Evaluation of the effectiveness of professionals and nonprofessionals as instructors of "coping with depression" classes for elders

Aging and Engaging: A Pilot Randomized Controlled Trial of an Online Conversational Skills Coach for Older Adults

OBJECTIVE

Communication difficulties negatively impact relationship quality and are associated with social isolation and loneliness in later life. There is a need for accessible communication interventions offered outside specialty mental health settings.

DESIGN

Pilot randomized controlled trial.

SETTING

Assessments in the laboratory and intervention completed in-home.

PARTICIPANTS

Twenty adults age 60 and older from the community and a geriatric psychiatry clinic.

INTERVENTION

A web-based communication coach that provides automated feedback on eye contact, facial expressivity, speaking volume, and negative content (Aging and Engaging Program, AEP), delivered with minimal assistance in the home (eight brief sessions over 4-6 weeks) or control (education and videos on communication).

MEASUREMENTS

System Usability Scale and Social Skills Performance Assessment, an observer-rated assessment of social communication elicited through standardized role-plays.

RESULTS

Ninety percent of participants completed all AEP sessions and the System Usability Scale score of 68 was above the cut-off for acceptable usability. Participants randomized to AEP demonstrated statistically and clinically significant improvement in eye contact and facial expressivity.

CONCLUSION

The AEP is acceptable and feasible for older adults with communication difficulties to complete at home and may improve eye contact and facial expressivity, warranting a larger RCT to confirm efficacy and explore potential applications to other populations, including individuals with autism and social anxiety.

A meta-analysis of the effect of therapist experience on outcomes for clients with internalizing disorders

Objective: This meta-analysis synthesized the literature regarding the effect of therapist experience on internalizing client outcomes to evaluate the utility of lay providers in delivering treatment and to inform therapist training. Method: The analysis included 22 studies, contributing 208 effect sizes. Study and client characteristics were coded to examine moderators. We conducted subgroup meta-analyses examining the relationship of therapist experience across a diverse set of internalizing client outcomes. Results: Results demonstrated a small, but significant relationship between therapist experience and internalizing client outcomes. There was no relationship between therapist experience and outcomes in clients with primary anxiety disorders. In samples of clients with primary depressive disorders and in samples of clients with mixed internalizing disorders, there was a significant relationship between experience and outcomes. The relationship between therapist experience and outcomes was stronger when clients were randomized to therapists, treatment was not manualized, and for measures of client satisfaction and "other" outcomes (e.g., dropout). Conclusions: It appears that therapist experience may matter for internalizing clients under certain circumstances, but this relationship is modest. Continuing methodological concerns in the literature are noted, as well as recommendations to address these concerns.

Effects of Mental Health Paraprofessional Training for Filipina Foreign Domestic Workers in Singapore

Research has found that 24% of foreign domestic workers (FDWs) in Singapore have poor mental health (24%), with depressive symptoms being identified as the second most severe psychological symptoms [1]. The study assessed the acceptability and effectiveness of a 4-week cognitive behavioral therapy (CBT)-based paraprofessional training program for FDWs in Singapore on depression literacy and CBT knowledge (primary outcomes), depression-related stigma, as well as attitudes towards seeking professional help (secondary outcomes) immediately and 2 months following the training. Forty female Filipino FDWs were recruited and randomized into either a CBT-based paraprofessional training program or wait-list (WL) group. Participants completed outcome measures before, after, and 2 months following their training. No significant difference was found on changes on any of the outcome variables in the intervention group as compared to the WL group. Following training, both groups showed significantly improved depression literacy, CBT knowledge, and attitudes towards seeking professional help. These changes were sustained at 2-month follow-up. All participants indicated a high level of satisfaction with the training program. While findings from between-group analyses do not support the efficacy of the CBT-based paraprofessional training program in improving depression literacy and related outcomes, participation in the program was associated with improvements in several outcomes within the training group. Future research should explore adaptations to the program (e.g., in terms of training duration and modes of delivery) that would increase its efficacy in improving depression literacy and CBT knowledge among FDWs.

