Outcome of depression in later life in primary care: longitudinal cohort study with three years' follow-up.
ABSTRACT To study the duration of depression, recovery over time, and predictors of prognosis in an older cohort (>or=55 years) in primary care.
Longitudinal cohort study, with three years' follow-up.
32 general practices in West Friesland, the Netherlands.
234 patients aged 55 years or more with a prevalent major depressive disorder.
Depression at baseline and every six months using structured diagnostic interviews (primary care evaluation of mental disorders according to diagnoses in Diagnostic and Statistical Manual of Mental Disorders, fourth edition) and a measure of severity of symptoms (Montgomery Asberg depression rating scale). The main outcome measures were time to recovery and the likelihood of recovery at different time points. Multivariable analyses were used to identify variables predicting prognosis.
The median duration of a major depressive episode was 18.0 months (95% confidence interval 12.8 to 23.1). 35% of depressed patients recovered within one year, 60% within two years, and 68% within three years. A poor outcome was associated with severity of depression at baseline, a family history of depression, and poorer physical functioning. During follow-up functional status remained limited in patients with chronic depression but not in those who had recovered.
Depression among patients aged 55 years or more in primary care has a poor prognosis. Using readily available prognostic factors (for example, severity of the index episode, a family history of depression, and functional decline) could help direct treatment to those at highest risk of a poor prognosis.
- SourceAvailable from: Harm Van Marwijk[Show abstract] [Hide abstract]
ABSTRACT: Background Depressive symptoms are highly prevalent in old age, but they remain mostly untreated. Several clinical trials have shown promising results in preventing or reducing depressive symptoms. However, it is not clear how robust these effects are in the real world of day-to-day care. Therefore, we have implemented the `Lust for Life¿ programme, which significantly reduced depressive symptoms in community-dwelling older adults in the first three months after implementation. This mixed-methods study was conducted alongside the trial to develop a contextualised understanding of factors affecting the implementation.MethodsA total of 263 persons of 65 years and older with depressive symptoms were recruited from 18 general practices and home care organizations in the Netherlands. We used qualitative data (in-depth interviews and focus group discussions with participants with depressive symptoms and healthcare professionals) as well as quantitative data (longitudinal data on the severity of depressive symptoms) to explore hindering and facilitating factors to the implementation of the `Lust for Life¿ programme.ResultsThe uptake of the routine screening was poor and imposed significant burdens on participants and healthcare professionals, and drop-out rates were high. Participants¿ perceived mental problems and need for care played a key role in their decision to participate in the programme and to step up to consequent interventions. Older people preferred interventions that focused on interpersonal contact. The programme was only effective when delivered by mental healthcare nurses, compared to home care nurses with limited experience in providing mental healthcare.Conclusions The intervention programme was effective in reducing depressive symptoms, and valuable lessons can be learned from this implementation trial. Given the low uptake and high investment, we advise against routine screening for depressive symptoms in general healthcare. Further, agreement between the participant and healthcare professional on perceived need for care and intervention is vital. Rather than providing a stepped care intervention programme, we showed that offering only one single preference-led intervention is effective. Lastly, since the provision of the interventions seems to ask for specific skills and experiences, it might require mental healthcare nurses to offer the programme.Trial registrationDutch trial register NTR2241.Implementation Science 08/2014; 9(1):107. · 3.47 Impact Factor
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ABSTRACT: The purpose of this study was to examine the prevalence of depressive symptoms, diabetes self-management, and quality of life in people with diabetes and foot ulcers. Ulcer status, mortality and amputations were also assessed at six months follow-up. This was a cross-sectional survey of people attending outpatient podiatry clinics at a major tertiary referral hospital. Depressive symptoms were measured using the Patient Health Questionnaire (PHQ). Diabetes self-care was assessed using the Summary of Diabetes Self Care Activities (SDSCA) measure. Health-related quality of life was measured using the physical component summary score (PCS) and the mental component summary score (MCS) of the SF-12. Of the 60 participants in the study 14 (23.3%) reported mild symptoms of depression (PHQ score 5-9) and 17 (28.3%) moderate to severe depressive symptoms (PHQ score > 9). Twenty-one (35%) met the criteria for previously recognized depression (on antidepressants and/or a diagnosis of depression in the last 12 months) and 17 (28.3%) for depression not previously recognized (PHQ > 4). Seventeen (28%) participants had been receiving antidepressant treatment for a median duration of 104 weeks (IQR 20, 494 