Evaluation of a Stepped Care Approach to Manage Depression in Diabetes

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

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Recruitment Status

COMPLETED

Clinical Phase

NA

Total Enrollment

260 participants

Study Classification

INTERVENTIONAL

Study Start Date

2012-02-29

Study Completion Date

2015-11-30

Brief Summary

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The study examines the efficacy of a stepped care approach for depressed diabetes patients (first study objective). 256 patients with diabetes and comorbid subthreshold or clinical depression will be randomly assigned to either a stepped care approach or a treatment-as-usual condition. The stepped care approach consists of three treatment steps comprising diabetes-specific cognitive-behavioral therapy (CBT) (group), depression-specific CBT (single), and psychotherapeutic and/or psychiatric treatment (single). Patients assigned to the stepped care approach will be treated stepwise until a clinically significant reduction of depressive symptoms is attained or all three treatment steps are passed.

The primary outcome of the first study objective is a clinically significant reduction of depressive symptoms in the 12-month follow-up. Secondary outcomes are reduction of diabetes-related distress and improvement of well-being, health-related quality of life, diabetes acceptance, diabetes self-care, and glycaemic control. Additionally, cost-benefit analyses will be performed.

The second study objective is to analyse associations between diabetes, depression, and the serum levels of inflammatory markers.

The third study objective is to analyse the courses of depressive conditions in diabetes with regard to recovery rates and incidence of major depression.

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Detailed Description

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Compared to persons without diabetes, rates of depressive disorders and mood are doubled in diabetes patients. Epidemiologic studies have shown point prevalence rates of 10 - 14% for major depressive disorder and an additional proportion of almost 20% with subthreshold depression (defined as elevated depressive symptoms without meeting criteria for a specified clinical disorder). Depression and subthreshold depression in diabetes are associated with reduced quality of life, increased diabetes-related distress, and elevated health care costs. Furthermore, depression as well as subthreshold depression seem to be major barriers to an effective self-management of the disease and have been associated with reduced glycaemic control and hyperglycaemia. Both conditions seem to be independent prognostic factors for subsequent morbidity and mortality in diabetes.

Depressive conditions are commonly treated with psychotherapeutic or pharmacologic antidepressive therapies. Since the majority of diabetes patients is suffering from subthreshold depression, evaluated and suitable specific intervention concepts are rare. Moreover, the large variation of symptom levels of depressive patient groups suggests that different types of treatment with different treatment intensities may be required to match individual demands. The issue of 'optimal' treatment also regards concerns about overtreatment and undertreatment of particular patient groups with depressive conditions. Thus, an successive order of treatment steps of increasing intensity appears useful. Since depression in diabetes often is associated with high diabetes-related problems and distress, diabetes-specific as well as depression-specific interventions may be required.

We developed a stepped care approach with three treatment steps comprising diabetes-specific CBT (group), depression-specific CBT (single), and psychotherapeutic and/or psychiatric treatment (single).

The study is a randomized efficacy trial in which the efficacy of the stepped care approach is compared to a treatment-as-usual condition (standard diabetes education). 256 patients with diabetes and comorbid subthreshold or clinical depression will be randomly assigned to either the stepped care approach or the treatment-as-usual condition. Patients assigned to the stepped care approach will be treated stepwise until a clinically significant reduction of depressive symptoms is attained or all three treatment steps are passed.

The primary outcome is a clinically significant reduction of depressive symptoms in the 12-month follow-up. Secondary outcomes are reduction of diabetes-related distress and improvement of well-being, health-related quality of life, diabetes acceptance, diabetes self-care, and glycaemic control. The decisive measurement of this outcomes are conducted 12 months after the treatment (12 month follow up). Additionally, cost-benefit analyses will be performed.

Besides testing the efficacy of the stepped care approach (first objective), there are two additional study objectives:

The second study objective is to analyse associations between diabetes, depression, and the serum levels of inflammatory markers (C-reactive protein (CRP), Interleukin (IL)-6, IL-18, IL-1Ra, Adiponectin, Monocyte chemoattractant protein (MCP)-1). Additionally, the impact of depression treatment on the levels of these markers will be examined.

The third study objective is to analyse the courses of depressive conditions in diabetes with regard to recovery rates and incidence of major depression in subclinically or clinically depressed diabetes patients treated as usual vs. given an intervention.

