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
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.
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.
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.
Lebowitz BD, Pearson JL, Schneider LS, et al. Diagnosis and treatment of depression in late life: consensus statement update. JAMA. 1997;278:1186–90.
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.
Whooley MA, Browner WS. Association between depressive symptoms and mortality in older women. Arch Intern Med. 1998;158:2129–35.
Schulberg HC, McClelland M, Gooding W. Six-month outcomes for medical patients with major depressive disorders. J Gen Intern Med. 1987;2:312–7.
Dowrick C, Buchan I. Twelve month outcome of depression in general practice: does detection or disclosure make a difference? BMJ. 1995;311:1274–6.
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.
Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med. 1995;4:99–105.
Tiemens BG, Ormel J, Simon GE. Occurrence, recognition, and outcome of psychological disorders in primary care. Am J Psychiatry. 1996;153:636–44.
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.
U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams & Wilkins; 1996.
Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa, Ont: Canada Communication Group; 1994.
Yesavage JA. Geriatric Depression Scale. Psychopharmacol Bull. 1988;24:709–11.
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.
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.
Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;5:165–73.
Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA. 1984;252:1905–7.
Mayfield D, McLeod G, Hall P. The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry. 1974;131:1121–3.
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.
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.
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.
Simon GE, Revicki D, VonKorff M. Telephone assessment of depression severity. J Psychiatr Res. 1993;27:247–52.
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.
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.
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.
Simon GE, Von Korff M, Wagner EH, Barlow W. Patterns of antidepressant use in community practice. Gen Hosp Psychiatry. 1993;15:399–408.
Simon GE, Lin EHB, Katon W, et al. Outcomes of “inadequate” antidepressant treatment. J Gen Intern Med. 1995;10:663–70.
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.
Keller MB, Klerman GL, Lavori PW, Fawcett JA, Coryell W, Endicott J. Treatment received by depressed patients. JAMA. 1982;248:1848–55.
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.
Perez-Stable EJ, Miranda J, Munoz RF, Ying YW. Depression in medical outpatients: underrecognition and misdiagnosis. Arch Intern Med. 1990;150:1083–8.
Eisenberg L. Treating depression and anxiety in primary care: closing the gap between knowledge and practice. N Engl J Med. 1992;326:1080–4.
Callahan CM, Dittus RS, Tierney WM. Primary care physicians’ medical decision making for late-life depression. J Gen Intern Med. 1996;11:218–25.
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.
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.
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.
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.
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.
Coyne JC, Schwenk TL, Fechner-Bates S. Nondetection of depression by primary care physicians reconsidered. Gen Hosp Psychiatry. 1995;17:3–12.
Beck DA, Koenig HG. Minor depression: a review of the literature. Int J Psychiatry Med. 1996;26:177–209.
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.
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.
Miranda J, Munoz R. Intervention for minor depression in primary care patients. Psychosom Med. 1994;56:136–41.
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.
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.
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.
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.
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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