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NIHR Signal A primary care intervention helps older people with depression

Published on 23 January 2018

doi: 10.3310/signal-000535

Enhanced case management (also called collaborative care) added to primary care reduced symptoms in people with clinical depression, compared with usual primary care. The benefit was similar to other depression treatments. However, the small benefit over usual care was not sustained to 12 months.

This NIHR-funded UK trial was carried out among nearly 500 adults aged at least 65 years. Primary care mental health practitioners delivered six sessions to encourage activity and social contact (five were by telephone). Medication monitoring and other psychological advice, linking up with other NHS staff, was also offered to those in the collaborative care group.

This relatively cheap intervention might be feasibly rolled-out to older people not using the Improving Access to Psychological Therapies programme. It is possible that greater treatment duration of the number of sessions might lead to longer-term impacts.

These results have contributed to the draft NICE depression guideline out for consultation in 2017. Those with physical health and mobility problems and other barriers to using services may especially benefit.

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Why was this study needed?

About one in seven people over the age of 75 are clinically depressed. Depression is associated with poor quality of life, worse physical health and increased use of health and social care services.

Older people and practitioners may view psychological difficulties as part of normal ageing or believe that psychological treatments are not effective. Perceptions and practical barriers to accessing care can lead to depression being under-treated. In 2014/15, only 7% of people completing treatment in the Improving Access to Psychological Therapies programme were older people.

Collaborative care is a structured patient-centred way for case managers to proactively manage treatments. Effectiveness evidence had been mainly from the US, so NICE recommended further research. UK trials have since given positive results for working-age adults, and older adults with sub-clinical depression.

CASPER-PLUS is the first large-scale UK trial to measure the clinical and cost-effectiveness of collaborative care for older people with clinical depression.

What did this study do?

This pragmatic trial randomised 485 adults with moderate to severe depression into collaborative care or usual primary care. Participants were recruited from 69 GP practices in northern England. Their average age was 72 years, and a high proportion had physical health problems. Exclusion criteria included suicidal risk, drug and alcohol problems, psychosis and cognitive impairment.

A collaborative care protocol incorporating low-intensity behavioural activation therapy was adapted for older people. Behavioural activation encourages increased activity and social contact, which may improve physical health symptoms as well as mood. One face to face session was followed by five telephone sessions over eight weeks. Case managers were primary care mental health workers supervised by a senior mental health specialist.

The collaborative care group had higher drop-out than the usual care group (25% at four months). Participants, practitioners and researchers were aware of treatment allocation, which may have influenced participant’s answers to the self-reported questionnaire.

What did it find?

  • Baseline depression scores were on average 14 out of 27 according to the 9-item self-report Patient Health Questionnaire (PHQ-9), in which higher numbers indicate worse symptoms. At four months after randomisation, average depression scores had reduced to 8.98 in the collaborative care group, compared to 10.9 in the usual care group (adjusted mean difference [MD] 1.92 points, 95% confidence interval [CI] 0.85 to 2.99 points; 390 participants).
  • At 12 and 18 months, depressive symptom scores were the same in the collaborative care and usual care groups at between 10.4 and 10.6.
  • Eighty-three per cent of the collaborative care group participated in the intervention. Reasons some didn’t include physical health problems and concerns about the intervention being intrusive. Some patients were uncertain about the benefits of behaviour-based therapy.

What does current guidance say on this issue?

NICE recommended in 2009 and 2011 that collaborative care is offered to patients with moderate to severe depression and a chronic physical health problem with difficulties undertaking daily tasks, whose symptoms do not respond to first-line interventions. They did not recommend this intervention for milder depression without these additional problems.

The 2009 guideline recommended low intensity guided self-help including behavioural activation for mild to moderate depression. NICE noted relatively weak evidence at that time for high-intensity behavioural activation. 

In 2017, NICE issued a draft updated guideline on the treatment and management of depression for consultation. The final guideline is due for publication in 2018.

What are the implications?

