1
|
Tops L, Beerten SG, Vandenbulcke M, Vermandere M, Deschodt M. Integrated Care Models for Older Adults with Depression and Physical Comorbidity: A Scoping Review. Int J Integr Care 2024; 24:1. [PMID: 38222854 PMCID: PMC10786096 DOI: 10.5334/ijic.7576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 12/07/2023] [Indexed: 01/16/2024] Open
Abstract
Objective Multimorbidity is a growing challenge in the care for older people with mental illness. To address both physical and mental illnesses, integrated care management is required. The purpose of this scoping review is to identify core components of integrated care models for older adults with depression and physical comorbidity, and map reported outcomes and implementation strategies. Methods PubMed, EMBASE, CINAHL and Cochrane Library were searched independently by two reviewers for studies concerning integrated care interventions for older adults with depression and physical comorbidity. We used the SELFIE framework to map core components of integrated care models. Clinical and organisational outcomes were mapped. Results Thirty-eight studies describing thirteen care models were included. In all care models, a multidisciplinary team was involved. The following core components were mainly described: continuity, person-centredness, tailored holistic assessment, pro-activeness, treatment interaction, individualized care planning, and coordination tailored to complexity of care needs. Twenty-seven different outcomes were evaluated, with more attention given to clinical than to organisational outcomes. Conclusion The core components that comprise integrated care models are diverse. Future studies should focus more on implementation aspects of the intervention and describe financial parts, e.g., the cost of the intervention for the healthcare user, more transparently.
Collapse
Affiliation(s)
- Laura Tops
- Academic Centre of General Practice, KU Leuven, Kapucijnenvoer 7, Box 7001, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Simon Gabriël Beerten
- Academic Centre of General Practice, KU Leuven, Kapucijnenvoer 7, Box 7001, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Mathieu Vandenbulcke
- Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
- Department of Geriatric Psychiatry, University Psychiatric Centre, KU Leuven, Leuven, Belgium
| | - Mieke Vermandere
- Academic Centre of General Practice, KU Leuven, Kapucijnenvoer 7, Box 7001, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Mieke Deschodt
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Competence Center for Nursing, University Hospitals Leuven, Belgium
- Gerontology and Geriatrics, University Hospitals Leuven, Belgium
| |
Collapse
|
2
|
Abstract
BACKGROUND Interpersonal Psychotherapy (IPT) is an affect- and relationally focused, time-limited treatment supported by research spanning >4 decades. IPT focuses on stressful interpersonal experiences of loss, life changes, disputes, and social isolation. It emphasizes the role of relationships in recovery. This scoping review describes, within a historical perspective, IPT's evolution as an evidence-supported treatment of psychiatric disorders. METHODS English-language publications (n = 1119) identified via EMBASE, MEDLINE, PsycINFO, and Web of Science databases (1974-2017), augmented with manual reference searches, were coded for clinical focus, population demographics, format, setting, publication type, and research type. Quantitative and qualitative analyses identified IPT publications' characteristics and trends over four epochs of psychotherapy research. RESULTS IPT literature primarily focused on depression (n = 772 articles; 69%), eating disorders (n = 135; 12%), anxiety disorders (n = 68; 6%), and bipolar disorder (n = 44; 4%), with rising publication rates and numbers of well-conducted randomized, controlled trials over time, justifying inclusion in consensus treatment guidelines. Research trends shifted from efficacy trials to effectiveness studies and population-based dissemination initiatives. Process research examined correlates of improvement and efficacy moderators. Innovations included global initiatives, prevention trials, and digital, web-based training and treatment. CONCLUSION Sparked by clinical innovations and scientific advances, IPT has evolved as an effective treatment of psychiatric disorders across the lifespan for diverse patients, including underserved clinical populations. Future research to elucidate mechanisms of change, improve access, and adapt to changing frameworks of psychopathology and treatment planning is needed. IPT addresses the universal centrality of relationships to mental health, which is as relevant today as it was over 40 years ago.
