Care management reduces depression and suicidal thoughts in older
primary care patients
Depression in older adults too often goes
unrecognized and untreated, resulting in untold misery, worsening of
medical illness, and early death.
A new study has identified one
important remedy: Adding a trained depression care manager to primary
care practices can increase the number of patients receiving treatment,
lead to a higher remission rate of depression, and reduce suicidal thoughts.
The two-year outcomes of the multicenter Prevention of Suicide in
Primary Care Elderly: Collaborative Trial (PROSPECT) study are published
online in the American Journal of Psychiatry.
Lead author of the study is Dr. George S. Alexopoulos, director of the
Institute of Geriatric Psychiatry at NewYork-Presbyterian
Hospital/Westchester Division and professor of psychiatry at Weill
Cornell Medical College.
"Almost one in 10 older adults in the United States has some form of
depression, and one-fifth among them contemplates suicide. Two-thirds of
these patients are treated by primary care physicians. Sadly, their
depression is often inadequately treated due to the primary care
physician's time constraints and the patient's reluctance to discuss
their symptoms and adhere to treatment," says Dr. Alexopoulos. "The
critical finding of the PROSPECT study is that adding a trained care
manager to primary care practices increases the number of depressed
older patients who receive treatment and improves their outcomes, not
only in the short term, but over two years.
"This is important because depression can either become chronic or
relapse after an initial improvement," adds Dr. Alexopoulos. "Most
diseases have worse outcomes when an old person becomes depressed.
Depression almost doubles the risk for death. It follows that treating
depression effectively can reduce sickness, disability and death."
The study, conduced by NewYork Presbyterian/Weill Cornell, the
University of Pittsburgh, and the University of Pennsylvania, followed
599 patients aged 60 years and older with depression at 20 primary care
practices of varying sizes in New York and Pennsylvania. Participants
were randomized to receive either the PROSPECT intervention or usual
care. Those in the PROSPECT group were assigned a care manager -- a
trained social worker, nurse or psychologist -- who helped the physician
offer treatment according to accepted practice guidelines, monitored
treatment response and provided follow-up over two years. Practice
guidelines included the antidepressant citalopram (Celexa), with the
option of other drugs or psychotherapy.
After two years, nearly 90 percent of patients in the PROSPECT care
management group had received treatment for depression, compared with 62
percent of those receiving usual care by their physicians. The decline
in suicidal ideation (thinking about and/or planning suicide) was 2.2
times greater in the PROSPECT group.
Remission of depression happened faster in the PROSPECT intervention
group and remission rates continued to increase between months 18 and
24, while no appreciable increase occurred in the usual care group
during the same period.
The PROSPECT intervention worked especially well for a subgroup of
patients with major depression, the more severe form of the disease,
with a greater number achieving remission, or the near absence of
symptoms. Patients with minor depression had favorable outcomes
regardless of their study group.
Various forms of care management are being used successfully for
cardiovascular patients needing anticoagulation medication and for
diabetes patients needing insulin monitoring, says Dr. Alexopoulos. "The
PROSPECT study has demonstrated that care management is highly
successful for older adults with major depression."
"At this time, our nation is focused on disease prevention as a way to
improve the health of Americans and to reduce health care cost. Reducing
depression over long periods of time can be one of the ways to achieve
this objective," continues Dr. Alexopoulos. "Care management, like that
of the PROSPECT study, is relatively inexpensive. Finding ways to
reimburse it can make it broadly available and have a major impact on
the overall heath care."
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