A randomised controlled trial of cognitive behaviour therapy vs treatment as usual in the treatment of mild to moderate late life depression

A network analysis of depression and anxiety symptoms among Chinese elderly living alone: based on the 2017-2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS)

BACKGROUND

Elderly individuals living alone represent a vulnerable group with limited family support, making them more susceptible to mental health issues such as depression and anxiety. This study aims to construct a network model of depression and anxiety symptoms among older adults living alone, exploring the correlations and centrality of different symptoms. The goal is to identify core and bridging symptoms to inform clinical interventions.

METHODS

Using data from the 2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS), this study constructed a network model of depression and anxiety symptoms among elderly individuals living alone. Depression and anxiety symptoms were assessed using the Center for Epidemiologic Studies Depression Scale-10 (CESD-10) and the Generalized Anxiety Disorder Scale-7 (GAD-7), respectively. A Gaussian Graphical Model (GGM) was employed to build the symptom network, and the Fruchterman-Reingold algorithm was used for visualization, with the thickness and color of the edges representing partial correlations between symptoms. To minimize spurious correlations, the Least Absolute Shrinkage and Selection Operator (LASSO) method was applied for regularization, and the optimal regularization parameters were selected using the Extended Bayesian Information Criterion (EBIC). We further calculated Expected Influence (EI) and Bridge Expected Influence (Bridge EI) to evaluate the importance of symptoms. Non-parametric bootstrap methods were used to assess the stability and accuracy of the network.

RESULTS

The Network centrality analysis revealed that GAD2 (Uncontrollable worry) and GAD4 (Trouble relaxing) exhibited the highest strength centrality (1.128 and 1.102, respectively), indicating their significant direct associations with other symptoms and their roles as core nodes in the anxiety symptom network. Other highly central nodes, such as GAD1 (Nervousness or anxiety) and GAD3 (Generalized worry), further underscore the dominance of anxiety symptoms in the overall network. Betweenness centrality results highlighted GAD1 (Nervousness or anxiety) and GAD2 (Uncontrollable worry) as critical bridge nodes facilitating information flow between different symptoms, while CESD3 (Feeling depressed) demonstrated a bridging role across modules. Weighted analyses further confirmed the central importance of GAD2 (Uncontrollable worry) and GAD4 (Trouble relaxing). Additionally, the analysis showed gender differences in the depression-anxiety networks of elderly individuals living alone.

CONCLUSION

This study, through network analysis, uncovered the complex relationships between depression and anxiety symptoms among elderly individuals living alone, identifying GAD2 (Uncontrollable worry) and GAD4 (Trouble relaxing) as core symptoms. These findings provide essential insights for targeted interventions. Future research should explore intervention strategies for these symptoms to improve the mental health of elderly individuals living alone.

Predictors of treatment outcome of psychological therapies for common mental health problems (CMHP) in older adults: A systematic literature review

Identifying factors that impact psychological treatment outcomes in older people with common mental health problems (CMHP) has important implications for supporting healthier and longer lives. The aim of the present study was to synthesise the evidence on predictors of psychological treatment outcomes in older people (aged 65+). PubMed, Scopus, Web of Science and PsycINFO were searched and 3929 articles were identified and screened, with 42 studies (N = 7978, M age = 68.9, SD age = 2.85) included: depression: k = 21, anxiety: k = 11, panic disorder: k = 3, mixed anxiety & depression: k = 3, PTSD: k = 2, various CMHP: k = 2, with CBT being the most common treatment (71%). The review identified 28 factors reported as significant predictors of treatment outcome in at least one study, across different domains: psychosocial (n = 9), clinical (n = 6), treatment-related (n = 6), socio-demographic (n = 4), neurobiological (n = 3). Homework completion was the most consistent predictor of positive treatment outcome. Baseline symptom severity was the most frequently studied significant predictor and across all conditions, with higher baseline symptom severity largely linked to worse treatment outcomes. No significant effects on treatment outcome were reported for gender, income and physical comorbidities. For a large majority of factors evidence was mixed or inconclusive. Further studies are required to identify factors affecting psychological treatment outcomes, which will be important for the development of personalised treatment approaches.

Long-term remission and relapse of anxiety and depression in older adults after Cognitive Behavioural Therapy (CBT): A 10-year follow-up of a randomised controlled trial

BACKGROUND

This study examined the long-term durability of cognitive behaviour therapy (CBT) for older adults with comorbid anxiety and depression 10 years after treatment, in comparison to an active control group.

METHOD

Participants from a randomised controlled trial for older adults with comorbid anxiety and depression (Wuthrich et al., 2016) were re-contacted. Participants had received either group CBT or an active control treatment (Discussion Group). The final sample (N = 54; Aged 70-84, Mage = 76.07, SD = 3.83; 59 % of the eligible original sample) completed a diagnostic interview, cognitive assessment and self-report measures of symptoms and quality of life.

RESULTS

CBT was associated with significantly improved long-term (10-year) efficacy for reducing anxiety and depression in older adults compared to the Discussion group. Effects included higher rates of remission (58 % remission of all diagnoses vs 27 %, 88 % of all depressive diagnoses vs 54 %, 63 % of all anxiety diagnoses vs 35 %, 67 % of primary diagnosis vs 42 %), lower rates of relapse (25-31 % vs 50-78 %) and lower rates of chronic treatment-resistance (8 % primary disorder vs 39 %, 21 % any disorder vs 58 %). Participants who showed an acute treatment response at post-treatment were 7-9 times more likely to be in remission after 10 years than those with residual symptoms.

LIMITATIONS

Results may not generalise to those who do not complete CBT, and the time trajectory of symptom change is unclear.

CONCLUSIONS

Long-term improvements in symptoms are specific to CBT. Results provide compelling evidence for CBT as an effective and durable treatment for late-life anxiety and depression.

Examining the description of the concept "treatment as usual" for patients with depression, anxiety and stress-related mental disorders in primary health care research - A systematic review

BACKGROUND

In randomized controlled trials (RCTs) within medical research, applied interventions are compared to treatment-as-usual (TAU) as the control condition. The aim of the current study was to examine how the concept of TAU is described when used as control condition in RCTs evaluating treatments for depression, anxiety syndromes, and stress-related mental disorders in primary care.

METHOD

A systematic review of RCTs utilizing TAU as control group in the RCT in accordance with PRISMA standards was conducted. We used one multidisciplinary database (Scopus), one database focused on nursing (Cinahl), and one medical database (PubMed). The searches were conducted in November 2021 and May 2022.

RESULTS

The included 32 studies comprised of 7803 participants. The content of TAU was classified as follows: 1) Basic descriptions of TAU lacking a detailed account as well as reference to local or national guidelines, 2) Moderate description of TAU including reference to national or local guidelines or a detailed description 3) Advanced description of TAU including references to national guidelines and a detailed description containing five key concepts: early assessment, accessibility, psychological treatment, medication, somatic examination. 18 studies had basic, 11 moderate, and 3 advanced descriptions of TAU.

LIMITATIONS

The limitations were that only studies published in English were included.

CONCLUSIONS

The current study provides an assessment tool with three classification levels for TAU. The description of TAU is still insufficient in RCT studies conducted in primary care, which may affect the interpretation of results. In future research a detailed description of TAU is recommended.

