Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Psychogeriatric home care led to more elderly patients recovering from depression

ACP J Club. 1997 May-Jun;126:66. doi:10.7326/ACPJC-1997-126-3-066


Source Citation

Banerjee S, Shamash K, Macdonald AJ, Mann AH. Randomised controlled trial of effect of intervention by psychogeriatric team on depression in frail elderly people at home. BMJ. 1996 Oct 26;313:1058-61.


Abstract

Objective

To determine the efficacy of a psychogeriatric team in treating depression in elderly disabled patients receiving home care (help with household tasks and personal care).

Design

Randomized, single-blind, controlled trial with follow-up at 6 months.

Setting

An inner-city borough in London, England, UK.

Patients

69 patients ≥ 65 years of age (mean age 81 y, 83% women) who received home care and were depressed according to criteria of the standardized automatic geriatric examination for computer-assisted taxonomy (AGECAT) but were not receiving psychiatric care. Prevalence of clinically significant depression in this disabled elderly population has been reported to be twice that in the general elderly population.

Intervention

33 patients were allocated to an intervention group, and 36 were allocated to a control group. Patients in the intervention group received an individualized management plan that was formulated by the psychogeriatric team. The plan included physical and psychological interventions and was delivered by a researcher working as a member of the team. Patients in the control group received care from a general practitioner.

Main outcome measure

Recovery from depression as determined by the geriatric mental state/AGECAT system.

Main results

Analysis was by intention to treat. 19 patients (58%) in the intervention group compared with 9 patients (25%) in the control group recovered from depression { P = 0.006. This absolute risk improvement of 33% means that 4 patients would need to be treated with an intervention by a psychogeriatric team (compared with general practitioner care) for 1 additional patient to recover from depression at 6 months, 95% CI 2 to 11; the relative risk improvement was 130%, CI 26% to 342%.}* The treatment benefit of an intervention by a psychogeriatric team persisted after controlling for possible confounding variables, including medications for treatment of depression.

Conclusion

Among frail elderly persons receiving home care, those receiving treatment by a psychogeriatric team were more likely to recover from depression than were those receiving care from a general practitioner.

Source of funding: Mental Health Foundation.

For article reprint: Dr. S. Banerjee, Section of Epidemiology and General Practice, Institute of Psychiatry, London SE5 8AF, England, UK. FAX 44-171-277-0283.

*Numbers calculated from data in article.


Commentary

Depressive symptoms are commonly seen in primary care settings (1). Elderly persons receiving home care are at high risk for depression. The prevalence of depression among the participants in the study by Banerjee and colleagues is consistent with that seen in hospitalized or institutionalized elderly persons.

In this study, patients were selected from the home care program through the use of AGECAT criteria to diagnose depression. These criteria are well validated; however, the definition of "home care" was not given in this study and may differ between countries.

Participants in this study received care based on a management plan that was formulated by a psychiatric team and was delivered during home visits. The intervention was evaluated as a whole and, therefore, the study does not allow investigation of which elements were associated with recovery from depression. The frequency and duration of visits were not described. Even though the effect of social resources was controlled for with statistical modeling, part of the treatment effect observed may have been a function of social interaction during the home visits. An important element contributing to the treatment effect may have been the prescription of antidepressants because at follow-up, fewer patients in the control group (16%) than in the intervention group (69%) were treated with antidepressants.

The cost of the intervention was not specified but included the relatively high cost of a half-time physician to care for patients in the intervention group. Persons with coexistent depression and dementia were excluded from this study, and the applicability of the findings to these patients cannot be assessed.

The results of this study suggest that disabled patients who are depressed are more likely to improve if their depression is first diagnosed and then actively managed. Specialist psychiatric services were used in this study, and such services may be useful to enhance the skills of primary care physicians in detecting and managing depression in older adults. The model described here may be of value in complex cases that do not improve after active management by primary care.

Kathryn M. Andolsek, MD, MPH
Duke University Medical CenterDurham, North Carolina, USA


Reference

1. Koenig HG, Blazer DG. Epidemiology of geriatric affective disorders. Clin Geriatr Med. 1992;8:235-51.