Zvi D. Gellis, PhD. University of Pennsylvania
Stanley G. McCracken, PhD, University of Chicago.
Between the years 2015 and 2030 older adults (65 years+) will account for 20% of the total population, up from 13% in 2000 (U.S. Bureau of the Census, 2000). Added to this trend is the increasing proportion of minority older adults including African-American, Latino, and Asian-Americans (Areán et al., 2005; Gellis & Taguchi, 2003; Harada & Kim, 1995), who tend to have more obstacles than Caucasians do in accessing mental health services. According to the Surgeon General’s Mental Health Report, depression in older adults leads to physical, mental, and social dysfunction (U.S. Department of Health and Human Services [DHHS], 1999). Primary care physicians often report feeling too pressured for time to investigate mental health problems in older people (Glasser & Gravdal, 1997).
The prevalence estimates of major depression in community elderly samples are low, ranging from 1 to 4% overall, with a higher prevalence among women. The prevalence rate for dysthymia is about 2% although for minor depression estimates are higher, ranging from 4 to 13% with the same pattern of distribution across gender, race, and ethnicity (Blazer, 2002; Beekman et al., 1995). There are no significant racial or ethnic differences in prevalence rates for depression (Beekman, Copeland, & Prince, 1999; Steffens et al., 2000; Zalaquett & Stens, 2006).
Estimates for rates of major depression in medically ill elderly range from 10-12% with an additional 23% experiencing significant depressive symptoms (Koenig, Meador, Cohen, & Blazer, 1988). In home health care, estimates of 13.5% for major depression and 27.5% for significant depressive symptoms were found (Bruce et al., 2002; Gellis, 2006). Rates of clinically significant depressive symptoms among medically ill elderly range from 10 to 43% (Williams-Russo, Sharrock, Mattis, Szatrowski, & Charlson, 1995; Peterson, Williams-Russo, Charlson, & Myers, 1996; Steffens et al., 2000). In fact, depression is twice as prevalent in home health care as in primary care; it is persistent, intermittent, and is associated with medical illness, pain, and disability (Lyness, King, Cox, Yoediono, & Caine, 1999). Late life depression is one of the most common mental disorders to present in primary care and home health care settings (Bruce et al., 2002; Gellis & Kenaley, 2008; Gellis, McGinty, Horowitz, et al., 2007; Lyness et al., 1999; Reynolds & Kupfer, 1999). Nearly 5 million of the 31 million Americans over 65 suffer from clinically significant depressive syndromes.
Prevalence rates of depression in long-term care vary depending on study definitions and measures used. For elderly patients with major depression, rates range from 6 to 24% in nursing homes (Blazer, 2002). Prevalence estimates for minor depression and dysthymia are even higher and range from 30 to 50% in the majority of studies; and for subthreshold clinically significant depressive symptoms, the range is 35 to 45% (Hyer, Carpenter, Bishmann, & Wu, 2005). Depression is underdetected in long-term care facilities and if detected, is inadequately treated (Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2001; Brown, Lapane, & Luisi, 2002).
A meta-analysis of depression outcomes at 24 months estimated that only 33% of older patients were well, 33% were depressed, 13% were hospitalized, and 21% had died (Cole, Bellavance, & Mansour, 1999). Depression is also an independent predictor of overall poor treatment compliance and may exacerbate other common chronic medical conditions in older adults (DiMatteo, Lepper, & Croghan, 2000). Moreover, late life depression slows recovery rates from illnesses and surgeries and is associated with increased mortality (Beekman et al., 1999; Unützer et al., 2003).
Cole and Dendukuri (2003) completed a systematic review of risk factors for depression in community-dwelling elderly that involved a qualitative and quantitative synthesis of the data. They examined 20 studies and identified key risk factors that included female gender, sleep disturbance, disability level, prior history of depression, and bereavement.
Depression with physical illness increases levels of functional disability (Alexopoulos et al., 1996; Proctor et al., 2003), use of health services (Beekman, Deeg, Braam, Smit, & van Tilburg, 1997; Saravay, Pollack, Steinberg, Weinsched, & Habert, 1996), and health care costs (Callahan, Kesterson, & Tierney, 1997; Manning & Wells, 1992; Simon, VonKorff, & Barlow, 1995), particularly among older adults (Unützer et al., 1997). It also delays or inhibits physical recovery (Covinsky, Fortinsky, Palmer, Kresvic, & Landefeld, 1997; Katz, 1996).
