Psychosocial interventions for late-life major depression: evidence-based treatments, predictors of treatment outcomes, and moderators of treatment effects

Effectiveness of Eight-Session Dialectical Behavior Therapy Skills Classes for Reducing Symptoms of Anxiety, Depression, and Emotional Dysregulation in a Transdiagnostic Population

Brief group-based psychological treatments are a common tool for increasing service access. Dialectical behavior therapy (DBT) skills groups have been used with several clinical populations to improve emotional regulation. This research aimed to examine the effectiveness of DBT-informed classes across four treatment settings in reducing symptoms of depression, anxiety, and emotional dysregulation, as well as examining participant factors associated with treatment responsiveness and class dropout. A total of 315 participants completed pre-post measures as a part of standard clinical care. Linear mixed model analyses showed that participants who completed DBT-informed classes experienced significant reductions in symptoms of depression, anxiety, and emotional dysregulation. Only an individual's baseline DSM-5 score significantly predicted responsiveness to treatment in terms of decreasing symptoms of anxiety, depression, and emotional dysregulation.

Biomarkers as predictors of CBT responsiveness in major depressive disorder: The role of heart rate variability and inflammation

OBJECTIVE

Biological risk factors for cardiovascular disease may relate to poor treatment responsiveness in major depressive disorder (MDD). These factors encompass low-grade inflammation and autonomic dysregulation, as indexed by decreased heart rate variability (HRV) and increased heart rate (HR). This secondary analysis examined whether higher levels of inflammatory markers or autonomic alterations relate to lower responsiveness to cognitive behavioral therapy (CBT) among individuals with MDD.

METHODS

Eighty antidepressant-free patients with MDD were randomly assigned to 14 weeks of CBT or waitlist (WL). Potential biological moderators at study entry included HR and HRV (24-h, daytime, nighttime) and inflammatory markers such as C-reactive protein (CRP), interleukin (IL)-6, and tumor necrosis factor (TNF)-α. Forty non-clinical controls were involved to verify biological alterations in MDD at study entry. Depressive symptoms were assessed at baseline and at the end of treatment.

RESULTS

Individuals with MDD exhibited reduced total 24-h HRV (i.e., triangular index) and daytime HRV (i.e., triangular index, HF-HRV, LF-HRV, RMSSD), as well as increased levels of inflammatory markers. Patients who received CBT exhibited stronger reductions in self- and clinician-rated depressive symptoms, compared to WL. False discovery rate-adjusted moderation analyses did not show overall moderating effects of biological measures on treatment responsiveness. However, higher CRP levels were specifically associated with poorer improvement in somatic depressive symptoms.

CONCLUSIONS

There was no overall evidence for a moderating role of inflammation or autonomic features in CBT responsiveness in MDD. Higher levels of CRP might, however, specifically be associated with less improvement in somatic depressive symptoms during CBT.

Predictors of treatment outcome of psychological therapies for common mental health problems (CMHP) in older adults: A systematic literature review

Identifying factors that impact psychological treatment outcomes in older people with common mental health problems (CMHP) has important implications for supporting healthier and longer lives. The aim of the present study was to synthesise the evidence on predictors of psychological treatment outcomes in older people (aged 65+). PubMed, Scopus, Web of Science and PsycINFO were searched and 3929 articles were identified and screened, with 42 studies (N = 7978, M age = 68.9, SD age = 2.85) included: depression: k = 21, anxiety: k = 11, panic disorder: k = 3, mixed anxiety & depression: k = 3, PTSD: k = 2, various CMHP: k = 2, with CBT being the most common treatment (71%). The review identified 28 factors reported as significant predictors of treatment outcome in at least one study, across different domains: psychosocial (n = 9), clinical (n = 6), treatment-related (n = 6), socio-demographic (n = 4), neurobiological (n = 3). Homework completion was the most consistent predictor of positive treatment outcome. Baseline symptom severity was the most frequently studied significant predictor and across all conditions, with higher baseline symptom severity largely linked to worse treatment outcomes. No significant effects on treatment outcome were reported for gender, income and physical comorbidities. For a large majority of factors evidence was mixed or inconclusive. Further studies are required to identify factors affecting psychological treatment outcomes, which will be important for the development of personalised treatment approaches.

Perceived Physical Health and Cognitive Behavioral Therapy vs Supportive Psychotherapy Outcomes in Adults With Late-Life Depression: A Secondary Analysis of a Randomized Clinical Trial

Importance

Physical diseases co-occur with late-life depression (LLD). The influence of physical diseases and the subjective perception of physical health (PPH) on treatment outcome in LLD, however, is not well understood.

Objective

To assess the association of physical diseases and PPH with the outcomes of 2 different types of psychotherapy in LLD.

Design, Setting, and Participants

This post hoc secondary analysis of a multicenter, observer-blinded, controlled, parallel-group randomized clinical trial assessed participants 60 years or older with moderate to severe depression recruited at 7 psychiatric-psychotherapeutic outpatient trial sites in Germany from October 1, 2018, to November 11, 2020. Data analysis was performed from April 1 to October 31, 2023.

Interventions

Patients received LLD-specific cognitive behavioral therapy (LLD-CBT) or supportive unspecific intervention (SUI).

Main Outcomes and Measures

Depression severity, response, and remission were measured during treatment and at 6-month follow-up by the change in the 30-item Geriatric Depression Scale (GDS) score. Physical health and PPH were assessed by the number of physical diseases, Charlson Comorbidity Index (CCI), and the World Health Organization Quality of Life Brief Version physical health subscale.

Results

A total of 251 patients were randomized to LLD-CBT (n = 126) or SUI (n = 125), of whom 229 (mean [SD] age, 70.2 [7.1] years; 151 [66%] female) were included in the intention-to-treat analysis. Patients with low and moderate PPH at baseline had significantly less reduction in the GDS score across both treatment groups than patients with high PPH (estimated marginal mean difference [EMMD], 2.67; 95% CI, 0.37-4.97; P = .02 for low PPH and EMMD, 1.82; 95% CI, 0.22-3.42; P = .03 for moderate vs high PPH). Higher PPH at baseline was associated with higher likelihood of response (odds ratio [OR], 1.04; 95% CI, 1.00-1.06; P = .009) and remission at the end of treatment (OR, 1.04; 95% CI, 1.02-1.08; P = .002) and response (OR, 1.05; 95% CI, 1.02-1.08; P < .001) and remission at follow-up (OR, 1.06; 95% CI, 1.03-1.10; P < .001) across both treatment groups. However, a significant interaction of PPH with treatment group was observed with low PPH at baseline being associated with significantly larger reduction in GDS scores in SUI compared with LLD-CBT at the end of treatment (EMMD, -6.48; 95% CI, -11.31 to -1.64; P = .009) and follow-up (EMMD, -6.49; 95% CI, -11.51 to -1.47; P = .01). In contrast, patients with high PPH at baseline had a significantly greater reduction in GDS scores in LLD-CBT compared with SUI at all time points (week 5: EMMD, -4.08; 95% CI, -6.49 to -1.67; P = .001; end-of-treatment: EMMD, -3.67; 95% CI, -6.72 to -0.61; P = .02; and follow-up: EMMD, -3.57; 95% CI, -6.63 to -0.51; P = .02). The number of physical diseases or CCI at baseline did not have an effect on the change in GDS score, response, or remission, neither across both groups nor within either group.

