Guideline for the management of late‐life depression in primary care

Baldwin, Robert C.; Anderson, D. N.; Black, Simon; Evans, Sandra; Jones, Rob; Wilson, Ken; Iliffe, Steve

doi:10.1002/gps.940

Cited by 98 publications

(59 citation statements)

References 61 publications

(67 reference statements)

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“…9 If depression was detected, evidence-supported guidance advocated the prescription of antidepressant drugs and appropriate provision of psychological care. 6,7,10 However, this indicator was retired in 2013 as part of the 2013/14 General Medical Services contract changes. 11 Irrespective of these recent Quality and Outcomes Framework changes, the focus to date has been on identifying and treating those with more severe depressive syndromes as set down in classificatory systems such as the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) 12 (major depressive disorder) or the International Statistical Classification of Diseases and Related Health Problems, 10th Revision 13 (moderate/ severe depressive disorder).…”

Section: Depression In Older Adultsmentioning

confidence: 99%

“…10 A large cross-sectional study conducted in 20 countries 4 showed that even relatively minor levels of depression are associated with a significant decrement in all quality-of-life domains and with a pattern of negative attitudes towards ageing. Subthreshold depression is also a clear risk factor for progression and the development of more severe depressive syndromes.…”

Section: Subthreshold Depressionmentioning

confidence: 99%

“…Yet the case for screening for depression among older adults was clear, given that a substantial proportion of that age group who have a depressive syndrome go unrecognised and untreated. 10 Indeed, the Chief Medical Officer's 2013 annual report, 16 which focused on mental health, highlighted that depression is poorly detected in primary care and that around 10-20% of people aged ≥ 65 years have depression. Given that the proportion of older people with subthreshold depression is likely to be far greater than the proportion with case-level depression, the rationale for the CASPER trial is strong.…”

Section: Rationale For the Casper Trialmentioning

confidence: 99%

“…2,10 Although a range of individual treatments have been shown to be effective in the management of clinical depression in older adults, including antidepressants and psychosocial interventions, 10 a repeated observation among those with depression has been the failure to integrate these effective elements of care into routine primary care services. 17 Additionally, the implementation of any form of care will require a strategy that both is of low intensity and can be offered within primary care.…”

Section: Rationale For the Casper Trialmentioning

confidence: 99%

See 3 more Smart Citations

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

Lewis

Adamson

Atherton

et al. 2017

Health Technol Assess

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BackgroundEfforts to reduce the burden of illness and personal suffering associated with depression in older adults have focused on those with more severe depressive syndromes. Less attention has been paid to those with mild disorders/subthreshold depression, but these patients also suffer significant impairments in their quality of life and level of functioning. There is currently no clear evidence-based guidance regarding treatment for this patient group.ObjectivesTo establish the clinical effectiveness and cost-effectiveness of a low-intensity intervention of collaborative care for primary care older adults who screened positive for subthreshold depression.DesignA pragmatic, multicentred, two-arm, parallel, individually randomised controlled trial with a qualitative study embedded within the pilot. Randomisation occurred after informed consent and baseline measures were collected.SettingThirty-two general practitioner (GP) practices in the north of England.ParticipantsA total of 705 participants aged ≥ 75 years during the pilot phase and ≥ 65 years during the main trial with subthreshold depression.InterventionsParticipants in the intervention group received a low-intensity intervention of collaborative care, which included behavioural activation delivered by a case manager for an average of six sessions over 7–8 weeks, alongside usual GP care. Control-arm participants received only usual GP care.Main outcome measuresThe primary outcome measure was a self-reported measure of depression severity, the Patient Health Questionnaire-9 items PHQ-9 score at 4 months post randomisation. Secondary outcome measures included the European Quality of Life-5 Dimensions, Short Form questionnaire-12 items, Patient Health Questionnaire-15 items, Generalised Anxiety Disorder seven-item scale, Connor–Davidson Resilience Scale two-item version, a medication questionnaire and objective data. Participants were followed up for 12 months.ResultsIn total, 705 participants were randomised (collaborative caren = 344, usual caren = 361), with 586 participants (83%; collaborative care 76%, usual care 90%) followed up at 4 months and 519 participants (74%; collaborative care 68%, usual care 79%) followed up at 12 months. Attrition was markedly greater in the collaborative care arm. Model estimates at the primary end point of 4 months revealed a statistically significant effect in favour of collaborative care compared with usual care [mean difference 1.31 score points, 95% confidence interval (CI) 0.67 to 1.95 score points;p < 0.001]. The difference equates to a standard effect size of 0.30, for which the trial was powered. Treatment differences measured by the PHQ-9 were maintained at 12 months’ follow-up (mean difference 1.33 score points, 95% CI 0.55 to 2.10 score points;p = 0.001). Base-case cost-effectiveness analysis found that the incremental cost-effectiveness ratio was £9633 per quality-adjusted life-year (QALY). On average, participants allocated to collaborative care displayed significantly higher QALYs than those allocated to the control group (annual difference in adjusted QALYs of 0.044, 95% bias-corrected CI 0.015 to 0.072;p = 0.003).ConclusionsCollaborative care has been shown to be clinically effective and cost-effective for older adults with subthreshold depression and to reduce the proportion of people who go on to develop case-level depression at 12 months. This intervention could feasibly be delivered in the NHS at an acceptable cost–benefit ratio. Important future work would include investigating the longer-term effect of collaborative care on the CASPER population, which could be conducted by introducing an extension to follow-up, and investigating the impact of collaborative care on managing multimorbidities in people with subthreshold depression.Trial registrationCurrent Controlled Trials ISRCTN02202951.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 21, No. 8. See the NIHR Journals Library website for further project information.