In the elderly, suicide is almost twice as frequent as in the general population (Conwell, Duberstein, & Caine, 2002. The elderly account for 20% of all suicides, yet they make up only 13% of the population (Hoyert, Kung, & Smith, 2005; Pearson & Brown, 2000). Some of the most common demographic correlates of suicide are older age, male gender, white race, and unmarried status (Peters, Kochanek, & Murphy, 1998). In the U.S., older white males age (85+) have the highest suicide completion rates (65 per 100,000) (U.S. Dept. of Health and Human Services, 2003), over six times the rate of all age-adjusted suicides (Peters et al., 1998). Men 80+ take their own lives at four to six times the rate of older women (Scocco & DeLeo, 2002). Depression, comorbid anxiety, substance abuse, isolation, loneliness, lack of social supports, and declining physical health are some of the risk factors for suicide among older adults (Conwell et al., 2002). Retrospective studies identified that greater than 70% of older suicide victims have had contact with their primary care provider within 3 months prior to their death (Conwell, Olsen, Caine, & Flannery, 1991; Conwell, 1994; Diekstra & van Egmond, 1989; Frierson, 1991; Uncapher, 2000). In these studies, the majority of older patients had late onset undetected or untreated depressive symptoms, likely reflecting high rates of comorbid illness and/or fears of pain or dependency on others (Duberstein, 1995).
A large multisite randomized trial known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) enrolled patients who met criteria for major depression, dysthymic disorder, or minor depression and tracked their status for a period of 2 years through acute, continuation, and maintenance phases of treatment (Bruce & Pearson, 1999; Alexopoulos et al., 2005). The experimental intervention was implemented by depression care managers who monitored psychopathology, treatment adherence, response, and side effects at predetermined times. Patients were offered antidepressant medications and/or interpersonal psychotherapy, an evidence-based intervention. The PROSPECT trial demonstrated that elderly patients receiving a depression care management intervention had less severe depressive symptoms and greater remission rates at 4, 8, and 12 months than patients receiving usual primary care (Bruce et al., 2004).
Psychosocial interventions have been demonstrated to be effective among older adults, particularly those who reject medication because of unpleasant side effects or who are coping with low social support or stressful situations (Choi & Morrow-Howell, 2007; Gellis, 2006). Evidence-based approaches such as structured problem-solving (PST) cognitive-behavioral (CBT), and interpersonal (IPT) therapies are effective intervention alternatives or adjuncts to medication treatment (Gath & Mynors-Wallis, 1997; Gellis, McGinty, Horowitz, et al., 2007; Hegel, Barrett, Cornell, & Oxman, 2002; Jacobson & Hollon, 1996; De Rubeis, Gelfand, Tang, & Simons, 1999; Schulberg, Pilkonis, & Houck, 1998).
There is evidence that psychosocial interventions alone are effective with older populations including minorities (Coulehan, Schulberg, Block, Madonia, & Rodriguez, 1997; Mossey, Knott, Higgins, & Talerico, 1996; Munoz, et. al., 1995). Cognitive therapies, including PST, are particularly promising (McCusker, Cole, Keller, Bellavance, & Berard, 1998; Nezu, 2004; Robinson et al., 1995) among older men and women of diverse ethnic backgrounds (Gil et al., 1996). Patient attitudes and preference for type of treatment has been shown to affect acceptance of and adherence to the prescribed treatment for depression (Schulberg, Magruder, & deGruy, 1996), and the majority of primary care patients prefer counseling over medication (Brody, Khaliq, & Thompson, 1997; Landreville, Landry, Baillargeon, Guerette, & Matteau, 2001).
PST interventions for depression by non-medical mental health practitioners have also demonstrated effectiveness for homebound, frail, medically ill populations (Gellis, McGinty, Horowitz, et al., 2007; Mynors-Wallis, Gath, Davies, Gray, & Barbour, 1997). Adjunct written educational materials for patients and family members have been shown to improve medication adherence and clinical outcomes (Robinson et al., 1997). Some studies have found that 6 sessions of PST are as effective as pharmacotherapy among ambulatory primary care patients with minor and major depression (Hegel et al., 2002; Mynors-Wallis, Gath, Lloyd-Thomas, & Tomlinson, 1995).
Literature reviews on the effect of CBT on late-life depression noted that CBT was at least as or more efficacious than pharmacotherapy and other forms of psychotherapy such as IPT, brief insight-oriented therapy, PST, and reminiscence therapy (Areán & Cook, 2002; Cuijpers, van Straten, & Smit, 2006; Laidlaw, 2001; Pinquart & Soerensen, 2001; Zalaquett & Stens, 2006).
