A Randomized Trial to Reduce the Prevalence of Depression and Self-Harm Behavior in Older Primary Care Patients

Almeida and colleagues' recently published study (1) is a sophisticated approach to addressing depression and suicidality in the elderly - a significant public health issue (2). In particular, General Practitioners are well placed to be gatekeepers for depression interventions directed toward this age group. Ageing individuals have regular/frequent contact with their GPs (often due to other physical issues) (3, 4), and often appreciate the familiarity and continuity of care and reassurance available at their usual clinic (5).

However, as Professor George S. Alexopoulos underscores in his recent e-letter (23rd July 2012), GPs are commonly pressed for time (e.g., patient load and short appointments), and identification of depression in older aged individuals can be difficult (6). Alternatively, patients may request long consults, but at significant additional cost, which in some cases, may be prohibitive for pensioners or those with limited funds.

The interesting results presented by Almeida et al. indicate the absence of an effect for the intervention on depression, but there appears to be more a positive impact on suicidality. Indeed, results suggest that this intervention imparts benefits by averting development of suicidal behaviour, rather than assisting recovery of those who already experience existing symptoms. Further research will be able to clarify as to whether there are differences in outcomes between patients who experience suicidal or self-harm ideation, and/or suicidal or self-harming behaviour. Nevertheless, these findings provide further evidence of primary prevention benefits for the general community.

Finally, Almeida et al.'s research highlights that depression and suicidality does not always go hand in glove, and as Professor Diego De Leo notes (e-letter 17th July 2012) the present findings indicate that suicidality does not appear to be mediated by depression. This further emphasises potential benefits to patient outcomes if clinicians assess depression and suicidality as separate constructs (7), though clearly symptoms frequently co-occur. This large, cross-national study contributes further important information assisting the prevention of suicide.

1. Almeida OP, Pirkis J, Kerse N, Sim M, Flicker L, Snowdon J, et al. A Randomized Trial to Reduce the Prevalence of Depression and Self-Harm Behavior in Older Primary Care Patients. The Annals of Family Medicine. 2012;10(4):347-56.

2. Chiu HFK, Chan SSM, Lam LCW. Suicide in the elderly. Current Opinion in Psychiatry. 2001;14(4):395-9.

3. Gill D, Dawes M, Sharpe M, Mayou R. GP frequent consulters: Their prevalence, natural history, and contribution to rising workload. British Journal of General Practice. 1998;48(437):1856-7.

4. Rennemark M, Holst G, Fagerstrom C, Halling A. Factors related to frequent usage of the primary healthcare services in old age: Findings from the Swedish National Study on Aging and Care. Health and Social Care in the Community. 2009;17(3):304-11.

5. Berkelmans PG, Berendsen AJ, Verhaak PF, Van Der Meer K. Characteristics of general practice care: What do senior citizens value? A qualitative study. BMC Geriatrics. 2010;10.

6. Hybels CF, Landerman LR, Blazer DG. Age differences in symptom expression in patients with major depression. International Journal of Geriatric Psychiatry. 2012;27(6):601-11.

7. Fairweather-Schmidt AK, Anstey KJ, Mackinnon AJ. Is suicidality distinguishable from depression? Evidence from a community-based sample. Australian and New Zealand Journal of Psychiatry. 2009;43(3):208 - 15.

Competing interests:   None declared

We congratulate the authors on this important, large scale trial into reducing the prevalence of depressive symptoms in older adults.

While there are limitations to this study, which the authors fully acknowledge, the findings suggest a beneficial effect in the prevention of onset of new cases of self-harm behaviour which differs from other trials of educational/guideline based interventions reported1,2 Previous However these trials have tended to focus on working age adults or unselected age groups. The DEPS-GP trial may be different since it focuses on older people. In keeping with these previous studies, this trial found no obvious effect in reducing prevalence of depression or self- harm in those who had symptoms at baseline.

These finding are very interesting and raise the question 'what are the active ingredients?' Are the noted beneficial effects due to the audited feedback, the education materials which influence the GP's approach, or could the accrual of points for the maintenance of professional standards be a factor? Furthermore, does the educational material and feedback concentrate the minds of GPs on older people and depression management? These questions remain to be answered.

A further question is what do GPs do when they find depression and what is the best course of action for those displaying depressive symptoms? Other barriers to effective management of mental health in primary care have been identified, including lack of resources, and patient barriers such as stigma and lack of recognition of own mental health conditions, although the latter relates to a study of younger people3.

