Outcome of depression in later life in primary care: Longitudinal cohort study with three years' follow-up

Department of General Practice and the EMGO Institute for Health and Care Research of VU University Medical Centre, Van der Boechorstraat 7, 1081 BT, Amsterdam, Netherlands.
BMJ (online) (Impact Factor: 17.45). 02/2009; 338(feb02 1):a3079. DOI: 10.1136/bmj.a3079
Source: PubMed


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.

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    • "Depressive disorders are the second leading cause of disability worldwide [1]. Although many efficacious interventions are available, most depressive disorders remain untreated, particularly in older adults [2,3]. Therefore, several strategies have been proposed to improve depression management, aimed at treating as well as preventing onset and recurrence [4]. "
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    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.
    Full-text · Article · Aug 2014 · Implementation Science
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    • "This association is especially important in multimorbid patients because duration and severity of depression have a higher negative impact on health-related quality of life than physical chronic conditions [25]. Additionally, depression is a common [26] and often chronic [27] comorbidity in elderly patients. And, in primary care patients, the probability of suffering from depression grows with increasing physical morbidity [28]. "
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    ABSTRACT: It is not well established how psychosocial factors like social support and depression affect health-related quality of life in multimorbid and elderly patients. We investigated whether depressive mood mediates the influence of social support on health-related quality of life. Cross-sectional data of 3,189 multimorbid patients from the baseline assessment of the German MultiCare cohort study were used. Mediation was tested using the approach described by Baron and Kenny based on multiple linear regression, and controlling for socioeconomic variables and burden of multimorbidity. Mediation analyses confirmed that depressive mood mediates the influence of social support on health-related quality of life (Sobel's p < 0.001). Multiple linear regression showed that the influence of depressive mood (beta = -0.341, p < 0.01) on health-related quality of life is greater than the influence of multimorbidity (beta = -0.234, p < 0.01). Social support influences health-related quality of life, but this association is strongly mediated by depressive mood. Depression should be taken into consideration in research on multimorbidity, and clinicians should be aware of its importance when caring for multimorbid patients.Trial register: ISRCTN89818205.
    Full-text · Article · Apr 2014 · BMC Family Practice
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    • "Those with depression believed that despite the chronicity of their own depression, the positive view of primary care and the help received there by those with depression offered hope for recovery. Depression has a mean duration of 18 months in those over the age of 55 in a recent study [32] and this hope for recovery may facilitate help-seeking from primary care in this age group. "
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    ABSTRACT: Detection of depression can be difficult in primary care, particularly when associated with chronic illness. Patient beliefs may affect detection and subsequent engagement with management. We explored patient beliefs about the nature of depression associated with physical illness. A qualitative interview study of patients registered with general practices in Leeds, UK. We invited patients with coronary heart disease or diabetes from primary care to participate in semi-structured interviews exploring their beliefs and experiences. We analysed transcripts using a thematic approach, extended to consider narratives as important contextual elements. We interviewed 26 patients, including 17 with personal experience of depression. We developed six themes: recognising a problem, complex causality, the role of the primary care, responsibility, resilience, and the role of their life story. Participants did not consistently talk about depression as an illness-like disorder. They described a change in their sense of self against the background of their life stories. Participants were unsure about seeking help from general practitioners (GPs) and felt a personal responsibility to overcome depression themselves. Chronic illness, as opposed to other life pressures, was seen as a justifiable cause of depression. People with chronic illness do not necessarily regard depression as an easily defined illness, especially outside of the context of their life stories. Efforts to engage patients with chronic illness in the detection and management of depression may need further tailoring to accommodate beliefs about how people view themselves, responsibility and negative views of treatment.
    Full-text · Article · Feb 2014 · BMC Family Practice
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