

Systematic, Proactive Monitoring Between Outpatient Encounters

For depression, as for many chronic disorders, systematic, between-visit patient monitoring appears essential for producing significant benefits.36,79,80 Patients with DM/D are particularly likely to require such regular monitoring and follow up. The complexity of DM/D patients' needs coupled with time constraints on face-to-face encounters suggest that telephone follow up may be the most practical approach. Telephone care has been shown to be an effective strategy for managing patients with depression,81-83 diabetes,84 and other chronic health conditions.85 In addition to health and behavioral monitoring, telephone calls also can be used to educate patients regarding their conditions, maintain a focus on treatment goals, and evaluate changes in health status that might be due to diabetes, depression, or other problems.

Coordination Across Providers

Coordination of clinical treatment and communication among providers are essential for DM/D patients. Organizations might be able to increase the coordination of care by placing mental health and primary care clinicians in the same location 79,86 and by ensuring that both mental health and primary care providers have access to a common, comprehensive medical record. A shared electronic medical record probably would be ideal.

Case management may be an important tool for integrating diabetes and depression care. Case managers could interface with patients' diabetes- and depressionrelated clinical teams, ensuring treatment synergies when possible and prioritizing interventions when conflicts exist. The evidence for case management's effectiveness among medically ill patients has been mixed.87 However, there have been some successes among patients with diabetes,84 and research consistently indicates that case management is beneficial in the treatment of depressed patients.36,79,80,82,88

Increasing the Availability of Cognitive Behavioral Therapy and Similar Approaches

Along with general efforts to ensure that depression care and diabetes care are sufficiently organized and appropriately accessed, healthcare systems also may need to ensure that CBT and related strategies are available in their organizations. Although antidepressant medications are effective and less expensive than CBT, many patients prefer psychotherapy and may accept these services while refusing medication-based treatments. In particular, minority patients prefer psychotherapy to antidepressants and may be underserved if such services are not available.89

Patients with diabetes and depression, particularly elderly patients, also may be at risk for adherence problems related to polypharmacy and may have difficulty paying for their prescription medications.90,91 Clinicians and patients are likely to welcome an alternative, effective treatment that does not add to the cost and complexity of ongoing medication regimens.

For these reasons, healthcare systems that ensure ready availability of CBT and related approaches may successfully engage a larger number of patients in depression-specific care and also achieve outcomes that are as good as or better than those achieved with antidepressant treatment alone. Cognitive behavioral therapy also has the advantage of specifically targeting perceptions and behaviors that are likely to improve diabetes-related self-care in addition to depression.

Physical Activity to Address Patients' Glucose Dysregulation and Depressive Symptoms

Promoting physical activity may be a particularly important component of the effective management of DM/D patients. However, healthcare organizations must offer sufficiently intensive interventions to support recently initiated activity changes. Strategies for facilitating and maintaining increases in physical activity include supervised exercise sessions, CBT-oriented individual and group sessions, and regular follow-up.92

It is currently recommended that healthy individuals participate in at least 30 minutes of moderate physical activity most days of the week.93 However, this is an arbitrary cutoff; in both the general population and in a large cohort of women with diabetes, increases in the intensity and volume of physical activity were found to be linearly correlated with decreased risk of cardiovas- cular disease and death.94 Even low-intensity activity is better than no activity.95 Both moderate and vigorous physical activity are correlated with improvements in depression,46 and moderate activity may actually be more effective than vigorous activity in reducing anxiety.94

Given that vigorous exercise programs often are difficult to maintain and are associated with decreased adherence,92 a program promoting walking may be the best option for sedentary patients with DM/D. Walking is the most common form of exercise among active diabetes patients,96 and it is safe for patients without prior cardiac risk screening, even those who have cardiovascular risk factors.97 Of course, DM/D patients who desire more vigorous activity should be encouraged to increase the intensity of their exercise when appropriate, and patients who are unable to walk should be encouraged to participate in alternative activities such as using an exercise bicycle or manually propelling their wheelchairs.

FUTURE DIRECTIONS FOR DM/D RESEARCH

Further Epidemiologic Research Is Needed

Because of the dearth of epidemiologic research (particularly with regard to self management) and intervention trials among patients with DM/D, the framework presented here is based on a compilation of studies examining various facets of these patients' treatment. Many of the pathways shown in the Figure are based on studies that used general clinic samples and patients who had either diabetes or depression, rather than both disorders simultaneously. Although these studies suggest ways in which the interrelationships between depression and diabetes are important for DM/D care, the relative importance of these relationships and the extent to which they are amenable to change have yet to be determined. These issues only can be addressed conclusively by larger, longitudinal studies with DM/D patients. Moreover, the current review presents only some of the most salient mechanisms linking depression and diabetes. Although research suggests that these are among the most important mechanisms, more focused research will be required to determine how important the pathways shown in the Figure are relative to other potential mechanisms not addressed in this review (eg, depression's effect on dietary behavior and perceived social support).

Many of the issues addressed in this review, though highly relevant to diabetes, are common among depressed patients with chronic medical disorders. It will be important to determine which pathways are especially important in diabetes care compared with care for other conditions. One recent study suggests that the effects of depression and diabetes on patients' functioning are additive rather than synergistic. 98 Nevertheless, issues such as the effect of depression on physical activity or health perception are crucial to address in diabetes care, whether or not their salience is any greater than for patients with other disorders and even though DM/D patients have other competing needs.