A meta-analysis of CBT efficacy for depression comparing adults and older adults

INTRODUCTION

This meta-analysis investigates CBT treatment efficacy fordepression, and compares outcomes between adults (young and middle aged) and older adults (OA).

METHODOLOGY

Effect sizes (Hedges' g) were obtained from 37 peer-reviewed RCTs, 25 adult papers (participant n = 2948) and 12 OA papers (participant n = 551), and analysed with the random effects model.

RESULTS

No significant difference between age groups is reported in terms of CBT efficacy for depression compared to other treatments (Q_between (1) = 0.06, p = .89), with the overall effect favouring CBT over any other treatments (g = 0.48, 95 % CI = 0.29-0.68). The same pattern of results was found when restricting studies to those which used active control conditions (Q_between (1) = 0.03, p = .86) or passive control conditions (Q (1) = 2.45, p = .12).

DISCUSSION

No significant differences in efficacy for CBT treatment for depression are found when comparing adults and OA. CBT is as efficacious with OA as with adults.

A pilot randomised controlled trial to assess the feasibility and acceptability of recovery-focused therapy for older adults with bipolar disorder

BACKGROUND

Despite increasing evidence for the effectiveness of individual psychological interventions for bipolar disorder, research on older adults is lacking. We report the first randomised controlled trial of psychological therapy designed specifically for older adults with bipolar disorder.

AIMS

To evaluate the feasibility and acceptability of recovery-focused therapy, designed in collaboration with older people living with bipolar disorder.

METHOD

A parallel, two-armed, randomised controlled trial comparing treatment as usual with up to 14 sessions of recovery-focused therapy plus treatment as usual, for older adults with bipolar disorder.

RESULTS

Thirty-nine participants (67% female, mean age 67 years) were recruited over a 17-month period. Feasibility and acceptability of recruitment, retention (>80% observer-rated outcomes at both 24 and 48 weeks) and intervention processes were demonstrated. The majority of participants started therapy when offered, adhered to the intervention (68% attended all sessions and 89% attended six or more sessions) and reported positive benefits. Clinical assessment measures provide evidence of a signal for effectiveness on a range of outcomes including mood symptoms, time to relapse and functioning. No trial-related serious adverse events were identified.

CONCLUSIONS

Recovery-focused therapy is feasible, acceptable and has the potential to improve a range of outcomes for people living with bipolar disorder in later life. A large-scale trial is warranted to provide a reliable estimate of its clinical and cost-effectiveness.

Psychologic Treatment of Depression Compared With Pharmacotherapy and Combined Treatment in Primary Care: A Network Meta-Analysis

PURPOSE

Most patients with depression are treated by general practitioners, and most of those patients prefer psychotherapy over pharmacotherapy. No network meta-analyses have examined the effects of psychotherapy compared with pharmacotherapy, combined treatment, care as usual, and other control conditions among patients in primary care.

METHODS

We conducted systematic searches of bibliographic databases to identify randomized trials comparing psychotherapy with pharmacotherapy, combined treatment, care as usual, waitlist, and pill placebo. The main outcome was treatment response (50% improvement of depressive symptoms from baseline to end point).

RESULTS

A total of 58 studies with 9,301 patients were included. Both psychotherapy and pharmacotherapy were significantly more effective than care as usual (relative risk [RR] for response = 1.60; 95% CI, 1.40-1.83 and RR = 1.65; 95% CI, 1.35-2.03, respectively) and waitlist (RR = 2.35; 95% CI, 1.57-3.51 and RR = 2.43; 95% CI, 1.57-3.74, respectively) control groups. We found no significant differences between psychotherapy and pharmacotherapy (RR = 1.03; 95% CI, 0.88-1.22). The effects were significantly greater for combined treatment compared with psychotherapy alone (RR = 1.35; 95% CI, 1.00-1.81). The difference between combined treatment and pharmacotherapy became significant when limited to studies with low risk of bias and studies limited to cognitive behavior therapy.

CONCLUSIONS

Psychotherapy is likely effective for the treatment of depression when compared with care as usual or waitlist, with effects comparable to those of pharmacotherapy. Combined treatment might be better than either psychotherapy or pharmacotherapy alone.

Translating evidence-based psychological interventions for older adults with depression and anxiety into public and private mental health settings using a stepped care framework: Study protocol

BACKGROUND

With expected increases in the number of older adults worldwide, the delivery of stepped psychological care for depression and anxiety in older populations may improve both treatment and allocative efficiency for individual patients and the health system.

DESIGN

A multisite pragmatic randomised controlled trial evaluating the clinical and cost-effectiveness of a stepped care model of care for treating depression and anxiety among older adults compared to treatment as usual (TAU) will be conducted. Eligible participants (n = 666) with clinically interfering anxiety and/or depression symptoms will be recruited from and treated within six Australian mental health services. The intervention group will complete a low intensity cognitive behavioural therapy (CBT) program: Internet-delivered or using a work-at-home book with brief therapist calls (STEP 1). Following STEP 1 a higher intensity face-to-face CBT (STEP 2) will then be offered if needed. Intention-to-treat analyses will be used to examine changes in primary outcomes (e.g. clinician-rated symptom severity changes) and secondary outcomes (e.g. self-reported symptoms severity, health related quality of life and service utilisation costs). An economic evaluation will be conducted using a cost-utility analysis to derive the incremental cost-effectiveness ratio for the stepped care intervention.

DISCUSSION

This study will demonstrate the relative clinical and economic benefits of stepped care model of psychological care for older adults experiencing anxiety and/or depression compared to TAU. The evaluation of the intervention within existing mental health services means that results will have significant implications for the translation of evidence-based interventions in older adult services across urban and rural settings.

TRAIL REGISTRATION

Prospectively registered on anzctr.org.au (ACTRN12619000219189) and isrctn.com (ISRCTN37503850).

Generalizability of pharmacologic and psychotherapy trial results for late-life unipolar depression

OBJECTIVES

Despite evidence of low representativeness of clinical trial results for depression in adults, the generalizability of clinical trial results for late-life depression is unknown. This study sought to quantify the representativeness of pharmacologic and psychotherapy clinical trial results for late-life unipolar depression.

METHOD

Data were derived from the 2004-2005 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative sample of 34,653 adults from the United States population. To assess the generalizability of clinical trial results for late-life depression, we applied a standard set of eligibility criteria representative of pharmacologic and psychotherapy clinical trials to all individuals aged 65 years and older in NESARC with a DSM-IV diagnosis of MDE and no lifetime history of mania/hypomania (n = 273) and in a subsample of individuals seeking help for depression (n = 78).

RESULTS

More than four of ten respondents and about two of ten respondents would have been excluded by at least one exclusion criterion in a typical pharmacologic and psychotherapy efficacy trial, respectively. Similar results (i.e.41.1% and 25.9%, respectively) were found in the subsample of individuals seeking help for depression. Excess percentage of exclusion in typical pharmacologic studies was accounted for by the criterion "significant medical condition". We also found that populations typically included in pharmacologic and psychotherapy clinical trials for late-life unipolar depression may substantially differ.

CONCLUSION

Psychotherapy trial results may be representative of most patients with late-life unipolar depression in routine clinical practice. By contrast, pharmacologic clinical trials may not be readily generalizable to community samples.

