0
May 28, 1997, Vol 277, No. 20 >
ARTICLE | May 28, 1997

Depressive Symptoms and the Cost of Health Services in HMO Patients Aged 65 Years and Older: Title and subTitle BreakA 4-Year Prospective Study FREE

Jürgen Unützer, MD, MPH; Donald L. Patrick, PhD, MSPH; Greg Simon, MD, MPH; David Grembowski, PhD; Edward Walker, MD; Carolyn Rutter, PhD; Wayne Katon, MD
[+] Author Affiliations

Presented as a poster exhibit at the annual meeting of the American Association for Geriatric Psychiatry, Tucson, Ariz, February 16, 1996.

Reprints: Jürgen Unützer, MD, MPH, Department of Psychiatry and Behavioral Sciences, Box 356560, University of Washington, Seattle, WA 98195 (e-mail: unutzer@u.washington.edu).


JAMA. 1997;277(20):1618-1623. doi:10.1001/jama.1997.03540440052032
Text Size: A A A
Published online
Article
References

Objective.  —To examine whether depressive symptoms in older adults contribute to increased cost of general medical services.

Design.  —A 4-year prospective cohort study.

Setting.  —Four primary care clinics of a large staff-model health maintenance organization (HMO) in Seattle, Wash.

Patients.  —A total of 5012 Medicare enrollees older than 65 years were invited to participate in the study; 2558 subjects (51%) were successfully enrolled. Nonparticipants were somewhat older and had a higher level of chronic medical illness.

Main Outcome Measures.  —Depressive symptoms as measured by the Center for Epidemiological Studies Depression scale, which was administered as part of a mail survey at baseline, at 2 years, and at 4 years; and total cost of medical services from the perspective of the HMO. Data were obtained from the cost accounting system of the HMO.

Results.  —In this cohort of older adults, depressive symptoms were common, persistent, and associated with a significant increase in the cost of general medical services. This increase was seen for every component of health care costs and was not accounted for by an increase in specialty mental health care. The increase in health care costs remained significant after adjusting for differences in age, sex, and chronic medical illness.

Conclusions.  —Depressive symptoms in older adults are associated with a significant increase in the cost of medical services, even after adjusting for the severity of chronic medical illness.

