Organization
Policy or recommendations
References
Centers for Medicare and Medicaid Services
Medicare Part B covers annual depression screening of up to 15 min in primary care settings with staff-assisted depression resources that will ensure proper diagnosis, treatment, and follow-up
[12]
US Preventive Services Task Force
Recommends depression screening in adults “when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.” When these supports are not in place, however, USPSTF does not recommend routine screening
[24]
American College of Physicians
Recommends annual 15 min depression screening for adults covered by Medicare. Suggested screening tool: PHQ (Patient Health Questionnaire)-9 or PHQ-2
[27]
Veterans Affairs Administration and Department of Defense
Issued joint clinical practice guideline (CPG) for the management of major depressive disorder. VA/DoD definition of a CPG: recommendations for the performance or exclusion of specific procedures or services derived through a rigorous methodological approach that includes determination of appropriate criteria such as effectiveness, efficacy, population benefit, or patient satisfaction; literature review to determine the strength of the evidence in relation to these criteria. CPG recommends PHQ-2 and PHQ-9 as screening tools and provides guidance for the use and interpretation of scores
[26]
American Geriatrics Society
Recommends using PHQ-2 for initial depression screening in older adults; if results are positive, a follow-up screening with either the PHQ-9 or GDS (Geriatric Depression Scale)-15 should be carried out
[23]
American College of Preventive Medicine
States that PCPs should follow USPSTF recommendations for screening in primary care and also maintains that depression care resources should be in place in all primary care practices
[25]
Since depression poses a considerable burden to countries’ healthcare systems and economies, many experts recommend a strategy of routine depression screening in at-risk populations to alleviate some of the morbidity and economic costs attributed to the disease [13, 23]. Furthermore, government agencies and professional organizations have issued recent guidelines or recommendations pertaining to screening of depression, particularly in the setting of primary care. Many of these guidelines and recommendations are highly relevant to screening among older adults.
The US Preventive Services Task Force (USPSTF) endorses screening in primary care practices where “staff-assisted depression care supports” to ensure accurate diagnosis and appropriate follow-up care are present [24], and many agencies and organizations in the United States have instituted policies in line with this recommendation. In order for routine depression screening in the elderly to be cost-effective, however, the appropriate follow-up measures must be taken with those who screen positive, including a diagnostic interview and/or referral to a mental health professional [23, 25]. For example, subsequent steps may include initiation of psychotherapy or antidepressant treatment. Thus, one reason that the USPSTF does not recommend screening for depression in settings where proper mental health resources do not exist is that the evidence suggests that outcomes are unlikely to improve without effective follow-up care [23]. The Centers for Medicare and Medicaid Services (CMS) have mandated that annual screening for depression in primary care settings be covered by Medicare Part B [12]. However, as per the USPSTF suggestion, Medicare will only cover the screening when the appropriate supports for proper diagnosis and treatment are available. These depression care resources may include staff that can provide either case management or referrals to mental health treatment, collaboration between primary care physicians and mental health specialists, and patient education [12]. In addition, the VA and Department of Defense jointly issued a clinical practice guideline pertaining to management of depression in primary care; among the recommendations is the use of screening tools—the two-item Patient Health Questionnaire (PHQ-2) and nine-item PHQ (PHQ-9)—and the CPG documents offer providers guidance on the interpretation of PHQ scores [26]. Depression screening is provided for patients in Veterans Affairs (VA) Medical Centers, where electronic medical record systems have been designed to alert staff when screenings should be carried out [11]. The American College of Physicians and the American College of Preventive Medicine also support the recommendations of the USPSTF [25, 27], and the American Geriatrics Society also recommends the PHQ-2 for initial screening and either PHQ-9 or 15-item Geriatric Depression Scale for follow-up screening in older adults [23].
9.3.2 Late-Life Depression Screening Tools
Several of the screening instruments that are used to detect depression in adult patients of all ages are effective at identifying late-life depression as well. Many validation studies found that both the 10- and 20-item Center for Epidemiologic Studies Depression Scales (CES-D) had high sensitivity and specificity when screening for depression in older adults [2, 28, 29]. In one study, Lyness and colleagues [28] compared the performance of the CES-D to the GDS and confirmed that both scales are efficient methods of detecting major depression in elderly patients. The Geriatric Depression Scale (GDS) was developed to recognize depression in older individuals and is a common method of screening for depression in this population [30]. While the efficacy of the GDS-30 and GDS-15 has been demonstrated by numerous validation studies, the sensitivity and specificity of some of the shorter versions of this scale were also found to be high [30–32]. The two- and nine-item versions of the PHQ are both frequently used to screen for depressive symptoms in primary care settings and are valid tools for detecting late-life depression [23, 33, 34]. Other depression screening instruments that have been used in older populations include the Hamilton Rating Scale for Depression, the Montgomery-Asberg Depression Rating Scale, and the Cornell Scale for Depression in Dementia [35, 36].
