Zvi D. Gellis, PhD. University of Pennsylvania
Stanley G. McCracken, PhD, University of Chicago
In each of the evidence-based literature reviews on geriatric mental health care, we have presented the current knowledge on effectiveness for known geriatric mental health interventions for anxiety, depression, schizophrenia, and depression in dementia. Further research is needed in the topical areas that were examined, and these needs are discussed below.
Late Life Anxiety. Further research on late life anxiety is needed in all areas since the knowledge base is in its infancy. Knowledge gaps exist on the frequency and severity of subthreshold anxiety in community dwelling older adults. Further studies are needed on the prevalence of anxiety in various settings such as primary care, home health care, ophthalmology clinics, assisted living facilities, and in the community including naturally occurring retirement communities (NORCs). Especially important is research on differential diagnosis of anxiety and depression and medical illnesses. Too little is known about the effectiveness of psychosocial treatments aside from cognitive behavioral therapy (CBT) and its effectiveness with various older populations, such as those with mild cognitive impairment (MCI) or visual impairments. Research on minorities is also important, an area in which too little is known.
Late Life Depression. Psychosocial interventions for late life depression have been demonstrated to be effective among older adults, particularly those who reject medication due to unpleasant side effects or who are coping with low social support or stressful situations. Evidence-based (Level A) manualized approaches, including CBT-Level A), interpersonal (IPT-Level A), and problem-solving (PST-Level A) therapies, are effective intervention alternatives or adjuncts to medication treatment.
Further research is needed on prevalence of mental health problems in community-dwelling older adults living in naturally NORCs and assisted living facilities. Providing social workers with training to screen, assess, and treat individuals in their homes for mental health problems, such as depression and/or anxiety comorbid with medical illnesses, will likely increase individual community tenure, decrease the likelihood of a premature hospitalization or institutionalization, and increase quality of life.
Research reveals that when older adults are screened and identified with depression, if given a choice, they prefer talk therapy to medication for treatment of their mental health problems. Therefore, further studies need to focus on brief interventions that are feasible, cost-effective, and replicable in various settings including home-based interventions in home health care, NORCs, and assisted-living settings. Community-based depression interventions are relatively new, and to date, only one research group has published positive findings in home health care using a psychosocial intervention. A majority of the research has been completed in primary care settings. In addition, culturally sensitive depression intervention research is needed with older minority populations. New and exciting research on tele-healthcare interventions for older adults with depression and heart disease is trail-blazing new frontiers with potentially robust outcomes.
Schizophrenia. As in other disorders, additional research is needed on the treatment, particularly psychosocial treatment, of older adults with schizophrenia. These studies should include adults 60 and over with early, late, and very late onset forms of the illness; minority subjects (ethnic minority, immigrant, refugee, and GLBT); and individuals living in a range of settings (community, assisted living, supported housing, and nursing homes). Many of the current treatment studies are limited by problems such as small sample sizes, including both middle-aged and older adults, and including only white subjects. In particular there is a need to investigate the degree to which the six interventions identified by the Robert Woods Johnson Foundation (assertive community treatment, supported employment, family psychoeducation, illness management and recovery, integrated dual disorders treatment for individuals with co-occurring severe mental illness and substance use problems, and medication management, [Drake, Merrens, & Lynde, 2005]) are effective in working with older adults and whether/how they might need to be adapted. For example, should supported employment be expanded for individual placement and support, and could family psychoeducation be used in its present form for caregivers who are not family members? In particular, given the trend toward maintaining people longer in the community, much more work needs to be done examining the effectiveness of community-based interventions. In addition to further study of these six interventions, additional study is needed on interventions like skills training, PST, and CBT that have been demonstrated effective with older adults with other disorders or with younger individuals with schizophrenia. Finally, additional study is needed clarifying the risks and benefits of the various pharmacological interventions for schizophrenia. For example, a great deal needs to be learned about the risk of serious side effects like transient ischemic attacks (TIAs), elongation of heart rate (QT) interval, and metabolic syndrome in older adults, particularly given the widespread use of atypical antipsychotic drugs in both individuals with behavioral and psychological symptoms of dementia, as well as those with psychotic disorders.
Other key areas in which additional research is needed include the course of the illness of early onset of schizophrenia (EOS), and the nature of late onset of schizophrenia (LOS) and very late onset of schizophrenia (VLOS). The classic longitudinal studies of the outcome of schizophrenia were conducted with participant groups that had little exposure to antipsychotic medication during the early years of their illness and no exposure to atypical antipsychotic drugs. Additionally, the early longitudinal studies employed global measures of symptoms. New research should include individuals living in a variety of settings. This is particularly important since it is unclear whether some of the differences in functioning seen between older adults living in the community, assisted living, and nursing homes is a cause or an effect of residence status. A more fine-grain longitudinal assessment is very important to understanding how positive, negative, cognitive, and mood symptoms change over time, and how functioning is affected by these changes. Studying LOS and VLOS has been hampered by the fact that these conditions occur at a very low rate. The field would benefit from multi-site collaborative research on these conditions.
Late Life Dementia and Depression. The reviews identified gaps in our knowledge regarding the effectiveness of interventions that are promising but untested or are in widespread use for reasons of tradition. Nonpharmacological interventions for individuals with depression and dementia fall into this category. Evidence on efficacy of treatment of depression in long-term care is sparse and deficient. Reminiscence therapy has been studied widely with mixed results. The life review model is a more structured approach and may be more effective. Indeed, a few psychosocial interventions such as group and individual behavioral therapies show some potential but require further investigation, improved study design, and clear intervention protocols for duplication and treatment component analysis. For these interventions, research gaps consist of questions regarding effectiveness, efficacy, and applicability to other populations and settings. The knowledge base will be bolstered with the use of robust research designs, including randomized trial and longitudinal design methodologies.
A social work focus on several policy priorities can support the provision of evidence-based mental health services to older adults. First, a delivery model of integration of health, mental health, and aging services for older adults should be considered. This has the potential to improve mental health screening in medical and community-based nonmedical settings. Such a model may require ongoing training, consultation, and information to providers, caregivers, and individuals. Second, re-examining Medicare should be a policy priority for service optimization. The financing mechanisms and fiscal viability of geriatric services should be considered so that evidence-based service delivery can be replicated, supported, and sustained. Potential improvements include optimizing reimbursements for providers and identification of the full array of mental health services that can be offered under Medicare. Third, service agencies can make more efficient use of mental health and health professionals by developing a workforce efficiency mechanism of alternative service roles for paraprofessionals and volunteers who can be recruited from ethnic minority populations to provide culturally competent services. Finally, increasing research knowledge on effective intervention models for diverse older populations is an essential priority to support the delivery of best practices.
Drake, R. E., Merrens, M. R., & Lynde, D. W. (Eds.). (2005). Evidence-based mental health practice: A textbook, New York: W. W. Norton & Company, Inc.
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