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Depression in long-term care patients : evaluation of a screening protocol and outcomes of drug therapy Soon, Judith Alice

Abstract

Depression is often underdiagnosed and undertreated in elderly long-term care patients. Recommendations have been made to increase the identification and treatment of depression in late life, despite the fact that efficacy and outcomes of antidepressant treatment have not been established in this population. The first component of this research was an 8-week randomized clinical trial to assess the effect of a screening protocol on physicians' identification and treatment of depression. The clinical screening study of 1602 patients in 22 long-term care facilities identified 103 untreated patients ≥ 65 years with adequate cognitive function and a Geriatric Depression Scale score ≥ 13. The 77 physicians of the 103 patients were randomized by cluster into an early (experimental, notified of screening results) or a delayed (control, notified 4 weeks later) group. The primary outcome was the effect of the screening protocol on physicians' decisions to prescribe antidepressant therapy or refer to mental health services. Physician response in the early group (25%) was greater than that in the delayed group (2%) (p < 0.005) by 4 weeks from baseline. The combined physician response rate was 36% (95% CI, 26% to 46%) at 8 weeks from notification, and overall physician action occurred in 69% (95% CI, 60% to 78%). Logistic regression suggested that physicians' decisions to treat or refer were not related to severity of symptoms of depression or other patient characteristics, but were primarily associated with physician-related characteristics. The second component of the research was a 26-week prospective, observational outcomes study of depressed patients newly treated with antidepressants, and a similar group of untreated patients. Therapeutic outcomes of interest were mean within-group changes in symptoms of depression, cognitive function, self-perceived health status, and functional ability at 6, 12, and 26 weeks for treated patients, and at 26 weeks for untreated patients. While symptoms of depression improved in treated patients over the period of 26 weeks, other measures of quality of life and physical function did not improve. Similar observations were made in the untreated group. The results support the idea that randomized controlled effectiveness studies in long-term care patients are both ethical and necessary.

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