Integrated Care for Co-morbid Depression and Diabetes in India

描述(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)是印度和全球主要的健康和经济负担。抑郁症和糖尿病通常并存，相互作用，当它们控制不佳时，会增加致残并发症、生活质量下降和死亡的风险。印度6100万糖尿病患者中有20%患有抑郁症，数据显示，在超过60%的糖尿病患者中，抑郁症和心血管疾病风险因素没有得到充分治疗。患者层面(例如，对治疗的依从性较低)、提供者层面(例如，强化治疗方面的不足)和系统层面的因素(例如，人力资源限制和缺乏管理慢性病的系统)是更好地控制这些疾病的常见障碍。我们的团队已经证明，同时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寻求专科医生(政府或私人)来满足他们的糖尿病和其他医疗保健需求，他们至少与医疗系统有一个联系点，可以利用这一点也改善抑郁症的护理。此外，只需进行适度的修改，就可以将抑郁症的干预措施整合到常规的糖尿病护理服务中。我们的综合多病症(抑郁症和糖尿病)干预模式融合了TeamCare和印度正在进行的心血管疾病风险降低试验(CARRS试验)的经验，涉及：1.加强护士的作用并培训她们进行疾病管理；2.整合“智能”技术；以及3.每周医生监督，以审查控制不佳的病例并做出响应的治疗调整。我们建议使用实施科学的方法将这一模式从研究转化为实践。首先，我们将收集有关患者、家属和护理的定性数据 提供者对疾病、治疗、障碍的看法，并获得关于干预组成部分的反馈。其次，我们将在文化上为印度量身定做干预材料。第三，在360名有抑郁症状和至少一个心血管疾病风险因素控制不佳的糖尿病患者中，我们将在印度三家大型糖尿病诊所进行为期24个月的单盲随机对照实施试验，与常规护理(向患者的常规提供者通知他们的抑郁症状和糟糕的心血管疾病风险因素控制)相比，评估我们综合模式的持续有效性、支出和成本效益。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心血管疾病风险因素)。最后，我们已安排与印度公共卫生基金会合作，制定可持续的试验后可伸缩性(例如，认证)和传播活动。我们的美国和印度调查团队拥有特定的专业知识和经验，与印度的同事合作了五年，并已做好准备，以高质量的结果完成这项工作，这可能会使印度约1200万糖尿病和抑郁症患者受益。

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.