A culturally adapted depression intervention for African American adults experiencing depression: Oh Happy Day

The purpose of this article is to describe development of a culturally adapted depression intervention (Oh Happy Day Class, OHDC) designed for African American adults experiencing major depressive disorder (MDD). This project included 2 pilot studies testing the feasibility and acceptability of the OHDC and examining short-term effects of the OHDC in reducing symptoms of MDD. The OHDC is a 2.5-hr weekly, culturally specific, cognitive behavioral, group counseling intervention for 12 weeks. Cultural adaptations of the OHDC are based on the ecological validity and culturally sensitive framework, along with an Afrocentric paradigm. Fifty African American participants with MDD were enrolled (15 in Pilot I and 35 in Pilot II). All participants in Pilots I and II received the 12-week intervention and completed assessments at baseline, mid-intervention, end-intervention, and 3 months postintervention. General linear mixed modeling for assessment of pre-post longitudinal data analysis was conducted. Results for Pilot I showed 73% of participants completed the full OHDC, a statistically significant decline in depression symptoms from pre- to postintervention, and a 0.38 effect size. Participants were very satisfied with the OHDC. In Pilot II, 66% of participants completed the full OHDC, and there was a significant pre-post intervention decrease in depression symptoms. For men, the OHDC showed a 1.01 effect size and for women, a 0.41 effect size. Both men and women were very satisfied with the OHDC based on the satisfaction measure. These promising findings are discussed with a focus on future plans for examining efficacy of the OHDC in a large-scale, randomized, control trial.

The Coping With Depression Course: A Group Psychoeducational Intervention for Unipolar Depression

Cognitive-behavioural interventions developed from a variety of theoretical orientations have been demonstrated to be safe and effective treatments for unipolar depression. In this article, one specific intervention is described: the Coping With Depression (CWD) Course, a multi-modal group psychoeducational treatment. The theoretical rationale and development of the CWD Course is reviewed, as well as the specific course content. Evidence for the efficacy of the CWD Course is presented and discussed. Also described are several modifications of the CWD Course, developed for use with special populations such as depressed adolescents, caretakers of frail elderly, health-impaired Native Americans, and English and Spanish-speaking medical outpatients. Future research and development directions for the CWD Course are examined, including replication of outcome results, generalization to real-life clinical settings and to diagnostically co-morbid populations, and the prevention of depression among individuals at elevated risk of affective disorder.

Training Addiction Counselors to Implement an Evidence-Based Intervention: Strategies for Increasing Organizational and Provider Acceptance

One barrier to widespread public access to empirically supported treatments (ESTs) is the limited availability and high cost of professionals trained to deliver them. Our earlier work from two clinical trials demonstrated that front-line addiction counselors could be trained to deliver a manualized, group-based cognitive behavioral therapy (GCBT) for depression, a prototypic example of an EST, with a high level of adherence and competence. This follow-up article provides specific recommendations for the selection and initial training of counselors, and for the structure and process of their ongoing clinical supervision. Unique challenges in working with counselors unaccustomed to traditional clinical supervision are highlighted. The recommendations are based on comprehensive feedback derived from clinician notes taken throughout the clinical trials, a focus group with counselors conducted one year following implementation, and interviews with key organization executives and administrators.

The public health impact of major depression: a call for interdisciplinary prevention efforts

Major depression is a consequential public health problem in the United States. Depression has long been recognized as an important target of intervention in psychology and psychiatry, but these fields have focused efforts primarily on treatment rather than prevention. Although effective preventive interventions targeting high-risk groups have been developed, they have thus far had poor reach and sustainability in the community. The development of sustainable preventive interventions that have the potential to impact population health represents a critical goal for the field. To this end, a research agenda incorporating the perspectives of both mental health disciplines and public health is proposed as a guide for future depression prevention research. Increased interdisciplinary collaboration between mental health disciplines and public health is recommended to develop, enact, and evaluate multilevel preventive interventions aimed at reducing the population health burden of major depression.

Training addiction counselors to implement CBT for depression

Many clients in publicly funded substance abuse treatment programs suffer from depression yet lack access to effective mental health treatment. This study sought to examine whether addiction counselors could be effectively trained to deliver group CBT for depression and to ascertain client perceptions of the treatment. Five counselors were trained in the therapy and treated 113 clients with depression symptoms. Counselors demonstrated high fidelity to the therapy and client perceptions of the therapy were positive. Our results suggest that training addiction counselors to deliver group CBT for depression is a promising integrated treatment approach for co-occurring depression and substance disorders.

