Late-life depression and anxiety are characterised by high prevalence, unfavourable prognosis, reduced quality of life, excess mortality and substantial societal costs [13
]. Fortunately, there are hopeful indications that the prevention of new cases of mental disorders seems to be possible [12
]. Subthreshold anxiety and depression (i.e., the presence of symptoms of anxiety or depression without evidence of the actual psychiatric disorder) are prognostic variables for major anxiety disorder and depression [13
]. Interventions in the subthreshold disorders may prevent the onset of new cases of major depression and anxiety disorder [18
]. Demonstration projects of shared care models for indicated prevention of new cases of mental disorders may be an important step forward to reduce the enormous burden of these disorders as was shown by a recent meta-analysis of randomised trials of preventive interventions [12
] In this study the indicated prevention of depression and anxiety is attempted by way of a stepped-care programme offering the aged subthreshold depressed or anxious participant, several interventions ranging from noncommittal to the requirement of some engagement.
A preliminary reflection on the limitations and strengths of our design:
A limitation of this pragmatic design is that it will be difficult to weigh the specific contributions of the various elements of this project. Another limitation may be that the quantity and type of questions (questions about mood may be confronting and depressing on their own) can lead to drop-out. The stimulating ideas and activities in the self-help course trying to achieve a positive and active attitude may have an opposite effect since the reader might instead be confronted with his/her limitations.
Strong aspects of this design:
- It is a unique practice-based project in which several evidence-based aspects of for instance the highly successful IMPACT treatment study (Improving Mood: Promoting Access to Collaborative Care Treatment) [16
] are incorporated, now for indicated prevention purposes and among a very old population. Where IMPACT provides its participants of 60 years of age or older with education, brief psychotherapy, medication and stepped care while outcomes and progress are regularly and closely monitored by a care manager, in this Dutch project the participants are older but very similar items compared to the IMPACT model are employed. However, the focus now is on symptoms and on indicated prevention, not on treatment of persons who drew up a specific treatment contract with their physician.
- A further strength of our study is that it encompasses anxiety: that even less studies among the elderly have looked at indicated prevention of anxiety [12
], and at co-morbidity of anxiety and depression [12
]. There are several community studies which show that anxiety is as important a problem for elderly as depression [2
The third strength is that we will also be able to reflect on the ethical dilemma of whether or not to include persons in programmes such as these who are at risk (i.e., not participants) but have no explicit request for care. The percentage uptake of the intervention in the various stepped care stages and the participants' preferences will show us whether an intervention aimed at symptoms and not at syndromes connects to the reality of distressed old people in the community. The questions would be whether these elderly are willing to acknowledge distress and to take active steps to feel better.
Strengths and limitations taken into account, the development and research of (cost) effective means to prevent depressive and anxiety disorder in the rapidly growing group of elderly is a matter of the greatest importance.
Timeframe of the study
Description of risks
To our knowledge, serious risks or undesired effects of completing questionnaires are not reported in the literature. There are no specific risks related to this study.
The participation in the study is voluntarily. Participants are informed that they can cancel their participation at any time without disclosing reasons for their cancellation and without negative consequences for their future medical care.
Vote of the ethics committee
The design and conduct of the study was approved by the ethics committee of VU University Medical Centre, Amsterdam.
Confidential information and participant names are secured by the medical confidentiality rules and are treated according to the code of conduct for medical research, developed by the FMWV (the Federation of Biomedical Scientific Societies).
The results of the participant questionnaires are not accessible to the General Practitioners. All study related documents and data are stored on a protected central server of the Institute for Research in Extramural Medicine, VU University Medical Centre, Amsterdam, the Netherlands. Only members of the study have access to the respective files.