weeks). Despite antidepressant treatment 12 participants (70.6% of those taking antidepressants) still reported moderate to severe depressive symptoms at the time of the study. Patients with PHQ scores > 4 reported poorer adherence to diabetes self-care activities including general diet, exercise, blood sugar monitoring and foot care when compared to those participants with PHQ scores < 5. No association was found between physical functioning (PCS) and depressive symptoms. Decreasing mental wellbeing (MCS) was associated with increasing depressive symptoms. At six months follow-up, there were three deaths and three amputations in participants with PHQ scores > 4 compared with no deaths and 2 amputations in participants with PHQ scores < 5. There was no association between depressive symptoms and ulcer healing or ulcer recurrence at the six-month follow-up. This study found a high prevalence of depressive symptoms both recognized and unrecognized in people with diabetes and foot ulcers. Depressive symptoms were associated with overall poorer diabetes self-management and health-related quality of life (HRQoL). There was no association between depressive symptoms and ulcer outcomes at six-months follow-up.Journal of Foot and Ankle Research 12/2014; 7(1):47. · 1.83 Impact Factor
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ABSTRACT: Depression accounts for the greatest disease burden of all mental health disorders, contributes heavily to healthcare costs, and by 2020 is set to become the second largest cause of global disability. Although 10% to 16% of people aged 65 years and over are likely to experience depressive symptoms, the condition is under-diagnosed and often inadequately treated in primary care. Later-life depression is associated with chronic illness and disability, cognitive impairment and social isolation. With a progressively ageing population it becomes increasingly important to refine strategies to identity and manage depression in older people. Currently, management may be limited to the prescription of antidepressants where there may be poor concordance; older people may lack awareness of psychosocial interventions and general practitioners may neglect to offer this treatment option.Methods/design: CASPER Plus is a multi-centre, randomised controlled trial of a collaborative care intervention for individuals aged 65 years and over experiencing moderate to severe depression. Selected practices in the North of England identify potentially eligible patients and invite them to participate in the study. A diagnostic interview is carried out and participants with major depressive disorder are randomised to either collaborative care or usual care. The recruitment target is 450 participants.The intervention, behavioural activation and medication management in a collaborative care framework, has been adapted to meet the complex needs of older people. It is delivered over eight to 10 weekly sessions by a case manager liaising with general practitioners.The trial aims to evaluate the clinical and cost effectiveness of collaborative care in addition to usual GP care versus usual GP care alone. The primary clinical outcome, depression severity, will be measured with the Patient Health Questionnaire-9 (PHQ-9) at baseline, 4, 12 and 18 months. Cost effectiveness analysis will assess health-related quality of life using the SF-12 and EQ-5D and will examine cost-consequences of collaborative care.A qualitative process evaluation will be undertaken to explore acceptability, gauge the extent to which the intervention is implemented and to explore sustainability beyond the clinical trial. Results will add to existing evidence and a positive outcome may lead to the commissioning of this model of service in primary care.Trial registration: ISRCTN45842879 (24 July 2012).Trials 11/2014; 15(1):451. · 2.12 Impact Factor
Outcome of depression in later life in primary care:
longitudinal cohort study with three years’ follow-up
E Licht-Strunk, general practitioner and postdoctoral fellow,1H W J Van Marwijk, general practitioner and
and applied biostatistics,3M De Haan, general practitioner and professor of general practice,1
A T F Beekman, psychiatrist and professor of psychiatry4
Objectives To study the duration of depression, recovery
over time, and predictors of prognosis in an older cohort
(≥55 years) in primary care.
Setting 32 general practices in West Friesland, the
Participants 234 patients aged 55 years or more with a
prevalent major depressive disorder.
Main outcome measures Depression at baseline and
every six months using structured diagnostic interviews
(primary care evaluation of mental disorders according to
diagnoses in Diagnostic and Statistical Manual of Mental
Disorders, fourth edition) and a measure of severity of
symptoms (Montgomery Åsberg depression rating scale).
likelihood of recovery at different time points.
Multivariable analyses were used to identify variables
Results The median duration of a major depressive
episode was 18.0 months (95% confidence interval 12.8
pooroutcomewasassociated withseverityof depression
at baseline, a family history of depression, and poorer
physical functioning. During follow-up functional status
remained limited in patients with chronic depression but
not in those who had recovered.
Conclusion Depression among patients aged 55 years or
more in primary care has a poor prognosis. Using readily
available prognostic factors (for example, severity of the
index episode, a family history of depression, and
highest risk of a poor prognosis.
