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Cited by 143Diabetes Management and EducationChronic Disease Management StrategiesMental Health Treatment and Access

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Effect of a Collaborative Care Model on Depressive Symptoms and Glycated Hemoglobin, Blood Pressure, and Serum Cholesterol Among Patients With Depression and Diabetes in India: The INDEPENDENT Randomized Clinical Trial

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Ali, Mohammed K., Chwastiak, Lydia, Poongothai, Subramani, Emmert-Fees, Karl M. F., Patel, Shivani A., Anjana, Ranjit Mohan, Sagar, Rajesh, Shankar, Radha, Sridhar, Gumpeny R., Kosuri, Madhu, Sosale, Aravind R., Sosale, Bhavana, Rao, Deepa, Tandon, Nikhil, Narayan, K. M. Venkat, Mohan, Viswanathan, for the INDEPENDENT Study Group·2020·JAMA
DOI 10.1001/jama.2020.11747PMC PMC7435347
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Abstract

Importance: Mental health comorbidities are increasing worldwide and worsen outcomes for people with diabetes, especially when care is fragmented. Objective: To assess whether collaborative care vs usual care lowers depressive symptoms and improves cardiometabolic indices among adults with diabetes and depression. Design, Setting, and Participants: Parallel, open-label, pragmatic randomized clinical trial conducted at 4 socioeconomically diverse clinics in India that recruited patients with type 2 diabetes; a Patient Health Questionnaire-9 score of at least 10 (range, 0-27); and hemoglobin A1c (HbA1c) of at least 8%, systolic blood pressure (SBP) of at least 140 mm Hg, or low-density lipoprotein (LDL) cholesterol of at least 130 mg/dL. The first patient was enrolled on March 9, 2015, and the last was enrolled on May 31, 2016; the final follow-up visit was July 14, 2018. Interventions: Patients randomized to the intervention group (n = 196) received 12 months of self-management support from nonphysician care coordinators, decision support electronic health records facilitating physician treatment adjustments, and specialist case reviews; they were followed up for an additional 12 months without intervention. Patients in the control group (n = 208) received usual care over 24 months. Main Outcomes and Measures: The primary outcome was the between-group difference in the percentage of patients at 24 months who had at least a 50% reduction in Symptom Checklist Depression Scale (SCL-20) scores (range, 0-4; higher scores indicate worse symptoms) and a reduction of at least 0.5 percentage points in HbA1c, 5 mm Hg in SBP, or 10 mg/dL in LDL cholesterol. Prespecified secondary outcomes were percentage of patients at 12 and 24 months who met treatment targets (HbA1c <7.0%, SBP <130 mm Hg, LDL cholesterol <100 mg/dL [<70 mg/dL if prior cardiovascular disease]) or had improvements in individual outcomes (≥50% reduction in SCL-20 score, ≥0.5-percentage point reduction in HbA1c, ≥5-mm Hg reduction in SBP, ≥10-mg/dL reduction in LDL cholesterol); percentage of patients who met all HbA1c, SBP, and LDL cholesterol targets; and mean reductions in SCL-20 score, Patient Health Questionnaire-9 score, HbA1c, SBP, and LDL cholesterol. Results: Among 404 patients randomized (mean [SD] age, 53 [8.6] years; 165 [40.8%] men), 378 (93.5%) completed the trial. A significantly greater percentage of patients in the intervention group vs the usual care group met the primary outcome (71.6% vs 57.4%; risk difference, 16.9% [95% CI, 8.5%-25.2%]). Of 16 prespecified secondary outcomes, there were no statistically significant between-group differences in improvements in 10 outcomes at 12 months and in 13 outcomes at 24 months. Serious adverse events in the intervention and usual care groups included cardiovascular events or hospitalizations (4 [2.0%] vs 7 [3.4%]), stroke (0 vs 3 [1.4%]), death (2 [1.0%] vs 7 [3.4%]), and severe hypoglycemia (8 [4.1%] vs 0). Conclusions and Relevance: Among patients with diabetes and depression in India, a 12-month collaborative care intervention, compared with usual care, resulted in statistically significant improvements in a composite measure of depressive symptoms and cardiometabolic indices at 24 months. Further research is needed to understand the generalizability of the findings to other low- and middle-income health care settings. Trial Registration: ClinicalTrials.gov Identifier: NCT02022111.

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  1. World Health Organization; Calouste Gulbenkian Foundation. Integrating the Response to Mental Disorders and Other Chronic Diseases in Health Care Systems. World Health Organization; 2014:6-50.

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Metadata

Authors
Ali, M. K., Chwastiak, L., Poongothai, S., Emmert-Fees, K. M. F., Patel, S. A., Anjana, R. M., Sagar, R., Shankar, R., Sridhar, G. R., Kosuri, M., Sosale, A. R., Sosale, B., Rao, D., Tandon, N., Narayan, K. M. V., Mohan, V., & for the INDEPENDENT Study Group
Affiliations
  • Emory University (US)
  • University of Washington (US)
  • Madras Diabetes Research Foundation (IN)
  • All India Institute of Medical Sciences (IN)
  • Endocrine and Diabetes Centre, Visakhapatnam, India
  • Andhra University (IN)
  • Diacon Hospital (IN)
Corresponding author
Ali, Mohammed K.
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2020-08-18
Volume
324
Issue
7
Pages
651
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2020.11747
PMC
PMC7435347
OpenAlex
W3064750188
Cited by
143
References
40
Citations by year
2026: 18 · 2025: 18 · 2024: 30 · 2023: 23 · 2022: 37 · 2021: 14 · 2020: 3
FWCI
14.52
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • mediaTUM – the media and publications repository of the Technical University Munich (Technical University Munich) (submittedVersion)
  • Site cant be reached (submittedVersion)
  • PuSH - Publication Server of Helmholtz Zentrum München (submittedVersion)
Funders
National Institute of Mental Health (R01MH100390)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
  • Health Sciences › Medicine › Epidemiology › Chronic Disease Management Strategies
  • Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
Keywords
collaborative care, depression, type 2 diabetes, HbA1c, blood pressure, LDL cholesterol, cardiometabolic outcomes, self-management support, care coordinators, electronic health records, decision support, psychiatric comorbidity, India, treatment goals, glycemic control, hypertension, dyslipidemia, usual care comparison
MeSH terms
Self-Management, Adult, Aged, Blood Pressure, Cooperative Behavior, Depression, Developing Countries, Diabetes Mellitus, Type 2, Female, Glycated Hemoglobin, Humans, India, Cholesterol, LDL, Male, Middle Aged, Patient Care Team, Socioeconomic Factors

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