Collaborative Care Models to Address Late-Life Depression: Lessons for Low-And-Middle-Income Countries

Introduction

Late-life depression is a disorder specific to the elderly population with very specific characteristics and prognosis (1, 2). In recent years, depressive disorders have been considered a public health concern due to its high prevalence and wide range of disabilities (3–6) Particularly, evidence from research have reported an association between depressive disorders, cognitive impairment, dementia, and suicide in elderly people. Moreover, research findings support the relationship between depressive disorders, low functionality, and poor quality of life within this population (2, 3, 7–9).

Incidence of late-life depression varies across countries. Rates often vary depending on the setting where this syndrome is evaluated. Djernes (10) has reported that in Canadian communities, the recurrence rate of depression in elderly people was <1%, which contrasts from the 42% reported among American nursing home patients. In a survey administered in both urban and rural locations throughout Peru, Mexico, and Venezuela (11), the prevalence of major depressive reported in older adults ranged from 26 to 31%. Lastly, the “Health, Wellbeing, and Aging” survey in Chile (12) found a prevalence of depression at 27% in older adults.

Depression among the geriatric population often goes undetected and undiagnosed. The main reason for this pertains to how dissimilar the clinical presentation is in the elderly population compared to the adult population (13–17). This implies that the elderly often do not meet criteria for a diagnosis of major depression. As a consequence, they often do not receive the appropriate or timely health treatment for their symptoms.

This is further complicated by the fact that older people diagnosed with depression usually do not use mental health services. According to the Global Action on Aging report (18), only half of the seniors population who are diagnosed with a mental illness receive treatment from health-care services (which is principally primary care), and only a fraction of those actually receive specific interventions from these services. Because older adults typically consult, assist, and prefer primary care; these settings are often the most convenient places to diagnosis and treat late-life depression. However, it is often the case that the health-care staff is not properly trained to treat this population.

On the other hand, there is consensus regarding the strategies to properly address late-life depression. According to researchers, first-line treatment for both mild and severe geriatric depression should be a combination of both antidepressants (especially ISRS) and psychotherapy (7, 17, 19) in order to be effective. Recent studies have reported improvement rates with antidepressants to be about 33% responses to treatment varied between 44 and 48% (20, 21). Nevertheless, even though medical treatment contributes significantly to the treatment of depression, only 30–40% of depressed older adults actually adhere to their medication (18).

Aside from psychopharmacological treatments, psychological treatments have also proven. In a meta-analysis by Cuijpers et al. (22), results indicated that having at least 6 months of psychotherapy were effective in reducing late-life depression. Specifically, some useful approaches to psychotherapy include cognitive behavioral therapy, life review therapy, and problem-solving therapy.

The current implementations of these treatments are far from ideal. This is especially in low-and-middle-income countries (LMICs), where there exists a “gap of treatment” concerning mental health. This refers to the discrepancy between the amounts of people who need healthcare with those who actually receive care (23). The World Health Organization (WHO) has reported that the treatment gap involves 76–90% of adult population in developing countries. Considering the complex and unique characteristics of late-life depression, this gap might be even larger in elderly population.

Consequently, collaborative and community care models have been developed to bridge the gaps and to improve the quality of depression care for older people in high-income countries (HICs). These kinds of interventions have been effective in improving treatment adherence and depressive outcomes in HICs (24). These have been particularly constructive for minority populations and individuals living below poverty levels. As such, receiving valuable input and lessons from there members may prove useful for the implementation of future programs in contexts with limited resources.

Collaborative Care Models to Improve Primary Care in Treatment to Late-Life Depression

For over a decade, collaborative programs have been established in US, United Kingdom, Canada, and Australia. Considering the quality of the evidence reported, the main programs include: (a) IMPACT, (b) PROSPECT, (c) Program to Encourage Active, Rewarding Lives for Seniors (PEARLS), and (d) HEALTHY IDEAS. Overviews of these interventions are presented below.

