Yield and costs of direct and stepped screening for depressive symptoms in subjects aged 75 years and over in general practice

Cost-effectiveness of guideline-based stepped and collaborative care versus treatment as usual for patients with depression - a cluster-randomized trial

BACKGROUND

Depression is associated with major patient burden. Its treatment requires complex and collaborative approaches. A stepped care model based on the German National Clinical Practice Guideline "Unipolar Depression" has been shown to be effective. In this study we assess the cost-effectiveness of this guideline based stepped care model versus treatment as usual in depression.

METHODS

This prospective cluster-randomized controlled trial included 737 depressive adult patients. Primary care practices were randomized to an intervention (IG) or a control group (CG). The intervention consisted of a four-level stepped care model. The CG received treatment as usual. A cost-utility analysis from the societal perspective with a time horizon of 12 months was performed. We used quality-adjusted life years (QALY) based on the EQ-5D-3L as effect measure. Resource utilization was assessed by patient questionnaires. Missing values were imputed by 'multiple imputation using chained equations' based on predictive mean matching. We calculated adjusted group differences in costs and effects as well as incremental cost-effectiveness ratios. To describe the statistical and decision uncertainty cost-effectiveness acceptability curves were constructed based on net-benefit regressions with bootstrapped standard errors (1000 replications). The complete sample and subgroups based on depression severity were considered.

RESULTS

We found no statically significant differences in costs and effects between IG and CG. The incremental total societal costs (+€5016; 95%-CI: [-€259;€10,290) and effects (+ 0.008 QALY; 95%-CI: [- 0.030; 0.046]) were higher in the IG in comparison to the CG. Significantly higher costs were found in the IG for outpatient physician services and psychiatrist services in comparison to the CG. Significantly higher total costs and productivity losses in the IG in comparison to the CG were found in the group with severe depression. Incremental cost-effectiveness ratios for the IG in comparison to the CG were unfavourable (complete sample: €627.000/QALY gained; mild depression: dominated; moderately severe depression: €645.154/QALY gained; severe depression: €2082,714/QALY gained) and the probability of cost-effectiveness of the intervention was low, except for the group with moderate depression (ICER: dominance; 70% for willingness-to-pay threshold of €50,000/QALY gained).

CONCLUSIONS

We found no evidence for cost-effectiveness of the intervention in comparison to treatment as usual.

TRIAL REGISTRATION

NCT, NCT01731717 . Registered 22 November 2012 - Retrospectively registered.

Latent class analysis of the Apathy Scale does not identify subtypes of apathy in general population-based older persons

OBJECTIVES

To identify clinically relevant subtypes of apathy in older persons using latent class analysis (LCA) and investigate the distribution of different characteristics across these subtypes.

MEASUREMENTS

Cross-sectional data of 122 older persons (mean age 84 years, 60% female) participating in the general population-based PROactive Management Of Depression in the Elderly study, with apathy according to a score of 14 or higher on the Apathy Scale, were included for LCA. All 14 items of the Apathy Scale were used as indicator variables. Several characteristics were examined including sociodemographics, depressive, and anxiety symptoms; global cognitive function; quality of life indicators; hazardous alcohol intake (drinking ≥ 14 consumptions per week); and perceived chronic pain.

RESULTS

Three distinct LCA classes were found classifying 17%, 7%, and 76% of the participants respectively. Individuals in the first class had a higher level of education and were less likely to live alone. Those in the second class had higher apathy and depression scores, lived more frequently alone and used more alcohol. Individuals in the third class showed a lower level of education and worse cognitive function. In multivariable multinomial analyses, only a lower educational level and higher scores on the Apathy Scale were significant predictors for class membership.

CONCLUSION

Differences between LCA-derived classes were minimal, suggesting that in a general population-based cohort the Apathy Scale measures a homogeneous construct. Copyright © 2016 John Wiley & Sons, Ltd.

