Psychosocial Treatment Options for Major Depressive Disorder in Older Adults

Improving social reward responsivity and social connectedness in psychotherapies for late-life depression: Engage & Connect as an example

Psychotherapies are effective in reducing late-life depression. Yet, about half of patients remain depressed at treatment end. Advances in neuroscience can inform simplified interventions that target key brain networks impacted by depression. Behavioral activation therapies that increase social connectedness may improve social reward responsivity and alter abnormalities of the Positive Valence System (PVS). Engage & Connect is an example for a scalable and simple neuroscience-informed psychotherapy, aimed to improve PVS functions and social reward responsivity by increasing engagement in rewarding social activities. Interventions that improve social reward responsivity can be promising first-line treatments for late-life depression in the community.

Depression during the COVID-19 pandemic among older Canadians with peptic ulcer disease: Analysis of the Canadian Longitudinal Study on Aging

The COVID-19 pandemic and associated public health measures have exacerbated many known risk factors for depression that may be particularly concerning for individuals with chronic health conditions, such as peptic ulcer disease (PUD). In a large longitudinal sample of older adults with PUD, the current study examined the incidence of depression during the pandemic among those without a pre-pandemic history of depression (n = 689) and the recurrence of depression among those with a history of depression (n = 451). Data came from four waves of the Canadian Longitudinal Study on Aging (CLSA). Multivariate logistic regression analyses were conducted to identify factors associated with incident and recurrent depression. Among older adults with PUD and without a history of depression, approximately 1 in 8 (13.0%) developed depression for the first time during the COVID-19 pandemic. Among those with a history of depression, approximately 1 in 2 (46.6%) experienced depression during the pandemic. The risk of incident depression and recurrent depression was higher among those who were lonely, those with functional limitations, and those who experienced an increase in family conflict during the pandemic. The risk of incident depression only was higher among women, individuals whose income did not satisfy their basic needs, those who were themselves ill and/or those whose loved ones were ill or died during the pandemic, and those who had disruptions to healthcare access during the pandemic. The risk of recurrent depression only was higher among those with chronic pain and those who had difficulty accessing medication during the pandemic. Implications for interventions are discussed.

A network meta-analysis of 12,116 individuals from randomized controlled trials in the treatment of depression after acute coronary syndrome

BACKGROUND

Post-acute coronary syndrome (ACS) depression is a common but not well understood complication experienced by ACS patients. Research on the effectiveness of various therapies remains limited. Hence, we sought to conduct a network meta-analysis to assess the efficacy of different interventions for post-ACS depression in improving patient outcomes.

METHODS AND FINDINGS

Three electronic databases were searched for randomised controlled trials describing different depression treatment modalities in post-ACS patients. Each article was screened based on inclusion criteria and relevant data were extracted. A bivariate analysis and a network meta-analysis was performed using risk ratios (RR) and standardized mean differences (SMD) for binary and continuous outcomes, respectively. A total of 30 articles were included in our analysis. Compared to standard care, psychosocial therapy was associated with the greatest reduction in depression scores (SMD:-1.21, 95% CI: -1.81 to -0.61, p<0.001), followed by cognitive behavioural therapy (CBT) (SMD: -0.75, 95% CI: -0.99 to -0.52, p<0.001), antidepressants (SMD: -0.73, 95% CI: -1.14 to -0.31, p<0.001), and lastly, combination therapy (SMD: -0.15, 95% CI: -0.28 to -0.03, p = 0.016). No treatment modalities was found to be more effective in reducing depression scores when compared to one another. Additional analysis showed that these treatment modalities did not have significant impact on the overall mortality, cardiac mortality and recurrent myocardial infarction.

CONCLUSION

This network meta-analysis found that the treatment effect of the various psychological modalities on depression severity were similar. Future trials on psychological interventions assessing clinical outcomes and improvement in adherence to ACS-specific interventions are needed.

