Patrick J. Raue

Re-engineering systems for the treatment of depression in primary care: cluster randomised controlled trial

Abstract Objective To test the effectiveness of an evidence based model for management of depression in primary care with support from quality improvement resources. Design Cluster randomised controlled trial. Setting Five healthcare organisations in the United States and 60 affiliated practices. Patients 405 patients, aged ≥ 18 years, starting or changing treatment for depression. Intervention Care provided by clinicians, with staff providing telephone support under supervision from a psychiatrist. Main outcome measures Severity of depression at three and six months (Hopkins symptom checklist-20): response to treatment (≥ 50% decrease in scores) and remission (score of < 0.5). Results At six months, 60% (106 of 177) of patients in intervention practices had responded to treatment compared with 47% (68 of 146) of patients in usual care practices (P = 0.02). At six months, 37% of intervention patients showed remission compared with 27% for usual care patients (P = 0.014). 90% of intervention patients rated their depression care as good or excellent at six months compared with 75% of usual care patients (P = 0.0003). Conclusion Resources such as quality improvement programmes can be used effectively in primary care to implement evidence based management of depression and improve outcomes for patients with depression.

Reducing Suicidal Ideation and Depression in Older Primary Care Patients: 24-Month Outcomes of the PROSPECT Study

OBJECTIVE The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) evaluated the impact of a care management intervention on suicidal ideation and depression in older primary care patients. This is the first report of outcomes over a 2-year period. METHOD Study participants were patients 60 years of age or older (N=599) with major or minor depression selected after screening 9,072 randomly identified patients of 20 primary care practices randomly assigned to provide either the PROSPECT intervention or usual care. The intervention consisted of services of 15 trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 24 months. RESULTS Compared with patients receiving usual care, those receiving the intervention had a higher likelihood of receiving antidepressants and/or psychotherapy (84.9%-89% versus 49%-62%) and had a 2.2 times greater decline in suicidal ideation over 24 months. Treatment response occurred earlier on average in the intervention group and increased from months 18 to 24, while no appreciable increase in treatment response occurred in the usual care group during the same period. Among patients with major depression, a greater number achieved remission in the intervention group than in the usual-care group at 4 months (26.6% versus 15.2%), 8 months (36% versus 22.5%), and 24 months (45.4% versus 31.5%). Patients with minor depression had favorable outcomes regardless of treatment assignment. CONCLUSIONS Sustained collaborative care maintains high utilization of depression treatment, reduces suicidal ideation, and improves the outcomes of major depression over 2 years.

Problem-Solving Therapy and Supportive Therapy in Older Adults With Major Depression and Executive Dysfunction

OBJECTIVE The purpose of this study was to determine whether problem-solving therapy is an effective treatment in older patients with depression and executive dysfunction, a population likely to be resistant to antidepressant drugs. METHOD Participants were adults age 60 and older with major depression and executive dysfunction. Problem-solving therapy was modified to be accessible to this population. Participants were randomly assigned to 12 weekly sessions of problem-solving therapy or supportive therapy and assessed at weeks 3, 6, 9, and 12. RESULTS Of the 653 individuals referred for this study, 221 met selection criteria and were enrolled in the study. Reduction of depressive symptom severity was comparable for the two treatment groups during the first 6 weeks of treatment, but at weeks 9 and 12 the problem-solving therapy group had a greater reduction in symptom severity, a greater response rate, and a greater remission rate than the supportive therapy group (response rates at week 9: 47.1% and 29.3%; at week 12:56.7% and 34.0%; remission rates at week 9: 37.9% and 21.7%; at week 12: 45.6% and 27.8%). Problem-solving therapy yielded one additional response or remission over supportive therapy for every 4.4-5.6 patients by the end of the trial. CONCLUSIONS These results suggest that problem-solving therapy is effective in reducing depressive symptoms and leading to treatment response and remission in a considerable number of older patients with major depression and executive dysfunction. The clinical value of this finding is that problem-solving therapy may be a treatment alternative in an older patient population likely to be resistant to pharmacotherapy.

