Depression in older primary care patients is a common and serious problem. Studies have shown that mood disorders such as major depression, dysthymia and minor depression increase mortality rates in senior citizens. In addition, these disorders have been found to exacerbate disability in medical patients over the age of 60. When the strains of medical illnesses are coupled with the stressors of poverty, coping with daily living becomes more problematic and further contributes to depression in older adults. Psychosocial therapies, such as cognitive-behavioral therapy, and clinical case management interventions may help to alleviate stress and depression in low-income and elderly primary care patients. Unfortunately, research investigating therapies aimed at treating depression in this population is seriously lacking. The purpose of this study is to compare the relative efficacy of cognitive-behavioral group therapy alone (CBGT), clinical case management alone (CCM), and CBGT coupled with CCM (CBGT+CCM) as treatments for depression in low-income primary care patients over the age of sixty. The study design is as follows: After referral from primary care physicians are made, those patients who meet criteria for either major or minor depression will be randomized by diagnostic strata to receive: 1) six months of cognitive-behavioral group therapy, 2) six months of clinical case management, or 3) six months of cognitive- behavioral group therapy augmented with six months of clinical case management. In the third condition, the clinical case management will be initiated and run concurrently with the group therapy. Evaluations of all outcome measures will take place one week before treatment starts, immediately after treatment ends, 6 months posttreatment, and 12 months post treatment. Outcome variables will include I) level of depression 2) quality of life, 3) medical symptoms and medical impact on daily functioning, 4) problem resolution, 5) psychiatric, medical and social service use and linkage, 6) life satisfaction and 7) treatment skills acquisition. Treatment compliance, attendance and attrition will also be analyzed. In addition, monthly post-treatment telephone assessments will be conducted to assess depression levels, medical and social service use and treatment skills generalization. The main hypotheses are that depression levels will decrease from baseline in all three treatments, but that group therapy augmented with clinical case management will result in further decreases in depression and social stress and will prevent relapse.
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