Cost-effectiveness of Tele-delivered behavioral activation by Lay counselors for homebound older adults with depression

BACKGROUND

Low-income homebound older adults have limited access to psychosocial treatments because of their homebound state and geriatric mental health workforce shortages. Little is known about cost effectiveness of lay-counselor-delivered, videoconferenced, short-term behavioral activation on this study population. The objective of this study was to assess the cost-effectiveness of lay-counselor-delivered, videoconferenced, short-term behavioral activation (Tele-BA) compared to clinician-delivered, videoconferenced problem-solving therapy (Tele-PST) and telephone support calls (attention control; AC) for low-income homebound older adults.

METHODS

We performed a cost-effectiveness analysis based on data from a recently completed, 3-group (Tele-BA, Tele-PST, and AC) randomized controlled trial with 277 participants aged 50+. We measured total costs of (1) intervention and (2) outpatient care, ED visits, and inpatient care using the Cornell Services Index. The effectiveness outcome was quality-adjusted life-years (QALY). We used EuroQol's EQ-5D-5L to assess each participant's health-related quality of life (HRQoL) at baseline and at 12, 24, and 36 weeks. The end-point measure of cost-effectiveness was the incremental cost-effectiveness ratio (ICER) of (1) Tele-BA versus AC, (2) Tele-PST versus AC, and (3) Tele-BA versus Tele-PST.

RESULTS

Relative to AC, both Tele-BA and Tele-PST are cost-saving treatment options. The ICERs for both Tele-BA and Tele-PST were well below $50,000, the lower-bound threshold for cost-effectiveness. Relative to AC, both Tele-PST, Tele-BA are cost-saving treatment options (i.e. lower costs and more QALYs).

CONCLUSION

Costs of tele- and lay-counselor-delivered depression treatment are modest and cost effective relative to providing telephone support. Though our results show that Tele-BA may not be cost effective relative to Tele-PST, a clinician-delivered psychotherapy, when a low bound ICER threshold of $50,000 would be used, lay counselors can fill the professional geriatric mental health workforce shortage gap and Tele-BA by lay counselors can improve homebound older adults' access to evidence-and skills-based, cost effective depression care.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02600754 (11/09/2015).

Acceptability and effects of tele-delivered behavioral activation for depression in low-income homebound older adults: in their own words

OBJECTIVES

To examine experiences and perspectives of low-income homebound older adults (N = 90) who participated in tele-delivered behavioral activation (Tele-BA) treatment for depression by bachelor's-level lay counselors.

METHODS

We used the 11-item Treatment Evaluation Inventory (TEI) to measure participants' acceptability of Tele-BA. We used inductive thematic analysis to explore participants' Tele-BA session goals and activities and unsolicited and solicited comments about their Tele-BA experience.

RESULTS

Participant's TEI score averaged 70 out of maximum possible 77. The most frequently chosen Tele-BA goals were to improve self-care management of physical and mental health, engage in self-enrichment/self-enjoyment, improve living environment and daily routine, and to increase social connectedness. The themes that emerged from participants' comments about Tele-BA were: (1) benefits of psychoeducation; (2) importance of and gratitude for working with a counselor; (3) benefits of activity planning; (4) understanding of behavior and mood connection; (5) positive effects of increased activity on health and self-enjoyment; (6) sense of being productive and useful from accomplishing goals; (7) hope for the future; and (8) pride in tele-treatment.

CONCLUSION

Participants' comments show that Tele-BA aimed at reinforcing healthy behaviors that improve both physical functioning and mood is well aligned with these older adults' perception of what treatment should be. The findings also provide support for lay counselors' clinical capacity. Given geriatric mental health workforce shortages, lay counselors may be able to effectively supplement existing professional mental health service systems.

Collaborative care for depression yields similar improvement among older and younger rural adults

BACKGROUND

Depressive disorders are among the most prevalent mental health conditions; however, significant barriers to treatment access persist. This study examined differences in depression outcomes between younger and older adults in a large-scale implementation demonstration of the collaborative care model (CoCM).