At all ages depression is a common and disabling
condition. Although physical disorders and dementia
increase noticeably with age, both the prevalence and
the consequences of depressive disorders retain an
enormous impact on the health of ageing populations.
functioning; wellbeing1; the onset and prognosis of
chronic physical illnesses such as cardiovascular
disorders2and diabetes3; mortality4; and utilisation of
health services.5Although the importance of depres-
sion in later life is widely acknowledged and recent
trials have shown convincingly that treatment can be
effective67depression in most older patients remains
undiagnosed and therefore untreated.8-10Given the
increase in the ageing population, it is unlikely that
provide treatment for all older patients with depres-
sion. It is therefore important to be able to predict the
outcome andto identifythosepatients most at risk of a
poor outcome such as chronicity. As most older
depressed patients contact their general practitioner,
Although several studies on prognosis are available,
numbers for analyses, had access to adequate diag-
nostic data at baseline and follow-up, or tested the
impact of prognostic factors, while using enough
observations to be able to model the variability in the
a group of older patients with depression in primary
care over three years to provide accurate estimates of
the duration of depressive episodes, the likelihood of
recovery over time, and predictors of the prognosis.
The West Friesland Study is a cohort study on
depression in later life (≥55 years) in primary care,
with follow-up for three years. We recruited general
west of the Netherlands. Thirty four general practi-
tioners from 32 practices provided patients for the
From June 2000 to December 2002 we used a two
stage screening procedure to recruit potential partici-
pants with a prevalent major depressive disorder. This
method is described in detail elsewhere.13Briefly,
consecutive patients aged 55 or more visiting their
general practitioner were invited to fill in the geriatric
1Department of General Practice
and the EMGO Institute for Health
and Care Research of VU
University Medical Centre, Van
der Boechorstraat 7, 1081 BT,
2Department of Health Sciences,
Faculty of Earth and Life Sciences,
VU University, Netherlands
3Department of Methodology and
Applied Biostatistics, Institute of
Health Sciences, Faculty of Earth
and Life Sciences, VU University
4Department of Psychiatry and
the EMGO Institute for Health and
Care Research of VU University
Correspondence to: E Licht-Strunk
Cite this as: BMJ 2009;338:a3079
BMJ | ONLINE FIRST | bmj.compage 1 of 7
depression scale-15 items,1415regardless of the reason
of 5 were invited for a diagnostic interview using the
primary care evaluation of mental disorders,16which
was carried out by trained interviewers within 14 days
of the depression scale having been completed. By
using this method we were able to include the whole
spectrum of patients with depression seen in general
practice, from new cases to patients with depression
who were receiving long term treatment. We inter-
viewed participants every six months for three years.
Written informed consent was obtained.
the Diagnostic and Statistical Manual of Mental Disorders,
fourth edition, was diagnosed using the primary care
evaluation of mental disorders (range 0-9).16This
instrument comprises nine items for depression and
was designed for diagnosing major depressive dis-
use. It is easy to use in daily practice and is
recommended by the Dutch College of General
We assessed the course of depression every six
months using the primary care evaluation of mental
disorders and the Montgomery Åsberg depression
rating scale (range 0-60),18a higher score indicating
more severe depression. This scale was designed to
measure the severity of depression. A cut-off of 10
defines recovery from depressive symptoms.19In the
present study we defined recovery as the patient no
longer fulfilling the diagnostic criteria for major
depressive disorders and having a score of less than
Potential predictors of prognosis
We used structured questionnaires at baseline and at
one, two, and three years to collect information on
personal characteristics, including age, sex, living
and use of medication. The questionnaire for chronic
pulmonary disease (asthma, chronic obstructive pul-
monary disease, chronic bronchitis), cardiovascular
or malignancies.20We chose the cut-off of none versus
one versus more than one disease to produce
subgroups of patients with more or less comorbidity.
We used the mini-mental status examination to
measure cognitive decline annually.21A cut-off of 24
care evaluation of mental disorders, which inquires
about panic attacks in the past month.16We used the
diagnostic interview schedule23to assess the age at
onset of the first depressive episode, family history of
depression, and the number of previous episodes of
depression. Early onset depression was defined as a
first depressive episode before age 55. We categorised
the number of previous episodes as none versus one
with a history of depression. Finally, we ascertained
physical functioning annually using the physical
component scale of the medical outcome study 36-
items, short form (range 0-100),2425a higher score
indicating better physical functioning.