Collapse
|
3
|
Kelly J, Jayaram H, Bhar S, Jesto S, George K. Psychotherapeutic skills training for nurses on an acute aged mental health unit: A mixed-method design. Int J Ment Health Nurs 2019; 28:501-515. [PMID: 30426645 DOI: 10.1111/inm.12555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2018] [Indexed: 11/29/2022]
Abstract
This study examines the need for, and outcomes of, a psychotherapeutic skills training programme, within an acute psychogeriatric unit. Nursing staff were surveyed to explore their training needs in psychotherapeutic skills with inpatients diagnosed with depressive, anxiety, or neurocognitive disorders. Staff were then invited to participate in a focus group (n = 6) to identify content of such training, possible barriers, and an implementation strategy. Next, to ascertain the feasibility and acceptability of such training, materials and schedules were developed and piloted with a small group of nurses (n = 8), before being administered to nurses across the unit (n = 23). Impacts of training on the confidence and competence of nurses to use such skills were investigated. Of nurses surveyed (n = 20), 80% wanted to use psychotherapeutic skills in routine practice, but only 35% had received training in such skills in the last 5 years. Focus group results identified that nurses wanted training in skills related to engaging patients, responding to resistance from patients, problem solving, reminiscence, relaxation, and cognitive behaviour therapy. Nurses who underwent the pilot training reported increases in confidence and competence in using such skills. These findings were replicated in the unit-wide training programme and were found to be durable across a 3-month follow-up period. This study highlighted the training needs of nurses working in an inpatient psychogeriatric setting, approaches to implementing new skills, and benefits of training for nurses' levels of confidence and competence in using psychotherapeutic skills.
Collapse
Affiliation(s)
- Julie Kelly
- Department of Psychological Sciences, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - Hemalatha Jayaram
- Aged Persons Mental Health Service, Eastern Health, Forest Hill, Melbourne, Victoria, Australia
| | - Sunil Bhar
- Department of Psychological Sciences, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - Sahaya Jesto
- Aged Persons Mental Health Service, Eastern Health, Forest Hill, Melbourne, Victoria, Australia
| | - Kuruvilla George
- Aged Persons Mental Health Service, Eastern Health, Forest Hill, Melbourne, Victoria, Australia
| |
Collapse
|
4
|
Mackin RS, Nelson JC, Delucchi K, Raue P, Byers A, Barnes D, Satre DD, Yaffe K, Alexopoulos GS, Arean PA. Cognitive outcomes after psychotherapeutic interventions for major depression in older adults with executive dysfunction. Am J Geriatr Psychiatry 2014; 22:1496-503. [PMID: 24378255 PMCID: PMC4108572 DOI: 10.1016/j.jagp.2013.11.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 11/08/2013] [Accepted: 11/12/2013] [Indexed: 10/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- R. Scott Mackin
- University of California, San Francisco, Department of Psychiatry, San Francisco, CA,Center for Imaging of Neurodegenerative Disease, Veterans Administration Medical Center, San Francisco, CA
| | - J. Craig Nelson
- University of California, San Francisco, Department of Psychiatry, San Francisco, CA
| | - Kevin Delucchi
- University of California, San Francisco, Department of Psychiatry, San Francisco, CA
| | - Patrick Raue
- Weill Cornell Medical College, Department of Psychiatry, New York, NY
| | - Amy Byers
- University of California, San Francisco, Department of Psychiatry, San Francisco, CA,Veterans Administration Medical Center, San Francisco, CA
| | - Deborah Barnes
- University of California, San Francisco, Department of Psychiatry, San Francisco, CA,Veterans Administration Medical Center, San Francisco, CA
| | - Derek D. Satre
- University of California, San Francisco, Department of Psychiatry, San Francisco, CA,Kaiser Permanente Division of Research, Oakland, CA
| | - Kristine Yaffe
- University of California, San Francisco, Department of Psychiatry, San Francisco, CA,Veterans Administration Medical Center, San Francisco, CA
| | | | - Patricia A. Arean
- University of California, San Francisco, Department of Psychiatry, San Francisco, CA
| |
Collapse
|
5
|
Abstract
Older adults with Diabetes Mellitus (DM) experience greater risk for comorbid depression compared to those who do not have DM. Undetected, untreated or under-treated depression impinges an individual's ability to manage their DM successfully, hinders their adherence to treatment regime, and undermines provider-patient relationships. Thus, in the context of caring for older adults with DM, comorbid depression presents special challenges and opportunities for clinicians. In this article, we summarize the clinical presentation of late-life depression, potential mechanisms of comorbidity of depression and DM, importance of depression in the successful management of DM, and available best practice models for depression treatment.
