Intervention in older people with depression may reduce mortality
It is increasingly recognised that suicide does not provide the only pathway from depression to death. Depression appears to be an independent risk factor for non-suicide mortality in patients with ischaemic heart disease and in the elderly. However, screening for depression in high-risk patients by itself is not the answer; the positive predictive value of screening tools is too low and the prognosis for depressive illness is poor, whether it is recognised or not.1
This study, from primary care, followed up depressed patients aged 60 years or older over a five-year period. Patients were identified using a 20-question screening tool (CES-D). The population was supplemented by a 5% random sample of patients with lower scores and by patients reporting previous episodes of depression. The total study population was 1,226 patients. Around 32% of the patients enrolled had major depression.
The 20 primary care practices participating were randomly assigned either to intervention or usual care. The intervention consisted of depression care managers, with close links to secondary care, working within the intervention practices.
Patients with major depression from the intervention group were more likely to respond to treatment and remain in remission. Moreover, there was a significant reduction in mortality (hazard ratio 0.55), which seemed to be almost entirely attributable to a reduction in cancer deaths. These results should be treated with caution: the trial was set up to assess the effect of care management on suicide risk, not death from other causes, and the mechanism for the apparent effect on cancer deaths is unclear.
This study provides support for the view that screening alone cannot improve outcomes for depressed patients and that the focus should be on achieving better organisation and delivery of care.3
In my practice our nurse has experience of providing shared care for depressed patients and hence has the skills to enable her to filter out many of the false positives. I have found that a shared care programme involving our practice nurse increased the proportion of patients who took antidepressants and returned for follow up.4 Others have also found that nurses and GPs working together can achieve ‘high levels of adherence to treatment and follow up.'5
However, managed care can only succeed if GPs are given adequate resources to provide it and if liaison between primary and secondary care is improved.
Gallo JJ, Bogner HR, Morales KH et al. The effect of a primary care practice-based depression intervention on mortality in older adults. Ann Intern Med 2007;146:689Reviewer
Dr Phillip Bland