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Randomized trial of case-finding for depression in elderly primary care patients

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Abstract

OBJECTIVE: To determine the effect of case-finding for depression on frequency of depression diagnoses, prescriptions for antidepressant medications, prevalence of depression, and health care utilization during 2 years of follow-up in elderly primary care patients.

DESIGN: Randomized controlled trial.

SETTING: Thirteen primary care medical clinics at the Kaiser Permanente Medical Center, an HMO in Oakland, Calif, were randomly assigned to intervention conditions (7 clinics) or control conditions (6 clinics).

PARTICIPANTS: A total of 2,346 patients aged 65 years or older who were attending appointments at these clinics and completed the 15-item Geriatric Depression Scale (GDS). GDS scores of 6 or more were considered suggestive of depression.

INTERVENTIONS: Primary care physicians in the intervention clinics were notified of their patients’ GDS scores. We suggested that participants with severe depressive symptoms (GDS score ≥ 11) be referred to the Psychiatry Department and participants with mild to moderate depressive symptoms (GDS score of 6–10) be evaluated and treated by the primary care physician. Intervention group participants with GDS scores suggestive of depression were also offered a series of organized educational group sessions on coping with depression led by a psychiatric nurse. Primary care physicians in the control clinics were not notified of their patients’ GDS scores or advised of the availability of the patient education program (usual care). Participants were followed for 2 years.

MEASUREMENTS AND MAIN RESULTS: Physician diagnosis of depression, prescriptions for antidepressant medications, prevalence of depression as measured by the GDS at 2-year follow-up, and health care utilization were determined. A total of 331 participants (14%) had GDS scores suggestive of depression (GDS ≥ 6) at baseline, including 162 in the intervention group and 169 in the control group. During the 2-year follow-up period, 56 (35%) of the intervention participants and 58 (34%) of the control participants received a physician diagnosis of depression (odds ratio [OR], 1.0; 95% confidence interval [CI], 0.6 to 1.6; P=.96). Prescriptions for antidepressants were received by 59 (36%) of the intervention participants and 72 (43%) of the control participants (OR, 0.8; 95% CI, 0.5 to 1.2; P=.3). Two-year follow-up GDS scores were available for 206 participants (69% of survivors): at that time, 41 (42%) of the 97 intervention participants and 54 (50%) of the 109 control participants had GDS scores suggestive of depression (OR, 0.7; 95% CI, 0.4 to 1.3; P=.3). Comparing participants in the intervention and control groups, there were no significant differences in mean GDS change scores (−2.4±SD 3.7 vs −2.1 SD±3.6; P=.5) at the 2-year follow-up, nor were there significant differences in mean number of clinic visits (1.8±SD 3.1 vs 1.6±SD 2.8; P=.5) or mean number of hospitalizations (1.1±SD 1.6 vs 1.0±SD 1.4; P=.8) during the 2-year period. In participants with initial GDS scores >11, there was a mean change in GDS score of −5.6±SD 3.9 for intervention participants (n=13) and −3.4±SD 4.5 for control participants (n=21). Adjusting for differences in baseline characteristics between groups did not affect results.

CONCLUSIONS: We were unable to demonstrate any benefit from case-finding for depression during 2 years of follow-up in elderly primary care patients. Studies are needed to determine whether case-finding combined with more intensive patient education and follow-up will improve outcomes of primary care patients with depression.

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References

  1. Depression Guideline Panel. Depression in Primary Care, Vol 1: Detection and Diagnosis. Clinical Practice Guideline. Washington, DC: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1993. AHCPR publication 93-0550.

  2. Hirschfeld RMA, Keller MB, Panico S, et al. The national depressive and manic-depressive association consensus statement on the undertreatment of depression. JAMA. 1997;277:333–40.

    Article  PubMed  CAS  Google Scholar 

  3. Bruce ML, Seeman TE, Merrill SS, Blazer DG. The impact of depressive symptomatology on physical disability: MacArthur Studies of Successful Aging. Am J Public Health. 1994;84:1796–9.

    Article  PubMed  CAS  Google Scholar 

  4. Lebowitz BD, Pearson JL, Schneider LS, et al. Diagnosis and treatment of depression in late life: consensus statement update. JAMA. 1997;278:1186–90.

    Article  PubMed  CAS  Google Scholar 

  5. Penninx BW, Guralnik JM, Ferrucci L, Simonsick EM, Deeg DJ, Wallace RB. Depressive symptoms and physical decline in community-dwelling older persons. JAMA. 1998;279:1720–6.

    Article  PubMed  CAS  Google Scholar 

  6. Whooley MA, Browner WS. Association between depressive symptoms and mortality in older women. Arch Intern Med. 1998;158:2129–35.