9.4 Examples and Cost-Effectiveness of Primary Prevention of Late-Life Depression
9.4.1 Studies of Cost-Benefit Analysis of Treatments to Prevent First Case or First Onset of Late-Life Depression
In order to determine which interventions to prevent and treat depression should be provided to those who screen positive for depressive symptoms and to high-risk populations in general, cost-effectiveness analyses must be completed for a variety of different treatments and preventive measures. The costs and benefits of depression screening in primary care were evaluated using Markov models in two studies, one of which included a brief psychological intervention for positive screens [13, 37]. Results from that study showed the combination of screening and psychotherapy to be cost-effective; from the payer perspective, the incremental cost-effectiveness ratio (ICER) was €1,403 per DALY prevented, and when the total economic costs of depression were considered, the intervention was found to be cost saving [13]. In the second study [37], cost-utility analyses estimated the cost of annual depression screening in a hypothetical cohort of primary care patients to be $192,444 per quality-adjusted life year (QALY) gained. The cost-utility ratio of one-time screening was found to be substantially lower at $32,053 per QALY, however, indicating that it is more likely to be considered a cost-effective strategy than the annual intervention.
Romeo and colleagues [20] evaluated a psychological intervention that was provided to elderly patients who had recently undergone hip surgery and did not find it to be a cost-effective option for depression prevention compared with usual care. Participants in the intervention group received six sessions of cognitive behavior therapy, and there was no significant difference in the number of cases of incident depression in the treatment versus control groups after the 6-week period (p = 0.10). The cost of the CBT intervention was not significantly different than that of usual care, but as the treatment did not prevent depression or lead to better outcomes on the Hospital Anxiety and Depression Scale (HADS), an economic evaluation showed that it was not a cost-effective alternative [20].
Other preventive measures that have been analyzed for cost-effectiveness include stepped care interventions, which may involve steps such as bibliotherapy, life review, problem-solving treatment, and antidepressant medications [38, 39]. One study examined the costs and outcomes of a stepped care program in nursing homes and found that after 10 months, the incidence of depression in the treatment group was not significantly lower than that of the control group (0.09 vs. 0.17, p > 0.05) [39]. Though average total costs were €838 higher in the intervention group than the control group, this difference was also not significant. Economic analyses determined that the excess cost of preventing depression in each additional patient in the stepped care group was €10,293; the high treatment costs combined with lack of improvement in outcomes meant that the intervention had a very low probability of being cost-effective. Results from an RCT in which a stepped care program was provided to adults aged 75 and older with subthreshold depression/anxiety were more promising, as the intervention significantly reduced the 12-month incidence of depression and anxiety disorders compared with routine care (RR = 0.49, 95 % CI: 0.24–0.98) [38]. Since the ICER was calculated to be €4,367 per disorder-free year, the stepped care program is more likely to be cost-effective than usual care if decision makers are willing to pay at least €5,000 per year of depression/anxiety averted.
The costs and benefits of an exercise intervention to prevent depression in nursing homes were evaluated by Underwood and colleagues [40], who found no significant differences in the odds of depression or severity of depressive symptoms after 12 months in the active versus control groups. Since the mean difference in QALYs between the two groups was −0.0014 (95 % CI: −0.0728 to 0.0699) and costs were higher, though not significantly, in the intervention group by £374 (95 % CI: −£655 to £1,404), the exercise program was not cost-effective. Smit and colleagues [41] asserted that preventive interventions are likely to be cost-effective if only high-risk individuals are targeted, and while this was not the case for the two studies mentioned above that involved nursing home residents, it was true when the study population consisted of elderly persons with subthreshold depression [38–40].