REFERENCES

1 +
Blazer DG. Depression in Late Life . 2nd ed. St Louis, Mo: Mosby-Year Book Inc; 1993;.
2 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition . Washington, DC: American Psychiatric Association; 1994;.
3 +
Craig TJ, Van Natta PA.  Disability and depressive symptoms in two communities . Am J Psychiatry . 1983;;140:598-601.
4 +
Kennedy GJ, Kelman HR, Thomas C.  The emergence of depressive symptoms in late life: the importance of declining health and increasing disability . J Community Health . 1990;;15:93-104.
5 +
Gurland BJ, Wilder DE, Berkman C.  Depression and disability in the elderly: reciprocal relations and changes with age . Int J Geriatr Psychiatry . 1988;;3:163-179.
6 +
Bruce ML, Seeman TE, Merrill SS, Blazer DG.  The impact of depressive symptomatology on physical disability: MacArthur studies of successful aging . Am J Public Health . 1994;;84:1796-1799.
7 +
Forell Y, Jorm AF, Winblad B.  Association of age, sex, cognitive dysfunction and disability with depressive symptoms in an elderly sample . Am J Psychiatry . 1994;;151:1600-1604.
8 +
Alexopoulos GS, Vrontou C, Kakuma T, et al.  Disability in geriatric depression . Am J Psychiatry . 1996;;153:877-885.
9 +
Murphy E.  The prognosis of depression in old age . Br J Psychiatry . 1983;;142:111-119.
10 +
Baldwin RC.  The outcome of depression in old age: special issue: affective disorders in old age . Int J Geriatr Psychiatry . 1991;;6:395-400.
11 +
Alexopoulos GS, Chester JG.  Outcomes of geriatric depression . Clin Geriatr Med . 1992;;8:363-376.
12 +
Frasure-Smith N, Lespérance F, Talajic M.  Depression following myocardial infarction: impact on 6-month survival . JAMA . 1993;;270:1819-1825.
13 +
Correction: JAMA . 1994;;271:1082.
14 +
Kouzis A, Eaton WW, Leaf PJ.  Psychopathology and mortality in the general population . Soc Psychiatry Psychiatr Epidemiol . 1995;;30:165-170.
15 +
Mechanic D, Clearly PD, Greenly JR.  Distress syndromes, illness behavior, access to care, and medical utilization in a defined population . Med Care . 1982;;20:361-372.
16 +
McFarland BH, Freeborn DK, Mullooly JP, Pope CR.  Utilization patterns among long-term enrollees in a prepaid group practice health maintenance organization . Med Care . 1985;;23:1221-1233.
17 +
Miranda J, Perez-Stable EJ, Munoz RF, et al.  Somatization, psychiatric disorder, and stress in utilization of ambulatory medical services . Health Psychol . 1991;;10:46-51.
18 +
Manning W, Wells KB.  The effects of psychological distress and psychological well-being on use of medical services . Med Care . 1992;;30:541-553.
19 +
Olfson M, Klerman GL.  Depressive symptoms and mental health service utilization in a community sample . Soc Psychiatry Psychiatr Epidemiol . 1992;;27:161-167.
20 +
Johnson J, Weissman MM, Klerman GL.  Service utilization and social morbidity associated with depressive symptoms in the community . JAMA . 1992;;267:1478-1483.
21 +
Kessler LG, Burns BJ, Shapiro S, et al.  Psychiatric diagnoses of medical service users: evidence users: evidence from the Epidemiological Catchment Area program . Am J Public Health . 1987;;77:18-24.
22 +
Katon W, VonKorff M, Lin E, et al.  Distressed high utilizers of medical care: DSMIII-R diagnoses and treatment needs . Gen Hosp Psychiatry . 1990;; 12:355-362.
23 +
Levenson J, Hamer RM, Rossiter LF.  Relation of psychopathology in general medical inpatients to use and cost of services . Am J Psychiatry . 1990;; 147:1498-1503.
24 +
Simon GE.  Psychiatric disorder and functional somatic symptoms as predictors of health care use . Psychiatr Med . 1992;;10:49-60.
25 +
Simon G, Ormel J, VonKorff M, Barlow W.  Health care costs associated with depressive and anxiety disorders in primary care . Am J Psychiatry . 1995;;152:352-357.
26 +