In terms of treatment, we believe collaborative care is an effective and efficient approach. A large US trial (IMPACT)4 using collaborative care has shown positive results in improving levels of depression among older adults, with sustained benefits, including reduced suicidal ideation. A similar study (CASPER)5, currently underway in the UK, aims to replicate these findings in a non-US, publicly funded healthcare system.

In light of the existing evidence, we would not recommend that strategies to detect and manage depression and suicidal ideation rely solely on GP education and the dissemination of guidelines. Such strategies should be seen alongside strategies such as collaboratiove care which re-engineer the whole system of primary care for older people with depression. We are of the view that , but we believe that population strategies also remain important and Almeida et al's substantial study adds to the knowledge-base in this area.

Helen Lewis, Karen Overend and Simon Gilbody. York, July 2012.

References:
1. Thompson C, Kinmonth AL, Stevens L, et al. Effects of a clinical practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial. Lancet. 2000;355(9199):185-191.
2. Tiemens BG, Ormel J, Jenner JA, et al. Training primary-care physicians to recognize, diagnose and manage depression: does it improve patient outcomes? Psychol Med. 1999;29(4):833-845.
3. Gulliver A, Griffiths K, Christensen H. Perceived barriers and facilitators to mental health help-seeking in young people: a systematic review BMC Psychiatry 2010; 10:113.
4. Unutzer J, Katon W, Callahan CM, et al; IMPACT Investigators. Improving Mood-Promoting Access to Collaborative Treatment. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288(22):2836-2845.
5. Mitchell N, Hewitt C, Adamson J, Parrott S, Torgerson D, Ekers D, Holmes J, Lester H, McMillan D, Richards D, Spilsbury K, Godfrey C, Gilbody S. A randomised evaluation of Collaborative care and active surveillance for screen-positive elders with sub-threshold depression (CASPER): study for a randomized controlled trial protocol. Trials 2011; 12:225

Competing interests:   None declared

Improving the care of depression by primary care physicians has been the "holy grail" of the health services field. Depression is a major health hazard because it is common and has devastating outcomes in all people. In older people, it is also fatal as it increases substantially both suicide and non-suicide mortality. Approximately 7% of older primary care patients have major depression and more are afflicted by less severe depression syndromes. Primary care physicians treat more than two thirds of older adults who are diagnosed with depression. Depressed older adults prefer to be treated by their own primary care physicians and only a minority follow-through when referred to mental health professionals.

Although primary care has long been recognized as the critical target for reducing the burden of depression in older adults, depression remains under-recognized and under-treated by primary care physicians. Attempts to improve identification and treatment range from introduction of office screening, to educational interventions of primary care physicians and staff, to collaborative care approaches involving trained care managers.

Educational interventions are particularly appealing because of their low cost and the likelihood to be implemented. However, the study by Almeida et al reaffirmed that educational interventions alone have at best a modest, if any, effect on the burden of depression and self-harm behavior in older primary care patients. The effect on self-harm, though it reached statistical significance, was not accounted by an increase in the intensity of treatment for depression. While not-surprising, the results of this study were disappointing because the investigators used a sophisticated approach to education, which included a practice audit with individualized automated audit feedback, printed educational material, and continuous medical education (CME) credit that served as a reward to participating physicians.

The results of the Almeida et al study indicate that there are no simple solutions to a complex problem. The primary care practitioner has to see many patients every day in order to cover an increasingly burdensome overhead and secure a reasonable income. Medical emergencies compete with the care of less dramatic medical disorders like depression. On the other hand, identification and treatment of late-life depression is time-consuming and often complex. More often than not, late-life depression develops in patients with high medical burden. The typical depressed older person faces a bewildering constellation of interacting health threats and social constraints compromising their outcomes. Comorbid medical conditions, stigma, bias and social stereotypes make history-taking time consuming and often difficult to interpret. Although many pharmacological and non-pharmacological treatments exist for late- life depression, each helps only a fraction of patients thus requiring consistent follow-up and sequential treatment decisions. Several collaborative care models have been shown to improve the outcomes of late- life depression in primary care. However, the current reimbursement system has hindered their implementation at least in the United States.

The study of Almeida et al has taught us that "you get what you pay for" one more time. The Health Care Reform is at the beginning of a long implementation process in the United States. Now, is the time to plan thoughtfully for the care of depression and other chronic conditions with broad impact on medical health, disability and suffering.

Competing interests:   None declared