CHICAGO—Women who drink higher amounts of sugar-sweetened beverages have an increased risk for developing type 2 diabetes and gaining weight, according to a study in the August 25 issue of JAMA, the Journal of the American Medical Association.

According to background information in the article, type 2 diabetes mellitus affects about 17 million U.S. individuals. The prevalence of diabetes and obesity has increased rapidly during the last decades, coinciding with an increase in soft drink consumption in the United States by 61 percent in adults from 1977 to 1997, and a more than doubling of soft drink consumption in children and adolescents from 1977-1978 to 1994-1998. Soft drinks are the leading source of added sugars in the U.S. diet, and may increase the risk of diabetes because they contain large amounts of high-fructose corn syrup, which raises blood glucose similarly to sucrose. Evidence has been limited on the link between sugar-sweetened soft drinks and risk of type 2 diabetes and obesity in adults.

Matthias B. Schulze, Dr.P.H., formerly of the Harvard School of Public Health, Boston, and colleagues examined the relationships between sugar-sweetened beverage consumption and weight gain and diabetes risk. The diabetes analysis included 91,249 women free of diabetes and other major chronic diseases at baseline in 1991. The weight change analysis included 51,603 women for whom complete dietary information and body weight were ascertained in 1991, 1995, and 1999. The women were part of the Nurses' Health Study II. The researchers identified 741 cases of type 2 diabetes during the follow-up.

The researchers found that women with stable consumption patterns had no difference in weight gain, but weight gain over a 4-year period was highest among women who increased their sugar-sweetened soft drink consumption from 1 or fewer drinks per week to 1 or more drinks per day (average weight gain, 10.3 pounds for 1991 to 1995 and 9.3 pounds for 1995 to 1999) and was smallest among women who decreased their intake (2.9 pounds and .3 pounds for the two periods, respectively) after adjusting for lifestyle and dietary factors. Increased consumption of fruit punch was also associated with greater weight gain compared with decreased consumption. After adjustment for potential confounders, women consuming 1 or more sugar-sweetened soft drinks per day had a 83 percent increased risk for type 2 diabetes compared with those who consumed less than 1 of these beverages per month. Similarly, consuming one drink or more per day of fruit punch was associated with twice the risk for diabetes compared with consuming less than one drink of fruit punch per month.

CHICAGO—Integrating psychotherapy by telephone into a program for treating depression can significantly improve outcomes, according to a study in the August 25 issue of JAMA, the Journal of the American Medical Association.

Both antidepressant medication and structured psychotherapy have been proven effective, but less than one-third of people with depressive disorders receive effective levels of either treatment, according to background information in the article. Of those beginning psychotherapy, 25 percent attend only one session and only half attend four or more sessions. Stigma remains an important barrier to treatment seeking and treatment adherence. Psychotherapy requires a significant commitment of time.

Gregory E. Simon, M.D., M.P.H., of the Center for Health Studies, Group Health Cooperative, Seattle, and colleagues conducted a randomized trial between November 2000 and May 2002 evaluating two approaches to addressing the barriers to effective depression treatment. The first program was an updated version of a telephone outreach and care management program to improve the quality of antidepressant pharmacotherapy. The second program included telephone care management and added an 8-session structured psychotherapy program delivered by telephone.

The study included 600 patients beginning antidepressant treatment for depression in primary care clinics. The treatments included: usual primary care; usual care plus a telephone care management program including three outreach calls (each contact included a brief, structured assessment of depressive symptoms, antidepressant medication use, and adverse effects), feedback to the treating physician, and care coordination; and usual care plus care management integrated with a structured 8-session cognitive-behavioral psychotherapy program delivered by telephone, with each session lasting 30-40 minutes. Sessions included discussing increasing pleasant and rewarding activities, and identifying, challenging, and distancing from negative thoughts. A participant workbook included in-session exercises and written homework exercises for completion between sessions.

The researchers found that compared with usual care, the telephone psychotherapy intervention led to lower average scores on a scale measuring depression. A higher proportion of patients reported that depression was "much improved" (80 percent vs. 55 percent) and a higher proportion of patients were "very satisfied" with depression treatment (59 percent vs. 29 percent). The telephone care management program without the psychotherapy component had smaller effects on patient-rated improvement (66 percent vs. 55 percent) and satisfaction (47 percent vs. 29 percent); effects on mean depression scores were not statistically significant.

"Telephone programs may sacrifice the richness of traditional in-person therapy, but they address several important barriers to dissemination of effective depression treatments," the authors write. "Vigorous telephone outreach allowed us to engage patients who might not be reached by traditional in-person treatment. Telephone sessions eliminated travel and waiting time and allowed more flexible scheduling. Greater privacy of telephone contacts helped to circumvent stigma."

"Efforts to improve management of depression in primary care must consider resource limitations and pressures to control costs. While we estimate the cost of providing telephone psychotherapy to be less than $50 per session, these additional resources should be directed to those patients most likely to benefit," they add.

CHICAGO—Medicare beneficiaries who exceed their annual drug benefit cap report having to reduce their use of essential medications and experience difficulty paying for prescription medications, according to a study in the August 25 issue of JAMA, the Journal of the American Medical Association.

The majority of Medicare drug benefits in managed care (Medicare+Choice) have annual dollar limits or caps and many beneficiaries face temporary but potentially significant gaps in coverage after exceeding caps before the end of the year, according to background information in the article. With the risk for coverage gaps in the newly adopted national Medicare drug benefit, understanding how caps and coverage gaps affect medication use is critical to designing adequate drug benefits for Medicare beneficiaries. The exact impact of caps and the coverage gap on medication use is uncertain.

Chien-Wen Tseng, M.D., M.P.H., of the University of Hawaii Department of Family Practice and Community Health and the Pacific Health Research Institute, Honolulu, and colleagues from the UCLA Robert Wood Johnson Clinical Scholars Program conducted a cross-sectional survey of Medicare+Choice beneficiaries with capped drug benefits to determine the cost-cutting strategies, the type of medications involved, and financial burden of drug costs for patients who exceeded caps and had a gap in coverage compared with those patients who did not exceed their caps.

The survey (completed in 2002) included Medicare+Choice beneficiaries aged 65 years and older with high medication costs and benefits capped on the plan's share of drug costs. Study participants (n=665) exceeded a $750 or $1,200 yearly cap in 2001 and had coverage gaps of 75-180 days. Control participants (n=643) had $2,000 caps which they did not exceed. Study and control participants were matched by average total drug expenditures per month.

The researchers found that a higher proportion of patients exceeding caps reported using less prescribed medication than controls (18 percent vs. 10 percent, respectively), but similar proportions reported stopping medications completely (8 percent for both) and of not starting prescribed medications (6 percent vs. 5 percent). Overall, 24 percent of patients exceeding caps decreased their use of at least one medication because of cost, compared to 16 percent of patients who did not exceed the cap.

"Patients exceeding caps more often called pharmacies to find the best price (46 percent vs. 29 percent), switched medications (15 percent vs. 9 percent), used samples (34 percent vs. 27 percent), and had difficulty paying for prescriptions (62 percent vs. 37 percent)," the authors write. "Twelve of the 20 therapeutic classes most often affected by decreases in use of medication were for chronic health problems such as hypertension, hyperlipidemia, and emphysema or asthma."

WOMEN WHO DRINK NON-DIET SOFT DRINKS DAILY AT GREATLY INCREASED RISK FOR DIABETES