Screening older adults for depression in primary care settings.

Primary care is a logical environment for depression recognition in older adults. Most older adults are diagnosed and treated for depression by primary care providers. Recognition systems for depression in this setting are particularly needed because the prevalence of depression in older primary care patients may range from 7% to 36%, depending on the instrument and diagnostic criteria used. Implementing systematic detection systems in primary care settings has proven difficult. In one study, only one third of all physicians surveyed used any formal screening tool. Though a number of barriers to recognition of depression have been identified, the authors focus their discussion in this article on two, time and patient factors, and review two screening instruments, the Geriatric Depression Scale--Short Form and the Center for Epidemiologic Studies Depression Scale, that may be able to address these factors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Efficacy of psychosocial treatments for geriatric depression: A quantitative review.

A meta-analysis of 17 studies examined the efficacy of psychosocial treatments for depression among older adults. Studies were included only if a comparison was made to a control condition (no treatment, delayed treatment, or placebo treatment) or another psychosocial intervention. Results indicated that treatments were reliably more effective than no treatment on self-rated and clinician-rated measures of depression. Effect sizes for studies involving participants with major depression disorder were also reliably different from zero, as were effect sizes from studies involving participants with less severe levels of depression. These findings compare favorably with several other quantitative reviews of treatments for depression. Results suggest more balanced presentations of the potential benefits of psychosocial interventions are warranted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is It Beneficial to Involve a Family Member? A Meta-Analysis of Psychosocial Interventions for Chronic Illness.

Links between chronic illness and family relationships have led to psychosocial interventions targeted at the patient's closest family member or both patient and family member. The authors conducted a meta-analytic review of randomized studies comparing these interventions with usual medical care (k=70), focusing on patient outcomes (depression, anxiety, relationship satisfaction, disability, and mortality) and family member outcomes (depression, anxiety, relationship satisfaction, and caregiving burden). Among patients, interventions had positive effects on depression when the spouse was included and, in some cases, on mortality. Among family members, positive effects were found for caregiving burden, depression, and anxiety; these effects were strongest for nondementing illnesses and for interventions that targeted only the family member and that addressed relationship issues. Although statistically significant aggregate effects were found, they were generally small in magnitude. These findings provide guidance in developing future interventions in this area. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Problem-solving treatment and coping styles in primary care for minor depression.

Research was undertaken to compare problem-solving treatment for primary care (PST-PC) with usual care for minor depression and to examine whether treatment effectiveness was moderated by coping style. PST-PC is a 6-session, manual-based, psychosocial skills intervention. A randomized controlled trial was conducted in 2 academic, primary care clinics. Those subjects who were eligible were randomized (N = 151), and 107 subjects completed treatment (57 PST-PC, 50 usual care) and a 35-week follow-up. Analysis with linear mixed modeling revealed significant effects of treatment and coping, such that those in PST-PC improved at a faster rate and those initially high in avoidant coping were significantly more likely to have sustained benefit from PST-PC. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychosocial treatments for attention-deficit/hyperactivity disorder in adults: Current evidence and future directions.

As recently as 1997, the empirical database guiding the selection of psychosocial treatments for adults with attention-deficit/hyperactivity disorder (ADHD) could be summarized as "entirely anecdotal" (American Academy of Child and Adolescent Psychiatry, 1997, p. 107S). However, there is preliminary evidence supporting the use of psychosocial interventions (in conjunction with pharmacotherapy) tailored to meet the unique needs of adults with ADHD. The aim of this article is to review the current evidence base for psychosocial treatments for adult ADHD. We provide background information about adult ADHD, review the extant research of psychosocial treatments, summarize important aspects of psychotherapy for adults with ADHD, and offer suggestions for future research that may improve psychosocial services and treatment outcomes for this clinical population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The long-term efficacy of two computer-tailored physical activity interventions for older adults: Main effects and mediators.

Objective: Low-cost (e.g., computer-tailored) interventions with sustained effects are needed to increase and maintain physical activity in older adults. This study examined the long-term efficacy of 2 computer-tailored physical activity interventions for older adults and its psychosocial and environmental mediators. Methods: A clustered randomized controlled trial (N = 1,971) was conducted that included 3 research arms: (a) basic computer-tailored print intervention, targeting psychosocial mediators; (b) environmentally computer-tailored print intervention, targeting psychosocial and environmental mediators; and (c) no-intervention control group. Interventions were developed using the intervention mapping approach and consisted of 3 computer-tailored letters delivered over 4 months. Questionnaires assessed the study outcomes (i.e., total weekly days and total weekly minutes of physical activity) at baseline and 12 months. Potential mediators (i.e., awareness, attitude, self-efficacy, intention, social influence, intrinsic motivation, self-regulation, and perceived environment) were assessed at baseline and at 3 or 6 months. Results: Multilevel regression analyses revealed that both interventions significantly changed total weekly days of physical activity compared with the control group, but only the environmentally computer-tailored print intervention significantly changed weekly minutes of physical activity. Multiple mediation models showed that the effects of both interventions on weekly days of physical activity were mediated by changes in awareness and intention. Conclusions: Computer-tailored interventions were effective in inducing long-term behavioral changes in physical activity behavior of older adults. Awareness and intention were found to be important mediators of changing daily physical activity and should be included in future computer-tailored intervention studies. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Evidence-based psychological treatments for late-life anxiety.