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial, subjective PPH was associated with treatment outcome, response, and remission in psychotherapy of LLD. Patients with LLD responded differently to LLD-CBT and SUI, depending on their baseline PPH score. Treatment approaches for patients with LLD should address PPH in personalized interventions.

Trial Registration

ClinicalTrials.gov Identifier: NCT03735576; Deutsches Register Klinischer Studien Identifier: DRKS00013769.

Effectiveness of multimodal intervention for depression, self-esteem, and quality of life among elderly people residing at selected old age homes in Jalandhar, Punjab

BACKGROUND

Depression is the most common mental disorder among old age people residing at old age homes. It is also associated with many physiological and psychological symptoms along with the impaired quality of life and self-esteem. The multimodal intervention, including physical activity, cognitive training, and social activities, has a positive effect on depression and self-esteem. However, only a few studies were conducted in India setup on the older population residing at old age homes. Hence, this study focused on finding the effectiveness of multimodal intervention for depression, quality of life, and self-esteem among elderly people residing at selected old age homes in Jalandhar, Punjab.

MATERIALS AND METHODS

A randomized, controlled trial design was adopted with longitudinal measurement of outcomes for 6 months. An simple random sampling technique was used to recruit 50 subjects to the experimental group and 50 subjects to the control group. Elderly people who are residing at selected old age homes in Jalandhar were selected for the study. The multimodal intervention was administered to the experimental group once weekly eight sessions over eight weeks after the pre-interventional assessment. The data were collected pre-intervention, at one month, three months, and six months after the intervention. The data were analyzed using Statistical Package for the Social Sciences (SPSS) version 23.0.

RESULTS

There were no significant differences in demographics between groups at baseline. The mean age of subjects was 64.35 ± 1.32 years in the experimental group and 64.12 ± 1.83 in the control group. The mean duration of stay in old age home was 3.64 ± 1.25 years in the experimental group and 4.05 ± 1.65 in the control group. There were significant multimodal intervention effects on decreasing depression (F = 20.15, P < 0.05, n_p²= 0.092) and increasing self-esteem (F = 84.65, P < 0.001, n_p²= 0.24) and quality of life (F = 62.32, P < 0.001, n_p²= 0.52) over the 6-month interval.

CONCLUSION

This study demonstrated that the multimodal intervention was effective in reducing depression among elderly people residing at selected old age homes. It also shows that self-esteem and quality of life improved significantly after intervention.

Biological factors influencing depression in later life: role of aging processes and treatment implications

Late-life depression occurring in older adults is common, recurrent, and malignant. It is characterized by affective symptoms, but also cognitive decline, medical comorbidity, and physical disability. This behavioral and cognitive presentation results from altered function of discrete functional brain networks and circuits. A wide range of factors across the lifespan contributes to fragility and vulnerability of those networks to dysfunction. In many cases, these factors occur earlier in life and contribute to adolescent or earlier adulthood depressive episodes, where the onset was related to adverse childhood events, maladaptive personality traits, reproductive events, or other factors. Other individuals exhibit a later-life onset characterized by medical comorbidity, pro-inflammatory processes, cerebrovascular disease, or developing neurodegenerative processes. These later-life processes may not only lead to vulnerability to the affective symptoms, but also contribute to the comorbid cognitive and physical symptoms. Importantly, repeated depressive episodes themselves may accelerate the aging process by shifting allostatic processes to dysfunctional states and increasing allostatic load through the hypothalamic-pituitary-adrenal axis and inflammatory processes. Over time, this may accelerate the path of biological aging, leading to greater brain atrophy, cognitive decline, and the development of physical decline and frailty. It is unclear whether successful treatment of depression and avoidance of recurrent episodes would shift biological aging processes back towards a more normative trajectory. However, current antidepressant treatments exhibit good efficacy for older adults, including pharmacotherapy, neuromodulation, and psychotherapy, with recent work in these areas providing new guidance on optimal treatment approaches. Moreover, there is a host of nonpharmacological treatment approaches being examined that take advantage of resiliency factors and decrease vulnerability to depression. Thus, while late-life depression is a recurrent yet highly heterogeneous disorder, better phenotypic characterization provides opportunities to better utilize a range of nonspecific and targeted interventions that can promote recovery, resilience, and maintenance of remission.

Message-based psychotherapy for older adults: A cohort comparison study

Objective

Digital Mental Health Interventions (DMHI) can diminish inequities in mental health care provision. As DMHIs increase in popularity, however, older adults may be unintentionally excluded due to barriers such as lack of awareness, internet access, digital tools, technological socialization and education, physiological accessibility, and communication technology infrastructure. The aim of this study was to examine longitudinal treatment engagement patterns and 15-week clinical outcomes of depressed and anxious older adults compared to a matched cohort of younger adults seeking treatment from a large asynchronous telemedicine provider.

Methods

The 2,470 older adults (55+ years) and a matched cohort of younger adults (26-35 years) diagnosed with depression or anxiety were treated by licensed therapists via messaging 5 days a week. Patterns of treatment engagement on the platform were compared across groups by examining total number of days in treatment, days actively messaging on the platform, and average words and messages per week sent by patients over the entire period they remained in treatment. Symptoms were assessed every 3 weeks using the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Scale (GAD-7), and changes were compared across age groups over 15 weeks.

Results

Older patients attended more days in treatment than younger patients, but there were no differences in number of days actively messaging on the platform, number of messages per week, or word count per week. The two age groups did not differ in their final anxiety or depressive symptoms when controlling for total number of weeks attended. Patients in the younger age group experienced a quicker rate of reduction than older adults in their anxiety, but not depressive symptoms.

Conclusions

Among individuals willing to initiate care through a DMHI, older adults had overall similar engagement as younger adults and they showed similar improvement in symptoms of depression and anxiety. Given the advantages of message-based care for aiding a mental health workforce in serving larger numbers of individuals in need and the expected growth of the aging population, these findings could help healthcare systems in evaluating a variety of treatment options and delivery media for meeting the healthcare needs of the future.

Protocol for a collaborative randomised effectiveness trial of lay-delivered versus clinician-delivered behavioural activation in senior centres

INTRODUCTION

Depression is common among community-dwelling older adults who make use of senior centre services yet remains undertreated due to a lack of acceptable and available treatments. Emerging evidence suggests that lay health providers can offer psychosocial interventions for mental health disorders experienced by older adults. We developed a streamlined Behavioural Activation intervention (called 'Do More, Feel Better'; DMFB) to be delivered by older adult volunteers and propose to compare its effectiveness to that of clinician-delivered behavioural activation (BA).

METHODS AND ANALYSIS

This study is a type I collaborative randomised effectiveness trial testing the effect of DMFB in comparison to BA among 288 senior centre clients (aged 60+). Participant clients will be recruited from 6 Seattle, 6 New York City and 6 Tampa area senior centres serving economically and ethnically diverse communities. Primary outcomes will be increased activity level (target) and decreased depressive symptoms. Secondary outcomes will be functioning and client satisfaction, and an exploratory outcome will be treatment fidelity.

ETHICS AND DISSEMINATION

The study received ethics approval from the University of Washington Institutional Review Board (STUDY00011434). Client, volunteer and clinician participants will all provide informed consent for study procedures through in-person or remote contact with investigators. Results of this study will be presented in peer-reviewed journals and at professional conferences.

