Cooper Zach W, Johnson Leslie C M, Patel Shivani A, Aravind Sosale Ramachandra, Tandon Nikhil, Anjana Ranjit Mohan, Poongothai Subramani, Sridhar Gumpeny R, Mohan Viswanathan, Chwastiak Lydia, Ali Mohammed K
University of Georgia School of Social Work, Athens, GA, USA.
Emory University, Department of Family and Preventive Medicine, School of Medicine, Atlanta, GA, USA.
J Gen Intern Med. 2025 Aug 13. doi: 10.1007/s11606-025-09810-1.
BACKGROUND: Collaborative care models (CoCM) improve both depression and cardiometabolic outcomes, but the mechanisms driving these effects remain unclear. OBJECTIVE: To determine whether changes in depressive symptoms, positive health behaviors (PHBs), body mass index (BMI), and waist circumference mediate the effect of an adapted CoCM on glycemic control among adults with cardiometabolic risk in India. DESIGN: Longitudinal structural equation modeling of data from the INtegrating DEPrEssioN and Diabetes TreatmENT (INDEPENDENT) Randomized Control Trial. PARTICIPANTS: Adults in India with type 2 diabetes or elevated cardiometabolic risk factors and clinically significant depressive symptoms. INTERVENTIONS: An adapted CoCM integrating behavioral activation (BA) within diabetes care, delivered by a multidisciplinary team to enhance engagement in self-care activities. MAIN MEASURES: Intervention exposure was the independent variable; mediators were depressive symptoms (Symptom Checklist-20), PHBs (Summary of Diabetes Self-Care Activities), BMI, and waist circumference; the primary outcome was hemoglobin A1c (HbA1c). Confirmatory factor analyses ensured measurement validity, with second-order factors capturing depressive symptom domains (anhedonia, somatization, internalizing symptoms, restlessness). KEY RESULTS: The intervention significantly reduced depressive symptoms from 0-6 months (β = -0.22, p < 0.01) and 6-12 months (β = -0.34, p < 0.01) and increased PHBs from 0-6 months (β = 0.15, p < 0.05) and 6-12 months (β = 0.11, p < 0.05). Higher depressive symptoms predicted lower PHBs at 6 months (β = -0.26, p < 0.01) and 12 months (β = -0.25, p < 0.01). PHBs mediated reductions in BMI (β = -0.08 to -0.09, p < 0.01) and waist circumference, which in turn mediated improvements in HbA1c. CONCLUSIONS: An adapted CoCM improved glycemic control and cardiometabolic risk by alleviating depressive symptoms, enhancing PHBs, and reducing BMI and waist circumference. Integrating BA within CoCM may be a key mechanism for optimizing outcomes in integrated cardiometabolic care.
背景：协作护理模式（CoCM）可改善抑郁和心血管代谢结局，但驱动这些效果的机制仍不清楚。 目的：确定抑郁症状、积极健康行为（PHB）、体重指数（BMI）和腰围的变化是否介导了一种适应性CoCM对印度患有心血管代谢风险的成年人血糖控制的影响。 设计：来自整合抑郁症和糖尿病治疗（INDEPENDENT）随机对照试验数据的纵向结构方程模型。 参与者：印度患有2型糖尿病或心血管代谢风险因素升高且有临床显著抑郁症状的成年人。 干预措施：一种在糖尿病护理中整合行为激活（BA）的适应性CoCM，由多学科团队提供，以增强对自我护理活动的参与度。 主要测量指标：干预暴露是自变量；中介变量是抑郁症状（症状清单-20）、PHB（糖尿病自我护理活动总结）、BMI和腰围；主要结局是糖化血红蛋白（HbA1c）。验证性因素分析确保测量效度，二阶因素捕获抑郁症状领域（快感缺失、躯体化、内化症状、烦躁不安）。 关键结果：干预在0至6个月（β=-0.22，p<0.01）和6至12个月（β=-0.34，p<0.01）显著降低了抑郁症状，在0至6个月（β=0.15，p<0.05）和6至12个月（β=0.11，p<0.05）增加了PHB。较高的抑郁症状在6个月（β=-0.26，p<0.01）和12个月（β=-0.25，p<0.01）预测较低的PHB。PHB介导了BMI（β=-0.08至-0.09，p<0.01）和腰围的降低，而腰围又介导了HbA1c的改善。 结论：一种适应性CoCM通过减轻抑郁症状、增强PHB以及降低BMI和腰围改善了血糖控制和心血管代谢风险。在CoCM中整合BA可能是优化综合心血管代谢护理结局的关键机制。
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