Improving Mood Promoting Access to Collaborative Treatment (IMPACT Project)

Improving Mood Promoting Access to Collaborative Treatment is a collaborative and paced care program to late-life depression developed by Uñützer et al. (25). The main goal of this initiative was to improve depression treatment by supporting the use of antidepressant medications and/or providing a course of Problem-Solving Treatment for Primary Care (PST-PC).

The intervention integrates the following components: (1) psycho-education about late-life depression; (2) case management for 12 months conducted by a depression clinical specialist (DCS), psychologists, and nurses; (3) coordination with a regular primary care provider; (4) antidepressant management; and (4) regular PST-PC. The Hopkins Symptom Checklist (HSCL)-20 was used to measure the number of depression-free days within the 24-month follow-up (26).

Follow-up results from Unutzer et al.’s (26) randomized controlled trial (RCT) showed that the intervention group reported significantly less depression severity than the usual care group. At 12 months, the complete remission rate was estimated at 25% compared to 8.3% among the control group. Participants also reported better adherence to antidepressants, as well as an improvement in quality of life and treatment satisfaction.

Prevention of Suicide in Primary Care Elderly (PROSPECT)

PROSPECT consists of a multisite RCT, which tested the impact of a primary care-based intervention aimed at reducing major risk factors for suicide in late life. The project considered depression among the elderly as the principal risk factor for suicide (27). The trial was conducted in 20 primary care centers in urban, suburban, and rural areas in New York City, Philadelphia, and Pittsburgh (7). The intervention was based on a clinical algorithm for treating geriatric depression in a primary care setting.

Fifteen care managers were enrolled in this study, including social workers, nurses, and psychologists. They participated in weekly supervisions and monthly interpersonal therapy sessions. The care managers monitored areas such as treatment adherence, pharmacological side-effects, and providing follow-up care. Remission was defined as the first occurrence of achieving a score of <10 according to the Hamilton Depression Scale.

The main finding was a significant decrease of suicidal rates in the intervention group (29.4–16.5%) compared with usual care group (20.1–17.1%) (27, 28).

Program to Encourage Active, Rewarding Lives for Seniors

The goal of the PEARLS program was to simultaneously reduce symptoms of depression while improving the quality of life among the elderly with diagnoses of minor depression and dysthymia. The major components of PEARLS consisted of the inclusion of care managers and problem-solving treatment for primary care (PST-PC). Social, physical, and pleasant activities were also integrated into the program.

At the 6-month assessment, findings demonstrated more than a 50% reduction of in the HSCL-20 depression score for the intervention group (8%) compared to controls (54%). At the 12-month assessment, these results were maintained. Complete remission of depression symptoms was also superior in the intervention group in the follow-up (29).

Identifying Depression, Empowering Activities for Seniors (HEALTHY IDEAS)

Healthy Ideas is a program inspired and developed from IMPACT and PEARLS. It was implemented through a case-management intervention at three social-service agencies. The program was designed to detect and reduce depressive symptoms among older adults with chronic health conditions and functional limitations (30) by collaborating with available community-based services.

According to Casado et al. (31), Healthy IDEAS includes the following main components: (a) screening and assessment, (b) psycho-education, (c) referral and linkage, and (d) behavioral activation. This also includes at least three face-to-face visits and multiple telephone contacts during 3–6 months.

Efficacy of Healthy IDEAS was evaluated through a RCT, which showed a reduction of depression severity and pain, and an increase in activity levels (30). The trial also included an analysis of the interactions among participants, as well as feedback from key stakeholders, case managers, clients, program leaders, and coaches. Most case managers regarded the program as feasible to implement (31).

In sum, the interventions described above have reported promising results in decreasing the burden associated with late-life depression. There is solid evidence regarding the usefulness of approaches such as psycho-education and case management to treat the older population. It may also be possible to implement these “key strategies” in developing countries, taking into account previous successful experiences across communities with mental health models in LMICs (32). Therefore, the feasibility of these interventions will depend mostly on the existence of preceding mental health policies, plans, and programs.

