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University of Pennsylvania and University of Pittsburgh Investigators Collaborate on Study

For many people, the older years are far from golden. Illness, loneliness, or the death of a spouse or friends can cause depression to become a constant companion. Depression is the most common diagnosis of those who commit suicide.

Although the elderly make up only 13% of the population, they comprise 18% of all suicide deaths.

Now, a study in the March 3 issue of the Journal of the American Medical Association (JAMA) suggests a way to help. Investigators at New York-Presbyterian Hospital/Westchester Division and the Universities of Pennsylvania and Pittsburgh have published findings of the PROSPECT Study (Prevention of Suicide in Primary Care Elderly: Collaborative Trial). The researchers' results show that older patients' suicidal thoughts and depression tend to go away more quickly when their own primary care physician uses a trained care manager to offer a guideline-driven antidepressant treatment and to encourage patients to adhere to treatment recommendations.

It is critical to improve the care of late-life depression because depression itself is painful, increases the risk of suicide or death by other medical illnesses, and causes disability and family disruption, said Dr. George Alexopoulos, the principal investigator of the PROSPECT Study, Director of the Weill Cornell Institute of Geriatric Psychiatry at New York-Presbyterian/Westchester, and Professor of Psychiatry at Weill Cornell Medical College.

Recognizing and diagnosing late-life depression is complex because patients and families often blame their symptoms on aging or on medical illnesses, said Dr. Martha Bruce, the leading author of the JAMA article, co-principal investigator of the PROSPECT Study, and Professor of Sociology in Psychiatry at Weill Cornell Medical College. Older patients may resist the diagnosis of depression because of the stigma associated with mental illness.

Even when depressed patients accept their diagnosis, they need a lot of encouragement in order to remain in treatment, said Dr. Alexopoulos. Hopelessness caused by their depression, makes them give up treatment since they are persuaded that nothing can change the way they feel.

The PROSPECT Study focused on primary care patients because two thirds of depressed elders receive care for depression by their own primary care physicians and rarely follow through when referred to a mental health specialist. However, the researchers knew that the average primary care doctor sees four patients in an hour, and cannot meet the time demands of a depressed older person.

From a physician's perspective, it requires a major effort to overcome resistance to treatment, said Dr. Alexopoulos. For these reasons, the PROSPECT Study focused on what happens in the primary care office and how it can improve that treatment, while recognizing that physicians have many constraints, hesaid.

The researchers' solution? A specially trained care manager who follows a set of treatment guidelines modified specifically for elderly patients. While trained by geriatric psychiatrists, the care manager reports to the primary care doctor, who is ultimately responsible for all treatment decisions.

Dr. Alexopoulos and his colleagues at New York-Presbyterian/Weill Cornell, Drs. Martha Bruce and Herbert Schulberg, worked with senior researchers at the University of Pennsylvania (principal investigator Dr. Ira Katz) and the University of Pittsburgh (principal investigator Dr. Charles Reynolds III) to test the PROSPECT intervention on patients at 20 primary care offices in New York City, Philadelphia, and Pittsburgh.

The study included 598 patients 60 years or older suffering from major depression or minor depression that persisted for at least a month. Approximately half of the patients received usual care by their own physicians while the remaining half received the PROSPECT intervention. The intervention consisted of the services of a depression care manager who collaborated with the patient's own physician.

The care managers — trained social workers, nurses, or psychologists — followed a step-by-step treatment guideline, which first offered an antidepressant (citalopram), or, if the patient requested it, interpersonal psychotherapy. The guideline provided detailed recommendations for patients who failed to respond to the initial treatment steps. The care managers not only helped primary care physicians with the recognition and treatment of depression, but also followed the patients either in person or by telephone and encouraged adherence to treatment.

The acceptance of the intervention by physicians was tremendous — the primary care physicians loved the care managers. None of the practitioners who agreed to participate withdrew from the study, said Dr. Reynolds, Principal Investigator of the Pittsburgh site and Professor of Psychiatry at the University of Pittsburgh.

The investigators examined the patients' level of suicidal ideation at four months, eight months, and one year after treatment, Suicidal ideation can be passive, such as thinking I wish I were dead or Life isn't worth living. Or it can be active, in which patients think and plan to commit suicide. For patients who had suicidal ideation at the beginning of the study — regardless of whether they had major or minor depression — suicidal thoughts resolved more quickly in primary care practices using care management intervention. Among intervention patients who reported suicidal ideation at the beginning of the study, 71% no longer had suicidal thoughts in the intervention practices eight months later. In contrast, only 44% of usual care patients who had suicidal thoughts at entry to the study lost these thoughts by the eighth month of follow-up.

Practices offering the care management intervention were more effective in reducing symptoms of major depression early in treatment. The beneficial effect of the care management intervention peaked at four months. However, one year later, the level of depressive symptoms was similar in practices with care managers and practices offering usual care.

Staying depressed for a year is a big problem because it means a year of disability and of increased risk for suicide, said Dr. Katz, Principal Investigator of PROSPECT's Philadelphia site and Professor of Psychiatry at the University of Pennsylvania. Even if you recover in the end, it's not something you would wish on someone.

If Medicare decides to reimburse such services, it may improve the care of depressed elders at a national level. This means reducing suffering, suicide risk, death rate, and disability. A modest amount of money to support trained care managers can buy a lot of health, said Dr. Alexopoulos.

Additional co-authors of the PROSPECT Study included Dr. Thomas Ten Have (University of Pennsylvania), Dr. Benoit Mulsant (University of Pittsburgh School of Medicine), Dr. Gregory Brown (University of Pennsylvania), and Dr. Gail McAvay (Weill Cornell Medical College; Qualidigm, Middletown, CT). The study was funded by the National Institute of Mental Health (NIMH).

In addition to the PROSPECT Study, The Weill Cornell Institute of Geriatric Psychiatry conducts many studies aimed to improve the treatment and care of late-life depression. Participants in these studies receive free treatment and transportation. Moreover, the Institute offers free telephone screening for geriatric depression (914-997-4331).