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Objective: The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) evaluated the impact of a care management intervention on suicidal ideation and depression in older primary care patients. This is the first report of outcomes over a 2-year period. Method: Study participants were patients 60 years of age or older (N=599) with major or minor depression selected after screening 9,072 randomly identified patients of 20 primary care practices randomly assigned to provide either the PROSPECT intervention or usual care. The intervention consisted of services of 15 trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 24 months. Results: Compared with patients receiving usual care, those receiving the intervention had a higher likelihood of receiving antidepressants and/or psychotherapy (84.9%-89% versus 49%-62%) and had a 2.2 times greater decline in suicidal ideation over 24 months. Treatment response occurred earlier on average in the intervention group and increased from months 18 to 24, while no appreciable increase in treatment response occurred in the usual care group during the same period. Among patients with major depression, a greater number achieved remission in the intervention group than in the usual-care group at 4 months (26.6% versus 15.2%), 8 months (36% versus 22.5%), and 24 months (45.4% versus 31.5%). Patients with minor depression had favorable outcomes regardless of treatment assignment. Conclusions: Sustained collaborative care maintains high utilization of depression treatment, reduces suicidal ideation, and improves the outcomes of major depression over 2 years.

Background: Although depressive conditions in later life are a major public health problem, the outcomes of minor and subsyndromal depression are largely unknown. Objective: To compare outcomes among patients with minor and subsyndromal depression, major depression, and no depression, and to examine putative outcome predictors. Design: Cohort study. Setting: Patients from primary care practices in greater New York City, and Philadelphia and Pittsburgh, Pennsylvania. Patients: 622 patients who were at least 60 years of age and presented for treatment in primary care practices that provided usual care in a randomized, controlled trial of suicide prevention. Of the 441 (70.9%) patients who completed 1 year of follow-up, 122 had major depression, 205 had minor or subsyndromal depression, and 114 did not have depression at baseline. Measurements: One year after a baseline evaluation, data were collected by using the following tools: Hamilton Depression Rating Scale, the depressive disorders section of the Structured Clinical Interview for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition), Charlson Comorbidity Index, Multilevel Assessment Instrument for measuring instrumental activities of daily living, Physical Component Summary of the Medical Outcomes Study Short Form-36, and Duke Social Support Index. Results: Patients with minor or subsyndromal depression had intermediate depressive and functional outcomes. Mean adjusted 1-year Hamilton depression score was 10.9 (95% CI, 9.6 to 12.2) for those with initial major depression, 7.0 (CI, 5.9 to 8.1) for those with minor or subsyndromal depression, and 2.9 (CI, 1.6 to 4.2) for those without depression (P < 0.001 for each paired comparison). Compared with patients who were not depressed, those who had minor or subsyndromal depression had a 5.5-fold risk (CI, 3.1-fold to 10.0-fold) for major depression at 1 year after controlling for demographic characteristics (P < 0.001). Cerebrovascular risk factors were not associated with a diagnosis of depression at 1 year after controlling for overall medical burden. Initial medical burden, self-rated health, and subjective social support were significant independent predictors of depression outcome. Limitations: Participants received care at practices that had personnel who had been given enhanced education about depression treatment; 29.1% of participants withdrew from the study before completing 1 year of follow-up. Conclusions: The intermediate outcomes of minor and subsyndromai depression demonstrate the clinical significance of these conditions and suggest that they are part of a spectrum of depressive illness. Greater medical burden, poor subjective health status, and poorer subjective social support confer a higher risk for poor outcome.

Objective: This study compared time to first remission for elderly depressed patients in primary care for practices that implemented a care management model versus those providing usual care. In addition, it sought to identify risk factors for nonremission that could guide treatment planning and referral to care managers or specialists. Method: Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) data were analyzed. Participants were older patients ([greater than or equal to] 60 years) selected following screening of 9,072 randomly identified primary care patients. The present analysis examined patients with major depression and a 24-item Hamilton Depression Rating Scale score of 18 or greater who were followed for at least 4 months (N=215). Primary care practices were randomly assigned to offer the PROSPECT intervention or usual care. The intervention consisted of services of trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 18 months. Results: First remission occurred earlier and was more common among patients receiving the intervention than among those receiving usual care. For all patients, limitations in physical and emotional functions predicted poor remission rate. Patients experiencing hopelessness were more likely to achieve remission if treated in intervention practices. Similarly, the intervention was more effective in patients with low baseline anxiety. Conclusions: Longitudinal assessment of depression, hopelessness, anxiety, and physical and emotional functional limitations in depressed older primary care patients is critical. Patients with prominent symptoms or impairment in these areas may be candidates for care management or mental health care, since they are at risk for remaining depressed and disabled.