ANALYSIS OF ROLLING GROUP THERAPY DATA USING CONDITIONALLY AUTOREGRESSIVE PRIORS

Group therapy is a central treatment modality for behavioral health disorders such as alcohol and other drug use (AOD) and depression. Group therapy is often delivered under a rolling (or open) admissions policy, where new clients are continuously enrolled into a group as space permits. Rolling admissions policies result in a complex correlation structure among client outcomes. Despite the ubiquity of rolling admissions in practice, little guidance on the analysis of such data is available. We discuss the limitations of previously proposed approaches in the context of a study that delivered group cognitive behavioral therapy for depression to clients in residential substance abuse treatment. We improve upon previous rolling group analytic approaches by fully modeling the interrelatedness of client depressive symptom scores using a hierarchical Bayesian model that assumes a conditionally autoregressive prior for session-level random effects. We demonstrate improved performance using our method for estimating the variance of model parameters and the enhanced ability to learn about the complex correlation structure among participants in rolling therapy groups. Our approach broadly applies to any group therapy setting where groups have changing client composition. It will lead to more efficient analyses of client-level data and improve the group therapy research community's ability to understand how the dynamics of rolling groups lead to client outcomes.

Les Strategies D'Adaptation des Personnes Agees aux Prises avec des Sentiments Depressifs

As an initial step in the improvement of interventions for the depressed elderly, the present study attempts to identify the strategies they spontaneously use to cope with depressive feelings. Fifty two older persons answered two questionnaires, one measuring the intensity of depressive symptomatology, the other dealing with coping strategies and their usefulness. Results suggest that, as a whole, coping strategies used by the elderly do not fundamentally differ from the ones advocated by younger individuals, in that they favor strategies involving goal-oriented action. The subjects who reported the most depressive feelings differed from the others on two points: they less frequently relied on the strategy of problem solving and they considered general activity as less useful in their struggle against depressive feelings. Implications for the development of services for the elderly, in particular the secondary prevention of depression, are drawn.

Disparate inclusion of older adults in clinical trials: priorities and opportunities for policy and practice change

Older adults are vastly underrepresented in clinical trials in spite of shouldering a disproportionate burden of disease and consumption of prescription drugs and therapies, restricting treatments' generalizability, efficacy, and safety. Eliminating Disparities in Clinical Trials, a national initiative comprising a stakeholder network of researchers, community advocates, policymakers, and federal representatives, undertook a critical analysis of older adults' structural barriers to clinical trial participation. We present practice and policy change recommendations emerging from this process and their rationale, which spanned multiple themes: (1) decision making with cognitively impaired patients; (2) pharmacokinetic differences and physiological age; (3) health literacy, communication, and aging; (4) geriatric training; (5) federal monitoring and accountability; (6) clinical trial costs; and (7) cumulative effects of aging and ethnicity.

Psychoeducational treatment and prevention of depression: the "Coping with Depression" course thirty years later

The "Coping with Depression" course (CWD) is by the far the best studied psychoeducational intervention for the treatment and prevention of depression, and is used in routine practice in several countries. The CWD is a highly structured cognitive-behavioral intervention, which has been adapted for several goals, contexts, and target populations. The efficacy of the CWD has been examined in 25 randomized controlled trials. We conducted a meta-analysis of these studies. The 6 studies aimed at the prevention of new cases of major depression were found to result in a reduced risk of getting major depression of 38% (incidence rate ratio was 0.62). The 18 studies examining the CWD as a treatment of depression found a mean effect size (Cohen's d) of 0.28. Direct comparisons with other psychotherapies did not result in any indication that the CWD was less efficacious. The CWD is a flexible treatment which can easily be adapted for different populations and this may have led researchers to use this intervention for complex target groups, which in turn may have resulted in a lower mean effect size. The CWD has contributed considerably to the development and innovation of prevention and treatment of depression in many target populations.

Outcome of cognitive behaviour therapy for minor depression in routine practice

OBJECTIVES

To examine (1) whether the improvement in depressive symptomatology in subjects participating in psychoeducational groups for minor depression in routine practice is comparable to the improvement realized in a randomized efficacy trial; and (2) whether the level of depressive symptoms of subjects who participated in this intervention is similar after treatment to the level of depressive symptoms of the general population.

DESIGN

Participants (N = 187) of 20 psychoeducational groups in routine practice in the Netherlands were examined before and after the intervention using the Centre for Epidemiological Studies - Depression scale (CES-D).

METHODS

The standardized improvement from pre- to post-test in subjects was compared to the improvement found in subjects participating in a randomized trial of the same intervention. Furthermore, we compared the post-test scores to the scores of the general population.