When appropriate we used independent t tests or χ2
tests to compare the baseline characteristics of partici-
had measurements at follow-up. To explore the
characteristics of dropouts we compared participants
had four or more.
Duration of depressive episodes and likelihood of recovery
We analysed the duration of the episodes of major
depressive disorders using time to recovery as the
of recovery at different time points were estimated
using Kaplan Meier methods. For these analyses we
included patients with at least one follow-up measure-
Potential predictors of outcome
We used Cox regression analyses to identify determi-
during follow-up). Firstly, we investigated whether
there was a linear relation between the potential
predictor variables and the outcome. We divided
(two or three), using cut-off scores described in the
literature or using the median of the sum score.
Secondly, we carried out univariable regression
analyses for all potential predictors with the outcome
measure. For the multivariable analyses we selected
variables that might be associated with the outcome
(P<0.20). Thirdly, we entered the predictors simulta-
neously in a multivariable regression model. We
Patients completing geriatric depression scale -15 items (n=4222)
More than two missing answers (n=37)
Score >5 (n=659)
Completed primary care evaluation of mental disorders (n=458)
Major depressive disorder present (n=244)
Refused diagnostic interview (n=201)
Included in study (n=234)
Refused to participate (n=10)
Fig 1 | Flow of respondents through study
page 2 of 7
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constructed the best predictive model using a manual
backward selection method. We deleted the variables
with the lowest predictive value (the largest P value in
the multivariable model). The best fitting model was
tested with the log likelihood ratio test (P<0.10). All
analyses were carried out using SPSS version 15.0.
Besides the predictors at baseline we also explored
changes in these variables during follow-up using data
from the annual measurements. We compared the
had depression. We used the same cohort as that for
Cox survival analyses—that is, patients with a major
depressive disorder at baseline and at least one follow-
Figure 1 shows the flow of respondents through the
invited to fill in the geriatric depression scale com-
pleted the questionnaire. Non-responders were more
often men and of similar age. Thirty seven responders
(0.9%) were excluded because they had missed more
completed the questionnaire, 659 (16%) scored above
the cut-off of 5. Of these, 458 (70%) gave informed
consent for a diagnostic interview using the primary
care evaluation of mental disorders. Responders and
non-responderswere notsignificantlydifferent for age
(mean difference 1.0 year, 95% confidence interval
−0.5 to 2.6; P=0.175), sex (odds ratio 1.0, 95%
confidence interval 0.7 to 1.4; P=0.822), or depression
score (mean difference 0.13, −0.6 to 0.3; P=0.658).
Of the 458 patients who took part in the diagnostic
interview, 244 (53%) fulfilled the criteria for a major
depressive disorder of whom 234 (96%) agreed to
characteristics of the cohort. Participants who missed
an assessment were invited to successive ones.
Two hundred and four participants (87%) had at least
had only completedthe baseline interview. They were
older than those with follow-up measurements (mean
difference 4.1 years, 0.8 to 7.4; P=0.04), but were not
P=0.77), level of education (low v middle v high;
P=0.87), categories of comorbidity (none v one v more
than one; P=0.37), living alone or with others (odds
ratio 0.7, 0.3 to 1.7; P=0.52), or baseline depression
score (mean difference 0.4, −0.1 to 0.9; P=0.10).
Overall, 175 respondents (75%) completed four or
with fewer than four measurements were older (mean
level of education (P=0.04) but were not different for
sex (odds ratio 0.6, 0.3 to 1.1; P=0.07), categories of
ratio 1.2, 0.6 to 2.2; P=0.60), or baseline depression
score (mean difference 0.2, −0.2 to 0.5; P=0.44).
Duration of depressive episodes and likelihood of
recovery over time
the 204 participants with at least one follow-up
measurement. The mean time to recovery was
19.3 months (95% confidence interval 17.5 to 21.2),
to 23.1). Overall, 35.1% (95% confidence interval
28.3% to 42.0%) of participants had recovered at one
year, 60.4% (53.0% to 67.7%) at two years, and 68.1%
(60.9% to 75.3%) at three years.
