title: Clinical Case Management versus Case Management with Problem-Solving Therapy in Low-Income, Disabled Elders with Major Depression: A Randomized Clinical Trial.
abstract: OBJECTIVE
  To test the hypotheses that (1) clinical case management integrated with problem-solving therapy (CM-PST) is more effective than clinical case management alone (CM) in reducing depressive symptoms of depressed, disabled, impoverished patients and that (2) development of problem-solving skills mediates improvement of depression.
  
  
  METHODS
  This randomized clinical trial with a parallel design allocated participants to CM or CM-PST at 1:1 ratio. Raters were blind to patients' assignments. Two hundred seventy-one individuals were screened and 171 were randomized to 12 weekly sessions of either CM or CM-PST. Participants were at least 60 years old with major depression measured with the 24-item Hamilton Depression Rating Scale (HAM-D), had at least one disability, were eligible for home-based meals services, and had income no more than 30% of their counties' median.
  
  
  RESULTS
  CM and CM-PST led to similar declines in HAM-D over 12 weeks (t = 0.37, df = 547, p = 0.71); CM was noninferior to CM-PST. The entire study group (CM plus CM-PST) had a 9.6-point decline in HAM-D (t = 18.7, df = 547, p <0.0001). The response (42.5% versus 33.3%) and remission (37.9% versus 31.0%) rates were similar (χ(2) = 1.5, df = 1, p = 0.22 and χ(2) = 0.9, df = 1, p = 0.34, respectively). Development of problem-solving skills did not mediate treatment outcomes. There was no significant increase in depression between the end of interventions and 12 weeks later (0.7 HAM-D point increase) (t = 1.36, df = 719, p = 0.17).
  
  
  CONCLUSIONS
  Organizations offering CM are available across the nation. With training in CM, their social workers can serve the many depressed, disabled, low-income patients, most of whom have poor response to antidepressants even when combined with psychotherapy.
authors: Department of Psychiatry, Weill Cornell Medical College, White Plains, NY. Electronic address: gsalexop@med.cornell.edu.
authors: George S
authors: GS
authors: Alexopoulos
authors: Department of Psychiatry, Weill Cornell Medical College, White Plains, NY.
authors: Patrick J
authors: PJ
authors: Raue
authors: Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA.
authors: Charles
authors: C
authors: McCulloch
authors: Department of Psychiatry, Weill Cornell Medical College, White Plains, NY.
authors: Dora
authors: D
authors: Kanellopoulos
authors: Department of Psychiatry, Weill Cornell Medical College, White Plains, NY.
authors: Joanna K
authors: JK
authors: Seirup
authors: Department of Psychiatry, Weill Cornell Medical College, White Plains, NY.
authors: Jo Anne
authors: JA
authors: Sirey
authors: Department of Public Health, Weill Cornell Medical College, White Plains, NY.
authors: Samprit
authors: S
authors: Banerjee
authors: Department of Psychiatry, Weill Cornell Medical College, White Plains, NY.
authors: Dimitris N
authors: DN
authors: Kiosses
authors: Department of Psychiatry, University of California San Francisco, San Francisco, CA.
authors: Patricia A
authors: PA
authors: Areán
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000928:Antidepressive Agents / Q000627:therapeutic use*; D019090:Case Management; D003865:Major Depressive Disorder / Q000628:therapy*; D006233:Persons with Disabilities / Q000534:rehabilitation*; D005260:Female; D006801:Humans; D008297:Male; D011203:Poverty; D011340:Problem Solving; D011569:Psychiatric Status Rating Scales; D011613:Psychotherapy / Q000379:methods*; D016896:Treatment Outcome
chemical_list: D000928:Antidepressive Agents
keywords: Case management; late-life depression; low income