Among low-income older adults with Major Depressive Disorder (MDD) or dysthymia, cognitive behavioral group therapy (CBGT) augmented with clinical case management and clinical case management alone led to greater improvements in depressive symptoms at the 12-month follow-up than did CBGT alone (Areán, Gum, & McCulloch, 2003). In a study of low-income older primary care patients with MDD, Spanish-speaking and English-speaking patients responded equally well to CBT alone versus case management (Miranda, Azocar, & Organista, 2003). Moreover, CBT and supplemental case management was associated with greater improvement in symptoms and functioning than CBT alone for Spanish speakers, but it was less effective for those whose first-language was English.
IPT is another evidence-based intervention for late life depression that focuses on the depressed person’s relationships and conflicts with family and friends (Hinrichsen, 1999). The overall purpose is to improve communication in those relationships and to develop or enhance the social support network of the identified depressed patient (Weissman & Markowitz, 1994). Several meta-analytic reviews noted findings of the efficacy of IPT for depression (de Melo, de Jesus, Bacaltchuk, Verdeli, & Neugebauer, 2005; Parker, Parker, Brotchie, & Stuart, 2006; Thase et al., 1997; Weston & Morrison, 2001).
Educational materials written for patients and family members have been shown to improve medication adherence and clinical outcomes (Robinson et al., 1997).
Interventions for depression generally range from 6 to 20 sessions, each lasting about an hour (Gellis, McGinty, Horowitz, et al., 2007; Hegel et al., 2002; Nezu, 2004; Nezu & Nezu, 2001).
Based on several literature reviews of pharmacologic treatment for geriatric depression, antidepressants are safe treatments for depressed older adults (Barkin, Schwer, & Barkin, 2000; Mamdani, Parikh, Austin, & Upshur, 2000; Salzman, Wong, & Wright, 2002; Solai, Mulsant, & Pollock, 2001). Almost all antidepressant medications are equally effective for treating major depression (Blazer, Hybel, Simensick, & Harbin, 2000; Salzman et al., 2002). During the past two decades, over 30 randomized placebo controlled clinical trials as well as many comparative trials (Das Gupta, 1998; Salzman et al., 2002) have been conducted that have documented the efficacy and safety of antidepressant medications (Tricyclics and SSRIs) for older adults with depression. Naturalistic studies have shown that medically ill older adults have more adverse effects to trycyclics than to SSRIs (Cole, Elie, McCusker, Bellavance, & Mansour, 2001; Landreville, Landry, Baillargeon, Guerette, & Matteau, 2001), and the use of SSRIs in primary care has become more common (Crystal, Sambamoorthi, Walkup, & Akincigil, 2003).
Minor depression, more often than major depression, is observed in numerous settings (Charney et al., 2003; Lavretsky & Kumar, 2002; Judd, Schettler, & Akiskal, 2002). Minor depression ranges from 10 to 30% in older community-dwelling adults (Hybels & Blazer, 2003) and approximately 5 to 9% in primary care settings (Lyness et al., 1999). Minor depression has been found to be associated with an increased risk for mortality in older men and to have a relatively high prevalence in some ethnic groups (Penninx et al., 1999). This subthreshold disorder is common in older minorities in primary care settings. As many as 15% of older Latinos, 12% of older Asian-Americans, and 10% of older African Americans meet the criteria for minor depression (Areán & Alvidrez, 2001).
A recent systematic review of adults and older adults diagnosed with minor depression found remission rates in the range of 46 to 71% after 3 to 6 years (Hermens et al., 2004). Two studies reported that 62% of adults and older adults still had minor depression at the 5-month follow-up evaluation, whereas 16% had persistent or recurrent minor depression at the 1-year follow-up (Broadhead, Blazer, George, & Tse, 1990; Penninx et al., 1999). At the 1-year follow-up, 12.7% of the adults originally with a diagnosis of minor depression had developed major depression (Broadhead et al., 1990). CPT, IPT, and PST models appear to be promising treatments for older adults with minor depression (Rowe & Rapaport, 2006). However, the research literature is less clear about these therapies effectiveness in minor depression compared to major depression because of the dearth of treatment studies, particularly among older adults.