Predictors of prognosis
Univariable Cox survival analysis showed that eight
variables were associated with time to recovery
(P<0.20; table 2). As the Montgomery Åsberg
depression rating scale and primary care evaluation
of mental disorders were both associated with the
Table 1 |Baseline characteristics of cohort of older depressed
patients (n=234) in primary care, the Netherlands. Values are
numbers (percentages) unless stated otherwise
Patients with major
Educational level (years):
Low (0-6)73 (31)
Middle (7-10)146 (62)
High (>10)15 (6)
Living alone 87 (37)
Mean (SD) MÅDRS score (0-60)19.6 (7.8)
Mean (SD) PRIME-MD score (0-9)6.6 (1.3)
Depression in family67 (29)
Previous depressive episodes:
Early onset depression (<55 years)148 (63)
Mean (SD) MMSE score26.7 (2.8)
Mean (SD) functional limitations (0-100) 40.8 (13.2)
Treatment for depression:
Referral 21 (9)
MÅDRS=Montgomery Åsberg depression rating scale; PRIME-MD=primary
care evaluation of mental disorders; MMSE=mini-mental state
*Answers missing for 17 cases.
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prognosis but were also highly correlated (Pearson’s r
0.5), only the scores on the primary care evaluation of
mental disorders were used for the multivariable
analyses as an indicator for severity of depression at
baseline. In the best fitting multivariable model poor
baseline (primary care evaluation of mental disorders,
range 0-9; hazard ratio 1.25, 95% confidence interval
1.08 to 1.45), a family history of depression (1.45, 0.97
to 2.17), and less physical functioning (0.98, 0.97 to
Only 40% of the patients with depression were
receiving treatment for depression at baseline—31%
were taking antidepressants and 9% were referred to
was found between treatment for depression
(antidepressants or referral) and recovery. Patients
sion at baseline (mean difference in score on Mont-
gomery Åsberg depression rating scale 4.5; P<0.01).
Cognitive decline did not change during follow-up,
and no difference was found between those who still
Only one patient dropped out during follow-up owing
to serious cognitive decline and missed the last
interview at three years. The prevalence of chronic
the depressed group than in the recovered group. The
Finally, the number of patients receiving treatment for
depression hardly changed during follow-up. At three
depression, compared with 24% in the recovered
to specialised mental health care, indicating that
treatment for depression in late life is mainly carried
out in primary care.
The prognosis for depression among older patients
(≥55 years) in primary care is poor. The median
Thirty five per cent had recovered within one year,
60% after two years, and 68% at three years.
A systematic review on the prognosis of depression
in later life reported a poorer outcome in inpatients;
Patients with major
depressive disorder (%)
0 10 2030 40 50
Fig 2 | Survival curve of 204 patients aged 55 years or more
with major depressive disorder in primary care
Table 2 |Univariable and multivariable Cox survival analyses for potential predictors of no recovery from major depressive
disorder (n=204), measured at baseline, with follow-up for three years
Hazard ratio (95% CI)P value Hazard ratio (95% CI)P value
Age (years)* 1.02 (1.00 to 1.04)0.143
Sex (women v men) 1.06 (0.75 to 1.52)0.729——
Middle v low1.28 (0.88 to 1.89)0.185——
High v low 0.95 (0.49 to 1.85)0.878——
Living alone (yes v no)* 1.32 (0.91 to 1.89)0.145——
Comorbidity (somatic or psychiatric):
Chronic somatic diseases
1 v 0
≥1 v 0
1.22 (0.72 to 2.04)0.463——
1.39 (0.85 to 2.27)0.191——
Anxiety (yes v no)* 1.28 (0.88 to 1.85)0.184——
Cognitive dysfunction, MMSE score
≥24 v <24
1.35 (0.79 to 2.27)0.270
MÅDRS score (0-60)*† 1.05 (1.03 to 1.08)<0.001——
PRIME-MD score (0-9)* 1.22 (1.06 to 1.41)<0.0011.25 (1.08 to 1.45) 0.003
Family history (yes v no)*1.30 (0.88 to 1.92) 0.1851.45 (0.97 to 2.17) 0.070
Early onset (<55 years)*1.30 (0.90 to 1.89)0.158
Treatment (yes v no)1.10 (0.77 to 1.57)0.617——
Quality of life, PCS (0-100)*0.99 (0.98 to 1.00) 0.0550.98 (0.97 to 0.99) 0.008
MMSE=mini-mental state examination score; MÅDRS=Montgomery Åsberg depression rating scale; PRIME-MD=primary care evaluation of mental
disorders; PCS=physical component scale of SF-36.
*P<0.20. These eight variables were associated with poor outcome in univariable analyses and therefore selected for multivariable analysis.