'I wanted to talk about it, but I couldn't', an H70 focus group study about experiencing depression in early late life

BACKGROUND

Knowledge about experiences of depression among younger-old adults from the general population is limited. The aim was to explore experiences of depression in early late life.

METHODS

Sixteen participants in the population-based Gothenburg H70 Birth Cohort Studies (12 women and 4 men) who had reported a history of depression between ages 60-70 took part in focus group discussions (n = 4). Data were analyzed using focus group methodology.

RESULTS

The analysis resulted in the overall theme 'I wanted to talk about it, but I couldn't'. The participants expressed unmet needs of communication about depression with family, friends, and healthcare staff. Participants wanted to know more about the causes and effects of depression, available treatment options and how to avoid recurrence. Lack of knowledge was a source of frustration; trust in health care providers was diminished. Being retired meant that opportunities for communication with co-workers were no longer available, and this made it harder to break negative thought and behavioral patterns. Being depressed meant losing one's normal self, and participants were grieving this. Thoughts of death and suicide were experienced in solitude; knowing that there was an escape could generate a feeling of comfort and control.

CONCLUSIONS

Younger-old adults have expressed a need to talk about their experiences of depression. They would like to know more about available treatments, potential side effects, and how to avoid recurrence. Care providers also need to be aware there is a need for an existential dialogue about death.

Cognitive behaviour therapy for depression in primary care: systematic review and meta-analysis

Depression is common in primary care, and most patients prefer psychological treatment over pharmacotherapy. Cognitive behaviour therapy (CBT) is an effective treatment, but there are gaps in current knowledge about CBT in the primary care context, especially with regard to long-term effects and the efficacy of specific delivery formats. This is an obstacle to the integration of primary care and specialist psychiatry. We conducted a systematic review and meta-analysis of randomised controlled trials of CBT for primary care patients with depression to investigate the effect of CBT for patients with depression in primary care. A total of 34 studies, with 2543 patients in CBT and 2815 patients in control conditions, were included. CBT was more effective than the control conditions [g = 0.22 (95% confidence interval (CI) 0.15-0.30)], and the effect was sustained at follow-up [g = 0.17 (95% CI 0.10-0.24)]. CBT also led to a higher response rate [odds ratio (OR) = 2.47 (95% CI 1.60-3.80)] and remission rate [OR = 1.56 (95% CI 1.15-2.14)] than the control conditions. Heterogeneity was moderate. The controlled effect of CBT was significant regardless of whether patients met diagnostic criteria for depression, scored above a validated cut-off for depression, or merely had depressive symptoms. CBT also had a controlled effect regardless of whether the treatment was delivered as individual therapy, group therapy or therapist-guided self-help. We conclude that CBT appears to be effective for patients with depression in primary care, and recommend that patients with mild to moderate depression be offered CBT in primary care.

Cognitive behavioral therapy for primary care depression and anxiety: a secondary meta-analytic review using robust variance estimation in meta-regression

Cognitive-behavioral therapy (CBT) is well supported for treating depressive and anxiety disorders. Trials of CBT for anxiety and depression in primary care have increased over the past decade, yet only one meta-analysis, published in 2015, examined this topic and the scope of that review is relatively narrow. This study conducted a systematic review and meta-analysis of primary care based CBT for depression and anxiety. A search of seven electronic databases, six professional websites, and reference lists from articles meeting inclusion criteria was conducted for studies published between 1900 and November 2018. Fifty-seven eligible studies (including 10,701 participants; 221 effect sizes) of randomized controlled trials were eligible and included for meta-analysis using robust variance estimation in meta-regression. Outcome indicators were depression and anxiety measures. An overall significant treatment effect, d = 0.400, 95% CI (0.235, 0.566), p < 0.001, of CBT for depression and anxiety disorders in primary care was identified. Subgroup analyses indicated significant treatment effect for: (1) depressive (d = 0.425, p < 0.001) and anxiety (d = 0.393, p < 0.01) outcomes, (2) studies conducted inside primary care (d = 0.412, p < 0.001), (3) studies using individual-based CBT (d = 0.412, p < 0.001), (4) studies without primary care physician involvement (d = 0.395, p < 0.001), and (5) studies using both tele-health (d = 0.563, p < 0.001) and in-person CBT (d = 0.363, p < 0.001). The percentage of White participants, treatment composition (CBT only versus CBT + other approaches), and treatment duration were significant moderators. Implications for clinical practice are discussed based on both moderator and subgroup analysis results.

Psychotherapeutic skills training for nurses on an acute aged mental health unit: A mixed-method design

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.

The effectiveness of four empirically supported psychotherapies for primary care depression and anxiety: A systematic review and meta-analysis

BACKGROUND

Depressive and anxiety disorders are highly prevalent and detrimental in primary care settings. However, there are gaps in the literature concerning effectiveness and generalizability of empirically supported interventions and treatment of both depression and anxiety in primary care settings. The aim of this review is to systematically assess and meta-analyze the effectiveness of brief empirically-supported psychotherapies for treating depression and/or anxiety in primary care.

METHODS

Seven electronic databases, five professional websites and manual search of reference lists were searched through April 2017 for randomized controlled trials (RCTs) of four psychotherapies treating primary care depression and anxiety: cognitive-behavior therapy (CBT), problem-solving therapy (PST), motivational interviewing (MI), and solution-focused brief therapy (SFBT).

RESULTS

From an initial pool of 1140 articles, 179 articles were eligible for full-text review and 65 articles were included for final analysis. Sixty-five articles containing 198 effect sizes reported an overall treatment effect size of d = 0.462, p < 0.001. Single-predictor meta-regression indicated that marital status, treatment modality (individual versus group), and treatment composition were significant moderators. Multiple-predictor meta-regression discovered treatment setting (inside versus outside primary care) significantly moderated treatment effect, b = -0.863, p = 0.039 after controlling for other intervention characteristics.

CONCLUSION

Treatment effects were found for CBT and PST, both for depressive and anxiety disorders. Interventions delivered outside primary care settings were more effective than those within, individual treatment had greater treatment effects compared to group treatment, and both technology-assisted and in-person treatments were found to be effective.

The effects of psychotherapy for depression on anxiety symptoms: a meta-analysis

BACKGROUND

More than half of patients who present with depressive disorders also have elevated comorbid anxiety symptoms. Given the high comorbidity between these disorders, it is important to understand the extent that psychotherapies for depression additionally ameliorate symptoms of anxiety.

METHODS

Systematic searches were conducted in PubMed, PSYCinfo, EMBASE, and the Cochrane Registry of Controlled Trials. Included studies were randomized controlled trials that compared psychotherapy compared with a control condition for the treatment of adults with a primary diagnosis or elevated symptoms of depression and that examined the effects of treatment on anxiety outcomes. Acute phase depression and anxiety (continuous measure) outcomes were extracted. Effect sizes were calculated by subtracting the average post-treatment scores of the psychotherapy group from the average post-treatment scores of the comparison group divided by the pooled standard deviation.

RESULTS

Fifty-two studies of varying quality met the inclusion criteria. Pooled effect sizes showed that anxiety outcomes were significantly lower in the psychotherapy conditions than in control conditions at post-treatment [g = 0.52; 95% confidence interval (CI) 0.44-0.60; NNT (numbers-needed-to-treat) = 3.50]. Moderate heterogeneity was observed (I2 = 55%, 95% CI 40-66). Bivariate metaregression analysis revealed a significant association between depression and anxiety effect sizes at post-treatment Longer-term follow-ups of up to 14 months post-baseline showed indications for a small lasting effect of psychotherapy on anxiety outcomes (g = 0.27).