TRIAL REGISTRATION NUMBER

NCT04621877; ClinicalTrials.gov.

Late-life depression and the family physician

Late-life depression (LLD) is a common disorder seen in clinical practice. Depression in this population group is often left undetected and untreated. The majority of elderly individuals who seek help present to the primary health care setting. The family physician is ideally placed to screen for symptoms of LLD, given that they often have longitudinal knowledge of the patient's history, premorbid personality, functioning and overall health status. An understanding of risk factors, differential diagnoses, appropriate opportunistic screening tools and decision-making around management plans can assist the family physician in the early detection and treatment of these patients. In doing so, this may lead to a decrease in mortality and morbidity and enhance the patient's quality of life.

Estimate of the prevalence of depression among older people in Africa: a systematic review and meta-analysis

OBJECTIVE

The current systematic review and meta-analysis aimed to estimate the pooled prevalence of depression among elderly people in Africa.

METHOD

We have searched CINAHIL, PubMed, SCOPUS and Psych-INFO databases to identify important observational studies which reported the prevalence of depression among the elderly. We used a random-effects model due to reported heterogeneity among the included studies. The publication bias was examined by using Egger's test, visual inspection of the symmetry in funnel plots and adjusted using Duval and Tweedie's Trim and Fill analysis. We have meta-analysed the pooled estimates of depression from primary studies by adjusting for publication bias. We used Cochran's Q and the I²-tests to measure heterogeneity across the studies.

RESULT

A total of 23 studies conducted in Africa were included in the current systematic review and meta-analysis, representing a total of 14, 350 elderly population. The pooled prevalence of depression among elderly people in Africa was estimated to be 26.3% (95% CI; 22.2, 30.4%). The estimated pooled prevalence of depression among the elderly in Africa was much higher (43.1%) in studies that used a screening tool to measure depression when compared to studies that used a diagnostic tool (24.2%). Also, the prevalence of depression among female elderly participant (43.10%) was higher than that of male elderly participant (30.90%).

CONCLUSION

One in five elderly population in Africa were depressed, which poses serious health concerns. Timely and targeted screening of depression among the elderly and evidence-based interventions were highly recommended.

Depressive symptom profiles predict dementia onset and brain pathology in older persons. The AGES-Reykjavik study

Late-life depression (LLD) increases risk for dementia and brain pathology, but possibly this is only true for one or more symptom profiles of LLD. In 4354 participants (76 ± 5 years; 58% female) from the Age, Gene/Environment Susceptibility (AGES)-Reykjavik Study, we identified five LLD symptom profiles, based on the Geriatric Depression Scale-15 (no LLD (57%); apathy (31%); apathy with emptiness (2%), mild LLD (8%) and severe LLD (2%)). Cox regression analyses showed that severe LLD, mild LLD and apathy increased risk of dementia up to 12 years, compared to no LLD. Additionally, hippocampal volume loss and white matter lesion increase, were assessed on 1.5 T MR images, at baseline and after 5 years follow-up. Only severe LLD showed increased WML volume over time, but not on hippocampal volume loss. WML increase over time mediated partially the relation between mild LLD and dementia but not for the other symptom profiles. It appears that hippocampal atrophy and LLD are independent predictors for dementia incidence, whereas for mild LLD the risk for dementia is partially mediated by WML changes.

Comparing the streamlined psychotherapy "Engage" with problem-solving therapy in late-life major depression. A randomized clinical trial

Effective psychotherapies for late-life depression are underutilized, mainly because of their complexity. "Engage" is a novel, streamlined psychotherapy that relies on neurobiology to identify core behavioral pathology of late-life depression and targets it with simple interventions, co-designed with community therapists so that they can be delivered in community settings. Consecutively recruited adults (≥60 years) with major depression (n = 249) were randomly assigned to 9 weekly sessions of "Engage" or to the evidence-based Problem-Solving Therapy (PST) offered by 35 trained community social workers and assessed by blind raters. "Engage" therapists required an average of 30% less training time to achieve fidelity to treatment than PST therapists and had one-third of the PST therapists' skill drift. Both treatments led to reduction of HAM-D scores over 9 weeks. The mixed effects model-estimated HAM-D ratings were not significantly different between the two treatments at any assessment point of the trial. The one-sided 95% CI for treatment-end difference was (-∞, 0.07) HAM-D points, indicating a non-inferiority margin of 1.3 HAM-D points or greater; this margin is lower than the pre-determined 2.2-point margin. The two treatment arms had similar response (HR = 1.08, 95% CI (0.76, 1.52), p = 0.67) and remission rates (HR = 0.89, 95% CI (0.57, 1.39), p = 0.61). We conclude that "Engage" is non-inferior to PST. If disseminated, "Engage" will increase the number of therapists who can reliably treat late-life depression and make effective psychotherapy available to large numbers of depressed older adults.

Mechanisms and Treatment of Late-Life Depression

(Appeared originally in Translational Psychiatry 2019; 9:188).

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Impact of the COVID-19 pandemic on working students: Results from the Labour Force Survey and the student lifestyle survey

OBJECTIVE

The COVID-19 pandemic has caused devastating damage to employment globally, particularly among the non-standard workforce. The objective of this study was to identify the effects of the pandemic on the employment status and lives of working students in Japan.

METHODS

The Labour Force Survey (January 2019 to May 2020) was used to examine changes in students' work situations. In addition, to investigate the economic and health conditions of university students during the pandemic, the Student Lifestyle Survey was conducted in late May 2020. This survey asked students at a national university in Tokyo about recent changes in their studies, work, and lives.

RESULTS

The number of working students reported in the Labour Force Survey has declined sharply since March 2020, falling by 780,000 (46%) in April. According to a survey of university students' living conditions, 37% were concerned about living expenses and tuition fees, and a higher percentage of students who were aware of financial insecurity had poor self-rated health.

CONCLUSION

Nearly half of working students have lost their jobs during the pandemic in Japan, which has affected their lives, studies, and health. There is a need to monitor the impact of economic insecurity on students' studies and health over time, and to expand the safety net for disadvantaged students.

Guided Self-Help Behavioral Activation Intervention for Geriatric Depression: Protocol for Pilot Randomized Controlled Trial

Background

Aging is a social concern. The increased incidence of depression in older populations in China poses a challenge to the health care system. Older adults who are depressed often suffer from a lack of motivation. Behavioral activation treatment, an evidence-based guided self-help treatment, is effective in reducing anhedonia and amotivation in depression; however, the efficacy of guided self-help behavioral activation in older adults with depression is not yet known.

Objective

The aim of this study is to pilot a self-help guided intervention for the treatment of depression in older adults.

Methods

This study has been designed as a pilot randomized controlled trial with inpatients (n=60; to be randomly allocated 1:1) between the ages of 60 and 70 and who have major depressive disorder. Patients attending clinical psychological clinics at the Mental Health Center of Chongqing will be randomized to either receive guided self-help behavioral activation (intervention) or to be on a 6-week waiting list (control). Participants in the treatment group will receive 6 sessions of guided self-help behavioral activation delivered over the telephone. The waiting list control group will receive the intervention after a period of 6 weeks. Exclusion criteria will be individuals who are at significant risk of harming themselves or others, who have a primary mental health disorder other than depression, or who have an intellectual disability that would hamper their ability to participate in the intervention. Effects of the treatment will be observed using outcomes in 3 domains: (1) clinical outcomes (symptom severity, recovery rate), (2) process variables (patient satisfaction, attendance, dropout), and (3) economic outcomes (cost and resource use). We will also examine mediators of outcomes in terms of patient variables (behavioral activation or inhibition motivation). We hypothesize that guided self-help behavioral activation will have a beneficial effect.