Collapse
Affiliation(s)
- Mijung Park
- Department of Health and Community Systems, University of Pittsburgh, School of Nursing, 3500 Victoria Street, 421 Victoria Building, Pittsburgh, PA 15213, USA.
| | - Charles F Reynolds
- NIMH Center of Excellence in Late Life Depression Prevention and Treatment, Hartford Center of Excellence in Geriatric Psychiatry, Aging Institute of UPMC Senior Services and University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15213-2582, USA
| |
Collapse
|
6
|
Khoury B, Ammar J. Cognitive behavioral therapy for treatment of primary care patients presenting with psychological disorders. Libyan J Med 2014; 9:24186. [PMID: 24690496 PMCID: PMC3972417 DOI: 10.3402/ljm.v9.24186] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 03/03/2014] [Indexed: 11/14/2022] Open
Abstract
Mental disorders affect a great number of people worldwide. Four out of the 10 leading causes of disability in the world are mental disorders. Because of the scarcity of specialists around the world and especially in developing countries, it is important for primary care physicians to provide services to patients with mental disorders. The most widely researched and used psychological approach in primary care is cognitive behavioral therapy. Due to its brief nature and the practical skills it teaches, it is convenient for use in primary care settings. The following paper reviews the literature on psychotherapy in primary care and provides some practical tips for primary care physicians to use when they are faced with patients having mental disorders.
Collapse
Affiliation(s)
- Brigitte Khoury
- Department of Psychiatry, American University of Beirut, Beirut, Lebanon;
| | - Joumana Ammar
- Department of Psychiatry, American University of Beirut, Beirut, Lebanon
| |
Collapse
|
7
|
Aburizik A, Dindo L, Kaboli P, Charlton M, Dawn K, Turvey C. A pilot randomized controlled trial of a depression and disease management program delivered by phone. J Affect Disord 2013; 151:769-774. [PMID: 23871127 DOI: 10.1016/j.jad.2013.06.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 05/22/2013] [Accepted: 06/19/2013] [Indexed: 01/18/2023]
Abstract
BACKGROUND Depression in medically ill patients occurs at twice the rate found in the general population. Though pharmacologic and psychotherapeutic interventions for depression are effective, response to treatment and access to care are barriers for this population. A multidimensional telehealth intervention was designed to focus on these barriers by delivering a phone based intervention that addressed managing one's illness and coping emotionally. METHODS Veterans with diabetes, hypertension, or chronic pain and depressive symptoms were randomized to one of three conditions: Usual Care (n=23), Illness Management Only (n=31), or Combined Psychotherapy and Illness Management (n=29). Those randomized to the Combined or Illness Management Only intervention group received 10 phone visits. Veterans in the Combined group received all aspects of the illness management program plus a manualized depression intervention. Subjects completed assessments at baseline, week 5, and 10 to test the main hypothesis that veterans in the Combined condition would have a greater decline in depressive symptoms. RESULTS The Combined intervention yielded a significant decline in depressive symptoms when compared with Usual Care. However, the there was no significant difference between the Combined and Illness Management Only groups. LIMITATIONS This is a pilot study with a small sample size relative to a standard randomized controlled trial in psychotherapy. CONCLUSIONS This telephone-based intervention succeeded in reducing depressive symptoms in veterans with chronic illness. It adds to the building evidence base for providing phone-delivered mental health services.
Collapse
Affiliation(s)
- Arwa Aburizik
- VA Office of Rural Health, Veterans Rural Health Resource Center-Central Region, Iowa City VAMC, Iowa City, IA and the Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Health Care System, Iowa City, IA, United States; Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa city, IA, United States
| | - Lilian Dindo
- Department of Psychiatry, The University of Iowa, Carver College of Medicine, Iowa City, IA, United States
| | - Peter Kaboli
- VA Office of Rural Health, Veterans Rural Health Resource Center-Central Region, Iowa City VAMC, Iowa City, IA and the Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Health Care System, Iowa City, IA, United States
| | - Mary Charlton
- VA Office of Rural Health, Veterans Rural Health Resource Center-Central Region, Iowa City VAMC, Iowa City, IA and the Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Health Care System, Iowa City, IA, United States; Department of Epidemiology, The University of Iowa College of Public Health, Iowa City, IA, United States
| | - Klein Dawn
- VA Office of Rural Health, Veterans Rural Health Resource Center-Central Region, Iowa City VAMC, Iowa City, IA and the Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Health Care System, Iowa City, IA, United States; Department of Psychiatry, The University of Iowa, Carver College of Medicine, Iowa City, IA, United States
| | - Carolyn Turvey
- VA Office of Rural Health, Veterans Rural Health Resource Center-Central Region, Iowa City VAMC, Iowa City, IA and the Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Health Care System, Iowa City, IA, United States; Department of Psychiatry, The University of Iowa, Carver College of Medicine, Iowa City, IA, United States.
