Collaborative care compared to enhanced standard treatment of depression with co-morbid medical conditions among patients from rural South India: a cluster randomized controlled trial (HOPE Study)

BACKGROUND

Depression is common among primary care patients in LMIC but treatments are largely ineffective. In this cluster-randomized controlled trial, we tested whether depression outcomes are different among recipients of a collaborative care model compared to enhanced standard treatment in patients with co-morbid chronic medical conditions.

METHODS

We conducted a cluster randomized controlled trial among participants 30 years or older seeking care at 49 primary health centers (PHCs) in rural Karnataka, diagnosed with major depressive disorder, dysthymia, generalized anxiety disorder, or panic disorder on the MINI-International Neuropsychiatric Interview plus either hypertension, diabetes, or ischemic heart disease. From a list of all PHCs in the district, 24 PHCs were randomized a priori to deliver collaborative care and 25 PHCs enhanced standard treatment. The collaborative care model consisted of a clinic-based and a community-based component. Study assessment staff was blinded to treatment arm allocation. The primary outcome was the individual-level PHQ-9 score over time.

RESULTS

Between May 2015 and Nov 2018, 2486 participants were enrolled, 1264 in the control arm, and 1222 in the intervention arm. They were assessed at baseline, 3, 6 and 12 months. The mean PHQ-9 depression score was around 8.5 at baseline. At each follow-up PHQ-9 scores were significantly lower in the intervention (5.24, 4.81 and 4.22 at respective follow-ups) than in the control group (6.69, 6.13, 5.23, respectively). A significant time-by-treatment interaction (p < 0.001) in a multi-level model over all waves, nested within individuals who were nested within PHCs, confirmed that the decrease in depression score from baseline was larger for collaborative care than enhanced standard care throughout follow-up.

CONCLUSIONS

The collaborative care intervention resulted in significantly lower depression scores compared to enhanced standard care among participants with co-morbid physical conditions. The findings have potential implications for integrating mental health and chronic disease treatment in resource constrained settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02310932 , registered on December 8, 2014, and Clinical Trials Registry India CTRI/2018/04/013001 , registered on April 4, 2018. Retrospectively registered.

Risk factors for severity of depression in participants with chronic medical conditions in rural primary health care settings in India

Background

Depression and chronic medical disorders are strongly linked. There are limited studies addressing the correlates of the severity of depression in patients with co-morbid disorders in primary care settings. This study aimed to identify the socio-demographic and disease-specific risk factors associated with the severity of depression at baseline among patients participating in a randomized controlled trial (HOPE study).

Methods

Participants were part of a randomized controlled trial in 49 primary care health centers in rural India. We included adults (≥ 30 years) with at least mild Depression or Anxiety Disorder and at least one Cardiovascular disorder or Type 2 Diabetes mellitus. They were assessed for the severity of depression using the PHQ-9, severity of anxiety, social support, number of co-morbid chronic medical illnesses, anthropometric measurements, HbA1c, and lipid profile.

Results

Proportionately there were more women in the moderate category of depression than men. Ordinal logistic regression showed co-morbid anxiety and a lower level of education significantly increased the odds of more severe depression, while more social support was significantly negatively associated with depression severity in women. In men, anxiety was positively associated with greater depression severity; while reporting more social support was negatively associated with depression.

Limitations

This is a cross-sectional study and thus, no causal conclusions are possible.

Conclusions

Anxiety and poor social support in both genders and lower educational levels in women were associated with increased severity of depression. Early identification of risk factors and appropriate treatment at a primary care setting may help in reducing the morbidity and mortality associated with depression.

Do SADQ and AUDIT identify independent impacts of alcohol abuse - clinical and biochemical markers respectively?

BACKGROUND AND OBJECTIVES

We have analyzed extant data to see if Alcohol Use Disorder Identification Test (AUDIT) and Severity of Alcohol Dependence Questionnaire (SADQ) assess overlapping aspects of alcoholism, and how they relate to lab measures of alcoholism.

MATERIALS AND METHODS

Consecutive male patients between 20 and 50 years were recruited from varied departments of a general hospital. AUDIT and SADQ, as well as liver function tests, were part of the data obtained.

RESULTS

Despite, a significant correlation between total scores of SADQ and AUDIT (ρ = 0.188, P < 0.021) and some of their sub-scores. SADQ scores alone were significantly correlating with clinical variables of alcoholism such as family history and age of onset; AUDIT did not. On the other hand, AUDIT total scores correlated with total and conjugated bilirubin, while SADQ did not.

INTERPRETATION AND CONCLUSION

Our data suggests that the two scales, AUDIT and SADQ may be tapping into two different outcomes of increased alcohol use namely clinical and biochemical markers, respectively. SADQ could be useful in studies looking at withdrawal related severity and clinical aspects of alcoholism; while AUDIT could be more suitable for studies looking at alcoholism-related medical morbidity. This needs to be confirmed in larger unselected samples from different community and clinical settings.

Valproate monotherapy induced-delirium due to hyperammonemia: A report of three adult cases with different types of presentation

One of the important adverse effects of valproate is delirium due to hyperammonemia. In this case report series, we are reporting three cases with interesting and different types of clinical presentation on valproate monotherapy. Valproate-induced delirium may be mistaken for psychosis or worsening of mania leading to improper diagnosis and poor management. We found that there was an elevated level of plasma ammonia in our cases during the delirious state and which decreased when valproate was discontinued. In our cases the serum valproate levels, liver function tests, electroencephalogram, and imaging studies were normal, which were deranged in the previous case reports. We are the first to rechallenge valproate in one of the cases, to prove that valproate caused the hyperammonemia. We suggest that plasma ammonia levels should be monitored routinely in all cases of altered mental status and receiving valproate therapy.