Comparative effectiveness of social problem-solving therapy and reminiscence therapy as treatments for depression in older adults

Cognitive outcomes after psychotherapeutic interventions for major depression in older adults with executive dysfunction

OBJECTIVE

The purpose of this study was to determine the impact of psychotherapy on cognitive functioning in older adults with late-life depression (LLD) and executive dysfunction.

METHODS

Two hundred twenty-one adults aged 60 years and older participated in a randomized clinical trial comparing the efficacy of Problem Solving Therapy (PST) and Supportive Therapy (ST) for LLD. Cognitive performance on seven tests of executive functioning, verbal learning, and memory was evaluated at baseline, after 12 weeks of treatment, and at 24 weeks after the completion of treatment.

RESULTS

Performance on a measure of executive functioning with a significant information processing speed component (Stroop Color and Word Test) improved after treatment, F (1, 312) = 8.50, p = 0.002, and improved performance was associated with a reduction in depressive symptoms but not treatment type. Performance on other measures of executive functioning, verbal learning, and memory did not change significantly after 12 weeks of psychotherapy treatment.

CONCLUSION

Our results suggest that improvements in cognitive functioning after psychotherapy treatment for depression in older adults with executive dysfunction are likely focal and not distributed across all cognitive domains. Although previous analyses reported that PST was superior to ST in the treatment of depression, this analysis indicated no difference between the two treatments with regard to improvements in cognitive functioning.

Waiting list may be a nocebo condition in psychotherapy trials: a contribution from network meta-analysis

OBJECTIVE

Various control conditions have been employed in psychotherapy trials, but there is growing suspicion that they may lead to different effect size estimates. The present study aims to examine the differences among control conditions including waiting list (WL), no treatment (NT) and psychological placebo (PP).

METHOD

We comprehensively searched for all randomized controlled trials (RCTs) comparing cognitive-behaviour therapies (CBT) against various control conditions in the acute phase treatment of depression, and applied network meta-analysis (NMA) to combine all direct and indirect comparisons among the treatment and control arms.

RESULTS

We identified 49 RCTs (2730 participants) comparing WL, NT, PP and CBT. This network of evidence was consistent, and the effect size estimates for CBT were substantively different depending on the control condition. The odds ratio of response for NT over WL was statistically significant at 2.9 (95% CI: 1.3-5.7). However, the quality of evidence, including publication bias, was less than ideal and none of the preplanned sensitivity analyses limiting to high-quality studies could be conducted, while findings of significant differences did not persist in post hoc sensitivity analyses trying to adjust for publication bias.

CONCLUSION

There may be important differences in control conditions currently used in psychotherapy trials.

Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: a randomized controlled trial

OBJECTIVE

Interventions directed at the mental health of family dementia caregivers may have limited impact when focused on caregivers who have provided care for years and report high burden levels. We sought to evaluate the mental health effects of problem-solving therapy (PST), designed for caregivers of individuals with a recent diagnosis of Mild Cognitive Impairment (MCI) or early dementia.

METHOD

Seventy-three (43 MCI and 30 early dementia) family caregivers were randomly assigned to receive PST or a comparison condition (nutritional education). Depression, anxiety, and problem-solving orientation were assessed at baseline and at 1, 3, 6, and 12 months post intervention.

RESULTS

In general, the PST caregiver intervention was feasible and acceptable to family caregivers of older adults with a new cognitive diagnosis. Relative to nutritional education, PST led to significantly reduced depression symptoms, particularly among early dementia caregivers. PST also lowered caregivers' anxiety levels, and led to lessening of negative problem orientation.

DISCUSSION

Enhanced problem-solving skills, learned early after a loved one's cognitive diagnosis (especially dementia), results in positive mental health outcomes among new family caregivers.

Managing depression in older age: psychological interventions

The number of studies on psychological treatments of depression in older adults has increased considerably in the past years. Therefore, we conducted an updated meta-analysis of these studies. A total of 44 studies comparing psychotherapies to control groups, other therapies or pharmacotherapy could be included. The overall effect size indicating the difference between psychotherapy and control groups was g=0.64 (95% CI: 0.47-0.80), which corresponds with a NNT of 3. These effects were maintained at 6 months or longer post randomization (g=0.27; 95%CI: 0.16-0.37). Specific types of psychotherapies that were found to be effective included cognitive behavior therapy (g=0.45; 95% CI: 0.29-0.60), life review therapy (g=0.59; 95% CI: 0.36-0.82) and problem-solving therapy (g=0.46; 95% CI: 0.18-0.74). Treatment compared to waiting list control groups resulted in larger effect sizes than treatments compared to care-as-usual and other control groups (p<0.05). Studies with lower quality resulted in higher effect sizes than high-quality studies (p<0.05). Direct comparisons between different types of psychotherapy suggested that cognitive behavior therapy and problem-solving therapy may be more effective than non-directive counseling and other psychotherapies may be less effective than other therapies. This should be considered with caution, however, because of the small number of studies. There were not enough studies to examine the long-term effects of psychotherapies and to compare psychotherapy with pharmacotherapy or combined treatments. We conclude that it is safe to assume that psychological therapies in general are effective in late-life depression, and this is especially well-established for cognitive behavior therapy and problem-solving therapy.

