Long Term Effect of Depression Care Management on Mortality
Long Term Effect of Depression Care Management on Mortality
Objective. To investigate whether an intervention to improve treatment of depression in older adults in primary care modified the increased risk of death associated with depression.
Design. Long term follow-up of multi-site practice randomized controlled trial (PROSPECT—Prevention of Suicide in Primary Care Elderly: Collaborative Trial).
Setting. 20 primary care practices in New York City, Philadelphia, and Pittsburgh, USA, randomized to intervention or usual care.
Participants. 1226 participants identified between May 1999 and August 2001 through a two stage, age stratified (60-74; ≥75 years) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of patients who screened negative.
Intervention. For two years, a depression care manager worked with primary care physicians in intervention practices to provide algorithm based care for depression, offering psychotherapy, increasing antidepressant dose if indicated, and monitoring symptoms, adverse effects of drugs, and adherence to treatment. This paper reports the long term follow-up.
Main Outcome Measure. Mortality risk based on a median follow-up of 98 (range 0.8-116.4) months through 2008.
Results. In baseline clinical interviews, 396 people were classified as having major depression, 203 had clinically significant minor depression, and 627 did not meet criteria for depression. At follow-up, 405 patients had died. Patients with major depression in usual care were more likely to die than were those without depression (hazard ratio 1.90, 95% confidence interval 1.57 to 2.31). In contrast, patients with major depression in intervention practices were at no greater risk than were people without depression (hazard ratio 1.09, 0.83 to 1.44). Patients with major depression in intervention practices, relative to usual care, were 24% less likely to have died (hazard ratio 0.76, 0.57 to 1.00; P=0.05). Preliminary data on cause of death are provided. No significant effect on mortality was found for minor depression.
Conclusions. Older adults with major depression in practices provided with additional resources to intensively manage depression had a mortality risk lower than that observed in usual care and similar to older adults without depression.
Prospective studies have consistently shown an association between depression and increased mortality in older adults. The biological, social, psychological, and behavioral mechanisms that mediate the effect of depression on mortality have only recently begun to be elucidated. A strong association exists between depression in late life and factors that increase mortality risk, such as poor adherence to medical treatment and self care for diabetes and cardiovascular disease, health behaviors such as smoking and lack of physical activity, cognitive impairment, and disability. Investigators seeking to understand the biological mechanisms linking depression and medical conditions have drawn attention to cardiovascular, immunologic, inflammatory, metabolic, and neuroendocrine pathways.
Randomized trials testing models of service delivery have shown that treatment of depression in later life in primary care settings can lead to remission of major depression, reduced symptoms of depression, improved quality of life, and a reduction in functional impairment. For example, Improving Mood-Promoting Access to Collaborative Treatment (IMPACT), a collaborative care program that involved a nurse or psychologist in the primary care office to support management by the primary care physician, was associated with improvements in depressive symptoms, functioning, and quality of life. Katon and colleagues reported that patients with depression and poorly controlled diabetes or cardiovascular disease in practices with collaborative care managed by a medically supervised nurse had greater improvement in glycated hemoglobin, lipids, blood pressure, and depression, as well as better quality of life, compared with patients in usual care. Despite plausible mechanisms linking depression and excess mortality in the context of medical illness, no randomized trials have reported whether improved management of depression is associated with reduced mortality risk.
In the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), 20 primary care practices were randomized to an intervention consisting of a depression care manager working with primary care physicians to provide algorithm based care or to usual care. Among older adults with major depression, the intervention was associated with improvement in depressive symptoms, remission, and suicidal ideation. Specifically, a significantly larger proportion of intervention patients with major depression responded to treatment, defined as a 50% or greater decrease in symptoms (for example, 42.7% v 29.1% at four months). Remission, defined as achieving reduction of symptoms below a predetermined threshold, was more common among patients with major depression in intervention practices (for example, 40.0%v22.5% at four months). Rates of suicidal ideation declined faster in intervention patients (from 29.4% to 16.5%) than with usual care (from 20.1% to 17.1%). The beneficial effects on remission of depression persisted at 24 months, with 45.4% of patients with major depression in intervention practices in remission (compared with 31.5% in usual care).
In this report, we focus on mortality after long term follow-up, and for clinical interest we provide preliminary data on cause of death. Our strategy was to assess whether the increased mortality risk among patients with depression can be reduced to the risk of patients who did not meet criteria for depression. In contrast to a typical randomized clinical trial, we also followed patients who did not meet criteria for depression, providing both a comparison to assess the effect of depression on mortality risk and a benchmark for gauging the influence of unmeasured characteristics of practice such as the interest and skill of the primary care physician, quality of care, and case mix of patients in the practice.