Results

The study was approved by the research ethics committee of the Mental Health Center of Chongqing in November 2019. As of July 2020, recruitment had not yet begun. Data collection is expected to be completed by December 2020. Data analysis is expected to be completed by June 2021. Results will then be disseminated to patients, to the public, to clinicians, and to researchers through publications in journals and presentations at conferences.

Conclusions

This will be the first study in China to investigate guided self-help interventions for patients who are older adults and who are depressed, a group which is currently underrepresented in mental health research. The intervention is modular and adapted from an empirically supported behavioral activation treatment for depression. The generalizability and broad inclusion criteria are strengths.

Trial Registration

Chinese Clinical Trial Register ChiCTR1900026066; http://www.chictr.org.cn/showprojen.aspx?proj=43548

International Registered Report Identifier (IRRID)

PRR1-10.2196/18259

The symptom network structure of depressive symptoms in late-life: Results from a European population study

The network theory conceptualizes mental disorders as complex networks of symptoms influencing each other by creating feedback loops, leading to a self-sustained syndromic constellation. Symptoms central to the network have the greatest impact in sustaining the rest of symptoms. This analysis focused on the network structure of depressive symptoms in late-life because of their distinct etiologic factors, clinical presentation, and outcomes. We analyzed cross-sectional data from wave 2 of the 19 country Survey of Health, Ageing, and Retirement in Europe (SHARE) and included non-institutionalized adults aged 65 years or older (mean age 74 years, 59% females) endorsing at least one depressive symptom on the EURO-D scale for depression (N =8,557). We characterized the network structure of depressive symptoms in late-life and used indices of "strength", "betweenness", and "closeness" to identify symptoms central to the network. We used a case-dropping bootstrap procedure to assess network stability. Death wishes, depressed mood, loss of interest, and pessimism had the highest values of centrality. Insomnia, fatigue and appetite changes had lower centrality values. The identified network remained stable after dropping 74.5% of the sample. Sex or age did not significantly influence the network structure. In conclusion, death wishes, depressed mood, loss of interest, and pessimism constitute the "backbone" that sustains depressive symptoms in late-life. Symptoms central to the network of depressive symptoms may be used as targets for novel, focused interventions and in studies investigating neurobiological processes central to late-life depression.

Depression and activity-limiting fall worry among older adults: longitudinal reciprocal relationships

OBJECTIVES

Late-life depression, falls, and fall worry are public health problems. While previous research confirms the cross-sectional relationship between depression and fall worry, few longitudinal studies have examined whether changes in fall worry are associated with changes in depressive illness and vice versa. This study examined longitudinal relationships between probable major depression (PMD) and activity-limiting fall worry (ALW).

DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS

This longitudinal panel observational study used data from the National Health and Aging Trends Study (NHATS) waves 5 (referred to as T1 in this study) and 6 (T2), conducted in 2015 and 2016, respectively (N = 6,299, aged 65 and older). We examined associations of new and continued ALW between T1 and T2 with T2 PMD, controlling for T1 PMD; and associations of new and continued PMD between T1 and T2 with T2 ALW, controlling for T1 ALW. We used χ2 and t tests for descriptive statistics and logistic regression for multivariable analysis.

RESULTS

Those with new ALW at T2 had significantly greater odds of T2 PMD compared to those without ALW at both time points (AOR = 2.64, 95% CI = 1.98-3.51), and those with new PMD at T2 had significantly greater odds of T2 ALW (AOR = 2.42, 95% CI = 1.66-3.52). Those with continued PMD also had greater odds of T2 ALW compared to those without PMD at either time point (AOR = 2.31, 95% CI = 1.62-3.29).

CONCLUSIONS

The findings add to knowledge about bidirectional (mutually reinforcing) relationships between depression and activity-limiting fall worry. Innovative interventions are needed to reduce both late-life depression and activity-limiting fall worry.

Diagnosing and Treating Depression in Patients with Alzheimer's Disease

Although cognitive and functional impairment are the hallmark features of Alzheimer's disease (AD), neuropsychiatric symptoms associated with AD account for increased rates of disability and profoundly impact the quality of life of both patients and their caregivers. This narrative review of current evidence provides practical guidance in diagnosing and managing depression in patients with AD using pharmacological and nonpharmacological interventions. After apathy, depression is the second most common neuropsychiatric symptom in AD. Diagnosing late-life depression (LLD), particularly in those affected by AD, is complicated because older patients may not meet the criteria for a major depressive disorder. Clinically, late-life depression and dementia can be indistinguishable. Although these two entities are now thought to be related, the pathologic mechanisms remain unclear. Evidence suggests that LLD may be a prodromal symptom of neurodegenerative disease. The various geropsychiatric measures currently used to diagnose, rate the severity of, and monitor the progress of treatment for depression are imperfect. Neuroimaging represents a promising avenue toward understanding the complex pathophysiologic relationships between dementia and LLD, and will support the pursuit of biomarker-driven diagnosis and treatment. Nonpharmacologic interventions to relieve depression in persons with cognitive impairment and dementia include emotion-oriented therapies, behavioral and cognitive-behavioral modification programs, and structured activity programs. Sensory-stimulation therapies and multisensory approaches show some promise for successfully treating depression in patients with dementia, but further rigorous research is needed to establish their validity. Clinical consensus and research appear to support selective serotonin reuptake inhibitors as a first choice for the pharmacological treatment of depression in patients with dementia. However, initial support for these therapies remains variable, and further investigation is needed. Extra care is required in prescribing to this population because of the generally high level of medical and psychiatric comorbidity and the potential difficulty in assessing the cognitively impaired patient's response.

Efficacy and tolerability of pharmacological and non-pharmacological interventions in older patients with major depressive disorder: A systematic review, pairwise and network meta-analysis

As there is currently no comprehensive evaluation about the efficacy and safety of interventions in elderly patients with major depressive disorder, we did a systematic review and network meta-analysis about all interventions in this population. We searched the specialised register of the Cochrane common mental disorders group, MEDLINE, EMBASE, PsycINFO, CochraneLibrary, ClinicalTrials.gov and the WHO registry until Dec 12, 2017 to identify all randomized controlled trials about the treatment of major depressive disorder in patients over an age of 65. The primary outcome was response defined as reduction of at least 50% on the Hamilton Depression Scale or any other validated depression scale. Secondary outcomes were remission, depressive symptoms, dropouts total, dropouts owing to inefficacy and dropouts due to adverse events, quality of life and social functioning. Additionally, we analysed 116 adverse events. We identified 129 references from 53 RCTs with 9274 participants published from 1990 to 2017. The mean participant age was 73.7 years. In terms of the primary outcome response to treatment the network-meta-analysis showed significant superiority compared to placebo for quetiapine and duloxetine; in addition, agomelatine, imipramine and vortioxetine outperformed placebo in pairwise meta-analyses, and there were also significant superiorities of several antidepressants compared to placebo in secondary efficacy outcomes. Very limited evidence suggests that competitive memory training, geriatric home treatment group and detached mindfulness condition reduce depressive symptoms. Several antidepressants and quetiapine have been shown to be efficacious in elderly patients with major depressive disorder, but due to the comparably few available data, the results are not robust. Differences in the multiple side-effects analysed should also be considered in drug choice. Although there were significant effects for some non-pharmacological treatments, the overall evidence for non-pharmacological treatments in major depressive disorder is insufficient, because it is based on a few trials with usually small sample sizes.