Collaborative care might be delivered by the Improving Access to Psychological Therapy programme, or suitably qualified staff in GP practices. The NHS target is to provide 3000 new mental health therapists co-located in primary care by 2020/21.

In this trial, psychological wellbeing practitioners were employed at NHS band 5. They received two days of additional training to deliver the intervention. 

The draft NICE depression guideline (2017) recommends that collaborative care should be considered for all older people with depression. As a result of recent UK trials, the draft guideline gives greater prominence to behavioural activation than in 2009.

Citation and Funding

Bosanquet K, Adamson J, Atherton K, et al. CollAborative care for Screen-Positive EldeRs with major depression (CASPER plus): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness. Health Technol Assess. 2017;21(67):1-252.

This project was funded by the National Institute for Health Research Health Technology Assessment programme (project number 10/57/43).

Bibliography

NHS Choices. Stress, anxiety and depression: Can I get free therapy or counselling? London: Department of Health; 2016.

NHS England and NHS Improvement. Mental health in older people: A practice primer. Redditch: NHS England; 2017.

NICE. Depression in adults. QS8. London: National Institute for Health and Care Excellence; 2011.

NICE. Depression in adults with a chronic physical health problem: recognition and management. CG91. London: National Institute for Health and Care Excellence; 2009.

NICE. Depression in adults: treatment and management. Guideline in development.  London: National Institute for Health and Care Excellence; expected publication 2018.

NIHR DC. Options in the care of people with depression. London: National Institute for Health Research Dissemination Centre; 2017.

Why was this study needed?

About one in seven people over the age of 75 are clinically depressed. Depression is associated with poor quality of life, worse physical health and increased use of health and social care services.

Older people and practitioners may view psychological difficulties as part of normal ageing or believe that psychological treatments are not effective. Perceptions and practical barriers to accessing care can lead to depression being under-treated. In 2014/15, only 7% of people completing treatment in the Improving Access to Psychological Therapies programme were older people.

Collaborative care is a structured patient-centred way for case managers to proactively manage treatments. Effectiveness evidence had been mainly from the US, so NICE recommended further research. UK trials have since given positive results for working-age adults, and older adults with sub-clinical depression.

CASPER-PLUS is the first large-scale UK trial to measure the clinical and cost-effectiveness of collaborative care for older people with clinical depression.

What did this study do?

This pragmatic trial randomised 485 adults with moderate to severe depression into collaborative care or usual primary care. Participants were recruited from 69 GP practices in northern England. Their average age was 72 years, and a high proportion had physical health problems. Exclusion criteria included suicidal risk, drug and alcohol problems, psychosis and cognitive impairment.

A collaborative care protocol incorporating low-intensity behavioural activation therapy was adapted for older people. Behavioural activation encourages increased activity and social contact, which may improve physical health symptoms as well as mood. One face to face session was followed by five telephone sessions over eight weeks. Case managers were primary care mental health workers supervised by a senior mental health specialist.

The collaborative care group had higher drop-out than the usual care group (25% at four months). Participants, practitioners and researchers were aware of treatment allocation, which may have influenced participant’s answers to the self-reported questionnaire.

What did it find?

  • Baseline depression scores were on average 14 out of 27 according to the 9-item self-report Patient Health Questionnaire (PHQ-9), in which higher numbers indicate worse symptoms. At four months after randomisation, average depression scores had reduced to 8.98 in the collaborative care group, compared to 10.9 in the usual care group (adjusted mean difference [MD] 1.92 points, 95% confidence interval [CI] 0.85 to 2.99 points; 390 participants).
  • At 12 and 18 months, depressive symptom scores were the same in the collaborative care and usual care groups at between 10.4 and 10.6.
  • Eighty-three per cent of the collaborative care group participated in the intervention. Reasons some didn’t include physical health problems and concerns about the intervention being intrusive. Some patients were uncertain about the benefits of behaviour-based therapy.

What does current guidance say on this issue?