METHODS

Secondary data analysis of a longitudinal, observational implementation demonstration at eight primary care clinics across low-resourced rural or frontier areas of the Western United States. Seven of these clinics were federally qualified health centers. The sample consisted of 3722 younger (18-64 years) and older (65+ years) adult primary care patients diagnosed with unipolar depression. All participants received depression treatment via CoCM, which enhances usual primary care and makes efficient use of specialists by using a behavioral healthcare manager and a psychiatric consultant to support primary care providers. Clinics were followed for up to 27 months. Patients were followed until they completed treatment or dropped out. The Patient Health Questionnaire (PHQ-9) assessed depressive symptoms at baseline (enrollment) and at most follow-up contacts. The primary treatment outcome was a change between a patient's first and last recorded PHQ-9 scores.

RESULTS

Across both age groups, there was an average overall reduction of 6.9 points on the PHQ-9. Older adults demonstrated a greater decrease in depression scores of 2.06 points (95% CI -2.98 to -1.14, p < 0.001) on the PHQ-9 compared with younger adults. Estimates were robust when adjusting for gender, race, and clinic.

CONCLUSIONS

CoCM resulted in meaningful improvement in depressive symptoms across age groups.

Does age matter? Initial treatment goals of older adults with major depression in outpatient cognitive behavioural therapy

BACKGROUND

Personal treatment goals (PTG) are important means to tailor psychotherapy to the needs of the patient, leading to increased engagement and greater improvement in relevant outcomes. According to lifespan developmental research, motivational goals in old age differ from goals of younger people, with management of losses rather than growth becoming more prevalent. However, this study is the first to systematically investigate age-specific differences in PTGs.

METHOD

We used routine data from patients with major depression assessed at the beginning of outpatient cognitive behavioural therapy. Initial high-priority PTGs were assessed using the Bern Inventory of Treatment Goals (BIT-C). Older patients (≥60 years, n = 52) were matched to younger patients (<60 years, n = 52) with regard to severity of depression, number of comorbidities, gender and level of education.

RESULTS

Using a mixed method approach, high-priority PTGs of both age groups were focused most strongly on reducing depressive symptoms and, subsequently, anxiety. At the same time, older patients focused more strongly on PTGs related to well-being and functioning, while younger patients' emphasis was on personal growth. Furthermore, better coping with the ageing process and physical losses emerged as important PTGs for some older patients.

CONCLUSION

Initial PTG themes are specific to diagnosis, but also seem to differ in regard to age. Thus, it is important to develop age-sensitive measures that allow appropriate and efficient tailoring of psychotherapy to meet older patients' needs and preferences.

The reciprocal relationship between depression and disability in low-income homebound older adults following tele-depression treatment

OBJECTIVES

Research has shown ample evidence for reciprocity between depression and disability. We examined whether decreases in disability among low-income, homebound older adults who received brief depression treatments were mediated by improvement in depressive symptoms and vice versa and whether the mediation effects varied by treatment modality.

METHODS

In a 3-arm randomized clinical trial, 277 low-income homebound individuals aged 50+ participated in behavioral activation tele-delivered by bachelor's-level lay counselors (Tele-BA), problem-solving therapy tele-delivered by licensed clinicians (Tele-PST), or telephone support calls (attention control). Depressive symptoms were assessed with the 24-item Hamilton Rating Scale for Depression and disability with the 12-item World Health Organization Disability Schedule 2.0. Along with mediation models, mediation was assessed controlling for autoregressive and contemporaneous effects.

RESULTS

Mediation models showed evidence of postintervention disability and depression mediating each other in separate mediation models. In the cross-lagged model, in which autoregressive and contemporaneous effects were included, only the depression-to-disability path exhibited mediation. There was no evidence of difference between Tele-BA and Tele-PST. Although the temporal precedence of treatment conditions on the outcomes is apparent, we could not establish a temporal precedence between disability and depression as these two measures exhibited parallel improvement.

