Randomized Trial of Integrated Depression Care Intervention for Homebound Older Adults with Cardiovascular Disease

Background and Purpose: Randomized controlled trial evaluated an integrated depression care intervention known as DART (Depression Assessment Reactivation and Treatment) for homebound older adults with cardiac disease who were recipients of home-based medical services. Heart disease is one of the most common primary diagnoses and the leading cause of death among older home healthcare patients confined to their homes due to medical disability. It is also one of the main causes of hospitalization of older adults and is associated with greater impairment than arthritis, diabetes, or lung disease. Major and subthreshold depression is common among cardiac patients where prevalence rates range from 16 to 37 percent and thus these patients are at high risk for negative outcomes. This study hypothesized that compared to usual care plus education intervention, an integrated depression care intervention (DART) would significantly reduce depression and anxiety scores, lead to improved quality of life, and greater satisfaction with treatment among older adults with cardiac disease.

Methods. Thirty-eight participants were recruited from a university-affiliated home health care agency for the trial. The DART intervention sessions were provided over a seven week period and included cardiac and depression care, problem solving strategies on managing medical conditions, behavioral activation, homework, and weekly check-in telephone calls. The control comparison group received a minimum of seven weeks of usual home-based skilled nursing care and included cardiac education and a depression brochure. Outcome measures included the Beck Depression Inventory, Hamilton Rating Scale for Depression, Beck Anxiety Inventory, and the Medical Outcome Survey SF-36 quality of life measure. Following the intervention, both groups completed the Patient Satisfaction Questionnaire. An “intent to treat” analysis was conducted with all randomized patients kept in the analysis. Baseline demographic variables were compared by using independent sample t-tests and chi-square tests. Random effects regression modeling (RERM) was the main analytic method used for assessing outcome measures.

Results: Compared with the control group, the integrated care group showed a significant decrease in depression but not anxiety scores. Participants receiving integrated care generally reported more favorable satisfaction with treatment than the control group. The DART group improved significantly as compared to the control group in 2 of 8 health-related quality of life subscales, specifically, mental health and emotional role function.

Conclusions and Implications: The DART intervention demonstrated that depression improved among cardiac homecare older adults and there was some reported positive change in quality of life. Authors discuss advances for integrated depression care for homebound older adults with respect to reimbursement and service delivery in real world community settings.