NICE recommended in 2009 and 2011 that collaborative care is offered to patients with moderate to severe depression and a chronic physical health problem with difficulties undertaking daily tasks, whose symptoms do not respond to first-line interventions. They did not recommend this intervention for milder depression without these additional problems.

The 2009 guideline recommended low intensity guided self-help including behavioural activation for mild to moderate depression. NICE noted relatively weak evidence at that time for high-intensity behavioural activation. 

In 2017, NICE issued a draft updated guideline on the treatment and management of depression for consultation. The final guideline is due for publication in 2018.

What are the implications?

Collaborative care might be delivered by the Improving Access to Psychological Therapy programme, or suitably qualified staff in GP practices. The NHS target is to provide 3000 new mental health therapists co-located in primary care by 2020/21.

In this trial, psychological wellbeing practitioners were employed at NHS band 5. They received two days of additional training to deliver the intervention. 

The draft NICE depression guideline (2017) recommends that collaborative care should be considered for all older people with depression. As a result of recent UK trials, the draft guideline gives greater prominence to behavioural activation than in 2009.

Citation and Funding

Bosanquet K, Adamson J, Atherton K, et al. CollAborative care for Screen-Positive EldeRs with major depression (CASPER plus): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness. Health Technol Assess. 2017;21(67):1-252.

This project was funded by the National Institute for Health Research Health Technology Assessment programme (project number 10/57/43).

Bibliography

NHS Choices. Stress, anxiety and depression: Can I get free therapy or counselling? London: Department of Health; 2016.

NHS England and NHS Improvement. Mental health in older people: A practice primer. Redditch: NHS England; 2017.

NICE. Depression in adults. QS8. London: National Institute for Health and Care Excellence; 2011.

NICE. Depression in adults with a chronic physical health problem: recognition and management. CG91. London: National Institute for Health and Care Excellence; 2009.

NICE. Depression in adults: treatment and management. Guideline in development.  London: National Institute for Health and Care Excellence; expected publication 2018.

NIHR DC. Options in the care of people with depression. London: National Institute for Health Research Dissemination Centre; 2017.

CollAborative care for Screen-Positive EldeRs with major depression (CASPER plus): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness

Published on 24 November 2017

Bosanquet K, Adamson J, Atherton K, Bailey D, Baxter C, Beresford-Dent J, Birtwistle J, Chew-Graham C, Clare E, Delgadillo J, Ekers D, Foster D, Gabe R, Gascoyne S, Haley L, Hamilton J, Hargate R, Hewitt C, Holmes J, Keding A, Lewis H, McMillan D, Meer S, Mitchell N, Nutbrown S, Overend K, Parrott S, Pervin J, Richards D A, Spilsbury K, Torgerson D, Traviss-Turner G, Trépel D, Woodhouse R & Gilbody S.