Simon GE, VonKorff M, Barlow W.  Health care costs of primary care patients with recognized depression . Arch Gen Psychiatry . 1995;;52:850-856.
27 +
Fries BE, Mehr DR, Foley WJ, Burke R.  Mental dysfunction and resource use in nursing homes . Med Care . 1993;;31:898-920.
28 +
Callahan CM, Hui SL, Nienaber NA, Musick BS, Tierney WM.  Longitudinal study of depression and health services use among elderly primary care patients . J Am Geriatr Soc . 1994;;42:833-838.
29 +
Blazer DG.  The danger of reducing reimbursement for psychiatric disorders in late life . Am J Psychiatry . 1996;;153:857-858.
30 +
Shapiro S, Skinner EA, Kessler LG, et al.  Utilization of health and mental health services: three Epidemiologic Catchment Area sites . Arch Gen Psychiatry . 1984;;41:971-978.
31 +
Waxman HM.  Community mental health care for the elderly: a look at the obstacles . Public Health Rep . 1986;;101:294-300.
32 +
Goldstrom ID, Burns BJ, Kessler LG, et al.  Mental health services use by elderly adults in a primary care setting . J Gerontol . 1987;;42:147-153.
33 +
Durham ML, Beresford S, Diehr P, et al.  Participation of higher users in a randomized trial of Medicare reimbursement for preventive services . Gerontologist . 1991;;31:603-606.
34 +
Grembowski D, Patrick D, Diehr P, et al.  Self-efficacy and health behavior among older adults . J Health Soc Behav . 1993;;34:89-104.
35 +
Radloff LS.  The CES-D scale: a self report depression scale for research in the general population . Appl Psychol Meas . 1977;;1:385-401.
36 +
Myers JK, Weissman MM.  Use of a self-report symptom scale to detect depression in a community sample . Am J Psychiatry . 1980;;137:1081-1084.
37 +
Husaini BA, Neff JA, Harrington JB, et al.  Depression in rural communities: validating the CES-D scale . J Community Psychol . 1980;;8:20-27.
38 +
Weissman MM, Sholomskas D, Pottenger M, et al.  Assessing depressive symptoms in five psychiatric populations: a validation study . Am J Epidemiol . 1977;;106:203-214.
39 +
VonKorff M, Wagner EH, Saunders K.  A chronic disease score from automated pharmacy data . J Clin Epidemiol . 1992;;1:197-203.
40 +
US Bureau of Labor Statistics. Monthly Labor Review and CPI Detailed Report. Washington, DC: US Bureau of Labor Statistics, Office of Prices and Living Conditions; 1995.
41 +
Royall RM.  Model robust confidence intervals using maximum likelihood estimators . Int Stat Rev . 1986;;54:221-226.
42 +
White H.  Maximum likelihood estimation of misspecified models . Econometrica . 1982;;50:1-25.
43 +
Wetzler S, Van Praag HM.  Assessment of depression . In: Wetzler S, ed. Measuring Mental Illness . Washington, DC: American Psychiatric Press; 1989;:71-88.
44 +
Zich JM, Attkisson CC, Greenfield TK.  Screening for depression in primary care clinics: the CES-D and the BDI . Int J Psychiatry Med . 1990;;20:259-277.
45 +
Foelker GA Jr, Shewchuck RM.  Somatic complaints and the CES-D . J Am Geriatr Soc . 1992;; 40:259-262.
46 +
Newman JP.  Aging and depression . Psychol Aging . 1989;;4:150-165.
47 +
Gallo JJ, Anthony JC, Muthen BO.  Age differences in the symptoms of depression: a latent trait analysis . J Gerontol . 1994;;49:251-264.
48 +
Alexopoulos GS.  Methodology of treatment studies in geriatric depression . Am J Geriatr Psychiatry . 1995;;3:280-289.
49 +
Ganguli M, Gilby J, Seaberg E, et al.  Depressive symptoms and associated factors in a rural elderly population: the MoVIES project . Am J Geriatr Psychiatry . 1995;;3:144-160.
50 +
Wells KB, Burnam MA, Rogers W, Hayes R, Camp P.  The course of depression in adult outpatients: results from the Medical Outcomes Study . Arch Gen Psychiatry . 1992;;49:788-794.
51 +
Hays RD, Wells KB, Sherbourne CD, Rogers W, Spritzer K.  Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses . Arch Gen Psychiatry . 1995;;52:11-19.
52 +
