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A Randomized Trial of Telephonic Counseling Plus Walking for Depressed Diabetes Patients

Piette, John D. PhD*,†; Richardson, Caroline MD*,†; Himle, Joseph PhD; Duffy, Sonia PhD, RN*,†; Torres, Trissa MD; Vogel, Mark PhD; Barber, Kimberly PhD; Valenstein, Marcia MD*,†

doi: 10.1097/MLR.0b013e318215d0c9
Original Articles

Background Patients with diabetes and depression often have self-management needs that require between-visit support. This study evaluated the impact of telephone-delivered cognitive behavioral therapy (CBT) targeting patients' management of depressive symptoms, physical activity levels, and diabetes-related outcomes.

Methods Two hundred ninety-one patients with type 2 diabetes and significant depressive symptoms (Beck Depression Inventory scores ≥14) were recruited from a community-based, university-based, and Veterans Affairs health care systems. A manualized telephone CBT program was delivered weekly by nurses for 12 weeks, followed by 9 monthly booster sessions. Sessions initially focused exclusively on patients' depression management and then added a pedometer-based walking program. The primary outcome was hemoglobin A1c levels measured at 12 months. Blood pressure was a secondary outcome; levels of physical activity were determined by pedometer readings; depression, coping, and health-related quality of life were measured using standardized scales.

Results Baseline A1c levels were relatively good and there was no difference in A1c at follow-up. Intervention patients experienced a 4.26 mm Hg decrease in systolic blood pressure relative to controls (P=0.05). Intervention patients had significantly greater increases in step counts (mean difference, 1131 steps/d; P=0.0002) and greater reductions in depressive symptoms (58% remitted at 12 mo vs. 39%; P=0.002). Intervention patients also experienced relative improvements in coping and health-related quality of life.

Conclusions This program of telephone-delivered CBT combined with a pedometer-based walking program did not improve A1c values, but significantly decreased patients' blood pressure, increased physical activity, and decreased depressive symptoms. The intervention also improved patients' functioning and quality of life.

*Ann Arbor VA Healthcare System

University of Michigan, Ann Arbor

Genesys Health System, Flint, MI

Supported by NIH grant ♯ 5R18DK66166-3, the Michigan Diabetes Research and Training Center (NIH ♯DK020572) and the Michigan Institute for Clinical and Health Research (NIH ♯UL1RR024986). John Piette is a VA Senior Research Career Scientist. At the time of the study, Caroline Richardson was supported by NIH training grant ♯ K23 HL075098. Dana Striplin, M.P.H., managed all data collection and participated in data analysis. Her effort was supported by NIH grant ♯ 5R18DK66166-3.

This NIH-funded trial (1R18DK066166-01A1) is registered with and the registration number is NCT01106885.

Results of this study were presented at the Annual Meeting of the Society for General Internal Medicine, April 28 to May 1, 2010, Minneapolis, MN.

Conflicts of Interest: No authors have any conflict of interest (financial or material support or assistance) related to this manuscript in any area, including the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, and approval of the final version of the paper.

John Piette and Marcia Valenstein had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis.

Reprints: John D. Piette, PhD, Department of Internal Medicine, University of Michigan, 300 N. Ingalls Bldg., Room 7E10, Ann Arbor, MI 48109-5429. e-mail:

© 2011 Lippincott Williams & Wilkins, Inc.