Is combined treatment key?

Gary Riggins was a big guy with bad  knees and out-of-control diabetes when he had a heart attack. His health  problems seemed overwhelming before he joined Group Health's TEAMcare study.  After getting treatment for depression and learning to control his blood  glucose levels, he's taking charge of his health.

The 58-year-old from Port Orchard  credits his TEAMcare nurse care manager, Sue Ruedebusch RN, for coaching him with  one-step-at-a-time goals that have added up to a healthier new life.

Ms. Ruedebusch also helped him to  understand that depression treatment could help him overcome many obstacles to  controlling his diabetes.

Mr. Riggins's experience  illustrates an enormous challenge. Most U.S. health care costs go to caring  for the 133 million Americans with chronic conditions, a number that's rising.  Almost half have at least two chronic illnesses. One of those chronic illnesses  is often depression, which can hinder a person’s ability to manage... everything.

"Depression can magnify the effects  of diabetes on the body, mind, and behaviors," explains Elizabeth Lin, MD, MPH,  a TEAMcare researcher and Group Health family physician. "It can make the body  produce more cortisol and adrenaline, or cause more inflammation resulting in  clogging of the arteries. It can make you feel helpless and hopeless, in turn  decreasing motivation to take better care of your health."

"This study is the culmination of  more than 25 years of collaboration by the UW and Group Health to improve care  for patients with chronic diseases including depression," says Wayne Katon, MD.  He is the vice-chair of Psychiatry and Behavioral Sciences at the UW and  principal investigator of the TEAMcare study, funded by the National Institute  of Mental Health.

Typical medical practice is not  organized to combine care for depression and other chronic disease, explains  Michael Von Korff, ScD, a GHRI senior scientist and co-principal investigator  in this study, which enrolled 214 patients from 2007 to 2009.

TEAMcare gives patients with  depression and other chronic illnesses a care manager, like Ms. Ruedebusch, to  see and call them often and coordinate treatment with others on the patient's  care team. This role is vital to the changes that Drs. Katon, Lin, and Von Korff  believe could cost-effectively revolutionize help for patients with multiple  conditions. The care manager monitors patients' mental and physical health  often, adjusting medication to reach specific goals. The care manager helps the  patient choose realistic goals—for instance, to reduce their blood glucose  level, a common goal in diabetes.

"Patients sometimes have a broken  record in their brain, telling them 'I can't do anything' about my diabetes,"  Lin says. The care manager concentrates on one-step-at-a-time goals that the  patient has chosen, a process called "treat to target" in the study lingo.

"Treat-to-target goals help  patients to focus on achievable goals, overcoming their sense of hopelessness,"  Dr. Von Korff says.

The study's initial data analyses  show significant progress in lowering patients' blood pressure, glucose, and  cholesterol levels—and improving depression outcomes.

"When a patient-centered program  addresses both physical and mental problems, patients can work with their  doctors to get chronic illness and depression under control," Dr. Lin adds. "So  they can enjoy the activities that make their life worth living."