| |
Collapse
|
8
|
Heller K, Viken RJ, Swindle RW. What do network members know? Network members as reporters of depression among Caucasian-American and African-American older women. Aging Ment Health 2013; 17:215-25. [PMID: 22971135 DOI: 10.1080/13607863.2012.721113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To determine whether family members and friends can be accurate reporters of depression in older women and whether their reports predict diagnostic depression concurrently and across a one-year time interval. METHOD African-American and Caucasian older women (N = 153; mean age = 75) previously screened for depression nominated network members (NMs) who could be contacted as informants. NMs completed an informant version of the CES-D, described their closeness to the participant, the extent of the participant's support from family and friends, and their assessment of the participant's typical coping strategies. These reports were then used to predict participant CES-D, Hamilton depression scores, and Structured Clinical Interview (SCID) depression diagnoses concurrently and at six-month and one-year intervals. RESULTS NMs' estimates of participants CES-D status were highly correlated with participants own CES-D scores, and also predicted Hamilton depression scores and SCID diagnoses concurrently and at six months and one year later. NMs' ratings of participants' use of positive coping also predicted depression at six months and one year. CONCLUSION NMs knew when elderly women were depressed and their reports were accurate predictors of depression even one year later, which implies that elderly depression does not abate spontaneously. Future research should test the possibility that family and friends might be recruited as allies in encouraging earlier treatment and in providing support to older adults through difficult life transitions.
Collapse
Affiliation(s)
- Kenneth Heller
- Department of Psychological and Brain Sciences, Indiana University Bloomington, Bloomington, IN, USA.
| | | | | |
Collapse
|
9
|
Gallo JJ, Morales KH, Bogner HR, Raue PJ, Zee J, Bruce ML, Reynolds CF. Long term effect of depression care management on mortality in older adults: follow-up of cluster randomized clinical trial in primary care. BMJ 2013; 346:f2570. [PMID: 23738992 PMCID: PMC3673762 DOI: 10.1136/bmj.f2570] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To investigate whether an intervention to improve treatment of depression in older adults in primary care modified the increased risk of death associated with depression. DESIGN Long term follow-up of multi-site practice randomized controlled trial (PROSPECT-Prevention of Suicide in Primary Care Elderly: Collaborative Trial). SETTING 20 primary care practices in New York City, Philadelphia, and Pittsburgh, USA, randomized to intervention or usual care. PARTICIPANTS 1226 participants identified between May 1999 and August 2001 through a two stage, age stratified (60-74; ≥ 75 years) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of patients who screened negative. INTERVENTION For two years, a depression care manager worked with primary care physicians in intervention practices to provide algorithm based care for depression, offering psychotherapy, increasing antidepressant dose if indicated, and monitoring symptoms, adverse effects of drugs, and adherence to treatment. This paper reports the long term follow-up. MAIN OUTCOME MEASURE Mortality risk based on a median follow-up of 98 (range 0.8-116.4) months through 2008. RESULTS In baseline clinical interviews, 396 people were classified as having major depression, 203 had clinically significant minor depression, and 627 did not meet criteria for depression. At follow-up, 405 patients had died. Patients with major depression in usual care were more likely to die than were those without depression (hazard ratio 1.90, 95% confidence interval 1.57 to 2.31). In contrast, patients with major depression in intervention practices were at no greater risk than were people without depression (hazard ratio 1.09, 0.83 to 1.44). Patients with major depression in intervention practices, relative to usual care, were 24% less likely to have died (hazard ratio 0.76, 0.57 to 1.00; P=0.05). Preliminary data on cause of death are provided. No significant effect on mortality was found for minor depression. CONCLUSIONS Older adults with major depression in practices provided with additional resources to intensively manage depression had a mortality risk lower than that observed in usual care and similar to older adults without depression. TRIAL REGISTRATION Clinical trials NCT00000367.