Mechanisms and treatment of late-life depression

Depression predisposes to medical illnesses and advances biological aging indicated by shorter telomere length, accelerated brain aging and advanced epigenetic aging. Medical illnesses also increase the risk of late-life depression. The reciprocal relationships of depression with aging-related and disease-related processes have generated pathogenetic hypotheses and provided treatment targets. Targeting risk factors of vascular disease in mid-life is a logical approach in prevention of vascular depression. The depression-executive dysfunction and the vascular depression syndromes have clinical presentations and neuroimaging findings consistent with frontostriatal abnormalities. Dopamine D_2/3 agonists are effective in depression of Parkinson's disease and their efficacy needs to be assessed in these two syndromes. Computerized cognitive remediation targeting functions of the cognitive control network may improve both executive functions and depressive symptoms of late-life major depression. Significant progress has been made in neurostimulation treatments in depressed younger adults. TMS targeting deep structures responsible for mood regulation is well tolerated by older adults and its efficacy in syndromes of late-life depression needs to be studied. Efficacious psychotherapies for late-life depression exist, but are underutilized in part because of their complexity. Streamlined, stepped psychotherapies targeting behaviors assumed to result from dysfunction of brain networks implicated in late-life depression can be easy to learn and have potential for dissemination. However, their effectiveness needs further investigation. Depression increases the risk of dementing disorders. Antidepressants are rather ineffective in treating depression of demented patients, but long-term use of antidepressants may reduce the risk of dementia. However, confirmation studies are needed.

Lighten UP! A Community-Based Group Intervention to Promote Eudaimonic Well-Being in Older Adults: A Multi-Site Replication with 6 Month Follow-Up

Objectives: Eudaimonic well-being (EWB), increasingly recognized as a critical component of health, typically declines in later life, and there are no existing programs to sustain or increase EWB in older adults. Lighten UP! is an 8-week program to promote EWB through facilitated group sessions in community settings and at-home practice. Building on earlier pilot research, the current study assessed the effect of the Lighten UP! Program using a longitudinal, multi-site design. Methods: Men and women (N = 169) aged 60 and over were recruited from three Wisconsin communities. EWB, life satisfaction, depression, and diverse aspects of health were assessed before and after the program and at 6-month follow up. Results: Participants reported significantly increased EWB; these changes were maintained 6 months later. The specific EWB domains of self-acceptance, positive relations, and personal growth showed the most robust gains. Participants also showed significant and sustained declines in depressive symptoms, anxiety, and hostility. Conclusions: Lighten UP! Program confirmed its positive effects for enhancing EWB in older adults living in multiple community settings. Clinical Implications: Programs that sustain or enhance EWB in older adults can be expected to yield improvements in diverse aspects of mental and physical health.

The effects of a Socially Supportive Activities Program (SSAP) on mood in long term care: A pilot study

This study examined the effects of a facilitated 10-week Socially Supportive Activities Program (SSAP) designed to improve mood in a geriatric institutional setting. A sample of 68 Taiwanese elders in long-term care facilities with depressive symptoms were randomly assigned to either an experimental group (N = 35) or a control group (N = 33). Outcomes were measured before the intervention, week 1, and at week 12, one-week post intervention. In the experimental group, pre-post measurement results demonstrated significant reductions in depressive symptoms, measured by Geriatric Depression Scale, and significantly higher levels of self-transcendence, measured by the Self-Transcendence Scale. An additional post-intervention measure of mood was collected with the Apparent Emotional Rating Scale. The AERS also demonstrated a significantly higher score (better mood) in the experimental group than in the control group. This study supports the use of a structured, facilitated, well-designed social activities program like the SSAP, to enhance and improve mood in elders who live in long-term care facilities.

Outcome of day treatment for older adults with affective disorders: An observational pre-post design of two transdiagnostic approaches

OBJECTIVE

First, to evaluate the outcome of 2 transdiagnostic day treatment programs. A 20-week psychotherapeutic day treatment (PDT) and an activating day treatment (ADT) program delivered in blocks of 4 weeks with a maximum of 24 weeks with respect to depression, anxiety, and hypochondriasis. Second, to explore the impact of cognitive impairment and personality pathology on treatment outcome.

METHODS

The course of depression (Inventory of Depressive Symptoms), anxiety (Geriatric Anxiety Inventory), and hypochondriasis (Whitley Index) were evaluated by linear mixed models adjusted for age, sex, level of education, and alcohol usage among 49 patients (mean age 65 years, 67% females) receiving PDT and among 61 patients (mean age 67.1, 61% females) receiving ADT. Pre-post effect-sizes were expressed as Cohen's d. Subsequently, cognitive impairment (no, suspected, established) and personality pathology (DSM-IV criteria as well as the Big Five personality traits) were examined as potential moderators of treatment outcome.

RESULTS

Among patients receiving PDT, large improvements were found for depression (d = 1.1) and anxiety (d = 1.2) but not for hypochondriasis (d = 0.0). Patients receiving ADT showed moderate treatment effects for depression (d = 0.6), anxiety (d = 0.6), as well as hypochondriasis (d = 0.6). Personality pathology moderates treatment outcome of neither PDT nor ADT. Cognitive impairment negatively interfered with the course of depressive symptoms among patients receiving PDT.

CONCLUSIONS

Transdiagnostic day treatment is promising for older adults with affective disorders with high feasibility.

Art therapy as an adjuvant treatment for depression in elderly women: a randomized controlled trial

Objective:

There are few quantitative studies on art therapy for the treatment of depression. The objective of this study was to evaluate if art therapy is beneficial as an adjuvant treatment for depression in the elderly.

Methods:

A randomized, controlled, single-blind study was carried out in a sample of elderly women with major depressive disorder (MDD) stable on pharmacotherapy. The experimental group (EG) was assigned to 20 weekly art therapy sessions (90 min/session). The control group (CG) was not subjected to any adjuvant intervention. Patients were evaluated at baseline and after 20 weeks, using the Geriatric Depression Scale (GDS), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and cognitive measures.

Results:

Logistic regression analysis adjusted for age revealed that women in EG (n=31) had significant improvement in GDS (p = 0.007), BDI (p = 0.025), and BAI (p = 0.032) scores as compared with controls (n=25). No difference was found in the cognitive measures.

Conclusion:

Art therapy as an adjunctive treatment for MDD in the elderly can improve depressive and anxiety symptoms.

