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Increasing numbers of persons live with complex chronic medical needs and are at risk for poor health outcomes. These patients require unique self-management support, as they must manage many, often interacting, tasks. As part of a conference on Managing Complexity in Chronic Care sponsored by the Department of Veterans Affairs, a working group was convened to consider self-management issues specific to complex chronic care. In this paper, we assess gaps in current knowledge on self-management support relevant to this population, report on the recommendations of our working group, and discuss directions for future study. We conclude that this population requires specialized, multidimensional self-management support to achieve a range of patient-centred goals. New technologies and models of care delivery may provide opportunities to develop this support. Validation and quantification of these processes will require the development of performance measures that reflect the needs of this population, and research to prove effectiveness.

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BACKGROUND: Depressive disorders are persistent, recurring illnesses that cause great suffering for patients and their families. PURPOSE: To evaluate the benefits and adverse effects of newer pharmacotherapies and herbal treatments for depressive disorders in adults and adolescents. DATA SOURCES: English-language and non-English-language literature from 1980 to January 1998 was identified from a specialized registry of controlled trials, meta-analyses, and experts. STUDY SELECTION: Randomized trials evaluating newer antidepressants (such as serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and St. John's wort) that reported clinical outcomes were selected. DATA EXTRACTION: Two persons independently abstracted data that were then synthesized descriptively; some data were pooled by using a random-effects model. DATA SYNTHESIS: Of 315 eligible trials, most evaluated antidepressants in adults with major depression, were conducted among outpatients, and examined acute-phase treatment. Newer antidepressants were more effective than placebo for major depression (relative benefit, 1.6 [95% CI, 1.5 to 1.7]) and dysthymia (relative benefit, 1.7 [CI, 1.3 to 2.3]). They were effective among older adults and primary care patients. Efficacy did not differ among newer agents or between newer and older agents. Hypericum (St. John's wort) was more effective than placebo for mild to moderate depression (risk ratio, 1.9 [CI, 1.2 to 2.8]), but publication bias may have inflated the estimate of benefit. Newer and older antidepressants did not differ for overall discontinuation rates, but side effect profiles varied significantly. Data were insufficient for determining the efficacy of newer antidepressants for subsyndromal depression, depression with coexisting medical or psychiatric illness, or depression in adolescents. CONCLUSIONS: Newer antidepressants are clearly effective in treating depressive disorders in diverse settings. Because of similar efficacy, both newer and older antidepressants should be considered when making treatment decisions. Better information is urgently needed on the efficacy of newer antidepressants in patients with nonmajor depression and in special populations, including adolescents.

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OBJECTIVE: To examine the effects of patient choice between two education curriculums that emphasized either the standard or nutritional management of type 2 diabetes on class attendance and other outcomes among a mostly Hispanic patient population. RESEARCH DESIGN AND METHODS: A total of 596 patients with type 2 diabetes were randomly assigned to either a choice or no choice condition. Patients in the choice condition were allowed to choose their curriculum, while patients in the no choice condition were randomly assigned to one of the two curriculums. Outcomes were assessed at baseline and at a 6-month follow-up. RESULTS: When given a choice, patients chose the nutrition curriculum almost four times more frequently than the standard curriculum. Contrary to our hypothesis, however, patients who had a choice did not significantly increase their attendance rates or demonstrate improvements in other diabetes outcomes compared with patients who were randomly assigned to the two curriculums. Patients in the nutrition curriculum had significantly lower serum cholesterol at a 6-month follow-up, whereas patients in the standard curriculum had significant improvements in glycemic control. Of the randomized patients, 30% never attended any classes; the most frequently cited reasons for nonattendance were socioeconomic. Hispanic patients, however, were just as likely as non-Hispanic patients to attend classes and participate at the follow-up. Patients who attended all five classes of either curriculum significantly increased their diabetes knowledge, gained less weight, and reported improved physical functioning compared with patients who did not attend any classes. CONCLUSIONS: Although providing patients with a choice in curriculums at the introductory level did not improve outcomes, differential improvements were noted between patients who attended curriculums with different content emphasis. We suggest that diabetes education programs should provide the opportunity for long-term, repetitive contacts to expand on the modest gains achieved at the introductory level, as well as provide more options to match individual needs and interests and to address socioeconomic barriers to participation.

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OBJECTIVES: Depressive disorders are persistent, recurring illnesses that impose enormous personal suffering on individuals and their families. Major depression alone is estimated as the fourth most important cause of worldwide loss in disability-adjusted life years and is likely to become the second most important within 20 years. A continued quest for more effective treatments has spawned newer antidepressants and herbal treatments, which have contributed to explosive growth in antidepressant prescribing, increasing pharmacy costs, and wider but sometimes confusing choices for clinicians and patients. This evidence report provides a comprehensive evaluation of the benefits and adverse effects of newer pharmacotherapies and herbal treatments for depressive disorders in adults and children. SEARCH STRATEGY: Pertinent literature from 1980 to January 1998 was identified from a specialized registry of controlled trials, meta-analyses, and experts. The registry contained trials addressing depression that had been identified from multiple electronic bibliographic databases, hand searches of journals, and pharmaceutical companies. The search, which yielded 1,277 records, combined terms "depression," "depressive disorder," or "dysthymic disorder" with a list of 32 specific "newer" antidepressant and herbal treatments. SELECTION CRITERIA: Randomized controlled trials were reviewed if they (1) were at least 6 weeks in duration; (2) compared a "newer" antidepressant with another antidepressant (newer or older), placebo, or psychosocial intervention; (3) involved participants with depressive disorders; and (4) had a clinical outcome. Two or more independent reviewers identified 315 trials that met these criteria. DATA COLLECTION AND ANALYSIS: Two persons independently abstracted data from each trial. Data were synthesized descriptively, paying attention to participant and diagnostic descriptors, intervention characteristics, study designs and clinical outcomes. Some data were analyzed quantitatively using an empirical Bayes random-effects estimator method. Primary outcomes were response rate, total discontinuation rates (dropouts), and discontinuation rates due to adverse events. Response rates were defined as a 50 percent or greater improvement in symptoms as assessed by a depression symptoms rating scale or a rating of much or very much improved as assessed by a global assessment method. MAIN RESULTS: There were 264 trials that evaluated antidepressants in patients (adults and children) with major depression. Of these, 81 compared newer agents with placebo, 150 newer with older agents, 32 newer agents with newer agents, and 1 newer agent with psychotherapy. There were 14 trials evaluating hypericum (St. John's wort), 27 trials each in primary care patients and older adults, 10 trials limited to patients with specific concomitant illnesses, 9 trials in patients with dysthymia, 3 trials each in patients with mixed anxiety depression and subsyndromal depression, 2 trials in adolescents, and 1 in the postpartum setting. Most trials were conducted in outpatients and examined only acute phase treatment of less than 12 weeks' duration. Newer antidepressants were more effective than placebo in treating major depression (risk ratio 1.6, 95% CI 1.5 to 1.7) and dysthymia (risk ratio 1.7, 95% CI 1.3 to 2.3). They were effective among older adults and in primary care patients. In general, there were no significant differences in efficacy among individual newer agents or between newer and older agents. Hypericum (St. John's wort) was more effective than placebo in treating mild to moderately severe depressive disorders (risk ratio 1.9, 95% CI 1.2 to 2.8). Whether hypericum (St. John's wort) is as effective as standard antidepressant agents given in adequate doses was not established. No significant differences were found between newer and older antidepressants in overall discontinuation rates. Selective serotonin reuptake inhibitors (SSRIs), reversi

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