The INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) study: Design and methods to address mental healthcare gaps in India

A. J. Kowalski, S. Poongothai, L. Chwastiak, M. Hutcheson, N. Tandon, R. Khadgawat, G. R. Sridhar, S. R. Aravind, B. Sosale, R. M. Anjana, D. Rao, R. Sagar, N. Mehta, K. M.V. Narayan, J. Unutzer, W. Katon, V. Mohan, M. K. Ali

Research output: Contribution to journalArticlepeer-review

11 Scopus citations


Introduction Depression and diabetes are highly prevalent worldwide and often co-exist, worsening outcomes for each condition. Barriers to diagnosis and treatment are exacerbated in low and middle-income countries with limited health infrastructure and access to mental health treatment. The INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) study tests the sustained effectiveness and cost-effectiveness of a multi-component care model for individuals with poorly-controlled diabetes and depression in diabetes clinics in India. Materials and methods Adults with diabetes, depressive symptoms (Patient Health Questionnaire-9 score ≥ 10), and ≥ 1 poorly-controlled cardiometabolic indicator (either HbA1c ≥ 8.0%, SBP ≥ 140 mm Hg, and/or LDL ≥ 130 mg/dl) were enrolled and randomized to the intervention or usual care. The intervention combined collaborative care, decision-support, and population health management. The primary outcome is the between-arm difference in the proportion of participants achieving combined depression response (≥ 50% reduction in Symptom Checklist score from baseline) AND one or more of: ≥ 0.5% reduction in HbA1c, ≥ 5 mm Hg reduction in SBP, or ≥ 10 mg/dl reduction in LDL-c at 24 months (12-month intervention; 12-month observational follow-up). Other outcomes include control of individual parameters, patient-centered measures (i.e. treatment satisfaction), and cost-effectiveness. Results The study trained seven care coordinators. Participant recruitment is complete – 940 adults were screened, with 483 eligible, and 404 randomized (196 to intervention; 208 to usual care). Randomization was balanced across clinic sites. Conclusions The INDEPENDENT model aims to increase access to mental health care and improve depression and cardiometabolic disease outcomes among complex patients with diabetes by leveraging the care provided in diabetes clinics in India ( number: NCT02022111).

Original languageEnglish (US)
Pages (from-to)113-124
Number of pages12
JournalContemporary Clinical Trials
StatePublished - Sep 2017
Externally publishedYes


  • Collaborative care
  • Decision support
  • Depression
  • Diabetes
  • Healthcare delivery

ASJC Scopus subject areas

  • Pharmacology (medical)


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