Clinical trial registration:

RBR-2YXY7Z

Individually tailored internet-based cognitive behaviour therapy for older adults with anxiety and depression: a randomised controlled trial

Mixed anxiety and depression is common among older adults. The aim of the study was to compare the effects of an eight-week-long tailored internet-supported cognitive behaviour therapy (ICBT) programme and to compare against the provision of weekly general support. A second aim was to investigate if pre-treatment cognitive flexibility and self-reported cognitive problems would predict outcome. We included 66 older adults (aged over 60 years) with mixed anxiety/depression following media recruitment and randomised them into treatment and control groups. We also included a one-year follow-up. As a measure of executive function, we used the Wisconsin Card Sorting Test (perseverative errors) and the Cognitive Failures Questionnaire during the pre-treatment phase. Results showed a moderate between-group effect on the main outcome measure, the Beck Anxiety Inventory (BAI) (d= .50), favouring the treatment group. Nearly half (45.5%) of that group were classified as responders. One person (3%) in the treatment group deteriorated. There were significant correlations between perseverative errors and outcome (on the BAI r = -.45), but not among self-reported cognitive function. We conclude that guided, tailored ICBT may be effective for some older adults and that the role of cognitive function needs to be investigated further.

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.

A pilot trial of acceptance and commitment therapy for symptoms of depression and anxiety in older adults residing in long-term care facilities

OBJECTIVES

The aim of this study was to evaluate the efficacy and acceptability of a psychological intervention based on acceptance and commitment therapy (ACT) to improve symptoms of depression and anxiety among older adults living in long-term care.

METHOD

Forty one residents aged between 63 and 97 years (M = 85.3 years) participated in this study. Residents were allocated to receive either a 12 session ACT intervention implemented by trainee psychology therapists or a wait-list control group. Measures of depression and anxiety were collected at baseline and 8 week post-intervention, and residents who received the intervention were tracked for three months. A treatment satisfaction questionnaire was administered to residents who received the intervention and a sample of 10 facility staff members.

RESULTS

Using an intention to treat approach and controlling for baseline scores, scores on depression measures were significantly lower after the ACT intervention than after the wait-list control. These outcomes were maintained at three-month follow-up. Treatment satisfaction was rated highly by both residents and their care staff.

CONCLUSION

This preliminary trial suggests that ACT shows promise as a therapeutic approach to address symptoms of depression in long-term care.

Therapeutic relationship in the treatment of geriatric depression with executive dysfunction

BACKGROUND

The effects of therapeutic relationship (TR) in elder mental health are understudied. A greater understanding of TR in geriatric psychotherapy is particularly needed for treating late-life depression with executive dysfunction, which predicts poor response to antidepressant medication and presents unique clinical challenges.

METHODS

Participants were older patients (N = 220) with major depression and executive dysfunction who received 12 weeks of problem-solving therapy or supportive therapy in a randomized control trial. Multilevel growth curve modeling and latent change scores were used to analyze TR dimensions of Understanding and Accepting at the patient level (individual patient ratings, N = 194) and therapist level (ratings of each therapist averaged across participants, N = 10).

RESULTS

TR predicted reduction of depression in both treatment groups, while treatment×TR interactions were not significant. Patients treated by therapists with higher average Understanding (patient and therapist level) and Accepting (therapist level) ratings had greater decreases in depression. The patient level×therapist level interaction for Understanding approached statistical significance (p=.065), suggesting a synergistic effect on treatment outcome. Together, Understanding and Accepting predicted 21% of variance in depression level changes.

LIMITATIONS

TR was not assessed throughout the course of treatment (only after the first therapy session and at post-treatment) and did not include ratings from an objective evaluator.

CONCLUSIONS

Assessment of patient's experience of the TR and of therapist ability to foster Understanding and Accepting can play a significant role in the delivery of geriatric psychosocial interventions.

Impact of Affective Disorders on Recovery of Baseline Function in Patients Undergoing Spinal Surgery: A Single Institution Study of 275 Patients

BACKGROUND

Decompressive spinal surgery patients have high expectations of recovering functionally, both at work and with leisurely activities. Affective disorders, such as depression or anxiety, are increasingly prevalent in this population and are associated with poorer baseline quality-of-life measures and worse postoperative outcomes. The study examined the results of affective disorders on self-reported recovery of baseline function (RBF) following decompressive spinal surgery.

METHODS

Medical records of 275 patients undergoing elective decompressive spinal surgery at a major academic institution were reviewed. There were 101 (36.7%) patients (with diagnosed anxiety or depression) in the affective disorder cohort (ADC) and 174 (63.6%) patients in the control cohort. The main outcome measure was self-reported RBF 3 months after surgery. Multivariate regression analysis was also used to determine whether affective disorders were a risk factor for poor RBF.

RESULTS

Baseline demographics, comorbidities, and perioperative variables between the two cohorts were similar, except for a higher proportion of females, more smokers, and longer length of stay in the ADC. On patient-reported outcome measures, the ADC had significantly decreased baseline scores and decreased improvement in scores over time. On univariate analysis, the ADC had significantly lower rates of RBF at 3 months after surgery. On regression analysis, affective disorders were an independent risk factors for poor RBF.

CONCLUSIONS

This study suggests that affective disorders are an independent risk factor for decreased recovery of baseline functionality after decompressive spinal surgery. Preoperatively identifying these patients could improve management of postoperative expectations and thereby improve surgical outcome.

Physical Exercise for Late-Life Depression: Customizing an Intervention for Primary Care

OBJECTIVES

To identify which individual- and context-related factors influence the translation into clinical practice of interventions based on physical exercise (PE) as an adjunct to antidepressants (AD) for the treatment of late-life major depression (LLMD).

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Primary care with psychiatric consultation-liaison programs (PCLPs)-organizational protocols that regulate the clinical management of individuals with psychiatric disorders.

PARTICIPANTS

Individuals aged 65 and older with major depression according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (N = 121).

INTERVENTION

Participants with LLMD were randomized to AD (sertraline) or AD plus PE (AD + PE).

MEASUREMENTS

Participant characteristics that were associated with greater effectiveness of AD + PE (moderators) were identified, and effect sizes were calculated from success rate differences. Whether the characteristics of the study setting influenced participant flow and attendance at exercise sessions was then explored, and primary care physicians (PCPs) were surveyed regarding their opinions on PE as a treatment for LLMD.

RESULTS

The following participant characteristics were associated with greater likelihood of achieving remission from depression with AD + PE than with AD alone: aged 75 and older (effect size 0.32), polypharmacy (0.35), greater aerobic capacity (0.48), displaying psychomotor slowing (0.49), and less-severe anxiety (0.30). The longer the PCLP had been established at a particular center, the more individuals were recruited at that center. After participating in the study, PCPs expressed positive views on AD + PE as a treatment for LLMD and were more likely to use this as a therapeutic strategy.

CONCLUSIONS

The combination of PE and sertraline could improve the management of LLMD, especially when customized for individuals with specific clinical features. Liaison programs might influence the implementation of similar interventions in primary care, and PCPs viewed them positively.

Clinical predictors of depression treatment outcomes in patients with coronary heart disease

OBJECTIVES

Patients with coronary heart disease (CHD) who respond to treatment for depression are at lower risk of mortality than are nonresponders. This study sought to determine whether variables that have been shown to predict both depression treatment outcomes in psychiatric patients and cardiac events in patients with CHD, also predict poor response to depression treatment in patients with CHD.

METHODS

One hundred fifty-seven patients with stable CHD who met the DSM-IV criteria for a major depressive episode were treated with cognitive behavior therapy (CBT) for 16weeks, either alone or in combination with an antidepressant.