†MÅDRS and PRIME-MD were highly correlated. Therefore only PRIME-MD was used for the multivariable model.
page 4 of 7
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only 13-18% had recovered after one year compared
with 35% in our study.26The researchers studied the
emergency room to medical services. A possible
explanation for the difference is the higher prevalence
of functional limitations among inpatients, which was
also a predictor of poor clinical outcome in our study.
The systematic review showed a better clinical out-
come in hospital based studies. This might be due to
of patients with a major depressive disorder were
receiving treatment at baseline. This is less than the
45% found in the Netherlands Mental Health Survey
and Incidence Study of adults with depression in the
community,28suggesting that a worse prognosis in
older patients might be partly due to less adequate
Predictors of prognosis
Poor outcome was associated with the severity of the
index episode, a family history of depression, and
functional decline. Previous community studies on
depression in later life also found evidence of an
association between these variables and the prognosis
for depression.12These clinical factors are all available
in routine practice and could therefore be used to help
decide on the aggressiveness of treatment. Our data
showed that functional limitations increased over the
three years of follow-up in the group with chronic
depression but not in those who had recovered. This
finding agrees with those of another study29and
underlines the importance of chronic depression as a
disabling illness. More research is needed on this
Whether there is an association between depression
in later life and cognitive decline is debatable. Some
researchershave foundevidenceforan association30-32
and others not.33-35The present study did not provide
Only a small proportion of patients with depression
were being treated at baseline and during follow-up.
This was also found in previous studies.2936We found
no association between treatment for depression and
the prognosis. Patients who were receiving treatment,
however, had more severe depression at baseline
(mean difference in score on Montgomery Åsberg
is determined by many factors, at least some of which
are inter-related. Therefore any definitive statement
about causal inference or confounding would be
premature. We provided data on factors that predict
the prognosis, controlling for their inter-relatedness.
This is highly relevant for clinical practice, as it
identifies those with the highest risk of a poor
Strengths and limitations
We used both diagnostic and dimensional data
ascertained at multiple time points during follow-up
to study the course of major depressive disorder in a
large cohort of older patients in primary care. These
strengths, together with follow-up for three years and
access to several putative prognostic factors, allowed a
thorough assessment of the prognosis of depression in
Our study did, however, have some limitations. We
included a sample of older patients with depression in
those with existing depression. As depression has a
to over-representation of patients with persistent long
term depression. The alternative strategy would have
been to include patients without depression and to
follow them up, concentrating on those with incident
depression. However, this was precluded because of
the large sample that would be needed at baseline and
Table 3 |Longitudinal data on cohort of older (≥55 years) depressed patients compared with
recovered patients with at least one measurement at follow-up, the Netherlands. Values are
numbers (percentages) unless stated otherwise
(n=204)1 year (n=185) 2 years (n=169) 3 years (n=160)
Major depressive disorder204 (100)120 (65) 67 (40)51 (32)
Recovered0 65 (35) 102 (60)109 (68)
Mean (SD) MÅDRS (0-60) score:
Major depressive disorder 19.3 (7.9)15.1 (7.6)17.8 (8.0) 17.5 (7.1)
—6.4 (4.2)7.9 (6.1)8.6 (6.2)
Major depressive disorder 68 (33)17 (14)13 (19) 9 (18)
—6 (9)6 (5) 13 (12)
Mean (SD) MMSE score:
Major depressive disorder 26.9 (2.6)27.1 (2.7)27.3 (2.6)27.3 (2.2)
— 27.7 (1.9) 27.8 (2.2) 27.2 (2.3)
Major depressive disorder:
0 28 (14)23 (19)11 (16) 7 (14)
59 (29)34 (28) 17 (26) 12 (23)
117 (57) 63 (53) 39 (58) 32 (63)
— 18 (28) 15 (15)26 (24)
—20 (31) 33 (32)24 (22)
— 27 (41)54 (53) 59 (54)
Mean (SD) functional limitations (0-100)
Major depressive disorder41.7 (13.1)40.3 (12.0)37.8 (12.5)37.2 (12.0)
— 44.0 (12.6)42.1 (11.3) 43.0 (12.1)
Treatment for depression
Major depressive disorder:
None126 (62) 84 (70)45 (67)32 (63)
Antidepressants 61 (30) 26 (22)19 (28)17 (33)
Referral17 (8)10 (8)3 (5)2 (4)
— 46 (71)79 (77) 83 (76)
—13 (20) 20 (20)21 (19)
—6 (9) 2 (3)5 (5)
—2 (1) 4 (2)9 (4)
MÅDRS=Montgomery Åsberg depression rating scale; MMSE=mini-mental state examination.
