Treatment for Depressed Primary Care Patients
Treatment for Depressed Primary Care Patients
This research study develop a collaborative depression care management model (C-DCM) that
 encourages collaboration between primary care physicians (PCPs) and trained social workers
 employed by community-based, public and nonprofit mental health clinics.
Major depression affects 5%-9% of older primary care patients, is often chronic or recurrent
 and disabling, and leads to frequent use of medical services. Most depressed elders are
 treated by primary care physicians (PCPs) and prior research has shown that collaboration
 between primary care physicians and depression care managers is effective in treating
 depression. The challenge has been in securing third-party reimbursement for such services.

 This research study will address this barrier by developing a collaborative depression care
 management model (C-DCM) that encourages collaboration between PCPs and trained social
 workers employed by community-based, public and nonprofit mental health clinics. In addition
 to developing C-DCM, a total of 112 primary care outpatients will participate in this study
 to test whether C-DCM is more effective than the standard of care in decreasing the severity
 of depression and disability experienced by older adults. Each subject will be randomized
 into either Usual Care or C-DCM. All subjects will be assessed at Baseline and at 2 and 4
 months while the C-DCM subjects will also meet with social worker depression case managers
 bi-weekly over four months. If shown effective, C-DCM may bring to bear an available, yet
 untapped resource in the care of depressed elders.
Inclusion Criteria:

 -  Age 60 years and older: This study focuses on the clinical complexities of late-life
 depression and its treatment. Family Services of Westchester (our partner community
 mental health agency) offers geriatric mental health counseling services to adults age
 60 and older.

 -  Diagnosis of unipolar major depression

 -  MADRS score >=18: Depression of such severity in primary care patients requires
 treatment.

 -  CANE score >0: Reflects the presence of at least one unmet need in the domains of
 housing, self-care, safety, finances, benefits, legal matters, transportation, etc.
 and thus need for social services.

 -  Capacity to provide written consent for both research assessment and depression care
 management: PCPs will be asked to clinically evaluate prospective participants'
 capacity to consent and document it in their medical record.

 -  Working knowledge of English: Command in English sufficient for comprehending
 questionnaires of the study and/or for understanding the DCM therapists. English does
 not have to be the subject's first language.

 Exclusion Criteria:

 -  Psychotic depression: This will be determined by the Structured Clinical Interview for
 DSM Disorders(SCID) assessment; presence of delusions and or hallucinations. This is a
 severe disorder typically referred for treatment to mental health specialists.

 -  Active suicidal ideation: This will be determined by the SCID and MADRS assessments.
 Older patients at these levels of risk for self-harm typically are referred to mental
 health specialists.

 -  Antisocial personality by Diagnostic and Statistical Manual of Mental Disorders
 (DSM)IV: This disorder will possibly interfere with adherence to research procedures
 and treatment.

 -  Significant Cognitive Impairment (MMSE score <24) or clinical diagnosis of dementia by
 DSM-IV: These conditions may limit the patient's ability to participate in treatment
 and require social service interventions exceeding those available through the
 proposed depression care management models.

 -  Current participation in specialist psychiatric care: Such patients will require the
 development of collaborative arrangements for depression care management which differ
 from those being tested in this study.

 -  Acute or severe medical illness: i.e., delirium, metastatic cancer, decompensated
 cardiac, liver or kidney failure, major surgery, stroke or myocardial infarction
 during the three months prior to entry; or drugs often causing depression, e.g.,
 steroids, reserpine, alpha-methyl-dopa, tamoxifen, vincristine.