Problem-Solving Therapy in the Elderly

We systematically reviewed randomized clinical trials of problem-solving therapy (PST) in older adults. Our results indicate that PST led to greater reduction in depressive symptoms of late-life major depression than supportive therapy (ST) and reminiscence therapy. PST resulted in reductions in depression comparable with those of paroxetine and placebo in patients with minor depression and dysthymia, although paroxetine led to greater reductions than placebo. In home health care, PST was more effective than usual care in reducing symptoms of depression in undiagnosed patients. PST reduced disability more than ST in patients with major depression and executive dysfunction. Preliminary data suggest that a home-delivered adaptation of PST that includes environmental adaptations and caregiver involvement is efficacious in reducing disability in depressed patients with advanced cognitive impairment or early dementia. In patients with macular degeneration, PST led to improvement in vision-related disability comparable to that of ST, but PST led to greater improvement in measures of vision-related quality of life. Among stroke patients, PST participants were less likely to develop a major or minor depressive episode than those receiving placebo treatment, although the results were not sustained in a more conservative statistical analysis. Among patients with macular degeneration, PST participants had significantly lower 2-month incidence rates of major depression than usual care participants and were less likely to suffer persistent depression at 6 months. Finally, among stroke patients, PST participants were less likely to develop apathy than those receiving placebo treatment. PST also has been delivered via phone, Internet, and videophone, and there is evidence of feasibility and acceptability. Further, preliminary data indicate that PST delivered through the Internet resulted in a reduction in depression comparable with that of in-person PST in home-care patients. PST delivered via videophone results in an improvement in hospice caregivers' quality of life and a reduction in anxiety comparable to those of in-person PST. PST-treated patients with cognitive impairment may require additional compensatory strategies, such as written notes, memory devices, environmental adaptations, and caregiver involvement.

Effect of life review writing on depressive symptoms in older adults: a randomized controlled trial

OBJECTIVE

We examined the effects of engaging in the occupation-based intervention of life review through writing on expressed depressive symptoms as measured with the Geriatric Depression Scale in older adults residing in senior residences.

METHOD

The study design was a randomized controlled trial that took place in four senior residences in New York City. Forty-five participants (23 treatment, 22 wait-list control) ≥ 65 yr old participated in the 8-wk, once-weekly autobiographical writing workshop, Share Your Life Story (Sierpina, 2002).

RESULTS

Depressive symptoms were significantly less prevalent for the treatment group than for the control group after the 8-wk life review program (repeated-measures analysis of variance p = .03).

CONCLUSION

The results suggest that the Share Your Life Story writing workshop is an effective occupation-based intervention for occupational therapists to use with older adults who reside in senior residences.

Cognition in Late Life Depression: Treatment Considerations

Late life depression (LLD) frequently presents with cognitive impairment, and growing evidence suggests that these disease processes are "linked" in multiple ways. For some individuals, LLD may be a recurrence of a long-standing depressive illness, while for others it may be the leading symptom of a developing neuropathological disorder. Overall, studies investigating the relationship between treatment of LLD and improvement in cognitive functioning have yielded mixed results. Research suggests that a subset of individuals with LLD and cognitive dysfunction will experience an improvement in cognitive function after antidepressant treatment, though a significant proportion will continue to exhibit cognitive impairment following resolution of their depressive symptoms. From a treatment standpoint, it is critical to ensure that an individual's depressive symptoms have been treated to remission, measured by a standardized rating scale such as the Geriatric Depression Scale (GDS). SSRI or SNRI monotherapy is often effective, and may be enhanced by employing an evidence-based psychotherapy such as Problem Solving Therapy (PST) or Interpersonal Therapy (IPT), modified to accommodate cognitive impairments that may be present. With respect to specific treatment of cognitive dysfunction, cognitive augmentation or training strategies can be helpful for some patients, and may be explored in combination with treatment of the primary depressive episode. While the introduction of a cholinesterase inhibitor (e.g. donepezil) may be considered, the potential benefit (modest improvement in cognition and functioning) must be weighed against an increased risk for worsening or recurrent depression. Finally, lifestyle factors-such as aerobic exercise, follow-up with a primary care physician for management of co-morbid medical illnesses, and regular participation in stimulating activities (such as through a senior center)-are important and should be included as part of the overall treatment plan.

Psychological treatment of late-life depression

This article summarizes the following psychological interventions for late-life depression: cognitive and behavioral therapy, problem-solving therapy, reminiscence and life review therapy, brief psychodynamic therapy, and interpersonal therapy. Results indicate that all psychological interventions reviewed were effective in reducing depressive symptoms in older adults. Future research should include larger sample sizes and focus on moderators of treatment such as age, depression severity, medical illness, and cognitive impairment.

Self-appraised problem-solving skills and the prediction of secondary complications among persons with spinal cord injuries

Secondary complications following spinal cord injury (SCI) include decubitus ulcers and recurrent urinary tract infections. These conditions can significantly impair quality of life and prove life-threatening; it is also believed that these conditions are mediated by behavioral pathways. According to the social problem-solving model, persons who report effective problem-solving skills should be capable of adhering to long-term therapeutic regimens of self-care necessary to prevent these complications. We tested this assumption in the present study. Discriminant function analyses revealed self-appraised skills in approaching and defining problems contributed to the prediction of secondary complications among 53 persons with SCI. Results are discussed in light of the social problem-solving model, and the utility of problem-solving interventions in rehabilitation is explored.

Technology-facilitated depression care management among predominantly Latino diabetes patients within a public safety net care system: comparative effectiveness trial design

Health disparities in minority populations are well recognized. Hispanics and Latinos constitute the largest ethnic minority group in the United States; a significant proportion receives their care via a safety net. The prevalence of diabetes mellitus and comorbid depression is high among this group, but the uptake of evidence-based collaborative depression care management has been suboptimal. The study design and baseline characteristics of the enrolled sample in the Diabetes-Depression Care-management Adoption Trial (DCAT) establishes a quasi-experimental comparative effectiveness research clinical trial aimed at accelerating the adoption of collaborative depression care in safety net clinics. The study was conducted in collaboration with the Los Angeles County Department of Health Services at eight county-operated clinics. DCAT has enrolled 1406 low-income, predominantly Hispanic/Latino patients with diabetes to test a translational model of depression care management. This three-group study compares usual care with a collaborative care team support model and a technology-facilitated depression care model that provides automated telephonic depression screening and monitoring tailored to patient conditions and preferences. Call results are integrated into a diabetes disease management registry that delivers provider notifications, generates tasks, and issues critical alerts. All subjects receive comprehensive assessments at baseline, 6, 12, and 18 months by independent English-Spanish bilingual interviewers. Study outcomes include depression outcomes, treatment adherence, satisfaction, acceptance of assessment and monitoring technology, social and economic stress reduction, diabetes self-care management, health care utilization, and care management model cost and cost-effectiveness comparisons. DCAT's goal is to optimize depression screening, treatment, follow-up, outcomes, and cost savings to reduce health disparities.