Collapse
Affiliation(s)
- Joseph J Gallo
- Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, 624 North Broadway, Baltimore, MD 21205, USA
| | | | | | | | | | | | | |
Collapse
|
10
|
Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, Dickens C, Coventry P. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev 2012; 10:CD006525. [PMID: 23076925 DOI: 10.1002/14651858.cd006525.pub2] [Citation(s) in RCA: 465] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Common mental health problems, such as depression and anxiety, are estimated to affect up to 15% of the UK population at any one time, and health care systems worldwide need to implement interventions to reduce the impact and burden of these conditions. Collaborative care is a complex intervention based on chronic disease management models that may be effective in the management of these common mental health problems. OBJECTIVES To assess the effectiveness of collaborative care for patients with depression or anxiety. SEARCH METHODS We searched the following databases to February 2012: The Cochrane Collaboration Depression, Anxiety and Neurosis Group (CCDAN) trials registers (CCDANCTR-References and CCDANCTR-Studies) which include relevant randomised controlled trials (RCTs) from MEDLINE (1950 to present), EMBASE (1974 to present), PsycINFO (1967 to present) and the Cochrane Central Register of Controlled Trials (CENTRAL, all years); the World Health Organization (WHO) trials portal (ICTRP); ClinicalTrials.gov; and CINAHL (to November 2010 only). We screened the reference lists of reports of all included studies and published systematic reviews for reports of additional studies. SELECTION CRITERIA Randomised controlled trials (RCTs) of collaborative care for participants of all ages with depression or anxiety. DATA COLLECTION AND ANALYSIS Two independent researchers extracted data using a standardised data extraction sheet. Two independent researchers made 'Risk of bias' assessments using criteria from The Cochrane Collaboration. We combined continuous measures of outcome using standardised mean differences (SMDs) with 95% confidence intervals (CIs). We combined dichotomous measures using risk ratios (RRs) with 95% CIs. Sensitivity analyses tested the robustness of the results. MAIN RESULTS We included seventy-nine RCTs (including 90 relevant comparisons) involving 24,308 participants in the review. Studies varied in terms of risk of bias.The results of primary analyses demonstrated significantly greater improvement in depression outcomes for adults with depression treated with the collaborative care model in the short-term (SMD -0.34, 95% CI -0.41 to -0.27; RR 1.32, 95% CI 1.22 to 1.43), medium-term (SMD -0.28, 95% CI -0.41 to -0.15; RR 1.31, 95% CI 1.17 to 1.48), and long-term (SMD -0.35, 95% CI -0.46 to -0.24; RR 1.29, 95% CI 1.18 to 1.41). However, these significant benefits were not demonstrated into the very long-term (RR 1.12, 95% CI 0.98 to 1.27).The results also demonstrated significantly greater improvement in anxiety outcomes for adults with anxiety treated with the collaborative care model in the short-term (SMD -0.30, 95% CI -0.44 to -0.17; RR 1.50, 95% CI 1.21 to 1.87), medium-term (SMD -0.33, 95% CI -0.47 to -0.19; RR 1.41, 95% CI 1.18 to 1.69), and long-term (SMD -0.20, 95% CI -0.34 to -0.06; RR 1.26, 95% CI 1.11 to 1.42). No comparisons examined the effects of the intervention on anxiety outcomes in the very long-term.There was evidence of benefit in secondary outcomes including medication use, mental health quality of life, and patient satisfaction, although there was less evidence of benefit in physical quality of life. AUTHORS' CONCLUSIONS Collaborative care is associated with significant improvement in depression and anxiety outcomes compared with usual care, and represents a useful addition to clinical pathways for adult patients with depression and anxiety.
Collapse
Affiliation(s)
- Janine Archer
- School of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, UK.
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Abstract
Depression is a common, disabling, and costly condition encountered in older patients. Effective strategies for detection and treatment of late-life depression are summarized based on a case of a 69-year-old woman who struggled with prolonged depression. Clinicians should screen older patients for depression using a standard rating scale, initiate treatment such as antidepressant medications or evidence-based psychotherapy, and monitor depression symptoms. Patients who are not improving should be considered for psychiatric consultation and treatment changes including electroconvulsive therapy. Several changes in treatment approaches are usually needed before patients achieve complete remission. Maintenance treatment and relapse-prevention planning (summarization of early warning signs for depression, maintenance treatments such as medications, and other strategies to reduce the risk of relapse [eg, regular physical activity or pleasant activities]) can reduce the risk of relapse. Collaborative programs, in which primary care clinicians work closely with mental health specialists following a measurement-based treatment-to-target approach, are significantly more effective than typical primary care treatment.