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Section: Depression In Older Adultsmentioning

confidence: 99%

Section: Subthreshold Depressionmentioning

confidence: 99%

Section: Rationale For the Casper Trialmentioning

confidence: 99%

Section: Rationale For the Casper Trialmentioning

confidence: 99%

See 2 more Smart Citations

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

Lewis

Adamson

Atherton

et al. 2017

Health Technol Assess

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show abstract

“…In the UK, an estimated 15% of adults aged over 65 years experience symptoms of depression; a prevalence rate that is relatively consistent across countries and cultures (Beekman, Copeland, & Prince, 1999;Braam, Copeland, Delespaul et al, 2014). In older adults depression is associated with greater medical illness, disability, functional decline, and is the leading cause of suicide in this age group (Baldwin, Anderson, Black et al, 2003).…”

Section: Introductionmentioning

confidence: 99%

Life adversity in depressed and non-depressed older adults: A cross-sectional comparison of the brief LTE-Q questionnaire and life events and difficulties interview as part of the CASPER study

Donoghue

Traviss‐Turner

House

et al. 2016

Journal of Affective Disorders

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250wBackground: There is a paucity of research on the nature of life adversity in depressed and nondepressed older adults. Early life events work used in-depth interviews; however, larger epidemiological trials investigate life adversity using brief questionnaires. This study investigates the type of life adversity experienced in later life and its association with depression and compares adversity captured using a brief (LTE-Q) and in-depth (LEDS) measure.Methods: 960 participants over 65 years were recruited in UK primary care to complete the PHQ-9 and LTE-Q.A sub-sample (n=19) completed the LEDS and a question exploring the subjective experience of the LTE-Q and LEDS.Results: Important life adversity was reported on the LTE-Q in 48% of the sample. In the LTE-Q sample the prevalence of depression (PHQ-E the odds of depression. The LTE-Q only captured a proportion of adversity measured by the LEDS (42% vs 84%). Both measures showed health, bereavement and relationship events were most common.Limitations: The cross-sectional design limits the extent to which inferences can be drawn around the direction of causality between adversity and depression. Recall in older adults is questionable.Conclusions: UK older adults face adversity in areas of health, bereavement and relationships which are associated with depression. This has clinical relevance for psychological interventions for older adults to consider social context and social support. It helps identify the strengths and weaknesses of a brief adversity measure in large scale research. Further research is needed to explore the mechanisms of onset and direction of causality.

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

Gilbody

Lewis

Adamson

et al. 2017

JAMA

101

139

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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.

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Guideline for the management of late‐life depression in primary care

Cited by 98 publications

References 61 publications

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

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

Life adversity in depressed and non-depressed older adults: A cross-sectional comparison of the brief LTE-Q questionnaire and life events and difficulties interview as part of the CASPER study

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

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