Patterns of reduced cortical thickness in late-life depression and relationship to psychotherapeutic response

OBJECTIVE

Cortical atrophy has been associated with late-life depression (LLD) and recent findings suggest that reduced right hemisphere cortical thickness is associated with familial risk for major depressive disorder, but cortical thickness abnormalities in LLD have not been explored. Furthermore, cortical atrophy has been posited as a contributor to poor antidepressant treatment response in LLD, but the impact of cortical thickness on psychotherapy response is unknown. This study was conducted to evaluate patterns of cortical thickness in LLD and in relation to psychotherapy treatment outcomes.

METHODS

Participants included 22 individuals with LLD and 12 age-matched comparison subjects. LLD participants completed 12 weeks of psychotherapy and treatment response was defined as a 50% reduction in depressive symptoms. All participants underwent magnetic resonance imaging of the brain, and cortical mapping of gray matter tissue thickness was calculated.

RESULTS

LLD individuals demonstrated thinner cortex than controls prominently in the right frontal, parietal, and temporal brain regions. Eleven participants (50%) exhibited positive psychotherapy response after 12 weeks of treatment. Psychotherapy nonresponders demonstrated thinner cortex in bilateral posterior cingulate and parahippocampal cortices, left paracentral, precuneus, cuneus, and insular cortices, and the right medial orbitofrontal and lateral occipital cortices relative to treatment responders.

CONCLUSIONS

Our findings suggest more distributed right hemisphere cortical abnormalities in LLD than have been previously reported. In addition, our findings suggest that reduced bilateral cortical thickness may be an important phenotypic marker of individuals at higher risk for poor response to psychotherapy.

Estimating remission from untreated major depression: a systematic review and meta-analysis

BACKGROUND

Few studies have examined spontaneous remission from major depression. This study investigated the proportion of prevalent cases of untreated major depression that will remit without treatment in a year, and whether remission rates vary by disorder severity.

METHOD

Wait-list controlled trials and observational cohort studies published up to 2010 with data describing remission from untreated depression at ≤ 2-year follow-up were identified. Remission was defined as rescinded diagnoses or below threshold scores on standardized symptom measures. Nineteen studies were included in a regression model predicting the probability of 12-month remission from untreated depression, using logit transformed remission proportion as the dependent variable. Covariates included age, gender, study type and diagnostic measure.

RESULTS

Wait-listed compared to primary-care samples, studies with longer follow-up duration and older adult compared to adult samples were associated with lower probability of remission. Child and adolescent samples were associated with higher probability of remission. Based on adult samples recruited from primary-care settings, the model estimated that 23% of prevalent cases of untreated depression will remit within 3 months, 32% within 6 months and 53% within 12 months.

CONCLUSIONS

It is undesirable to expect 100% treatment coverage for depression, given many will remit before access to services is feasible. Data were drawn from consenting wait-list and primary-care samples, which potentially over-represented mild-to-moderate cases of depression. Considering reported rates of spontaneous remission, a short untreated period seems defensible for this subpopulation, where judged appropriate by the clinician. Conclusions may not apply to individuals with more severe depression.

Personalizing behavioral interventions: the case of late-life depression

This article reviews the potential utility of behavioral interventions in personalized depression treatment. The paper begins with a definition of personalized treatment, moves to current thinking regarding the various causes of depression, and proposes how those causes can be used to inform the selection of behavioral interventions. Two examples from the late-life depression field will illustrate how a team of researchers at Cornell University (NY, USA) and University of California, San Francisco (CA, USA) created a research partnership to select and study behavioral interventions for older adults with risk factors associated with poor response to selective serotonin reuptake inhibitor medications. The paper ends with a discussion of how the process used by the Cornell University-University of California, San Francisco team can be applied to the selection and development of behavioral interventions for other psychiatric disorders.

The functional implications of motor, cognitive, psychiatric, and social problem-solving states in Huntington's disease

OBJECTIVE

Huntington's disease (HD) is a genetic, neurodegenerative disorder characterized by motor, cognitive, and psychiatric dysfunction. In HD, the inability to solve problems successfully affects not only disease coping, but also interpersonal relationships, judgment, and independent living. The aim of the present study was to examine social problem-solving (SPS) in well-characterized HD and at-risk (AR) individuals and to examine its unique and conjoint effects with motor, cognitive, and psychiatric states on functional ratings.

METHOD

Sixty-three participants, 31 HD and 32 gene-positive AR, were included in the study. Participants completed the Social Problem-Solving Inventory-Revised: Long (SPSI-R:L), a 52-item, reliable, standardized measure of SPS. Items are aggregated under five scales (Positive, Negative, and Rational Problem-Solving; Impulsivity/Carelessness and Avoidance Styles). Participants also completed the Unified Huntington's Disease Rating Scale functional, behavioral, and cognitive assessments, as well as additional neuropsychological examinations and the Symptom Checklist-90-Revised (SCL-90R). A structural equation model was used to examine the effects of motor, cognitive, psychiatric, and SPS states on functionality.

RESULTS

The multifactor structural model fit well descriptively. Cognitive and motor states uniquely and significantly predicted function in HD; however, neither psychiatric nor SPS states did. SPS was, however, significantly related to motor, cognitive, and psychiatric states, suggesting that it may bridge the correlative gap between psychiatric and cognitive states in HD.