The Experience of Chile

Launched in 2001, the Chilean Mental Health and Psychiatry Plans recommend the implementation of familiar and community mental health programs. As a result, several interventions concerning mental health promotion, prevention, treatment, and rehabilitation have been put into action in the last 15 years (33), including the introduction of a Program of Treatment for Depression in Primary Health Care (PTDPHC) in 2003 (34). This national strategy incorporated protocols to detect and treat depression for people over 15 years old in the national health-care system. This program relies on a national and integrated network between each levels of care into the health services (especially among first and second level of care). The approaches to treatment consist of psycho-education, counseling, psychotherapy and, depending on severity, pharmacology as well. This strategy is incorporated into the Regime of Explicit Health Guarantees (34) – one of the principal improvements of the Chilean Health Reform (32) – which offers access, quality, opportunity, and financial support to coverage a list of priority diseases including depression.

Initiatives such as the Older People National Health Program are being currently implemented with an emphasis on prevention of dysfunction among the elderly. The delivery of this program involves a screening exam to detect any conditions affecting functionality, as well as case-management delivery to support elders in their communities. Antidepressants (ISRSS) are prescribed as first line of treatment in conjunction with psychotherapy, counseling, and psycho-education.

The effectiveness of the Older People National Health Program has not yet been evaluated but has shown positive initial findings regarding the impact of the Depression National Primary Care Program. For instance, Alvarado and Rojas (35) have reported significant improvements in both depressive and anxious symptoms. However, these analyses did not report specific outcomes to older people with depression.

Some of the limitations found in this study were (a) a tendency for PHC physicians to underestimate the intensity of depressive symptoms; (b) the standard use of treatments according to the severity of the clinical profiles that are not tailored to specific populations; and (c) high rates of treatment dropout (35, 36).

Conclusion

We reviewed the most important collaborative care models to address late-life depression. All these programs have reported positive results in decreasing depression symptoms and improving adherence to treatment and health service satisfaction.

The feasibility of the implementation of these interventions will depend mostly on the foundation of the mental health community’s policies and plans. In this case, Chile becomes in a strong candidate to integrate a collaborative model to improve the elderly assistance. This could be also applied to countries such as Brazil or Panama (32).

The cost of the implementation has been identified as the major barrier of collaborative care models. However, even in settings with less health-care resources; the programs discussed here might provide valuable insights. For instance, the use of psycho-education and care managers for both late-life depression and comorbid primary care conditions are two among feasible strategies to transfer and include in LMICs (37). Further, we strongly recommend using the task-shifting model for delivering these treatments. This approach has an extensive trajectory in resource-poor contexts with extraordinary results in diminishing treatment gaps and enhancing quality of care (32). Consequently, health-care services through a task-shifting delivery would benefice to elderly people with depression in LMICs.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We want to thank to Constanza Villegas Cuevas for her support edition in the final version of this manuscript.

References

1. Dechent C. Depresión geriátrica y trastornos cognitivos [Spanish]. Rev Hosp Clin Univ Chile (2008) 19:339–46.

Google Scholar

2. Sarró-Maluquer M, Ferrer-Feliu A, Rando-Matos Y, Formiga F, Rojas-Farreras S. Depression in the elderly: prevalence and associated factors [Spanish]. Semergen (2013) 39(7):354–60. doi: 10.1016/j.semerg.2013.01.007

CrossRef Full Text | Google Scholar

3. Blazer D. Depression in late life: review and commentary. Geriatr Psychiatry (2009) 7(1):118–36 [Reprinted Depression in Late Life: Review and Commentary. Journal of Gerontology: Medical Sciences 2003]. doi:10.1176/foc.7.1.foc118

CrossRef Full Text | Google Scholar

4. Covinsky KE, Cenzer IS, Yaffe K, O’Brien S, Blazer DG. Dysphoria and anhedonia as risk factors for disability or death in older persons: implications for the assessment of geriatric depression. Am J Geriatr Psychiatry (2014) 22(6):606–13. doi:10.1016/j.jagp.2012.12.001

