Multifaceted shared care intervention for late life depression in residential care: randomised controlled trialCommentary: Beyond the boundary for a randomised controlled trial?
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7211.676 (Published 11 September 1999) Cite this as: BMJ 1999;319:676
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
EDITOR – Llewellyn-Jones et al’s study of a multifaceted treatment
intervention for depressed elderly residential home residents is a welcome
addition to the literature on treatment of late life depression. It is
unfortunate that improvements in the chief outcome measure, the score on
the Geriatric Depression Scale (GDS), are very small. The authors appear
to overplay this outcome while failing to emphasise their biggest
contribution, which lies in their ambitious intervention.
In most trials of antidepressant interventions in older subjects,
recovery is defined as a reduction of at least 50% in the most commonly
used outcome measure, the Hamilton Depression Rating Scale. Their finding
of a mean fall of under 2 points on GDS (scored from 30) score seems
unlikely to represent a clinically meaningful outcome. This improvement
appears to gain its reported significance from the clustering of
depression scores at outset of treatment just above the cutoff score for
depression of 10. Potential reasons for the poor result are many and have
been partly covered in the accompanying commentary by Deeks and Juszczak.
Their intervention represents an attempt to change the whole culture
surrounding depression in a large institution, from awareness through to
treatment. Long term residential care in the United Kingdom and many other
countries is now largely under private provision, so attempts by
psychiatric services to influence treatment of late life depression in
this setting are bound to be indirect. This will have to include the
fostering of a culture of recognition and treatability of depression, and
effective liaison with, and education of, caregivers.in the absence of
direct psychiatric responsibility for care. The authors’ description of
their intervention might be a blueprint of how to do this. I suspect that
the gains accruing from this, though intangible in terms of the study
outcomes, are great. I hope they disseminate their detailed methods
widely.
Bart Sheehan
clinical lecturer in old age psychiatry
University of Oxford,
Department of Psychiatry, Warneford Hospital,
Headington, Oxford OX3 7JX
1 Llewellyn-Jones RH, Balkie KA, Smithers H, Cohen J, Snowdon J,
Tennant CC. Multifaceted shared care intervention for late life depression
in residential care: randomised controlled trial. BMJ 1999;319:676-82 (11
September.)
2 Evans M, Hammond M, Wilson K, Lye M Copeland J. Placebo controlled
treatment trial of depression in elderly physically ill patients. Int J
Ger Psychiat 1997:12:817-824.
3 Deeks JJ, Juszczak. Commentary:Beyond the boundary for a randomised
controlled trial? BMJ 1999;319:682.
Competing interests: No competing interests
I agree with Professor Ames that this study deserves a loud cheer,
and I tried to make that clear in my Editor's choice that accompanied the
article. I wrote: "Medical journals have tended to include many more
efficacy than effectiveness studies, not least because effectiveness
studies tend to be messier. That's why we applaud the study of a group
from Sydney to see if a multifaceted shared care intervention could work
in elderly depressed patients in residential care. This is exactly the
sort of research we need more of, even though our statisticians question
the study in a commentary." Next time I'll try and cheer louder.
Richard Smith
Editor, BMJ
Competing interests: No competing interests
After reading the paper by Llewellyn-Jones et al. on multi-faceted
shared care intervention for late life depression in residential care[1],
together with Haynes'[2] accompanying editorial and the commentary by
Deeks and Juszczak[3] I was left with the feeling that this important
piece of research had been greeted with two faint cheers rather than the
three heartier ones it probably deserved.
Neither the editorial nor the commentary makes the very important points
that
1. Depression among the elderly is common, under-detected, under-treated
and a significant public health problem
2. Depression among the elderly in residential care is extremely common,
grossly under-detected and under-treated and seems to have an appalling
prognosis[4]
3. Because the aetiology of such late life depressions is usually multi-
factorial we need to evaluate multi-pronged interventions on large
populations.
