An evaluation of the beyondblue Depression Training Program for aged care workers

Study protocol for ELders AT Ease (ELATE): a cluster randomised controlled trial of cognitive behaviour therapy to reduce depressive symptoms in aged care residents

BACKGROUND

This protocol describes a study of the effectiveness of cognitive behaviour therapy (CBT) for reducing depressive symptoms in older adults living in residential aged care (RAC) facilities in Australia. Depressive symptoms are highly prevalent in this population, yet the benefits of CBT for reducing such symptoms in RAC facilities have not been widely investigated. Elders at Ease (ELATE) is a 16-session CBT intervention designed for implementation in RAC facilities. The intervention includes cognitive, behavioural and reminiscence strategies and is delivered by mental health trainees (MHTs) in collaboration with RAC facility staff and residents' family.

METHODS AND ANALYSIS

ELATE will be evaluated using a cluster randomised trial comparing outcomes for residents who participate in the intervention with those living in usual care control facilities. The participants are RAC residents aged 65 years or above, with depressive symptoms (Patient Health Questionnaire-2 ≥ 3) and normal cognition or mild cognitive impairment (Standardised Mini Mental Status Examination ≥ 21). They are assessed at four time points: baseline prior to randomisation (T1), mid-treatment (T2; 2.5 months post randomisation), post-treatment (T3; 5 months post-randomisation) and 3-month follow-up (T4; 8 months post randomisation). The primary outcome is change in depressive symptoms between T1 and T3. Secondary outcomes are depressive symptoms at T4, anxiety, suicide ideation, sleep problems, quality of life, staff and family knowledge of late-life depression, stress levels and efficacy in caring for residents, and MHT levels of geropsychology competencies. Residents receiving the intervention are hypothesised to report a greater decrease in depressive symptoms between T1 and T3 compared to residents receiving usual care. The primary analysis is a regression, clustered over site to account for correlated readings, and independent variables are condition and depressive symptoms at T1. A cost-utility analysis is also undertaken.

DISCUSSION

ELATE is a comprehensive CBT intervention for reducing depressive symptoms in RAC residents. It is designed to be implemented in collaboration with facility staff and residents' families, individually tailored to residents with normal cognition to mild cognitive impairment and delivered by trainee therapists. ELATE offers a model that may be widely applicable across the RAC sector.

TRIAL REGISTRATION

Trial registered with the Australian and New Zealand Clinical Trial Registry (ANZCTR) Number ACTRN12619001037190, prospectively registered on 22 July 2019.

Behavioral Activation in Nursing Homes to Treat Depression (BAN-Dep): Results From a Clustered, Randomized, Single-Blinded, Controlled Clinical Trial

OBJECTIVES

To determine if behavioral activation (BA) delivered by trained staff decreases prevalence of clinically significant symptoms of depression among older adults living in residential aged care facilities (RACFs).

METHODS

Clustered, randomized, single-blinded, controlled trial of BA for adults aged over 60 years living permanently in a RACF with symptoms of depression (Patient Health Questionnaire, PHQ-9 ≥ 5). BA was delivered over 8-12 weeks using a structured workbook. The proportion of residents with PHQ-9 ≥ 10 at weeks 12, 26, and 52, as well as anxiety symptoms (GAD-7), physical (PCS), and mental (MCS) quality of life, loneliness, and loss to follow-up were main outcomes of interest RESULTS: We recruited 54 RACFs (26 intervention) and 188 of their residents (89 intervention). Participants were aged 61-100 years and 132 (70.2%) were women. PHQ-9 ≥ 10 interacted with BA at week 12 (OR = 0.34, 95%CI = 0.11-1.07), but differences between the groups were not statistically significant at any time-point. GAD-7 ≥ 10 interacted with BA at week 26 (OR = 0.12, 95%CI = 0.02-0.58), but not at any other time-point. Overall, the intervention had no effect on the scores of the PHQ-9, GAD-7, PCS, MCS, and loneliness scale. Loss to follow-up was similar between groups. Adherence to all stages of the intervention was poor (36.2%).

CONCLUSIONS

Disruption by the COVID-19 pandemic and staffing issues in RACFs undermined recruitment and adherence. In such a context, a BA program delivered by RACF staff was not associated with better mental health outcomes for residents over 52 weeks.