    Article  PubMed  CAS  Google Scholar 

  7. Schulberg HC, McClelland M, Gooding W. Six-month outcomes for medical patients with major depressive disorders. J Gen Intern Med. 1987;2:312–7.

    Article  PubMed  CAS  Google Scholar 

  8. Dowrick C, Buchan I. Twelve month outcome of depression in general practice: does detection or disclosure make a difference? BMJ. 1995;311:1274–6.

    PubMed  CAS  Google Scholar 

  9. Callahan CM, Hendrie HC, Dittus RS, Brater DC, Hui SL, Tierney WM. Improving treatment of late life depression in primary care: a randomized clinical trial. J Am Geriatr Soc. 1994;42:839–46.

    PubMed  CAS  Google Scholar 

  10. Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med. 1995;4:99–105.

    Article  PubMed  CAS  Google Scholar 

  11. Tiemens BG, Ormel J, Simon GE. Occurrence, recognition, and outcome of psychological disorders in primary care. Am J Psychiatry. 1996;153:636–44.

    PubMed  CAS  Google Scholar 

  12. Williams JW, Mulrow CD, Kroenke K, et al. Case-finding for depression in primary care: a randomized trial. Am J Med. 1999;106:36–43.

    Article  PubMed  Google Scholar 

  13. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams & Wilkins; 1996.

    Google Scholar 

  14. Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa, Ont: Canada Communication Group; 1994.

    Google Scholar 

  15. Yesavage JA. Geriatric Depression Scale. Psychopharmacol Bull. 1988;24:709–11.

    PubMed  CAS  Google Scholar 

  16. Gerety MB, Williams J Jr, Mulrow CD, et al. Performance of casefindings tools for depression in the nursing home: influence of clinical and functional characteristics and selection of optimal threshold scores. J Am Geriatr Soc. 1994;42:1103–9.

    PubMed  CAS  Google Scholar 

  17. Lyness JM, Noel TK, Cox C, King DA, Conwell Y, Caine ED. Screening for depression in elderly primary care patients: a comparison of the Center for Epidemiologic Studies—Depression Scale and the Geriatric Depression Scale. Arch Intern Med. 1997;157:449–54.

    Article  PubMed  CAS  Google Scholar 

  18. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;5:165–73.

    Article  Google Scholar 

  19. Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA. 1984;252:1905–7.

    Article  PubMed  CAS  Google Scholar 

  20. Mayfield D, McLeod G, Hall P. The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry. 1974;131:1121–3.

    PubMed  CAS  Google Scholar 

  21. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.

    Article  PubMed  CAS  Google Scholar 

  22. U.S. Department of Health and Human Services. ICD-9-CM. The International Classification of Diseases, 9th Revision, Clinical Modification, Vol 1. Washington, DC: US Government Printing Office; 1980.

    Google Scholar 

  23. Wells KB, Burnam MA, Leake B, Robins LN. Agreement between face-to-face and telephone-administered versions of the depression section of the NIMH Diagnostic Interview Schedule. J Psychiatr Res. 1988;22:207–20.

    Article  PubMed  CAS  Google Scholar 

  24. Simon GE, Revicki D, VonKorff M. Telephone assessment of depression severity. J Psychiatr Res. 1993;27:247–52.

    Article  PubMed  CAS  Google Scholar 

  25. Simon GE, Goldberg D, Tiemens BG, Ustun TB. Outcomes of recognized and unrecognized depression in an international primary care study. Gen Hosp Psychiatry. 1999;21:97–105.

    Article  PubMed  CAS  Google Scholar 

  26. Depression Guideline Panel. Depression in Primary Care, Vol 2: Treatment of Major Depression. Clinical Practice Guideline. Washington, DC: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1993. AHCPR publication 93-0551.

    Google Scholar 

  27. Katon W, von Korff M, Lin E, Bush T, Ormel J. Adequacy and duration of antidepressant treatment in primary care. Med Care. 1992;30:67–76.

    Article  PubMed  CAS  Google Scholar 

  28. Simon GE, Von Korff M, Wagner EH, Barlow W. Patterns of antidepressant use in community practice. Gen Hosp Psychiatry. 1993;15:399–408.

    Article  PubMed  CAS  Google Scholar 

  29. Simon GE, Lin EHB, Katon W, et al. Outcomes of “inadequate” antidepressant treatment. J Gen Intern Med. 1995;10:663–70.

    Article  PubMed  CAS  Google Scholar 

  30. Wells KB, Katon W, Rogers B, Camp P. Use of minor tranquilizers and antidepressant medications by depressed outpatients: results from the medical outcomes study. Am J Psychiatry. 1994;151:694–700.