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

5. Im-Kim J-I, Choe M-A, Chae YR. Prevalence and predictors of geriatric depression in community-dwelling elderly. Asian Nurs Res (Korean Soc Nurs Sci) (2009) 3(3):121–9. doi:10.1016/S1976-1317(09)60023-2

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

6. Ruo B, Rumsfeld JS, Hlatky MA, Liu H, Browner WS, Whooley MA. Depressive symptoms and health-related quality of life: the heart and soul study. JAMA (2003) 290(2):215–21. doi:10.1001/jama.290.2.215

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

7. Alexopoulos G, Kelly RE Jr. Research advances in geriatric depression. World Psychiatry (2009) 8:140–9.

Google Scholar

8. Hall C, Reynolds C III. Review late-life depression in the primary care setting: challenges, collaborative care, and prevention. Maturitas (2014) 79(2):147–52. doi:10.1016/j.maturitas.2014.05.026

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

9. Peña-Solano DM, Herazo-Dilson MI, Calvo-Gómez JM. Depresión en ancianos. Rev Fac Med (2009) 57:347–55.

Google Scholar

10. Djernes JK. Prevalence and predictors of depression in populations of elderly: a review. Acta Psychiatr Scand (2006) 113:372–87. doi:10.1111/j.1600-0447.2006.00770.x

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

11. Guerra M, Ferri CP, Sosa AL, Salas A, Gaona C, Gonzales V, et al. Late-life depression in Peru, Mexico and Venezuela: the 10/66 population-based study. Br J Psychiatry (2009) 195(6):510–5. doi:10.1192/bjp.bp.109.064055

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

12. Albala C, García C, Marin PP, Vio del Rio F, Lera L. Encuesta Salud, Bienestar y Envejecimiento (SABE) en Santiago de Chile. Santiago: Instituto de Nutrición y Tecnología de los Alimentos, Universidad de Chile (Junio) (Spanish) (2011).

Google Scholar

13. Alexopoulos G, Borson S, Benoit D, Jason M, Olin J, Oslin D. Assessment of late life depression. Biol Psychiatry (2002) 52:164–74. doi:10.1016/S0006-3223(02)01381-1

CrossRef Full Text | Google Scholar

14. Glover J, Srinivasan S. Assessment of the person with late-life depression. Psychiatr Clin North Am (2013) 36(4):545–60. doi:10.1016/j.psc.2013.08.004

CrossRef Full Text | Google Scholar

15. Hegeman JM, Kok RM, Van der Mast RC, Giltay EJ. Phenomenology of depression in older compared with younger adults: meta-analysis. Br J Psychiatry (2012) 200:275–81. doi:10.1192/bjp.bp.111.095950

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

16. Aziz R, Steffens DC. What are the causes of late-life depression? Psychiatr Clin N (2013) 36(4):497–516. doi:10.1016/j.psc.2013.08.001

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

17. Dines P, Hu W, Sajatovic M. Depression in later life: an overview of assessment and management. Psychiatr Danub (2014) 26(1):78–84.

Pubmed Abstract | Pubmed Full Text | Google Scholar

18. Administration on Aging. Older People and Mental Health: Issues and Opportunities. Washington, DC: Department of Health and Human Services, Administration on Aging (2001).

Google Scholar

19. World Health Organization. mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in Non-Specialized Health Settings. Department of Mental Health and Substance Abuse World Health Organization (2010).

