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« on: April 05, 2008, 04:07:16 pm » |
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May 18, 2007 — In several primary care clinics, fewer elderly patients with major depression died within a 5-year period after participating in a depression care management intervention, according to the results of a randomized controlled trial reported in the May 15 issue of the Annals of Internal Medicine.
"Prospective, observational studies from many settings have shown that depression is independently associated with an increased risk for death," write Joseph J. Gallo, MD, MPH, from the University of Pennsylvania School of Medicine in Philadelphia, and colleagues. "However, few studies have evaluated whether an intervention focused on depression can modify this risk."
The investigators evaluated the relationship between a depression care management intervention and the risk for death among older primary care patients during a 5-year interval, using data from the Prevention of Suicide in Primary Care Elderly: Collaborative Trial supplemented with data from the National Death Index.
At 20 primary care practices in New York and Philadelphia and Pittsburgh, Pennsylvania, 1226 randomly sampled patients were identified through a 2-stage, age-stratified depression screening and randomized to receive or not to receive a depression care intervention.
Age stratification was into 2 groups: 60 to 74 years and 75 years or older. The intervention consisted of a depression care manager working with primary care clinicians to provide algorithm-based care. Endpoints were depression status based on clinical interview and vital status at 5 years, based on the National Death Index.
At baseline, 396 patients met criteria for major depression and 203 patients met criteria for clinically significant minor depression. After median follow-up of 52.8 months, 223 patients had died. Compared with patients in usual care practices, patients with depression in intervention practices were less likely to have died (adjusted hazard ratio
, 0.67; 95% confidence interval [CI], 0.44 - 1.00).
Mortality risk for death was reduced in patients with major depression (adjusted HR, 0.55; 95% CI, 0.36 - 0.84) but not in patients with clinically significant minor depression (adjusted HR, 0.97; 95% CI, 0.49 - 1.92). A reduction in deaths from cancer almost entirely explained the observed benefit on mortality risk.
"Older primary care patients with major depression in practices that implemented depression care management were less likely to die over a 5-year period than were patients with major depression in usual care practices," the authors write. "The effect seemed to be limited to deaths due to cancer. The mechanism for such an effect is unclear and warrants further investigation."
Study limitations include unclear mechanism for an effect on deaths from cancer; possible misclassification of depression status, cause of death, and vital status; and inability to rule out the possibility that the observed mortality rate reduction among patients with depression in intervention practices may result from factors other than the specific effects of a depression management program.
"The backdrop of varying patient and provider perspectives needs to be studied and considered in any redesign that seeks to mitigate system-level factors that currently discourage integration of mental health treatment into primary care settings — integrated care that is preferred by patients and providers," the authors conclude. "If we are to prepare for the increasing need for mental health services among older persons and to ease the burden of disability associated with depression, we must engage primary care practices as partners in developing services that interrupt the pathway from depression to death."
The National Institute of Mental Health funded this study. One of the authors is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar (2004 - 2008). The authors have disclosed no relevant financial relationships.
Ann Intern Med. 2007;146:689-698.
Source: http://www.medscape.com/viewarticle/556713?src=mp
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