    PubMed  CAS  Google Scholar 

  31. Keller MB, Klerman GL, Lavori PW, Fawcett JA, Coryell W, Endicott J. Treatment received by depressed patients. JAMA. 1982;248:1848–55.

    Article  PubMed  CAS  Google Scholar 

  32. Lin EH, Von Korff M, Katon W, et al. The role of the primary care physician in patients’ adherence to antidepressant therapy. Med Care. 1995;33:67–74.

    Article  PubMed  CAS  Google Scholar 

  33. Perez-Stable EJ, Miranda J, Munoz RF, Ying YW. Depression in medical outpatients: underrecognition and misdiagnosis. Arch Intern Med. 1990;150:1083–8.

    Article  PubMed  CAS  Google Scholar 

  34. Eisenberg L. Treating depression and anxiety in primary care: closing the gap between knowledge and practice. N Engl J Med. 1992;326:1080–4.

    Article  PubMed  CAS  Google Scholar 

  35. Callahan CM, Dittus RS, Tierney WM. Primary care physicians’ medical decision making for late-life depression. J Gen Intern Med. 1996;11:218–25.

    PubMed  CAS  Google Scholar 

  36. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA. 1995;273:1026–31.

    Article  PubMed  CAS  Google Scholar 

  37. Schulberg HC, Block MR, Madonia MJ, et al. Treating major depression in primary care practice: eight-month clinical outcomes. Arch Gen Psychiatry. 1996;53:913–9.

    PubMed  CAS  Google Scholar 

  38. Wells KB, Sherbourne CD, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283:212–20.

    Article  PubMed  CAS  Google Scholar 

  39. Rubenstein LV, Jackson-Triche M, Unutzer J, et al. Evidence-based care for depression in managed primary care practices. Health Aff. 1999;18:89–105.

    Article  CAS  Google Scholar 

  40. Ormel J, Tiemens B. Recognition and treatment of mental illness in primary care: towards a better understanding of a multifaceted problem. Gen Hosp Psychiatry. 1995;17:160–4.

    Article  PubMed  CAS  Google Scholar 

  41. Coyne JC, Schwenk TL, Fechner-Bates S. Nondetection of depression by primary care physicians reconsidered. Gen Hosp Psychiatry. 1995;17:3–12.

    Article  PubMed  CAS  Google Scholar 

  42. Beck DA, Koenig HG. Minor depression: a review of the literature. Int J Psychiatry Med. 1996;26:177–209.

    Article  PubMed  CAS  Google Scholar 

  43. Judd LL, Akiskal HS, Maser JD, et al. A prospective 12-year study of subsyndromal and syndromal depressive symptoms in unipolar major depressive disorders. Arch Gen Psychiatry. 1998;55:694–700.

    Article  PubMed  CAS  Google Scholar 

  44. Lyness JM, King DA, Cox C, Yoediono Z, Caine ED. The importance of subsyndromal depression in older primary care patients: prevalence and associated functional disability. J Am Geriatr Soc. 1999;47:647–52.

    PubMed  CAS  Google Scholar 

  45. Miranda J, Munoz R. Intervention for minor depression in primary care patients. Psychosom Med. 1994;56:136–41.

    PubMed  CAS  Google Scholar 

  46. Paykel ES, Hollyman JA, Freeling P, Sedgwick P. Predictors of therapeutic benefit from amitriptyline in mild depression: a general practice placebo-controlled trial. A Affect Disord. 1988;14:83–95.

    Article  CAS  Google Scholar 

  47. Elkin I, Shea MT, Watkins JT, et al. National Institute of Mental Health Treatment of Depression Collaborative Research Program: general effectiveness of treatments. Arch Gen Psychiatry. 1989;46:971–82.

    PubMed  CAS  Google Scholar 

  48. Mulrow CD, Williams J Jr, Gerety MB, Ramirez G, Montiel OM, Kerber C. Case-finding instruments for depression in primary care settings. Ann Intern Med. 1995;122:913–21.

    PubMed  CAS  Google Scholar 

  49. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression: two questions are as good as many. J Gen Intern Med. 1997;12:439–45.

    Article  PubMed  CAS  Google Scholar 

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Correspondence to Mary A. Whooley MD.

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Dr. Whooley is supported by a Research Career Development Award from the Department of Veterans Affairs Health Services Research and Development Service. This study was funded by a grant from the Garfield Memorial Fund.

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Whooley, M.A., Stone, B. & Soghikian, K. Randomized trial of case-finding for depression in elderly primary care patients. J GEN INTERN MED 15, 293–300 (2000). https://doi.org/10.1046/j.1525-1497.2000.04319.x

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  • DOI: https://doi.org/10.1046/j.1525-1497.2000.04319.x

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