Integrated Management of Depression in the Elderly

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These drugs have undesirable effects, especially among the older population, with their use often being continued indefinitely and unnecessarily. It would therefore seem reasonable to test new therapeutic modalities which, a priori, would have fewer adverse effects and, most likely, a lower impact on health expenditure. Among the reasons why exercise could improve depression is the belief that, on the one hand, it could act as a distraction from negative thoughts and that, on the other, it is possibly important to master new skills.

In addition, social contact could form part of this mechanism. Recent studies suggest that exercise stimulates the growth of new nerve cells and releases proteins, e. Even so, a significant degree of uncertainty surrounds the effectiveness of exercise on depression [ 10 , 11 ], mainly due to methodological considerations [ 12 ]. It should be stressed that older adults tend to be underrepresented in clinical trials in which both pharmacological and non-pharmacological measures for depressive disorders are assessed.

Accordingly, and because these disorders present with special characteristics and a wide degree of clinical polymorphism among the elderly difficulty in recognising the symptoms of depression, frequent somatic complaints, etc. This population group often presents with co-morbidities and, as a result, may be undergoing poly-pharmacy treatments. It is therefore important to demonstrate the effectiveness of non-pharmacological measures, such as physical exercise, in the case of depressive disorders.

The National Institute for Clinical Excellence NICE [ 13 ] conducted a systematic review on the likelihood of remission, reduction of symptoms and adherence to treatment among patients with depression who did and those who did not do exercise, and the different treatments available pharmacological, psychotherapeutic, etc.

Although the data which compared physical activity to antidepressant drugs indicated that there were no significant differences, the confidence intervals used by the studies were very wide, with the result that there was insufficient evidence to arrive at a conclusion. Overall, however, the studies suggested a benefit for physical activity -and more specifically for group-based physical activity- in the treatment of minor depression and mild-to-moderate major depression.

In addition, physical activity has the advantage of contributing other health benefits, beyond a simple improvement in symptoms of depression [ 14 ]. The Guideline of the Institute for Clinical Systems Improvement [ 15 ] considers that physical activity could be a useful tool for ameliorating the symptoms of major depression. Another systematic review [ 16 ], in which only three studies with patients suffering from major depression were included, reported that physical exercise programmes significantly reduced the symptoms of depression, though the conclusions were limited by the heterogeneity and methodological shortcomings of the three studies evaluated.

A Cochrane review [ 17 ] analysed the relationship between physical exercise and depression. An attempt was made to answer the question of whether exercise might be more effective than drugs, psychological therapy or therapeutic abstention in reducing symptoms of depression. To this end, a total of 39 clinical trials of widely differing quality were jointly analysed. The results showed that: as compared to no treatment or a control group, exercise may have a moderately beneficial effect on symptoms of depression; and as compared to pharmacological treatment or psychological therapy, no differences were in evidence conclusions based on very few studies.

This review was an update of a previous review [ 22 ] which suggested that exercise could reduce depressive symptoms. New research studies are needed to further detail the type of exercise that could be beneficial for older adults with depression, analyse whether such exercise could be a therapeutic alternative to antidepressants or psychological treatment, and determine the related risks and costs.

Prescribing physical exercise in the consulting room, as if it was a remedy for chronic disease, calls for knowledge about which exercise is the most suitable to the task, and the duration, frequency and intensity required. Available evidence suggests that exercise may benefit depressed patients and be comparable to antidepressant treatment [ 23 ]. It seems reasonable, therefore, for exercise to be recommended to people with depressive symptoms and those who meet diagnostic criteria for depression [ 24 ].

As yet however, the best way of implementing this recommendation in clinical practice is not known Sonnott, It has not been possible to provide patients with accurate information about how effective exercise can be, the relative benefits of aerobic, resistance or combined exercise, whether it is better to do such exercise individually or in a group, and the optimal duration of a session. Hence, to obtain a more accurate idea of the effect of exercise on depression among older adults, there is a need for new trials based on scientifically solid methodology, an adequate number of participants, and a sufficiently long follow-up.

