Interpersonal psychotherapy (IPT) for late-life depression in general practice: uptake and satisfaction by patients, therapists and physicians

Interpersonal Psychotherapy for Late-life Depression and its Potential Application in China

Interpersonal psychotherapy (IPT) is a time-limited, structured, interpersonally oriented psychotherapy, with demonstrated efficacy for the treatment of major depression across the lifespan. IPT uses a medical model of illness and links depressed mood to four research-informed interpersonal problem areas: complicated grief, role transitions, role disputes, and interpersonal deficits/sensitivity. The IPT model of vulnerability to depression nicely dovetails with interpersonal issues that are faced by older adults, and this article focuses on the application of IPT for late-life depression in China. The group format of IPT may be a practical and efficient method of improving access to an established depression-focused treatment for China's rapidly aging population and has the advantage of providing important social support for patients who feel lonely, isolated, and stigmatized. Short-term interventions like IPT are more cost-effective from a public health perspective and can easily be delivered in primary care facilities, where many elderly patients receive care. IPT is effective in different cultures, and possible cultural adaptations of IPT for older adults in China are discussed herein.

Psychotherapy for depression in primary care: a panel survey of general practitioners' opinion and prescribing practice

PURPOSE

Psychotherapy is recommended as first-line treatment in patients presenting with mild-to-moderate depression. Although this disorder is mostly managed in primary care, little is known about General Practitioners' (GPs) practice of prescribing psychotherapy. The objectives were to explore GPs' opinion on psychotherapy for depression, and the personal and professional characteristics associated with reported strategies for prescribing psychological therapy and/or an antidepressant in mild-to-moderate depression.

METHODS

A cross-sectional survey was carried out among participants in a panel of randomly selected GPs (2,114/2,496 participated: 84.7%). GPs were interviewed using a standardized questionnaire covering their professional and personal characteristics, their practices and opinions in the area of depression management. A multi-model averaging approach was used to explore the characteristics associated with practice of prescribing psychological therapy in mild-to-moderate depression.

RESULTS

Most GPs had a favourable opinion regarding the efficacy of psychotherapy in depression. Slightly more than one out of four reported prescribing psychological therapy alone often/very often in mild-to-moderate depression. These GPs were more likely to be female (OR = 1.56, 95% CI 1.24; 1.97), to have a personal history of psychotherapy (OR = 1.76, 95% CI 1.31; 2.38), no history of depression in someone close (OR = 0.80, 95% CI 0.65; 0.99), and to consider that antidepressants are over-prescribed (OR = 2.02, 95% CI 1.63; 2.49). No association was found with professional characteristics.

CONCLUSIONS

GPs' personal experience has a greater impact on psychological therapy prescription than professional characteristics. This finding suggests that educational efforts are required for providing GPs decision-making skills regarding psychological therapy prescription, based upon evidence-based medicine rather than subjective factors.

Cognition in Late Life Depression: Treatment Considerations

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

Internet-delivered interpersonal psychotherapy versus internet-delivered cognitive behavioral therapy for adults with depressive symptoms: randomized controlled noninferiority trial

BACKGROUND

Face-to-face cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) are both effective treatments for depressive disorders, but access is limited. Online CBT interventions have demonstrated efficacy in decreasing depressive symptoms and can facilitate the dissemination of therapies among the public. However, the efficacy of Internet-delivered IPT is as yet unknown.

OBJECTIVE

This study examines whether IPT is effective, noninferior to, and as feasible as CBT when delivered online to spontaneous visitors of an online therapy website.

METHODS

An automated, 3-arm, fully self-guided, online noninferiority trial compared 2 new treatments (IPT: n=620; CBT: n=610) to an active control treatment (MoodGYM: n=613) over a 4-week period in the general population. Outcomes were assessed using online self-report questionnaires, the Center for Epidemiological Studies Depression scale (CES-D) and the Client Satisfaction Questionnaire (CSQ-8) completed immediately following treatment (posttest) and at 6-month follow-up.

RESULTS

Completers analyses showed a significant reduction in depressive symptoms at posttest and follow-up for both CBT and IPT, and were noninferior to MoodGYM. Within-group effect sizes were medium to large for all groups. There were no differences in clinical significant change between the programs. Reliable change was shown at posttest and follow-up for all programs, with consistently higher rates for CBT. Participants allocated to IPT showed significantly lower treatment satisfaction compared to CBT and MoodGYM. There was a dropout rate of 1294/1843 (70%) at posttest, highest for MoodGYM. Intention-to-treat analyses confirmed these findings.

CONCLUSIONS

Despite a high dropout rate and lower satisfaction scores, this study suggests that Internet-delivered self-guided IPT is effective in reducing depressive symptoms, and may be noninferior to MoodGYM. The completion rates of IPT and CBT were higher than MoodGYM, indicating some progress in refining Internet-based self-help. Internet-delivered treatment options available for people suffering from depression now include IPT.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN): 69603913; http://www.controlled-trials.com/ISRCTN69603913 (Archived by WebCite at http://www.webcitation.org/6FjMhmE1o).

Social relationships and depression: ten-year follow-up from a nationally representative study

BACKGROUND

Social network characteristics have long been associated with mental health, but their longitudinal impact on depression is less known. We determined whether quality of social relationships and social isolation predicts the development of depression.

METHODS

The sample consisted of a cohort of 4,642 American adults age 25-75 who completed surveys at baseline in 1995-1996 and at ten-year follow-up. Quality of relationships was assessed with non-overlapping scales of social support and social strain and a summary measure of relationship quality. Social isolation was measured by presence of a partner and reported frequency of social contact. The primary outcome was past year major depressive episode at ten-year follow-up. Multivariable logistic regression was conducted, adjusting for the presence of potential confounders.

