Integrated Care for Co-morbid Depression and Diabetes in India

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DESCRIPTION (provided by applicant): Depression and cardio-metabolic illnesses like diabetes and cardiovascular disease (CVD) are leading health and economic burdens in India and globally. Depression and diabetes commonly co-exist, adversely interact, and compound the risks of disabling complications, reduced quality of life, and mortality when they are poorly- controlled. Depression affects 20% of the 61 million people with diabetes in India, and data suggest that depression and CVD risk factors are under-treated in over 60% of people with diabetes. A number of patient- level (e.g., low adherence to treatments), provider-level (e.g., deficiencies in treatment intensification), and system-level factors (e.g., human resource constraints and lack of systems to manage chronic diseases) are commonly-cited barriers to achieving better control of these conditions. Our team has shown that targeting both depression and diabetes control has important synergistic benefits (TEAMCare study). Since diabetes patients in India tend to access specialists (government or private) for their diabetes and other health care needs, they at least have a point of contact with the health system which can be leveraged to also improve depression care. Also, interventions for depression can be integrated into routine diabetes care delivery with only modest modifications. Our integrated multi-condition (depression and diabetes) intervention model merges experiences from TEAMCare and an ongoing trial of CVD risk reduction in India (CARRS Trial) and involves: 1. enhancing the role of nurses and training them in disease management; 2. integrating 'intelligent' technology; and 3. weekly physician oversight to review poorly-controlled cases and make responsive treatment adjustments. We propose to take this model from research to practice using an implementation sciences approach. First, we will collect qualitative data regarding patients', families', and care providers' perceptions of disease, treatments, barriers, and elicit feedback regarding the intervention's components. Second, we will culturally tailor our intervention materials for India. Third, in 360 diabetes patients with depressive symptoms and at least one poorly-controlled CVD risk factor, we will evaluate the sustained effectiveness, expenditures, and cost-utility of our integrated model compared to usual care (notifying patients' routine providers of their depressive symptoms and poor CVD risk factor control) in a single blind, randomized controlled implementation trial at three large diabetes clinics in India over 24-months. We hypothesize that 30% of intervention arm participants compared to 15% of usual care participants will achieve combined improvements (in depression score plus at least one CVD risk factor). Finally, we have arranged to work with the Public Health Foundation of India to develop sustainable post-trial scalability (e.g., certification) and dissemination activities. Our team of US and India investigators has specific expertise and experience, five years of collaboration with colleagues in India, and is well poised to complete this work with high-quality outputs that could be beneficial for the estimated 12 million people with diabetes and depression in India.