This project identified evidence-based psychotherapy treatments for anxiety disorders in older adults. The authors conducted a review of the geriatric anxiety treatment outcome literature by using specific coding criteria and identified 17 studies that met criteria for evidence-based treatments (EBTs). These studies reflected samples of adults with generalized anxiety disorder (GAD) or samples with mixed anxiety disorders or symptoms. Evidence was found for efficacy for 4 types of EBTs. Relaxation training, cognitive-behavioral therapy (CBT), and, to a lesser extent, supportive therapy and cognitive therapy have support for treating subjective anxiety symptoms and disorders. CBT for late-life GAD has garnered the most consistent support, and relaxation training represents an efficacious, relatively low-cost intervention. The authors provide a review of the strengths and limitations of this research literature, including a discussion of common assessment instruments. Continued investigation of EBTs is needed in clinical geriatric anxiety samples, given the small number of available studies. Future research should examine other therapy models and investigate the effects of psychotherapy on other anxiety disorders, such as phobias and posttraumatic stress disorder in older adults. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Late-life suicide and depression in the primary care setting

Late-life depression and suicidal behavior in the primary care setting is a significant public health concern. The prevalence of depression in this population is substantial, yet rates of detection and treatment are far from adequate. Untreated depression has significant consequences with regard to morbidity and mortality. Although suicide is a relatively low-base-rate behavior, a substantial proportion of late-life suicides have contact with their primary care provider prior to their death; thus this offers an avenue for suicide prevention. There is a growing knowledge base concerning what constitutes barriers to the recognition and treatment of late-life depression as well as what constitutes useful screening tools and treatments for the depressed elderly. Important new findings with regard to the functional effects of subsyndromal depression, possible subtypes of late-life depression, the clinical utility of SSRIs and psychotherapeutic interventions, and innovative and collaborative models of care hold promise for advancing the science and practice of treating late-life depression.     

Randomized trial of social rehabilitation and integrated health care for older people with severe mental illness.

Objective: The Helping Older People Experience Success (HOPES) program was developed to improve psychosocial functioning and reduce long-term medical burden in older people with severe mental illness (SMI) living in the community. HOPES includes 1 year of intensive skills training and health management, followed by a 1-year maintenance phase. Method: To evaluate effects of HOPES on social skills and psychosocial functioning, we conducted a randomized controlled trial with 183 older adults with SMI (58% schizophrenia spectrum) age 50 and older at 3 sites who were assigned to HOPES or treatment as usual with blinded follow-up assessments at baseline and 1- and 2-year follow-up. Results: Retention in the HOPES program was high (80%). Intent-to-treat analyses showed significant improvements for older adults assigned to HOPES compared to treatment as usual in performance measures of social skill, psychosocial and community functioning, negative symptoms, and self-efficacy, with effect sizes in the moderate (.37–.63) range. Exploratory analyses indicated that men improved more than women in the HOPES program, whereas benefit from the program was not related to psychiatric diagnosis, age, or baseline levels of cognitive functioning, psychosocial functioning, or social skill. Conclusions: The results support the feasibility of engaging older adults with SMI in the HOPES program, an intensive psychiatric rehabilitation intervention that incorporates skills training and medical case management, and improves psychosocial functioning in this population. Further research is needed to better understand gender differences in benefit from the HOPES program. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of drug solubility, drug loading, and polymer molecular weight on drug release from Polyox tablets

BACKGROUND: This study augments a randomized controlled trial to analyze the cost-effectiveness of 2 standardized treatments for major depression relative to each other and to the "usual care" provided by primary care physicians. METHODS: A randomized controlled trial was conducted in which primary care patients meeting DSM-III-R criteria for current major depression were assigned to pharmacotherapy (where nortriptyline hydrochloride was given) or interpersonal psychotherapy provided in a standardized framework or a primary physician's usual care. Two outcome measures, depression-free days and quality-adjusted days, were developed using information on depressive symptoms over time. The costs of care were calculated. Cost-effectiveness ratios comparing the incremental outcomes with the incremental costs for the different treatments were estimated. Sensitivity analyses were performed. RESULTS: In terms of both economic costs and quality-of-life outcomes, patients assigned to the pharmacotherapy group did slightly better than those assigned to interpersonal psychotherapy. Both standardized therapies provided better outcomes than primary physician's usual care, but each consumed more resources. No meaningful cost-offsets were found. The incremental direct cost per additional depression-free day for pharmacotherapy relative to usual care ranges from $12.66 to $16.87 which translates to direct cost per quality-adjusted year gained from $11270 to $19510. CONCLUSIONS: Standardized treatments for depression lead to better outcomes than usual care but also lead to higher costs. However, the estimates of the cost per quality-of-life year gained for standardized pharmacotherapy are comparable with those found for other treatments provided in routine practice.     