Broadhead WE, Blazer DG, George LK, Tse CK.  Depression, disability days, and days lost from work in a prospective epidemiological survey . JAMA . 1990;;264:2525-2528.
53 +
Horwath E, Johnson J, Klerman GL, Weissman MM.  Depressive symptoms as relative and attributable risk factors for first-onset major depression . Arch Gen Psychiatry . 1992;;49:817-823.
54 +
Kennedy GJ, Kelman HR, Thomas C.  Persistence in remission of depressive symptoms in late life . Am J Psychiatry . 1991;;148:174-178.
55 +
Katz IR, Parmelee PA, Streim JE.  Depression in older patients in residential care: significance of dysphoria and dimensional assessment . Am J Geriatr Psychiatry . 1995;;3:161-169.
56 +
Blazer DG, Hughes DC, George LK.  The epidemiology of depression in an elderly community population . Gerontologist . 1987;;27:281-287.
57 +
Zonderman AB, Costa PT. The absence of increased levels of depression in older adults: evidence from a national representative study. Presented at the annual meeting of the American Psychological Association; August 16-20,1991; San Francisco, Calif.
58 +
Penninx BW, Beekman AT, Ormel J, et al.  Psychological status among elderly people with chronic diseases: does type of disease play a part? J Psychosomat Res . 1996;;40:521-534.
59 +
Borson S, Barnes RA, Kukull WA, et al.  Symptomatic depression in elderly medical outpatients: prevalence, demography, and health services utilization, I . J Am Geriatr Soc . 1986;;34:341-347.
60 +
Barrett JE, Barrett JA, Oxman TE, Gerber PD.  The prevalence of psychiatric disorders in a primary care practice . Arch Gen Psychiatry . 1988;; 45:1100-1106.
61 +
Katz IR. Depression in the frail elderly: psychiatric-medical comorbidity. Presented at the annual meeting of the American Psychiatric Association; October 8, 1995; Miami, Fla.
62 +
Katon W.  The impact of major depression on chronic medical illness . Gen Hosp Psychiatry . 1996;; 18:215-219.
63 +
Rost K, Smith R, Matthews DB, Guise B.  The deliberate misdiagnosis of major depression in primary care . Arch Fam Med . 1994;;3:333-337.
64 +
Blazer DG.  The Oars Durham surveys: description and application . In: Multidimensional Functional Assessment: The Oars Methodology: A Manual . 2nd ed. Durham, NC: Center for the Study of Aging and Human Development; 1978;.
65 +
Banazak DA.  Late-life depression in primary care . J Gen Intern Med . 1996;;11:163-167.
66 +
Greenberg PE, Stiglin LE, Finkelstein SN, et al.  The economic burden of depression . J Clin Psychiatry . 1993;;54:405-418.
67 +
Rice DP, Feldman JJ.  Living longer in the United States: demographic changes and health needs of the elderly . Milbank Mem Fund Q Health Soc . 1983;;61:362-396.
68 +
Sherman J. Medicare's Mental Health Benefits: Coverage, Utilization, and Expenditures . Washington, DC: Public Policy Institute, American Association of Retired Persons; 1992;.
69 +
Paveza GJ, Cohen D.  Treatment of mental health problems in the elderly . In: Levin LB, Petrila J, eds. Mental Health Services: A Public Health Perspective . New York, NY: Oxford University Press; 1996;.
70 +
Mumford E, Schlesinger HJ, Glass GV, Patrick C, Cuerdon T.  A new look at evidence about reduced cost of medical utilization following mental health treatment . Am J Psychiatry . 1984;;141:1145-1158.
71 +
Sturm R, Wells KB.  How can care for depression become more cost-effective? JAMA . 1995;;273: 51-58.
72 +
Judd LL, Rappaport MH, Paulus MP, et al.  Subsyndromal symptomatic depression: a new mood disorder? J Clin Psychiatry . 1994;;55:18-28.
73 +
Agency for Health Care Policy and Research Depression Guideline Panel. Depression in Primary Care: Clinical Practice Guideline, No. 5. Rockville, Md: Agency for Health Care Policy and Research; March 1993. US Dept of Health and Human Services, AHCPR publication No. 93-0550.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Blazer DG. Depression in Late Life . 2nd ed. St Louis, Mo: Mosby-Year Book Inc; 1993;.