Collaborative care regarding major depressed patients: A review of guidelines and current practices

Major Depressive Disorder (MDD) is a severe and common mental disorder. A growing body of evidence suggests that stepped and/or collaborative care treatment models have several advantages for severely depressed patients and caretakers. However, despite the availability of these treatment strategies and guidance initiatives, many depressive patients are solely treated by the general practitioner (GP), and collaborative care is not common. In this paper, we review a selected set of international guidelines to inventory the best strategies for GPs and secondary mental health care providers to collaborate when treating depressed patients. Additionally, we systematically searched the literature, listing potential ways of cooperation, and potentially supporting tools. We conclude that the prevailing guidelines only include few and rather vague directions regarding the cooperation between GPs and specialised mental health practitioners. Inspiring recent studies, however, suggest that relatively little efforts may result in effective collaborative care and a broader implementation of the guidelines in general.

Cost-effectiveness of collaborative care for the treatment of depressive disorders in primary care: a systematic review

BACKGROUND

For the treatment of depressive disorders, the framework of collaborative care has been recommended, which showed improved outcomes in the primary care sector. Yet, an earlier literature review did not find sufficient evidence to draw robust conclusions on the cost-effectiveness of collaborative care.

PURPOSE

To systematically review studies on the cost-effectiveness of collaborative care, compared with usual care for the treatment of patients with depressive disorders in primary care.

METHODS

A systematic literature search in major databases was conducted. Risk of bias was assessed using the Cochrane Collaboration's tool. Methodological quality of the articles was assessed using the Consensus on Health Economic Criteria (CHEC) list. To ensure comparability across studies, cost data were inflated to the year 2012 using country-specific gross domestic product inflation rates, and were adjusted to international dollars using purchasing power parities (PPP).

RESULTS

In total, 19 cost-effectiveness analyses were reviewed. The included studies had sample sizes between n = 65 to n = 1,801, and time horizons between six to 24 months. Between 42% and 89% of the CHEC quality criteria were fulfilled, and in only one study no risk of bias was identified. A societal perspective was used by five studies. Incremental costs per depression-free day ranged from dominance to US$PPP 64.89, and incremental costs per QALY from dominance to US$PPP 874,562.

CONCLUSION

Despite our review improved the comparability of study results, cost-effectiveness of collaborative care compared with usual care for the treatment of patients with depressive disorders in primary care is ambiguous depending on willingness to pay. A still considerable uncertainty, due to inconsistent methodological quality and results among included studies, suggests further cost-effectiveness analyses using QALYs as effect measures and a time horizon of at least 1 year.

Quality of life in community-dwelling older persons with apathy

OBJECTIVE

To investigate the relationship between apathy and perceived quality of life in groups both with and without depressive symptoms or cognitive impairment.

METHODS

We conducted a cross-sectional study comparing quality of life in older persons with and without apathy in 19 Dutch general practices. Participants were 1,118 older persons aged at least 75 years without current treatment for depression and a Mini-Mental State Examination score of at least 19. Perceived quality of life was determined using Cantril's Ladder for overall quality of life, EuroQol (EQ)-5D thermometer for subjective health quality, and De Jong-Gierveld Loneliness questionnaire for perceived loneliness. Apathy was assessed with the Apathy Scale.

RESULTS

Of the 1,118 older persons, apathy was present in 122 (11%) of them. Overall, apathy was associated with having no work, lower level of education, presence of depressive symptoms, cognitive impairment, and decreased scores on all quality of life measures. Among the 979 (88%) older persons without depressive symptoms and cognitive impairment, apathy was present in 73 (7.5%) of them, showing similar associations as in the total population. In the 77 (7%) persons with cognitive impairment only, apathy was correlated to a lower score on the EQ-5D thermometer. However, in the 51 (5%) depressed persons without cognitive impairment, presence of apathy did not contribute to their decreased quality of life.

CONCLUSION

Apathy frequently occurred in community-dwelling older persons, also in the absence of depressive symptoms and cognitive impairment. In them, apathy contributed to the perception of a diminished quality of life in various aspects of daily life.

Effects of a stepped-care intervention programme among older subjects who screened positive for depressive symptoms in general practice: the PROMODE randomised controlled trial

OBJECTIVES

to determine (cost)-effectiveness of a stepped-care intervention programme among subjects ≥ 75 years who screened positive for depressive symptoms in general practice.

DESIGN

the pragmatic cluster-randomised controlled trial with 12-month follow-up.

SETTING

sixty-seven Dutch general practices.

