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）是印度和全球主要的健康和经济负担。抑郁症和糖尿病通常共存，相互作用，如果控制不当，会加重致残并发症、生活质量降低和死亡率的风险。印度6100万糖尿病患者中有20%患有抑郁症，数据表明，60%以上的糖尿病患者的抑郁症和心血管疾病风险因素未得到充分治疗。许多患者层面（例如，治疗依从性低）、提供者层面（例如，治疗强化不足）和系统层面因素（例如，人力资源限制和缺乏慢性病管理系统）是实现更好地控制这些疾病的常见障碍。我们的团队已经表明，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通过专家（政府或私人）来解决他们的糖尿病和其他医疗保健需求，他们至少有一个与卫生系统的接触点，可以利用这一点来改善抑郁症的治疗。此外，对抑郁症的干预可以纳入常规糖尿病护理，只需稍加修改。我们的综合多条件（抑郁症和糖尿病）干预模型结合了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。加强护士的作用并对她们进行疾病管理方面的培训；2. 集成“智能”技术；和3。每周进行医生监督，审查控制不良的病例，并作出相应的治疗调整。我们建议使用实施科学方法将该模型从研究应用到实践。首先，我们将收集有关患者、家属和护理的定性数据

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.