Effects of Problem-Solving Therapy and Clinical Case Management on Disability in Low-Income Older Adults

The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) as a measure among elderly population. A review

OBJECTIVES

To review the World Health Organization Disability Assessment Schedule (WHODAS2.0) application in elderly population.

METHODS

A review of English articles was performed using the following databases: PubMed/Medline, Scopus, Web of Science, Cochrane, Embase. Only articles assessing disability through WHODAS2.0 in elderly population (>60-years-old) were included according to PRISMA Statement.

RESULTS

37 papers satisfied the inclusion criteria reporting 125.624 cases of elderly whose disability was assessed using WHODAS2.0 in different versions (36-items-version in 15 studies; 12-items-version in 15 papers; both versions in 3 articles; data unavailable in 4 studies). Four different aims were recognized: WHODAS 2.0 was used in 12 studies to assess the prevalence of disability, 25 studies of association between disability and environmental or medical conditions; 9 studies of validation of WHODAS and 2 studies to verify the outcome of therapies on functioning. Conclusions: WHODAS2.0 is a valid measure of disability among elderly, able to identify the relation between disability, and medical and environmental factors. Unfortunately, only few Countries apply the "bio-psycho-social" approach to social and health policies context. Therefore, it is recommended to adopt a rehabilitation perspective in every legislation. These results could serve as baseline data to monitor the application of WHODAS2.0 over the coming years.

Association Between Depression Symptoms and Disability Outcomes in Older Adults at Risk of Mobility Decline

Objective

To assess the association between depression symptoms and physical functioning and participation in daily life over 2 years in older adults at risk of mobility decline.

Design

A secondary analysis of 2-year observational data from the Boston Rehabilitative Impairment Study of the Elderly.

Setting

Nine primary care clinics within a single health care system.

Participants

Participants (N=432; mean age ± SD, 76.6±7.0y; range, 65-96y; 67.7% women) were community-dwelling adults (>65y) at risk of mobility decline.

Interventions

Not applicable.

Main Outcome Measures

Secondary data analyses of the Late Life Function and Disability Instrument (primary outcome), Short Physical Performance Battery (secondary outcome), and Patient Health Questionnaire-9 (PHQ-9) (predictor). Measures were administered at baseline, 12 months, and 24 months. Participants completed a self-report survey asking about 16 medical comorbidities, and demographic information was collected at baseline.

Results

Participants had an average ± SD PHQ-9 score of 1.3±3.1, ranging from 0 to 24 at baseline. Twenty-nine percent of participants reported a history of depression. Greater depression symptoms were associated with lower physical functioning (unstandardized beta [B]=-0.14, SE=0.05, P=.011) and restricted participation (frequency subscale: B=-0.21, SE=0.11, P=.001; limitation subscale: B=-0.45, SE=0.04, P<.001) cross-sectionally over 2 years. PHQ-9 was not significantly associated with the rate of change in Late Life Function and Disability Instrument score over 2 years.

Conclusions

Treating depression in primary care may be an important strategy for reducing the burden of functional limitations and participation restrictions at any 1 time. Further research is needed on treatment models to cotarget depression and physical functioning among at-risk older adults.

Home Visits for Postpartum Depression Intervention among Low-Income Latinas: Results from the PST4PPD Project

Research shows that U.S. Latinas are at risk for high rates of postpartum depression (PPD) but have low rates of treatment compared to non-Hispanic White mothers. This study examined the feasibility of a multi-site home-visiting intervention (PST4PPD) conducted by bilingual community health workers (CHW) among low-income Latina mothers. A one-group, pre/posttest design and paired sample's t-test were used to measure changes in depressive symptoms and self-efficacy for participants (n = 76) across five sites. The Edinburgh Postnatal Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ-9) were used to assess depression; the New General Self-Efficacy Scale and the Maternal Efficacy Questionnaire measured general self-efficacy and parenting self-efficacy. Depression scores decreased significantly from pretest to posttest. Participants' general self-efficacy, maternal self-efficacy, and PPD knowledge increased. With a 76% completion rate, demonstrable improvements were seen in participants' depression and self-efficacy. Implications for addressing modifiable factors such as self-efficacy and stress management are discussed.