Perceptions and practice behaviors regarding late-life depression among private duty home care workers: a mixed-methods study

Background: This study aimed to examine personal care aides (PCAs)' knowledge, beliefs, and attitudes towards late-life depression and their experience caring for older adults with depression.Method: This study used a mixed-methods convergent parallel design involving an online survey (n = 87) and semi-structured interviews (n = 22). Survey respondents were recruited using convenience sampling and interviewees using purposive sampling from private duty home care agencies in Michigan. Qualitative data analyzed using a technique involving data reduction and open coding. Survey data were analyzed using descriptive statistics.Results: Most PCAs underestimated suicide rate among older adults, overrated self-help ability of the depressed person, underrated difficulty diagnosing depression, and attributed depression to personality flaws. PCAs favored psychotherapy and informal support and generally regarded medication as unhelpful, particularly in mild/moderate depression. Despite these discordances, PCAs' self-reported practice behaviors included strategies (i.e., communication, behavioral, cognitive, emotional regulation, relational, and external) that were largely consistent with the scientific view, particularly relating to behavioral activation. A prominent theme from PCAs' narratives was individualized care, reflected in their assessment of depressive symptoms, attitude towards depression treatment, and strategies caring for clients.Conclusions: Several areas of PCAs' perceptions regarding late-life depression were discordant with the current scientific view, although their practice behaviors were largely consistent with the principles of evidence-based practice for depression. Specialized mental health training, a standard depression care protocol, and higher training standards are essential to mobilize the large number of PCAs to improve the mental health outcomes of hard-to-reach older adults.

Barriers to the Recognition of Geriatric Depression in Residential Care Facilities in Alberta

This study explored the barriers that regulated nurse professionals encountered in recognizing and assessing geriatric depression in residential care facilities in the Canadian province of Alberta. The study used a convergent parallel mixed methods design, including a cross-sectional survey (N = 635) and qualitative interviews (N = 14) with regulated nurse professionals. Findings revealed six major barriers to the recognition of geriatric depression in Alberta, including 1) insufficient clinical knowledge and training in geriatric depression; 2) misconceived beliefs about geriatric depression; 3) limited access to resources; 4) unclear depression assessment protocol and procedures in facilities; 5) characteristics of models of care and organizational culture in facilities; and 6) communication difficulties among all stakeholders in the process. Socio-cultural values and beliefs about geriatric depression played a key role in the complex interaction of the various structural and agential barriers to the effective recognition and assessment of depression in residential care facilities in Alberta.

Behavioural activation in nursing homes to treat depression (BAN-Dep): study protocol for a pragmatic randomised controlled trial

INTRODUCTION

Depression is a common disorder among older people living in residential aged care facilities. Several trials have demonstrated the effectiveness of behavioural therapies in treating depressive symptoms in older adults living in the community and in residential aged care. Behavioural Activation is demonstrably effective even when delivered by non-specialists (staff without formal psychological training), although strategies for adapting its use in residential aged care facilities are yet to be explored. This study will determine whether training residential care staff in the use of a structured Behavioural Activation programme is more effective at decreasing depressive symptoms among older residents than internet-based training about depression recognition and management alone.

METHOD AND ANALYSIS

The behavioural activation in nursing homes to treat depression (BAN-Dep) trial is a pragmatic two-arm parallel clustered randomised controlled trial. It will recruit 666 residents aged 60 or older from 100 residential aged care facilities, which will be randomly assigned to the Behavioural Activation or control intervention. Staff in both treatment groups will be encouraged to complete the Beyondblue Professional Education to Aged Care e-learning programme to improve their recognition of and ability to respond to depression in older adults. Selected staff from intervention facilities will undergo additional training to deliver an 8-module Behavioural Activation programme to residents with subthreshold symptoms of depression-they will receive ongoing Mental support from trained Behavioural Activation therapists. Outcome measures will be collected by blind research officer at baseline and after 3, 6 and 12 months. The Patient Health Questionnaire-9 is the primary outcome measure of the study.

ETHICS AND DISSEMINATION

The trial will comply with the principles of the Declaration of Helsinki for Human Rights and is overseen by the University of Western Australia (reference RA/4/20/4234) and Melbourne Health (reference number HREC/18/MH/47) Ethics Committees. The results of this research project will be disseminated through publications and/or presentations in a variety of media to health professionals, academics, clinicians and the public. Only de-identified group data will be presented.

TRIAL REGISTRATION

ACTRN12618000634279.

Mental health knowledge and training needs among direct care workers: a mixed methods study

OBJECTIVES

Direct care providers (DCWs) spend the most time with clients in the home, and as such, play an integral role in identifying mental health problems. However, DCWs receive little preparation in mental health and there is little research regarding their role in the mental health care of clients. The purpose of this study was to explore DCWs' knowledge, attitudes, and experiences of caring for clients with mental health problems from the perspectives of DCWs and key administrators (KAs).