RESULTS

The mean Beck Depression Inventory (BDI-II) score was 30.2±8.5 at baseline and 8.5±7.8 at 16weeks. Over 50% of the participants were in remission (HAM-D-17 score ≤7) at the end of treatment. Of the hypothesized predictors, severe depression at baseline (p=0.02), stressful life events during the first (p=0.03) and last (p<0.0001) 8weeks of treatment, and the completion of CBT homework assignments (p=0.001) predicted depression outcomes. History of prior episodes, anxiety symptoms, antidepressant therapy at study enrollment, and medical hospitalizations or emergency department visits during treatment did not predict treatment outcome.

CONCLUSIONS

Patients who are under considerable stress do not respond as well to evidence-based treatments for depression as do patients with less stress. If future studies support these findings, more work will be needed to better address stressful life events in patients who may otherwise remain at high risk for mortality and medical morbidity following depression treatment.

Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults

OBJECTIVE

Major depressive disorder (MDD) affects many older adults and is associated with poor medical and mental health outcomes. Problem Solving Therapy (PST) has emerged as a promising psychotherapy for MDD in older adults, although the efficacy of PST in this population has not been well described. We examined the effectiveness of PST for the treatment of MDD in older adults in a systematic review and meta-analysis.

METHODS

We searched electronic databases to identify randomized controlled trials comparing PST to a control condition or other treatment for MDD in adults with an average age of 60 years or older. We used meta-analysis to arrive at pooled summary measures of the efficacy of PST when compared to control conditions on the change in depressive symptoms and other outcomes.

RESULTS

Nine studies with a total of 569 participants (290 PST, 279 control) met inclusion criteria. Most studies administered PST in person and were between 6 and 12 weeks in duration. Meta-analysis of six studies evaluating the effect of PST on depression using the Hamilton Rating Scale for Depression identified a significant reduction in depression associated with PST (pooled mean difference = -6.94, 95%CI -10.91 to -2.97, d = 1.15, P = 0.0006). PST was also effective in reducing disability in studies reporting this outcome.

CONCLUSIONS

Our review supports the existing research literature on PST suggesting that it is an effective treatment for older people with MDD. Further study is required to understand long-term outcomes associated with PST and its efficacy when compared to other treatments.

The relationships among perceived discrimination, self-perceptions of aging, and depressive symptoms: a longitudinal examination of age discrimination

OBJECTIVES

This study examined the relationship between changes in perceived discrimination and changes in depressive symptoms among older people. The association between perceived age discrimination and depressive symptoms was also analyzed longitudinally along with tests to determine whether self-perception of aging mediates this association.

METHOD

Data from two waves (2008 and 2012) of the Health and Retirement Study were used. Longitudinal models were tested using a nationally representative sample of 3921 participants who responded to psychosocial questionnaires in both waves and answered questions about perceived everyday discrimination and attributions of discrimination in 2008.

RESULTS

Changes in perceived discrimination was significantly associated with changes in depressive symptoms over time. Perceived age discrimination was significantly related to a change in depressive symptoms over four years and self-perceptions of aging mediated the relationship between perceived age discrimination and depressive symptoms.

CONCLUSION

Findings demonstrate the importance of recognizing perceived discrimination and negative self-perceptions of aging as well as how the negative effects of age discrimination on self-perceptions of aging can be risk factors for the development of depressive symptoms in late life.

Deconstructing Chronic Low Back Pain in the Older Adult: Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part IV: Depression

OBJECTIVE

To present the fourth in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of twelve important contributors to pain and disability in older adults with CLBP. This article focuses on depression.

METHODS

The evaluation and treatment algorithm, a table articulating the rationale for the individual algorithm components, and stepped-care drug recommendations were developed using a modified Delphi approach. The Principal Investigator, a three-member content expert panel, and a nine-member primary care panel were involved in the iterative development of these materials. The algorithm was developed keeping in mind medications and other resources available within Veterans Health Administration (VHA) facilities. As panelists were not exclusive to the VHA, the materials can be applied in both VHA and civilian settings. The illustrative clinical case was taken from one of the contributor's clinical practice.

RESULTS

We present an algorithm and supportive materials to help guide the care of older adults with depression, an important contributor to CLBP. The case illustrates an example of a complex clinical presentation in which depression was an important contributor to symptoms and disability in an older adult with CLBP.

CONCLUSIONS

Depression is common and should be evaluated routinely in the older adult with CLBP so that appropriately targeted treatments can be planned and implemented.

Refining Evidence-Based Treatments for Late-Life Depression

The recent increase in the aging population, specifically in the United States, has raised concerns regarding treatment for mental illness among older adults. Late-life depression (LLD) is a complex condition that has become widespread among the aging population. Despite the availability of behavioral interventions and psychotherapies, few depressed older adults actually receive treatment. In this paper we review the research on refining treatments for LLD. We first identify evidence-based treatments (EBTs) for LLD and the problems associated with efficacy and dissemination, then review approaches to conceptualizing mental illness, specifically concepts related to brain plasticity and the Research Domain Criteria (RDoc). Finally, we introduce ENGAGE as a streamlined treatment for LLD and discuss implications for future research.

Models of care for late-life depression of the medically ill: examples from chronic obstructive pulmonary disease and stroke

Depression worsens most treatment outcomes in medically ill older adults. Chronic medical illnesses weaken and demoralize patients and compromise their ability to adhere to treatments requiring consistency and effort. Acute medical illnesses create a psychosocial storm that finds patients and their ecosystem unprepared. We describe two intervention models that can be used to target and personalize treatment in depressed, chronically, or acutely medically ill older adults. The Personalized Adherence Intervention for Depression and COPD (PID-C) is a model intervention for depressed patients with chronic medical illnesses. It targets patient-specific barriers to treatment engagement and aims to shift the balance in favor of treatment participation. PID-C led to higher remission rates of depression, reduction in depressive symptoms, and reduction in dyspnea-related disability. The addition of problem-solving training enables patients to use resources available to them and hopefully improve their outcomes. Ecosystem-focused therapy (EFT) is a model intervention for depression developing in the context of an acute medical event. It was developed for patients with poststroke depression (PSD) and targets five areas, part of the "psychosocial storm" originating from the patient's sudden disability and the resulting change in the patient's needs and family's life. A preliminary study suggests that EFT is feasible and efficacious in reducing depressive symptoms and signs and disability in PSD.

Moderators of response to cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care

BACKGROUND

Stratified medicine aims to improve clinical and cost-effectiveness by identifying moderators of treatment that indicate differential response to treatment. Cognitive behavioural therapy (CBT) is often offered as a 'next-step' for patients who have not responded to antidepressants, but no research has examined moderators of response to CBT in this population. We aimed, therefore, to identify moderators of response to CBT in treatment resistant depression.

METHODS

We used linear regression to test for interactions between treatment effect and 14 putative moderator variables using data from the CoBalT randomised controlled trial. This trial examined the effectiveness of CBT given in addition to usual care (n=234) compared with usual care alone (n=235) for primary care patients with treatment resistant depression.

RESULTS

Age was the only variable with evidence for effect modification (p Value for interaction term=0.012), with older patients benefiting the most from CBT. We found no evidence of effect modification by any other demographic, life, illness, personality trait, or cognitive variable (p≥0.2).

CONCLUSIONS

Given the largely null findings, a stratified approach that might limit offering CBT is premature; CBT should be offered to all individuals where antidepressant medication has failed.

