Integrated Care for Co-morbid Depression and Diabetes in India

描述（由申请人提供）：抑郁症和心脏代谢疾病，如糖尿病和心血管疾病（CVD）是印度和全球的主要健康和经济负担。抑郁症和糖尿病通常共存，不利地相互作用，并且当它们控制不良时，使致残并发症、生活质量降低和死亡率的风险复合。印度6100万糖尿病患者中有20%患有抑郁症，数据显示，超过60%的糖尿病患者的抑郁症和心血管疾病风险因素治疗不足。许多患者水平（例如，对治疗的依从性低），提供者水平（例如，治疗强化的不足），以及系统水平的因素（例如，人力资源限制和缺乏慢性病管理系统）是更好地控制这些疾病的常见障碍。我们的团队已经证明，针对抑郁症和糖尿病控制具有重要的协同效益（TEAMCare研究）。由于印度的糖尿病患者倾向于接触专家（政府或私人）以满足他们的糖尿病和其他医疗保健需求，他们至少与卫生系统有一个联系点，可以利用这个联系点来改善抑郁症护理。此外，抑郁症的干预措施可以整合到常规的糖尿病护理服务中，只需进行适度的修改。我们的综合多条件（抑郁症和糖尿病）干预模型融合了TEAMCare的经验和印度正在进行的降低心血管疾病风险的试验（CARRS试验），包括：1。加强护士在疾病管理方面的角色及培训; 2.融合“智能”技术; 3.每周医生监督审查控制不良的病例，并做出相应的治疗调整。我们建议采取这种模式从研究到实践，采用实施科学的方法。首先，我们将收集有关患者、家庭和护理的定性数据 提供者对疾病，治疗，障碍的看法，并就干预的组成部分征求反馈。第二，我们将在文化上为印度量身定制我们的干预材料。第三，在360名有抑郁症状和至少一个控制不良的心血管疾病危险因素的糖尿病患者中，我们将评估与常规护理相比，我们的综合模式的持续有效性、支出和成本效用（通知患者的常规提供者他们的抑郁症状和心血管疾病风险因素控制不良），在印度的三个大型糖尿病诊所进行了为期24个月的随机对照实施试验。我们假设30%的干预组参与者与15%的常规护理参与者相比将实现综合改善（抑郁评分加上至少一个CVD风险因素）。最后，我们已安排与印度公共卫生基金会合作，开发可持续的试验后可扩展性（例如，认证）和传播活动。我们的美国和印度研究人员团队拥有特定的专业知识和经验，与印度同事合作了五年，并已准备好完成这项工作，并提供高质量的产出，这可能有利于印度约1200万糖尿病和抑郁症患者。

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.