Abstract and Introduction
Abstract
Objective. To investigate whether an intervention to improve treatment of depression in older adults in primary care modified the increased risk of death associated with depression.
Design. Long term follow-up of multi-site practice randomized controlled trial (PROSPECT—Prevention of Suicide in Primary Care Elderly: Collaborative Trial).
Setting. 20 primary care practices in New York City, Philadelphia, and Pittsburgh, USA, randomized to intervention or usual care.
Participants. 1226 participants identified between May 1999 and August 2001 through a two stage, age stratified (60-74; ≥75 years) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of patients who screened negative.
Intervention. For two years, a depression care manager worked with primary care physicians in intervention practices to provide algorithm based care for depression, offering psychotherapy, increasing antidepressant dose if indicated, and monitoring symptoms, adverse effects of drugs, and adherence to treatment. This paper reports the long term follow-up.
Main Outcome Measure. Mortality risk based on a median follow-up of 98 (range 0.8-116.4) months through 2008.
Results. In baseline clinical interviews, 396 people were classified as having major depression, 203 had clinically significant minor depression, and 627 did not meet criteria for depression. At follow-up, 405 patients had died. Patients with major depression in usual care were more likely to die than were those without depression (hazard ratio 1.90, 95% confidence interval 1.57 to 2.31). In contrast, patients with major depression in intervention practices were at no greater risk than were people without depression (hazard ratio 1.09, 0.83 to 1.44). Patients with major depression in intervention practices, relative to usual care, were 24% less likely to have died (hazard ratio 0.76, 0.57 to 1.00; P=0.05). Preliminary data on cause of death are provided. No significant effect on mortality was found for minor depression.
Conclusions. Older adults with major depression in practices provided with additional resources to intensively manage depression had a mortality risk lower than that observed in usual care and similar to older adults without depression.
Introduction
Prospective studies have consistently shown an association between depression and increased mortality in older adults. The biological, social, psychological, and behavioral mechanisms that mediate the effect of depression on mortality have only recently begun to be elucidated. A strong association exists between depression in late life and factors that increase mortality risk, such as poor adherence to medical treatment and self care for diabetes and cardiovascular disease, health behaviors such as smoking and lack of physical activity, cognitive impairment, and disability. Investigators seeking to understand the biological mechanisms linking depression and medical conditions have drawn attention to cardiovascular, immunologic, inflammatory, metabolic, and neuroendocrine pathways.
Randomized trials testing models of service delivery have shown that treatment of depression in later life in primary care settings can lead to remission of major depression, reduced symptoms of depression, improved quality of life, and a reduction in functional impairment. For example, Improving Mood-Promoting Access to Collaborative Treatment (IMPACT), a collaborative care program that involved a nurse or psychologist in the primary care office to support management by the primary care physician, was associated with improvements in depressive symptoms, functioning, and quality of life. Katon and colleagues reported that patients with depression and poorly controlled diabetes or cardiovascular disease in practices with collaborative care managed by a medically supervised nurse had greater improvement in glycated hemoglobin, lipids, blood pressure, and depression, as well as better quality of life, compared with patients in usual care. Despite plausible mechanisms linking depression and excess mortality in the context of medical illness, no randomized trials have reported whether improved management of depression is associated with reduced mortality risk.
In the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), 20 primary care practices were randomized to an intervention consisting of a depression care manager working with primary care physicians to provide algorithm based care or to usual care. Among older adults with major depression, the intervention was associated with improvement in depressive symptoms, remission, and suicidal ideation. Specifically, a significantly larger proportion of intervention patients with major depression responded to treatment, defined as a 50% or greater decrease in symptoms (for example, 42.7% v 29.1% at four months). Remission, defined as achieving reduction of symptoms below a predetermined threshold, was more common among patients with major depression in intervention practices (for example, 40.0%v22.5% at four months). Rates of suicidal ideation declined faster in intervention patients (from 29.4% to 16.5%) than with usual care (from 20.1% to 17.1%). The beneficial effects on remission of depression persisted at 24 months, with 45.4% of patients with major depression in intervention practices in remission (compared with 31.5% in usual care).
In this report, we focus on mortality after long term follow-up, and for clinical interest we provide preliminary data on cause of death. Our strategy was to assess whether the increased mortality risk among patients with depression can be reduced to the risk of patients who did not meet criteria for depression. In contrast to a typical randomized clinical trial, we also followed patients who did not meet criteria for depression, providing both a comparison to assess the effect of depression on mortality risk and a benchmark for gauging the influence of unmeasured characteristics of practice such as the interest and skill of the primary care physician, quality of care, and case mix of patients in the practice.