Collaborative care and active surveillance for screen-positive elders with sub-clinical depression: a pilot study and definitive and randomised evaluation - the CASPER trial
One in seven people over 75 meet the criteria for clinical depression, yet those with milder symptoms—who still suffer impaired quality of life—have no clear treatment guidance. This trial randomly assigns 500 older adults with sub-threshold depression to either usual GP care or a collaborative care package that combines screening, low-intensity psychological support, and active monitoring, without relying on antidepressants (which generally do not work in this group). The problem is that mild depression in the elderly is almost entirely managed in primary care, but effective elements like psychological interventions are rarely integrated into routine practice. No evidence-based approach currently exists for these patients. If the collaborative care model proves cost-effective and acceptable to patients, it could give GPs a practical, non-drug pathway for managing sub-threshold depression in older adults. That would directly reduce suffering and functional decline in a large, underserved group—without requiring specialist mental health services. The study also tests how acceptable and deliverable the intervention is, which is critical for any future rollout.
View original technical description
Depression accounts for the greatest burden of disease among all mental health problems, and is expected to become the second-highest amongst all general health problems by 2020. By the age of 75, 1 in 7 older people meet formal diagnostic criteria for depression. Efforts to ameliorate the burden of illness and personal suffering associated with depression in the elderly have focussed on those with more severe depressive syndromes. Less attention has been paid to those with mild disorders/sub-threshold depressive syndromes but these patients also suffer impairments in their quality of life and level of functioning. There is currently no clear evidence-based guidance regarding treatment for this patient group. The vast majority of depression in the elderly is managed entirely in primary care, without recourse to specialist mental health services. A range of individual treatments have been shown to be effective in the management of clinical depression in the elderly, including anti-depressants and psychosocial interventions. However, a repeated observation amongst those with depression has been the failure to integrate these effective elements of care into routine primary care services. The current study brings together 3 established elements (screening for depression, collaborative care and low intensity psychological intervention) to see whether collaborative care reduces depression symptom severity in older adults in a cost-effective manner compared withholder adults who are managed by usual GP care. This intervention does not involve the use of anti-depressants which are generally not effective in this group. The study will randomly allocate 500 participants to receive either usual GP care alone or collaborative care plus usual GP care. We will assess depressive symptoms using the PHQ-9. We will recruit participants via their GP practice in 3 centres (York, Leeds and Hull). We will follow-up participants for 12 months. Collaborative care and low intensity psychological intervention is currently not routinely offered, therefore it is unclear how acceptable this form of treatment is. The study will examine this issue and how it should be delivered, by discussions with participants and those delivering collaborative care.
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