Collaborative Care Effective for Older Adults with Depressive Symptoms

A new study suggests that depressive symptoms in older adults can be improved with non-invasive behavioral activation techniques. These approaches appear to have a preventative effect, serving to prevent further depressive symptoms from developing.

Recent studies indicate that older adults experience a high prevalence of depressive symptoms, with 1 in 7 meeting diagnostic criteria for major depressive disorder. A new study, published last month in the Journal of the American Medical Association (JAMA) examined an intervention called collaborative care for older adults with depressive symptoms. They found that collaborative care appeared to prevent the occurrence of further depressive symptoms when compared with usual care.

Collaborative care, in this instance, consisted of a case manager helping patients to find ways of reengaging with enjoyable activities and social for major depressive disorder. The usual care control group received treatment at the provider’s discretion. Many of the collaborative care contacts were made via telephone, increasing the potential for access to treatment.

The researchers in this study, led by Simon Gilbody, PhD, at the University of York, England, recruited 705 older adults (65 years and older) with subthreshold depressive symptoms. That is, the participants had some of the experiences associated with depression, but it was not significantly impairing their functioning enough to meet the criteria for major depressive disorder. The researchers believed that these individuals were at high risk of developing depression in the future. They conceived of this treatment intervention as a preventative measure.

The researchers divided the participants into two groups, the collaborative care group and a placebo control group receiving usual care. At the end of the 12-month follow-up period, only 15.7% of the participants in the collaborative care group met criteria for depression, compared with 27.8% of those in the control group. That is, older adults who received collaborative care were significantly less likely to meet criteria for depression after a year than those who received usual care.

The results of the study appear to indicate the behavioral activation successfully prevents the development of further depressive symptoms, and is an appropriate treatment for subthreshold depression. However, the researchers note that it is of “uncertain clinical importance” because the participants in the study were not experiencing a diagnosable mental disorder. That is, the researchers were providing treatment to individuals who were technically psychologically healthy. There has been debate about whether subthreshold symptoms tend to develop into more intense depression, or whether they represent normal human experiences of sadness and other painful emotions, which do not require treatment. Because the depression scores for this population were so low, very little improvement was even possible.

Additionally, because a number of participants dropped out of the study before the 12-month follow-up, more research would help clarify the effectiveness of the intervention. Comparison between this intervention and other interventions might also be helpful.

However, behavioral activation delivered through the collaborative care model is relatively inexpensive and has little potential for harm. The recommendation to re-engage with meaningful, pleasurable activity and social interaction has few side effects and many possible positive rewards. The possibility that this intervention could reduce depressive symptoms is not surprising, and it provides a hopeful alternative to antidepressant medications, which carry a heavy side-effect burden, particularly for older individuals.

 

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Gilbody, S., Lewis, H., Adamson, J., Atherton, K., Bailey, D., Birtwistle, J. . . McMillan, D. (2017). Effect of collaborative care vs usual care on depressive symptoms in older adults with subthreshold depression: The CASPER randomized clinical trial. JAMA, 317(7), 728-737. doi:10.1001/jama.2017.0130 (Abstract)