Effectiveness of Case Management with Problem-Solving Therapy for Rural Older Adults with Depression

OBJECTIVE

To evaluate the effect of case management with problem solving therapy (CM-PST) on depression and disability among rural older adults and compare its effect with outcomes derived from a previous, but similar study among 84 urban older adults.

METHODS

This study examined the comparative effectiveness of a CM-PST intervention for older adults with depression and unmet needs across rural and urban settings. Participants received 12 one-hour sessions of CM-PST with a master's-level clinician. A total of 56 rural and 84 urban adults aged 60 and older experiencing mild to moderate depression received services in their homes.

RESULTS

The rural CM-PST intervention resulted in significantly reduced depression (reduction of 13.9 points, 95% CI 12.2 to 15.7, t(422)= 15.35, p<0.0001) and disability by week 12 (reduction of 6.7 points, 95% CI 4.8 to 8.5, t(425)= 7.01, p<0.0001). Reductions in depression and disability were sustained through week 24. The reductions in depression (F=3.98 df=4,388. p=0.0035) and disability (F=2.71, df=4,381, p=0.03) found in the rural sample were comparable to, or better than, those found in the urban sample. Improvements in unmet need and resilience predicted lower depression scores at 12 weeks, while improvements in unmet need and hopelessness predicted improvements in disability. No moderators of depression were identified, but baseline values of self-efficacy, resilience, and hopelessness moderated disability.

CONCLUSIONS

CM-PST was as effective at reducing depression and disability among rural older adults as it was for urban older adults. Home-delivered CM-PST can be successfully adapted to meet the specific needs of rural seniors using resources often available in rural communities.

Adapting an intervention of brief problem-solving therapy to improve the health of women with antenatal depressive symptoms in primary healthcare in rural Ethiopia

BACKGROUND

Evidence-based brief psychological interventions are safe and effective for the treatment of antenatal depressive symptoms. However, the adaptation of such interventions for low- and middle-income countries has not been prioritised. This study aimed to select and adapt a brief psychological intervention for women with antenatal depressive symptoms attending primary healthcare (PHC) in rural Ethiopia.

METHODS

We employed the Medical Research Council (MRC) framework for the development and evaluation of complex interventions. Alongside this, we used the ADAPT-ITT model of process adaptation and the ecological validity model (EVM) to guide content adaptation. We conducted formative work, comprising a qualitative study, a series of three participatory theories of change workshops and an expert adaptation workshop to assess the needs of the target population and to select an intervention for adaptation. The adaptation process followed a series of steps: (1) training Ethiopian mental health experts in the original South African problem-solving therapy (PST version 0.0) and an initial adaptation workshop leading to PST Version 1.0. (2) Version 1.0 was presented to perinatal women and healthcare professionals in the form of a 'theatre test', leading to further adaptations (version 2.0). (3) Local and international stakeholders reviewed version 2.0, leading to version 3.0, which was used to train 12 PHC staff using clinical cases. (4) Finally, feedback about PST version 3.0 and its delivery was obtained from PHC staff.

RESULTS

In the first step, we modified case examples and terminology from the South African model, introduced an in-session pictorial flipchart for this low literacy setting, and added strategies to facilitate women's engagement before translating into Amharic. In the second step, adaptations included renaming of the types of problems and inclusion of more exercises to demonstrate proposed coping strategies. In the third step, the components of motivational interviewing were dropped due to cultural incongruence. In the final step, refresher training was delivered as well as additional training on supporting control of women's emotions to address PHC staff training needs, leading to the final version (version 4.0).

CONCLUSION

Using a series of steps, we have adapted the content and delivery of brief PST to fit the cultural context of this setting. The next step will be to assess the feasibility and acceptability of the intervention and its delivery in antenatal care settings.

