A stepped care intervention is effective for elderly people with subthreshold depression or anxiety

Publication Summary

QUESTION Question: Does an indicated prevention programme reduce the development of major depression and anxiety in an elderly population with subthreshold symptoms? Patients: 170 participants (aged >75 years; 73.5% female) identified through a database of participants in the Preventative Intervention for Frail Elderly (PIKO) project. Those who scored >16 on the self-reported Centre for Epidemiologic Studies Depression Scale (CES-D) during the PIKO study (between October 2005 and October 2005), were aged 75 years or over and who did not meet the DSM-IV criteria for depressive or anxiety disorder in the 12 months prior to their PIKO questioning, were approached to participate in this study. Exclusions: DSM-IV depression or anxiety disorder detected by the Mini International Neuropsychiatric Interview (MINI); serious cognitive disorder according to the self-rated Informant Questionnaire on Cognitive Decline in the Elderly. Setting: 33 primary care practices in northwest Netherlands; October 2004–October 2005. Intervention: A stepped care programme involving 3 month cognitive behavioural therapy (CBT) based self-help, bibliography intervention followed by brief CBT based problem solving treatment (PST). Participants were visited by a home care nurse who provided written information on coping with depression and anxiety symptoms. A self-help course (Coping with Depression and Anxiety) was offered at a subsequent visit providing guidance on improving social skills, increasing pleasant activities and relaxation to cope with depressive or anxious thinking patterns. This was followed by PST, which consisted of seven sessions, administered by a trained community psychiatric nurse, focusing on practical skill building for daily life problems. Participants were assessed with CES-D every 3 months during the intervention. Those with consistently elevated CES-D scores received written advice to discuss medications with their GP and those meeting MINI criteria for depression or anxiety at 6 or 12 months were referred to their GP. Controls received usual care which included unrestricted treatment for depression or anxiety concerns. Outcomes: Cumulative 12 month incidence of DSM-IV depression or anxiety (generalised anxiety, panic disorder, social phobia, agoraphobia) assessed using the MINI. The outcome was assessed at 6 and 12 months. CES-D for subthreshold anxiety and depression was administered at baseline, 3, 6, 9 and 12 months. Patient follow-up: 81.2%. METHODS Design: Randomised controlled trial. Allocation: Unclear. Blinding: Unclear. Follow-up period: One year (assessments at 6 and 12 months). MAIN RESULTS At 12 months, the incidence of depressive and anxiety disorders was lower in the intervention group than in the control group (11.6% vs 23.8%, respectively). The intervention significantly reduced the risk of a major disorder (relative risk 0.49, 95% confidence interval 0.24 to 0.98; number needed to treat 8.2). Twenty-eight participants in the intervention group received antidepressants compared with 23 participants in the control group (p = 0.28). There were significantly more dropouts in the intervention group (24 vs 8; p = 0.009). CONCLUSIONS A stepped-care intervention administered to elderly people with subthreshold depression and anxiety is more effective than usual care in preventing the development of depression and anxiety disorders.