CONCLUSIONS

This meta-analysis provides evidence that psychotherapy aimed at depression can also reduce anxiety symptoms in relation to control conditions.

'I had a sort of epiphany!' An exploratory study of group mindfulness-based cognitive therapy for older people with depression

OBJECTIVES

Mindfulness-based cognitive therapy (MBCT) has been successful in reducing depressive symptoms in people with chronic-recurrent depression. However, the research evaluating the efficacy of this approach, and other innovative treatments for mood disorders, has mainly been with people under 65 years. This paper aims to help redress this imbalance by exploring older people's own reflections of their experience of MBCT.

METHODS

A qualitative approach was used to explore 13 participants' experiences of MBCT; participants were interviewed pre and post-intervention and again after six months. To see whether the standard course requires any adaptations for older participants, the two MBCT course facilitators were interviewed post-intervention.

RESULTS

Thematic analysis identified five overarching themes and showed that older people reported positive changes in their mental health and well-being and reported being 'released from the past'. The facilitators reported that they needed to be aware of later life issues, such as loneliness and potential physical limitations, but otherwise only minor adaptations were needed to the standard MBCT course for older people.

CONCLUSION

MBCT is an acceptable approach for people aged 65 years and over and further research should explore potential mechanisms of change including changes in meta-cognitive awareness and self-compassion.

Predictors of treatment outcome in depression in later life: A systematic review and meta-analysis

BACKGROUND

Predictor analyses of late-life depression can be used to identify variables associated with outcomes of treatments, and hence ways of tailoring specific treatments to patients. The aim of this review was to systematically identify, review and meta-analyse predictors of outcomes of any type of treatment for late-life depression.

METHODS

Pubmed, Embase, CINAHL, Web of Science and PsycINFO were searched for studies published up to December 2016. Primary and secondary studies reported treatment predictors from randomised controlled trials of any treatment for patients with major depressive disorder aged over 60 were included. Treatment outcomes included response, remission and change in depression score.

RESULTS

Sixty-seven studies met the inclusion criteria. Of 65 identified statistically significant predictors, only 7 were reported in at least 3 studies. Of these, 5 were included in meta-analyses, and only 3 were statistically significant. Most studies were rated as being of moderate to strong quality and satisfied key quality criteria for predictor analyses.

LIMITATIONS

The searches were limited to randomised controlled trials and most of the included studies were secondary analyses.

CONCLUSIONS

Baseline depression severity, co-morbid anxiety, executive dysfunction, current episode duration, early improvement, physical illnesses and age were reported as statistically significant predictors of treatment outcomes. Only the first three were significant in meta-analyses. Subgroup analyses showed differences in predictor effect between biological and psychosocial treatment. However, high heterogeneity and small study numbers suggest a cautious interpretation of results. These predictors were associated with various mechanisms including brain pathophysiology, perceived social support and proposed distinct types of depressive disorder. Further investigation of the clinical utility of these predictors is suggested.

Non-pharmacological treatment for depressed older patients in primary care: A systematic review and meta-analysis

Background

Late-life depression is most often treated in primary care, and it usually coincides with chronic somatic diseases. Given that antidepressants contribute to polypharmacy in these patients, and potentially to interactions with other drugs, non-pharmacological treatments are essential. In this systematic review and meta-analysis, we aimed to present an overview of the non-pharmacological treatments available in primary care for late-life depression.

Method

The databases of PubMed, PsychINFO, and the Cochrane Central Register of Controlled Trials were systematically searched in January 2017 with combinations of MeSH-terms and free text words for “general practice,” “older adults,” “depression,” and “non-pharmacological treatment”. All studies with empirical data concerning adults aged 60 years or older were included, and the results were stratified by primary care, and community setting. We narratively reviewed the results and performed a meta-analysis on cognitive behavioral therapy in the primary care setting.

Results

We included 11 studies conducted in primary care, which covered the following five treatment modalities: cognitive behavioral therapy, exercise, problem-solving therapy, behavioral activation, and bright-light therapy. Overall, the meta-analysis showed a small effect for cognitive behavioral therapy, with one study also showing that bright-light therapy was effective. Another 18 studies, which evaluated potential non-pharmacological interventions in the community suitable for implementation, indicated that bibliotherapy, life-review, problem-solving therapy, and cognitive behavioral therapy were effective at short-term follow-up.

Discussion

We conclude that the effects of several treatments are promising, but need to be replicated before they can be implemented more widely in primary care. Although more treatment modalities were effective in a community setting, more research is needed to investigate whether these treatments are also applicable in primary care.

Trial registration

PROSPERO CRD42016038442.

Effect of treatments for depression on quality of life: a meta-analysis

Cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are the two first-line treatments for depression, but little is known about their effects on quality of life (QOL). A meta-analysis was conducted to examine changes in QOL in adults with major depressive disorder who received CBT (24 studies examining 1969 patients) or SSRI treatment (13 studies examining 4286 patients) for their depression. Moderate improvements in QOL from pre to post-treatment were observed in both CBT (Hedges' g = .63) and SSRI (Hedges' g = .79) treatments. The effect size remained stable over the course of the follow-up period for CBT. No data were available to examine follow-ups in the SSRI group. QOL effect sizes decreased linearly with publication year, and greater improvements in depression were significantly associated with greater improvements in QOL for CBT, but not for SSRIs. CBT and SSRIs for depression were both associated with moderate improvements in QOL, but are possibly caused by different mechanisms.

Cognitive Behavioral Group Therapy Reduces Stress and Improves the Quality of Life in Patients with Parkinson's Disease

Objective: The aim of this study is to compare a cognitive behavioral group therapy (CBT) with a health enhancement program (HEP) for stress reduction and the impact on quality of life (QoL) in patients with Parkinson’s disease (PD).

Method: Thirty patients with PD participated in the study: 16 received CBT including stress-reducing elements and 14 took part in a HEP. The two groups did not differ significantly in their baseline demographic characteristics. The patients in both groups underwent weekly sessions of 2 h duration for 9 weeks. The Parkinson’s Disease Questionnaire with 39 items (PDQ-39), the Burden Questionnaire for Parkinson’s Disease (translated from the original German: Belastungsfragebogen für Parkinsonpatienten (BELA) and the Disease-Related Questionnaire [Fragebogen zur krankheitsbezogenen Kommunikation (FKK)] were used for assessment. Ratings were completed at baseline and after 9 weeks (immediately after the last treatment session).

Results: The patients in the CBT group achieved significantly better BELA, FKK and PDQ-39 scores (p < 0.05). Subscale analysis revealed that the scores on the BELA subscales “emotional well-being” and “somatic motor function” contributed significantly to stress reduction (p < 0.05). The FKK revealed significant improvement in social skills in the CBT group (p < 0.05).

Conclusion: Cognitive Behavioral Group Therapy appears to be an effective way for patients with PD to lessen stress and improve their quality of life.

