Reducing Dirstress and Improving Self-Care in Diabetes

描述（由申请人提供）：糖尿病影响650万至1300万美国人，每年直接医疗保健费用支出超过440亿美元。少数民族（非洲人、亚洲人和美洲原住民、西班牙裔）的患病率大约是非西班牙裔白人的两倍（NHW）。20% -25%的nhw糖尿病患者伴有抑郁和抑郁加重（D/D），但少数民族患者的比例明显更高。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保健费用增加有关。迄今为止，还没有针对糖尿病患者D/D的全面、长期研究，而且在大多数患者接受护理的初级保健机构中，针对D/D和糖尿病的实际、基于证据的干预措施也很少。鉴于D/D的普遍性以及D/D给这些患者带来的行为和生物学风险的增加，这项竞争更新应用(1)扩大了对D/D、自我保健和代谢控制之间相互关系的观察，我们现有的3波纵向队列从18个月到42个月，以评估这些过程对心血管和其他糖尿病相关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)收集这些患者主观经历的D/D模式、原因和影响的详细定性数据；(3)利用所有这些发现来完善和选择性地结合两种现有的、基于证据的干预措施（一种自动化的、糖尿病特定的自我保健计划vs.一种自我保健计划加一个现场解决问题的减轻痛苦计划vs.增强的常规护理），以一种新的、高度痛苦的、多种族的患者为样本，进行一项实际的、三组临床试验；(4)使用RE-AIM框架评估干预措施，通过综合传播包分享结果。该研究对临床护理具有重要意义：它将(1)描述D/D、自我保健和代谢控制之间关系的机制和亚群模式及其对主要长期糖尿病相关结局的影响；(2)描述D/D在不同患者样本（种族、年龄、性别）中对糖尿病的各种影响；(3)在随机对照试验中检验专门针对D/D的实用的、基于证据的干预措施与仅针对自我保健的干预措施的加性效应；(4)开发一套用于初级保健的综合实用干预材料。糖尿病患者经历高水平的D/D会增加严重疾病结局的风险。拟议的研究将扩大D/D、自我保健和代谢控制的研究，从18个月到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；将为患者长期的D/D个人经历提供有价值的主观信息；并将测试和传播两项以初级保健为基础的干预措施的结果，这些干预措施将在不同的患者样本中解决自我保健和D/D问题。

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.