Much effort has been expended trying to improve the psychiatric skills of primary care physicians, but with only modest effects (Lin et al., 1997; Rihmer, Rutz, & Pihlgren, 1995). Integration of specialty mental health care within primary care and system of care enhancements, such as “collaborative or integrative care” are found to be more effective (Meyers, 1996; Schulberg et al., 1998; Gilbody, Whitty, Grimshaw, & Thomas, 2003). Collaborative care approaches are multifaceted intervention packages that involve nurses, social workers, or other depression care managers, and vary in content and intensity (Katon et al., 1999; Swindle et al., 2003). These interventions often aim to increase knowledge about depression (psychoeducation), improve adherence to antidepressant medication, improve physician-patient communication, and decrease depressive symptoms (Unützer et al., 2001; Von Korff & Goldberg, 2001).
A systematic review of 21 studies on educational and organizational interventions to improve depression management in primary care settings found positive results (Gilbody et al., 2003). Intervention components that were found effective included enhanced depression care manager role, clinician education, and improvement in communication between primary care provider and psychiatry liaison. Documentation alone of simple practice guidelines and educational strategies were generally ineffective.
A recent systematic review of 22 studies on PST was undertaken to determine the effectiveness of PST on reducing depressive symptoms in noninstitutionalized adults 18 years and older (Gellis & Kenaley, 2008. Four studies employed a multi-faceted intervention (Ciechanowski et al., 2004 [Program to Encourage Active, Rewarding Lives for Seniors or PEARLS]; Doorenbos et al., 2005; Katon et al., 2004; Unützer et al., 2002 [IMPACT]). The studies found that combined use of PST and antidepressant treatment had more favorable depression outcomes compared with PST alone. (To view a description and synopsis of the research on IMPACT and PEARLS go to: http://www.nrepp.samhsa.gov/listofprograms.asp?textsearch=Optional+Search+Terms&ShowHide=1&Sort=A1&T2=2&T3=3&A6=6).
In a systematic review of 34 studies of multifaceted collaborative care interventions with outcome data on depressive symptoms and 28 studies on antidepressant medication use, positive effects were found for both antidepressant use and depressive symptom reduction (Bower, Gilbody, Richards, Fletcher, & Sutton, 2006). The studies reviewed found no variables that predicted variation of effectiveness by antidepressant medication use. Nonetheless, several key predictors of good depressive symptom outcomes were found, including mental health training background of staff, systematic identification of patients, and continuous depression specialist supervision.
Flaherty and colleagues (1998) found that a collaborative management home care intervention for depression resulted in lower hospitalization rates (23.5%) compared to that of an historical control group (40.6%). A randomized controlled trial with blind follow-up evaluation 6 months after recruitment found that psychogeriatric team home care versus usual primary care improved depressive outcomes for 58% versus 25% of people 65 and over (Banerjee, Shamash, Macdonald, & Mann, 1996).
Compared with the general elderly population, home care recipients are older, more socially isolated, more likely to be women, and more likely to have high rates of physical illness, disability, and depression (Banerjee, 1993). However, few elderly persons receive appropriate treatment of depression. For instance, in two studies only 21% (Brown, McAvay, Raue, Moses, & Bruce, 2003) and 16% (Banerjee et al., 1996) received treatment.
The client, treating physician, and health care organizational factors interact to impede the detection and treatment of depression, particularly among older clients (Klinkman, 1997; Meyers, 1996; Schulberg et al., 1996). Older clients are less likely than younger ones to voluntarily report affective symptoms of depression (Lyness et al., 1995). They are more likely to ascribe symptoms of depression to a physical illness (Knauper & Wittchen, 1994). Depressed older adults of various ethnic backgrounds are less likely to use specialty care and more likely to use the general health care system (Brown et al., 1995; Unützer et al., 1997).
A recent randomized controlled trial in home care tested the effectiveness of home-delivered problem solving therapy (PST-HC) for depression in medically ill elderly over a 6-month period (Gellis, McGinty, Horowitz, Bruce, & Misener, 2007). Data suggested significant reductions in depression scores at post-baseline, and at 3 and 6 months, relative to the usual primary care condition. They also reported higher quality of life and improved problem solving ability. In a randomized trial of brief PST, the therapy was found to result in decreased symptoms of minor depression in older home care patients post-treatment, and the decrease was maintained over a 6-month period (Gellis, McGinty, Tierney, et al., 2007). Participants in the PST group were also more satisfied with treatment compared to the those in the control group.
A recent study attempted to obtain estimates of depression and related factors, and treatment rates of 196 ALF residents recruited from 22 facilities in Maryland (Watson et al., 2006). Most residents were female and widowed; a majority met criteria for dementia (68%), and 24% of the participants met the cutoff score for depression on the Cornell Scale for Depression in Dementia. Almost half (43%) of those depressed were receiving some type of antidepressant medication, while 57% of those depressed had not been referred to nor were receiving any psychiatric services.