Suicide in an ageing UK population: problems and prevention

Purpose

Suicide can be an emotive, and at times, controversial subject. The purpose of this paper is to reflect on the social, health, personal, and cultural issues that can arise in later life and the potential reasons for suicide. It will analyse already recognised risk factors of suicide in older adults and focus on improving knowledge about the social meaning and causation of suicide for older people. It will also consider suicide prevention policies, their practice implications, and whether they are successful in protecting this potentially vulnerable cohort.

Design/methodology/approach

A synopsis of available literature in the form of a general review paper of suicide of older adults.

Findings

There is evidence that the ageing process often leads to a set of co-morbidities and a complex and diverse set of individual challenges. This in turn equates to an increased risk of suicide. There is no easy answer to why there is evidence of a growing number of older adults deciding that suicide is there only option, and even fewer suggestions on how to manage this risk.

Social implications

The entry of the “baby boom” generation into retirement will lead to the potential of an increase in both suicide risk factors and older adults completing suicide. This is on the background of a demographic surge which is likely to place additional pressures on already under-resourced, and undervalued, statutory and non-statutory services.

Originality/value

A literature search found very little information regarding older adults and suicide risk, assessment, treatment or prevention.

Effect of psychotherapy for depression on quality of life: meta-analysis

BACKGROUND

Several meta-analyses have shown that psychotherapy is effective for reducing depressive symptom severity. However, the impact on quality of life (QoL) is as yet unknown.

AIMS

To investigate the effectiveness of psychotherapy for depression on global QoL and on the mental health and physical health components of QoL.

METHOD

We conducted a meta-analysis of 44 randomised clinical trials comparing psychotherapy for adults experiencing clinical depression or elevated depressive symptoms with a control group. We used subgroup analyses to explore the influence of various study characteristics on the effectiveness of treatment.

RESULTS

We detected a small to moderate effect size (Hedges' g = 0.33, 95% CI 0.24-0.42) for global QoL, a moderate effect size for the mental health component (g = 0.42, 95% CI 0.33-0.51) and, after removing an outlier, a small but statistically significant effect size for the physical health component (g = 0.16, 95% CI 0.05-0.27). Multivariate meta-regression analyses showed that the effect size of depressive symptoms was significantly related to the effect size of the mental health component of QoL. The effect size of depressive symptoms was not related to global QoL or the physical health component.

CONCLUSIONS

Psychotherapy for depression has a positive impact on the QoL of patients with depression. Improvements in QoL are not fully explained by improvements in depressive symptom severity.

How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence

We report the current best estimate of the effects of cognitive behavior therapy (CBT) in the treatment of major depression (MDD), generalized anxiety disorder (GAD), panic disorder (PAD) and social anxiety disorder (SAD), taking into account publication bias, the quality of trials, and the influence of waiting list control groups on the outcomes. In our meta-analyses, we included randomized trials comparing CBT with a control condition (waiting list, care-as-usual or pill placebo) in the acute treatment of MDD, GAD, PAD or SAD, diagnosed on the basis of a structured interview. We found that the overall effects in the 144 included trials (184 comparisons) for all four disorders were large, ranging from g=0.75 for MDD to g=0.80 for GAD, g=0.81 for PAD, and g=0.88 for SAD. Publication bias mostly affected the outcomes of CBT in GAD (adjusted g=0.59) and MDD (adjusted g=0.65), but not those in PAD and SAD. Only 17.4% of the included trials were considered to be high-quality, and this mostly affected the outcomes for PAD (g=0.61) and SAD (g=0.76). More than 80% of trials in anxiety disorders used waiting list control groups, and the few studies using other control groups pointed at much smaller effect sizes for CBT. We conclude that CBT is probably effective in the treatment of MDD, GAD, PAD and SAD; that the effects are large when the control condition is waiting list, but small to moderate when it is care-as-usual or pill placebo; and that, because of the small number of high-quality trials, these effects are still uncertain and should be considered with caution.

THE LONG-TERM EFFICACY OF ACUTE-PHASE PSYCHOTHERAPY FOR DEPRESSION: A META-ANALYSIS OF RANDOMIZED TRIALS

BACKGROUND

Understanding the effectiveness of treatment for depression in both the short term and long term is essential for clinical decision making. The present meta-analysis examined treatment effects on depression and quality of life in acute-phase psychotherapeutic interventions compared to no treatment control groups for adult depression at 6 months or longer postrandomization.

METHODS

A systematic literature search resulted in 44 randomized controlled trials with 6,096 participants. Acute-phase psychotherapy was compared to control groups at 6-month or longer postrandomization. Odds ratios of a positive outcome were calculated.

RESULTS

Psychotherapy outperformed control groups at 6 months or longer postrandomization (OR = 1.92, 95% CI: 1.60-2.31, P < .001). Heterogeneity was moderate (I²: 65, 95% CI: 53-74, P < .001). However, effects significantly decreased with longer follow-up periods. Additionally, a small positive effect of psychotherapy was observed for quality of life, while similar effects were obtained in separate analyses of each type of psychotherapy, with the exception of nondirective supportive therapy. Studies that provided booster sessions had better treatment results compared with studies that did not provide any further sessions. Finally, we found that trials on psychotherapy aimed at major depressive disorder (MDD) had better outcomes than those that were aimed at elevated depressive symptoms.

CONCLUSIONS

There is substantial evidence that acute-phase psychotherapy results in a better treatment effects on depression and quality of life in the long term for adult patients with depression.

Efficacité de la psychothérapie comparativement à la pharmacothérapie dans le traitement des troubles anxieux et dépressifs chez l’adulte : une revue de la littérature

Dans l’optique de l’amélioration d’une couverture de la psychothérapie au Québec, le ministère de la Santé et des Services sociaux a confié à l’Institut national d’excellence en santé et en services sociaux le mandat d’évaluer l’efficacité de la psychothérapie comparée à la pharmacothérapie dans le traitement des adultes souffrant de troubles anxieux et dépressifs. Une mise à jour d’une revue de la littérature récente et de bonne qualité a été effectuée grâce à une revue des revues systématiques traitant de la psychothérapie comparée à la pharmacothérapie dans le traitement des adultes anxieux et dépressifs avec un horizon temporel compris entre 2009 et 2013. Le niveau de l’ensemble de la preuve scientifique permet de dire que de manière générale, il n’y a pas de différence significative entre la psychothérapie et la pharmacothérapie sur le plan de la réduction des symptômes des patients souffrant de troubles anxieux ou dépressifs modérés, ce qui indique une efficacité comparable de ces deux modes de traitement. Cependant, les avantages de la psychothérapie sont maintenus plus longtemps après la fin du traitement que ceux des médicaments. La psychothérapie offre donc une meilleure protection contre la rechute. Par ailleurs, la combinaison de la psychothérapie et de la pharmacothérapie présente une efficacité supérieure à celle de la psychothérapie seule dans les cas chroniques ou graves.

Physical fitness exercise versus cognitive behavior therapy on reducing the depressive symptoms among community-dwelling elderly adults: A randomized controlled trial

BACKGROUND

Depression is a major health problem for community-dwelling elderly adults. Since limited resources are available to decrease the high prevalence of depressive symptoms among the elderly adults, improved support for them can be provided if we can determine which intervention is superior in ridding depressive symptoms.

OBJECTIVE

To compare the effectiveness of the physical fitness exercise program and the cognitive behavior therapy program on primary (depressive symptoms) and secondary outcomes (6-min walk distance, quality of life, and social support) for community-dwelling elderly adults with depressive symptoms.