Protocol for a sequential, multiple assignment, randomised trial to test the effectiveness of message-based psychotherapy for depression compared with telepsychotherapy

INTRODUCTION

Digital mental health tools have become popular alternatives to traditional psychotherapy. One emerging form of digital mental health is message-based care, the use of text messages or asynchronous voice or video messaging to provide psychotherapy. There has been no research into whether this is an effective method of psychotherapy as a stand-alone treatment or in combination with traditional psychotherapy.

METHODS AND ANALYSIS

This is a sequential, multiple assignment randomised trial to compare message-based care, videoconference-psychotherapy and a combination of the two treatments in 1000 depressed adults. Participants will be recruited through Talkspace, a digital mental health company, and randomised to receive 6 weeks of either message-based care only or videoconference-psychotherapy only. At 6 weeks, participants will be evaluated for their response to treatment. Those with a 50% or more response to treatment will continue with their assigned condition. Those who do not respond will be randomised to either monthly videoconference-psychotherapy or weekly videoconference-psychotherapy plus message-based care. Primary outcomes will be depression and social functioning. We will also explore moderators of treatment outcome.

ETHICS AND DISSEMINATION

The study received ethics approval from the University of Washington Institutional Review Board. Results of this study will be presented in peer-reviewed journals and at professional conferences.

TRIAL REGISTRATION NUMBER

NCT04513080; Pre-results.

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.

Brief problem-solving therapy for antenatal depressive symptoms in primary care in rural Ethiopia: protocol for a randomised, controlled feasibility trial

BACKGROUND

Despite a high prevalence of antenatal depression in low- and middle-income countries, there is very little evidence for contextually adapted psychological interventions delivered in rural African settings. The aims of this study are (1) to examine the feasibility of procedures for a future fully powered efficacy trial of contextually adapted brief problem solving therapy (PST) for antenatal depression in rural Ethiopia, and (2) to investigate the acceptability, fidelity and feasibility of delivery of PST in routine antenatal care.

METHODS

Design: A randomised, controlled, feasibility trial and mixed method process evaluation.

PARTICIPANTS

Consecutive women attending antenatal clinics in two primary care facilities in rural Ethiopian districts. Eligibility criteria: (1) disabling levels of depressive symptoms (Patient Health Questionnaire (PHQ-9) score of five or more and positive for the 10th disability item); (2) gestational age 12-34 weeks; (3) aged 16 years and above; (4) planning to live in the study area for at least 6 months; (5) no severe medical or psychiatric conditions.

INTERVENTION

Four sessions of adapted PST delivered by trained and supervised antenatal care staff over a maximum period of eight weeks.

CONTROL

enhanced usual care (EUC).

SAMPLE SIZE

n = 50. Randomisation: individual randomisation stratified by intimate partner violence (IPV). Allocation: central phone allocation. Outcome assessors and statistician masked to allocation status. Primary feasibility trial outcome: dropout rate. Primary future efficacy trial outcome: change in PHQ-9 score, assessed 9 weeks after recruitment.

SECONDARY OUTCOMES

anxiety symptoms, trauma symptoms, intimate partner violence, disability, healthcare costs at 9 weeks; postnatal outcomes (perinatal and neonatal complications, onset of breast feeding, child health) assessed 4-6 weeks postnatal. Other trial feasibility indicators: recruitment, number and duration of sessions attended. Audio-recording of randomly selected sessions and in-depth interviews with purposively selected participants, healthcare providers and supervisors will be analysed thematically to explore the acceptability and feasibility of the trial procedures and fidelity of the delivery of PST.

DISCUSSION

The findings of the study will be used to inform the design of a fully powered efficacy trial of brief PST for antenatal depression in routine care in rural Ethiopia.

TRIAL REGISTRATION

The protocol was registered in the Pan-African clinical trials registry, (PACTR): registration number: PACTR202008712234907 on 18/08/2020; URL: https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9578 .

