Evidence
Alert

A primary care intervention helps older people with depression

Enhanced case management (also called collaborative care) added to primary care reduced symptoms in people with clinical depression, compared with usual primary care. The benefit was similar to other depression treatments. However, the small benefit over usual care was not sustained to 12 months.

This NIHR-funded UK trial was carried out among nearly 500 adults aged at least 65 years. Primary care mental health practitioners delivered six sessions to encourage activity and social contact (five were by telephone). Medication monitoring and other psychological advice, linking up with other NHS staff, was also offered to those in the collaborative care group.

This relatively cheap intervention might be feasibly rolled-out to older people not using the Improving Access to Psychological Therapies programme. It is possible that greater treatment duration of the number of sessions might lead to longer-term impacts.

These results have contributed to the draft NICE depression guideline out for consultation in 2017. Those with physical health and mobility problems and other barriers to using services may especially benefit.

Why was this study needed?

About one in seven people over the age of 75 are clinically depressed. Depression is associated with poor quality of life, worse physical health and increased use of health and social care services.

Older people and practitioners may view psychological difficulties as part of normal ageing or believe that psychological treatments are not effective. Perceptions and practical barriers to accessing care can lead to depression being under-treated. In 2014/15, only 7% of people completing treatment in the Improving Access to Psychological Therapies programme were older people.

Collaborative care is a structured patient-centred way for case managers to proactively manage treatments. Effectiveness evidence had been mainly from the US, so NICE recommended further research. UK trials have since given positive results for working-age adults, and older adults with sub-clinical depression.

CASPER-PLUS is the first large-scale UK trial to measure the clinical and cost-effectiveness of collaborative care for older people with clinical depression.

What did this study do?

This pragmatic trial randomised 485 adults with moderate to severe depression into collaborative care or usual primary care. Participants were recruited from 69 GP practices in northern England. Their average age was 72 years, and a high proportion had physical health problems. Exclusion criteria included suicidal risk, drug and alcohol problems, psychosis and cognitive impairment.

A collaborative care protocol incorporating low-intensity behavioural activation therapy was adapted for older people. Behavioural activation encourages increased activity and social contact, which may improve physical health symptoms as well as mood. One face to face session was followed by five telephone sessions over eight weeks. Case managers were primary care mental health workers supervised by a senior mental health specialist.

The collaborative care group had higher drop-out than the usual care group (25% at four months). Participants, practitioners and researchers were aware of treatment allocation, which may have influenced participant’s answers to the self-reported questionnaire.

What did it find?

  • Baseline depression scores were on average 14 out of 27 according to the 9-item self-report Patient Health Questionnaire (PHQ-9), in which higher numbers indicate worse symptoms. At four months after randomisation, average depression scores had reduced to 8.98 in the collaborative care group, compared to 10.9 in the usual care group (adjusted mean difference [MD] 1.92 points, 95% confidence interval [CI] 0.85 to 2.99 points; 390 participants).
  • At 12 and 18 months, depressive symptom scores were the same in the collaborative care and usual care groups at between 10.4 and 10.6.
  • Eighty-three per cent of the collaborative care group participated in the intervention. Reasons some didn’t include physical health problems and concerns about the intervention being intrusive. Some patients were uncertain about the benefits of behaviour-based therapy.

What does current guidance say on this issue?

NICE recommended in 2009 and 2011 that collaborative care is offered to patients with moderate to severe depression and a chronic physical health problem with difficulties undertaking daily tasks, whose symptoms do not respond to first-line interventions. They did not recommend this intervention for milder depression without these additional problems.

The 2009 guideline recommended low intensity guided self-help including behavioural activation for mild to moderate depression. NICE noted relatively weak evidence at that time for high-intensity behavioural activation.

In 2017, NICE issued a draft updated guideline on the treatment and management of depression for consultation. The final guideline is due for publication in 2018.

What are the implications?

Collaborative care might be delivered by the Improving Access to Psychological Therapy programme, or suitably qualified staff in GP practices. The NHS target is to provide 3000 new mental health therapists co-located in primary care by 2020/21.

In this trial, psychological wellbeing practitioners were employed at NHS band 5. They received two days of additional training to deliver the intervention.

The draft NICE depression guideline (2017) recommends that collaborative care should be considered for all older people with depression. As a result of recent UK trials, the draft guideline gives greater prominence to behavioural activation than in 2009.

Citation and Funding

Bosanquet K, Adamson J, Atherton K, et al. CollAborative care for Screen-Positive EldeRs with major depression (CASPER plus): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness. Health Technol Assess. 2017;21(67):1-252.

This project was funded by the National Institute for Health Research Health Technology Assessment programme (project number 10/57/43).

 

Bibliography

NHS website. Stress, anxiety and depression: Can I get free therapy or counselling? London: Department of Health and Social Care; 2018.

NHS England and NHS Improvement. Mental health in older people: A practice primer. Redditch: NHS England; 2017.

NICE. Depression in adults. QS8. London: National Institute for Health and Care Excellence; 2011.

NICE. Depression in adults with a chronic physical health problem: recognition and management. CG91. London: National Institute for Health and Care Excellence; 2009.

NICE. Depression in adults: treatment and management. Guideline in development.  London: National Institute for Health and Care Excellence; expected publication 2018.

NIHR DC. Options in the care of people with depression. London: National Institute for Health Research Dissemination Centre; 2017.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

 

Definitions

Low-intensity psychological treatments are generally for people with mild to moderate depression or anxiety. Mental health practitioners facilitate the patient to use structured self-help materials, sometimes involving the telephone or internet. Qualified psychological wellbeing practitioners can work within Improving Access to Psychological Therapies services, and receive 45 days of accredited training.

In contrast, high-intensity treatments are usually delivered face to face for an extended number of sessions by highly trained psychologists and therapists.

Behavioural activation (low or high intensity) encourages patients with depression to approach activities they may have been avoiding, through the development of goals and activity schedules.

 

Commentaries

Expert commentary

Depression in older people is common, overlooked and poorly treated. Further, older people are shamefully under-represented in Improving Access to Psychological Therapies, despite evidence that they have recovery rates that are better than those in younger patients.

Demonstration of the effectiveness of a low-intensity psychological intervention that offers faster recovery of low mood and anxiety symptoms than usual treatment in primary care is important and timely.

Collaborative care offers a cost-effective and scalable model that Improving Access to Psychological Therapies and GPs could begin to use immediately to improve outcomes in a population of unwell people with enormous recognised but unmet need.

Robert Howard, Professor of Old Age Psychiatry, University College London