Effect of Collaborative Care vs Usual Care on Depressive Symptoms in Older Adults With Subthreshold Depression

Abstract

IMPORTANCE There is little evidence to guide management of depressive symptoms in older people. OBJECTIVE To evaluate whether a collaborative care intervention can reduce depressive symptoms and prevent more severe depression in older people. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted from May 24, 2011, to November 14, 2014, in 32 primary care centers in the United Kingdom among 705 participants aged 65 years or older with Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) subthreshold depression; participants were followed up for 12 months. INTERVENTIONS Collaborative care (n=344) was coordinated by a case manager who assessed functional impairments relating to mood symptoms. Participants were offered behavioral activation and completed an average of 6 weekly sessions. The control group received usual primary care (n=361). MAIN OUTCOMES AND MEASURES The primary outcome was self-reported depression severity at 4-month follow-up on the 9-item Patient Health Questionnaire (PHQ-9; score range, 0-27). Included among 10 prespecified secondary outcomes were the PHQ-9 score at 12-month follow-up and the proportion meeting criteria for depressive disorder (PHQ-9 score Ն10) at 4-and 12-month follow-up. RESULTS The 705 participants were 58% female with a mean age of 77 (SD, 7.1) years. Four-month retention was 83%, with higher loss to follow-up in collaborative care (82/344 [24%]) vs usual care (37/361 [10%]). Collaborative care resulted in lower PHQ-9 scores vs usual care at 4-month follow-up. The proportions of participants meeting criteria for depression at 4-month follow-up were 17.2% (45/262) vs 23.5% (76/324), respectively (difference, −6.3% [95% CI, −12.8% to 0.2%]; relative risk, 0.83 [95% CI, 0.61-1.27]; P = .25) and at 12-month follow-up were 15.7% (37/235) vs 27.8% (79/284) (difference, −12.1% [95% CI, −19.1% to −5.1%]; relative risk, 0.65 [95% CI, 0.46-0.91]; P = .01). Collaborative Care Usual Care Difference (95% CI) P Value PHQ-9 score, mean At 4 mo (primary outcome) 5.36 6.67 −1.31 (−1.95 to −0.67) <.001 At 12 mo 5.93 7.25 −1.33 (−2.10 to −0.55) .001 CONCLUSIONS AND RELEVANCE Among older adults with subthreshold depression, collaborative care compared with usual care resulted in a statistically significant difference in depressive symptoms at 4-month follow-up, of uncertain clinical importance. Although differences persisted through 12 months, findings are limited by attrition, and further research is needed to assess longer-term efficacy.

CollAborative care for Screen-Positive EldeRs with major depression (CASPER plus): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness

“…50 The effect size is consistent with findings from systematic reviews of collaborative care, as summarised in a recent Cochrane review, 22 and is also of the same order of magnitude as that seen in UK trials of collaborative care for working-age adults, such as those observed in the recently published CADET 69 and also in the recently completed CASPER trial for older people with lower-severity depression. 29,30 The CASPER plus trial also showed benefits across a range of secondary outcomes, and it was notable that there were improvements in anxiety symptoms, somatoform symptoms and quality of life (mental domain as measured by the SF-12). These benefits were seen in the short term (4 months) and were also sustained at 12 months for secondary outcomes (but not for the outcome of depression severity).…”

“…To detect a minimum standard effect size of 0.35 (aligning with the US IMPACT study 16 and our previous CASPER trial 29,30 ) with 80% power and a two-sided 5% significance level, 260 patients (130 per arm) would be required. Although this is an individually randomised trial, there may be potential clustering at the level of each collaborative care case manager, and hence the sample size was inflated to account for this.…”

Behavioural activation by mental health nurses for late-life depression in primary care: a randomized controlled trial

“…The patients eligible for treatment in PCCs will be a more mixed population suffering from clinically relevant depressive symptoms although less severe than patients referred to specialist care. In studies on collaborative care for depressed older adults, BA-treatment by MHNs is delivered in 8 to 10 15–45 min sessions [34, 35]. We decided to adjust BA intensity to a level that would fit the contemporary Dutch model for MHN-delivered care in PCCs.…”

“…In another RCT ‘collaborative care’ BA was the principal treatment compared to TAU for older adults with subclinical depressive symptoms. The study found a small to medium effect of collaborative care on depressive symptoms compared to TAU [35]. In both studies, BA was only a component of a new care management plan, so the direct effects of BA on depressive symptoms could not be determined.…”

Nieuws

“…Ouderen die hier last van hebben, rapporteren vaak een lagere kwaliteit van leven. Dat is reden te meer, zo dachten onderzoekers uit York (UK) 1 , om deze 'subthreshold symptoms' nader onder de loep te nemen. Zij onderzochten daarvoor 705 ouderen met een gemiddelde leeftijd van 77 jaar.…”