Community screening, outreach and primary care management of late life depression

Abstract

ABSTRACT

Background: Late life depression is clinically under-recognized and under treated. About 17% of Singapore elderly have psychiatric disorders but only 6% of them did seek treatment. In recent decades, the development and validation of depression screening tools, primary care physician education and clinical practice guidelines have enhanced the prospect of early identification of depression and effective treatment. Recent studies have shown that multidisciplinary collaborative care treatment programmes were efficacious in improving outcomes of depression. Objectives: To evaluate the effectiveness of a community-based early psychiatric intervention strategy (CEPIS) of routine population screening and a structured, multi-facetted, collaborative shared care programme for primary care treatment of depression Methods: A total of 4633 community dwelling elderly (= 60 yrs) who regularly used community social services centres, were screened using 15 items Geriatric Depression Screening Scale. Independently, concurrent diagnoses of major depression were made using Structured Clinical Interview for DSM IV (SCID). Participants who were screened positive for depressive symptoms (GDS = 5) were visited by community nurses with psycho-education training in the programme and persuaded to seek care from CEPIS network of general practitioners. Consented and eligible elderly participants with depressive symptoms were randomized into two treatment groups; either usual care (UC) or collaborative care (CC) for primary care treatment of depression. Assessments of depressive symptoms, physical functional ability (IADL and BADL) and health related quality of life (SF-12) were performed at baseline, 3 months, 6 months and 12 months after intervention.

Results: We found that the 15 item GDS was an excellent screening tool for major depressive disorder among this heterogeneous population of Asian elderly community dwellers (sensitivity =0.96, specificity =0.95) (Study I). Differential item functioning analysis of GDS suggested item responses bias associated with increasing age, physical disorder, gender, and ethnicity, but these were likely to have only modest influence of overall test performance (Study II). Following nurses? psycho-education for treatment of depression, treatment seeking rate was 73.8%, greatly more than the reported rate of spontaneous of treatment seeking of 10.3% prior to the programme (Study III). Multidisciplinary collaborative care of depressed elderly showed better treatment outcomes compared to usual care in the randomized controlled trial. Compared to UC participants, significantly higher number of CC elderly participants, reported ?satisfied? with the practical support they received from physicians and nurses (73%, p=0.023) and ?very satisfied? with the overall care and help in the programme (30%, p=0.022) (Study IV). Among primary care physicians who participated in CC arm, 60 to 80% reported greater confidence about diagnosis and treatment of depression after CEPIS, and that the CEPIS model was replicable and applicable in primary care management of depression, and favoured encouraging the Ministry of Health and the College of General Practitioners to support this strategy. (Study IV). Conclusions: In the CEPIS programme, a population-based strategy of active outreach was effective in identifying and treating more cases of depression among the elderly. Structured collaborative care with treatment algorithms was found to improve outcomes of depression and health related quality of life among community dwelling depressed elderly in Singapore.