At the start of this newly published paper in the Journal of the American Medical Association, Simon Gilbody and colleagues remind us of the misery of depression. It is, now, the second leading cause of disability worldwide. It is also experienced along a continuum, with milder depressive experiences serving as risk factors for later, more severe, difficulties.
Effective and efficient interventions early in the depression trajectory are therefore welcome as they hold out the prospect of preventing future disability and distress. But what, exactly, might these interventions be, and how might they be organised? The CASPER trial set out to answer some of these questions.
CASPER is a big study, involving 705 people aged 65 or over with sub-threshold depression, recruited from 32 primary care practices in the North of England. Initial contact was made via postal questionnaire, and following assessments of eligibility and recruitment, participants were randomised to one of two groups:
- Collaborative care with behavioural activation
- Treatment as usual
Collaborative care is attracting lots of interest, as earlier posts here, here and here attest. In CASPER it involved a case manager, with either a mental health nursing or graduate psychology background, offering a single face-to-face session and then seven telephone sessions with participants. Case managers had access to supervision, and offered encouragement to participants to adhere to any prescribed medications. They also provided a structured programme of behavioural activation. This is described by NICE as a promising intervention, involving help being given to people to schedule social activities they might otherwise avoid, but is also one that needs further testing. The COBRA trial published last year provided strong evidence for behavioural activation for depression.
CASPER’s primary outcome was severity and symptoms of depression, measured at four months using the 9-item, self-report, Patient Health Questionnaire (PHQ-9). A variety of secondary outcomes included: PHQ-9 scores at 12 months; the use of PHQ-9 scores at both 4 and 12 months to serve as indicators of depression diagnosis; measures of quality of life and anxiety; and prescription of mental health medications.
At the key four month point collaborative care reduced older people’s self-reported depressive symptoms compared to symptoms reported by those receiving usual care, with statistically significant differences also found at one year follow-up. Harder to judge, as the CASPER team note, is the clinical meaningfulness of these reductions.
Amongst the secondary outcomes, the proportion of participants with PHQ-9 scores of 10 or above (and therefore indicative of depression) at 12 months was lower in the collaborative care group than in the usual care group.
The collaborative care intervention also improved anxiety and functional status compared with usual care.
- Collaborative care (with telephone support and behavioural activation) reduces the self-reported symptoms of older people with sub-threshold depression compared to usual care.
- Although there is no health economics component formally reporting the costs of collaborative care in this JAMA paper, the fact that interventions were largely provided via telephone contact suggests this to be a relatively inexpensive way of providing services. (Note: a separate cost effectiveness CASPER paper is in the pipeline)
- However, whilst reductions in depressive symptoms in CASPER’s participants can be measured and are statistically significant, their clinical meaningfulness is less clear.
- Whilst collaborative care (combined with a variety of direct interventions) is increasingly being used in primary care studies with people with commonly experienced mental health difficulties, as the CASPER team suggest future research is needed into its longer-term effects and its use with different groups.
Gilbody S, Lewis H, Adamson J, Atherton K, Bailey D, Birtwistle J, Bosanquet K, Clare E, Delgadillo J, Ekers D, Foster D, Gabe R, Gascoyne S, Haley L, Hamilton J, Hargate R, Hewitt C, Holmes J, Keding A, Lilley-Kelly A, Meer S, Mitchell N, Overend K, Pasterfield M, Pervin J, Richards DA, Spilsbury K, Traviss-Turner G, Trépel D, Woodhouse R, Ziegler F, McMillan D. (2017) Effect of Collaborative Care vs Usual Care on Depressive Symptoms in Older Adults With Subthreshold Depression: The CASPER Randomized Clinical Trial. JAMA. 2017;317(7):728-737. doi:10.1001/jama.2017.0130