Reducing Dirstress and Improving Self-Care in Diabetes

糖尿病影响着650万至1300万美国人，每年的直接医疗保健费用超过440亿美元。少数族裔（非洲人、亚洲人和美洲土著人、西班牙裔）的发病率大约是非西班牙裔白人的两倍。糖尿病非健康工作者中有20%~ 25%的人同时患有抑郁和抑郁加重（D/D），但少数民族的比例明显高于其他民族。D/D与自我护理行为减少、代谢控制不良、并发症风险增加和医疗费用增加有关。到目前为止，还没有对糖尿病患者的D/D进行全面、长期的研究，并且在大多数患者接受护理的初级保健环境中，针对D/D和糖尿病的实用、循证干预措施很少。考虑到D/D的普遍性以及D/D对这些患者造成的增加的行为和生物风险，这种竞争性更新应用（1）扩展了对D/D之间相互关系的观察，自我护理和代谢控制与我们现有的3波纵向队列从18至42个月，以评估这些过程对心血管和其他糖尿病相关的生物行为终点的长期影响（这将是迄今为止规模最大、时间最长的此类研究）;（2）收集关于这些患者中D/D的主观经历模式、原因和影响的详细定性数据;（3）利用所有这些研究结果，改进并有选择地联合收割机结合两种现有的循证干预措施（自动化的、糖尿病专用的自我护理程序与自我护理程序加现场解决问题的减轻痛苦程序与增强的日常护理）转化为实用的，3组临床试验，采用新的、高度痛苦的、多种族的患者样本;（4）使用RE-AIM框架评估干预措施，通过全面的传播包分享结果。该研究对临床护理具有重要意义：它将（1）描述D/D、自我护理和代谢控制之间关系的机制和亚组模式及其对主要长期糖尿病相关结局的影响;（2）描述D/D对不同患者样本中糖尿病的各种影响（种族，年龄，性别）;（3）在随机对照试验中测试一个实际的，以证据为基础的干预措施，专门针对D/D与一个单独解决自我保健的叠加效应;（4）开发一个全面的实用干预材料包，用于初级保健。描述：经历高水平D/D的糖尿病患者发生严重疾病结局的风险增加。拟议的研究将把D/D、自我护理和代谢控制随时间的研究从18个月扩展到42个月，以确定它们对长期心血管和其他糖尿病相关终点的影响;将提供有关患者随时间推移的D/D个人经历的有价值的主观信息;并将测试和传播两个初级保健为基础的干预措施，解决自我保健和D/D在不同的病人样本的结果。

DESCRIPTION (provided by applicant): Diabetes affects between 6.5 and 13 million Americans and is associated with an expenditure of over $44 billion in direct health care costs per year. Prevalence rates for ethnic minorities (African, Asian and Native American, Hispanic) are approximately twice that of non Hispanic Whites (NHW). Depression and elevated distress (D/D) occur as co-morbid conditions in 20% -25% of NHWs with diabetes, but the rates are significantly higher among ethnic minorities. D/D is associated with decreased self-care behavior, poor metabolic control, increased risk for complications, and higher health-care costs. To date, there have been no comprehensive, long-term studies of D/D among patients with diabetes and there have been few practical, evidenced-based interventions that are directed at D/D and diabetes in primary care settings, where most patients receive care. Given the pervasiveness of D/D and the increased behavioral and biological risk that D/D poses for these patients, this competing renewal application (1) expand observation of the interrelationships among D/D, self-care and metabolic control with our existing 3-wave longitudinal cohort from 18 to 42 months to assess the longer term impact of these processes on cardiovascular and other diabetes-related bio-behavioral endpoints (this will be the largest and longest such study to date); (2) gather detailed qualitative data on the subjectively experienced patterns, causes and effects of D/D among these patients; (3) use all of these findings to refine and selectively combine two existing, evidenced-based, interventions (an automated, diabetes-specific self-care program vs. a self-care program plus a live problem solving distress-reduction program vs. enhanced usual care) into a practical, 3-arm clinical trial with a new, highly distressed, multi-ethnic patient sample; and (4) evaluate the intervention using the RE-AIM framework, sharing the results through a comprehensive dissemination package. The proposed research has major implications for clinical care: it will (1) describe the mechanisms and sub group patterns of relationships among D/D, self-care, and metabolic control and their effects on major longer-term diabetes-related outcomes; (2) describe the variety of effects of D/D on diabetes in a diverse patient sample (ethnicity, age, gender); (3) test in an RCT the additive effect of a practical, evidenced-based intervention that specifically targets D/D vs. one that addresses self-care alone; and (4) develop a comprehensive package of practical intervention materials for use in primary care. DESCRIPTION: People with diabetes who experience high levels of D/D are at increased risk for serious disease outcomes. The proposed research will expand the study of D/D, self-care and metabolic control over time from 18 to 42 months to determine their effects on longer-term cardiovascular and other diabetes-related endpoints; will provide valuable subjective information on patients' personal experience of D/D over time; and will test and disseminate the results of two primary care-based interventions that address self-care and D/D in a diverse patient sample.