Identifying critical psychotherapy targets in serious cardiac conditions: The importance of addressing coping with symptoms, healthcare navigation, and social support

OBJECTIVE

In seriously ill cardiac patients, several psychotherapy efficacy studies demonstrate little to no reduction in depression or improvement in quality of life, and little is known about how to improve psychotherapies to best address the range of patient needs. An interpersonal and behavioral activation psychotherapy was a key component of the Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) multisite randomized clinical trial. Although depressive symptoms did improve in the CASA trial, questions remain about how best to tailor psychotherapies to the needs of seriously ill patient populations. The study objective was to describe psychosocial needs emerging during a clinical trial of a palliative care and interpersonal and behavioral activation psychotherapy intervention that were not specifically addressed by the psychotherapy.

METHOD

During the CASA trial, patient needs were prospectively tracked by the psychotherapist in each visit note using an a priori code list. Preplanned analysis of study data using directed content analysis was conducted analyzing the a priori code list, which were collapsed by team consensus into larger themes. The frequency of each code and theme were calculated into a percentage of visits.

RESULT

A total of 150 patients received one or more visits from the therapist and were included in the analysis. Participants screened positive for depressive disorder (47%), had poor heart failure-specific health status (mean Kansas City Cardiomyopathy Questionnaire score = 48.6; SD = 17.4), and multiple comorbidities (median 4.3). Common needs that emerged during the therapy included difficulty coping with fatigue (48%), pain (28%), and satisfaction issues with medical care (43%). The following broader themes emerged: social support (77% of sessions), unmet symptom needs (67%), healthcare navigation (48%), housing, legal, safety, and transportation (32%), and end of life (12%).

SIGNIFICANCE OF RESULTS

Coping with chronic symptoms and case management needs commonly emerged during psychotherapy visits. Future psychotherapy interventions in seriously ill populations should consider the importance of coping with chronic symptoms and case management.

Effectiveness of Shared Decision-Making for Elderly Depressed Minority Primary Care Patients

OBJECTIVE

The authors assessed the impact of a shared decision-making (SDM) intervention among elderly depressed minority primary care patients not currently receiving treatment.

METHODS

A total of 202 English and Spanish-speaking primary care participants aged 65 and older who scored positive on the Patient Health Questionnaire-9 (≥10) were randomized at the physician level to receive a brief SDM intervention or usual care (UC). Primary analyses focused on patient adherence to either psychotherapy or antidepressant medication, and reduction in depression severity (Hamilton Depression Rating Scale) over 12 weeks.

RESULTS

Patients randomized to physicians in the SDM condition were significantly more likely than patients of physicians randomized to UC to receive a mental health evaluation or initiate some form of treatment (39% versus 21%), and to adhere to psychotherapy visits over 12 weeks. There were no differences between groups in adherence to antidepressant medication or in reduction of depressive symptoms.

CONCLUSION

Among untreated elderly depressed minority patients from an inner-city municipal hospital, a brief SDM intervention was associated with greater initiation and adherence to psychotherapy. However, low treatment adherence rates across both groups and the intervention's lack of impact on clinical outcomes highlight the need to provide focused and accessible mental health services to patients choosing active treatments.

Depression Agency-Based Collaborative: Effect of Problem-Solving Therapy on Risk of Common Mental Disorders in Older Adults With Home Care Needs

BACKGROUND

Interventions to prevent depression in older adults have mainly focused on young-old ambulatory adults, not on the old-old with disabilities who receive supportive services in their homes.

OBJECTIVE

The Depression Agency-Based Collaborative (Dep-ABC) is a single-blind pilot randomized controlled trial assessing the effect of an intervention-development strategy using problem-solving therapy (PST) on the risk of common mental health disorders in this vulnerable population.

METHODS

The intervention involved six to eight sessions of PST over 12 weeks. Participants were followed up to 12 months postintervention.

RESULTS

Dep-ABC randomized 104 participants-68.4% of eligible and 17.5% of all older adults screened. The proportion of participants with incident major depressive disorder or generalized anxiety disorder was 11.4% in PST and 14.3% in the enhanced usual care control arm. A test of the interaction between time and intervention for anxiety symptoms favored the PST arm (p = 0.04).

