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Original Investigation |

A Telephone-Based Program to Provide Symptom Monitoring Alone vs Symptom Monitoring Plus Care Management for Late-Life Depression and Anxiety A Randomized Clinical Trial

Shahrzad Mavandadi, PhD1,2; Amy Benson, MSEd, MPhilEd2; Suzanne DiFilippo, RN2; Joel E. Streim, MD1,2; David Oslin, MD1,2
[+] Author Affiliations
1Veterans Integrated Services Network 4 Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
2Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA Psychiatry. 2015;72(12):1211-1218. doi:10.1001/jamapsychiatry.2015.2157.
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Importance  Mental health (MH) conditions are undertreated in late life. It is important to identify treatment strategies that address variability in treatment content and delivery and take individual-specific symptoms into account, particularly among low-income, community-dwelling older adults.

Objective  To evaluate program feasibility and MH outcomes among community-dwelling older adults randomized to 1 of 2 treatment arms of varying intensity of evidence-based, collaborative MH care management services (ie, the Supporting Seniors Receiving Treatment and Intervention [SUSTAIN] program) that provide standardized, measurement-based, software-aided MH assessment and symptom monitoring and connection to community resources via telephone.

Design, Setting, and Participants  Trial participants were 1018 older, community-dwelling, low-income adults prescribed an antidepressant or anxiolytic by a primary care or non-MH professional and experiencing clinically significant MH symptoms at intake. The participant subsample was drawn from a larger parent sample of older adults enrolled in the SUSTAIN program. Individuals were randomized to receive MH symptom monitoring alone (hereafter monitoring alone) or MH symptom monitoring plus care management (hereafter care management) provided by an MH professional. Baseline characteristics were examined, and changes in clinical MH outcomes were evaluated at 3-month and 6-month follow-up. The study dates were August 5, 2010, to May 5, 2014.

Interventions  Monitoring alone or care management delivered by an MH professional.

Main Outcomes and Measures  Overall MH functioning (primary) and depressive and anxiety symptoms.

Results  A total of 509 participants were randomized to the monitoring alone group and 509 to the care management group; 377 and 401 completed ≥2 research assessments in the monitoring alone and case management groups, respectively. Compared with those randomized to monitoring alone, individuals randomized to care management showed greater improvements in the 3 domains of MH functioning (β [SE], 0.36 [0.12]; 95% CI, 0.12 to 0.60; P = .004), depressive symptoms (β [SE], −0.20 [0.06]; 95% CI, −0.32 to −0.09; P < .001), and anxiety symptoms (β [SE], −0.23 [0.05]; 95% CI, −0.33 to −0.14; P < .001) over time.

Conclusions and Relevance  The SUSTAIN program, which provides assessment, monitoring, care management, and brief therapies for MH symptoms and needs in primary care settings, is feasible and scalable. A more intense level of care (ie, symptom monitoring plus care management) is associated with more favorable individual outcomes for low-income, community-dwelling older adults experiencing clinically significant MH symptoms.

Trial Registration  clinicaltrials.gov Identifier: NCT02440594

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Figure 1.
CONSORT Diagram of Participant Randomization

CM indicates care management; CONSORT, Consolidated Standards of Reporting Trials; MA, monitoring alone; MH, mental health; PACE/PACENET, Pharmaceutical Assistance Contract for the Elderly/Pharmaceutical Assistance Contract for the Elderly Needs Enhancement Tier; and SUSTAIN, Supporting Seniors Receiving Treatment and Intervention.

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Figure 2.
Group Differences in Longitudinal Change in Overall Mental Health Functioning

Data points represent unadjusted, observed mean (SD) values for overall mental health functioning (measured by the 12-Item Short-Form Health Survey mental component subscale score) for the monitoring alone (MA) and care management (CM) arms at each time point. Higher values denote better mental health functioning.

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Figure 3.
Group Differences in Longitudinal Change in Depression Symptom Severity and Anxiety Symptom Severity

Data points represent unadjusted, observed mean (SD) values for depression symptom severity (measured by the PHQ-9) and anxiety symptom severity (measured by the GAD-7) for the monitoring alone (MA) and care management (CM) arms at each time point. Higher values denote greater depression and anxiety symptoms. GAD-7 indicates Generalized Anxiety Disorder 7-Item Scale; PHQ-9, Patient Health Questionnaire 9-Item.

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