A strategy that would enable healthcare providers who are caring for elderly patients with chronic mental illness to choose pharmacological interventions with favorable risk/benefit profiles is suggested. The strategy involves evaluating data from efficacy studies that concentrate on the use of atypical antipsychotics in the treatment of elderly patients with psychotic illness.

Objective: This study determined the efficacy of antidepressant medication for the treatment of depression in the 'old-old.' Method: This randomized 8-week medication trial compared citalopram, 10-40 rag/day, to placebo in the treatment of patients 75 and older with unipolar depression. Results: A total of 174 patients who were 58% women with a mean age of 79.6 years (SD=4.4) and a mean baseline Hamilton Depression Rating Scale score of 24.3 (SD=4.1) were randomly assigned to treatment at 15 sites. There was a main effect for site but not for treatment condition. The remission rate, defined as a final Hamilton depression scale score 24) tended to have a higher remission rate with medication than with placebo (35% versus 19%). Conclusions: In the oldest group of community-dwelling patients to be studied to date, medication was not more effective than placebo for the treatment of depression. However, given the considerable psychosocial support received by all patients, the placebo condition represents more than the ingestion of an inactive pill. Across sites, there was considerable range in response to medication, 18% to 82%, and to placebo, 16% to 80%.

Depression in older people is a significant physical and mental health problem. Compelling evidence suggests it can be diagnosed accurately and treated effectively. When healthy, members of the current generation [...]

This article discusses the relationship between disease and depression among aged physically disabled persons. Diseases most negatively affecting patients' mental and physical health include arthritis, speech disorder, circulation disorders, and glaucoma.

This article discusses the prevalent problem of underdiagnosing mental depression in the aged. The authors, arguing depression in the elderly is common but underdiagnosed, offer a list of important symptoms, such as a preoccupation with death, and maintain treatment must be continuous since geriatric depression is a chronic and relapsing illness.

Extended-release venlafaxine has been found to be equally safe and well tolerated by younger and older patients in the treatment of generalized anxiety disorder (GAD). It showed similar efficacy in those 60 years old and older and those younger than 60. Conclusions are based on the pooled analysis of five randomized placebo-controlled clinical trials, three in the United States and two in Europe.

A randomized, double-blind, placebo-controlled study of the efficacy and safety of donepezil in patients with Alzheimer's disease in the nursing home setting.

A longitudinal assessment study of 2572 patients aged 60+ has been carried out to look at the relationship between functional disability and improvement in late-life depression after acute inpatient treatment. Improvement in symptoms was significantly related to improvement in instrumental activities of daily living and to health-related quality of life. The disabling nature of depression has been substantiated. It appears that the effect of treating depression is not the only factor in the reversal of disability.

Oxybutynin chloride can cause cognitive impairment in older people. This drug is an antispasmodic sold under the trade name Ditropan. It is an anticholinergic drug and can cross the blood-brain barrier. Cognitive ability was tested in 12 volunteers 65 years or older after they took oxybutynin chloride, a placebo, or diphenhydramine hydrochloride, another anticholinergic drug. Oxybutynin caused deficiencies on 7 of 15 cognitive measures.

Improving the public health of older populations requires further research, but it is important to evaluate all options to best treat such illnesses as depression, alcohol related disorders, and anti-social behaviors. Delivering mental health care to older patients is difficult because the evidence available to guide clinical decision-making does not address primary care patients. However, it is important that mental health professionals and primary physicians collaborate with each other.

A study is conducted to evaluate the older adult patient reports of improvement in the depressive symptoms. These reports can be used to design treatment decision tools.

The effects of depression and other nonmotor symptoms on functional ability in Parkinson's disease (pd) are examined. Results indicate that psychiatric and other nonmotor symptoms contribute significantly to disability in PD.