East Carolina University COMRADE Project

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Locations: Edgecombe County, Pitt County, and Greene County, North Carolina

East Carolina University (ECU) in partnership with stakeholders from rural, eastern North Carolina, implemented an individually-tailored, stepped-care intervention for patients experiencing uncontrolled type 2 diabetes and distress or depression. This approach featured combining primary care, cognitive behavioral treatment, and community support. The goals of this project were to implement and evaluate the effectiveness of the approach in a pragmatic trial, its impact on psychological mediators, and establish a cost-effective care model.


The rate of depression is twice as high among patients experiencing type 2 diabetes than those that are not and have worse adherence to medical treatment, resulting in poor glycemic control. Consequently, poorly controlled diabetes frequently results in exacerbated symptoms of depression. Diabetes-related distress, anxiety related to disease management, further worsens depressive symptoms. The current project builds upon a pilot study that detected a high prevalence with both regimen-related distress and depression with poor glycemic control.


The intervention was delivered by a case manager, project coordinator, health psychologist, and community health workers. Patients were placed in a level of the intervention based on disease and severity. As a severity-stratified stepped care model that includes four steps distinguished by intensity of treatment, COMRADE was implemented using a care manager linked to medical, pharmacologic, and behavioral colleagues. The community-based component utilized community health workers to provide support and facilitate access to resources.


A carefully designed integrated care behavioral health intervention can be successfully delivered in rural primary care practices producing reductions in A1c levels, but also resulting in more profound improvements in Diabetes-related Distress and self-care behaviors.

It can also produce greater improvements in those on oral medication regimens compared to insulin-treated patients, and that it can result in greater improvement in medication adherence if distress is reduced

Participants especially found especially helpful:

  • Accountability to interventionists
  • Information/knowledge gained, especially about food/nutrition
  • Having a “safe” person to talk to in a confidential manner