Coordinated Treatment of Depression in Elderly People in Primary Care

Abstract

epression is one of the commonest mental illnesses affecting persons aged 65 and above (whom we shall call "the elderly" in the rest of this article), with an annual prevalence of 14% (1). Approximately 10% of elderly patients in primary care have depression (2). This highly prevalent condition is clinically significant because it markedly impairs functional ability and quality of life (3), elevates mortality due to suicide (4), and worsens concomitant somatic illnesses (5). Elderly patients with depression suffer from specific care deficits. Depression is often more difficult to diagnose in the elderly because of concomitant somatic illnesses, along with a tendency for the manifestations of depression to be somatically oriented (6, 7). The elderly rarely receive psychotherapy even when it is indicated and are less likely to be treated in accordance with the guidelines (8). The reasons for this include negative attitudes toward aging that cause patients, physicians, and psychotherapists to have low expectations for the treatability of depression, as well as lack of information, the fear that patients will be stigmatized, and inadequate network integration of physicians and psychotherapists (9, 10). Most elderly patients with depression are treated solely in primary care (11, 12). Elderly patients, like younger ones, may need psychosocial intervention (13, 14); it has been found that elderly patients are more likely to be open to receiving such kind of treatment if the diagnosis is established by a primary care physician (13). Newer care models address these care deficits (15). One of the more successful ones is the "Improving Mood-Promoting Access to Collaborative Treatment" (IMPACT) model (16), in which the depressed patient is treated in collaboration by the primary care physician, a care manager, and a supervising psychiatrist or psychotherapist. This model was developed in the USA, and studies there have shown it to be beneficial; it has since been implemented in other countries and found to be beneficial there as well (17). The model has now been adapted for use in Germany. In the GermanIMPACT study, we evaluated its effectiveness in comparison to the alternative of usual treatment.

Types of Utilization and Types of Treatment Response in a Collaborative Care Approach for Depressive Disorders in Old Age in Primary Care

“…The control group received treatment as usual (TAU) by GPs. This complex intervention, which was carried out over 1 year, was superior to TAU; 25.6% of the intervention group showed a remission of depressive symptoms compared with 10.9% of TAU (16). This result is comparable with the original US study (17), as well as with other international adaptations (18).…”

“…After 12 months, the adjusted and estimated remission rate in the intervention group was 25.6% (95% confidence interval, 18.3-32.8), correspondence, 10.9% (5.4-16.5) in the control group (p = 0.004). The detailed study design and the main outcomes are described elsewhere (15,16). The rate of response to treatment was even higher in the intervention group, 22.5% (14.6-30.5) compared with 10.5% (4.1-16.9) in the control group.…”

Cost-effectiveness analysis of collaborative treatment of late-life depression in primary care (GermanIMPACT)

“…All patients gave their written informed consent for study participation prior to the study. A detailed description of the study methods can be found elsewhere [15, 16].…”

“…Such a collaborative care approach for late-life depression is the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) program which has already been proven effective and cost-effective in the USA [13, 14]. The IMPACT program has been recently adapted to the German primary care context and a compatible concept has been developed and proven effective [15, 16].…”

Current state of research on psychotherapy for home-living vulnerable older adults with depression

“…The IMPACT intervention significantly reduced depressive symptoms compared to treatment as usual. A German adaptation, the GermanIMPACT has been conducted as a cluster RCT [41] and yielded significantly positive results concerning depression remission rates compared to treatment as usual [17]. While the participating physicians perceived the program as reducing their workload, the general participation of primary care physicians was low.…”