Health Technology Assessment Volume 21 Issue 67 , 2017

Background Depression in older adults is common and is associated with poor quality of life, increased morbidity and early mortality, and increased health and social care use. Collaborative care, a low-intensity intervention for depression that is shown to be effective in working-age adults, has not yet been evaluated in older people with depression who are managed in UK primary care. The CollAborative care for Screen-Positive EldeRs (CASPER) plus trial fills the evidence gap identified by the most recent guidelines on depression management. Objectives To establish the clinical effectiveness and cost-effectiveness of collaborative care for older adults with major depressive disorder in primary care. Design A pragmatic, multicentred, two-arm, parallel, individually randomised controlled trial with embedded qualitative study. Participants were automatically randomised by computer, by the York Trials Unit Randomisation Service, on a 1 : 1 basis using simple unstratified randomisation after informed consent and baseline measures were collected. Blinding was not possible. Setting Sixty-nine general practices in the north of England. Participants A total of 485 participants aged ≥ 65 years with major depressive disorder. Interventions A low-intensity intervention of collaborative care, including behavioural activation, delivered by a case manager for an average of six sessions over 7–8 weeks, alongside usual general practitioner (GP) care. The control arm received only usual GP care. Main outcome measures The primary outcome measure was Patient Health Questionnaire-9 items score at 4 months post randomisation. Secondary outcome measures included depression severity and caseness at 12 and 18 months, the EuroQol-5 Dimensions, Short Form questionnaire-12 items, Patient Health Questionnaire-15 items, Generalised Anxiety Disorder-7 items, Connor–Davidson Resilience Scale-2 items, a medication questionnaire, objective data and adverse events. Participants were followed up at 12 and 18 months. Results In total, 485 participants were randomised (collaborative care, n = 249; usual care, n = 236), with 390 participants (80%: collaborative care, 75%; usual care, 86%) followed up at 4 months, 358 participants (74%: collaborative care, 70%; usual care, 78%) followed up at 12 months and 344 participants (71%: collaborative care, 67%; usual care, 75%) followed up at 18 months. A total of 415 participants were included in primary analysis (collaborative care, n = 198; usual care, n = 217), which revealed a statistically significant effect in favour of collaborative care at the primary end point at 4 months [8.98 vs. 10.90 score points, mean difference 1.92 score points, 95% confidence interval (CI) 0.85 to 2.99 score points; p < 0.001], equivalent to a standard effect size of 0.34. However, treatment differences were not maintained in the longer term (at 12 months: 0.19 score points, 95% CI –0.92 to 1.29 score points; p = 0.741; at 18 months: < 0.01 score points, 95% CI –1.12 to 1.12 score points; p = 0.997). The study recorded details of all serious adverse events (SAEs), which consisted of ‘unscheduled hospitalisation’, ‘other medically important condition’ and ‘death’. No SAEs were related to the intervention. Collaborative care showed a small but non-significant increase in quality-adjusted life-years (QALYs) over the 18-month period, with a higher cost. Overall, the mean cost per incremental QALY for collaborative care compared with usual care was £26,016; however, for participants attending six or more sessions, collaborative care appears to represent better value for money (£9876/QALY). Limitations Study limitations are identified at different stages: design (blinding unfeasible, potential contamination), process (relatively low overall consent rate, differential attrition/retention rates) and analysis (no baseline health-care resource cost or secondary/social care data). Conclusion Collaborative care was effective for older people with case-level depression across a range of outcomes in the short term though the reduction in depression severity was not maintained over the longer term of 12 or 18 months. Participants who received six or more sessions of collaborative care did benefit substantially more than those who received fewer treatment sessions but this difference was not statistically significant. Future work recommendations Recommendations for future research include investigating the longer-term effect of the intervention. Depression is a recurrent disorder and it would be useful to assess its impact on relapse and the prevention of future case-level depression. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 67. See the NIHR Journals Library website for further project information.

Low-intensity psychological treatments are generally for people with mild to moderate depression or anxiety. Mental health practitioners facilitate the patient to use structured self-help materials, sometimes involving the telephone or internet. Qualified psychological wellbeing practitioners can work within Improving Access to Psychological Therapies services, and receive 45 days of accredited training.

In contrast, high-intensity treatments are usually delivered face to face for an extended number of sessions by highly trained psychologists and therapists.

Behavioural activation (low or high intensity) encourages patients with depression to approach activities they may have been avoiding, through the development of goals and activity schedules.

Expert commentary

Depression in older people is common, overlooked and poorly treated. Further, older people are shamefully under-represented in Improving Access to Psychological Therapies, despite evidence that they have recovery rates that are better than those in younger patients.

Demonstration of the effectiveness of a low-intensity psychological intervention that offers faster recovery of low mood and anxiety symptoms than usual treatment in primary care is important and timely.

Collaborative care offers a cost-effective and scalable model that Improving Access to Psychological Therapies and GPs could begin to use immediately to improve outcomes in a population of unwell people with enormous recognised but unmet need. 

Robert Howard, Professor of Old Age Psychiatry, University College London