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Long term effect of depression care management on mortality in older adults: follow-up of cluster randomized clinical trial in primary care

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2570 (Published 05 June 2013) Cite this as: BMJ 2013;346:f2570
  1. Joseph J Gallo, professor1,
  2. Knashawn H Morales, assistant professor2,
  3. Hillary R Bogner, associate professor3,
  4. Patrick J Raue, associate professor4,
  5. Jarcy Zee, pre-doctoral trainee2,
  6. Martha L Bruce, professor4,
  7. Charles F Reynolds III, professor5
  1. 1Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, 624 North Broadway, Baltimore, MD 21205, USA
  2. 2Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, 423 Guardian Drive, Philadelphia, PA 19104, USA
  3. 3Department of Family Medicine, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine
  4. 4Department of Psychiatry, Weill Cornell Medical College, 21 Bloomingdale Road, White Plains, New York, USA
  5. 5Department of Psychiatry, University of Pittsburgh School of Medicine, WPIC / Bellefield Towers, Room 758, 3811 O’Hara Street, Pittsburgh, PA 15213, USA
  1. Correspondence to: C F Reynolds III Reynoldscf{at}upmc.edu
  • Accepted 8 April 2013

Abstract

Objective To investigate whether an intervention to improve treatment of depression in older adults in primary care modified the increased risk of death associated with depression.

Design Long term follow-up of multi-site practice randomized controlled trial (PROSPECT—Prevention of Suicide in Primary Care Elderly: Collaborative Trial).

Setting 20 primary care practices in New York City, Philadelphia, and Pittsburgh, USA, randomized to intervention or usual care.

Participants 1226 participants identified between May 1999 and August 2001 through a two stage, age stratified (60-74; ≥75 years) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of patients who screened negative.

Intervention For two years, a depression care manager worked with primary care physicians in intervention practices to provide algorithm based care for depression, offering psychotherapy, increasing antidepressant dose if indicated, and monitoring symptoms, adverse effects of drugs, and adherence to treatment. This paper reports the long term follow-up.

Main outcome measure Mortality risk based on a median follow-up of 98 (range 0.8-116.4) months through 2008.

Results In baseline clinical interviews, 396 people were classified as having major depression, 203 had clinically significant minor depression, and 627 did not meet criteria for depression. At follow-up, 405 patients had died. Patients with major depression in usual care were more likely to die than were those without depression (hazard ratio 1.90, 95% confidence interval 1.57 to 2.31). In contrast, patients with major depression in intervention practices were at no greater risk than were people without depression (hazard ratio 1.09, 0.83 to 1.44). Patients with major depression in intervention practices, relative to usual care, were 24% less likely to have died (hazard ratio 0.76, 0.57 to 1.00; P=0.05). Preliminary data on cause of death are provided. No significant effect on mortality was found for minor depression.

Conclusions Older adults with major depression in practices provided with additional resources to intensively manage depression had a mortality risk lower than that observed in usual care and similar to older adults without depression.

Trial registration Clinical trials NCT00000367.

Footnotes

  • Contributors: JJG, HRB, and PJR did the literature searches. KHM and JZ created the figures. JJG, MLB, and CFR were responsible for the overall design and conduct of the study. KHM and JZ were responsible for data management and did the analyses with input from JJG, MLB, CFR, HRB, and PJR. All authors were involved in interpretation of the findings and in preparation of the manuscript. All approved the final submitted version. JJG, MLB, and CFR are the guarantors.

  • Funding: This study was funded by the National Institute of Mental Health (R01 MH065539). JJG, KHM, and HRB were supported by NIMH awards K24 MH070407, K01MH073903, and K23 MH67671. MLB and PJR were supported by P30 MH085943, and CFR was supported by P30 MH090333 from NIMH. JZ was supported by NIMH award T32 MH065218. PROSPECT was a collaborative research study funded by the NIMH. The three groups included the Advanced Centers for Intervention and Services Research of Cornell University (PROSPECT Coordinating Center; principal investigator: George S Alexopoulos; co-principal investigators: MLB and Herbert C Schulberg; R01 MH59366, P30 MH68638); University of Pennsylvania (principal investigator Ira Katz; co-principal investigators Thomas Ten Have and Gregory K Brown; R01 MH59380, P30 MH52129); and University of Pittsburgh (principal investigator CFR; co-principal investigator Benoit H Mulsant; R01 MH59381, P30 MH52247). Additional small grants came from Forest Laboratories and the John D Hartford Foundation. The sponsor had no role in the design and conduct of the study; in data collection or management, analysis, and interpretation of the data; or in preparation, review, and approval of the manuscript. All the authors had full access to all the data.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organization for the submitted work other than those listed under funding; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study received approval from the institutional review boards at all collaborating universities and independent review at the National Center for Health Statistics. Each participant gave written consent, including permission to obtain death certificate information.

  • Data sharing: No additional data available.

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