Randomized trial of case-finding for depression in elderly primary care patients

OBJECTIVE: To determine the effect of case-finding for depression on freque ncy of depression diagnoses, prescriptions for antidepressant medications, prevalence of depression, and health care utilization during 2 years of fol low-up in elderly primary care patients. DESIGN: Randomized controlled trial. SETTING: Thirteen primary care medical clinics at the Raiser Permanente Med ical Center, an HMO in Oakland, Calif, were randomly assigned to interventi on conditions (7 clinics) or control conditions (6 clinics). PARTICIPANTS: A total of 2,346 patients aged 65 years or older who were att ending appointments at these clinics and completed the 15-item Geriatric De pression Scale (GDS). GDS scores of 6 or more ware considered suggestive of depression. INTERVENTIONS: Primary care physicians in the intervention clinics were not ified of their patients' GDS scores. We suggested that participants with se vere depressive symptoms (GDS score greater than or equal to 11) be referre d to the Psychiatry Department and participants with mild to moderate depre ssive symptoms (GDS score of 6-10) be evaluated and treated by the primary care physician. Intervention group participants with GDS scores suggestive of depression were also offered a series of organized educational group ses sions on coping with depression led by a psychiatric nurse. Primary care ph ysicians in the control clinics were not notified of their patients' GDS sc ores or advised of the availability of the patient education program (usual care). Participants were followed for 2 years. MEASUREMENTS AND MAIN RESULTS: Physician diagnosis of depression, prescript ions for antidepressant medications, prevalence of depression as measured b y the GDS at 2-year follow-up, and health care utilization were determined. A total of 331 participants (14%) had GDS scores suggestive of depression (GDS greater than or equal to 6) at baseline, including 162 in the interven tion group and 169 in the control group. During the 2-year follow-up period , 56 (35%) of the intervention participants and 58 (34%) of the control par ticipants received a physician diagnosis of depression (odds ratio [OR], 1. 0; 95% confidence interval [CI], 0.6 to 1.6; P = .96). Prescriptions for an tidepressants were received by 59 (36%) of the intervention participants an d 72 (43%) of the control participants (OR, 0.8; 95% CI, 0.5 to 1.2; P = .3 ). Two-year follow-up GDS scores were available for 206 participants (69% o f survivors): at that time, 41 (42%) of the 97 intervention participants an d 54 (50%) of the 109 control participants had GDS scores suggestive of dep ression (OR, 0.7; 95% CI, 0.4 to 1.3; P = .3). Comparing participants in th e intervention and control groups, there were no significant differences in mean GDS change scores (-2.4 +/- SD 3.7 vs -2.1 SD +/- 3.6; P = .5) at the 2-year follow-up, nor were there significant differences in mean number of clinic visits (1.8 +/- SD 3.1 vs 1.6 +/- SD 2.8; P = .5) or mean number of hospitalizations (1.1 +/- SD 1.6 vs 1.0 +/- SD 1.4; P = .8) during the 2-y ear period. In participants with initial GDS scores > 11, there was a mean change in GDS score of -5.6 +/- SD 3.9 for intervention participants (n = 1 3) and -3.4 +/- SD 4.5 for control participants (n = 21). Adjusting for dif ferences in baseline characteristics between groups did not affect results. CONCLUSIONS: We were unable to demonstrate any benefit from case-finding fo r depression during 2 years of follow-up in elderly primary care patients. Studies are needed to determine whether case-finding combined with more int ensive patient education and follow-up will improve outcomes of primary car e patients with depression.