CONCLUSIONS

Brief depression treatments for low-income homebound older adults were effective in reducing both depression and disability among these disabled older adults. The importance of this study lies in the comparable effects of Tele-BA and Tele-PST. Lay-counselor model is a promising alternative to clinician-delivered psychotherapy for growing numbers of homebound older adults.

Sadness and Worry in Older Adults: Differentiating Psychiatric Illness from Normative Distress

Older adults experience greater emotional well-being in late life. However, older adults may be vulnerable to certain physiologic risk factors, including less physiologic resilience to prolonged stress. Depression and anxiety can be difficult to diagnose in late life owing to differences in self-reported symptoms from younger adults and unclear distinctions between normative and non-normative emotional experiences. We discuss age differences in the presentations of depression and anxiety, and normative and non-normative late life developmental trajectories around bereavement and grief, social isolation and loneliness, and thoughts of death and suicide. We provide recommendations for clinicians for assessing and diagnosing older adults.

Disruption of Neural Homeostasis as a Model of Relapse and Recurrence in Late-Life Depression

The significant public health burden associated with late-life depression (LLD) is magnified by the high rates of recurrence. In this manuscript, we review what is known about recurrence risk factors, conceptualize recurrence within a model of homeostatic disequilibrium, and discuss the potential significance and challenges of new research into LLD recurrence. The proposed model is anchored in the allostatic load theory of stress. We review the allostatic response characterized by neural changes in network function and connectivity and physiologic changes in the hypothalamic-pituitary-adrenal axis, autonomic nervous system, immune system, and circadian rhythm. We discuss the role of neural networks' instability following treatment response as a source of downstream disequilibrium, triggering and/or amplifying abnormal stress response, cognitive dysfunction and behavioral changes, ultimately precipitating a full-blown recurrent episode of depression. We propose strategies to identify and capture early change points that signal recurrence risk through mobile technology to collect ecologically measured symptoms, accompanied by automated algorithms that monitor for state shifts (persistent worsening) and variance shifts (increased variability) relative to a patient's baseline. Identifying such change points in relevant sensor data could potentially provide an automated tool that could alert clinicians to at-risk individuals or relevant symptom changes even in a large practice.

The Neuroscience of Nonpharmacological Traditional Chinese Therapy (NTCT) for Major Depressive Disorder: A Systematic Review and Meta-Analysis

Background

Depression is a common disease affecting a large number of people across the world. Many researchers have focused on treatment for depression based on Western scientific approaches, but research based on traditional Chinese medicine (TCM) interventions, studying its clinical effectiveness and the underlying mechanisms involved, has been limited. The aim of this review is to conduct a pioneering systematic review with meta-analysis of existing studies that investigate the neuroscience basis of nonpharmacological traditional Chinese therapy (NTCT).

Methods

Both English (Pubmed, Embase, Scopus, SPORTDiscus, PsycINFO) and Chinese (China National Knowledge Infrastructure (CNKI)) databases were searched from inception to October 2018. The effects of NTCT on major depressive disorder, brain activity, and neurophysiological biomarker related outcomes were extracted. Study quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. The effect size of each study was reported by the mean difference of change scores.

Results

Six of twelve eligible studies showed that there was a significant improvement in favor of acupuncture in depressive symptoms (SMD -0.69, 95% CI -1.09 to -0.28, p=0.002, I ² = 73%, p< 0.0008). Based on the available evidence, NTCT including acupuncture, Qigong, and Tai Chi was found to possibly improve brain metabolites, brain activity, and immune and endocrine systems in patients with major depressive disorder.

