Background
Prioritised recommendations | Full recommendation to be discussed in the groups and interviews |
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1. Social contact | Primary care physicians and other healthcare professionals should discuss social contact with elderly patients with depression and recommend actions (e.g. group activities) for those who have limited social contact. •When needed, regular social contact with trained volunteers, recruited from Centres for Voluntary Organisations, the Red Cross, Mental Health or community day care centres. When possible, the patient’s relatives should be involved in the plan to improve social contact. |
2. Collaborative care plan | All municipalitiesa should develop a plan for collaborative care for patients with moderate to severe depression. The plan should describe the responsibilities and communication between professionals who have contact with the patient, within primary care and between primary and specialist care. In addition, the plan should appoint depression care managers who have a responsibility for following the patient. The plan should describe routines for referral to specialist care. |
3. Depression care manager | Primary care physicians should offer patients with moderate to severe depression regular contact with a depression care manager. |
4. Counselling | Primary care physicians or qualified healthcare professionals should offer advice to elderly patients with depression regarding: • Self-assisted programmes, such as literature or web-based programmes based on cognitive behavioural therapy principles • Structured physical activity programmes, individually or group-based • Healthy sleeping habits • Anxiety coping strategies • Problem solving therapy |
5. Mild depression | Primary care physicians should usually not prescribe antidepressants to patients with mild depression. Primary care physicians may consider prescribing antidepressant medication to patients who suffer from a mild episode of depression and have previously responded to antidepressant medication when moderately or severely depressed. |
6. Severe depression, recurrent depression and dysthymia | Primary care physicians should offer these patients a combination of antidepressant medication and psychotherapy. If the physician is not trained to provide the patient with psychotherapy, patients should be referred to trained healthcare professionals. |
Methods
Design
Participants, inclusion and eligibility criteria
Interventions
Strategy | Content | |
---|---|---|
1 | Collaborative care plan. Resources for administrators and policy makers: development of the plan | Help for healthcare administrators to develop a collaborative care plan in the community, presented on a designated website for the project. |
2 | Collaborative care plan. Resources for administrators and policy makers: content of the plan | Suggested content to include in the collaborative care plan, with an option to adjust or tailor interventions to the community. |
3 | Resources for healthcare professionals | Templates, manuals and pamphlets to be distributed to healthcare professionals in the municipality. |
4 | Resources for patients, their relatives and volunteers | Pamphlets to be distributed to patients and their relatives. |
5 | Outreach visits to general practitioners | Visits to general practitioners to provide information on the recommendations and determinants of practice and to discuss local considerations that might imply that the interventions should be adjusted or targeted to selected practices. |
6 | Web resources and data systems | A comprehensive website that includes the recommendations and the underlying evidence, tools for diagnosis and treatment and all educational resources, available for healthcare professionals and inhabitants in the intervention municipalities. |
Outcome measures
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Improvements in depression symptoms, as measured by the general practitioner, patient or family members. The general practitioners used the Clinical Global Impression improvement scale [25]. Patients’ assessment of continuous depression and anxiety symptoms was measured using the Hospital Anxiety and Depression Scale [26], and patients’ or family members’ assessment of improvements in depression symptoms was measured using the Patient’s Global Impression scale [27, 28].
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Social contact.
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Physical activity, sleep problems management.
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Anxiety problems management.
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Problem solving ability.
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Utilisation of web- or book-based self-help programmes.
