title: Multimorbidity, Depression, and Mortality in Primary Care: Randomized Clinical Trial of an Evidence-Based Depression Care Management Program on Mortality Risk.
abstract: BACKGROUND
  Two-thirds of older adults have two or more medical conditions that often take precedence over depression in primary care.
  
  
  OBJECTIVE
  We evaluated whether evidence-based depression care management would improve the long-term mortality risk among older adults with increasing levels of medical comorbidity.
  
  
  METHODS
  Longitudinal analyses of the practice-randomized Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT). Twenty primary care practices randomized to intervention or usual care.
  
  
  METHODS
  The sample included 1204 older primary care patients completing the Charlson Comorbidity Index (CCI) and other interview questions at baseline.
  
  
  METHODS
  For 2 years, a depression care manager worked with primary care physicians to provide algorithm-based care for depression, offering psychotherapy, increasing the antidepressant dose if indicated, and monitoring symptoms, medication adverse effects, and treatment adherence.
  
  
  METHODS
  Depression status based on clinical interview, CCI to evaluate medical comorbidity, and vital status at 8 years (National Death Index).
  
  
  RESULTS
  In the usual care condition, patients with the highest levels of medical comorbidity and depression were at increased risk of mortality over the course of the follow-up compared to depressed patients with minimal medical comorbidity [hazard ratio 3.02 (95% CI, 1.32 to 8.72)]. In contrast, in intervention practices, patients with the highest level of medical comorbidity and depression compared to depressed patients with minimal medical comorbidity were not at significantly increased risk [hazard ratio 1.73 (95% CI, 0.86 to 3.96)]. Nondepressed patients in intervention and usual care practices had similar mortality risk.
  
  
  CONCLUSIONS
  Depression management mitigated the combined effect of multimorbidity and depression on mortality. Depression management should be integral to optimal patient care, not a secondary focus.
authors.affiliation: Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, 624 North Broadway, Baltimore, MD, 21205, USA. jgallo2@jhu.edu.
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Gallo
authors.affiliation: Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, 624 North Broadway, Baltimore, MD, 21205, USA.
authors.forename: Seungyoung
authors.initials: S
authors.lastname: Hwang
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Jin Hui
authors.initials: JH
authors.lastname: Joo
authors.affiliation: Department of Family Medicine and Community Health, University of Pennsylvania Health System, Philadelphia, PA, USA.
authors.forename: Hillary R
authors.initials: HR
authors.lastname: Bogner
authors.affiliation: Department of Biostatistics and Clinical Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
authors.forename: Knashawn H
authors.initials: KH
authors.lastname: Morales
authors.affiliation: Department of Psychiatry, Weill Cornell Medical College, White Plains, NY, USA.
authors.forename: Martha L
authors.initials: ML
authors.lastname: Bruce
authors.affiliation: Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Charles F
authors.initials: CF
authors.lastname: Reynolds
mesh_terms: D000368:Aged; D018687:Antidepressive Agents, Second-Generation / Q000627:therapeutic use; D015283:Citalopram / Q000627:therapeutic use; D015897:Comorbidity; D003863:Depression / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D019468:Disease Management; D055317:Evidence-Based Practice / Q000379:methods* / Q000639:trends; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D011320:Primary Health Care / Q000379:methods* / Q000639:trends; D011613:Psychotherapy / Q000379:methods / Q000639:trends; D012307:Risk Factors; D013405:Suicide / Q000639:trends; D000092864:Suicide Prevention
chemical_list: D018687:Antidepressive Agents, Second-Generation; D015283:Citalopram