Conclusions

Acupuncture could effectively relieve depressive syndromes. The clinical effects of acupuncture might be attributable to their influence on three proposed pathways, namely, the hypothalamic-pituitary-adrenal (HPA) axis, the locus coeruleus (LC)-immunity pathway, and the negative feedback loop of the hippocampus. Nevertheless, conclusions are limited due to the small number of studies included and the low-quality of the study designs. In the future, a cross-sectional study is needed to test the proposed plausible pathways. PROSPERO registration number is CRD42017080937.

Identification and treatment of depressive disorders in older adults with cancer

The increasing number of older adults living with cancer will inevitably include vulnerable subgroups who experience a range of depressive symptoms throughout the care continuum. It is well established that depression can lead to decreased quality of life, poor treatment adherence, increased length of hospital stay and health service utilization, and in severe cases, suicide. Thus, clinicians working in oncology must be able to identify, conceptualize, and treat (or connect to services) the mental health concerns of their older patients. This brief review describes the unique etiologies, features, and treatments for depressive syndromes among older adults in the oncology setting, drawing on the literature and prevailing depression management guidelines from both psycho-oncology and geriatric depression research.

Group schema-focused therapy enriched with psychomotor therapy versus treatment as usual for older adults with cluster B and/or C personality disorders: a randomized trial

BACKGROUND

Several types of psychotherapy have been proven successful in the treatment of personality disorders in younger age groups, however studies among older patients are lacking. We developed a group schema-focused therapy (SFT) enriched with psychomotor therapy (PMT) for older adults with cluster B and/or C personality disorders. This paper describes the design of a randomized controlled trial (RCT). We will evaluate the (cost-)effectiveness of this therapy protocol in specialized mental health care. We hypothesize that our treatment program is cost-effective and superior to treatment as usual (TAU) in reducing psychological distress and improving quality of life in older adults treated to specialized mental healthcare.

METHODS

A multicenter RCT with a one-year follow-up comparing group schema-focused therapy enriched with psychomotor therapy (group SFT + PMT) and TAU for adults aged 60 years and older who suffer from either a cluster B and/or C personality disorder. The primary outcome is general psychological distress measured with the 53-item Brief Symptom Inventory. Secondary outcomes are the Schema Mode Inventory (118-item version) and the Young Schema Questionnaire. Cost-effectiveness analysis will be performed from a societal perspective with the EuroQol five dimensions questionnaire and structured cost-interviews.

DISCUSSION

This study will add to the knowledge of psychotherapy in later life. The study specifically contributes to the evidence on (cost-) effectiveness of group SFT enriched with PMT adapted to the needs of for older adults with cluster b and/or c personality.

TRIAL REGISTRATION

Netherlands Trial Register NTR 6621 . Registered on 20 August 2017.

Are care staff equipped for end-of-life communication? A cross-sectional study in long-term care facilities to identify determinants of self-efficacy

Background

End-of-life conversations are rarely initiated by care staff in long-term care facilities. A possible explanation is care staff’s lack of self-efficacy in such conversations. Research into the determinants of self-efficacy for nurses and care assistants in end-of-life communication is scarce and self-efficacy might differ between care staff of mental health facilities, nursing homes, and care homes. This study aimed to explore differences between care staff in mental health facilities, nursing homes, and care homes with regard to knowledge about palliative care, time pressure, and self-efficacy in end-of-life communication, as well as aiming to identify determinants of high self-efficacy in end-of-life communication.

Methods

Two cross-sectional Dutch studies, one in mental health facilities and one in nursing and care homes (PACE study). Nurses and care assistants were invited to complete a questionnaire in 2015. Multivariable logistic regression analyses were performed to identify determinants of high self-efficacy.