Cognitive Behavioral Therapies in older adults with depression and cognitive deficits: a systematic review

OBJECTIVES

The objective of this study is to investigate the effectiveness of cognitive behavioral therapies (CBTs) in improving depressive symptoms, disability, and cognition in older adults with depression and cognitive deficits.

DESIGN

It was performed a systematic search for articles published between 1994 and February 2014 in the MEDLINE/Pubmed, PsycINFO, and SCIELO. The studies should have provided information about benefits after CBTs to older adults with depression and cognitive deficits.

RESULTS

Cognitive behavioral therapy focused on problem solving is the main approach studied, having better effectiveness than supportive therapy in randomized clinical trials. Significant improvements in mood and disability were consistent, although evidence of changes in cognitive measures is controversial, less studied, and limited. Nevertheless, improvements in executive functions, processing speed, and changes in patients' perspectives of problem solving skills, such as generating alternatives and decision-making, were described. Also, it would be necessary that future studies more often evaluate cognitive status of depressed elders, as well as cognitive changes after psychotherapy. It should be emphasized that there is a lack of studies in this field, and more approaches in CBTs need to be investigated to this population.

CONCLUSION

Older adults with depression and cognitive deficits can benefit from CBTs. Improvements in mood and disability are more consistent than changes in cognition, which are little studied after CBTs. It is necessary more studies in the field, as well as, to investigate more approaches in CBTs to older adults with depression and cognitive deficits.

Aging and the effects of emotion on cognition: Implications for psychological interventions for depression and anxiety

We review findings from laboratory research on age differences in the effects of emotion on cognition. Particular attention is given to sadness leading to mood congruent memory and to anxiety leading to selective attention bias to threat. While older adults in normal moods show the positivity effect as expected from socio-emotional selectivity theory, older adults whose mood has changed from baseline to sad or anxious show these mood-related cognitive biases. These mood-related biases are a foundational part of the theory underlying cognitive behavior therapy (CBT) and so these laboratory findings suggest ways that CBT may work differently with older adults. Pilot work suggests that the presence or absence of these effects may also predict responsiveness to treatment using CBT.

Problem adaptation therapy for older adults with major depression and cognitive impairment: a randomized clinical trial

IMPORTANCE

Problem adaptation therapy (PATH) is a treatment for older adults with major depression, cognitive impairment (from mild cognitive deficits to moderate dementia), and disability. Antidepressants have limited efficacy in this population and psychosocial interventions are inadequately investigated.

OBJECTIVE

To test the efficacy of 12-week PATH vs supportive therapy for cognitively impaired patients (ST-CI) in reducing depression and disability in 74 older adults with major depression, cognitive impairment, and disability.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial at the Weill Cornell Institute of Geriatric Psychiatry from April 1, 2006, to September 31, 2011. Interventions were administered at the participants' homes. Participants included 74 older individuals (age ≥ 65 years) with major depression and cognitive impairment to the level of moderate dementia. They were recruited through collaborating community agencies of Weill Cornell Institute of Geriatric Psychiatry and were randomly assigned to 12 weekly sessions of PATH or ST-CI (14.8% attrition rate).

INTERVENTIONS

Home-delivered PATH vs home-delivered ST-CI. Problem adaptation therapy integrates a problem-solving approach with compensatory strategies, environmental adaptations, and caregiver participation to improve patients' emotion regulation. Supportive therapy for cognitively impaired patients focuses on expression of affect, understanding, and empathy.

MAIN OUTCOMES AND MEASURES

Mixed-effects models for longitudinal data compared the efficacy of PATH with that of ST-CI in reducing depression (Montgomery-Asberg Depression Rating Scale) and disability (World Health Organization Disability Assessment Schedule II) during 12 weeks of treatment.

RESULTS

Participants in PATH had significantly greater reduction in depression (Cohen d, 0.60; 95% CI, 0.13-1.06; treatment × time, F(1,179) = 8.03; P = .005) and disability (Cohen d, 0.67; 95% CI, 0.20-1.14; treatment × time, F(1,169) = 14.86; P = .001) than ST-CI participants during the 12-week period (primary outcomes). Furthermore, PATH participants had significantly greater depression remission rates than ST-CI participants (37.84% vs 13.51%; χ(2) = 5.74; P = .02; number needed to treat = 4.11) (secondary outcome).

CONCLUSIONS AND RELEVANCE

Problem adaptation therapy was more efficacious than ST-CI in reducing depression and disability. Problem adaptation therapy may provide relief to a large group of depressed and cognitively impaired older adults who have few treatment options.

TRIALS REGISTRATION

Clinicaltrials.gov Identifier: NCT00368940.

Neuroplasticity-based computerized cognitive remediation for treatment-resistant geriatric depression

Executive dysfunction (ED) in geriatric depression (GD) is common, predicts poor clinical outcomes and often persists despite remission of symptoms. Here we develop a neuroplasticity-based computerized cognitive remediation treatment (CCR-GD) to target ED in GD. Our assumption is that remediation of these deficits may modulate the underlying brain network abnormalities shared by executive dysfunction and depression. We compare CCR-GD to a gold standard treatment (escitalopram: 20mgs/12 weeks) in 11 treatment resistant older adults with major depression; and 33 matched historical controls. We find that 91% of participants complete CCR-GD. CCR-GD is equally as effective at reducing depressive symptoms as escitalopram but does so in 4 weeks instead of 12. In addition CCR-GD improves measures of executive function more than the escitalopram. We conclude that CCR-GD may be equally effective as escitalopram in treating GD. In addition, CCR-GD participants showed greater improvement in executive functions than historical controls treated with escitalopram.

Psychotherapies for Late-Life Depression

Late-life depression often occurs in the context of cognitive impairment, medical burden, and disability. For this reason, the assessment of depressed older adults consists of detailed psychiatric history and mental status examination and focuses on their broader clinical context and their ecosystem. This article outlines assessment procedures and the principles of therapies developed to utilize their assets and address limitations imposed by their clinical problems and their behavioral consequences.

Older adults and psychoanalytic treatment: it's about time

It has become increasingly apparent that older adults may not only benefit from psychoanalysis and psychodynamic psychotherapy but may be particularly well suited to such treatment. Clinical evidence to support this is presented, including discussion of the successful psychoanalysis of a woman in her seventies. An overview of the psychoanalytic literature indicates that psychoanalytic beliefs about the feasibility of treating older patients have always been favorable, but have had difficulty gaining traction. The modern psychoanalytic literature is compatible with extra-analytic studies of aging that provide further rationale for the potential usefulness of psychoanalytically oriented interventions in the elderly population.

Pretreatment cortisol levels predict posttreatment outcomes among older adults with depression in cognitive behavioral therapy

Previous studies suggest that individuals with elevated levels of cortisol (the "stress hormone") could be particularly resistant to treatment for depression. However, most of these studies have been conducted in the context of antidepressant medications, and no study has examined pretreatment cortisol levels as a predictor of treatment outcomes among older adults with depression in cognitive-behavioral therapy (CBT), despite the relevance of this population for such a research question. The current study includes 54 older adults with depression who provided salivary cortisol samples at baseline and completed measures of depression at pretreatment and posttreatment, following a 12-week course of CBT. Structural equation modeling results suggest that those with higher daily outputs of cortisol and flatter diurnal slopes were less likely to benefit from CBT-a finding which if replicated could have important implications for clinical practice and future research.