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the long follow-up required to build the necessary
section of patients with depression, as the condition is
present at any time in general practice, but might
overestimate chronicity because of the sampling of
older whovisitedtheir doctor,regardlessof thereason
the practice and 98% were living independently, they
were a selection of the more healthy older population.
Furthermore, those lost to the analyses throughout the
prognosis (table 2), it can be assumed that older
patients might be frailer and more at risk of functional
limitations. Given that functional limitations are a
an underestimation of the true course of depression
owing to attrition of the frailest patients during follow-
We assessed prognosis every six months. Using an
an overestimation of the duration of depression
because patients might have recovered earlier. We
the index episode at inclusion. This has the effect of
systematically underestimating the true duration of
either the follow-up was less than three years or the
interval between measurements was more than six
months, which may have led to bias. For example, the
interval between assessments for a respondent who
period the patient could have recovered, leading to a
potential overestimation of time to recovery. Those
a lower level of education than those with more
measurements. Both variables were not associated
with the outcome.
Our design was observational, providing an insight
into the clinical course of depression without inter-
vening with structured treatment protocols. This
makes the results representative of the population
is not harmful to most patients, the effect of our
naturalistic design would be to underestimate the true
clinical course of depression among older patients.
more antidepressants or referred more patients to
specialised mental health care than was reported,
of self reporting treatment is that we are more likely to
have collected data on actual treatment received by
Our results support our hypothesis that the prognosis
of depression in later life in primary care would be
poor. One possible explanation for this is inadequate
treatment in older patients with depression, as most
(60% of patients with major depressive disorder at
treatment for their condition. Analyses of data on
patients with undetected depression during the first
was still present in 67% of these patients after one
of a poor outcome can help to improve treatment and
therefore prognosis. We found that a poor outcome
was predicted by clinical factors that should be readily
available in routine practice. If confirmed in other
studies, these factors could be incorporated in profes-
sional guidelines, helping clinicians to identify older
patients needing earlier, better integrated, and more
aggressive treatment. Finally, research is needed to
learn more about the longitudinalassociation between
depression and functional limitations.
We thank the respondents for their participation.
Contributors:EL-S carried out the study, did the analyses, and wrote the
obtained the grants, helped in the analyses and interpretation of the data,
analyses and interpretation of the data and cowrote the paper. MdH
supervised the project and cowrote the paper. All authors approved the
final version of the manuscript. EL-S and HvM are guarantors.
Funding:The data reported on were collected in the context of the West
Friesland Study, which was financed by The Netherlands Organisation for
Health Research and Development (grant No 2200.0019) and the Dutch
Organization for Scientific Research (MW grant 904.57.127).
Ethicalapproval:This study was approved by the medical ethical
committee of the VU University Medical Centre.
The functioningand well-beingof depressed patients. Results from
the medical outcomes study.JAMA 1989;262:914-9.
Bremmer MA,Hoogendijk WJ, Deeg DJ, Schoevers RA, Schalk BW,
cardiac events. Am J Geriatr Psychiatry 2006;14:523-30.
comorbid depressionin adultswith diabetes: a meta-analysis.
Diabetes Care 2001;24:1069-78.
Penninx BW,Geerlings SW, Deeg DJ, van Eijk JT, van Tilburg W,
Beekman AT. Minor and major depression and the risk of death in
older persons. Arch Gen Psychiatry 1999;56:889-95.
Peytremann-Bridevaux I, Voellinger R, Santos-Eggimann B.
Healthcare and preventive services utilization of elderly Europeans
with depressive symptoms. J Affect Disord 2008;105:247-52.
et al. A randomised controlled trial to test the feasibility of a
collaborative care modelfor themanagement ofdepressioninolder
people. Br J Gen Pract 2007;57:364-70.
WHAT IS ALREADY KNOWN ON THIS TOPIC
Depressioninlater life iscommon inprimary careand has anenormousimpactonwellbeing
WHAT THIS STUDY ADDS
Depression in patients aged 55 or more in primary care has a poor prognosis
Identified prognostic factors (for example, severity of the index episode, a family history of
depression, and functional decline) are readily available in clinical practice and could help
direct treatment to those at highestrisk of a poor prognosis
page 6 of 7
BMJ | ONLINE FIRST | bmj.com
et al. Collaborative care management of late-life depression in the
primary care setting: a randomized controlled trial. JAMA
YoungAS, Klap R, Sherbourne CD, Wells KB. The quality of care for
depressive and anxiety disorders in the United States. Arch Gen
Crabb R,Hunsley J. Utilization of mental health care services among
older adults with depression. J Clin Psychol 2006;62:299-312.
