From the Journals

Collaborative care aids seniors’ mild depression

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Behavioral activation aspect appears beneficial

The CASPER trial “provides the first evidence that collaborative care may benefit patients with subthreshold depression,” Kurt Kroenke, MD, wrote in an accompanying editorial. In addition to the improvements on the Patient Health Questionnaire and the reduction in risk of progression to threshold level depression, the findings further support the use of behavioral activation, which was the core treatment in the study, he said. “Strong evidence for the effectiveness of behavioral activation was provided by the recent COBRA trial. … and behavioral activation was found to be noninferior to cognitive-behavioral therapy for the outcome of depression,” he wrote. However, more research is needed before clinicians routinely expand treatment beyond major depression to include subthreshold depression, Dr. Kroenke noted. Key factors include the variable rate of progression from subthreshold depression to major depression, the duration and context of subthreshold depression, patient preferences, and the possible role of antidepressants, he noted. However, the CASPER findings show “new evidence that collaborative care improves outcomes for at least some patients with subthreshold depression,” Dr. Kroenke said. “Patients with persistent symptoms, functional impairment, and a desire for treatment may particularly benefit,” he added (JAMA. 2017;317:702-4).

Kurt Kroenke, MD, is affiliated with the VA Health Services Research and Development Service Center for Health Communication and Information, Regenstrief Institute and Indiana University, both in Indianapolis. He had no financial conflicts to disclose.



A collaborative care model significantly mitigated mild depression in adults aged 65 and older, compared with usual care in the short term, based on data from 705 patients. The findings were published online Feb. 21.

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In the Collaborative Care for Screen Positive Elders (CASPER) trial, the researchers randomized 344 patients to collaborative care, and 361 control patients received standard primary care. The collaborative care intervention involved assessment of functional impairment and mood, followed by eight weekly sessions of behavioral activation that consisted of telephone support and symptom monitoring at each session after an initial face-to-face session. Symptoms were assessed using the 9-item Patient Health Questionnaire depression score (PHQ-9), with a scale of 0-27.

Overall, patients in the collaborative care group improved from an average score of 7.8 at baseline to 5.4 after 4 months; the usual care group improved from an average of 7.8 at baseline to 6.7 at 4 months. The difference in scores persisted at 12 months in the secondary analysis (JAMA. 2017;317:728-37. doi: 10.1001/jama.2017.0130). “For populations with case-level depression, a successful treatment outcome has been defined as 5 points on the PHQ-9,” the researchers noted. “This magnitude of benefit was not observed in either group of the trial when comparing scores before and after treatment, although this result would be anticipated given the lower baseline PHQ-9 scores in populations with subthreshold depression.’

The study participants came from 32 primary care practices in northern England; the average age was 77 years, and 58% were women.

The results were limited by several factors, including the absence of a standardized interview to diagnose depression, differences in retention and attrition between groups, and the absence of long-term follow-up, “and further research is needed to assess longer-term efficacy,” the researchers said.

Neither Dr. Gilbody nor his colleagues had financial conflicts to disclose.

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