A chronic disease management approach may be as applicable to elderly depression as it is to other chronic conditions like heart disease, asthma or diabetes. Chronic disease management is a more co-ordinated and organized way of treating an illness, often with the aid of a team, rather than a single doctor. The potential gains for the patient with elderly depression, and other chronic conditions, include fewer treatment days, avoidance of hospitalization, prevention of progression or relapse, and better quality of life. However, the application of chronic disease management to elderly depression is still largely experimental – though findings are promising.

A major feature of the chronic disease management model in elderly depression is the ‘stepped care’ approach in which separate pathways are used for managing mild/moderate and severe depression. These involve sequential application of different types of treatment with ongoing monitoring of the patient’s progress. For instance, researchers in The Netherlands describe the pathway for management of mild/moderate depression in the first six to 12 weeks as including ‘watchful waiting’, education, self help, counselling, psychotherapy and exercise. Antidepressants are not used during this period. For severe depression, however, antidepressants and/or psychotherapy would be used. In the UK, the National Institute for Health and Clinical Excellence suggests a four step approach depending upon the severity of the depression.

So far, however, we do not have much information on how successful these stepped care approaches are in elderly depression. The Netherlands experiment showed promising findings in the mild/moderate depression group but found that as many as 43% of severely depressed patients did not receive antidepressants or psychotherapy within the month, contrary to the guidelines. Even in the US, where the chronic disease management approach is more familiar, its application in depression lags behind that for diabetes, cardiovascular disease and asthma. A comparison carried out in the state of Minnesota showed that a clear divergence in application of chronic disease management in diabetes and depression; for instance, 71% of patients with diabetes received individual goal setting (an important element of this approach) compared to only 24% of patients with depression. Evidently, guidelines alone are not enough. What is needed is effective and persistent case management.

Collaborative care in elderly depression requires a team of nurses, psychological and behavioural therapies, psychiatrists, pharmacists, social workers and geriatricians. A key feature of collaborative care is the appointment of a care manager who co-ordinates the work of the team. There is evidence that collaborative care produces better results than ‘usual care’ if it is well managed and integrated. Indeed, a review of depression in primary care by UK researchers shows that clinician education packages delivered alone are not cost effective, for they come at increased cost without improved outcomes. Therefore education, in itself, is not enough.

In the US, the IMPACT trial * (Improving Mood: Promoting Access to Collaborative Treatment) has followed up a group of 1,801 patients with elderly depression, who were randomly assigned to either collaborative care or usual care. Cost savings for collaborative care were a little over 10% compared to usual care and the researchers concluded ‘for older adults with depression, collaborative care not only produces substantial clinical improvements but also carries the likelihood of long-term cost savings compared with care as usual.

Therefore, collaborative care can work in elderly depression, although it will take time before guidelines existing in both the US and Europe are put into routine clinical practice.

Source:

Unützer J et al Long-term cost effects of collaborative care for late-life depression American Journal of Managed Care February 2008;14:95-100

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