November 2005
Reviewer: Jeff C. Huffman, MD
Improving depression outcomes in older adults with comorbid medical illness
Harpole LH, Williams JW, Olsen MK, et al
Gen Hosp Psychiatry 2005; 27(1):4-12
Summary: An intervention utilizing specialized depression case management improves both mood symptoms and quality of life in depressed primary care patients over 60. Furthermore, such an intervention is effective in older adults with multiple medical comorbidites, a population whose depression has historically been difficult to treat.
Background/Methods: This article outlines a portion of results from the IMPACT trial, a large randomized controlled multicenter trial of approximately 1800 depressed adults over 60 years of age at 18 primary care sites. Patients were randomized to either usual care or the study intervention. The study intervention utilized a ‘depression clinical specialist' (DCS), a nurse or psychologist who helped to coordinate depression care and to provide psychoeducation. In addition, the DCS either supported antidepressant prescription by the primary care physician or provided a manualized 6-8 session psychotherapy treatment called Problem-Solving Treatment. Subjects completed ratings on several study instruments, including the SCL-20 (depression), the SF-12 (mental health component), and a quality of life scale, at baseline and 3, 6, and 12 months.
Results: Intervention patients had signficiantly lower depression severity and greater rates of depression response and remission at all follow-up assessments. In addition, study intervention lead to improved SF-12 (mental health component) and quality of life scores as compared to usual care. In addition, though patients with ‘high medical combridity' (5 or more comorbid chronic medical conditions) had at baseline higher rates of depression and lower quality of life, such patients had similar rates of response to depression as patients with lower medical comorbidity. The study intervention also led to improvement in quality of life and mental health in such patients.
Comment: This important study has several critical findings: (1) that it is possible to create an effective, systematic approach to depression in primary care settings (at least for patients over 60), (2) that this approach is effective in the treatment of depression, and (3) that such treatment is effective even in patients with multiple medical comorbidities. Given that the majority of depressed patients present not to a specialist but instead go to their PCP, this work targets a ‘silent majority' of depressed patients not seen by psychiatrists. In addition, prior studies have found that older adults and patients with medical comorbidities have had depression that is more difficult to treat, and thus the effectiveness of this intervention is heartening. Strengths of this study include the large sample size, multisite nature of the study (18 sites in five states), and that the study is a randomized controlled trial. It would be interesting to know whether the intervention was cost-effective or reduced health care utilization, and whether specific subpopulations derived greater benefit from the intervention.
The intervention does appear to be somewhat more complex than it first appears—the intervention is not just case management, which implies only coordination with treaters, but also includes psychoeducation with patients and, in some cases, 6-8 sessions of manualized therapy. Hence one may consider the intervention as including both case management and psychotherapy added to usual care. To implement the intervention in primary care clinic would require significant training of, and time commitment from, the DCS as well as enough willing/able candidates to perform the role of DCS in a given clinic (as well as enough trainers) to make the intervention possible.
Overall, however, this large, well-designed study suggests that the treatment of depressed older adults in the primary care settings can be both systematic and effective with the addition of a trained mental health specialist to coordinate care and perform specific clinical interventions.