Overview. This is a proposal for a randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in patients with type 2 diabetes. It is modeled after our successful program of NIH-funded research targeting health behaviors in individuals with HIV and comorbid depression. This is a logical extension of our work in HIV that will support an evidence-based psychosocial intervention approach for individuals with depression and comorbid health conditions. Background: The prevalence of depression in individuals with chronic health conditions is higher than general population estimates, and is associated with increased mortality (Cujipers &Schoevers, 2004). The present study targets individuals with depression and type 2 diabetes because of the difficulty these patients have with treatment adherence and the vast importance of adherence for treatment outcomes. As in other chronic illnesses, in type 2 diabetes, depression is associated with worse treatment adherence, poorer disease outcomes, more severe functional impairment, and increased mortality (Lustman, et al., 2000;Lin, et al., 2004;Ciechanowski, et al., 2003;Egede, 2004;Katon et al., 2005). Our intervention integrates cognitive behavioral therapy (CBT), the most widely studied and efficacious psychosocial intervention for depression, with behavioral strategies for health behavior change. CBT has been shown to be successful in treating symptoms of depression among patients with type 2 diabetes (e.g., Lustman, et al., 1998). However, integrating CBT for depression with behavioral strategies for health behavior change has not been widely studied. Our program of research in HIV suggests that integrating CBT for adherence with CBT for depression (CBT-AD) is a successful in improving both of these problems in individuals with HIV and there is strong evidence CBT-AD would also be successful in type 2 diabetes. Conceptual Model: Symptoms and sequelae of depression (e.g., poor concentration, low motivation, decreased interest, sad mood, increased feelings of guilt and worthlessness, and suicidal ideation) can interfere with important behaviors necessary to manage a health regimen. We hypothesize that, for individuals with a unipolar depressive mood disorder, a psychological intervention that targets health behaviors (i.e., treatment adherence) integrated with coping skills for depression, is needed to improve psychiatric, quality of life, self-care, and medical outcomes relative to diabetes education and adherence training alone. Overview of Research Plan. Patients with depression and poor type 2 diabetes control (hemoglobin A1C >7.5%) will be randomized to treatment with either: (1) CBT-AD, a integrated treatment of CBT for depression and adherence, including our single-session intervention for medical adherence (adapted from HIV) or (2) enhanced treatment as usual plus the single session adherence intervention. Both groups-will receive diabetes education from a dietitian and a diabetes nurse educator.