CONCLUSION

SPS may be worth assessing in conjunction with the standard gamut of clinical assessments in HD. Suggestions for future research and implications for patients, families, caregivers, and clinicians are discussed.

Activity scheduling as a core component of effective care management for late-life depression

BACKGROUND

Activity scheduling is an established component of evidenced-based treatment for late-life depression in primary care. We examined participant records from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial to identify activity scheduling strategies used in the context of successful depression care management (CM), associations of activity scheduling with self-reported activity engagement, and depression outcomes.

METHODS

This study used observational mixed methods analysis of 4335 CM session notes from 597 participants in the intervention arm of the IMPACT trial. Grounded theory was used to identify 17 distinct activity categories from CM notes. Logistic regression was used to evaluate associations between activity scheduling, activity engagement, and depression outcomes at 12 months. All relevant institutional review boards approved the research protocol.

RESULTS

Seventeen distinct activity categories were generated. Most patients worked on at least one social and one solitary activity during their course of treatment. Common activity categories included physical activity (32%), medication management (22%), active-non-physical (19%), and passive (14%) activities. We found significant, positive associations between activity scheduling, self-reported engagement in activities at 12 months, and depression outcomes at 12 months.

CONCLUSION

Older primary care patients in CM for depression worked on a wide range of activities. Consistent with depression theory that has placed emphasis on social activities, the data indicate a benefit for intentional social engagement versus passive social and solitary activities. Care managers should encourage patients to balance instrumental activities (e.g., attending to medical problems) with social activities targeting direct interpersonal engagement.

The effects of reminiscence therapy on depressive symptoms of Chinese elderly: study protocol of a randomized controlled trial

BACKGROUND

Depression is one of the most common mental disorders with a high prevalence among the older adults. In recent years, after realizing some side effects of the antidepressants, non-pharmacological psychological treatments begin to attract accruing attention. Reminiscence therapy is one of the psychological treatments that specially designed for the elderly to improve their mental health status by recalling and assessing their existing memory. Though some studies indicate reminiscence therapy can be effective and beneficial for the mental health of elderly, the conclusions are not consistent yet. The aim of this research is to assess the effectiveness of reminiscence therapy for Chinese elderly.

METHODS

Sixty older adults (≥60 years of age) with mild to moderate depression will be randomly assigned to an experimental or a control condition. The participants in the experiment group will receive the reminiscence therapy under the Watt's protocol with adaptation to Chinese Culture which consists of six weekly sessions of 90 minutes each. The control group will be treated as before. An assessor who is blind to intervention will conduct the measures before treatment, after treatment immediately, and three months after treatment.

DISCUSSION

This study will provide the evidence whether the reminiscence therapy is effective to treat depressive symptoms of Chinese elderly. This research has been registered in the clinicaltrials.gov (NCT01553669).

Depression interventions among racial and ethnic minority older adults: a systematic review across 20 years

While there is strong evidence in support of geriatric depression treatments, much less is available with regard to older U.S. racial and ethnic minorities. The objectives of this review are to identify and appraise depression treatment studies tested with samples of U.S. racial and ethnic minority older adults. We include an appraisal of sociocultural adaptations made to the depression treatments in studies meeting our final criteria. Systematic search methods were utilized to identify research published between 1990 and 2010 that describe depression treatment outcomes for older adults by racial/ethnic group, or for samples of older adults who are primarily (i.e., >50%) racial/ethnic minorities. Twenty-three unduplicated articles included older adults and seven met all inclusion criteria. Favorable depression treatment effects were observed for older minorities across five studies that took place in different types of settings and with varying levels of sociocultural adaptations. The effectiveness of depression care remains mixed, although collaborative or integrated care shows promise for African Americans and Latinos. The degree to which the findings generalize to non-English-speaking, low acculturated, and low-income older persons, and to other older minority groups (i.e., Asian and Pacific Islanders, and American Indian and Alaska Natives), remains unclear. Given the high disease burden among older minorities with depression, it is imperative to provide timely, accessible, and effective depression treatments. Increasing their participation in behavioral health research should be a national priority.

Cognition, coping, and outcome in Parkinson's disease

BACKGROUND

Cognitive impairment and depression are common and disabling non-motor symptoms of Parkinson's disease (PD). Previous studies have shown associations between them but the nature of the relationship remains unclear. In chronic illness, problem- or task-oriented coping strategies are associated with better outcome but often require higher level cognitive functioning. The present study investigated, in a sample of patients with PD, the relationships between cognitive function, choice of coping strategies, and a broad index of outcome including depression, anxiety, and health-related quality of life (QoL). It was hypothesized that the coping strategy used could mediate the association between cognition and outcome.

METHODS

347 participants completed the Coping Inventory for Stressful Situations, the Hospital Anxiety and Depression Scale, the Parkinson's Disease Questionnaire-8, the Unified Parkinson's Disease Rating Scale, and the Addenbrooke's Cognitive Examination-Revised. Structural Equation Modeling was used to test the hypothesized model of cognition, coping, and outcome based on a direct association between cognition and outcome and an indirect association mediated by coping.

RESULTS

Overall, poorer cognition predicted less use of task-oriented coping, which predicted worse outcome (a latent variable comprised of higher depression and anxiety and lower QoL). The analyses suggested a small indirect effect of cognition on outcome mediated by coping.

CONCLUSIONS

The findings suggest that patients who fail to employ task-oriented coping strategies may be at greater risk of depression, anxiety, and poor health-related QoL. Even mild to moderate cognitive impairment may contribute to reduced use of task-oriented coping. Suitably adapted cognitive-behavioral approaches may be useful to enable the use of adaptive coping strategies in such patients.

Effects of reminiscence interventions on psychosocial outcomes: a meta-analysis

OBJECTIVES

This study integrated results from controlled trials of reminiscence interventions.