10 Licht-Strunk E, Beekman ATF, de Haan M, van Marwijk HWJ. The
prognosis of undetected depression in older general practice
patients. A one year follow-up study. J Affect Disord
2008; Jul 14 [Epub ahead of print].
11 Gilchrist G, Gunn J. Observational studies of depression in primary
care: what dowe know? BMC FamPract 2007;8:28.
consultingtheir general practitioner in the Netherlands. Int J Geriatr
14 Sheikh JI YJ. Geriatric depression scale: recent evidence and
development of a shorter version. Clin Gerontol 1986;5:165-72.
15 Burke WJ, Roccaforte WH,Wengel SP. The short form of the geriatric
depression scale: a comparisonwith the 30-itemform.J Geriatr
Psychiatry Neurol 1991;4:173-8.
16 Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV, III, Hahn SR,
et al. Utility of a new procedure for diagnosingmental disorders in
primary care. The PRIME-MD 1000 study. JAMA 1994;272:1749-56.
Weel-BaumgartenE, et al. Dutch College of General Practitioners
Guideline Depression, first revision [NHG-Standaard Depressieve
stoornis (depressie). Eerste herziening. In Dutch].Huisarts Wet
18 Montgomery SA,AsbergM. A new depressionscale designed to be
sensitive to change. Br J Psychiatry 1979;134:382-9.
19 Hawley CJ, Gale TM, Sivakumaran T. Defining remission by cut off
score on the MADRS: selecting the optimal value.J Affect Disord
20 Kriegsman DM, Penninx BW,van Eijk JT, Boeke AJ, Deeg DJ. Self-
reportsand general practitioner information on the presence of
chronic diseases in community dwelling elderly. A study on the
Clin Epidemiol 1996;49:1407-17.
21 FolsteinMF, FolsteinSE,McHugh PR. Mini-mental state. A practical
method for grading the cognitive state of patients for the clinician.J
22 Kafonek S, Ettinger WH, Roca R, Kittner S, Taylor N,German PS.
care facility. J Am GeriatrSoc 1989;37:29-34.
23 Robins LN, Helzer JE,CroughanJ, Ratcliff KS. National Institute of
Mental Health diagnostic interviewschedule. Its history,
characteristics, and validity. Arch Gen Psychiatry 1981;38:381-9.
(SF-36). I. Conceptual framework and item selection. Med Care
Am J Geriatr Psychiatry 2006;14:966-75.
27 Cole MG, Bellavance F. The prognosis of depression in old age. Am J
Geriatr Psychiatry 1997;5:4-14.
The Netherlands Mental Health Survey and Incidence Study
(NEMESIS). BrJ Psychiatry 2002;181:208-13.
29 LenzeEJ,SchulzR,MartireLM,ZdaniukB,GlassT,KopWJ,et al.The
Health Study. J Am GeriatrSoc 2005;53:575.
30 Raji MA, Reyes-Ortiz CA, Kuo YF, Markides KS, Ottenbacher KJ.
Depressive symptoms and cognitive change in older Mexican
Americans. J Geriatr Psychiatry Neurol 2007;20:145-52.
predictor of subsequent hip and nonhip fractures among older
MexicanAmericans. J Natl Med Assoc 2007;99:412-8.
32 StimpsonJP, Kuo YF, Ray LA,Raji MA, PeekMK. Risk of mortality
related to widowhood in older Mexican Americans. AnnEpidemiol
33 Beekman AT, GeerlingsSW, DeegDJ,Smit JH, Schoevers RS, de
Beurs E, et al. The natural history of late-life depression: a 6-year
prospective study inthe community. Arch Gen Psychiatry
34 Forsell Y,JormAF, Winblad B. The outcome of depression and
dysthymia in a very elderly population: Results from a three-year
follow-up study. Aging Ment Health1998;2:100-4.
35 SchulbergHC, Mulsant B, Schulz R, Rollman BL, HouckPR,
ReynoldsCF, III. Characteristics and course of major depression in
older primary care patients. Int J Psychiatry Med 1998;28:421-36.
practitioners. Br J Gen Pract 1993;43:203-8.
Accepted: 20 October 2008
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