Treating Depressed Older Adults in Primary Care: Narrowing the Gap between Efficacy and Effectiveness

Unützer, Jürgen; Katon, Wayne; Sullivan, Mark D.; Miranda, Jeanne

doi:10.1111/1468-0009.00132

Cited by 154 publications

(118 citation statements)

References 116 publications

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“…Stigma may help explain the fact that few older adults identified depression spontaneously as one of their problems (7,(33)(34)(35), although participants acknowledged that others had characterized their condition as depression, and the sample had relatively high rates of past and current depression treatment. Their infrequent identification of depression may also reflect their view of its close association with other problems, particularly those pertaining to physical health, social support, physical functioning, and pain-a view consistent with the biopsychosocial perspective (36)(37)(38) and social models of depression (39), in which depression is viewed as arising from adverse personal and social circumstances that accrue in old age (40).…”

Section: Discussionmentioning

confidence: 99%

Perceptions About Competing Psychosocial Problems and Treatment Priorities Among Older Adults With Depression

Proctor

Hasche²,

Morrow‐Howell³

et al. 2008

Psychiatric Services

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Objective-Depression often co-occurs with other conditions that may pose competing demands to depression care, particularly in later life. This study examined older adults' perceptions of depression among cooccurring social, medical, and functional problems and compared the priority of depression with that of other problems.Methods-The study's purposeful sample comprised 49 adults age 60 or older with a history of depression and in publicly funded community long-term care. Fourpart, mixed-methods interviews sought to capture participants' perceptions of life problems as well as the priority they placed on depression. Methods included standardized depression screening, semistructured qualitative interviews, listing of problems, and qualitative and quantitative analysis of problem rankings.Results-Most participants identified health, functional, and psychosocial problems cooccurring with depressive symptoms. Depression was ranked low among the co-occurring conditions; 6% ranked depression as the most important of their problems, whereas 45% ranked it last. Relative rank scores for problems were remarkably similar, with the notable exception of depression, which was ranked lowest of all problems. Participants did not see depression as a high priority compared with co-occurring problems, particularly psychosocial ones.Conclusions-Effective and durable improvements to mental health care must be shaped by an understanding of client perceptions and priorities. Motivational interviewing, health education, and assessment of treatment priorities may be necessary in helping older adults value and accept depression care. Nonspecialty settings of care may effectively link depression treatment to other services, thereby increasing receptivity to mental health services.Depression is a major chronic illness that affects one-fourth to one-fifth of communitydwelling older adults (1,2). It diminishes quality of life, exacerbates physical and functional dependency (3-6), and increases medical costs (7,8). Although depression in later life can be effectively treated, most elderly people with depression remain untreated (9). Older adults are vulnerable to mental health service barriers (10), low detection and treatment rates in primary medical care (11,12), and pervasive stigma-their own as well as that from their family members and treatment providers. Depression treatment is further complicated by comorbidity with other problems. Although older adults with functional disability have higher rates of depression (13), they and their providers may demote depression treatment to a lower priority when medical, functional, and psychosocial comorbidities vie for attention (14). Competing demands may diminish depression as a priority concern, thereby contributing to inadequate rates of depression treatment (15).(e-mail: ekp@wustl.edu). The authors report no competing interests. NIH Public Access NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptThis study explored depression as a treatment priority among a gr...

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Section: Discussionmentioning

confidence: 99%

Perceptions About Competing Psychosocial Problems and Treatment Priorities Among Older Adults With Depression

Proctor

Hasche²,

Morrow‐Howell³

et al. 2008

Psychiatric Services

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“…33,34 When faced with competing demands for treating multiple chronic illnesses, physicians may give depression less priority for treatment compared with such illnesses as diabetes or arthritis. [35][36][37] The current fi ndings suggest, however, that depression severity is more pervasively associated with quality of life, functional status, and disability in depressed elders than most chronic medical illnesses.…”

Section: Discussionmentioning

confidence: 99%

Depression and Comorbid Illness in Elderly Primary Care Patients: Impact on Multiple Domains of Health Status and Well-being

Noël

Williams

Unützer

et al. 2004

The Annals of Family Medicine

223

136

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PURPOSE Our objective was to examine the relative association of depression severity and chronicity, other comorbid psychiatric conditions, and coexisting medical illnesses with multiple domains of health status among primary care patients with clinical depression. METHODSWe collected cross-sectional data as part of a treatment effectiveness trial that was conducted in 8 diverse health care organizations. Patients aged 60 years and older (N = 1,801) who met diagnostic criteria for major depression or dysthymia participated in a baseline survey. A survey instrument included questions on sociodemographic characteristics, depression severity and chronicity, neuroticism, and the presence of 11 common chronic medical illnesses, as well as questions screening for panic disorder and posttraumatic stress disorder. Measures of 4 general health indicators (physical and mental component scales of the SF-12, Sheehan Disability Index, and global quality of life) were included. We conducted separate mixed-effect regression linear models predicting each of the 4 general health indicators.RESULTS Depression severity was signifi cantly associated with all 4 indicators of general health after controlling for sociodemographic differences, other psychological dysfunction, and the presence of 11 chronic medical conditions. Although study participants had an average of 3.8 chronic medical illnesses, depression severity made larger independent contributions to 3 of the 4 general health indicators (mental functional status, disability, and quality of life) than the medical comorbidities.CONCLUSIONS Recognition and treatment of depression has the potential to improve functioning and quality of life in spite of the presence of other medical comorbidities. 2004;2:555-562. DOI: 10.1370/afm.143. Ann Fam Med INTRODUCTIONE pidemiological and clinical studies consistently indicate that depression adversely affects the lives of older adults. The relative contribution to adverse effects is not entirely clear, because depression often occurs in conjunction with other psychiatric illnesses, such as anxiety disorders; somatic symptoms, such as pain; and chronic medical illnesses, such as diabetes. The latter is particularly of concern, because it is often diffi cult to know whether a particular symptom, such as lethargy, is caused by depression, a coexisting medical illness, or both. Patients with chronic medical illness are known to have a high prevalence of comorbid depression.1 Furthermore, both major depressive disorder and subsyndromal depression have been associated with increased somatic symptoms, morbidity, mortality, health care utilization, and costs in the presence of comorbidities. 5-7 Furthermore, severity of depressive symptoms is inversely related to patients' health-related quality of life, even after controlling for age, sex, and medical comorbidities. 8,9 Many older persons, however, have more than one chronic illness that may differentially impair health status. Elders with multiple comorbidities may be particularly vulne...

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“…For these interactions to take place, an infrastructure needs to support this dyad. The model is effective across a wide range of chronic diseases, including depression, as evidenced by results from studies of multiple programs such as the PROSPECT, 16 IMPACT, 17 and Partners in Care 18 programs.…”

Section: ■■ Potential Strategiesmentioning

confidence: 99%

Depression and Primary Care

Pincus¹

2006

JMCP

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Treating Depressed Older Adults in Primary Care: Narrowing the Gap between Efficacy and Effectiveness

Cited by 154 publications

References 116 publications

Perceptions About Competing Psychosocial Problems and Treatment Priorities Among Older Adults With Depression

Perceptions About Competing Psychosocial Problems and Treatment Priorities Among Older Adults With Depression

Depression and Comorbid Illness in Elderly Primary Care Patients: Impact on Multiple Domains of Health Status and Well-being

Depression and Primary Care

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