METHODS

Meta-analysis was used to aggregate results from 128 studies on 9 outcome VARIABLES.

RESULTS

Compared to non-specific changes in control-group members, moderate improvements were observed at posttest with regard to ego-integrity (g=0.64) and depression (g=0.57 standard deviation units). Small effects were found on purpose in life (g=0.48), death preparation (g=0.40), mastery (g=0.40), mental health symptoms (g=0.33), positive well-being (g=0.33), social integration (g=0.31), and cognitive performance (g=0.24). Most effects were maintained at follow-up. We observed larger improvements of depressive symptoms in depressed individuals (g=1.09) and persons with chronic physical disease (g=0.94) than in other individuals, and in those receiving life-review therapy (g=1.28) rather than life-review or simple reminiscence. Moderating effects of the control condition were also detected.

CONCLUSIONS

Reminiscence interventions affect a broad range of outcomes, and therapeutic as well as preventive effects are similar to those observed in other frequently used interventions.

Treatment of depression in late life

This paper updates the 1996 review of treatment approaches published in the Am J Geriatr Psychiatry (1996;4[suppl 1]:S51-S65 [see ref33]) and a chapter in A Guide to Treatments that Work (Nathan PE, Gorman JM, eds), Oxford University Press, New York, 1998 [see ref 54]:. The major focus is on psychophannacoiogy with attention also to the évidence for the efficacy of psychotherapeutic and somatic approaches.

Depression in late life

Despite its prevalence and seriousness, depression in late life remains underappreciated as a source of disability and suffering for older people and their families. Despite a solid and substantial body of research, recognition of depression remains problematic and is often attributed to normal developmental changes in aging. Treatment efficacy data notwithstanding, the adequacy and appropriateness of treatment is highly variable. This paper contains a broad overview of new research developments in depression in late life and the disabilities associated with it Serving as an introduction to the specific papers that follow in this issue of Dialogues in Clinical Neuroscience, this article scans the knowledge base in basic, clinical, and health services research, identifying the highlights of current work in the area and proposing areas of needed expansion of research efforts.

Contribution of spontaneous improvement to placebo response in depression: a meta-analytic review

OBJECTIVES

It is unknown to what degree spontaneous improvement accounts for the large placebo response observed in antidepressant trials for Major Depressive Disorder (MDD). The purpose of this study was to estimate the spontaneous improvement observed in treatment-seeking individuals with acute MDD by determining the symptom change in depressed patients assigned to wait-list controls in psychotherapy studies.

METHOD

The databases PubMed and PsycINFO were searched to identify randomized, prospective studies randomizing outpatients to psychotherapy or a wait-list control condition for the treatment of acute MDD. Standardized effect sizes calculated from each identified study were aggregated in a meta-analysis to obtain a summary statistic for the change in depression scores during participation in a wait-list control.

RESULTS

Ten trials enrolling 340 participants in wait-list control conditions were identified. The estimated effect size for the change in depression scores during wait-list control was 0.505 (95% CI 0.271-0.739, p < 0.001), representing an average improvement of 4 points on the Hamilton Rating Scale for Depression.

DISCUSSION

Depressed patients acutely experience improvement even without treatment, but spontaneous improvement is unlikely to account for the magnitude of placebo response typically observed in antidepressant trials. These findings must be interpreted in light of the small number wait-list control participants available for analysis as well as certain methodological heterogeneity in the psychotherapy studies analyzed.

Posttraumatic stress disorder at the end of life: extant research and proposed psychosocial treatment approach

According to some estimates, 84% of people experience a traumatic event during their lives (Vrana & Lauterbach, 1994), and 15% to 24% then develop posttraumatic stress disorder (PTSD). Many carry with them lasting effects of trauma as they age and enter the last phase of life. PTSD manifests in unique ways at the end of life, possibly disrupting factors associated with a positive dying process, including social support, medical communication, life review, and acceptance of death. Terminally ill people with PTSD may suffer more emotional distress, lower quality of life, and poorer medical prognosis than those without PTSD. Unfortunately, healthcare providers may not be trained to address this issue. This article reviews the literature concerning how PTSD may affect the end of life and proposes an intervention model based on a palliative care philosophy.

The effectiveness of problem solving therapy in deprived South African communities: results from a pilot study

BACKGROUND

The majority of South Africans with a DSM-IV diagnosis receive no treatment for their mental health problems. There is a move to simplify treatment for common mental disorders (CMDs) in order to ease access. Brief problem solving therapy (PST) might fill the treatment gap for CMD's in deprived communities in South Africa. This pilot study evaluates the feasibility, acceptability and effectiveness of this PST program for CMD's in deprived communities around Cape Town.

METHODS

A Dutch problem solving program was adapted and translated into English, Xhosa and Afrikaans and thereafter implemented in townships around Cape Town. An initial attempt to recruit participants for online PST proved difficult, and so the program was adapted to a booklet format. Volunteers experiencing psychological distress were invited to participate in the either individually or group delivered 5-week during self-help program. To evaluate the effectiveness, psychological distress was administered through self-report questionnaires. After completion of the intervention participants also rated the program on various acceptability aspects.

RESULTS

Of 103 participants, 73 completed 5 weeks of brief PST in a booklet/workshop format. There were significantly more dropouts in those who used the booklet individually than in the group. Psychological distress measured on the K-10 and SRQ fell significantly and the program was evaluated positively.

CONCLUSIONS

The results suggest that brief problem solving in a booklet/workshop format may be an effective, feasible and acceptable short-term treatment for people with CMD's in deprived communities. In this setting, group delivery of PST had lower drop-out rates than individual delivery, and was more feasible and acceptable. Randomized controlled trials are needed to evaluate the effect of brief self-help PST more rigorously.