Google Scholar

20. Katona C, Bindmanb D, Katonaba CP. Division Antidepressants for older people: what can we learn from the current evidence base? Maturitas (2014) 79(2):174–8. doi:10.1016/j.maturitas.2014.05.016

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

21. Kok RM, Nolen WA, Heeren TJ. Efficacy of treatment in older depressed patients: a systematic review and meta-analysis of double-blind randomized controlled trials with antidepressants. J Aff Disord (2012) 10(141):103–15. doi:10.1016/j.jad.2012.02.036

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

22. Cuijpers P, Karyotakia E, Pot AM, Parke M, Reynolds CF III. Managing depression in older age: psychological interventions. Maturitas (2014) 79(2):160–9. doi:10.1016/j.maturitas.2014.05.027

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

23. Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. Lancet (2007) 370(9590):878–89. doi:10.1016/S0140-6736(07)61239-2

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

24. Katon W, Lin E, Von Korff M, Ciechanowski P, Ludman E, Young B, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med (2010) 363:2611–20. doi:10.1056/NEJMoa1003955

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

25. Uñützer J, Katon W, Williams J, Callahan C, Harpole L, Hunkeler E, et al. Improving primary care for depression in late life. The design of a multicenter randomized trial. Med Care (2001) 39(8):785–99. doi:10.1097/00005650-200108000-00005

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

26. Unützer J, Tang L, Oishi S, Katon W, Williams JW, Hunkeler E, et al. Reducing suicidal ideation in depressed older primary care patients. J Am Geriatr Soc (2006) 54:1550–6. doi:10.1111/j.1532-5415.2006.00882.x

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

27. Bruce ML, Ten Have TR, Reynolds CF III, Katz I, Schulberg H, Mulsant B, et al. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA (2004) 291(9):1081–91. doi:10.1001/jama.291.9.1081

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

28. George S, Alexopoulos G, Katz I, Bruce M, Heo M, Ten Have T, et al. Remission in depressed geriatric primary care patients: a report from the PROSPECT study. Am J Psychiatry (2005) 162(4):718–24. doi:10.1176/appi.ajp.162.4.718

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

29. Ciechanowski P, Wagner E, Schmaling K, Schwartz S, Williams B, Dierhr P, et al. Community-integrated home-based depression treatment in older adults: a randomized controlled trial. JAMA (2004) 291(13):1569–77. doi:10.1001/jama.291.13.1569

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

30. Quijano LM, Stanley MA, Petersen NJ, Casado BL, Steinberg EH, Cully J, et al. Healthy IDEAS: a depression intervention delivered by community-based case managers serving older adults. J Appl Gerontol (2007) 26:139–56. doi:10.1177/0733464807299354

CrossRef Full Text | Google Scholar

31. Casado BL, Quijano LM, Stanley M, Cully J, Steinberg E, Wilson NL. Healthy IDEAS: implementation of a depression program through community-based case management. Gerontol Soc Am (2008) 48(6):828–38. doi:10.1093/geront/48.6.828

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

32. Alvarado R, Minoletti A, Valencia E, Rojas G, Susser E. The need for new models of care for people with severe mental illness in low- and middle-income countries. In: Thornicroft G, Ruggeri M, Goldberg D, editors. Improving Mental Health Care: The Global Challenge. Chichester: John Wiley & Sons (2013). p. 78–95.

Google Scholar

33. Ministerio de Salud, Chile. Plan Nacional de Salud Mental y Psiquiatría (2000) [Spanish].

Google Scholar

34. Alvarado R, Rojas G, Minoletti A, Alvarado F, Domínguez C. Depression program in primary health care: the Chilean experience. Int J Ment Health (2012) 41(1):38–47. doi:10.2753/IMH0020-7411410103

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

35. Alvarado R, Rojas G. Evaluation of the program for detection and treatment of depression in Chilean primary health care centers. Rev Med Chile (2011) 139(5):592–9. doi:10.4067/S0034-98872011000500005

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

36. Alvarado R, Vega J, Sanhueza G, Muñoz MG. Evaluation of the program for depression detection, diagnosis, and comprehensive treatment in primary care in Chile. Rev Panam Salud Publica (2005) 18(4/5):278–86. doi:10.1590/S1020-49892005000900008

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

37. Katon W. Collaborative depression care models from development to dissemination. Am J Prev Med (2012) 42(5):550–2. doi:10.1016/j.amepre.2012.01.017

CrossRef Full Text | Google Scholar