DESIGN AND SETTINGS

A prospective randomized control trial was conducted in three communities in northern Taiwan.

PARTICIPANTS

The elderly adults in the three communities were invited to participate by mail, phone calls, and posters. There were a total of 57 participants who had depressive symptoms and all without impaired cognition that participated in this trial. None of the participants withdrew during the 9 months of follow-up for this study.

METHODS

Fifty-seven participants were randomly assigned to one of the three groups: the physical fitness exercise program group, the cognitive behavior therapy (CBT) group, or the control group. The primary (Geriatric Depression Scale-15, GDS-15), and secondary outcomes (6-min walk distance, SF-36, and Inventory of Socially Supportive Behaviors scales, ISSB) were collected immediately (T2), at 3 months (T3), and at 6 months after the interventions (T4).

RESULTS

After the interventions, the CBT group participants demonstrated significantly lower symptoms of depression (p=0.009) at T2 and perceived more social support from those around them (p<0.001, <0.001 and =0.004, respectively) at three time-point comparisons than the control group. Moreover, after intervention, participants in the physical fitness exercise program group had decreased GDS-15 scores at three time-point comparisons (p=0.003, 0.012 and 0.037, respectively), had a substantially greater 6-min walk distance (p=0.023), a better quality of life (p<0.001), and a better perceived social support at T2 (p<0.001).

CONCLUSIONS

Immediately after a 12-week intervention, there were significant decreases in depressive symptoms and more perceived social support amongst those in the CBT group. When considering the effectiveness in the decrease of depressive symptoms longer term, the increase in the 6-min walk distance and raising the patients' quality of life, physical fitness exercise program may be a better intervention for elderly adults with depressive symptoms.

Treatment-as-usual (TAU) is anything but usual: a meta-analysis of CBT versus TAU for anxiety and depression

OBJECTIVES

There were three aims of this study, the first was to examine the efficacy of CBT versus treatment-as-usual (TAU) in the treatment of anxiety and depressive disorders, the second was to examine how TAU is defined in TAU control groups for those disorders, and the third was to explore whether the type of TAU condition influences the estimate of effects of CBT.

METHOD

A systematic search of Cochrane Central Register of Controlled Trials, PsycINFO, and CINAHL was conducted.

RESULTS

48 studies of CBT for depressive or anxiety disorders (n=6926) that specified that their control group received TAU were identified. Most (n=45/48) provided an explanation of the TAU group however there was significant heterogeneity amongst TAU conditions. The meta-analysis showed medium effects favoring CBT over TAU for both anxiety (g=0.69, 95% CI 0.47-0.92, p<0.001, n=1318) and depression (g=0.70, 95% CI 0.49-0.90, p<0.001, n=5054), with differential effects observed across TAU conditions.

CONCLUSIONS

CBT is superior to TAU and the size of the effect of CBT compared to TAU depends on the nature of the TAU condition. The term TAU is used in different ways and should be more precisely described. The four key details to be reported can be thought of as "who, what, how many, and any additional treatments?"

A systematic review and meta-analysis of psychotherapy for late-life depression

OBJECTIVES

To determine the efficacy of psychotherapy in late-life depression and to determine the effect of the type of control group on the magnitude of psychotherapy effects.

DESIGN

A systematic review and meta-analysis of randomized controlled psychotherapy trials for late-life depression.

SETTING

Outpatient clinics or in subjects' home.

PARTICIPANTS

Subjects aged 55 years or older with acute-phase depressive disorder.

MEASUREMENTS

Change in depressive symptoms was measured with validated scales. Standardized mean differences (SMD) were calculated for each therapy-control contrast, as meta-analytic summaries for contrasts using a similar control, and for all contrasts combined.

RESULTS

The search identified 27 trials with 37 therapy-control contrasts and 2,245 subjects. Trials utilized five types of control groups (waitlist, treatment-as-usual, attention, supportive therapy, placebo). In the combined contrasts, psychotherapy was effective (SMD: 0.73; 95% confidence interval [CI]: 0.51, 0.95; z=6.42, p<0.00001). The SMD varied widely (from 0.05 to 1.36) and significantly (χ2=35.67, df=4, p<0.00001) between subgroups by type of control. In five trials that compared psychotherapy with supportive therapy, the SMD was 0.39 (95% CI: 0.16, 0.61; z=3.37, p<0.0007; I2=0%). The SMD was 0.11 within the waitlist controls and 1.10 within the supportive therapy subgroup.

CONCLUSIONS

Psychotherapy is effective for late-life depression, but the magnitude of the effect varies widely with the type of control group. Supportive therapy appears to best control for the nonspecific elements of psychotherapy and is associated with considerable change itself, but few trials have utilized it as a control.

Effectiveness of cognitive behavioural therapy for anxiety and depression in primary care: a meta-analysis

BACKGROUND

Cognitive behavioural therapy (CBT) is increasingly being delivered in primary care, in a variety of delivery formats such as guided self-help CBT, telephone-based CBT, computerized CBT and standard, one-to-one CBT. However, the vast majority of research has focused on CBT in specialized services, and no previous meta-analysis has examined CBT's effectiveness across delivery formats in primary care.

OBJECTIVE

To determine the effectiveness of multi-modal CBT (i.e. CBT across delivery formats) for symptoms of anxiety and depression, in primary care.

METHODS

A meta-analysis of CBT-focused RCTs, for symptoms of anxiety or depression, in primary care. The authors searched four databases. To be included, RCTs had to be set in primary care or have primary care participants.

RESULTS

Twenty-nine RCTs were included in three separate meta-analyses. Results showed multi-modal CBT was more effective than no primary care treatment (d =0.59), and primary care treatment-as-usual (TAU) (d = 0.48) for anxiety and depression symptoms. Moreover, multi-modal CBT in addition to primary care TAU was shown to be more effective than primary care TAU for depression symptoms (no comparisons of this kind were available for anxiety) (d = 0.37).

CONCLUSIONS

The results from conducted meta-analyses indicate that multi-modal CBT is effective for anxiety and depression symptoms in primary care. Furthermore, based on CBT's economic viability, increasing the provision of CBT in primary care seems justified. Future research should examine if varying levels of qualification among primary care CBT practitioners impacts on the effectiveness of CBT in this setting.

The effect of psychotherapy for depression on improvements in social functioning: a meta-analysis

BACKGROUND

Patients with depression often report impairments in social functioning. From a patient perspective, improvements in social functioning might be an important outcome in psychotherapy for depression. Therefore, it is important to examine the effects of psychotherapy on social functioning in patients with depression.

METHOD

We conducted a meta-analysis on studies of psychotherapy for depression that reported results for social functioning at post-treatment. Only studies that compared psychotherapy to a control condition were included (31 studies with 2956 patients).

RESULTS

The effect size of psychotherapy on social functioning was small to moderate, before [Hedges' g = 0.46, 95% confidence interval (CI) 0.32-0.60] and after adjusting for publication bias (g = 0.40, 95% CI 0.25-0.55). Univariate moderator analyses revealed that studies using care as usual as a control group versus other control groups yielded lower effect sizes, whereas studies conducted in the USA versus other countries and studies that used clinician-rated instruments versus self-report yielded higher effect sizes. Higher quality studies yielded lower effect sizes whereas the number of treatment sessions and the effect size of depressive symptoms were positively related to the effect size of social functioning. When controlling for these and additional characteristics simultaneously in multivariate meta-regression, the effect size of depressive symptoms, treatment format and number of sessions were significant predictors. The effect size of social functioning remained marginally significant, indicating that improvements in social functioning are not fully explained by improvements in depressive symptoms.

