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Behavioral Activation Therapy for Rural Veterans with Diabetes and Depression
Aanand Dinkar Naik, MD BA
Michael E. DeBakey VA Medical Center, Houston, TX
Jeffrey Cully PhD MEd
Michael E. DeBakey VA Medical Center, Houston, TX
Funding Period: April 2012 - September 2016
The co-occurrence of diabetes and depressive symptoms is highly prevalent and has dramatic consequences on the quality of life and health of affected patients. Due to the complex interrelation between these conditions, patients often experience both psychological and physiological difficulties. Furthermore, veterans with diabetes and depressive symptoms in rural settings have limited access to care. Interventions that reach veterans in rural / community-based primary care are needed, especially those that blend treatment strategies for physical and emotional health.
The specific objective of this study was to compare the effectiveness of the Healthy Outcomes through Patient Empowerment (HOPE) intervention to enhanced usual care (EUC) on diabetes (HbA1c) and depression (PHQ-9) outcomes at 6 and 12 month follow-up. The exploratory aims of the project included: 1) The examination of the role of moderators and mediators on intervention effectiveness; 2) the evaluation of factors that mediate or moderate effectiveness at 6 and 12 months for patients enrolled in the HOPE intervention arm; and, 3) The evaluation of the potential for embedding the HOPE intervention processes within a VA CBOC using the RE-AIM framework for evaluating effectiveness of behavioral interventions.
The HOPE study is a randomized controlled trial. We enrolled 225 Veterans from the Michael E. DeBakey VA Medical Center and surrounding community-based outpatient clinics with uncontrolled diabetes and clinically-significant depressive symptoms. One hundred thirty-six Veterans were randomized to the HOPE Intervention and 89 to Enhanced Usual Care (EUC). Eligible, veterans lived 20 miles or more from the tertiary center where they are treated or receive their primary care through one of the surrounding VA community-based clinics. Veterans had an HbA1c level above 7.5 in the last 12 months and achieved a score of 10 or greater on the PHQ-9 scale administered by the study staff. Veterans randomized to both groups received screening, education, and notification of clinical findings along with follow-up in usual primary care. Participants randomized to HOPE also received behavioral coaching telephone sessions over a six month period. Coaches used a standardized, theory-based process for conducting the sessions with the aim of creating patient-centered and articulated goals and behavioral action plans. Hemoglobin A1c and PHQ-9 measurements along with self-report questionnaires were collected at baseline, 6 and 12 months follow-up. Changes in measurements from baseline were compared between groups.
The proposed hypotheses for the study were: 1. that after 6 months (active treatment phase), HOPE will produce greater improvements in diabetes control (measured by hemoglobin A1c levels) and depression (measured by PHQ-9 scores) than will EUC. 2. that at 12 months (6-month active phase plus 6-month maintenance phase), HOPE participants will continue to evidence significantly greater improvements in HbA1c and PHQ-9 compared with EUC participants.
Preliminary Analyses for the primary outcomes demonstrated small intervention effect sizes for change in depression (PHQ-9) of d=0.34 and diabetes-related QoL (PAID) of d=0.32; and no intervention effect for change in glycemic control (HbA1c) with d=0.06. PHQ-9 and HbA1c values did reach levels of minimally clinically significant change in the intervention group at 12-month follow-up (PHQ-9: from 15.8 +/- 4.2 to 10.1 +/- 6.9; HbA1c: 9.2 +/-1.4 to 8.7 +/-1.6); but these changes were not statistically significant compared to the usual care group in a time by treatment analyses: PHQ-9 (p=.10) and HbA1c (p=.74).
In each main area assessed, Veterans in the HOPE group had improvements in their depression symptoms (PHQ-9 change 5.7), glycemic control (A1c change 0.5), and diabetes distress (PAID change 17.4) but these changes were not statistically significant compared with the enhanced usual care group in our Intent to Treat Analyses. We are proceeding with additional analyses to explore treatment dose effects and other "treatment as received" analyses to determine if certain patients experience greater treatment related effects than others.
The HOPE Project demonstrated modest benefits on depression symptoms and diabetes related QoL for Veteran participants one-year after enrollment. There was no treatment benefits at one-year follow-up for glycemic control (HbA1c). Furthermore, the changes from 6 to 12 months were stable or even improved in the intervention group compared to some regression among usual care participants for the main outcomes.
The results of the study were not as robust as anticipated overall when comparing the HOPE intervention to enhanced usual care. Additional analyses are planned to identify characteristics of patients and potential dose-response effects that may be associated with higher likelihood of benefit from enrollment in the HOPE intervention. If present, the HOPE intervention could be targeted to this more selective at-risk population.
External Links for this Project
NIH ReporterGrant Number: I01HX000486-01A2
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DRA: Diabetes and Other Endocrine Disorders, Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Comparative Effectiveness, Treatment - Efficacy/Effectiveness Clinical Trial
MeSH Terms: none