title: Effects of a stepped-care intervention programme among older subjects who screened positive for depressive symptoms in general practice: the PROMODE randomised controlled trial.
abstract: OBJECTIVE
  to determine (cost)-effectiveness of a stepped-care intervention programme among subjects ≥ 75 years who screened positive for depressive symptoms in general practice.
  
  
  METHODS
  the pragmatic cluster-randomised controlled trial with 12-month follow-up.
  
  
  METHODS
  sixty-seven Dutch general practices.
  
  
  METHODS
  two hundred and thirty-nine subjects ≥ 75 years screened positive for untreated depressive symptoms (15-item Geriatric Depression Scale ≥ 5).
  
  
  METHODS
  usual care (34 practices, 118 subjects) was compared with the stepped-care intervention (33 practices, 121 subjects) consisting of three steps: individual counselling; Coping with Depression course; and-if indicated-referral back to general practitioner to discuss further treatment. Measurements included severity of depressive symptoms [Montgomery-Åsberg Depression Rating Scale (MADRS)], quality of life, mortality and costs.
  
  
  RESULTS
  at baseline subjects mostly were mildly/moderately depressed. At 6 months MADRS scores had improved more in the usual care than the intervention group (-2.9 versus -1.1 points, P=0.032), but not at 12 months (-3.1 versus -4.6, P=0.084). No significant differences were found within two separate age groups (75-79 years and ≥ 80 years). In intervention practices, 83% accepted referral to the stepped-care programme, and 19% accepted course participation. The control group appeared to have received more psychological care.
  
  
  CONCLUSIONS
  among older subjects who screened positive for depressive symptoms, an offered stepped-care intervention programme was not (cost)-effective compared with usual care, possibly due to a low uptake of the course offer.
  
  
  BACKGROUND
  www.controlled-trials.com/ISRCTN 71142851v.
authors.affiliation: Department of Public Health and Primary Care,  Leiden University Medical Center, Leiden,  The  Netherlands.
authors.forename: Gerda M
authors.initials: GM
authors.lastname: van der Weele
authors.forename: Margot W M
authors.initials: MW
authors.lastname: de Waal
authors.forename: Wilbert B
authors.initials: WB
authors.lastname: van den Hout
authors.forename: Anton J M
authors.initials: AJ
authors.lastname: de Craen
authors.forename: Philip
authors.initials: P
authors.lastname: Spinhoven
authors.forename: Theo
authors.initials: T
authors.lastname: Stijnen
authors.forename: Willem J J
authors.initials: WJ
authors.lastname: Assendelft
authors.forename: Roos C
authors.initials: RC
authors.lastname: van der Mast
authors.forename: Jacobijn
authors.initials: J
authors.lastname: Gussekloo
mesh_terms: D000223:Adaptation, Psychological; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000375:Aging / Q000523:psychology*; D016000:Cluster Analysis; D003362:Cost-Benefit Analysis; D003376:Counseling; D003863:Depression / Q000175:diagnosis / Q000191:economics / Q000401:mortality / Q000523:psychology / Q000628:therapy*; D005260:Female; D058006:General Practice / Q000191:economics; D017048:Health Care Costs; D007722:Health Knowledge, Attitudes, Practice; D006299:Health Services for the Aged / Q000191:economics; D006792:House Calls; D006801:Humans; D008297:Male; D008605:Mental Health Services / Q000191:economics; D009042:Motivation; D009426:Netherlands; D010342:Patient Acceptance of Health Care; D010353:Patient Education as Topic; D016016:Proportional Hazards Models; D011569:Psychiatric Status Rating Scales; D012017:Referral and Consultation; D012720:Severity of Illness Index; D016896:Treatment Outcome