SUBJECTS

two hundred and thirty-nine subjects ≥ 75 years screened positive for untreated depressive symptoms (15-item Geriatric Depression Scale ≥ 5).

METHODS

usual care (34 practices, 118 subjects) was compared with the stepped-care intervention (33 practices, 121 subjects) consisting of three steps: individual counselling; Coping with Depression course; and-if indicated-referral back to general practitioner to discuss further treatment. Measurements included severity of depressive symptoms [Montgomery-Åsberg Depression Rating Scale (MADRS)], quality of life, mortality and costs.

RESULTS

at baseline subjects mostly were mildly/moderately depressed. At 6 months MADRS scores had improved more in the usual care than the intervention group (-2.9 versus -1.1 points, P=0.032), but not at 12 months (-3.1 versus -4.6, P=0.084). No significant differences were found within two separate age groups (75-79 years and ≥ 80 years). In intervention practices, 83% accepted referral to the stepped-care programme, and 19% accepted course participation. The control group appeared to have received more psychological care.

CONCLUSIONS

among older subjects who screened positive for depressive symptoms, an offered stepped-care intervention programme was not (cost)-effective compared with usual care, possibly due to a low uptake of the course offer.

TRIAL REGISTRATION

www.controlled-trials.com/ISRCTN 71142851v.

The influence of the administration method on scores of the 15-item Geriatric Depression Scale in old age

Many rating scales can be self-administered or interviewer-administered, and the influence of administration method on scores is unclear. We aimed to study this influence on scores of the Geriatric Depression Scale (GDS-15), used as a screening instrument in general practice. In two general practices 376 registered patients aged 75 years and older were asked to participate. Exclusion criteria were dementia and current treatment for depression. The GDS-15 was administered twice within 1 month: self-administered by mail, and interviewer-administered during home visits. The sequence of administering the methods was different for the two practices. We analyzed differences in total and item GDS-scores. Of 141 subjects who participated (response rate 55%) 59 were men (42%). Mean age was 81.4 years (SD 4.8). When the GDS-15 was self-administered, 33 subjects (23.4%) left items unanswered. There were no items unanswered when the GDS-15 was interviewer-administered. On average the self-administered total GDS scores were 0.70 points higher than interviewer-administered scores (95% confidence interval=0.41; 0.98), with a large range of variation in the scores (limits of agreement -2.69 to 4.08). Item-item comparisons showed high percentages of agreement. Chance-corrected agreement (kappa) was moderate to fair, but three items showed only slight agreement (kappa values <0.21). In conclusion, compared to interviewer-administered scores, scores on the GDS-15 when self-administered were higher. The method of administration should be taken into account when interpreting scores.

Response to an unsolicited intervention offer to persons aged ≥ 75 years after screening positive for depressive symptoms: a qualitative study

BACKGROUND

Screening can increase detection of clinically relevant depressive symptoms, but screen-positive persons are not necessarily willing to accept a subsequent unsolicited treatment offer. Our objective was to explore limiting and motivating factors in accepting an offer to join a "coping with depression" course, and perceived needs among persons aged ≥75 years who screened positive for depressive symptoms in general practice.

METHODS

In a randomized controlled trial, in which 101 persons who had screened positive for depressive symptoms were offered a "coping with depression" course, a sample of 23 persons were interviewed, of whom five (22%) accepted the treatment offer. Interview transcripts were coded independently by two researchers.

RESULTS

All five individuals who accepted a place on the course felt depressed and/or lonely and had positive expectations about the course. The main reasons for declining to join the course were: not feeling depressed, or having negative thoughts about the course effect, concerns about group participation, or about being too old to change and learn new things. Although perceived needs to relieve depressive symptoms largely matched the elements of the course, most of those who had been screened were not (yet) prepared to accept an intervention offer. Many expressed the need to discuss this treatment decision with their general practitioner.

CONCLUSIONS

Although the unsolicited treatment offer closely matched the perceived needs of people screening positive for depressive symptoms, only those who combined feelings of being depressed or lonely with positive expectations about the offered course accepted it. Treatment should perhaps be more individually tailored to the patient's motivational stage towards change, a process in which general practitioners can play an important role.