Treating Depression in Older Adults Is Cost-Effective

But Primary Care Management Remains Suboptimal

It has been well-demonstrated that depression is a common and debilitating condition in the elderly and that effective treatments are available. So why are so many older adults with depression undertreated or not treated at all in the primary care setting?

J Gen Intern Med

A group of Dutch investigators thought the answer might lie in the lack of comprehensive disease management programs, and they conducted a cost-effectiveness analysis to see if they were right (. 2006; 21: 1020-1026).

Using the mood module of the Primary Care Evaluation of Mental Disorders (PRIME-MD), 178 patients aged ≥55 years (out of 4000 patients screened) from 34 primary care practices screened positive for major depression, 145 of whom completed follow-up.

The primary care practices were randomized to an intervention group (n = 18) or a usual-care group (n = 16). Physicians in the intervention group received 4 hours of training on screening for, diagnosing, and treating depression. Therapy for patients with depression included education, drug therapy, and supportive contacts.

In the usual-care group, physicians who recognized patients with major depression treated them according to Dutch guidelines, which call for education and coaching, possibly with the addition of drug therapy and/or referral to psychotherapy.

At 12-month follow-up, a similar proportion of patients in the intervention (43%) and usual-care groups (48%) were judged to have recovered (ie, no PRIME-MD diagnosis of major depression). No statistically significant between-group differences were found in severity of depressive symptoms, quality of life, or healthcare utilization. And although psychotropic medication costs were higher in the intervention group, these were offset by higher physiotherapy costs in the usual-care group.

Based on these results, the investigators recommended continuing usual care (ie, following evidence-based guidelines) for depression in the older adult within the primary care setting.

This leaves open the question, “How do we resolve the paradox that antidepressant drugs work and we frequently prescribe them in primary care, but patients do not seem to get better?” writes Christopher M. Callahan, MD, Indiana University Center for Aging Research, Indianapolis, in an accompanying editorial (pages 1125-1127).

This question is all the more taxing, since most patients with depression consult their primary care physician for treatment. Dr Callahan doubts the answer is more antidepressant prescriptions, since 190 million such prescriptions are written each year in the United States, mostly by primary care physicians, at an annual cost of $12 billion.

He reminds physicians that handing a patient a prescription for an antidepressant does not qualify as treatment for major depression. There are no quick and inexpensive solutions to the problem of inadequate depression management in primary care.

Although antidepressants and psychotherapy are effective treatments for major depression, Dr Callahan notes they must be incorporated into a system of care that includes:

• Closely monitoring the patient’s response to treatment

• Making adjustments in the treatment when needed

• Giving the patient access to support outside of the office visit

• Ensuring that the patient receives appropriate reimbursement

• Providing access to specialty care for the minority of patients who will require it.