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Investigators Find Ways To Improve Care For Depression 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 a recent issue of the Journal of the American Medical Asso-ciation (JAMA) suggests a way to help. Investigators at New York-Presbyter-ian Hospital/Westchester Division and the Universities of Pennsylvania and Pittsburgh have published findings of the PROSPECT Study (Prevention of Suicide in Primary Care Elderly: Col-laborative 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 Institue of Geria-tric Psychiartry at New York-Presby-terian/ 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 lead-ing 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 ac-cept their diagnosis, they need a lot of encouragement in order to remain in treatment," said Dr. Alexopoulos. "Hope-lessness 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 de-pressed older person. "From a physician’s perspective, it requires a major effort to overcome resistance to treatment," said Dr. Alexo-poulos. "For these reasons, the PROS-PECT study focused on what happens in the primary care office and how it can improve that treatment, while recognizing that physicians have many constraints," he said. The researchers’ solution? A specially trained "care manager" who follows a set of treatment guidelines mo-dified 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 colleague worked with senior researchers at the University of Pennsylvania to test the intervention on patients at 20 primary care offices in New York City, Phila-delphia, 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. Approx-imately 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 investigators examined the pa-tients’ 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 in-tervention. Among intervention patients who reported suicidal ideation at the Continued on page 49 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." 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. 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." Dr. Alexopoulos and his colleague worked with senior researchers at the University of Pennsylvania to test the 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 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."
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