CONCLUSIONS

Psychotherapy for depression results in small to moderate improvements in social functioning. These improvements are strongly associated with, but not fully explained by, improvements in depressive symptoms.

Choosing treatment for depression in older adults and evaluating response

An update is provided on the current information regarding late life depression with regard to assessment, clinical implications, and treatment recommendations. Several treatments are considered evidence-based, but when deployed into field trials, the efficacy of these treatments falls short. It is thought that the lower impact in community trials is due in large part to patient, clinical, environmental, socio-economic, and cognitive correlates that influence treatment response. The aim is to assist providers in making decisions about what type of treatment to recommend based on a sound assessment of these clinical correlates.

A potential model for primary care mental health services in Ireland

Objectives:

A high demand for the inclusion of psychosocial interventions for primary care mental health presentations has become more apparent in recent years. Current policies have proposed models of care highlighting principles required for a quality service. However, implementation has been slow to date. This article aims to inform the current debate relating to primary care service delivery models for mental health presentations and to contribute towards future planning initiatives.

Method:

A narrative review of a range of policies and selected articles relevant to primary care mental health in an Irish context.

Results:

The search produced four distinct themes: current service provision in Ireland; stakeholders' views; psychological care options; and potential service structures. Thereafter, a potential service delivery model is proposed. This formulated model employs a combination of elements from the reviewed themes to provide a clinically- and cost-effective, equitable and accessible service driven by service user and carer input.

Conclusions:

Although this review was selective in nature, the proposed potential model can complement future research agendas for more favourable primary care practice in Ireland. Recommendations are made for the planning of services including policy implementation procedures, training and communication.

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.

Effectiveness of cognitive behavior therapy for severe mood disorders in an acute psychiatric naturalistic setting: a benchmarking study

The current study examined the effectiveness of brief cognitive behavior therapy (CBT) for severe mood disorders in an acute naturalistic setting. The sample included 951 individuals with either major depressive disorder (n = 857) or bipolar disorder with depressed mood (n = 94). Participants completed a battery of self-report measures assessing depression, overall well-being, and a range of secondary outcomes both before and after treatment. We found significant reductions in depressive symptoms, worry, self-harm, emotional lability, and substance abuse, as well as significant improvements in well-being and interpersonal relationships, post-treatment. Comparable to outpatient studies, 30% of the sample evidenced recovery from depression. Comparison of findings to benchmark studies indicated that, although the current sample started treatment with severe depressive symptoms and were in treatment for average of only 10 days, the overall magnitude of symptom improvement was similar to that of randomized controlled trials. Limitations of the study include a lack of control group, a limitation of most naturalistic studies. These findings indicate that interventions developed in controlled research settings on the efficacy of CBT can be transported to naturalistic, "real world" settings, and that brief CBT delivered in a partial hospital program is effective for many patients with severe depressive symptoms.

Psychotherapies for Late-Life Depression

Late-life depression often occurs in the context of cognitive impairment, medical burden, and disability. For this reason, the assessment of depressed older adults consists of detailed psychiatric history and mental status examination and focuses on their broader clinical context and their ecosystem. This article outlines assessment procedures and the principles of therapies developed to utilize their assets and address limitations imposed by their clinical problems and their behavioral consequences.

Unique and shared techniques in cognitive-behavioural and short-term psychodynamic psychotherapy: a content analysis of randomised trials on depression

Randomised controlled trials (RCTs) of psychotherapeutic interventions assume that specific techniques are used in treatments, which are responsible for changes in the client's symptoms. This assumption also holds true for meta-analyses, where evidence for specific interventions and techniques is compiled. However, it has also been argued that different treatments share important techniques and that an upcoming consensus about useful treatment strategies is leading to a greater integration of treatments. This makes assumptions about the effectiveness of specific interventions ingredients questionable if the shared (common) techniques are more often used in interventions than are the unique techniques. This study investigated the unique or shared techniques in RCTs of cognitive-behavioural therapy (CBT) and short-term psychodynamic psychotherapy (STPP). Psychotherapeutic techniques were coded from 42 masked treatment descriptions of RCTs in the field of depression (1979-2010). CBT techniques were often used in studies identified as either CBT or STPP. However, STPP techniques were only used in STPP-identified studies. Empirical clustering of treatment descriptions did not confirm the original distinction of CBT versus STPP, but instead showed substantial heterogeneity within both approaches. Extraction of psychotherapeutic techniques from the treatment descriptions is feasible and could be used as a content-based approach to classify treatments in systematic reviews and meta-analyses.

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.

Comparison of the effectiveness of cognitive behavioral therapy for depression among older versus younger veterans: results of a national evaluation

OBJECTIVES

The effectiveness of cognitive behavioral therapy for depression (CBT-D) among older adults in routine clinical settings has received limited attention. The current article examines and compares outcomes of older versus younger veterans receiving CBT-D nationally.

METHOD

Patient outcomes were assessed using the Beck Depression Inventory-II and World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed using the Working Alliance Inventory-Short Revised.

RESULTS

A total of 764 veterans aged 18-64 and 100 veterans aged 65+ received CBT-D; 68.0% of older and 68.3% of younger patients completed all sessions or finished early due to symptom relief, and mean depression scores declined from 27.0 (standard deviation [SD] = 10.7) to 16.2 (SD = 12.4) in the older group and from 29.1 (SD = 11.2) to 17.8 (SD = 13.5) in the younger group. Within-group effect sizes were d = 1.01 for both groups. Significant increases in quality of life and therapeutic alliance were observed for both groups.

DISCUSSION

CBT-D resulted in significant improvements in depression and quality of life among older patients. Outcomes and rate of attrition were equivalent to younger patients. Findings indicate that CBT-D is an effective and acceptable treatment for older veterans in real-world settings with often high levels of depression.

Computerised cognitive behavioural therapy for depression and anxiety with older people: a pilot study to examine patient acceptability and treatment outcome

OBJECTIVE

The study objective was to determine the acceptability and treatment outcome of using Beating the Blues (BTB) with older people (6 + years). Specific aims included identifying the treatment uptake and drop-out rate, and describing the role of basic demographics in therapy uptake.

METHOD

Fifty-eight participants, experiencing symptoms of depression, were given a free choice of receiving treatment as usual (TAU) plus BTB (TAU + BTB) or TAU alone. All participants completed demographic questionnaires and a range of outcome measures at baseline, 2 months after baseline (end of treatment) and 3 months after baseline (follow-up).

RESULTS

Thirty-three participants (56.9%) opted to receive BTB and reported having more experience and confidence using a computer than those who declined BTB. Twenty-four participants (72.7%) went on to complete all eight BTB sessions. Statistical analysis found significant differences between the two treatment groups, with the TAU + BTB group showing greater improvements in their symptoms of depression and anxiety than the TAU group by the end of treatment and at follow-up. Furthermore, the TAU+ BTB group had a significantly higher percentage of participants who met criteria for clinically significant improvement in their symptoms of depression by the end of treatment and at follow-up.

