Collaborative Care More Likely than Usual Care to Effectively Treat Late-Life Depression
]]>Depression]]> is a common ailment in older adults, affecting about six percent of Americans age 65 and older in a given year. Two main types of depression that affect the elderly are major depression and dysthymic disorder. Major depression is characterized by a disabling combination of symptoms, including sadness, anxiety, hopelessness, fatigue, difficulty concentrating, and thoughts of death and suicide that interfere with the ability to work, eat, sleep, and derive pleasure from activities that were once enjoyable. Dysthymic disorder , or dysthymia , involves the same symptoms as major depression, but is not disabling. Instead, chronic, long-lasting symptoms prevent the affected person from functioning well and having a positive outlook. Dysthymia increases risk of developing major depression.
Despite the fact that late-life depression can be successfully treated with antidepressant medications or psychotherapy, older adults often receive inadequate treatment for depression in primary care settings.
In a study published in the December 11, 2002 Journal of the American Medical Association (JAMA), researchers found that collaborative care, involving a team of medical professionals, was significantly more effective at treating late-life depression than usual care.
About the Study
Researchers from 18 primary health clinics studied 1801 patients, aged 60 years and older, who were enrolled in the study between July 1999 and August 2001. All patients had a diagnosis of major depression, dysthymic disorder, or both at the time of enrollment. Patients were excluded from the study if they had current drinking problems; a history of ]]>bipolar disorder]]> or psychosis; were currently being treated by a psychiatrist; met the criteria for severe cognitive impairment; or were found to be at acute risk for suicide.
The 895 patients in the control group were randomly assigned to receive usual care. The remaining 906 patients were randomly assigned to the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) intervention. Patients assigned to the IMPACT program were assigned a depression care manager (either a nurse or psychologist trained as a depression clinical specialist). The depression care manager (DCM) conducted a clinical and psychosocial history, reviewed educational materials about depression with the patient, and discussed patient preference for depression treatment with antidepressant medications or psychotherapy. The DCM worked closely with the patient, a supervising psychiatrist, and a liaison primary care physician over the course of the 12-month study period to create, implement, and fine-tune a depression treatment program. Interviewers, who were not aware of the patients’ treatment assignments, conducted telephone interviews just prior to the intervention, and at three months, six months, and 12 months to assess severity of depression, effectiveness of treatment, degree of functional impairment, and quality of life.
At the end of the study, researchers examined the following factors in each patient: use of antidepressant medication or psychotherapy; satisfaction with depression care; mean depression scores (SCL-20 scores); treatment response (greater than or equal to a 50% decrease in SCL-20 score from baseline); complete remission of depression symptoms (SCL-20 score <0.5); major depression as assessed by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID); health-related functional impairment; and quality of life. The researchers compared the outcome of these variables in patients who had received usual care versus patients who participated in the IMPACT program.
At 12 months, IMPACT patients were significantly more likely to have a 50% or greater reduction in depressive symptoms from baseline than patients receiving usual care (45% versus 19%). IMPACT patients also had significantly lower depression severity (0.4 difference on a scale of 0–4) than control patients at the one-year mark. In addition, IMPACT patients had a significantly greater reduction in rates of major depression (from a mean of 71% at baseline to 22% at 6 months) compared to usual care patients (from a mean of 68% at baseline to 35% at 6 months). Patients who went through the IMPACT program were also significantly more likely to use antidepressants or psychotherapy than patients in usual care, and had significantly higher rates of treatment response and rates of complete remission of depressive symptoms than control patients at 12 months.
Patients who went through the IMPACT program also reported a better quality of life and less health-related impairment of work, family, and social function than controls.
How Does This Affect You?
A large number of older Americans suffer from depression, yet depression is not a “normal” part of aging. This study highlights the effectiveness of treatment—specifically collaborative treatment—on late-life depression, and demonstrates that effectively treating depression can result in an overall improved quality of life.
The first important step in any type of treatment is to identify depression. This can be difficult in the elderly because both doctors and patients often assume the symptoms of depression to be the inevitable consequences of various medical conditions that so commonly plague us as we age.
The symptoms of depression are variable, and a person struggling with depression may express one or any combination these symptoms:
- Persistent feelings of sadness, anxiety or emptiness
- Feeling guilty, worthless or helpless
- Loss of interest in hobbies and activities
- Loss of interest in sex
- Feeling tired
- Trouble concentrating, remembering, making decisions
- Trouble sleeping, waking up too early, or oversleeping
- Eating more or less than usual
- Weight gain or weight loss
- Thoughts of death or suicide with or without suicide attempts
- Restlessness or irritability
- Physical symptoms that defy standard diagnosis and do not respond well to medical treatments
Depression in the elderly is prevalent and treatable. This study demonstrates the importance of ongoing communication between the patient and physician. Both parties must be prepared to openly discuss emotional problems as thoroughly as physical ones, and to review treatment options, preferences, and satisfaction with the results.
American Association for Geriatric Psychiatry
National Institute of Mental Health
National Institutes of Health
National Institute on Aging
National Institutes of Health
National Mental Health Association
Unützer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting. JAMA . 2002;288:2836-2845.
Last reviewed Dec 12, 2002 by ]]>Richard Glickman-Simon, MD]]>
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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