Late-life depression: evidence-based treatment and promising new directions for research and clinical practice

As the population ages, successive cohorts of older adults will experience depressive disorders. Late-life depression (LLD) carries additional risk for suicide, medical comorbidity, disability, and family caregiving burden. Although response and remission rates to pharmacotherapy and electroconvulsive therapy are comparable with those in midlife depression, relapse rates are higher, underscoring the challenge to achieve and maintain wellness. This article reviews the evidence base for LLD treatment options and provides an analysis of treatment options for difficult-to-treat LLD variants (eg, psychotic depression, vascular depression). Treatment algorithms are also reviewed based on predictors of response and promising novel treatment options.

Psychosocial interventions for late-life major depression: evidence-based treatments, predictors of treatment outcomes, and moderators of treatment effects

This systematic review evaluates the efficacy of psychosocial interventions for the acute treatment of late-life depression and identifies predictors of treatment outcomes and moderators of treatment effects. Problem-solving therapy, cognitive behavioral therapy, and treatment initiation and participation program have supportive evidence of efficacy, pending replication. Although the data on predictors of treatment outcomes and moderators of treatment effects are preliminary, it appears that baseline anxiety and stress level, personality disorders, endogenous depression, and reduced self-rated health predict worse depression outcomes. Future research may examine the moderating effects of baseline depression severity and identify other clinical or demographic moderators.

Is group psychotherapy effective in older adults with depression? A systematic review

OBJECTIVE

Earlier reviews and meta-analyses have consistently concluded that psychological treatment of depression is effective in older adults. We conducted a systematic review randomised controlled trials of group psychotherapy to present the best available evidence in relation to its effectiveness in older adults with depressive disorders.

METHODS

Electronic databases were searched to identify randomised controlled trials. Selected studies were quality assessed and data extracted by two reviewers.

RESULTS

Six trials met the inclusion criteria. The trials included in the review examined group interventions based on the cognitive behavioural therapy (CBT) model with active therapeutic interventions or waiting list controls. Group psychotherapy is an effective intervention in older adults with depression in comparison to waiting list controls, the overall effect size is very modest (MD = -3.92, 95%CI: -6.18, -1.67). The reported benefits of group intervention in comparison to other active interventions did not reach statistical significance. The benefits of group psychotherapy were maintained at follow-up. The quality of the studies varied and studies were heterogeneous.

CONCLUSIONS

Although quality of many studies was not optimal, the results of this meta analysis support the results of earlier meta analyses. Group cognitive behavioural therapy is effective in older adults with depression.

Problem-solving therapy and supportive therapy in older adults with major depression and executive dysfunction: effect on disability

CONTEXT

Older patients with depression and executive dysfunction represent a population with significant disability and a high likelihood of failing pharmacotherapy.

OBJECTIVES

To examine whether problem-solving therapy (PST) reduces disability more than does supportive therapy (ST) in older patients with depression and executive dysfunction and whether this effect is mediated by improvement in depressive symptoms.

DESIGN

Randomized controlled trial.

SETTING

Weill Cornell Medical College and University of California at San Francisco.

PARTICIPANTS

Adults (aged >59 years) with major depression and executive dysfunction recruited between December 2002 and November 2007 and followed up for 36 weeks. Intervention Twelve sessions of PST modified for older depressed adults with executive impairment or ST. Main Outcome Measure Disability as quantified using the 12-item World Health Organization Disability Assessment Schedule II.

RESULTS

Of 653 individuals referred to this study, 221 met the inclusion criteria and were randomized to receive PST or ST. Both PST and ST led to comparable improvement in disability in the first 6 weeks of treatment, but a more prominent reduction was noted in PST participants at weeks 9 and 12. The difference between PST and ST was greater in patients with greater cognitive impairment and more previous episodes. Reduction in disability paralleled reduction in depressive symptoms. The therapeutic advantage of PST over ST in reducing depression was, in part, due to greater reduction in disability by PST. Although disability increased during the 24 weeks after the end of treatment, the advantage of PST over ST was retained.

CONCLUSIONS

These results suggest that PST is more effective than ST in reducing disability in older patients with major depression and executive dysfunction, and its benefits were retained after the end of treatment. The clinical value of this finding is that PST may be a treatment alternative in an older patient population likely to be resistant to pharmacotherapy.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00052091.

Relations entre certaines caractéristiques des sujets et la réponse à la thérapie cognitive de la dépression avec des personnes âgées

Available research supports the therapeutic usefulness of cognitive therapy for depressed older adults. Few studies have addressed the issue of response prediction. This research investigates the associations between several pre-intervention characteristics of subjects and therapy outcomes in the context of a group intervention. The characteristics under study were severity of depressive symptommatology, endogenous depression profile, subjective health status, perceived social support, and frequency of cognitive depressive symptoms representing a negative view of oneself. A more severe depressive symptomatology and a more negative health perception were associated with a less favourable outcome of therapy. Although the majority of endogenous patients benefitted from the intervention, only a minority reached the level of symptom remission at the end of treatment. A more pronounced cluster of symptoms characterized by negative thoughts about oneself tended to be associated with a worse outcome. Perceived social support was unrelated to therapy outcome.

Problem-solving therapy and supportive therapy in older adults with major depression and executive dysfunction

OBJECTIVE

The purpose of this study was to determine whether problem-solving therapy is an effective treatment in older patients with depression and executive dysfunction, a population likely to be resistant to antidepressant drugs.

METHOD

Participants were adults age 60 and older with major depression and executive dysfunction. Problem-solving therapy was modified to be accessible to this population. Participants were randomly assigned to 12 weekly sessions of problem-solving therapy or supportive therapy and assessed at weeks 3, 6, 9, and 12.

