Dysthymia

It is well known that elderly persons are subject to major depression, albeit at a lower rate than younger persons. Elderly persons also may have minor depression or dysthymia, which might be amenable to treatment with medication or behavioral intervention. Ciechanowski and colleagues examined whether an intervention focused on problem solving would be more effective than usual care in the treatment of dysthymia and depression in elderly patients.

Persons 60 years and older who received senior services or lived in senior housing projects were screened for depression, as were self-referred persons. They were randomized to usual care or a program used to treat dysthymia and minor depression, the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS), adapted to a home-based problem-solving treatment. The program involved eight 50-minute in-home sessions given over 19 weeks, with evaluation at baseline, six months, and 12 months. In patients with insufficient improvement, the primary care physician was contacted to evaluate the patient for antidepressant use and previously unidentified risk factors for depression. Outcomes included rates of depression (as assessed by a validated scale); health-related quality of life, including physical, emotional, and social function; health care utilization; and antidepressant use.

Most patients were low-income women. Intervention patients received a mean of 6.6 visits. There were no differences in antidepressant use between the groups at any time during the study. Significant differences favoring the intervention group were noted in depression scores, improvement of more than 50 percent, and remission. The scores in all of these categories dropped, but not significantly, between six and 12 months.

The PEARLS intervention resulted in greater remission of depression at 12 months in study subjects compared with the usual-care group (36 versus 12 percent). Depression severity also was decreased in patients who received the intervention. Functional and emotional well-being improved in the intervention group at 12 months. The lack of improvement in social and physical well-being may have been a result of physical and practical barriers in the target population. In addressing the nonsignificant decline in improvement in depression between six and 12 months in the intervention group, the authors speculate that better overall improvement may have been obtained with ongoing intervention sessions. In spite of the modest gains, this study demonstrates a successful, community-based, nonpharmacologic intervention for depression.

CAROLINE WELLBERY, M.D.

Ciechanowski P, et al. Community-integrated home-based depression treatment in older adults. A randomized controlled trial. JAMA April 7, 2004;291:1569-77.

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