CONCLUSION

PST did not lower the risk of incident common mental illness but did lower anxiety symptom burden. Apart from low power, the effects of PST may have been blunted by referral for medical and aging services in the enhanced usual care group.

Problem Solving in Technology-Rich Environments and Self-Rated Health Among Adults in the U.S.: An Analysis of the Program for the International Assessment of Adult Competencies

Problem-solving skills in the context of technologically complex modern societies have become increasingly important to health management in later life. This study is designed to investigate the associations between problem-solving skills in technology-rich environments (PSTRE) and health, and to explore whether age differences exist. Using data from the 2012/2014 Program for the International Assessment of Adult Competencies (PIAAC), we used logistic regression to examine the relationship between PSTRE and self-reported health among a representative sample of American adults aged 35 years and older (N = 3,260). Overall, greater PSTRE (odds ratio [OR] = 1.012, p < .001) was significantly associated with better self-rated health even after adjusting for the sociodemographic characteristics. Yet, PSTRE was only partially predictive of health in some age groups. Our findings highlight the potential of PSTRE to reduce health disparities among middle-aged and older adults living in modern technology and information-rich societies.

Community-Based Outreach and Treatment for Underserved Older Adults With Clinically Significant Worry: A Randomized Controlled Trial

OBJECTIVE

To determine whether Calmer Life (CL) improved worry, generalized anxiety disorder-related (GAD-related) symptoms, anxiety, depression, sleep, trauma-related symptoms, functional status, and quality of life better than Enhanced Community Care with Resource Counseling (ECC-RC) at 6 months and 9 months.

METHODS

A randomized, controlled, comparative-effectiveness study involving underserved, low-income, mostly minority neighborhoods in Houston, Texas, looked at individuals ≥50 with significant worry and interest in psychosocial treatment. Interventions were CL, cognitive behavioral therapy with resource counseling, facilitation of communication with primary care providers about worry/anxiety, integration of religion/spirituality, person-centered skill content and delivery and nontraditional community providers, ECC-RC, and enhanced standard community-based information/ resource counseling addressing basic unmet and mental health needs. Primary outcomes were worry and GAD-related symptom severity. Secondary outcomes were anxiety, depression, sleep difficulties, trauma-related symptoms, functional status, quality of life, service use and satisfaction.

RESULTS

Similar, moderate improvements followed CL and ECC-RC on worry, GAD-related symptoms, anxiety, depression, sleep, trauma-related symptoms, and mental health quality of life at 6 and 9 months, but with symptoms at both times and higher satisfaction with CL at both. Fewer ECC-RC participants reported a hospital admission in the prior 3 months than those in CL at 6 and 9 months; at 9 months, fewer reported a visit with a provider in the previous 3 months.

CONCLUSION

Both interventions showed similar improvements at 6 and 9 months, but symptoms remained that might require care. Either intervention or a combination may be useful for low-income older adults with identified worry/anxiety.

A 12-Week Multi-Domain Lifestyle Modification to Reduce Depressive Symptoms in Older Adults: A Preliminary Report

OBJECTIVE

The objective of this study was to compare the effectiveness of usual care management (UCM) and a newly-developed lifestyle modification with contingency management (LMCM) for geriatric depressive symptoms in the community.

METHODS

A randomized controlled trial was conducted in 93 older adults with major depressive disorder at community mental health centers. A 12 week multi-domain LMCM was developed by providing positive reinforcement using 'gold medal stickers' as a symbolic incentive to motivate their participation and adherence. Participants were allocated to LMCM (n=47) and UCM (n=46) groups. They were then subjected to the 12 week treatment. Effects of the two intervention methods on Geriatric Depression Scale were determined using mixed model analysis.

RESULTS

Participants in the LMCM group had greater decline in GDS score per month than participants in the UCM group after adjusting for age, sex, years of education, living alone, and MMSE scores at baseline examination [coefficient for GDS score (95% CI): -1.08 (-1.51, -0.65), p<0.001, reference: UCM group].