Collapse
Affiliation(s)
- Jürgen Unützer
- Psychiatry and Behavioral Sciences Chief of Psychiatry, University of Washington Medical Center Director, UW AIMS Center (http://uwaims.org) Director, IMPACT Implementation Program (http://impact-uw.org) 1959 NE Pacific Street Box 356560 Seattle, Washington 98195-6560
| | - Mijung Park
- Postdoctoral fellow of Geriatric Mental Health Services Research Department of Psychiatry and Behavioral Sciences University of Washington
| |
Collapse
|
12
|
Abstract
Depression is highly prevalent and debilitating among medically ill patients. As high as one third of the primary practise patients screen positive for depression symptoms and over half of the patients diagnosed with major depressive disorder are treated in primary care. However, current primary care service arrangements do not efficiently triage patients who screen positive for depression into appropriate treatments that reflect their individual needs and preferences. In this paper, we describe a tool that aims to fill the gap between screening the patients for depression and triaging them to appropriate care. This is a three-session adaptation of interpersonal psychotherapy: ipt; evaluation, support, triage (IPT-EST). We first outline IPT-EST procedures that aim to provide structure and content to primary care practitioners who identify patients with positive depression symptoms, thus assisting the practitioners to explore the patients' psychosocial triggers of depression, give basic strategies to manage these interpersonal stressors and provide decisions tools about triaging patients with severe/persistent depression into appropriate treatment.
Collapse
Affiliation(s)
- Myrna Weissman
- College of Physicians and Surgeons, Columbia University, New York, USA.
| | | |
Collapse
|
13
|
Fortney JC, Pyne JM, Smith JL, Curran GM, Otero JM, Enderle MA, McDougall S. Steps for implementing collaborative care programs for depression. Popul Health Manag 2010; 12:69-79. [PMID: 19320606 DOI: 10.1089/pop.2008.0023] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Numerous studies have demonstrated that collaborative care (care management) for depression improves outcomes, yet few clinics have implemented this evidence-based practice. To promote adoption of this best practice, our objective was to describe the steps needed to tailor collaborative care models for local needs, resources, and priorities while maintaining fidelity to the evidence base. Based on lessons learned from 2 multisite Veterans Affairs implementation studies conducted in 2 different clinical, organizational, and geographic contexts, we describe in detail the steps needed to adapt an evidence-based collaborative care program for depression for local context while maintaining highly fidelity to the research evidence. These steps represent a detailed checklist of decisions and action items that can be used as a tool to plan the implementation of a collaborative care model for depression. We also identify other tools (eg, decision support systems, suicide risk assessment) and resources (eg, training materials) that will support implementation efforts. These implementation tools should help clinicians and administrators develop informed strategies for rolling out collaborative care models for depression.
Collapse
Affiliation(s)
- John C Fortney
- Health Services Research and Development (HSR&D), Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas 72114, USA.
| | | | | | | | | | | | | |
Collapse
|
14
|
Joo JH, Morales KH, de Vries HF, Gallo JJ. Disparity in use of psychotherapy offered in primary care between older african-american and white adults: results from a practice-based depression intervention trial. J Am Geriatr Soc 2010; 58:154-60. [PMID: 20122047 PMCID: PMC6203297 DOI: 10.1111/j.1532-5415.2009.02623.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to assess ethnic differences in use of psychotherapy (having met at least once with a psychotherapist) for late-life depression in primary care. Participants were identified through a two-stage, age-stratified (60-74, > or =75) depression screening of randomly sampled patients from 20 practices in New York City, Philadelphia, and Pittsburgh in a practice-randomized trial. Practices were randomly assigned to usual care or to an intervention with a depression care manager who worked with primary care physicians to provide algorithm-based care. Depression status based on clinical interview and any use of psychotherapy within the 2-year follow-up interval were the primary dependent variables under study. The focus was on 582 persons with complete data. Participants were sorted into major depression (n=385, 112 African American and 273 white) and clinically significant minor depression (n=197, 51 African American and 146 white) based on clinical diagnostic assessment. Persons who self-identified as African American were less likely than whites to use interpersonal therapy (IPT) if they had minor depression, even after adjusting for potentially influential variables including age, cognitive functioning, and whether the dose of antidepressant was adequate (adjusted odds ratio (AOR)=0.22, 95% confidence interval (CI)=0.06-0.80). Ethnicity was not significantly associated with IPT use in persons with major depression (AOR=0.71, 95% CI=0.37-1.37). Older African Americans with minor depression were less likely than whites to use psychotherapy. Targeted strategies are needed to mitigate the disparity in use of psychotherapy.
