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Rapid Responses: Rapid Responses published:
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Two faint cheers
- David Ames (29 September 1999)
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A loud editorial cheer
- Richard Smith (30 September 1999)
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Celebrate the real positives
- Bart Sheehan (8 October 1999)
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Triple jeopardy:old, depressed and disabled
- Ian Cameron (14 October 1999)
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David Ames
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After reading the paper by Llewellyn-Jones et al. on multi-faceted shared care intervention for late life depression in residential care[1], together with Haynes'[2] accompanying editorial and the commentary by Deeks and Juszczak[3] I was left with the feeling that this important piece of research had been greeted with two faint cheers rather than the three heartier ones it probably deserved. Neither the editorial nor the commentary makes the very important points that
1. Depression among the elderly is common, under-detected, under-treated
and a significant public health problem It is very difficult to do good quality research on depression in residential care and your editorial and commentary certainly get that point across in spades. However, although the design of the study conducted by Llewellyn-Jones et al. can be subject to justifiable criticism, it would seem virtually impossible to mount both arms of such a trial simultaneously within one large residential institution. The variability that would be produced by using two or more institutions probably would outweigh the temporal variability introduced by the methodology of Llewellyn-Jones et al. Even modest improvements in depression scores and modest changes in general practitioner behaviour may have significant impacts on overall population morbidity from depression. A small decrease in alcohol use in a community is associated with a significant benefit to some at risk individuals and the same may be true of small improvements in depression scores. Finally, it seems a bit unfair for Haynes to criticise the dropout rates in the study. If you are going to do research with very old people some of them are going to die and any intervention which prevented that would certainly be worth a headline in the BMJ! DAVID AMES References: 1. Llewellyn-Jones RH, Baikie KA, Smithers H, Cohen J, Snowdon J, Tennant CC. Multi-faceted shared care intervention for late life depression in residential care: a randomised controlled trial. BMJ (1999);319:676-682. 2. Haynes B. Can it work? Does it work? Is it worth it? BMJ (1999);319:652-653. 3. Deeks JJ, Juszczak E. Commentary: beyond the boundary for a randomised controlled trial? BMJ (1999);318:682. 4. Ames D. Depressive disorders among elderly people in long-term institutional care. ANZ J Psychiatry (1993);27:379-391. |
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Richard Smith, Editor BMJ
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I agree with Professor Ames that this study deserves a loud cheer, and I tried to make that clear in my Editor's choice that accompanied the article. I wrote: "Medical journals have tended to include many more efficacy than effectiveness studies, not least because effectiveness studies tend to be messier. That's why we applaud the study of a group from Sydney to see if a multifaceted shared care intervention could work in elderly depressed patients in residential care. This is exactly the sort of research we need more of, even though our statisticians question the study in a commentary." Next time I'll try and cheer louder. Richard Smith |
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Bart Sheehan, Lecturer in Old Age Psychiatry Oxford University Dept. of Psychiatry
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EDITOR – Llewellyn-Jones et al’s study of a multifaceted treatment intervention for depressed elderly residential home residents is a welcome addition to the literature on treatment of late life depression. It is unfortunate that improvements in the chief outcome measure, the score on the Geriatric Depression Scale (GDS), are very small. The authors appear to overplay this outcome while failing to emphasise their biggest contribution, which lies in their ambitious intervention. In most trials of antidepressant interventions in older subjects, recovery is defined as a reduction of at least 50% in the most commonly used outcome measure, the Hamilton Depression Rating Scale. Their finding of a mean fall of under 2 points on GDS (scored from 30) score seems unlikely to represent a clinically meaningful outcome. This improvement appears to gain its reported significance from the clustering of depression scores at outset of treatment just above the cutoff score for depression of 10. Potential reasons