Providing simple, low-cost tech-enabled care to people with diabetes for one year halved symptoms of depression and boosted heart health by lowering blood pressure and bad cholesterol, and improving blood glucose control, according to a first-of-its-kind study.

Improvements in the cardio-metabolic parameters, however, waned once integrated care was stopped after a year, which suggests the need for continued support for blood sugar, blood pressure and cholesterol levels, said the study, which was published on Tuesday in the Journal of the American Medical Association (JAMA).

The Integrating Depression and Diabetes Treatment (Independent) study compared integrated care with standard care in 404 diabetes patients in Delhi, Chennai, Bangalore, and Visakhapatnam with moderate-to-severe depressive symptoms over a two-year period and found major improvements in the group receiving the integrated approach. The improvements were most pronounced in patients with the worst parameters at the start of the study.

Around one in five people (19.7%) with diabetes have depression in India, compared to 15.1% people in the general population. “There is a bidirectional relationship between depression and diabetes, as chronic diseases like diabetes can lead to depression, and vice versa. Depression can cause stress-induced diabetes and also impact a person’s ability to manage self-care, leading to complications,” said principal investigator of the project from India, Dr Viswanathan Mohan, chairman, Dr Mohan’s Diabetes Specialties Centre and director, Madras Diabetes Research Foundation.

Since there are not enough psychiatrists in India to treat everyone with depression symptoms, which range from feeling low, tiredness and in suicidal ideation, the study used care coordinators to screen people with diabetes for signs of depression.

“Diabetes educators, dietitians, health workers or any graduate can be trained as non-physician care coordinators to screen for depression, and provide counselling for mild cases and refer people with suicidal ideation to psychiatrists for remote management. With the help of decision-support software, care coordinators helped lower symptoms of depression and several metabolic parameters, such as blood sugar, blood pressure and cholesterol profiles of patients and lowered risk of complications such as heart disease, eye disease (retinopathy), kidney failure and amputations,” said Dr Mohan.

The low-cost model is accessible and scalable and can be applied in underresourced settings everywhere in the world, he said.

“The CARRS (Center for Cardio-metabolic Risk Reduction in South Asia) study on diabetes management showed in 2018 that low-cost software used by a non-physician care coordinators can optimise treatment and lower complications in diabetes improving blood glucose-control and lower blood pressure and ‘bad’ LDL cholesterol at no added cost. We added depression to the mix and found it improved outcomes under supervision,” said co-investigator Dr Nikhil Tandon, professor of endocrinology, All India Institute of Medical Sciences, New Delhi.

In India, close to 70 million people have diabetes and another 40 million are insulin-resistant, which is a precursor to diabetes. More than four in five diabetics on medication in India do not have their blood glucose under control, according to Dr Mohan’s DiabCare India study 2011. Neuropathy was the most common complication (41.4%); other complications were: Foot (32.7%), eye (19.7%), cardiovascular (6.8%) ,and nephropathy (6.2%), with the number of diabetic complications increasing with mean duration of disease.

“Too often, mental health is overlooked due to fragmented care, stigma of psychiatric illnesses, and shortages of mental health professions,” said first author Dr Mohammed Ali, associate professor of Global Health and Epidemiology at Rollins School of Public Health, Emory University, Atlanta, US.