Depression among type 2 diabetes rural Appalachian clinic attendees

In Appalachia, diabetes hits hard. Depression does, too. Together, they form a difficult pair to beat.

To help patients fight back, a team of Ohio University College of Osteopathic Medicine (OU-COM) and Ohio University researchers have put together a new approach to the double-edged problem. Program ACTIVE (Appalachians Coming Together to Increase Vital Exercise) is a two-year intervention feasibility study to test the effectiveness of a combination of exercise and talk therapy as a treatment for depression in patients with type 2 diabetes.

“Diabetes is a difficult disease,” said Mary de Groot, Ph.D., assistant professor of psychology and lead author of a paper produced by the research team. “Add depression on top of that, and it makes it that much tougher.”

Their paper, “Depression among type 2 Diabetes Rural Appalachian Clinic Attendees,” is published in the June issue of Diabetes Care, the journal of the American Diabetes Association.

The researchers point out that previously published studies have shown that depressive symptoms in diabetics are “associated with worsened blood glucose levels, diabetes complications, increased functional disability, worsened
adherence to diabetes regimen, higher ambulatory care costs, and increased mortality.”

The study looked at type 2 diabetes patients attending family medicine and endocrinology appointments in rural Appalachian counties of Southeastern Ohio and West Virginia. Of those 201 patients, 31 percent reported co-morbid diabetes and depression through completion of the Beck Depression Inventory, a self-report questionnaire assessment.

That rate is similar to the national co-morbidity rate, somewhat surprisingly low considering the relatively high rate of poverty where the patients live. For instance, Meigs County, Ohio, has a poverty rate of 19.8 percent, compared to 10.6 percent for the state of Ohio.

“My vision of it is that people in Appalachia have sort of a higher tolerance for bad things,” said Frank Schwartz, M.D., assistant professor of endocrinology at OU-COM and director of the Appalachian Rural Health Institute (ARHI) Diabetes Center.

“What is compelling is the length of episodes of depression,” said de Groot, the principal investigator. A follow-up study of the patients involved showed that 88 percent of those who had initially identified themselves as suffering from depression also did so 18 months later. Depression severity was associated with younger age, unemployment and a greater number of prescribed medications. These findings are consistent with those observed in urban samples.

“Part of the significance of the paper is that it helps put rural Appalachia on the map in terms of depression and diabetes,” de Groot said.

According to Schwartz, in research conducted by the ARHI Diabetes Center, Appalachia has a diabetes prevalence rate of 11.3 percent — well above the 7.6 percent national rate.

De Groot and her colleagues encourage doctors to screen their diabetic patients for depression. People with diabetes are twice as likely to have an experience with depression as those without diabetes.

For patients, de Groot said, it is vital to share feelings and mood symptoms with their doctors. It's important, too, to know that talk therapy has been shown to be effective in treating depression in type 2 diabetes, she said, and that antidepressant medications have been effective in treating depression in people with type 1 and type 2 diabetes.

Program ACTIVE is the researchers' way of doing something about the situation.

To meet the depression criterion for Program ACTIVE, patients must have felt consistently depressed or down for most of the day nearly every day for two weeks or longer. Associated symptoms people experience are:

• a significant decrease in interest in activities they would ordinarily enjoy;
• changes in sleep;
• changes in appetite;
• weight loss or gain;
• difficulty with concentration;
• feelings of worthlessness;
• and significantly decreased energy.

Program ACTIVE, which is funded by the National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK), combines 12 weeks of exercise with 10 sessions of talk therapy for patients with type 2 diabetes and depression for two weeks or longer. The aim is to assess improvements made during the program in depression, diabetes and cardiovascular risk factors.

Participants have free access to the workout facilities at the Athens Community Center, which is one of the program's community partners, as are
University Medical Associates, Family Health Care Inc. and Holzer Clinic in Athens. Talk therapy, or cognitive behavioral therapy, sessions are conducted in Athens.

Thus far, six people have completed the program, and plans call for that total to reach 50 over the next year. To participate, call (740) 597-2584 or (888) 771-0002.

“If we can show effective intervention, this will become a program that is implemented in many high-risk environments,” Schwartz said.

Schwartz and his colleague at the Cornwell Center for Cardiovascular and Diabetes Care in Athens, Jay Shubrook, D.O., assistant professor of family medicine at OU-COM, are co-investigators in Program ACTIVE, as is Michael Kushnick, Ph.D., exercise physiologist with Ohio University's Department of Recreation and Sports Sciences.

The team received funding for its initial study from the Ohio University Diabetes Research Initiative (DRI), and the NIDDK. Ohio University's DRI funded the 18-month follow-up study.

In addition to de Groot, Schwartz and Shubrook, co-authors of the paper are Robert Gotfried, D.O.; Brenda Pinkerman, Ph.D., who earned a doctorate in clinical psychology from Ohio University; and graduate students Todd Doyle, Erin Hockman and Charles Wheeler.

The mission of Ohio University College of Osteopathic Medicine is innovative learning, focused research and compassionate care for Ohio and beyond. Each year more than 100 osteopathic physicians graduate from OU-COM, Ohio's only college of osteopathic medicine. Fifty-four percent of OU-COM alumni practice in primary care fields, and more than 60 percent of its graduates remain in Ohio, where they are more likely to practice in rural and other physician-shortage areas.

http://www.oucom.ohiou.edu/