METHOD

Mixed method design. Structured interviews were conducted with DCWs. Focus groups were conducted with KAs.

RESULTS

Twenty-nine DCWs and 12 KAs took part in the study. Loneliness and memory problems in clients were the most prevalent challenges identified by DCWs. DCWs' self-reported mental health knowledge was mid to high across all domains, although they had many misconceptions about mental health and aging. Helpful strategies in working with clients included communication skills, rapport-building, behavioral, cognitive, emotion-regulation, and making use of external resources. KAs noted individual differences in DCWs' mental health knowledge and indicated that mental health issues were often viewed by DCWs as dispositional problems or a normal part of aging. KAs viewed DCWs' greatest challenges as personalizing difficult client behaviors, lack of knowledge about how to manage specific behaviors, and difficulties managing their own emotions towards clients.

CONCLUSION

Data from this study suggest important areas for DCW development. However, system issues that affect DCWs such as workload, resources, mental health stigma, and diverse client populations should be addressed concurrently.

Evaluation of A Training Program to Assist Care Staff to Better Recognize and Manage Depression among Palliative Care Patients and Their Families

This study was designed to evaluate the effectiveness of a training program to improve the knowledge, attitudes, and self-efficacy of palliative care staff and thus enable them to better detect and manage depression among palliative care patients and their families. Participants were 90 professional carers who completed a four-session training program. Knowledge, attitudes, self-efficacy, and barriers to working with depressed patients were assessed pre-intervention, post-intervention, and at a three-month follow-up. The results demonstrated that compared to the control group, the intervention group had improved in all of these areas. Improvements were maintained at the three-month follow-up in all areas except attitudes. The results of this study indicate the importance of training in managing depression among palliative care staff. Booster sessions will likely be needed to ensure that training program gains are maintained.

Support workers can develop the skills to work with complexity in community aged care: An Australian study of training provided across aged care community services

Enhancing support workers' (SW) role is timely given increasing demands on human and financial health care resources. This article presents outcomes of a program, delivered to 140 participants from five community aged care providers in Australia, designed to enhance knowledge, skills, and confidence of community aged care SWs, building their practical skills in understanding, recognizing, and responding to complexity. Evaluation training modules on communication, complexity, behavior change, and chronic condition self-management support involved pre/post surveys with SWs and their supervisors. SWs reported greater awareness, skills, and confidence in working with complexity, reinforcing the value of their existing practices and skills. Coordinators reported greater appreciation of SWs' skills, and greater awareness of gaps in SWs' support and supervision needs. Educators, policy makers, and services should account for these contributions, given growing fiscal restraint and focus on reablement and consumer-directed care.

Support workers as agents for health behavior change: An Australian study of the perceptions of clients with complex needs, support workers, and care coordinators

An expanding aging population has placed increased demands on health care resources in many countries. Enhancing community aged care support workers' role to support greater client self-management and reablement is therefore timely. This article presents perceptions of the impact of an Australian practice change initiative designed to enhance knowledge, skills, and confidence of support workers to support behavior change in clients with complex health care needs. A comprehensive training program was delivered in 2013. Methods included thematic analysis of interviews with clients, focus groups with support workers and coordinators, and collection of case studies of client/support worker behavior change interactions. Client, support worker, and coordinator responses were highly positive, reporting improvement in the quality of interactions with clients, client health outcomes, care coordination, communication, and teamwork. Mental health literacy remained the biggest knowledge gap. This research showed that support workers are ideally placed to be more actively involved in motivating clients to achieve behavior change goals.

[Treatment pathways in the care of patients with schizophrenia and depression]

BACKGROUND

In mental healthcare the concept of pathways addresses diverse issues and problem areas, such as heterogeneous health service offers, the regional variability of treatment concepts and clear-cut guidelines on how and where to obtain treatment for a particular mental disorder. The ambiguous aspects of the concept require international and national definitions and consensus which must also cover quality criteria.

METHODS

This article gives an overview of currently available evidence for the analysis of clinical pathways and pathways to care in international mental healthcare, covering studies on schizophrenia and depression from 2010 to 2014.

RESULTS AND DISCUSSION

The ambiguity of the concept impedes the overview and does not provide unequivocal results. The development, implementation and analyses of guidelines or clear-cut clinical and pathways to care must consider individual, clinical and care system aspects as well as the interplay of these factors. Results suggest that system aspects tend to dominate over clinical factors of schizophrenia and depression. As a consequence, the definition, implementation and evaluation of clinical pathways or pathways to mental healthcare is first and foremost a responsibility of the respective national mental healthcare system and must be understood on that level, before findings are summarized internationally and models of best practice are debated.