Researchers examined a large data set of assisted living residents (N=2,078 residents aged 65 and older) in 193 assisted living facilities (Watson, Garrett, Sloane, Gruber-Baldini, & Zimmerman, 2003). They found relationships between depression and cognitive impairment, agitation, recent hospitalization, dependence on others for more than three activities of daily living, psychosis, and social withdrawal. At the 1-year follow-up study, 370 depressed residents had been transferred to a nursing home, and 250 residents with severe depressive symptoms had died.
A randomized trial in Australia examined the effectiveness of a population based, multifaceted shared care intervention for late life depression in 220 depressed residential care residents in one large residential facility (Llwellyn-Jones et al., 2001). The intervention sought to provide depression related health education and activity programs for residents, increase the detection rate of depression by care staff, get elderly people to accept that depression is treatable, and provide accessible treatment programs in residential care. Follow-up results at the 9.5 month point showed that the experimental condition had resulted in reduced depressive scores compared to scores associated with the usual primary care control condition.
McCabe and colleagues (2006) studied the prevalence of depression among older people with cognitive impairment and found that 17.7% met criteria for a diagnosis of MDD, while 38.9% had clinically significant depressive symptoms. Individuals with moderate to severe cognitive impairment were more likely to present with MDD than were those with mild cognitive impairment or normal cognitive function. Depression is frequently a comorbid condition with dementia with estimates at 30% (Evers et al., 2002; Terri & Wagner, 1992), and studies indicate that depression is a risk factor for dementia (Alexopoulos, Meyers, Young, Mattis, & Kakuma, 1993; Lichtenberg & Mast, 2003).
In a study of outcomes of depression in 201 long-term care residents with dementia and depression, it was found that at 6 months post-admission, 15% of the original sample was still depressed, and at 12 months only 7.5% were depressed (Payne et al., 2002).
A recent study focused on specific factors that might contribute to nursing home placement by examining the detection and course of coexisting dementia and depression (CDD) in elderly patients compared with patients with either disorder alone (Kales, Chen, Blow, Welsh, & Mellow, 2005). This study found lower rates of depression detection by treating (i.e., non-study) physicians in CDD patients. Only 35% of the CDD group were correctly diagnosed and received adequate treatment. The CDD group had significantly higher levels of functional impairment when compared to the dementia-only group. The CDD subjects used nursing home care at significantly higher rates.
Many long-term care residents present with signs and symptoms that overlap with depression (for example, anhedonia, irritability, flat affect) (Gauthier, 2003). Smalbrugge and colleagues (2005) examined the occurrence and risk indicators of depression, anxiety, and comorbid anxiety and depression among 333 nursing home patients in the Netherlands. Using a diagnostic research interview, they estimated the prevalence of major depression at 17.1%, anxiety at 4.8%, and comorbid anxiety and depression at 5.1%. The prevalence of depressive disorders (both major and minor) was 22.2%, and that of anxiety was 9.9%. The researchers concluded that the comorbidity of anxiety and depression is most prevalent in more severely depressed and anxious nursing home patients.
A randomized trial compared an individual 8-week life review treatment with friendly visiting as the control on depressive symptoms in 201 nursing home residents (Haight, Michel, & Hendrix, 1998). Results demonstrated that the treatment group had reduced BDI scores compared to control participants at 1-year follow-up evaluations.
In a small pilot study, Hyer and colleagues (1990) compared the effectiveness of a 12-week group psychotherapy, in a cognitive behavioral format, to usual primary care in a sample of 22 residents. At post-treatment, depression scores decreased in the treatment group but not in the control group.
Teri and colleagues (1997) conducted a randomized controlled trial of two psychosocial interventions for depression in Alzheimer’s patients living with their caregivers in the community. Participants met diagnostic criteria for major or minor depression. Patient-caregiver dyads were randomly assigned to 1 of 4 conditions and assessed at pre-, post-, and 6-months follow-up intervals. Conditions included (1) behavior therapy-pleasant events (BT-PE), (2) behavior therapy-problem solving (BT-PS), (3) typical care control (TCC), and (4) wait-list control (WLC). They found that patients in both behavioral treatments showed significant improvement but not in the other two conditions. Caregivers in each behavioral condition also showed significant improvement in depressive symptomatology. In contrast, caregivers for patients in the other two conditions did not.
Researchers have recommended a combined approach to depression treatment including behavioral interventions and antidepressants (Lyketsos & Olin, 2002).
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