Screening Performance of the 15-Item Geriatric Depression Scale in a Diverse Elderly Home Care Population

OBJECTIVE To empirically evaluate the psychometric properties of the 15-item Geriatric Depression Scale (GDS-15); determine the optimal cutoff points and screening performance for the detection of major depression; and examine differential item functioning (DIF) to determine the variability of item responses across sociodemographics in an elderly home care population. DESIGN A secondary analysis of data collected from a random sample study. SETTING Homebound subjects newly admitted over a 2-year-period to a large visiting nurse service agency in Westchester, New York. PARTICIPANTS Five hundred twenty-six subjects over age 65, newly admitted to home care for skilled nursing. MEASUREMENTS Major depression was diagnosed using both patient, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and best estimate procedures. Self-report measures included the GDS-15, activities of daily living (ADL), instrumental ADL, and pain intensity. Cognitive impairment was assessed using the Mini-Mental State Examination and medical morbidity using the Charlson Comorbidity Index. RESULTS Optimal cutoff (5) yielded sensitivity 71.8% and specificity of 78.2%, however, the accuracy of the GDS-15 was not influenced by severity of medical burden. Persons with a cluster of ailments were twice as likely (Adj odds ratio = 2.47; 95% confidence interval = 1.49-4.09) to be diagnosed with depression. DIF analyses revealed no variability of item responses across sociodemographics. CONCLUSION Main findings suggest that the accuracy of the GDS-15 was not influenced by severity of clinical or functional factors, or sociodemographics. This has broad implications suggesting that the very old, ill, and diverse populations can be appropriately screened for depression using the GDS-15.

Patients' depression treatment preferences and initiation, adherence, and outcome: a randomized primary care study.

OBJECTIVE The authors examined the association of treatment preferences with treatment initiation, adherence, and clinical outcome among nonsenior adult and senior primary care patients with depression. METHODS Sixty primary care participants meeting DSM-IV criteria for major depression were randomly assigned to receive treatment congruent or incongruent with their primary stated preference. Participants received either 20 weeks of escitalopram, with monitoring by a care manager, or 12 weekly sessions of interpersonal psychotherapy followed by two monthly booster sessions. Adherence to treatment and depression severity were reassessed at weeks 4, 8, 12, and 24. RESULTS Participants expressed stronger preferences for psychotherapy than for antidepressant medication. Preference strength was a more sensitive measure of outcome than was congruence versus incongruence of preference with the assigned treatment. Across age groups, preference strength was significantly associated with treatment initiation and 12-week adherence rate but not with depression severity or remission. CONCLUSIONS A continuous measure of preference strength may be a more useful measure in clinical practice than preferences per se. Future research should focus on whether and how greater facilitation of the treatment decision-making process between patient and clinician influences clinical outcome.

Problem-solving therapy and supportive therapy in older adults with major depression and executive dysfunction: effect on disability.

CONTEXT Older patients with depression and executive dysfunction represent a population with significant disability and a high likelihood of failing pharmacotherapy. OBJECTIVES To examine whether problem-solving therapy (PST) reduces disability more than does supportive therapy (ST) in older patients with depression and executive dysfunction and whether this effect is mediated by improvement in depressive symptoms. DESIGN Randomized controlled trial. SETTING Weill Cornell Medical College and University of California at San Francisco. PARTICIPANTS Adults (aged >59 years) with major depression and executive dysfunction recruited between December 2002 and November 2007 and followed up for 36 weeks. Intervention Twelve sessions of PST modified for older depressed adults with executive impairment or ST. Main Outcome Measure Disability as quantified using the 12-item World Health Organization Disability Assessment Schedule II. RESULTS Of 653 individuals referred to this study, 221 met the inclusion criteria and were randomized to receive PST or ST. Both PST and ST led to comparable improvement in disability in the first 6 weeks of treatment, but a more prominent reduction was noted in PST participants at weeks 9 and 12. The difference between PST and ST was greater in patients with greater cognitive impairment and more previous episodes. Reduction in disability paralleled reduction in depressive symptoms. The therapeutic advantage of PST over ST in reducing depression was, in part, due to greater reduction in disability by PST. Although disability increased during the 24 weeks after the end of treatment, the advantage of PST over ST was retained. CONCLUSIONS These results suggest that PST is more effective than ST in reducing disability in older patients with major depression and executive dysfunction, and its benefits were retained after the end of treatment. The clinical value of this finding is that PST may be a treatment alternative in an older patient population likely to be resistant to pharmacotherapy. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00052091.

