Expressed emotion in family members of depressed older adults

Care Recipient Controlling and Manipulative Behavior and Caregiver Depressive Symptoms: The Role of Race, Caregiver Resentment, and Mutual Communal Behavior

BACKGROUND AND OBJECTIVES

We explored whether relationship quality, as measured by mutual communal behavior, would serve as a buffer against caregiver resentment and, consequently, depressive symptoms when care recipients (CRs) engage in problem behavior (i.e., controlling and manipulative behavior [CMB]). Using the common core model of caregiver distress, we hypothesized that caregiver resentment would explain why caregivers were depressed when their CRs engage in CMB. We predicted that the indirect effect of CRCMB on depressive symptoms via resentment would depend on the strength of the communal bond between the caregiver and CR. Resentment was expected to play a significant role in explaining the association between CRCMB and depressive symptoms for caregivers in less communal relationships, but a small or nonexistent role for those in highly communal relationships. We also investigated whether these effects were different for Black and White caregivers.

RESEARCH DESIGN AND METHODS

Data were obtained from 187 Black and 247 White caregivers from the second Family Relationships in Late Life Project. Before testing our model, we confirmed the measurement equivalence/invariance of the four scales used in this study.

RESULTS

Resentment mediated the association between CRCMB and depressive symptoms. However, the indirect effect was larger among highly communal caregivers. Caregiver race did not moderate the moderated mediation.

DISCUSSION AND IMPLICATIONS

The communal bond between the caregiver and CR does not entirely protect the caregiver from depressive symptoms, particularly among highly communal caregivers. Interventions aimed at improving caregiver outcomes should acknowledge the unique vulnerabilities of caregivers in close relationships.

Emotional suppression, caregiving burden, mastery, coping strategies and mental health in spousal caregivers

OBJECTIVES

The main aim was to explore the multiple mediation effects of personal resources (mastery, engagement and disengagement coping strategies) between caregiving burden and depression in spousal caregivers, based on integrated stress process models. A further aim was to examine whether emotional suppression moderates the relationship between perceived burden and depression.

METHOD

Cross-sectional data were collected in 2010-2011 by structured interviews from a sample of 110 spousal caregivers. Coefficients strategy with bootstrapping tested the strength and significance of the conditional indirect effects of simultaneous multiple mediators; and the conditional effect of burden on depression at different emotional suppression values.

RESULTS

Caregiving burden was indirectly associated with depression, through mastery and disengagement coping, but not through engagement coping. Mastery was negatively associated with depression, while disengagement coping was positively associated with depression. Emotional suppression and functional disability were positively associated with depressive symptoms. A significant burden-by-emotional suppression interaction was found for predicting depressive symptoms.

CONCLUSION

The study supports the conditional indirect effect in which burden can affect depression by reducing the mastery and increasing the disengagement coping simultaneously. The study provides also initial support for the moderating effect of emotional suppression, which can increase the deleterious effects of burden on depression. Researchers and practitioners should be aware of these issues of family care in spousal caregivers.

Expressed emotion and depression in caregivers of older adults with dementia: results from Taiwan

OBJECTIVES

The purpose of this study was to examine the relationship between (1) expressed emotion (EE) and characteristics of Taiwanese dementia patients and their family caregivers and (2) EE and depressed mood, burden, and perception of health in Taiwanese caregivers of elderly persons with dementia.

METHODS

Sixty-five primary caregivers of elderly persons with mild to severe dementia were recruited from institutions in Taiwan and they completed four standardized questionnaires: Level of Expressed Emotion (LEE) scale, Center for Epidemiologic Studies Depression (CES-D) scale, Zarit Burden Inventory (ZBI), and General Health Perceptions subscale of the Medical Outcomes Study Short Form 36 Health Survey (MOS SF-36).

RESULTS

EE was positively associated with caregiver depression (r = .543; p < .001) and burden (r = .532; p < .001), and negatively associated with caregivers' perceived health (r = -.316; p = .010). The higher the caregivers' depression and burden, the greater was their EE and the lower the caregivers' perceived health, the higher was their EE. EE was negatively associated with caregiver education (r = -.279; p = .024) and income (r = -.261; p = .036). The lower the caregivers' education and income, the higher was their EE.

CONCLUSION

The significant relationship between EE and caregivers' mood and perceived burden suggests that caregivers with elevated mood or burden may put persons with dementia at greater risk for toxic, negative interactions from them. Although this study's design precludes attributing directionality, more depressed caregivers are at a greater risk of higher EE which may affect care of their elderly demented family members. Additional research is warranted with a larger sample size and/or a longitudinal design.

Caregiver attributions for late-life depression and their associations with caregiver burden

Late-life depression (LLD) has detrimental effects on family caregivers that may be compounded when caregivers believe that depressive behaviors are volitional or within the patient's capacity to control. In this study we examined three person-centered caregiver attributions that place responsibility for LLD on the patient (i.e., character, controllability, and intention), and the impact of such attributions on levels of general caregiver burden and burden specific to patient depressive symptoms. Participants were 212 spouses and adult children of older adults enrolled in a depression treatment study. Over one third of caregivers endorsed character attributions, which significantly predicted greater levels of both general and depression-specific burden. Intention attributions were significantly associated with general burden, but not depression-specific burden. Contrary to our expectation, controllability attributions did not predict either type of burden. Our findings suggest that the assessment of family caregiver attributions for LLD may be useful in identifying caregivers at risk for burden and subsequent health effects, as well as those who may need education and support to provide effective care to a vulnerable population of older adults.