Collapse
Affiliation(s)
- Jin Hui Joo
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | | | | | | |
Collapse
|
15
|
Peng XD, Huang CQ, Chen LJ, Lu ZC. Cognitive behavioural therapy and reminiscence techniques for the treatment of depression in the elderly: a systematic review. J Int Med Res 2009; 37:975-82. [PMID: 19761679 DOI: 10.1177/147323000903700401] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- X-D Peng
- State Key Laboratory of Biotherapy and Cancer Centre, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | | | | | | |
Collapse
|
16
|
Bao Y, Post EP, Ten Have TR, Schackman BR, Bruce ML. Achieving Effective Antidepressant Pharmacotherapy in Primary Care: The Role of Depression Care Management in Treating Late-Life Depression. J Am Geriatr Soc 2009; 57:895-900. [DOI: 10.1111/j.1532-5415.2009.02226.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
17
|
Choi NG. The integration of social and psychologic services to improve low-income homebound older adults' access to depression treatment. FAMILY & COMMUNITY HEALTH 2009; 32:S27-S35. [PMID: 19065091 DOI: 10.1097/01.fch.0000342837.97982.36] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Despite their high vulnerability to depression, a majority of low-income, homebound older adults face multiple barriers to accessing psychologic services. These older adults require both social services for managing their multiple financial and functional needs and psychologic services for managing their depression. Mental health needs of these older adults may be better met if aging service providers provide both social services and psychotherapy. This study outlines the rationale for integrating the social and psychologic services for homebound older adults and the need for research evidence on the feasibility, efficacy, and replicability of implementing such an integrated model.
Collapse
Affiliation(s)
- Namkee G Choi
- School of Social Work, The University of Texas at Austin, TX 78712, USA.
| |
Collapse
|
18
|
Abstract
This review article discusses the complexities of diagnosing depression in older, geriatric cancer patients. There has been little research conducted with this population on the assessment, recognition, and treatment of depression, and thus increased attention is required to improve care for these individuals. Depressive symptoms often manifest themselves differently in both cancer patients and older patients, and therefore a modified and adapted way of assessment must be employed when thinking about diagnosing and treating these patients.
Collapse
Affiliation(s)
- Mark I. Weinberger
- Department of Psychiatry, Weill Cornell Medical College, White Plains, NY 10605
| | - Andrew J. Roth
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021
| | - Christian J. Nelson
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021
| |
Collapse
|
19
|
Alexopoulos GS, Raue PJ, Kanellopoulos D, Mackin S, Arean PA. Problem solving therapy for the depression-executive dysfunction syndrome of late life. Int J Geriatr Psychiatry 2008; 23:782-8. [PMID: 18213605 DOI: 10.1002/gps.1988] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The 'depression executive dysfunction syndrome' afflicts a considerable number of depressed elderly patients and may be resistant to conventional pharmacotherapy. Non-pharmacological approaches addressing their behavioral deficits may reduce disability and experienced stress and improve depression. METHODS This paper focuses on problem solving therapy (PST) because it targets concrete problems that can be understood by patients with executive dysfunction and trains patients to address them using an easy to comprehend structured approach. RESULTS We suggest that PST is a suitable treatment for patients with the depression-executive dysfunction syndrome because it has been found effective in uncomplicated geriatric major depression and in other psychiatric disorders accompanied by severe executive dysfunction. Furthermore, PST can address specific clinical features of depressed patients with executive dysfunction, especially when modified to address difficulties with affect regulation, initiation and perseveration. CONCLUSIONS A preliminary study suggests that appropriately modified PST improves problem solving skills, depression and disability in elderly patients with the depression-executive dysfunction syndrome of late life. If these findings are confirmed, PST may become a therapeutic option for a large group of depressed elderly patients likely to be drug resistant.
Collapse
Affiliation(s)
- George S Alexopoulos
- Department of Psychiatry, Weill Cornell Medical College, White Plains, NY 10605, USA.
| | | | | | | | | |
Collapse
|
20
|
|
21
|
Miller MD. Using interpersonal therapy (IPT) with older adults today and tomorrow: a review of the literature and new developments. Curr Psychiatry Rep 2008; 10:16-22. [PMID: 18269890 DOI: 10.1007/s11920-008-0005-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Interpersonal psychotherapy (IPT) has been shown to be an efficacious evidence-based treatment for major depression in combination with antidepressant medication, as a maintenance treatment in combination with medication, and as monotherapy (with placebo). After reviewing the salient features of IPT that make it a good fit for treating older patients, I summarize the extant literature. New adaptations of IPT for depressed older adults with cognitive impairment are delineated. An argument is articulated for why IPT may be the ideal psychotherapy for older patients.
