Appalachian region especially vulnerable
May 25, 2007
In Appalachia, diabetes hits hard. Depression does, too. Together, they form a difficult pair to beat.
To help patients fight back, a team of Ohio University College of Osteopathic Medicine (OU-COM) and Ohio University researchers have created a new approach to the double-edged problem. Program ACTIVE (Appalachians Coming Together to Increase Vital Exercise) is a two-year study to test the effectiveness of a combination of exercise and talk therapy to treat depression in patients with type 2 diabetes.
"Diabetes is a difficult disease," said Mary de Groot, assistant professor of psychology and lead author of a paper produced by the research team. "Add depression on top of that, and it makes it that much tougher."
Their paper, "Depression Among Type 2 Diabetes Rural Appalachian Clinic Attendees," is published in the June issue of Diabetes Care, the journal of the American Diabetes Association.
The study looked at type 2 diabetes patients in rural Appalachian counties of Southeastern Ohio and West Virginia. Of those 201 patients, 31 percent indicated on a questionnaire that they had both diabetes and depression. That rate is similar to the national "co-morbidity" rate (the two symptoms together) - surprisingly low considering the relatively high rate of poverty where the patients live. For instance, Meigs County, Ohio, has a poverty rate of 19.8 percent, compared to 10.6 percent for the state of Ohio.
"My vision of it is that people in Appalachia have sort of a higher tolerance for bad things," said Frank Schwartz, M.D., assistant professor of endocrinology at OU-COM and director of the Appalachian Rural Health Institute (ARHI) Diabetes/Endocrine Center.
Research conducted by the ARHI Diabetes Center shows Appalachia has a diabetes prevalence rate of 11.3 percent - well above the 7.6 percent national rate.
"What is compelling is the length of episodes of depression," said de Groot, the principal investigator. A follow-up study of the involved patients showed that 88 percent of those who had initially identified themselves as suffering from depression also did so 18 months later. Depression severity was associated with younger age, unemployment and a greater number of prescribed medications. These findings are consistent with those observed in urban samples.
De Groot and her colleagues encourage doctors to screen their diabetic patients for depression. People with diabetes are twice as likely to have an experience with depression as those without diabetes.
For patients, de Groot said, it is vital to share feelings and mood symptoms with their doctors. Talk therapy has been shown to be effective in treating depression in type 2 diabetes, she said, and that antidepressant medications have been effective in treating depression in people with type 1 and type 2 diabetes.
Program ACTIVE is the researchers' way of doing something about the situation.
To meet the depression criterion for Program ACTIVE, patients must have felt consistently depressed or down for most of the day nearly every day for two weeks or longer. Associated symptoms people experience are:
- a significant decrease in interest in activities they would ordinarily enjoy;
- changes in sleep;
- changes in appetite;
- weight loss or gain;
- difficulty concentrating;
- feelings of worthlessness;
- significantly decreased energy.
Program ACTIVE, which is funded by the National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK), combines 12 weeks of exercise with 10 sessions of talk therapy for patients with type 2 diabetes coupled with depression for two weeks or longer. The aim is to assess improvements made during the program in depression, diabetes and cardiovascular risk factors.
Participants have free access to the workout facilities at the Athens Community Center, which is one of the program's community partners. Other partners include University Medical Associates, Family Health Care Inc. and Holzer Clinic in Athens. Talk therapy sessions are conducted in Athens.
"If we can show effective intervention, this will become a program that is implemented in many high-risk environments," Schwartz said.
The co-investigators in Program ACTIVE are Schwartz; Jay Shubrook, D.O., assistant professor of family medicine at OU-COM; and Michael Kushnick, Ph.D., exercise physiologist with Ohio University's Department of Recreation and Sports Sciences.
Paper co-authors are de Groot, Schwartz and Shubrook and Robert Gotfried, D.O.; Brenda Pinkerman, Ph.D., who earned a doctorate in clinical psychology from Ohio University; and graduate students Todd Doyle, Erin Hockman and Charles Wheeler.
The team received funding for its initial study from the Ohio University Diabetes Research Initiative (DRI), and the NIDDK. Ohio University's DRI funded the 18-month follow-up study.
Six people have completed Program ACTIVE to date, and doctors hope to see that total reach 50 patients over the next year. To participate, call 740-597-2584 or 888-771-0002.