RESULTS

Risk of depression was significantly greater among those with baseline social strain (OR, 1.99; 95% CI, 1.47-2.70), lack of social support (OR, 1.79; 95% CI, 1.37-2.35), and poor overall relationship quality (OR 2.60; 95% CI, 1.84-3.69). Those with the lowest overall quality of social relationships had more than double the risk of depression (14.0%; 95% CI, 12.0-16.0; p<.001) than those with the highest quality (6.7%; 95% CI, 5.3-8.1; p<.001). Poor quality of relationship with spouse/partner and family each independently increased risk of depression. Social isolation did not predict future depression, nor did it moderate the effect of relationship quality.

CONCLUSIONS

Quality of social relationships is a major risk factor for major depression. Depression interventions should consider targeting individuals with low quality of social relationships.

Prospective cohort study of suicide attempters aged 70 and above: one-year outcomes

BACKGROUND

Most elderly persons who attempt suicide suffer from depression. This study aimed to investigate one-year outcomes in suicide attempters aged 70+, and to identify predictors of these outcomes.

METHODS

101 persons (mean age 80) who were hospitalized after a suicide attempt were interviewed at baseline and followed for one year by record linkage. Face-to-face interviews were carried out with 71% of those who were alive after one year (60 out of 85). Outcome measures included major/minor depression, Montgomery-Asberg Depression Rating Scale (MADRS) score, repeat non-fatal/fatal suicidal behavior and all-cause mortality.

RESULTS

One half (52%) of all those who were interviewed scored <10 on the MADRS at follow-up. Among those with major depression at baseline, two thirds (26 out of 39) no longer fulfilled criteria for this disorder. Factors associated with non-remission of major depression (MADRS ≥ 10) included higher baseline depression and anxiety scores, higher suicide intent and lower Sense of Coherence. There were two suicides and six non-fatal repeat attempts. The relative risk of death (any cause) was 2.53 (95% CI = 1.45-4.10, p<0.001).

LIMITATIONS

This is a naturalistic study; participants received non-uniform treatment as usual. The proportion with repeat suicidal behavior was lower than anticipated and the study was thus underpowered with regard to this outcome.

CONCLUSIONS

Half of the surviving attempters were free from depressive symptoms at one-year follow-up and there were relatively few repeat attempts. However, all cause mortality remained high in this elderly cohort.

Brief self-rated screening for depression on the Internet

BACKGROUND

The Internet offers promising possibilities for the quick screening of depression for treatment and research purposes. This paper aims to validate three self-rated measures to screen for depression on the Internet: SID (single-item depression scale), CES-D (Center for Epidemiological Studies Depression scale) and K10 (Kessler psychological distress scale).

METHODS

Of the 502 subjects aged 18-80 who rated the SID, CES-D and K10 measures on the Internet, 157 (31%) subjects were also interviewed by telephone using the WHO Composite International Diagnostic Interview (C)IDI) for DSM-IV-disorders.

RESULTS

Cronbach's alpha for both web self-rated measures CES-D and K10 was 0.90. The SID correlated 0.68 (P<0.001) with the CES-D and with the K10. The CES-D correlated 0.84 with the K10 (P<0.001). Subjects with a DSM-IV diagnosis for any depressive disorder had significantly higher means (P<0.001) on the three self-rated measures for depressive symptoms than subjects without a diagnosis of any depressive disorder. Using any depressive disorder as the gold standard, the area under the curve (AUC) of the SID was 0.71 (95% CI: 0.63-0.79), which was significantly lower than the AUC of the CES-D (AUC: 0.84; 95% CI: 0.77-0.90, P=0.003) and of the K10 (AUC: 0.81; 95% CI: 0.73-0.88, P=0.0024). The AUCs for the K10 and CES-D did not differ significantly from each other.

LIMITATIONS

The CIDI interviews were not recorded, so inter-rater reliability could not be calculated.

CONCLUSIONS

The CES-D and K10 are reliable, valid tools for care providers to quickly screen depressive patients on the Internet and for researchers to collect data.

ROBERTE. Research advances in geriatric depression

Technical advances have facilitated the exploration of factors related to geriatric depression and have helped generate novel biological and psychosocial treatment approaches. This review summarizes the main advancements in epidemiology, clinical presentation and course, genetics, and other areas of biological research. Treatment interventions outlined in this paper include electroconvulsive therapy, repetitive transcranial magnetic stimulation, magnetic seizure therapy, vagus nerve stimulation, deep brain stimulatn, depression prophylaxis, multidisciplinary approaches to depression treatment, and psychotherapy. Forms of psychotherapy for geriatric depression summarized include interpersonal psychotherapy, supportive psychotherapy, cognitive-behavioral therapy, problem-solving therapy, and ecosystem-focused therapy. Neuroimaging techniques based on magnetic resonance imaging are discussed briefly, including volumetric brain studies, diffusion tensor imaging, fractional anisotropy, fiber tractography, magnetization transfer imaging, and blood-oxygenation-level-dependent functional magnetic resonance imaging. Finally, treatment effectiveness is addressed in a discussion of new models to improve access to and quality of care offered in the community.

Untangling the complexities of depression diagnosis in older cancer patients

This review article discusses the complexities of diagnosing depression in older, geriatric cancer patients. There has been little research conducted with this population on the assessment, recognition, and treatment of depression, and thus increased attention is required to improve care for these individuals. Depressive symptoms often manifest themselves differently in both cancer patients and older patients, and therefore a modified and adapted way of assessment must be employed when thinking about diagnosing and treating these patients.