RESULTS

The improvement of depressive symptoms in routine practice was of the same magnitude as the improvement in the randomized trial. However, a considerable proportion of the participants (54.5%) still scored above the cut-off score of the CES-D at post-test, and the mean CES-D score of the participants (M = 17.0; SD = 9.8) differed significantly (p < .01) from the mean score in the general population (M = 9.7; SD = 8.6).

CONCLUSION

Psychoeducational intervention can be an important help for people with depressive symptoms. The improvement in terms of depressive symptoms in routine practice does not differ from the improvement found in a randomized trial. However, participants remained considerably more depressed than the general population and this intervention is, for many, not sufficient as a form of treatment.

Suboptimal antidepressant use in the elderly

Ongoing changes in available agents and health care delivery systems have made it imperative to study the quality of antidepressant use in vulnerable and traditionally underserved elderly. We conducted a retrospective cohort study among 12,130 new antidepressant users aged > or =65 years with a recent diagnosis of depression in the Pennsylvania Pharmaceutical Assistance Contract for the Elderly Program from January 1, 1994, to December 31, 1999. Additional use information was available through Medicare data. Potentially hazardous antidepressant regimens were defined as use of highly anticholinergic agents or daily dosages in excess of geriatric prescribing guidelines. Low-intensity regimens were defined by lower than recommended daily dosages, too-short durations of therapy, or lack of follow-up. Of all elderly antidepressant users, 43.3% were taking suboptimal regimens. Potentially hazardous regimens were used by 11.9%, including 7.3% taking highly anticholinergic agents and 5.3% using excessively high daily dosages. Low-intensity regimens were used by 34.8% of patients, including 7.6% with excessively low daily dosages, 19.3% with short durations of therapy, and 14.8% with inadequate follow-up. Potentially hazardous regimens were associated with ages 65 to 74 years, nursing home residence, cancer diagnoses, less comorbidity, use of other psychiatric medications, making more physician visits, and earlier calendar years. Low-intensity regimens were associated with ages > or =85 years, nonwhite race, greater comorbidity, fewer physician visits or inpatient days in the baseline 6 months, and not using other psychiatric medications. Suboptimal antidepressant use remains common in the elderly, especially the use of inadequately intensive regimens. Interventions are needed to improve the quality and outcomes of antidepressant use in this vulnerable population.

Change in indices of distress among Latino and Anglo female caregivers of elderly relatives with dementia: site-specific results from the REACH national collaborative study

PURPOSE

Few empirical studies have compared the efficacy between psychoeducational (skill-building) approaches for reducing caregivers' psychological distress and interventions modeled after typical community-based support groups. We compare the impact of two distinct interventions on Anglo and Latino caregivers of elderly relatives with dementia.

DESIGN AND METHODS

The change from preassessment to postassessment (baseline to 3 months) for 213 female caregivers (122 Anglo and 91 Latino) is presented. They were seen weekly for 10 weeks in either the Coping With Caregiving psychoeducational program (instruction and practice in small groups to learn specific cognitive and behavioral skills) or in the Enhanced Support Group condition (guided discussion and empathic listening to develop reciprocal support within the group). Both programs were tailored to be sensitive to the cultural concerns of Anglo and Latino caregivers, and they were delivered in either English or Spanish by trained interventionists.

RESULTS

Overall, participants in the Coping With Caregiving condition reported a significant reduction in depressive symptoms, increased use of adaptive coping strategies, and a trend toward decreased use of negative coping strategies when compared with those in the Enhanced Support Group condition. Results were similar for both ethnic groups: there were no main effects for ethnicity, and no significant ethnicity by treatment interaction effects.

IMPLICATIONS

This study provides empirical support that female caregivers benefit more from a skill-building approach to managing their distress than from support group membership alone. We find it very encouraging that the Latino caregivers responded well on key outcome variables, suggesting that Latinos will participate in clinical research and will benefit from their involvement when services are provided to meet their specific needs.