Long term effect of depression care management on mortality in older adults: follow-up of cluster randomized clinical trial in primary care

Objective To investigate whether an intervention to improve treatment of depression in older adults in primary care modified the increased risk of death associated with depression. Design Long term follow-up of multi-site practice randomized controlled trial (PROSPECT—Prevention of Suicide in Primary Care Elderly: Collaborative Trial). Setting 20 primary care practices in New York City, Philadelphia, and Pittsburgh, USA, randomized to intervention or usual care. Participants 1226 participants identified between May 1999 and August 2001 through a two stage, age stratified (60-74; ≥75 years) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of patients who screened negative. Intervention For two years, a depression care manager worked with primary care physicians in intervention practices to provide algorithm based care for depression, offering psychotherapy, increasing antidepressant dose if indicated, and monitoring symptoms, adverse effects of drugs, and adherence to treatment. This paper reports the long term follow-up. Main outcome measure Mortality risk based on a median follow-up of 98 (range 0.8-116.4) months through 2008. Results In baseline clinical interviews, 396 people were classified as having major depression, 203 had clinically significant minor depression, and 627 did not meet criteria for depression. At follow-up, 405 patients had died. Patients with major depression in usual care were more likely to die than were those without depression (hazard ratio 1.90, 95% confidence interval 1.57 to 2.31). In contrast, patients with major depression in intervention practices were at no greater risk than were people without depression (hazard ratio 1.09, 0.83 to 1.44). Patients with major depression in intervention practices, relative to usual care, were 24% less likely to have died (hazard ratio 0.76, 0.57 to 1.00; P=0.05). Preliminary data on cause of death are provided. No significant effect on mortality was found for minor depression. Conclusions Older adults with major depression in practices provided with additional resources to intensively manage depression had a mortality risk lower than that observed in usual care and similar to older adults without depression. Trial registration Clinical trials NCT00000367.

Impact of family burden and patient symptom status on clinical outcome in bipolar affective disorder

Studies have suggested that family burden adversely affects clinical outcome in the major mental disorders. Logistic regression analysis was used to evaluate the effect of family burden reported at baseline (acute model), or 7 months (stabilization model), on the risk of having a subsequent affective episode, in a sample of 264 patients with Research Diagnostic Criteria-diagnosed bipolar illness. Higher levels of baseline burden and a depressive index episode significantly increased the risk for a major episode at 7 months. Higher 7-month burden significantly increased the risk for a major episode at 15 months among patients with relatively low 7-month BPRS symptom levels. Caregiver burden reported at times of symptom relapse and during stabilization predicts subsequent adverse clinical outcomes among patients with bipolar disorder and suggests a need for family support.

A Randomized Trial of Depression Assessment Intervention in Home Health Care

OBJECTIVES: To determine whether an educational intervention would improve depression assessment and appropriate referral. Secondary analyses tested whether referral led to depression improvement.

Suicidal Ideation and Risk Levels Among Primary Care Patients With Uncomplicated Depression

PURPOSE We investigated the prevalence, severity, and course of passive and active suicidal ideation occurring in primary care patients with an uncomplicated depressive disorder. METHODS We studied suicidal ideation experienced by patients recruited in 60 primary care practices participating in a randomized controlled trial of depression management. Risk levels associated with suicidal ideation and plans were determined by a 2-stage procedure using pertinent items of the Patient Health Questionnaire-9, the Hopkins Symptom Checklist-20, and the Cornell structured assessment interview and management algorithm. RESULTS Of the 761 patients whom physicians judged in need of treatment for a clinical depression, 405 (53%) were experiencing uncomplicated dysthymia, major depression, or both. Among these depressed patients, about 90% had no risk or a low risk of self-harm based on the presence and nature of suicidal ideation; the rest had an intermediate risk. Almost all patients who were initially classified at the no or low risk levels remained at these levels during the subsequent 6 months. The incidence of suicidal ideation at a risk level requiring the physician’s immediate attention in this no- or low-risk subgroup was 1.1% at 3 months and 2.6% at 6 months. CONCLUSIONS Almost all patients with uncomplicated dysthymia, major depression, or both acknowledging suicidal ideation of the minimal risk type when initially assessed maintained this minimal risk status during the subsequent 6 months.