Remission in depressed geriatric primary care patients: a report from the PROSPECT study

Abstract

Objective: This study compared time to first remission for elderly depressed patients in primary care for practices that implemented a care management model versus those providing usual care. In addition, it sought to identify risk factors for nonremission that could guide treatment planning and referral to care managers or specialists.

Method: Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) data were analyzed. Participants were older patients (> or =60 years) selected following screening of 9,072 randomly identified primary care patients. The present analysis examined patients with major depression and a 24-item Hamilton Depression Rating Scale score of 18 or greater who were followed for at least 4 months (N=215). Primary care practices were randomly assigned to offer the PROSPECT intervention or usual care. The intervention consisted of services of trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 18 months.

Results: First remission occurred earlier and was more common among patients receiving the intervention than among those receiving usual care. For all patients, limitations in physical and emotional functions predicted poor remission rate. Patients experiencing hopelessness were more likely to achieve remission if treated in intervention practices. Similarly, the intervention was more effective in patients with low baseline anxiety.

Conclusions: Longitudinal assessment of depression, hopelessness, anxiety, and physical and emotional functional limitations in depressed older primary care patients is critical. Patients with prominent symptoms or impairment in these areas may be candidates for care management or mental health care, since they are at risk for remaining depressed and disabled.

FIGURE 1

Cumulative Probability of Remission Among Elderly Depressed Primary Care Patients in Practices Implementing a Care Management Intervention Versus Practices Providing Usual Care

FIGURE 2

Estimated Probability of Remission^a in Elderly Depressed Primary Care Patients in Practices Implementing a Care Management Intervention Versus Practices Providing Usual Care, by Level of Hopelessness^b

FIGURE 3

Estimated Probability of Remission^a in Elderly Depressed Primary Care Patients in Practices Implementing a Care Management Intervention Versus Practices Providing Usual Care, by Level of Anxiety.^b