Cost-Effectiveness of a Disease Management Program for Major Depression in Elderly Primary Care Patients

Department of Psychiatry, VU University Amsterdam, Amsterdamo, North Holland, Netherlands
Journal of General Internal Medicine (Impact Factor: 3.42). 11/2006; 21(10):1020-6. DOI: 10.1111/j.1525-1497.2006.00555.x
Source: PubMed


Major depression is common in older adults and is associated with increased health care costs. Depression often remains unrecognized in older adults, especially in primary care.
To evaluate the cost-effectiveness of a disease management program for major depression in elderly primary care patients compared with usual care.
Economic evaluation alongside a cluster randomized-controlled trial.
Consecutive patients of 55 years and older were screened for depression using the Geriatric Depression Scale and the PRIME-MD was used for diagnosis.
General practitioners in the intervention group received training on how to implement the disease management program consisting of screening, patient education, drug therapy with paroxetine, and supportive contacts. General practitioners in the usual care group were blind to the screening results. Treatment in this group was not restricted in any way.
Severity of depression, recovery from depression, and quality of life. Resource use measured over a 12-month period using interviews and valued using standard costs.
Differences in clinical outcomes between the intervention and usual care group were small and statistically insignificant. Total costs were 2,123 dollars in the intervention and 2,259 dollars in the usual care group (mean difference -136 dollars, 95% confidence interval: -1,194 dollars; 1,110 dollars). Cost-effectiveness planes indicated that there were no statistically significant differences in cost-effectiveness between the 2 groups.
This disease management program for major depression in elderly primary care patients had no statistically significant relationship with clinical outcomes, costs, and cost-effectiveness. Therefore, based on these results, continuing usual care is recommended.

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    • "As shown in Table 1, there were five RCTs [14-18] included in only the USPSTF review, four [19-22] included in both the USPSTF and Cochrane reviews, and two [23,24] included in at least one version of the Cochrane review, as well as a 2002 version of the USPSTF review [25] but not the 2009 USPSTF review. Of the 11 RCTs included in either the 2009 USPSTF or Cochrane reviews, one [20] fulfilled two of the three key criteria for a depression screening trial, six [16,17,21-24] fulfilled one, and four [14,15,18,19] did not fulfill any. Of the 11 RCTs, only two [20,21] determined trial eligibility and randomized prior to screening; only two [16,17] excluded already diagnosed and treated patients; and only four [20,22-24] provided similar depression management options to patients in both trial arms. "
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    ABSTRACT: The United States Preventive Services Task Force (USPSTF) recommends screening adults for depression in primary care settings when staff-assisted depression management programs are available. This recommendation, however, is based on evidence from depression management programs conducted with patients already identified as depressed, even though screening is intended to identify depressed patients not already recognized or treated. The objective of this systematic review was to evaluate whether there is evidence from randomized controlled trials (RCTs) that depression screening benefits patients in primary care, using an explicit definition of screening. We re-evaluated RCTs included in the 2009 USPSTF evidence review on depression screening, including only trials that compared depression outcomes between screened and non-screened patients and met the following three criteria: determined patient eligibility and randomized prior to screening; excluded patients already diagnosed with a recent episode of depression or already being treated for depression; and provided the same level of depression treatment services to patients identified as depressed in the screening and non-screening trial arms. We also reviewed studies included in a recent Cochrane systematic review, but not the USPSTF review; conducted a focused search to update the USPSTF review; and reviewed trial registries. Of the nine RCTs included in the USPSTF review, four fulfilled none of three criteria for a test of depression screening, four fulfilled one of three criteria, and one fulfilled two of three criteria. There were two additional RCTs included only in the Cochrane review, and each fulfilled one of three criteria. No eligible RCTs were found via the updated review. The USPSTF recommendation to screen adults for depression in primary care settings when staff-assisted depression management programs are available is not supported by evidence from any RCTs that are directly relevant to the recommendation. The USPSTF should re-evaluate this recommendation.Registration: PROSPERO (#CRD42013004276).
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    • "The three studies solely providing physician education found no change in symptom severity. Neither lectures for more qualified assessment and treatment [33,38], nor training in brief cognitive behavioural therapy [41] led to significant symptom change in patients of trained physicians. Introducing additional guidelines and using them during practitioner training, two studies showed a mid and long term significant change in symptom load [39,43-45]. "
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