The Effect of a Primary Care Practice–Based Depression Intervention on Mortality in Older Adults

A Randomized Trial

15 May 2007 | Volume 146 Issue 10 | Pages 689-698

Background: Few studies have tested the effects of a depression intervention on the risk for death associated with depression.

Objective: To test whether an intervention to improve depression care can modify the risk for death.

Design: Practice-based, randomized, controlled trial.

Setting: 20 primary care practices in New York, New York, and Philadelphia and Pittsburgh, Pennsylvania.

Patients: 1226 randomly sampled patients identified through a 2-stage, age-stratified (60 to 74 years and 75 years) depression screening.

Intervention: Depression care manager working with primary care physicians to provide algorithm-based care.

Measurements: Depression status based on clinical interview and vital status at 5 years by using the National Death Index.

Results: At baseline, 396 patients met criteria for major depression and 203 patients met criteria for clinically significant minor depression. After a median follow-up of 52.8 months, 223 patients died. Patients with depression in intervention practices were less likely to have died than those in usual care practices (adjusted hazard ratio, 0.67 [95% CI, 0.44 to 1.00]). Risk for death was reduced in patients with major depression (adjusted hazard ratio, 0.55 [CI, 0.36 to 0.84]) but not in patients with clinically significant minor depression (adjusted hazard ratio, 0.97 [CI, 0.49 to 1.92]). The benefit seemed to be almost entirely attributable to a reduction in deaths due to cancer.

Limitations: The mechanism for an effect on deaths due to cancer is unclear. Depression status, cause of death, and vital status might have been misclassified.

Conclusions: Older primary care patients with major depression in practices that implemented depression care management were less likely to die over a 5-year period than were patients with major depression in usual care practices. The effect seemed to be limited to deaths due to cancer. The mechanism for such an effect is unclear and warrants further investigation.

ClinicalTrials.gov registration number: NCT00000367.

Editors' Notes Context Persons with depression are more likely to die, but studies have not shown that treatment of depression reduces mortality. Contribution Investigators observed a 45% reduction in the hazard of death among patients with major depression cared for in primary care practices that were randomly assigned to a depression care management program. Cautions The reduction in deaths occurred almost exclusively among patients who died of cancer. The mechanism for the effect is unclear and might be due to misclassification of cause of death or vital status. Implication A practice-level depression care management program seemed to reduce deaths due to cancer in older patients with major depression. —The Editors

 

Author and Article Information

From the University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and Weill Medical College of Cornell University, White Plains, New York.

Grant Support: The mortality follow-up of PROSPECT participants was funded by the National Institute of Mental Health (principal investigator, Joseph J. Gallo, MD, MPH [R01 MH065539]). The PROSPECT was a collaborative research study funded by the National Institute of Mental Health. The 3 groups included in the funded study were the Advanced Centers for Intervention and Services Research of Cornell University (coordinating center; principal investigator, George S. Alexopoulos, MD, and co-principal investigators, Martha L. Bruce, PhD, MPH, and Herbert C. Schulberg, PhD [R01 MH59366, P30 MH68638]), University of Pennsylvania (principal investigator, Ira Katz, MD, PhD, and co-principal investigators, Thomas Ten Have, PhD, and Gregory K. Brown, PhD [R01 MH59380, P30 MH52129]), and University of Pittsburgh (principal investigator, Charles F. Reynolds III, MD, and co-principal investigator, Benoit H. Mulsant, MD [R01 MH59381, P30 MH52247]). Additional small grants came from Forest Laboratories and the John D. Hartford Foundation. Participation of Drs. Gallo, Bogner, Post, and Bruce was also supported by National Institute of Mental Health awards (K24 MH070407, K23 MH67671, K23 MH01879, and K02 MH01634). Dr. Bogner is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar (2004 to 2008).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Joseph J. Gallo MD, MPH, Department of Family Medicine and Community Health, School of Medicine, University of Pennsylvania, 3400 Spruce Street, 2 Gates Building, Philadelphia, PA 19104; e-mail, galloj{at}uphs.upenn.edu.

Current Author Addresses: Drs. Gallo and Bogner: Department of Family Medicine and Community Health, School of Medicine, University of Pennsylvania, 3400 Spruce Street, 2 Gates Building, Philadelphia, PA 19104.

Dr. Morales: Center for Clinical Epidemiology and Biostatistics, School of Medicine, University of Pennsylvania, 423 Guardian Drive, 626 Blockley Hall, Philadelphia, PA 19104.

Dr. Post: University of Michigan and Ann Arbor Veterans Affairs Healthcare System, Health Services Research & Development (11H), 2215 Fuller Road, Ann Arbor, MI 48105.

Dr. Lin: Cambridge Health Alliance, 120 Beacon Street, Somerville, MA 02143.

Dr. Bruce: Cornell University, 21 Bloomingdale Road, White Plains, NY 10605.

Author Contributions: Conception and design: J.J. Gallo, H.R. Bogner, M.L. Bruce.

Analysis and interpretation of the data: J.J. Gallo, H.R. Bogner, K.H. Morales, J.Y. Lin, M.L. Bruce.

Drafting of the article: J.J. Gallo, H.R. Bogner, K.H. Morales, M.L. Bruce.

Critical revision of the article for important intellectual content: J.J. Gallo, H.R. Bogner, K.H. Morales, E.P. Post, M.L. Bruce.

Final approval of the article: J.J. Gallo, H.R. Bogner, K.H. Morales, E.P. Post, M.L. Bruce.

Statistical expertise: K.H. Morales, E.P. Post.

Obtaining of funding: J.J. Gallo, E.P. Post, M.L. Bruce.

Administrative, technical, or logistic support: E.P. Post.

Collection and assembly of data: J.J. Gallo, E.P. Post, M.L. Bruce.

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The Effect of a Primary Care Practice-Based Depression Intervention on Mortality in Older Adults: Re

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