2 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition . Washington, DC: American Psychiatric Association; 1994;.
3 +
Craig TJ, Van Natta PA.  Disability and depressive symptoms in two communities . Am J Psychiatry . 1983;;140:598-601.
4 +
Kennedy GJ, Kelman HR, Thomas C.  The emergence of depressive symptoms in late life: the importance of declining health and increasing disability . J Community Health . 1990;;15:93-104.
5 +
Gurland BJ, Wilder DE, Berkman C.  Depression and disability in the elderly: reciprocal relations and changes with age . Int J Geriatr Psychiatry . 1988;;3:163-179.
6 +
Bruce ML, Seeman TE, Merrill SS, Blazer DG.  The impact of depressive symptomatology on physical disability: MacArthur studies of successful aging . Am J Public Health . 1994;;84:1796-1799.
7 +
Forell Y, Jorm AF, Winblad B.  Association of age, sex, cognitive dysfunction and disability with depressive symptoms in an elderly sample . Am J Psychiatry . 1994;;151:1600-1604.
8 +
Alexopoulos GS, Vrontou C, Kakuma T, et al.  Disability in geriatric depression . Am J Psychiatry . 1996;;153:877-885.
9 +
Murphy E.  The prognosis of depression in old age . Br J Psychiatry . 1983;;142:111-119.
10 +
Baldwin RC.  The outcome of depression in old age: special issue: affective disorders in old age . Int J Geriatr Psychiatry . 1991;;6:395-400.
11 +
Alexopoulos GS, Chester JG.  Outcomes of geriatric depression . Clin Geriatr Med . 1992;;8:363-376.
12 +
Frasure-Smith N, Lespérance F, Talajic M.  Depression following myocardial infarction: impact on 6-month survival . JAMA . 1993;;270:1819-1825.
13 +
Correction: JAMA . 1994;;271:1082.
14 +
Kouzis A, Eaton WW, Leaf PJ.  Psychopathology and mortality in the general population . Soc Psychiatry Psychiatr Epidemiol . 1995;;30:165-170.
15 +
Mechanic D, Clearly PD, Greenly JR.  Distress syndromes, illness behavior, access to care, and medical utilization in a defined population . Med Care . 1982;;20:361-372.
16 +
McFarland BH, Freeborn DK, Mullooly JP, Pope CR.  Utilization patterns among long-term enrollees in a prepaid group practice health maintenance organization . Med Care . 1985;;23:1221-1233.
17 +
Miranda J, Perez-Stable EJ, Munoz RF, et al.  Somatization, psychiatric disorder, and stress in utilization of ambulatory medical services . Health Psychol . 1991;;10:46-51.
18 +
Manning W, Wells KB.  The effects of psychological distress and psychological well-being on use of medical services . Med Care . 1992;;30:541-553.
19 +
Olfson M, Klerman GL.  Depressive symptoms and mental health service utilization in a community sample . Soc Psychiatry Psychiatr Epidemiol . 1992;;27:161-167.
20 +
Johnson J, Weissman MM, Klerman GL.  Service utilization and social morbidity associated with depressive symptoms in the community . JAMA . 1992;;267:1478-1483.
21 +
Kessler LG, Burns BJ, Shapiro S, et al.  Psychiatric diagnoses of medical service users: evidence users: evidence from the Epidemiological Catchment Area program . Am J Public Health . 1987;;77:18-24.
22 +
Katon W, VonKorff M, Lin E, et al.  Distressed high utilizers of medical care: DSMIII-R diagnoses and treatment needs . Gen Hosp Psychiatry . 1990;; 12:355-362.
23 +
Levenson J, Hamer RM, Rossiter LF.  Relation of psychopathology in general medical inpatients to use and cost of services . Am J Psychiatry . 1990;; 147:1498-1503.
24 +
Simon GE.  Psychiatric disorder and functional somatic symptoms as predictors of health care use . Psychiatr Med . 1992;;10:49-60.
25 +
Simon G, Ormel J, VonKorff M, Barlow W.  Health care costs associated with depressive and anxiety disorders in primary care . Am J Psychiatry . 1995;;152:352-357.
26 +
Simon GE, VonKorff M, Barlow W.  Health care costs of primary care patients with recognized depression . Arch Gen Psychiatry . 1995;;52:850-856.