Barriers to treatment for older adults seeking psychological therapy

BACKGROUND

Older adults with mental health disorders underutilize mental health services more than other adults. While there are well known general barriers to help seeking across the population, specific barriers for older adults include difficulties with transportation, beliefs that it is normal to be anxious and depressed in old age, and beliefs by referrers that psychological therapy is less likely to be effective. This study examined barriers related to identifying the need for help, seeking help and participating in therapy in a clinical population of older adults.

METHOD

Sixty older adults (aged 60-79 years) with comorbid anxiety and unipolar mood disorders completed barriers to treatment questionnaires before and after psychological group treatment, as well as measures of cognitive ability, anxiety, depression, and quality of life at baseline.

RESULTS

The greatest barriers to help seeking related to difficulties identifying the need for help, with 50% of the sample reporting their belief that their symptoms were normal as a major barrier. Other major barriers identified were related to: self-reliance, cost of treatment, and fear of medication replicating previous findings. The main barriers reported for difficulties in continuing therapy included not finding therapy helpful, cost of treatment, and thinking that the therapist did not understand their issues.

CONCLUSIONS

The main barriers identified related to issues with identifying the need to seek help. More attention is needed to educate older adults and professionals about the need for, and effectiveness of, psychological therapies for older adults with anxiety and depression to reduce this barrier to help seeking.

Staff-focused interventions to increase referrals for depression in aged care facilities: a cluster randomized controlled trial

OBJECTIVE

While there is evidence that depression training can improve the knowledge of staff in residential care facilities, there is an absence of research determining whether such training translates into practice change. This study aimed to evaluate the impact of staff training and the introduction of a protocol for routine screening and referral for depression on the numbers of residents detected and referred by care staff for further assessment.

METHOD

A cluster randomized controlled design was used to compare the referral rates for residents in seven facilities randomly allocated into one of three conditions: staff training, staff training plus a screening and referral protocol and wait-list control. Participants were 216 aged care residents (M age = 87 years), who agreed to a 12-month audit of their facility file.

RESULTS

Staff training on its own did not increase the rate of referrals for depression; however, staff training plus the screening protocol and referral guidelines did lead to a significant increase in the number of residents who were referred to a medical practitioner for further assessment. However, this increase in care staff referrals did not result in substantial changes in the treatment prescribed for residents.

CONCLUSION

Staff training in depression, supplemented with a protocol for routine screening and guidelines on referring residents, can improve pathways to care. However, strategies to overcome barriers to appropriate subsequent treatment of depression are required for staff-focused initiatives to translate into better outcomes for depressed older adults. Methodological limitations of this study are discussed.

More age-care staff report helping care recipients following a brief depression awareness raising intervention

Background

Those working with elderly care recipients require a good working knowledge of depression and appropriate help giving responses. While it is important for age-care staff to recognize depression in care recipients it is also critical that they know the appropriate course of action to assist a care recipient who may be depressed. This study aims to determine the knowledge of age-care staff of appropriate help giving responses, their confidence in knowing what kind of assistance to provide and their actual likelihood of providing help to potentially depressed care recipients and to examine if these measures improve following an intervention training program.

Methods

One hundred and two age-care staff were surveyed on their confidence in helping age-care recipients and on their knowledge of appropriate ways to provide assistance. Staff then participated in a two hour depression awareness raising intervention. The survey was repeated immediately following the training and again six months later.

Results

Staff confidence in knowing how to provide assistance increased significantly subsequent to training and remained significantly improved at the six month follow up. In addition, a significantly higher proportion of staff reported helping care recipients at the six month follow up.

Conclusions

This study highlights the potential of a brief staff training program to provide a cost effective means to improve staff self-confidence and increase the likelihood of staff providing assistance to depressed care recipients.

A randomized control trial to evaluate the beyondblue depression training program: does it lead to better recognition of depression?

OBJECTIVES

The aim of this study was to determine if a depression training program could assist aged care staff to better recognize depression among older people in residential care. The use of a "paper trail" for a screening tool and a study champion in combination with this training was evaluated to determine if this improved the level of detection of depression.

METHOD

The study took the form of a randomized control trial. A total of 107 professional carers from residential aged care services in Melbourne, Australia, participated in the study. Thirty-four carers were allocated to the training-only group and completed a six-session depression training program, 35 carers were allocated to the training-plus-screening protocol group, and 38 carers were assigned to a wait-list control group. In total, 216 residents were screened for depression. Carers in all conditions were asked to identify those residents who they perceived to be depressed. Residents were independently assessed with the SCID-I to determine their depression status.