Mechanisms of change in interpersonal therapy (IPT)

Although interpersonal therapy (IPT) has demonstrated efficacy for mood and other disorders, little is known about how IPT works. We present interpersonal change mechanisms that we hypothesize account for symptom change in IPT. Integrating relational theory and insights based on research findings regarding stress, social support, and illness, IPT highlights contextual factors thought to precipitate and maintain psychiatric disorders. It frames therapy around a central interpersonal problem in the patient's life, a current crisis or relational predicament that is disrupting social support and increasing interpersonal stress. By mobilizing and working collaboratively with the patient to resolve this problem, IPT seeks to activate several interpersonal change mechanisms. These include: 1) enhancing social support, 2) decreasing interpersonal stress, 3) facilitating emotional processing, and 4) improving interpersonal skills. We hope that articulating these mechanisms will help therapists to formulate cases and better maintain focus within an IPT framework. Here we propose interpersonal mechanisms that might explain how IPT's interpersonal focus leads to symptom change. Future work needs to specify and test candidate mediators in clinical trials. We anticipate that pursuing this more systematic strategy will lead to important refinements and improvements in IPT and enhance its application in a range of clinical populations.

Behandlungsverlauf bei depressiven Störungen

Zusammenfassung. Theoretischer Hintergrund: Derzeit ist unklar, auf welche Faktoren frühe Symptomveränderungen während einer Psychotherapie zurückzuführen sind. Fragestellung: Die vorliegende Studie untersucht verschiedene intrapsychische und interpersonelle Prädiktoren des Patienten und seines Partners auf den Symptomverlauf während einer Depressionsbehandlung. Methode: Die Analysen wurden mittels hierarchisch-linearen Modellen durchgeführt und basieren auf Daten von 60 Paaren, die im Rahmen einer kontrolliert-randomisierten Studie Psychotherapie in Anspruch nahmen. Resultate: Die Ergebnisse zeigen, dass bei den intrapsychischen Variablen vor allem Depressionsdauer, individuelles Coping und allgemeine Lebenszufriedenheit und bei den interpersonellen Variablen die soziale Unterstützung und das negative Verhalten im Konfliktgespräch den Symptomverlauf während der Therapie vorhersagen können. Das Hinzufügen von interpersonellen zu den intrapsychischen Variablen erhöht die Varianzaufklärung von 30% auf 50%. Schlussfolgerung: Interpersonelle Probleme sollten vermehrt in die Therapieplanung einbezogen werden, da sie einen wichtigen Einfluss auf den Symptomverlauf haben, jedoch bisher oft vernachlässigt wurden.

[Interpersonal psychotherapy in the treatment of depression in older adults]

In this paper, the authors explain why Interpersonal Psychotherapy (PTI) is a particularly apt psychosocial treatment for depression in older adults ; they discuss issues that can emerge in the process of implementing PTI with older adults ; review the research conducted on older adults treated with PTI, and present two case summaries to illustrate the application of PTI to this population. PTI suits depressed older adults especially well because its foci match many of the issues that older adults face and that for some can trigger depression. In addition, PTI is a good fit for older adults because of its psychoeducational component, use of the medical paradigm, and collaborative, problem-focused, time-limited nature. PTI necessitates very little adaptation for older adults but should be informed by knowledge of gerontology and geropsychology. Some research and their clinical practice suggest that acute (i.e., weekly) PTI reduces depression symptoms in older adults but more research needs to be conducted. Interpersonal Counseling, a modified version of PTI, has been found to be effective in the treatment of depressive symptoms in older adults with medical problems. Continuation/Maintenance (i.e., monthly) PTI has been shown to be beneficial to some but not all older adults with major depression. Two cases are described that illustrate the implementation of PTI. One case focuses on interpersonal disputes and the other focuses on role transition.

Expressed emotion and relapse of psychopathology

Expressed emotion (EE) is a measure of the family environment that predicts worse clinical outcomes for patients with a range of disorders. This article describes the assessment of EE and the evidence linking EE to clinical relapse in patients with psychopathology. This is followed by consideration of the possible explanatory models that might account for the EE-relapse link and a review of the evidence suggesting that EE may play a causal role in the relapse process. The results of studies describing the effect of EE on patients, as well as cross-cultural aspects of the construct, are highlighted. Finally, the possibility that high levels of EE may stress patients by perturbing activity in neural circuits that underlie psychopathology is considered and new directions for EE research are outlined.

Expanding the usefulness of Interpersonal Psychotherapy (IPT) for depressed elders with co-morbid cognitive impairment

BACKGROUND

The utility of Interpersonal Psychotherapy (IPT) has been documented as a maintenance treatment for late life depression as mono-therapy or in combination with antidepressant medication. Late life depression, however, is frequently co-morbid with declining memory or other cognitive abilities such that the usefulness of one-to-one psychotherapies is called into question for this subgroup. Additionally, concerned caregivers often accompany these patients to request help and their role in the presenting symptoms and in their potential resolution must also be addressed by any successful psychotherapy in this population.

OBJECTIVES

To explore ways in which IPT could be modified to better serve the particular presentation and needs of depressed elders with cognitive decline along with their caregivers.

METHODS

Various modifications of traditional IPT techniques were experimented with and refined in our collaborative late life research center using regular group supervision and feedback from patients and their caregivers.

RESULTS

A key component of these modifications involves the integration of the caregiver into the treatment process in flexible ways that recognize their own role transition that is taking place simultaneously with that of the patient's role transition from a greater to a lesser functional state. Other techniques for resolving role conflicts, particularly those directly involving care issues for the patient, are also delineated. These modifications are collectively referred to as IPT-CI for cognitive impairment. A brief case vignette is presented.

CONCLUSION

The modifications outlined in this communication reflect an evolving work-in-progress and serve as a framework for the future development of a manual of guidelines to assist healthcare personnel to optimally treat this population and their caregivers.