27 +
Fries BE, Mehr DR, Foley WJ, Burke R.  Mental dysfunction and resource use in nursing homes . Med Care . 1993;;31:898-920.
28 +
Callahan CM, Hui SL, Nienaber NA, Musick BS, Tierney WM.  Longitudinal study of depression and health services use among elderly primary care patients . J Am Geriatr Soc . 1994;;42:833-838.
29 +
Blazer DG.  The danger of reducing reimbursement for psychiatric disorders in late life . Am J Psychiatry . 1996;;153:857-858.
30 +
Shapiro S, Skinner EA, Kessler LG, et al.  Utilization of health and mental health services: three Epidemiologic Catchment Area sites . Arch Gen Psychiatry . 1984;;41:971-978.
31 +
Waxman HM.  Community mental health care for the elderly: a look at the obstacles . Public Health Rep . 1986;;101:294-300.
32 +
Goldstrom ID, Burns BJ, Kessler LG, et al.  Mental health services use by elderly adults in a primary care setting . J Gerontol . 1987;;42:147-153.
33 +
Durham ML, Beresford S, Diehr P, et al.  Participation of higher users in a randomized trial of Medicare reimbursement for preventive services . Gerontologist . 1991;;31:603-606.
34 +
Grembowski D, Patrick D, Diehr P, et al.  Self-efficacy and health behavior among older adults . J Health Soc Behav . 1993;;34:89-104.
35 +
Radloff LS.  The CES-D scale: a self report depression scale for research in the general population . Appl Psychol Meas . 1977;;1:385-401.
36 +
Myers JK, Weissman MM.  Use of a self-report symptom scale to detect depression in a community sample . Am J Psychiatry . 1980;;137:1081-1084.
37 +
Husaini BA, Neff JA, Harrington JB, et al.  Depression in rural communities: validating the CES-D scale . J Community Psychol . 1980;;8:20-27.
38 +
Weissman MM, Sholomskas D, Pottenger M, et al.  Assessing depressive symptoms in five psychiatric populations: a validation study . Am J Epidemiol . 1977;;106:203-214.
39 +
VonKorff M, Wagner EH, Saunders K.  A chronic disease score from automated pharmacy data . J Clin Epidemiol . 1992;;1:197-203.
40 +
US Bureau of Labor Statistics. Monthly Labor Review and CPI Detailed Report. Washington, DC: US Bureau of Labor Statistics, Office of Prices and Living Conditions; 1995.
41 +
Royall RM.  Model robust confidence intervals using maximum likelihood estimators . Int Stat Rev . 1986;;54:221-226.
42 +
White H.  Maximum likelihood estimation of misspecified models . Econometrica . 1982;;50:1-25.
43 +
Wetzler S, Van Praag HM.  Assessment of depression . In: Wetzler S, ed. Measuring Mental Illness . Washington, DC: American Psychiatric Press; 1989;:71-88.
44 +
Zich JM, Attkisson CC, Greenfield TK.  Screening for depression in primary care clinics: the CES-D and the BDI . Int J Psychiatry Med . 1990;;20:259-277.
45 +
Foelker GA Jr, Shewchuck RM.  Somatic complaints and the CES-D . J Am Geriatr Soc . 1992;; 40:259-262.
46 +
Newman JP.  Aging and depression . Psychol Aging . 1989;;4:150-165.
47 +
Gallo JJ, Anthony JC, Muthen BO.  Age differences in the symptoms of depression: a latent trait analysis . J Gerontol . 1994;;49:251-264.
48 +
Alexopoulos GS.  Methodology of treatment studies in geriatric depression . Am J Geriatr Psychiatry . 1995;;3:280-289.
49 +
Ganguli M, Gilby J, Seaberg E, et al.  Depressive symptoms and associated factors in a rural elderly population: the MoVIES project . Am J Geriatr Psychiatry . 1995;;3:144-160.
50 +
Wells KB, Burnam MA, Rogers W, Hayes R, Camp P.  The course of depression in adult outpatients: results from the Medical Outcomes Study . Arch Gen Psychiatry . 1992;;49:788-794.
51 +
Hays RD, Wells KB, Sherbourne CD, Rogers W, Spritzer K.  Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses . Arch Gen Psychiatry . 1995;;52:11-19.
52 +
Broadhead WE, Blazer DG, George LK, Tse CK.  Depression, disability days, and days lost from work in a prospective epidemiological survey . JAMA . 1990;;264:2525-2528.
