As a major public health issue in China and worldwide, late life depression is associated with physical limitations, greater functional impairment, increased utilization and cost of health care, and suicide. Like other chronic diseases in elders such as hypertension and diabetes, depression is a chronic disease that the new National Health Policy of China (2009 released) indicates should be managed in primary care settings. Collaborative care, linking primary and mental health specialty care, has been shown to be effective for the treatment of late life depression in primary care settings in Western countries. Based on chronic disease management theory and the collaborative care model (CCM), we propose to test a Depression Care Management (DCM) intervention, which includes treatment guidelines (TG) to support primary care physicians'(PCPs) management of depression in their older patients;primary care nurses as care managers (CMs) to monitor the progress of treatment, support patient's adherence, educate patients/family and facilitate communication between providers;and psychiatrists to provide consultation and supervision of care managers. Using a randomized controlled design, we will examine whether the DCM is an effective treatment for patients with late life depression in urban China.
Our specific aims are: (1) to determine whether the DCM intervention results in improved outcomes compared with CAU at both the provider (e.g., greater adherence to quality indicators) and patient levels (e.g., greater reduction in depressive symptoms);and (2) to compare DCM with CAU with regard to a range of outcomes in other pertinent domains, both at the provider (e.g., improvements in knowledge/attitudes) and patient (e.g., functioning, satisfaction) levels. The study will take place in 16 primary care clinics (PCCs) randomly assigned to deliver either DCM or CAU (8 clinics each) to 320 patients (agede60 years) with major depression (20/clinic;n=160 in each treatment condition). In the DCM arm, PCPs will prescribe 16 weeks of antidepressant medication according to the TG protocol. CMs monitor the progress of treatment and side effects, educate patients/family, and facilitate communication between providers;psychiatrists will provide weekly group psychiatric consultation and CM supervision. Patients in both DCM and CAU arms will be assessed by clinical research coordinators at baseline, 4, 8, 12, 18, and 24 months. HDRS, MMSE, CAS, SF-12, Treatment Stigma and the Client Satisfaction Questionnaire will be used to assess patients'outcomes;and clinic practices, attitudes/knowledge, and satisfaction will be providers'outcomes. The weighted generalized estimating equations (WGEE) and generalized linear mixed-effects model (GLMM) will be used to analyze the longitudinal data. This proposed project would increase our understanding of the effectiveness of the CCM for late life depression in Chinese primary care settings, and lay the groundwork for future R01 proposals.
Depression in late life is a global public health problem, and particularly under-detected and undertreated in China, with research suggesting that over 90% of patients in China have not been diagnosed or treated. The National Health Care Policy of China has designated depression as a public health priority and proposes that depression be managed in primary care settings. The proposed study tests the effectiveness of depression care management in Chinese primary care settings as one route to addressing the public health burden of late life depression.
