Depression Remission, Receipt of Problem-Solving Therapy, and Self-Care Behavior Frequency Among Low-Income, Predominantly Hispanic Diabetes Patients

PURPOSE: Adding to higher prevalence of diabetes, low-income Hispanic patients with diabetes show suboptimal self-care behaviors and diabetes progression. It is proposed that comorbid depression is one of culprits that may undermine motivation to engage in self-care behaviors. This association may be attributable to feelings of hopelessness or lack of interest observed among patients with depression. Thus, we have proposed that depression remission may lead to better self-care behaviors for diabetes. However, evidence is very limited. For example, few randomized clinical trials (RCTs) could demonstrate significantly increased self-care behaviors of intervention groups, which showed significant drop of depressive symptoms. The indirect evidence needs more sophisticated analysis. Therefore, we conducted regression analyses, controlling for confounders, to examine correlation between depression remission, which was observed in a RCT, and self-care behavior frequency change. Also, problem-solving therapy (PST) for diabetes patients was aimed at identifying emotional distress associated with diabetes self-care management in an effort to reduce the emotional distress and improve the self-care management. We also examined the effect of PST on self-care behaviors, together with depression remission.

METHODS: we used data collected from a RCT (N=387) that tested collaborative depression care. Longitudinal data collections were conducted at baseline (T1) and at subsequent follow-ups: 6 months (T2), 12 months (T3), 18 months (T4), and 24 months (T5) post-baseline. The Patient Health Questionnaire-9 (PHQ-9) and the Hopkins Symptom Checklist-20 (SCL-20) were used to define depression remission in that they are used as gold standard in RCTs testing depression treatment. A bilingual social worker provided PST sessions between 8 and 12 times and provided data of PST receipt. Lastly, the Summary of Diabetes Self-Care Activities (SDSCA) was used, which documented weekly frequency of the following behaviors: healthy diet, exercise, self-blood glucose monitoring (SBGM), and foot care. Controlling for possible demographic and clinical confounders, multivariate regression was used to examine associations between depression remission at T3, PST receipt reported at T3, and frequency of each self-care behavior change between baseline and 12 (N = 281: T3-T1), 18 (N = 249: T4-T1)), and 24 (N = 235: T5-T1) months.

RESULTS: In models with PHQ-9, depression remission was positively associated with diet (T3-T1) (p<.05) and exercise (T3-T1) (p<.05). In models with SCL-20, depression remission was positively associated with all behaviors in cross-sectional models (T3-T1): diet (p<.01), exercise (p<.01), SBGM (p<.001), foot care (p<.001). With respect to predictive models, SCL-20’s depression remission was associated with diet (T4-T1) (p<.01), and exercise (p<.05) (T-5-T1). PST receipt was not significantly associated with self-care behaviors.

IMPLICATIONS: Overall, inconsistent relationships were observed depending on depression measurement (PHQ-9 vs. SCL-20), type of self-care behaviors, and time when self-care behavior was measured (cross-sectional vs. predictive model). Significant associations were more likely to be observed in cross-sectional analyses and models regressed on diet and exercise. We believe that depression remission or the receipt of PST may not be reliable antecedents of enhanced self-care behaviors. Integrating patient self-care management within PST depression treatment is recommended in order to meet low-income patient’s unmet needs for successful diabetes management.