Sample size
Recruitment, randomisation and blinding
Data collection
Statistical methods
Ethics
Results
Variables | Intervention | Control |
p
|
---|---|---|---|
General practitioners |
N = 51 |
N = 73 | |
Clusters (municipalities) | 26 | 28 | |
Female (%) | 21 (41 %) | 32 (43 %) | ns |
Age (SD) | 47.3 (11.39 | 49.4 (10.4) | ns |
Year in practice (SD) | 16.1 (11.5) | 17.3 (10.9) | ns |
Specialist in family medicine yes (%) | 31 (61 %) | 51 (70 %) | ns |
Practices | |||
No of patients on list (SD) | 1056 (352) | 1084 (354) | ns |
Large municipality/city (%) | 9 (18 %) | 43 (59 %) | <0.001 |
Many elderly on list (%) | 39 (76 %) | 42 (57 %) | 0.03 |
Patients |
N = 182 |
N = 203 | |
Female (%) | 116 (64 %) | 159 (78 %) | 0.002 |
Age (SD) | 73.9 (7.6) | 75.1 (7.7) | ns |
Mild depressive episode (F32.0) | 21 (12 %) | 35 (17 %) | ns |
Moderate depressive episode (F32.1) | 22 (12 %) | 23 (11 %) | ns |
Severe depressive episode (F32.2-3) | 28 (15 %) | 35 (17 %) | ns |
Recurrent depression or dysthymia (F33.0-3, F34.1) | 111 (61 %) | 110 (55 %) | ns |
Primary outcomes
Intervention | Control | Estimated differencea between intervention and control group (%) (lower CL (%), upper CL (%)) | |||
---|---|---|---|---|---|
N
| Mean (%) (SD (%)) |
N
| Mean (%) (SD (%)) | ||
Primary outcome | |||||
Mean adherence | 51 | 58 (20) | 73 | 53 (18) | 2 (−11, 7) |
Secondary outcome | |||||
GP assessed CGI-Ib
| 141 | 2.58 (1.04) | 170 | 2.55 (1.04) | 0.046 (−0.29, 0.38) |
Patient assessed PGIb
| 55 | 2.20 (1.37) | 69 | 2.10 (1.36) | 0.18 (−0.47, 0.83) |
HADS depression | 60 | 6.55 (4.74) | 70 | 6.83 (4.17) | −0.55 (−2.70, 1.60) |
HADS anxiety | 58 | 8.09 (4.86) | 69 | 8.49 (4.11) | −0.075 (−2.01, 2.16) |
HADS total | 58 | 14.62 (9.01) | 68 | 15.12 (7.64) | −0.38 (−4.27, 3.51) |
Lonelinessc
| 60 | 1.58 (1.11) | 74 | 1.65 (1.00) | 0.34 (−0.97, 0.30) |
Sleeping problems improvedb
| 31 | 2.32 (1.01) | 43 | 2.05 (1.11) | 0.57 (−0.06, 1.20) |
Ability to cope with anxiety improvedb
| 38 | 2.45 (1.16) | 40 | 2.07 (1.39) | 0.28 (−0.29, 0.91) |
Problem solvingb
| 53 | 2.79 (1.22) | 68 | 2.54 (1.30) | 0.28 (−0.34, 0.91) |
Secondary outcomes
Observed (raw data) | Estimated OR from final multivariate mixed modela
| ||||||
---|---|---|---|---|---|---|---|
Intervention | Control | OR (control vs intervention) | Lower CL | Upper CL | |||
n
|
N
|
n
|
N
| ||||
Often/sometimes loneliness | 34 | 60 | 46 | 74 | 1.81 | 0.43 | 7.66 |
Established contact voluntary organisations | 11 | 59 | 14 | 73 | 3.01 | 0.97 | 9.30 |
More physically active | 9 | 60 | 18 | 74 | 1.42 | 0.21 | 9.45 |
Self-help programme/literature | 6 | 60 | 7 | 71 | 1.62 | 0.37 | 7.17 |
Adherence to antidepressant >0 | 28 | 60 | 26 | 74 | 1.02 | 0.26 | 4.05 |
Post hoc analyses
Intervention (observed in raw data) | Control (observed in raw data) | Estimated differencea between intervention and control group (%) (lower CL (%), upper CL (%)) from final multivariate mixed model | |||
---|---|---|---|---|---|
N
| Mean (%) (SD (%)) |
N
| Mean (%) (SD (%)) | ||
Depressive episode | |||||
Mild | 15 | 49 (21) | 26 | 55 (18) | −6 (−18, 6) |
Moderate | 16 | 49 (23) | 17 | 45 (21) | 3 (−18, 25) |
Severe | 18 | 49 (17) | 22 | 51 (16) | −4 (−12, 20) |
Recurrent depression/dysthymia | 42 | 67 (26) | 48 | 59 (24) | 5(−7, 17) |