Diagnosis and treatment of older adults with depression in primary care

This article provides an overview of current challenges in the diagnosis and treatment of depressed older adults in primary care and considers suggestions for clinicians, researchers, and policy makers to improve care for this population. Despite the enormous toll of depression on individuals and society and the availability of effective treatments, depressed older adults remain largely untreated or undertreated. They rarely see mental health professionals, but have relatively frequent contact with primary care providers. In primary care, the chronic and recurrent nature of depression and a number of patient, provider, and policy-related barriers interfere with effective depression treatment. Recent research suggests that improving care for individuals with late life depression will require education and engagement of older adults and their primary care providers as active partners in caring for depression. It will also require additional human resources and systematic models of care dedicated to proactively managing depression as a chronic illness. Finally, it will require training of mental health professionals to effectively collaborate with their colleagues in primary care in treating depressed older adults. Further improvement in depression care would likely result from the implementation of true parity for mental health treatments for older adults.

Sociodemographic, physical, and psychosocial characteristics of depressed and non-depressed family caregivers of stroke survivors

A variety of sociodemographic, physical, and psychosocial variables are linked to depressive behaviour in family caregivers. This study was conducted to determine the best predictors of caregiver depression at onset of the caregiver role among persons providing care to a stroke survivor. The relative contributions of stroke survivor and caregiver sociodemographic characteristics, as well as caregiver general health, physical functioning, social support, life satisfaction, preparedness, and reaction in the prediction of depression status, were examined. A correlational study of 52 primary family caregivers of individuals who had a cerebrovascular accident was conducted. General health and physical functioning scales from the SF-36, and measures of caregiver social support, life satisfaction, preparedness, and reaction were used. Caregiver depression was best predicted by lower life satisfaction, lower physical functioning, and a lack of tangible social support.

A qualitative evaluation of an assisted self-help group for drug-addicted clients in a structured outpatient treatment setting

We conducted a qualitative evaluation of a semi-structured, client-led support group that addressed drug use recovery issues and was assisted by a psychological consultant. Seven regular group members and their counselors were interviewed about the effect of the assisted self-help group on drug use and the clients' quality of life, and these interviews were content analyzed. In addition, the psychological consultant made group process observations for each session of the first three months. Clients reported group strengths as: Feeling supported and understood, being able to speak freely without fear of staff reprisals, obtaining information/feedback, improved mood, and decreased drug use. With the provision of professional support and guidance, this group shows promise as an adjunct to standard outpatient drug abuse treatment by allowing for some degree of client independence and extending the scarce resource of professional counseling.

An examination of the therapeutic benefits of focus groups on elderly worriers

This study examines the effects on elderly worriers, of a focus group discussion about the topic of worry. All subjects (N = 21) were self-designated worriers, and at least seventy years of age. Pretest and-Posttest measures included questionnaires on worry, life satisfaction, and psychological symptom domains unrelated to the focus group topic. The percentage of the day spent worrying variable, which was the criterion variable for admittance into the groups, showed a significant reduction from pre to post. The focus group participants also evaluated the focus group experience as positive and beneficial. The value of focus groups for therapeutic effectiveness and data collection with the elderly are discussed.

Behavior management training for nurse aides: is it effective?

Nursing assistants are responsible for 80% to 90% of all direct resident care in nursing homes, but are the least well trained personnel. Even with currently mandated training, specific skills to meet mental health needs are not taught. Training in behavior management skills prepares aides to observe and respond to problem behaviors more effectively. Aides view their own use of skills as increased by this training. To be practically useful, mental health training programs for nurse aides should be provided by professional personnel in brief, concrete, self-contained units that model the skills they present.

Professional interface with mutual-aid self-help groups: a review

The ideal interface between self-help group and professional being of both theoretical and practical interest, this paper reviews the conceptual underpinnings of the interface issue and empirical studies in which the professional or self-help group member perspective on this issue was elicited or comparative analyses were conducted. Empirical studies measuring self-help group members' perceptions and studies of professionals' views indicate that professional interaction with self-help groups is desirable but that professional lack of information concerning self-help groups and lack of preparation for appropriate roles are perceived as barriers to such interaction. These studies clearly show that the indirect, non-authoritarian role of the professional as consultant receives the most support. Consultation and collaboration are recurrent themes in the empirical investigations of the professional interface with self-help groups. Balance and exchange theories could provide useful theoretical foundations for this collaborative practice. Clearly, educational preparation is needed to enable health professionals to embark on the essential transition from provider to partner with self-help groups.

Intervention research approaches

This article reviews the process of intervention research, with particular emphasis on interventions with and for older adults. First, we consider the context of intervention research: What are the resources and constraints that shape the process of intervention and research? Second, we outline a taxonomy of interventions, reflecting different combinations of level and timing of interventions. Third, we consider the types of research designs that are most appropriate in the different contexts of applied research.