9.4.2 Summary Table of Studies and Results (Table 9.2)
Table 9.2
Cost-benefit analyses of primary prevention of late-life depression
Study/authors | Year | Study design | Study population | N | Intervention/exposure | Evaluation tool | Author findings |
|---|---|---|---|---|---|---|---|
van den Berg et al. (Bilthoven, the Netherlands) | 2011 | Markov model | Hypothetical cohort of people diagnosed with subthreshold depression | Opportunistic screening and minimal contact psychotherapy | ICER, DALYs | From the payer perspective, the ICER was €1,400 per DALY, and when taking nonmedical costs into consideration, the intervention was cost saving. If willing to pay €20,000 per DALY avoided, the intervention is 80 % likely to be cost-effective | |
Bosmans et al. (Amsterdam, the Netherlands) | 2014 | RCT | Residents of elderly care homes (mean age = 84) with subthreshold depression | 185 | Stepped care prevention program including activity scheduling, life review, and visit to general practitioner in cycles of 3 months | MINI, CES-D | After 10 months of follow-up, the incidence of depression in the treatment group was lower but not significantly different than that of the control group (0.09 vs. 0.17, respectively). Average total costs were €838 higher in the intervention group than the control group, though this difference was also not significant. According to the ICER, preventing depression in one patient via the intervention would cost €10,293 more than usual care. The intervention was therefore not found to be a cost-effective alternative to usual care |
Valenstein et al. (Ann Arbor, MI) | 2001 | Markov model | Hypothetical cohort of 40-year-old primary care patients | Screening for depression via self-administered questionnaire: either opportunistic screening, one-time screening, or screening every 1, 2, 3, or 5 years | Direct and indirect costs, QALYs | The societal cost of annual screening versus no screening was estimated to be $192,444/QALY. One-time screening was found to be more cost-effective, at $32,053/QALY, compared to no screening. When considering direct screening and treatment costs only (payer perspective), the costs of annual and one-time screening versus no screening were $225,467/QALY and $45,298/QALY, respectively | |
Romeo et al. (London, UK) | 2011 | RCT | Elderly adults who have recently had hip surgery | 293 | For patients with GDS ≤ 6, 6 weeks of cognitive behavior therapy (CBT) for preventing depression, and for those with GDS > 6, 6 weeks of nurse-led intervention for treating depression | GDS, HADS | While the cost of treatment as usual was £201 higher than the nurse-led intervention, this difference was not significant. Those in the intervention group had a lower mean HADS score after 6 weeks than those in the control group (5.7 vs. 7.8), though this difference was also not significant. In the CBT versus control group depression prevention study, no significant difference in costs or depression score was found. CBT was therefore not found to be a cost-effective preventive intervention |
Van’t Veer-Tazelaar et al. (Amsterdam, the Netherlands) | 2010 | RCT | Elderly adults ≥75 with subthreshold depression or anxiety | 170 | Stepped care preventive intervention (including bibliotherapy, problem-solving treatment, screening, medication) in cycles of 3 months | MINI/DSM-IV, CES-D | The intervention was more costly than usual care (incremental cost = €532). It was effective in significantly reducing the 12-month incidence of depression and anxiety disorders, however (RR = 0.49, 95 % CI = 0.24–0.98). The incremental cost-effectiveness ratio was calculated to be €4,367 for a disorder-free year. The stepped care intervention appears to be a cost-effective alternative to routine care if willing to pay €5,000 per depression/anxiety-free year |
Smit et al. (Utrecht, the Netherlands) | 2006 | Cohort | Community residents aged 55–85 | 2,200 | Risk factors for depression (small social network, chronic diseases, depressive symptoms) | CES-D | Risk factors that significantly predicted incident depression were chronic diseases, depressive symptoms, functional limitations, and female sex (IRRs = 1.55, 2.09, 1.52, and 1.79, respectively). Targeting those in the community who are exposed to a combination of these risk factors for inclusion in preventive interventions is likely to be cost-effective, as only a small but high-risk portion of the population will be receiving the intervention. As the excess costs of major/minor depression have been computed to be $1,045 per person per half year, the costs of an intervention would ideally not exceed $1,045 per avoided case |
Underwood et al. (Coventry, UK) | 2013 | RCT | Residents of elderly care homes ≥65 | 1,054 | “Whole-home” intervention w/ training for staff and physiotherapist-led exercise group 2×/week versus depression awareness training program for staff (control) | GDS-15, EQ-5D | 12 months after randomization, no significant difference between the groups was found in either the severity of depressive symptoms (according to GDS-15) or odds of being depressed. Cost of the exercise intervention was £374/person and mean difference in quality-adjusted life years was −0.0014 (95 % CI −0.0728 to 0.0699), meaning that the exercise intervention was more costly but not more effective than the control intervention |
9.5 Examples and Cost-Effectiveness of Secondary Prevention of Late-Life Depression
9.5.1 Studies of Cost-Benefit Analysis of Treatments to Prevent Recurrence of Late-Life Depression or Worsening of Depression in People Already Diagnosed with Depression
Depression care may have a greater probability of being cost-effective if it is focused on reducing depressive symptoms in older adults that have screened positive for them or others who have an elevated chance of developing depression, as only a small but high-risk portion of the population will then be receiving the treatment [41]. Economic evaluation of a problem-solving therapy intervention in primary care patients with mental health problems showed that PST was cost-effective, even though the average change in HADS scores in the treatment group was not significantly different than that of the usual care group after 9 months of follow-up (mean difference = −0.2; 95 % CI = −3.7, 3.2) [42]. The average total costs of those receiving PST were lower, however, because of the high indirect costs of depression in the control group. Knapp and colleagues [43] found that another psychological intervention, which was provided to family caregivers of people with dementia, was more effective at reducing depressive symptoms and not significantly more costly than usual care. The study participants who received eight sessions of a manual-based coping strategy program in addition to routine care had lower HADS scores (mean difference = −1.79; 95 % CI = −3.32 to −0.33) and more QALYs (mean difference = 0.03; 95 % CI = −0.01 to 0.08) than control participants over the 8-month follow-up period. Since the costs of the intervention were not significantly higher than the usual treatment, there is a high likelihood of the manual-based coping strategy program being cost-effective.
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