Collapse
Affiliation(s)
- Mark D Miller
- Western Psychiatric Institute and Clinic, 3811 O'Hara Street, Pittsburgh, PA 15213, USA.
| |
Collapse
|
22
|
Bogner HR, Morales KH, Post EP, Bruce ML. Diabetes, depression, and death: a randomized controlled trial of a depression treatment program for older adults based in primary care (PROSPECT). Diabetes Care 2007; 30:3005-10. [PMID: 17717284 PMCID: PMC2803110 DOI: 10.2337/dc07-0974] [Citation(s) in RCA: 144] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We sought to test our a priori hypothesis that depressed patients with diabetes in practices implementing a depression management program would have a decreased risk of mortality compared with depressed patients with diabetes in usual-care practices. RESEARCH DESIGN AND METHODS We used data from the multisite, practice-randomized, controlled Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), with patient recruitment from May 1999 to August 2001, supplemented with a search of the National Death Index. Twenty primary care practices participated from the greater metropolitan areas of New York City, New York; Philadelphia, Pennsylvania; and Pittsburgh, Pennsylvania. In all, 584 participants identified though a two-stage, age-stratified (aged 60-74 or >or=75 years) depression screening of randomly sampled patients and classified as depressed with complete information on diabetes status are included in these analyses. Of the 584 participants, 123 (21.2%) reported a history of diabetes. A depression care manager worked with primary care physicians to provide algorithm-based care. Vital status was assessed at 5 years. RESULTS After a median follow-up of 52.0 months, 110 depressed patients had died. Depressed patients with diabetes in the intervention category were less likely to have died during the 5-year follow-up interval than depressed diabetic patients in usual care after accounting for baseline differences among patients (adjusted hazard ratio 0.49 [95% CI 0.24-0.98]). CONCLUSIONS Older depressed primary care patients with diabetes in practices implementing depression care management were less likely to die over the course of a 5-year interval than depressed patients with diabetes in usual-care practices.
Collapse
Affiliation(s)
- Hillary R Bogner
- Department of Family Practice and Community Medicine, University of Pennsylvania, 3400 Spruce St., 2 Gates Building, Philadelphia, PA 19104, USA.
| | | | | | | |
Collapse
|
23
|
Gallo JJ, Bogner HR, Morales KH, Post EP, Lin JY, Bruce ML. The effect of a primary care practice-based depression intervention on mortality in older adults: a randomized trial. Ann Intern Med 2007; 146:689-98. [PMID: 17502629 PMCID: PMC2818643 DOI: 10.7326/0003-4819-146-10-200705150-00002] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Few studies have tested the effects of a depression intervention on the risk for death associated with depression. OBJECTIVE To test whether an intervention to improve depression care can modify the risk for death. DESIGN Practice-based, randomized, controlled trial. SETTING 20 primary care practices in New York, New York, and Philadelphia and Pittsburgh, Pennsylvania. PATIENTS 1226 randomly sampled patients identified through a 2-stage, age-stratified (60 to 74 years and > or =75 years) depression screening. INTERVENTION Depression care manager working with primary care physicians to provide algorithm-based care. MEASUREMENTS Depression status based on clinical interview and vital status at 5 years by using the National Death Index. RESULTS At baseline, 396 patients met criteria for major depression and 203 patients met criteria for clinically significant minor depression. After a median follow-up of 52.8 months, 223 patients died. Patients with depression in intervention practices were less likely to have died than those in usual care practices (adjusted hazard ratio, 0.67 [95% CI, 0.44 to 1.00]). Risk for death was reduced in patients with major depression (adjusted hazard ratio, 0.55 [CI, 0.36 to 0.84]) but not in patients with clinically significant minor depression (adjusted hazard ratio, 0.97 [CI, 0.49 to 1.92]). The benefit seemed to be almost entirely attributable to a reduction in deaths due to cancer. LIMITATIONS The mechanism for an effect on deaths due to cancer is unclear. Depression status, cause of death, and vital status might have been misclassified. CONCLUSIONS Older primary care patients with major depression in practices that implemented depression care management were less likely to die over a 5-year period than were patients with major depression in usual care practices. The effect seemed to be limited to deaths due to cancer. The mechanism for such an effect is unclear and warrants further investigation. ClinicalTrials.gov registration number: NCT00000367.
Collapse
Affiliation(s)
- Joseph J Gallo
- Department of Family Medicine and Community Health, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
| | | | | | | | | | | |
Collapse
|