RESULTS

Of the 653 individuals referred for this study, 221 met selection criteria and were enrolled in the study. Reduction of depressive symptom severity was comparable for the two treatment groups during the first 6 weeks of treatment, but at weeks 9 and 12 the problem-solving therapy group had a greater reduction in symptom severity, a greater response rate, and a greater remission rate than the supportive therapy group (response rates at week 9: 47.1% and 29.3%; at week 12:56.7% and 34.0%; remission rates at week 9: 37.9% and 21.7%; at week 12: 45.6% and 27.8%). Problem-solving therapy yielded one additional response or remission over supportive therapy for every 4.4-5.6 patients by the end of the trial.

CONCLUSIONS

These results suggest that problem-solving therapy is effective in reducing depressive symptoms and leading to treatment response and remission in a considerable number of older patients with major depression and executive dysfunction. The clinical value of this finding is that problem-solving therapy may be a treatment alternative in an older patient population likely to be resistant to pharmacotherapy.

Continuous and dichotomous outcomes in studies of psychotherapy for adult depression: a meta-analytic comparison

BACKGROUND

In treatment research on depressive disorders, outcomes can be based on continuous outcomes but also on dichotomous outcomes. Although it is possible to convert the two types of outcomes to each other, it has not been tested whether this results in systematic differences.

METHOD

We selected studies on psychotherapy for adult depression from an existing database, in which both continuous and dichotomous outcomes were presented. We calculated effect sizes using both types of outcomes, and compared the results.

RESULTS

Although there were considerable differences between the two types of outcomes in individual studies, both types of outcomes resulted in very similar pooled effect sizes. The pooled effect size based on the continuous outcome were somewhat more conservative (d=0.59; OR=2.92) than the one based on the dichotomous outcome (d=0.64; OR=3.17). Heterogeneity was higher in the analyses based on the continuous outcomes than in those based on the dichotomous outcomes. Sensitivity analyses and subgroup analyses confirmed that the pooled effect sizes were very similar, that the effect sizes were somewhat smaller when the continuous outcomes are used, and that heterogeneity was higher in the analyses based on the continuous outcomes.

CONCLUSION

Overall, the two types of outcomes result in comparable pooled effect sizes and can both be used in meta-analyses. However, the results of the two types of outcomes should not be used interchangeably, because there may be systematic differences in heterogeneity and subgroup analyses.

Adapting problem-solving therapy for depressed older adults in methadone maintenance treatment

Late-life depression is prevalent in older adults who are dependent on opiates. Depressive disorders among opiate abusers have detrimental effects on their well-being and ability to refrain from illegal drugs. There are numerous barriers to the provision of appropriate mental health care to older adults receiving methadone maintenance treatment. This article focuses on problem-solving therapy (PST) and presents evidence that PST may be a promising nonpharmacological treatment for older methadone clients with comorbid depressive disorders that can be applied within the staffing and resource limits of methadone maintenance treatment facilities. The advantages of PST relative to other behavioral therapies for this population are based on evidence that PST is less cognitively demanding for an older adult population with mood and substance use disorders. A properly modified PST for an older adult substance-dependent population with subsyndromal or diagnosed depression may be a viable option for methadone maintenance programs with limited resources.

A review of empirically supported psychological therapies for mood disorders in adults

BACKGROUND

The mood disorders are prevalent and problematic. We review randomized controlled psychotherapy trials to find those that are empirically supported with respect to acute symptom reduction and the prevention of subsequent relapse and recurrence.

METHODS

We searched the PsycINFO and PubMed databases and the reference sections of chapters and journal articles to identify appropriate articles.

RESULTS

One hundred twenty-five studies were found evaluating treatment efficacy for the various mood disorders. With respect to the treatment of major depressive disorder (MDD), interpersonal psychotherapy (IPT), cognitive behavior therapy (CBT), and behavior therapy (BT) are efficacious and specific and brief dynamic therapy (BDT) and emotion-focused therapy (EFT) are possibly efficacious. CBT is efficacious and specific, mindfulness-based cognitive therapy (MBCT) efficacious, and BDT and EFT possibly efficacious in the prevention of relapse/recurrence following treatment termination and IPT and CBT are each possibly efficacious in the prevention of relapse/recurrence if continued or maintained. IPT is possibly efficacious in the treatment of dysthymic disorder. With respect to bipolar disorder (BD), CBT and family-focused therapy (FFT) are efficacious and interpersonal social rhythm therapy (IPSRT) possibly efficacious as adjuncts to medication in the treatment of depression. Psychoeducation (PE) is efficacious in the prevention of mania/hypomania (and possibly depression) and FFT is efficacious and IPSRT and CBT possibly efficacious in preventing bipolar episodes.

CONCLUSIONS

The newer psychological interventions are as efficacious as and more enduring than medications in the treatment of MDD and may enhance the efficacy of medications in the treatment of BD.

An individualized dyadic problem-solving education intervention for patients and family caregivers during allogeneic hematopoietic stem cell transplantation: a feasibility study

BACKGROUND

Allogeneic hematopoietic stem cell transplantation (HSCT) generates multiple problems that vary in complexity and create significant distress for both patients and their caregivers. Interventions that address patient and family caregiver distress during allogeneic hematopoietic stem cell transplantation (HSCT) have not been tested.

OBJECTIVE

To evaluate the feasibility of conducting an individualized dyadic problem-solving education (PSE) intervention during HSCT and estimate a preliminary effect size on problem-solving skills and distress.

METHODS

The PSE intervention consisted of 4 sessions of the Prepared Family Caregiver PSE model. Data were collected with an interventionist log, subject interviews and standardized questionnaires.

RESULTS

Of the 34 adult dyads screened, 24 were ineligible primarily because of being non-English-speaking (n = 11) and inconsistent caregivers (n = 10). Ten dyads (n = 20) were enrolled, and 8 dyads (n = 16) completed the intervention. Of the 31 sessions, 29 were completed (94%). Worsening patient condition was the primary reason for sessions to be incomplete. Patients attended 90% of the sessions; caregivers attended 74%. Reasons for missed sessions included patient symptom distress and limited caregiver availability. Dyads reported being very satisfied (mean, 4.8 [SD, 1.8]; range, 1-5), stating "an opportunity to talk" and "creative thinking" were most beneficial.