Conditions

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Major Depressive Disorder Minor Depressive Disorder Sub-Threshold Depression Diabetes Mellitus

Study Design

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Allocation Method

RANDOMIZED

Intervention Model

PARALLEL

Primary Study Purpose

TREATMENT

Blinding Strategy

NONE

Study Groups

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Stepped Care Approach for Depression

Step 1: Diabetes-Specific CBT (5 group sessions)

Step 2: Depression-Specific CBT (6 single sessions)

Step 3: Referral to Psychotherapist and/or Psychiatrist

Group Type EXPERIMENTAL

Step 1: Diabetes-Specific CBT (5 group sessions)

Intervention Type BEHAVIORAL

Diabetes-Specific CBT (5 group sessions) focusing on diabetes-related problems and distress ('DIAMOS - Strengthening Diabetes Motivation').

Includes:

* Diabetes problem analysis/ definition
* Diabetes problem solving intervention
* Cognitive restructuring of diabetes problems
* Activation of personal and social resources
* Goal definition and agreement

Step 2: Depression-Specific CBT (6 single sessions)

Intervention Type BEHAVIORAL

Depression-Specific CBT (6 single sessions) focusing on depressive cognitions and affective problems (manualised).

Includes:

* Functional explanatory model of depression
* Cognitive restructuring of negative thoughts
* Practice of alternative beneficial thoughts
* Specific cognitive interventions regarding self-criticism, guilt, low self-esteem, fear, and inactivity.

Step 3: Referral to Psychotherapist and/or Psychiatrist

Intervention Type BEHAVIORAL

Non-responders to previous treatment steps will be referred to an psychotherapist and/or psychiatrist for intensified treatment. Treatments procedures will be monitored and interventions will be scored to enable the evaluation of treatment effects.

Treatment-as-usual

Standard Diabetes Education

Group Type ACTIVE_COMPARATOR

Standard Diabetes Education

Intervention Type BEHAVIORAL

Standard diabetes education and professional care.

Includes:

* Health care and specific topics (e. g. blood pressure)
* Diabetes complications
* Healthy and unhealthy foods, cooking recommendations and recipes
* Foot care: exercises, care and control, injuries, and diabetic neuropathy
* Sports, activities and exercise
* Social aspects of living with diabetes

Interventions

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Step 1: Diabetes-Specific CBT (5 group sessions)

Diabetes-Specific CBT (5 group sessions) focusing on diabetes-related problems and distress ('DIAMOS - Strengthening Diabetes Motivation').

Includes:

* Diabetes problem analysis/ definition
* Diabetes problem solving intervention
* Cognitive restructuring of diabetes problems
* Activation of personal and social resources
* Goal definition and agreement

Intervention Type BEHAVIORAL

Step 2: Depression-Specific CBT (6 single sessions)

Depression-Specific CBT (6 single sessions) focusing on depressive cognitions and affective problems (manualised).

Includes:

* Functional explanatory model of depression
* Cognitive restructuring of negative thoughts
* Practice of alternative beneficial thoughts
* Specific cognitive interventions regarding self-criticism, guilt, low self-esteem, fear, and inactivity.

Intervention Type BEHAVIORAL

Step 3: Referral to Psychotherapist and/or Psychiatrist

Non-responders to previous treatment steps will be referred to an psychotherapist and/or psychiatrist for intensified treatment. Treatments procedures will be monitored and interventions will be scored to enable the evaluation of treatment effects.

Intervention Type BEHAVIORAL

Standard Diabetes Education

Standard diabetes education and professional care.

Includes:

* Health care and specific topics (e. g. blood pressure)
* Diabetes complications
* Healthy and unhealthy foods, cooking recommendations and recipes
* Foot care: exercises, care and control, injuries, and diabetic neuropathy
* Sports, activities and exercise
* Social aspects of living with diabetes

Intervention Type BEHAVIORAL

Eligibility Criteria

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Inclusion Criteria

* Age \>=18 and \<=70
* Diabetes mellitus
* Elevated depressive symptoms (CES-D score \>=16) and/or elevated diabetes-related distress (PAID score \>=40)
* Sufficient language skills (German)
* Written informed consent

Exclusion Criteria

* Severe depressive episode (F32.2/ F32.3)
* Current psychotherapeutic/ psychiatric treatment
* Current antidepressive medication
* Suicidal intention
* Current schizophrenia/ psychotic disorder, specified eating disorder, bipolar disorder, addictive disorder, personality disorder
* Severe physical illness (i.e. cancer, multiple sclerosis, dementia)
* Terminal illness
* Bedriddenness
* Guardianship

Minimum Eligible Age

18 Years

Maximum Eligible Age

70 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No