Future Directions for Research on Case Management

The management challenges presented by patients with DM/D suggest that the science of case management must move beyond single-disease interventions to interventions that are suitable for patients with multiple disorders. Future research should determine whether case managers working with patients who have multiple disorders are more effective when they are specialists in 1 of the conditions (eg, a psychiatric nurse for DM/D patients) or when they are generalists. Research also must determine whether case managers are more effective when they focus on a small number of medical problems and patient behaviors, or when they involve themselves in managing a wider range of services. For example, case managers could focus exclusively on monitoring patients' medication adherence and symptoms, or they also could assist patients in obtaining social services such as transportation to clinics or in completing benefits applications. Some of these issues have been addressed in studies comparing chronic disease services delivered by specialist versus generalist physicians 99 and studies that examine case management strategies for clinical problems other than DM/D.100

A recent multisite trial has demonstrated that depression care management, incorporating a tailored focus on antidepressant management and behavioral counseling, can be effective in assisting depressed primary care patients and may increase their physical functioning, (thereby facilitating physical activity promotion). 101 One ongoing study, the Pathways study, is testing the effectiveness of a collaborative care intervention to improve outcomes for DM/D patients. The findings from this study will make an important contribution to this area of research, where directly relevant, empirical evidence is lacking.102

Identifying Treatments That Address Multiple Disorders Simultaneously

Programs addressing multiple disorders must search for commonalities in treatment (eg, the commonalities outlined above in CBT approaches to physical activity and depression). Creative and efficient strategies for addressing patients' multiple health problems are essential, because neither they nor their providers can realistically be expected to focus on more than a few treatment goals at any given time. Von Korff and colleagues103 have demonstrated that patients are more likely to follow treatment plans when they collaboratively define problems and set goals with their physicians. Bradley et al 104 and Bogardus et al 105 also have developed useful frameworks for understanding the goal-setting process in chronic illness management and translating that process into more effective patient care.

For patients with multiple disorders, clinicians might be able to motivate behavioral changes that benefit several co-occurring disorders during "teachable moments" that present themselves when patients face the health consequences of 1 of their conditions. For example, when patients experience a consequence of diabetes such as a foot injury or infection, clinicians might help them note discrepancies between their current and desired health status and the potential advantages of more closely monitoring their glucose, initiating regular exercise, and following through with medical appointments. Patients who experience success in changing 1 health behavior also may develop greater self efficacy in related areas of self care and may be willing to initiate other behavioral changes as a result.

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Regardless of efforts to make care as efficient as possible, patients with multiple health problems almost inevitably will have a greater number of healthcare visits than patients with only 1 problem. With appropriate planning, these additional visits can be used to ensure that regular monitoring of all co-occurring disorders is completed. In a recent Veterans Affairs study, investigators found that patients who had both diabetes and schizophrenia were as likely or likely to have routine diabetes care as patients who had diabetes alone, in part due to their larger number of multiclinic visits (ie, visits in which they attended both a mental health and a primary care clinic) (C. R. Bingham, PhD, oral communication, August 2003). Of course, cross-specialty follow-up (eg, reminders regarding HbA1C testing during psychiatry visits) will only be possible when providers share a common medical record and are in reasonable geographic proximity.

The Role of Health Information Technology

Evidence is mounting that health information technology may be useful for the care of chronic illnesses, and may be especially useful for patients with comorbid disorders, such as those with DM/D. Interactive voice response systems can be used to deliver repeated depressive symptom assessments,106 reminders that assist patients in managing their complex interactions with healthcare providers,107 or medication adherence prompts.108 Recent studies have found that automated telephone assessments may be a cost effective adjunct to clinic-based follow-up, allowing health systems to monitor large numbers of patients and extend services to diabetes patients who have difficulty accessing face-to-face care.109,110 There is no evidence that patients with depression have any greater difficulty using automated calls or other forms of health information technology than other patients; in fact, depressed patients may be especially likely to benefit, given their tendency to miss clinic-based appointments and to require more intensive follow-up. Computerized monitoring may be especially important when assessing "sensitive" issues such as mental health 111,112 or self care. For patients with computers, email is a viable and possibly effective way to increase access to ongoing education and ready answers to questions about health concerns such as weight management. 113,114 One Web-based support system for mood disorders reportedly logs more than 500 000 visits annually 115 ; and Web-based support services may improve patient satisfaction, mental health, and physical symptoms.116,117

Toward a Generalizable Framework for Treating Patients with Multiple Chronic Illnesses

Many of the management issues described here for DM/D patients are likely to apply to patients with multiple illnesses, whether or not diabetes and depression are among them. Collaborative goal setting, cross-specialty coordination, polypharmacy, and the role of case managers are only a few of the areas in which there are likely to be opportunities for improving service delivery. Nevertheless, each dimension of treatment will have nuances that are specific to the given combination of disorders. Although the care of patients with DM/D may have much in common with the care of patients with other combinations of diseases, such analogies clearly have limits. Nevertheless, this review suggests that a careful understanding of the mechanisms linking common comorbid illnesses may be a valuable starting point for developing more effective management strategies.

Acknowledgments

Kiran Khanuja, MD, and John Zeber, MHA, assisted with identifying articles for the review and manuscript preparation.

From the Center for Practice Management and Outcomes Research, VA Ann Arbor Health Care System, Ann Arbor, Mich (JDP, CR, MV); the Michigan Diabetes Research and Training Center, Ann Arbor (JDP); and the Department of Internal Medicine (JDP), the Department of Family Medicine (CR), and the Department of Psychiatry and the Depression Center (MV), University of Michigan, Ann Arbor.

This study was supported by grants from the Department of Veterans Affairs and the Agency for Health Care Research and Quality, and the Michigan Diabetes Research and Training Center.

The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

Address correspondence to: John D. Piette, PhD, The Center for Practice Management and Outcomes Research, VA Ann Arbor Health Care System, PO Box 130170, Ann Arbor, MI 48113-0170. E-mail: jpiette@umich.edu.

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