CONCLUSION

Results suggest that dyads can participate in PSE during HSCT and view it as beneficial. Participants identified the active process of solving problems as helpful.

IMPLICATIONS FOR PRACTICE

Targeted interventions that promote effective, meaningful behaviors are needed to guide patients and caregivers through HSCT. Future research recommendations include testing a version of PSE with fewer sessions, including spousal and nonspousal caregivers and those who are non-English speaking.

Online cognitive behavioral therapy and problem-solving therapy for depressive symptoms: Exploring mechanisms of change

The purpose of this study was to evaluate treatment specificity and potential mediators of two online therapies for depressive symptoms. We conducted a randomized controlled trial in which 263 participants were randomized to online cognitive behavioral therapy (CBT), online problem-solving therapy (PST) or a waiting list control group. Both treatments were more effective than the control group in reducing dysfunctional attitudes, worry, negative problem orientation and enhancing feelings of control. No differences between the treatments were found on each of the potential mediators. Furthermore, results suggest that dysfunctional attitudes, worrying, a negative problem orientation and perceived control all played a mediating role in CBT as well as in PST. Our findings suggest that regardless of the theoretical background to the therapy, the psychological processes necessary for symptom reduction seem to be comparable.

Reminiscence and mental health: a review of recent progress in theory, research and interventions

This article explores recent progress in theory, research and practical applications of reminiscence. It first describes the evidence for reminiscence as a naturally occurring process, and discusses the different functions of reminiscence and their relationships with mental health and lifespan processes. Three basic types of reminiscence that relate to mental health are specified: conversations about autobiographical memories and the use of personal recollections to teach and inform others have social functions; positive functions for the self include the integration of memories into identity, recollections of past problem-solving behaviours, and the use of memories to prepare for one's own death; negative functions for the self are the use of past memories to reduce boredom, to revive bitterness, or to maintain intimacy with deceased persons. It is proposed that in interventions the three types are addressed differently: simple reminiscence stimulates social reminiscence and bonding and promotes positive feelings; life review uses the positive functions to enhance personal wellbeing; and life-review therapy seeks to reduce the negative uses and thereby alleviate symptoms of mental illness. Studies of the effectiveness of interventions have provided some evidence that interventions are effective in relation to their goals. The review closes with recommended directions for future reminiscence research.

Cognitive behavioural therapy and reminiscence techniques for the treatment of depression in the elderly: a systematic review

Psychotherapy, including cognitive behavioural therapy (CBT), reminiscence and general psychotherapy (GPT), is viewed as effective treatment for depression, but its efficacy in older people is not well defined. This systematic review included 14 randomized controlled trials that assessed the efficacy of psychotherapy for treating depression in elderly people (> or = 55 years). The results of this meta-analysis showed that, compared with placebo, psychotherapy was more effective in reducing depression scores (standardized mean difference -0.92; 95% confidence interval -1.21, -0.36). Subgroup analysis showed that CBT, reminiscence and GPT were all more effective than placebo; psychotherapy as an adjunct to antidepressant medication did not increase effectiveness. There was no significant difference between CBT and reminiscence in improving depression. A higher drop-out rate was observed in studies that did not include psychotherapy versus those that did, although this difference was not statistically significant. Thus, various general formats of psychotherapy are effective for treating depression in older people, although psychotherapy does not significantly increase the effectiveness of anti-depressant medication.

Varying cluster sizes in trials with clusters in one treatment arm: sample size adjustments when testing treatment effects with linear mixed models

Trials in which treatments induce clustering of observations in one of two treatment arms, such as when comparing group therapy with pharmacological treatment or with a waiting-list group, are examined with respect to the efficiency loss caused by varying cluster sizes. When observations are (approximately) normally distributed, treatment effects can be estimated and tested through linear mixed model analysis. For maximum likelihood estimation, the asymptotic relative efficiency of unequal versus equal cluster sizes is derived. In an extensive Monte Carlo simulation for small sample sizes, the asymptotic relative efficiency turns out to be accurate for the treatment effect, but less accurate for the random intercept variance. For the treatment effect, the efficiency loss due to varying cluster sizes rarely exceeds 10 per cent, which can be regained by recruiting 11 per cent more clusters for one arm and 11 per cent more persons for the other. For the intercept variance the loss can be 16 per cent, which requires recruiting 19 per cent more clusters for one arm, with no additional recruitment of subjects for the other arm.

Problem solving, treatment adherence, and weight-loss outcome among women participating in lifestyle treatment for obesity

OBJECTIVE

This study examined whether improvements in problem-solving abilities mediate the relation between treatment adherence and weight-loss outcome in the behavioral treatment of obesity.

METHOD

272 women (mean+/-SD age=59.4+/-6.2 years, BMI=36.5+/-4.8) participated in a 6-month lifestyle intervention for obesity. Body weight and problem-solving skills (as measured by the Social Problem Solving Inventory-Revised) were assessed pre- and posttreatment. The completion of self-monitoring logs during the intervention served as the marker of treatment adherence.

RESULTS

At posttreatment, participants lost 8.4+/-5.8 kg, an 8.8% reduction in body weight. Changes in weight were associated with increased problem-solving skills and with higher levels of treatment adherence. Improvements in problem-solving skills partially mediated the relation between treatment adherence and weight-loss outcome. Moreover, participants with weight reductions > or = 10% demonstrated significantly greater improvements in problem-solving skills than those with reductions <5%.

DISCUSSION

Improvements in problem-solving skills may enable participants to overcome barriers to adherence and thereby enhance treatment-induced weight losses.