Home-Based Activity Program for Older People With Depressive Symptoms: DeLLITE–A Randomized Controlled Trial

Health care is all about improving health of real life people, living in a real life world. And as this makes for unpredictable and difficult to control circumstances, health care is intrinsically complex. Health care research, in coping with these unpredictable has developed a methodology to control, or exclude, the unpredictable circumstances people live in and this has led to the development of disease-specific evidence for practice. This evidence has separated specific effective interventions, that truly influence the course of the disease, from factors that influence the context surrounding that disease. ‘Evidence based medicine’ as evolved into recommendations for disease management according the best available scientific information.

The problem encountered in daily practice, is that it is often very difficult to distinguish the ‘disease’ from the context, and what presents itself as ‘context’ may easily be the core health problem tomorrow. This is nicely illustrated in the paper of Keirse at al, that analyzed the effect of a physical activity program with a social visits’ program on the mood and health status of elderly depressed patients in the community. Research purists might criticize the researchers for their failure to define exactly the focus of their study: was it directed – this criticism may run – at the mood of the elderly in this study, their physical wellbeing or their social activity – and how specific are their interventions and for what? It is difficult to over-estimate the importance of the decision of the researchers not to fall into this methodology trap: they deserve praise for their courage to apply an experimental RCT design, but keep the clinical complexity intact and study a coherent set of interventions As it is unlikely that a single intervention will change a complex system to change, as most professionals in primary care will be all too familiar with, the distinction between ‘specific’ and ‘a-specific’ interventions becomes less relevant.

Nevertheless, in the valuing of health care, this distinction is tangible present. An interesting illustration comes from the UK Quality and Outcome framework, where practices are awarded for the prescription ‘specific’ interventions recommended in guidelines. Kendrick et al analyzed the actual performance of family physicians (FP) in patients with depression and found that they did in fact prescribe more ‘specific’ interventions (prescribing anti-depressants or referring for psychotherapy) when patients were more severely depressed [1]. But this was only the case for patients with a stand-alone depression. When patients had a more complicated situation due to co-morbidity – patients with characteristics comparable to the patients studied by Keirse et al – FPs prescribed less specific interventions. Lack of understanding of why this is the case currently hampers progress of safe and effective health care. But it is not unlikely that this is related to the valuing of ‘specific’ and ‘a-specific’ interventions: with multiple problems to address, FPs may prefer less specific interventions that address more than one problem at the same time [2]. It is a logical assumption to expect physical activity in the context of social support to enhance social involvement and improve people’s mood – even though physical fitness training would not classify in the same league of ‘specific’ interventions for depression like antidepressants or psychotherapy. And with improved physical fitness would come other health benefits for frail elderly, that antidepressants or psychotherapy will not bring.

Nevertheless, the study did not find an effect in comparison to usual care, and may feature as a ‘negative’ study. Again, it is important to be aware of the context of research and practice. The experience in the care of patients plays an important, but undervalued role in identifying potential effective interventions, for example the benefits of social engagement and activation of elderly people who live on their own in the community. The input of such empirism in the research setting is a key factor of the primary care)research setting: practice based research networks serve to bring research to daily practice and practice experience into research. But this makes it unlikely that the practice setting in which Keirse et al tested their explicit physical training and social engagement, did not already – implicitly – contain these elements. And therefore the findings may be due, rather than to a lack of effect, to a lack of contrast between the study conditions. For that reason, it would be helpful to gain a better understanding of the usual care provided, before it would be concluded that the promotion of physical fitness and social engagement under elderly people in the community.

References

1. Kendrick T et al. Management of depression in UK general practice . BMJ 2009;338:b750

2. Van Weel C, Van Weel-Baumgarten E, Van Rijswijk E. Treatment of depression in primary care. BMJ 2009;338:b934.

Competing interests:   None declared