Results

Five hundred forty one nurses and care assistants completed a survey; 137 worked in mental health facilities, 172 in nursing homes, and 232 in care homes. Care staff at mental health facilities were the most knowledgeable about the World Health Organization’s definition of palliative care: 76% answered 4–5 out of 5 items correctly compared to 38% of nursing home staff and 40% of care home staff (p < 0.001). Around 60% of care staff in all settings experienced time pressure. Care staff had high self-efficacy regarding end-of-life communication with patients: the overall mean score across all facilities was 5.47 out of 7 (standard deviation 1.25). Determinants of high self-efficacy were working in a mental health facility, age > 36, female, with formal palliative care training, and knowledge of the palliative care definition.

Conclusion

Mental healthcare staff knew more about palliative care and had higher self-efficacy in end-of-life communication compared to nursing and care home staff. Educating care staff about providing palliative care and training them in it might improve end-of-life communication in these facilities.

Cancer and Aging: Reflections for Elders (CARE): A pilot randomized controlled trial of a psychotherapy intervention for older adults with cancer

OBJECTIVE

Cancer and Aging: Reflections for Elders (CARE) is a novel, telephone-delivered intervention designed to alleviate distress in older cancer patients. This pilot randomized controlled trial tested the feasibility and initial efficacy of CARE, drawing from age-appropriate developmental themes and well-established coping theory.

METHOD

Eligible patients were ≥70 years old; ≥6 months post-diagnosis of lung, prostate, breast, lymphoma, or gynecological cancer; on active cancer treatment or within 6 months of ending cancer treatment; and had elevated scores on the Distress Thermometer (≥4) or Hospital Anxiety and Depression Scale (≥6). Participants completed five sessions of psychotherapy over 7 weeks with assessments at study entry, post-intervention, and 2 months post-intervention. Primary outcomes were feasibility and initial efficacy on anxiety and depression; secondary outcomes included demoralization, coping, loneliness, and spiritual well-being.

RESULTS

Fifty-nine participants were randomized to either the CARE arm (n = 31) or the enhanced Social Work Control arm (n = 28). The intervention was feasible and tolerable, meeting a priori criteria for rates of eligibility, acceptance, retention, assessment, and treatment fidelity. Upon completion of the intervention, participants in the CARE arm demonstrated lower mean depression scores (d = 0.58 [CI: 0.04-1.12], P = 0.01) and trended towards increased coping-planning (d = 0.30 [CI: -0.83 to 0.24], P = 0.18). Promising trends in anxiety (d = 0.41 [CI: -0.17 to 0.98], P = 0.10) emerged at 2 months post-intervention; effects for coping-planning dissipated.

CONCLUSION

These pilot data suggest the CARE intervention is feasibly delivered, potentially impacts important psychosocial variables, and is accessible for older, frail patients with cancer. Future research will evaluate this intervention on a larger scale.

Depression and glioblastoma, complicated concomitant diseases: a systemic review of published literature

Glioblastoma multiforme (GBM) is the most common primary brain cancer. Depression is a common co-morbidity of this condition. Despite this common interaction, relatively little research has been performed on the development of GBM-associated depression. We performed a literary search of the PubMed database for articles published relating to GBM and depression. A total of 85 articles were identified with 46 meeting inclusion criteria. Depression significantly impacts care, decreasing medication compliance, and patient survival. Diagnostically, because depression and GBM share intricate neuro-connectivity in a way that effect functionality, these diseases can be mistaken for alternative psychological or pathological disorders, complicating care. Therapeutically, anti-depressants have anti-tumor properties; yet, some have been shown to interfere with GBM treatment. One reason for this is that the pathophysiological development of depression and GBM share several pathways including altered regulation of the 5-HT receptor, norepinephrine, and 3':5'-cyclic monophosphate. Over time, depression can persist after GBM treatment, affecting patient quality of life. Together, depression and GBM are complicated concomitant diseases. Clinicians must be aware of their co-existence. Because of overlapping molecular pathways involved in both diseases, careful medication selection is imperative to avoid potential adverse interactions. Since GBMs are the most common primary brain cancer, physicians dealing with this disease should be prepared for the development of depression as a potential sequela of this condition, given the related pathophysiology and the known poor outcomes.