Changes in social support as mediators of the impact of a psychosocial intervention for spouse caregivers of persons with Alzheimer's disease.

The spouse caregivers of 406 patients with Alzheimer's disease were randomly assigned to an enhanced counseling and support intervention or to a usual care control condition. Structured interviews were conducted to assess changes in social support and psychosocial outcomes for the 312 caregivers who provided care in the home for at least 1 year. The number of support persons, satisfaction with the support network, and support persons' assistance with caregiving all increased significantly as a function of the intervention. Structural equation models indicated increased satisfaction with the social support network mediated a significant proportion of the intervention's impact on caregiver depression. A portion of this mediated effect was further mediated by changes in caregiver stress appraisals. Implications for strengthening intervention programs for spouse caregivers of individuals with Alzheimer's disease are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Angiocardiographic digital still images compressed via irreversible methods: concepts and experiments

OBJECTIVE: Primary care occupies a strategic positive in the evaluation, treatment, and prevention of the mental disturbances of later life. This article highlights four themes that are crucial to understanding mental disturbances among older adults: 1) subsyndromal depression, 2) coexisting depression and anxiety, 3) comorbidity of depression and chronic medical conditions, and 4) risk factors for cognitive impairment. METHOD: The literature was selectively reviewed for each theme to ask the central question, "What can primary care physicians learn about mental disturbances of their older patients from epidemiologic and community studies?" RESULTS: The primary care setting itself is an important venue for an examination of aging issues and mental health. Workers in the "middle ground of psychiatric epidemiology"--primary health care--have not yet reached a full appreciation for the value of research in the primary care setting for enhancing our understanding of the mental disturbances of late life, and how these intersect with other salient factors. CONCLUSIONS: Primary care physicians and others who work in primary care should advocate for further mental health integration and research in primary care. Research is needed that will lead to new ways of maximizing the health and quality of life of older adults and their families.     

Cognitive-behavioral interventions with older adults: Integrating clinical and gerontological research.

Psychotherapeutic interventions utilizing cognitive-behavioral strategies have been used widely with older adults. To appropriately adapt these techniques, characteristics unique to older adults must be taken into account. These factors include aspects of the social environment, cohort effects, cognitive changes with aging, personality, and emotional development, which have been described in an emerging body of research literature from the field of gerontology. In addition, clinical studies have examined the efficacy of cognitive-behavioral interventions in treating older clients for anxiety, depression, insomnia, and other disorders. This review describes current empirical evidence in gerontology and treatment outcome research that informs the practice of psychotherapy in this population and provides recommendations for conducting therapy with older adults. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessment depression in primary care practice with the Beck Depression Inventory and the Hamilton Rating Scale for Depression.

Individuals suffering from depression seek help as frequently in the primary care setting as in psychiatric facilities. As primary care physicians increasingly provide such treatments, they will need to assess a patient's clinical status before, during, and after treatment. The authors evaluated the concordance and factor structures of 2 widely used depression inventories, the Beck Depression Inventory and the Hamilton Rating Scale for Depression, in a sample of primary care patients participating in a randomized, control trial of treatments for major depression. The 2 scales were significantly correlated and assessed similar rates of improvement at multiple assessment points. Factor analyses indicated that despite their equivalent assessment of severity of depression, the 2 instruments emphasize different dimensions of depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Behavior Therapy for Depressed Cancer Patients in Primary Care.

Major depression is a common psychiatric disorder among cancer patients and is associated with psychosocial impairment and decreased quality of life. Although some research has explored psychological interventions with cancer patients, outcome studies investigating the benefits of behavior therapy among cancer patients with well diagnosed depression are nonexistent. The present study was a preliminary clinical trial (n=6) used to assess the effectiveness of a Brief Behavioral Activation Treatment for Depression (BATD) among depressed cancer patients in primary care. Results revealed strong treatment integrity, good patient compliance, excellent patient satisfaction with the BATD protocol, and significant pre-post treatment gains across measures assessing depression, quality of life, and medical outcomes. These gains were associated with strong effect sizes and were maintained at 3-month follow up. BATD may represent a practical primary care treatment that may remedy problems associated with traditional psychosocial interventions. Study limitations and future research directions are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Evidence-based psychological treatments for insomnia in older adults.