This will take the form of a randomised clinical trial Fig. We intend to use the ICD criteria, which require a minimum of 4 out of 10 symptoms, including at least 2 of the following 3, namely, depressed mood, anhedonia and loss of energy. The 10 symptoms include: depressed mood; loss of interest or pleasure; loss of or increase in weight; insomnia or hypersomnia; agitation or slowing of movements; fatigue or loss of energy; feelings of inadequacy or guilt; poor concentration; poor self-esteem; and recurrent thoughts of death.

The duration of the episode must be a minimum of two weeks. The inclusion criteria will be the following: subjects with the above criteria of mild or moderate depressive episode belonging to the participating health centres. Participants will be consecutively selected at 20 family medicine clinics belonging to 3 health centres. The trial will be deemed to have ended in the following circumstances: completion of the observation period; patient withdrawal; or withdrawal of informed consent. Patients will be included in the intervention group physical exercise or the control group antidepressant therapy by simple randomisation generated by a computer software programme.

The randomisation sequence will be concealed throughout the recruitment period. With respect to antidepressant drug therapy, the NICE guideline holds to the general view that there is little difference among the various antidepressants in terms of efficacy. The cost-effectiveness analysis will take into account the direct costs of both the exercise and antidepressant-treatment programmes, including staff expenses, medication, follow-up visits and monitoring.

An intention-to-treat analysis will be used to calculate the following parameters with their corresponding confidence intervals: absolute increase in benefit; relative increase in benefit; and number needed to treat. The trend in the parameters of interest in the two groups will be described and compared comparison of proportions and means in independent groups.

An analysis by subgroup will be performed according to different variables, including sex, intensity of physical activity, adherence to recommendations, etc. Finally, the effect of the intervention in terms of reducing depressive symptoms will be estimated using a logistic regression model, with statistical adjustment between possible confounding and interaction terms.

The model will be interpreted on the basis of the statistical significance of the coefficients and the value of the odds ratios of the explanatory variables. The results could be useful when it comes to finding a better and more effective approach to a health problem that is prevalent among older adults, and reducing the related disease burden on society as a whole. In terms of the number of patients and duration of follow-up, the proposed clinical trial is a project which easily surpasses the few studies on this subject that have been previously conducted on the elderly. Its aim is to provide scientific evidence on a therapeutic resource -physical exercise- which has undeniable health benefits and can be applied to certain health problems, such as depressive disorders, which are of great magnitude and considerable socio-economic relevance, and have a significant impact on the quality of life of older adults.

The project will make it possible to establish the type of specific physical exercise recommendations that are capable of reducing depressive symptoms among older people who meet clinical criteria for depressive disorders. We will evaluate the mechanism of action, or pathways, by which treatment gains are obtained. Given that behavioral activation represents conceptually the key active ingredient of the proposed intervention, we plan to evaluate its mediational effect.

We will also evaluate whether the intervention has a differential treatment effect based on a study participant's gender, age, and living arrangement alone or with others. Given that previous research suggests that participant characteristics may moderate depressive symptoms and treatment outcomes, these exploratory analyses will provide insight as to whether this particular treatment benefits some groups more than others.

Participants enrolled in the trial were recruited from two sources, a program providing short-term in-home support for individuals who are medically comprised referred to as the In-Home Support Program; IHSP or the community at-large. IHSP provides homebound elders assistance regaining independence after illness or hospitalization through home health and homemaker services, home delivered meals, transportation, or companions but does not typically involve formal and systematic depression screening.

Recruitment from IHSP involved integrating depression screening in the assessment process of participants in the program. Recruitment to the community at-large involved print media, presentations to community groups, and print media. Other criteria are practical and include having a home telephone and planning to live in the area for 8 months.

Individuals are not eligible with serious mental illness histories, life-limiting illnesses, involvement in another clinical depression trial, or if living in assisted living or nursing home facilities. Individuals receiving anti-depressant medications or other mental health treatments are eligible.