RESULTS

Trained staff were not found to be better in detecting depression than non-trained staff. Staff in the training-plus-screening condition correctly identified more residents as depressed, but also classified more non-depressed residents as depressed.

CONCLUSION

The findings demonstrate the need for a greater focus on recognizing depression among carers working in aged care facilities. Protocols should be developed to assist carers to detect, refer, and monitor depression in residents.

Depression training in nursing homes: lessons learned from a pilot study

Late-life depression is common among nursing home residents, but often is not addressed by nurses. Using a self-directed CD-based depression training program, this pilot study used mixed methods to assess feasibility issues, determine nurse perceptions of training, and evaluate depression-related outcomes among residents in usual care and training conditions. Of 58 nurses enrolled, 24 completed the training and gave it high ratings. Outcomes for 50 residents include statistically significant reductions in depression severity over time (p < 0.001) among all groups. Depression training is an important vehicle to improve depression recognition and daily nursing care, but diverse factors must be addressed to assure optimal outcomes.

Measuring carers' knowledge of depression in aged care settings: the Knowledge of Late Life Depression Scale-Revised

BACKGROUND

Aged care staff is increasingly relied upon to assist with the recognition and treatment of depression in older care recipients. However, there exist few reliable and comprehensive measures that assess aged care staffs' knowledge about late life depression. The Knowledge of Late-Life Depression Scale is one such scale. In this study we modified this measure in an attempt to improve its psychometric properties so that it can be used with confidence in research and practise. Our modifications to the original measure resulted in the Knowledge of Late-Life Depression Scale-Revised.

METHOD

Aged care staff (N=149) from 20 low level care facilities and community care facilities in Melbourne, Australia, completed the Knowledge of Late-Life Depression Scale-Revised.

RESULTS

Using Confirmatory Factor Analysis and reliability analysis, the Knowledge of Late-Life Depression Scale-Revised was found to demonstrate three robust and internally consistent factors. These factors were: symptoms of depression, facts about depression, and myths of depression. The revised measure was found to yield superior psychometric properties compared to the original measure.

LIMITATIONS

Replication studies are required, especially with other aged carer samples to ensure that the factor structure and internal consistency of the measure are supported across different aged care contexts in Australia and elsewhere.

CONCLUSIONS

The Knowledge of Late-Life Depression-Revised is a measure that can be used by researchers and agencies to assess the knowledge of depression among professional care staff. The measure is expected to be especially useful as an assessment tool for training and educational purposes.

Intervention for depression among palliative care patients and their families: A study protocol for evaluation of a training program for professional care staff

Background

Clinical depression is highly prevalent yet under-detected and under-treated in palliative care settings and is associated with a number of adverse medical and psychological outcomes for patients and their family members. This article presents a study protocol to evaluate a training intervention for non-physician palliative care staff to improve the recognition of depression and provide support for depressed patients and their family members. Details of the hypotheses and expected outcomes, study design, training program development and evaluation measures are described.

Methods and Design

A randomised controlled trial will be implemented across two palliative care services to evaluate the "Training program for professional carers to recognise and manage depression in palliative care settings". Pre-, post- and three-month follow-up data will be collected to assess: the impact of the training on the knowledge, attitudes, self-efficacy and perceived barriers of palliative care staff when working with depression; referral rates for depression; and changes to staff practices. Quantitative and qualitative methods, in the form of self-report questionnaires and interviews with staff and family members, will be used to evaluate the effectiveness of the intervention.

Discussion

This study will determine the effectiveness of an intervention that aims to respond to the urgent need for innovative programs to target depression in the palliative care setting. The expected outcome of this study is the validation of an evidence-based training program to improve staff recognition and appropriate referrals for depression, as well as improve psychosocial support for depressed patients and their family members.

Trial Registration

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000183088

Recommendations for staff education and training for older people with mental illness in long-term aged care

BACKGROUND

This paper was written as a result of the International Psychogeriatric Association Task Force on Mental Health Services in Long-Term Care. The appraisal presented here aims to (1) identify the best available evidence that underpins best practice for geriatric mental health education and training of staff working in long-term care, and (2) summarize the appraisal of the literature to provide recommendations for practice.

METHODS

An initial search of databases found 138 papers related to the search strategy. Selected papers were summarized and compared against set inclusion criteria. This resulted in 17 papers suitable for review.

RESULTS

The majority of papers focused on behavior skills training. A number of key factors were identified that determine the success of geriatric mental health education and training and recommendations are outlined.

CONCLUSIONS

Methodological weaknesses are common and highlight the need for further replication studies using strong research designs.