for the poor result are many and have been partly covered in the accompanying commentary by Deeks and Juszczak. Their intervention represents an attempt to change the whole culture surrounding depression in a large institution, from awareness through to treatment. Long term residential care in the United Kingdom and many other countries is now largely under private provision, so attempts by psychiatric services to influence treatment of late life depression in this setting are bound to be indirect. This will have to include the fostering of a culture of recognition and treatability of depression, and effective liaison with, and education of, caregivers.in the absence of direct psychiatric responsibility for care. The authors’ description of their intervention might be a blueprint of how to do this. I suspect that the gains accruing from this, though intangible in terms of the study outcomes, are great. I hope they disseminate their detailed methods widely. Bart Sheehan 1 Llewellyn-Jones RH, Balkie KA, Smithers H, Cohen J, Snowdon J, Tennant CC. Multifaceted shared care intervention for late life depression in residential care: randomised controlled trial. BMJ 1999;319:676-82 (11 September.) 2 Evans M, Hammond M, Wilson K, Lye M Copeland J. Placebo controlled treatment trial of depression in elderly physically ill patients. Int J Ger Psychiat 1997:12:817-824. 3 Deeks JJ, Juszczak. Commentary:Beyond the boundary for a randomised controlled trial? BMJ 1999;319:682. |
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Ian Cameron, Associate Professor of Rehabilitation Medicine University of Sydney
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Editor, Llewellyn-Jones and his colleagues [1] should be complimented for their achievement .They have provided strong evidence that a multifactorial intervention for late life depressive illness has a measurable beneficial effect. However, I should declare my biases. I have provided specialist medical services to the community that Llewellyn-Jones et al studied and I am a researcher who tries to engage similar participants in clinical trials of multifactorial interventions. Rehabilitation, falls, and geriatric evaluation and management research share the same issues as depression. Haynes [2] and Deeks and Juszczak [3] and the letters in reply raise important issues. I wish to comment on some of them. While this area of clinical investigation remains in development it is the real world of clinically relevant research. The researchers did well to follow-up the percentage of participants that they did. The number eligible was 220 and they managed to have outcomes on 185 (85%). This includes participants who died (n=15) because this is a legitimate endpoint for the frail older people studied. The study showed an improvement of about 2 points on the 30 item GDS. Is this worthwhile? As a clinician I vote yes. Remember this is the real world of aged care with limited resources and very hard pressed nursing, personal care staff and general practitioners. If the intervention works in this large and architecturally outdated facility in Sydney it will be even more effective in well resourced retirement communities. In the United Kingdom, the structure of general practice (which encourages closer medical supervision of frail older people) should also improve the effectiveness of the intervention. The intervention has components that should be available to all older people as a right. Callahan argues for a basic humane health service as a minimum for all older people [4]. The intervention falls into this league. Cost effectiveness analyses are unlikely to support the types of programs pioneered by Llewellyn-Jones and colleagues unless they reduce the need for hospitalisation or increased assistance with activities of daily living. Because hospitalisation with depressive illness is uncommon in the population studied and most participants already required some assistance with activities of daily living, sample sizes for a cost effectiveness study are likely to be very large. In a population with a genuine unmet health need it is almost axiomatic that it will cost more to meet this need. Evidence based healthcare seems to be better accepted if the evidence supports a lower cost intervention. If the evidence supports the efficacy of a more costly intervention healthcare managers and planners seem less interested. Ian Cameron References 1. Llewellyn-Jones RH, Baikie KA, Smithers H, Cohen J, Snowdon J, Tennant CC. Multifaceted shared care intervention for late life depression in residential care: randomised controlled trial. BMJ 1999;319:676-82. 2. Haynes, B. Can it work? Does it work? Is it worth it? BMJ 1999;319:652-653. 3. Deeks JJ, Juszczak E. Commentary: beyond the boundary for a randomised controlled trial? BMJ 1999;318:682. 4. Callahan D. Setting Limits: Medical Goals in an Aging Society. Simon and Schuster New York, 1987. |
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