CONCLUSION

LMCM is safe and easy to use with a low cost. LMCM is suitable as psychosocial intervention for older adults with depressive symptoms in the community.

Advances in Psychotherapy for Depressed Older Adults

PURPOSE OF REVIEW

We review recent advances in psychotherapies for depressed older adults, in particular those developed for special populations characterized by chronic medical illness, acute medical illness, cognitive impairment, and suicide risk factors. We review adaptations for psychotherapy to overcome barriers to its accessibility in non-specialty settings such as primary care, homebound or hard-to-reach older adults, and social service settings.

RECENT FINDINGS

Recent evidence supports the effectiveness of psychotherapies that target late-life depression in the context of specific comorbid conditions including COPD, heart failure, Parkinson's disease, stroke and other acute conditions, cognitive impairment, and suicide risk. Growing evidence supports the feasibility, acceptability, and effectiveness of psychotherapy modified for a variety of health care and social service settings. Research supports the benefits of selecting the type of psychotherapy based on a comprehensive assessment of the older adult's psychiatric, medical, functional, and cognitive status, and tailoring psychotherapy to the settings in which older depressed adults are most likely to present.

Improving late life depression and cognitive control through the use of therapeutic video game technology: A proof-of-concept randomized trial

BACKGROUND

Existing treatments for depression are known to have only modest effects, are insufficiently targeted, and are inconsistently utilized, particularly in older adults. Indeed, older adults with impaired cognitive control networks tend to demonstrate poor response to a majority of existing depression interventions. Cognitive control interventions delivered using entertainment software have the potential to not only target the underlying cerebral dysfunction associated with depression, but to do so in a manner that is engaging and engenders adherence to treatment protocol.

METHODS

In this proof-of-concept trial (Clinicaltrials.gov #: NCT02229188), individuals with late life depression (LLD) (22; 60+ years old) were randomized to either problem solving therapy (PST, n = 10) or a neurobiologically inspired digital platform designed to enhance cognitive control faculties (Project: EVO™, n = 12). Given the overlapping functional neuroanatomy of mood disturbances and executive dysfunction, we explored the impact of an intervention targeting cognitive control abilities, functional disability, and mood in older adults suffering from LLD, and how those outcomes compare to a therapeutic gold standard.

RESULTS

EVO participants demonstrated similar improvements in mood and self-reported function after 4 weeks of treatment to PST participants. The EVO participants also showed generalization to untrained measures of working memory and attention, as well as negativity bias, a finding not evident in the PST condition. Individuals assigned to EVO demonstrated 100% adherence.

CONCLUSIONS

This study provides preliminary findings that this therapeutic video game targeting cognitive control deficits may be an efficacious LLD intervention. Future research is needed to confirm these findings.

Psychosocial Treatment Options for Major Depressive Disorder in Older Adults

Late-life depression (LLD) is a public health concern with deleterious effects on overall health, cognition, quality of life, and mortality. Although LLD is relatively common, it is not a normal part of aging and is often under-recognized in older adults. However, psychotherapy is an effective treatment for LLD that aligns with many patients' preferences and can improve health and functioning. This review synthesized the current literature on evidence-based psychotherapies for the treatment of depression in older adults. Findings suggest that active, skills-based psychotherapies (cognitive behavioral therapy [CBT] and problem-solving therapy [PST]) may be more effective for LLD than non-directive, supportive counseling. PST may be particularly relevant for offsetting skill deficit associated with LLD, such as in instances of cognitive impairment (especially executive dysfunction) and disability. Emerging treatments also consider contextual factors to improve treatment delivery, such as personalized care, access, and poverty. Tele-mental health represents one such exciting new way of improving access and uptake of treatment by older adults. Although these strategies hold promise, further investigation via randomized controlled trials and comparative effectiveness are necessary to advance our treatment of LLD. Priority should be given to recruiting and training the geriatric mental health workforce to deliver evidence-based psychosocial interventions for LLD.