It is very difficult to do good quality research on depression in
residential care and your editorial and commentary certainly get that
point across in spades. However, although the design of the study
conducted by Llewellyn-Jones et al. can be subject to justifiable
criticism, it would seem virtually impossible to mount both arms of such a
trial simultaneously within one large residential institution. The
variability that would be produced by using two or more institutions
probably would outweigh the temporal variability introduced by the
methodology of Llewellyn-Jones et al. Even modest improvements in
depression scores and modest changes in general practitioner behaviour may
have significant impacts on overall population morbidity from depression.
A small decrease in alcohol use in a community is associated with a
significant benefit to some at risk individuals and the same may be true
of small improvements in depression scores. Finally, it seems a bit
unfair for Haynes to criticise the dropout rates in the study. If you are
going to do research with very old people some of them are going to die
and any intervention which prevented that would certainly be worth a
headline in the BMJ!
DAVID AMES
References:
1. Llewellyn-Jones RH, Baikie KA, Smithers H, Cohen J, Snowdon J,
Tennant CC. Multi-faceted shared care intervention for late life
depression in residential care: a randomised controlled trial. BMJ
(1999);319:676-682.
2. Haynes B. Can it work? Does it work? Is it worth it? BMJ
(1999);319:652-653.
3. Deeks JJ, Juszczak E. Commentary: beyond the boundary for a
randomised controlled trial? BMJ (1999);318:682.
4. Ames D. Depressive disorders among elderly people in long-term
institutional care. ANZ J Psychiatry (1993);27:379-391.
Competing interests: No competing interests
Triple jeopardy:old, depressed and disabled
Editor,
Llewellyn-Jones and his colleagues [1] should be complimented for
their achievement .They have provided strong evidence that a
multifactorial intervention for late life depressive illness has a
measurable beneficial effect. However, I should declare my biases. I have
provided specialist medical services to the community that Llewellyn-Jones
et al studied and I am a researcher who tries to engage similar
participants in clinical trials of multifactorial interventions.
Rehabilitation, falls, and geriatric evaluation and management research
share the same issues as depression.
Haynes [2] and Deeks and Juszczak [3] and the letters in reply raise
important issues. I wish to comment on some of them.
While this area of clinical investigation remains in development it
is the real world of clinically relevant research. The researchers did
well to follow-up the percentage of participants that they did. The number
eligible was 220 and they managed to have outcomes on 185 (85%). This
includes participants who died (n=15) because this is a legitimate
endpoint for the frail older people studied.
The study showed an improvement of about 2 points on the 30 item GDS.
Is this worthwhile? As a clinician I vote yes. Remember this is the real
world of aged care with limited resources and very hard pressed nursing,
personal care staff and general practitioners. If the intervention works
in this large and architecturally outdated facility in Sydney it will be
even more effective in well resourced retirement communities. In the
United Kingdom, the structure of general practice (which encourages closer
medical supervision of frail older people) should also improve the
effectiveness of the intervention.
The intervention has components that should be available to all older
people as a right. Callahan argues for a basic humane health service as a
minimum for all older people [4]. The intervention falls into this league.
Cost effectiveness analyses are unlikely to support the types of programs
pioneered by Llewellyn-Jones and colleagues unless they reduce the need
for hospitalisation or increased assistance with activities of daily
living. Because hospitalisation with depressive illness is uncommon in the
population studied and most participants already required some assistance
with activities of daily living, sample sizes for a cost effectiveness
study are likely to be very large. In a population with a genuine unmet
health need it is almost axiomatic that it will cost more to meet this
need.
Evidence based healthcare seems to be better accepted if the evidence
supports a lower cost intervention. If the evidence supports the efficacy
of a more costly intervention healthcare managers and planners seem less
interested.
Ian Cameron
References
1. Llewellyn-Jones RH, Baikie KA, Smithers H, Cohen J, Snowdon J,
Tennant CC. Multifaceted shared care intervention for late life
depression in residential care: randomised controlled trial. BMJ
1999;319:676-82.
2. Haynes, B. Can it work? Does it work? Is it worth it? BMJ
1999;319:652-653.
3. Deeks JJ, Juszczak E. Commentary: beyond the boundary for a
randomised controlled trial? BMJ 1999;318:682.
4. Callahan D. Setting Limits: Medical Goals in an Aging Society.
Simon and Schuster New York, 1987.
Competing interests: No competing interests