53 +
Horwath E, Johnson J, Klerman GL, Weissman MM.  Depressive symptoms as relative and attributable risk factors for first-onset major depression . Arch Gen Psychiatry . 1992;;49:817-823.
54 +
Kennedy GJ, Kelman HR, Thomas C.  Persistence in remission of depressive symptoms in late life . Am J Psychiatry . 1991;;148:174-178.
55 +
Katz IR, Parmelee PA, Streim JE.  Depression in older patients in residential care: significance of dysphoria and dimensional assessment . Am J Geriatr Psychiatry . 1995;;3:161-169.
56 +
Blazer DG, Hughes DC, George LK.  The epidemiology of depression in an elderly community population . Gerontologist . 1987;;27:281-287.
57 +
Zonderman AB, Costa PT. The absence of increased levels of depression in older adults: evidence from a national representative study. Presented at the annual meeting of the American Psychological Association; August 16-20,1991; San Francisco, Calif.
58 +
Penninx BW, Beekman AT, Ormel J, et al.  Psychological status among elderly people with chronic diseases: does type of disease play a part? J Psychosomat Res . 1996;;40:521-534.
59 +
Borson S, Barnes RA, Kukull WA, et al.  Symptomatic depression in elderly medical outpatients: prevalence, demography, and health services utilization, I . J Am Geriatr Soc . 1986;;34:341-347.
60 +
Barrett JE, Barrett JA, Oxman TE, Gerber PD.  The prevalence of psychiatric disorders in a primary care practice . Arch Gen Psychiatry . 1988;; 45:1100-1106.
61 +
Katz IR. Depression in the frail elderly: psychiatric-medical comorbidity. Presented at the annual meeting of the American Psychiatric Association; October 8, 1995; Miami, Fla.
62 +
Katon W.  The impact of major depression on chronic medical illness . Gen Hosp Psychiatry . 1996;; 18:215-219.
63 +
Rost K, Smith R, Matthews DB, Guise B.  The deliberate misdiagnosis of major depression in primary care . Arch Fam Med . 1994;;3:333-337.
64 +
Blazer DG.  The Oars Durham surveys: description and application . In: Multidimensional Functional Assessment: The Oars Methodology: A Manual . 2nd ed. Durham, NC: Center for the Study of Aging and Human Development; 1978;.
65 +
Banazak DA.  Late-life depression in primary care . J Gen Intern Med . 1996;;11:163-167.
66 +
Greenberg PE, Stiglin LE, Finkelstein SN, et al.  The economic burden of depression . J Clin Psychiatry . 1993;;54:405-418.
67 +
Rice DP, Feldman JJ.  Living longer in the United States: demographic changes and health needs of the elderly . Milbank Mem Fund Q Health Soc . 1983;;61:362-396.
68 +
Sherman J. Medicare's Mental Health Benefits: Coverage, Utilization, and Expenditures . Washington, DC: Public Policy Institute, American Association of Retired Persons; 1992;.
69 +
Paveza GJ, Cohen D.  Treatment of mental health problems in the elderly . In: Levin LB, Petrila J, eds. Mental Health Services: A Public Health Perspective . New York, NY: Oxford University Press; 1996;.
70 +
Mumford E, Schlesinger HJ, Glass GV, Patrick C, Cuerdon T.  A new look at evidence about reduced cost of medical utilization following mental health treatment . Am J Psychiatry . 1984;;141:1145-1158.
71 +
Sturm R, Wells KB.  How can care for depression become more cost-effective? JAMA . 1995;;273: 51-58.
72 +
Judd LL, Rappaport MH, Paulus MP, et al.  Subsyndromal symptomatic depression: a new mood disorder? J Clin Psychiatry . 1994;;55:18-28.
73 +
Agency for Health Care Policy and Research Depression Guideline Panel. Depression in Primary Care: Clinical Practice Guideline, No. 5. Rockville, Md: Agency for Health Care Policy and Research; March 1993. US Dept of Health and Human Services, AHCPR publication No. 93-0550.

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NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
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