Care Management Reduces Depression And Suicidal Thoughts In Older Primary Care Patients

The two-year outcomes of the multicenter Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) study are published online in the American Journal of Psychiatry.

Lead author of the study is Dr. George S. Alexopoulos, director of the Institute of Geriatric Psychiatry at NewYork-Presbyterian Hospital/Westchester Division and professor of psychiatry at Weill Cornell Medical College.

"Almost one in 10 older adults in the United States has some form of depression, and one-fifth among them contemplates suicide. Two-thirds of these patients are treated by primary care physicians. Sadly, their depression is often inadequately treated due to the primary care physician's time constraints and the patient's reluctance to discuss their symptoms and adhere to treatment," says Dr. Alexopoulos. "The critical finding of the PROSPECT study is that adding a trained care manager to primary care practices increases the number of depressed older patients who receive treatment and improves their outcomes, not only in the short term, but over two years.

"This is important because depression can either become chronic or relapse after an initial improvement," adds Dr. Alexopoulos. "Most diseases have worse outcomes when an old person becomes depressed. Depression almost doubles the risk for death. It follows that treating depression effectively can reduce sickness, disability and death."

The study, conduced by NewYork Presbyterian/Weill Cornell, the University of Pittsburgh, and the University of Pennsylvania, followed 599 patients aged 60 years and older with depression at 20 primary care practices of varying sizes in New York and Pennsylvania. Participants were randomized to receive either the PROSPECT intervention or usual care. Those in the PROSPECT group were assigned a care manager — a trained social worker, nurse or psychologist — who helped the physician offer treatment according to accepted practice guidelines, monitored treatment response and provided follow-up over two years. Practice guidelines included the antidepressant citalopram (Celexa), with the option of other drugs or psychotherapy.

After two years, nearly 90 percent of patients in the PROSPECT care management group had received treatment for depression, compared with 62 percent of those receiving usual care by their physicians. The decline in suicidal ideation (thinking about and/or planning suicide) was 2.2 times greater in the PROSPECT group.

Remission of depression happened faster in the PROSPECT intervention group and remission rates continued to increase between months 18 and 24, while no appreciable increase occurred in the usual care group during the same period.

The PROSPECT intervention worked especially well for a subgroup of patients with major depression, the more severe form of the disease, with a greater number achieving remission, or the near absence of symptoms. Patients with minor depression had favorable outcomes regardless of their study group.

Various forms of care management are being used successfully for cardiovascular patients needing anticoagulation medication and for diabetes patients needing insulin monitoring, says Dr. Alexopoulos. "The PROSPECT study has demonstrated that care management is highly successful for older adults with major depression."

"At this time, our nation is focused on disease prevention as a way to improve the health of Americans and to reduce health care cost. Reducing depression over long periods of time can be one of the ways to achieve this objective," continues Dr. Alexopoulos. "Care management, like that of the PROSPECT study, is relatively inexpensive. Finding ways to reimburse it can make it broadly available and have a major impact on the overall heath care."

Dr. Alexopoulos serves as a paid member of the speaker's bureau and a paid member of the Scientific Advisory Board for Forest Laboratories Inc., the maker of the antidepressant drug citalopram (Celexa). Forest offered free citalopram and a small stipend to support the study.

Co-authors include Drs. Martha L. Bruce and Patrick J. Raue of NewYork-Presbyterian/Westchester and Weill Cornell Medical College; Dr. Charles F. Reynolds III of the University of Pittsburg; Drs. Ira R. Katz, David W. Oslin and Thomas Ten Have of the University of Pennsylvania; and Dr. Benoit H. Mulsant of the University of Toronto.