The review describes evidence-based psychological treatments (EBTs) for insomnia in older adults. Following coding procedures developed by the American Psychological Association's Committee on Science and Practice of the Society for Clinical Psychology, two treatments were found to meet EBT criteria: sleep restriction-sleep compression therapy and multicomponent cognitive-behavioral therapy. One additional treatment (stimulus control therapy) partially met criteria, but further corroborating studies are needed. At the present time, there is insufficient evidence to consider other psychological treatments, including cognitive therapy, relaxation, and sleep hygiene education, as stand-alone interventions beneficial for treating insomnia in older adults. Additional research is also needed to examine the efficacy of alternative-complementary therapies, such as bright light therapy, exercise, and massage. This review highlights potential problems with using coding procedures proposed in the EBT coding manual when reviewing the existing insomnia literature. In particular, the classification of older adults as persons age 60 and older and the lack of rigorous consideration of medical comorbidities warrant discussion in the future. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evidence-based psychological treatments for disruptive behaviors in individuals with dementia.

In this article, the authors review the literature regarding evidence-based psychological treatments (EBTs) for behavioral disturbances in older adults with dementia, as proposed by the American Psychological Association's Committee on Science and Practice of the Society for Clinical Psychology. Fifty-seven randomized clinical trials were reviewed for inclusion on the basis of titles or abstract information. Forty-three were excluded either because they did not meet EBT methodological criteria or because they involved environmental or psychoeducational nursing interventions in which the psychological component could not be separately evaluated. Fourteen studies were considered for inclusion as EBTs; of these, 8 showed significant differences between treatment and control groups. Results of this review indicate that behavioral problem-solving therapies that identify and modify antecedents and consequences of problem behaviors and increase pleasant events and individualized interventions based on progressively lowered stress threshold models that include problem solving and environmental modification meet EBT criteria. Additional randomized clinical trials are needed to evaluate the generalizability and efficacy of these and other promising psychological interventions in a variety of settings with individuals who have a range of cognitive, functional, and physical strengths and limitations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychological interventions for arthritis pain management in adults: A meta-analysis.

Context: The psychosocial impact of arthritis can be profound. There is growing interest in psychosocial interventions for managing pain and disability in arthritis patients. Objective: This meta-analysis reports on the efficacy of psychosocial interventions for arthritis pain and disability. Data Sources: Articles evaluating psychosocial interventions for arthritis were identified through Cochrane Controlled Trials, EMBASE, Ovid MEDLINE, and Ovid PsycINFO data sources. Study Selection: Randomized controlled trials testing the efficacy of psychosocial interventions in arthritis pain management were reviewed. Data Extraction: Twenty-seven randomized controlled trials were analyzed. Pain intensity was the primary outcome. Secondary outcomes included psychological, physical, and biological functioning. Data Synthesis: An overall effect size of 0.177 (95% CI = 0.256-0.094) indicated that patients receiving psychosocial interventions reported significantly lower pain than patients in control conditions (combined p = .01). Meta-analyses also supported the efficacy of psychosocial interventions for the secondary outcomes. Conclusions: These findings indicate that psychosocial interventions may have significant effects on pain and other outcomes in arthritis patients. Ample evidence for the additional benefit of such interventions over and above that of standard medical care was found. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparative efficacy of cognitive and behavioral bibliotherapy for mildly and moderately depressed older adults.

The efficacy of bibliotherapy for mildly and moderately depressed older adults was examined. Cognitive bibliotherapy and behavioral bibliotherapy were compared with a delayed-treatment control condition. Results indicate that the two experimental conditions were superior to the control condition, but that the cognitive and behavioral bibliotherapies were nondifferentially efficacious. Sixty-six percent of the subjects demonstrated clinically significant change. There were no specific effects associated with either the cognitive or the behavioral interventions. Treatment gains were maintained at 6-month follow-up. The implications of bibliotherapy for geriatric depression as an alternative or adjunct to traditional treatments are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Procedures for identifying evidence-based psychological treatments for older adults.

The authors describe the methods used to identify evidence-based psychological treatments for older adults in this contribution to the special section. Coding teams were assembled to review the literature on several problems relevant to mental health and aging. These teams used the manual developed by the Committee on Science and Practice of the Society for Clinical Psychology (Division 12) of the American Psychological Association that provided definitions of key constructs used in coding. The authors provide an overview of the process followed by the review teams and of some of the issues that emerged to illustrate the steps involved in the coding procedure. Identifying evidence-based treatments is a fundamental aspect of promoting evidence-based practice with older adults; such practice is advocated by most health care disciplines, including psychology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)