CONCLUSION

Although further research is required, including a randomised controlled trial, the results of this initial pilot study provide evidence that BTB may offer an acceptable and effective treatment option for older people.

An integrative group therapy model for depression and anxiety in later life

Research shows that elderly patients are fully capable of benefiting from psychotherapy, and often prefer this non-pharmacological treatment option. Further, there is consensus among geriatric clinicians and researchers that a group format for psychotherapy is likely especially helpful for the elderly. In this paper, we describe a unique group therapy program for elderly patients referred to a community outpatient setting for depression and/or anxiety. This integrated group therapy program, unlike existing programs, combines a more structured cognitive-behavior therapy (CBT) with a more process-oriented interpersonal therapy (IPT), specifically targeting the coexistence of depression and anxiety in the elderly. We present two cases of prototypical patients benefiting from the program, and also provide preliminary empirical support for the effectiveness of this group program.

[Effect of schema-focused therapy on depression, anxiety and maladaptive cognitive schemas in the elderly]

INTRODUCTION

Depression is one of the most frequent mental disorders in older people, known to increase rates of disability and mortality. Depression in late life, commonly accompanied by multiple medical illnesses, reduces quality of life and is a strong risk factor for suicide. Despite its clinical significance, depression remains underdiagnosed and inadequately treated in older patients. Cognitive-behavioural psychotherapies have the most empirical support in treating late-life depression, and are recommended by numerous guidelines in this indication. Group interventions are also recommended for older adults because they offer peer support, mitigate social isolation, encourage shared empathy and provide a context for peer feedback help from the group. Previous studies have shown that maladaptive schemas have an important role in the development or maintenance of depression and anxiety in older people, either as risk factors or as vulnerability markers, but there are no studies that have examined the effectiveness of schema-focused therapy to improve depression in late life.

OBJECTIVES

The main goals of the present study were to explore the relationship of maladaptive schemas with depression and anxiety severity in aged inpatients, and to evaluate the efficacy of a cognitive-behavioural individual and group treatment program that includes schema-focused therapy on depression, anxiety, and cognitive schemas activation.

METHODS

The sample consisted of aged depressed inpatients (n=51) treated in a psychiatric unit. Participants completed measures of depression (Geriatric Depression Scale [GDS]) and anxiety (State-Trait Anxiety Inventory [STAI]) severity and maladaptive schemas (Cognitive Inventory of Subjective Distress [CISD]) at pre- and post-intervention (mean hospital stay: 4weeks).

RESULTS

The maladaptive schemas Loss of Individuality, Refusal of Assistance and Vulnerability are more activated in our sample of depressed subjects with regard to the reference population. Most of specific maladaptive schemas (except Fear of Losing Control) were significantly correlated to depression and anxiety-state severity. The GDS and the STAI scores, and the activation of five of seven maladaptive schemas measured by the CISD decreased significantly after treatment.

DISCUSSION

This study confirms the results of previous research and shows that specific maladaptive schemas are related to depression and anxiety severity in clinically depressed aged patients. Contrary to other previous studies, we find that the activation of maladaptive schemas can decrease during a group psychotherapeutic program that includes schema-focused therapy. These findings support the feasibility of individual and group schema-focused therapy to assist older people suffering from depression effectively.

How much psychotherapy is needed to treat depression? A metaregression analysis

BACKGROUND

Although psychotherapies are effective in the treatment of adult depression it is not clear how this treatment effect is related to amount, frequency and intensity of therapy.

METHODS

To fill this gap in knowledge, the present metaregression analysis examined the association between the effects of psychotherapy for adult depression and several indicators of amount, frequency and intensity of therapy. The analysis included 70 studies (92 comparisons) with 5403 patients, in which individual psychotherapy was compared with a control group (e.g. waiting list, care-as-usual).

RESULTS

There was only a small association between number of therapy sessions and effect size, and this association was no longer significant when the analysis adjusted for other characteristics of the studies. The multivariable analyses also found no significant association with the total contact time or duration of the therapy. However, there was a strong association between number of sessions per week and effect size. An increase from one to two sessions per week increased the effect size with g=0.45, while keeping the total number of treatment sessions constant.

DISCUSSION

More research is needed to establish the robustness of this finding. Based on these findings, it may be advisable to concentrate psychotherapy sessions within a brief time frame.

Psychological management of unipolar depression

OBJECTIVE

To be used in conjunction with 'Pharmacological management of unipolar depression' [Malhi et al. Acta Psychiatr Scand 2013;127(Suppl. 443):6-23] and 'Lifestyle management of unipolar depression' [Berk et al. Acta Psychiatr Scand 2013;127(Suppl. 443):38-54]. To provide clinically relevant recommendations for the use of psychological treatments in depression derived from a literature review.

METHOD

Medical databases including MEDLINE and PubMed were searched for pertinent literature, with an emphasis on recent publications.

RESULTS

Structured psychological treatments such as cognitive behaviour therapy and interpersonal therapy (IPT) have a robust evidence base for efficacy in treating depression, even in severe cases of depression. However, they may not offer benefit as quickly as antidepressants, and maximal efficacy requires well-trained and experienced therapists. These therapies are effective across the lifespan and may be preferred where it is desired to avoid pharmacotherapy. In some instances, combination with pharmacotherapy may enhance outcome. Psychological therapy may have more enduring protective effects than medication and be effective in relapse prevention. Newer structured psychological therapies such as mindfulness-based cognitive therapy and acceptance and commitment therapy lack an extensive outcome literature, but the few published studies yielding positive outcomes suggest they should be considered options for treatment.

CONCLUSION

Cognitive behaviour therapy and IPT can be effective in alleviating acute depression for all levels of severity and in maintaining improvement. Psychological treatments for depression have demonstrated efficacy across the lifespan and may present a preferred treatment option in some groups, for example, children and adolescents and women who are pregnant or postnatal.

The effects of psychotherapy for adult depression on suicidality and hopelessness: a systematic review and meta-analysis

BACKGROUND

Although treatment guidelines suggest that suicidal patients with depression should be treated for depression with psychotherapy, it is not clear whether these psychological treatments actually reduce suicidal ideation or suicide risk.

METHODS

We conducted a systematic review and meta-analysis of studies on psychotherapy for depression in which outcomes on suicidality were reported. We also focused on outcomes on hopelessness because this is strongly associated with suicidal behavior in depression.

RESULTS

Thirteen studies (with 616 patients) were included, three of which examined the effects of psychotherapy for depression on suicidal ideation and suicide risk, and eleven on hopelessness. No studies were found with suicide attempts or completed suicides as the outcome variables. The effects on suicidal ideation and suicide risk were small (g=0.12; 95% CI: -0.20-0.44) and not statistically significant. A power calculation showed that these studies only had sufficient power to find an effect size of g=0.47. The effects on hopelessness were large (g=1.10; 95% CI: 0.72-1.48) and significant, although heterogeneity was very high. Furthermore, significant publication bias was found. After adjustment of publication bias the effect size was reduced to g=0.60.

DISCUSSION

At this point, there is insufficient evidence for the assumption that suicidality in depressed patients can be reduced with psychotherapy for depression. Although psychotherapy of depression may have small positive effects on suicidality, available data suggest that psychotherapy for depression cannot be considered to be a sufficient treatment. The effects on hopelessness are probably higher.