As individuals from IHSP may be more medically and functionally compromised than those enrolled from the community at-large, we used a stratified randomized design to assure equivalence between groups along this dimension. Permuted block randomization with each stratum IHSP versus other recruitment source to control for possible changes over time in subject mix was employed. The blocking number was developed by the trial senior statistician and was not disclosed to the investigative team.

In selecting measures for this study, we chose those with known reliability and validity; sensitivity to change that is expected to occur as a consequence of intervention; relevance to and wide usage in depression research, and acceptability by the target population. Our primary outcome measure is the Patient Health Questionnaire PHQ-9 , a brief, 9-item self-report measure specifically developed as an assessment tool for the diagnosis of depression in primary care.

In addition to its psychometric soundness and demonstrated reliability, validity, sensitivity and specificity, the measure is also widely used in community-based settings and research trials. It yields a depression severity score 0 to 27 and a diagnostic category minimal to none, mild, moderate, moderate severe, severe mapping on to the 9 DSM-IV. Administration involves initially asking two items loss of interest; feeling upset, distressed or depressed.

Individuals reporting that either symptom occurs more than half the time over past two weeks are administered 7 other items [ 29 ]. Thus, two scores can be derived: symptom severity and categorical diagnosis. We also consider as a complementary secondary outcome a change in categorical diagnoses in which we seek to determine the number of persons who shift to none to minimal diagnostic category at 4 months.

A categorical approach provides a clinical interpretation of treatment efficacy and also whether the intervention addresses certain syndromes better than others e. While the PHQ-9 is a self-report measure, self-report has been shown to be highly associated with clinical determinations. Also, the measure has been shown to be effective when administered in person or via telephone. The secondary outcome measures for the trial are presented in Table 1.

Up to 10 one hour sessions occur over 4 months. A home visit can be replaced with check-in telephone calls once steady progress is demonstrated. Sessions integrate five treatment components previously shown to be effective and modified in BTB to resonate with cultural preferences: case management, referral and linkage, depression education, stress reduction techniques, and behavioral activation.

Table 2 Critical is tailoring to participants' depression knowledge level, care management needs, and self-identified goals and behavioral activation plans. Initial sessions occur weekly and then bi-weekly. In session one, building rapport and a therapeutic relationship begins; also, interventionists assess care management needs and begin education about depressive symptoms making connections between behavior and mood.

Explained is that with depression, activities once pleasurable are often stopped which may heighten symptomatology. Likewise, previously pleasurable activities may no longer be pleasurable. Interventionists also discuss sharing depressive symptoms with physicians if medication may be necessary or for future consideration and strategies to use when physicians are of a different race.

Interventionists introduce deep breathing as a basic stress reduction technique and help participants identify stressful points in the day for its use. Other stress reduction techniques counting, music are introduced to provide additional tools. In sessions , interventionists continue addressing care management needs and introduce behavioral activation. Interventionists review daily routines and help participants select a goal and specific activity to add pleasure and personal satisfaction.

Active problem solving and motivational interviewing techniques help participants achieve identified activity goals. Potential barriers in carrying out activities are identified and solutions derived which may also require care management arranging transportation to engage in desired activities.


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Sessions involve reinforcement of activity engagement, identification of new activity goals and specific steps to achieve them. In sessions , interventionists review and reinforce all techniques, help participants identify and use behavioral activation strategies, and obtain closure. Approximately sessions are devoted to behavioral activation.

The control group does not receive any study-related contact following the baseline interview. After completion of the 4-month reassessment, participants in this group receive the entire BTB intervention as delivered to the initial treatment group. We based our sample size calculation on the following assumptions: a one primary outcome severity of depressive symptoms ; b treatment effect sizes reported in previously published intervention studies testing one or more components of the intervention we employ in BTB effect sizes range from.

A larger effect size may not be plausible, whereas a smaller effect size brings us at or near levels where the study could have statistical but not clinical significance. In order for this brief, targeted intervention to be worth implementing in a service context, it must yield more than trivial effects.

Depression in older adults | Royal College of Psychiatrists

Since our planned analyses are primarily analysis of covariance, we calculated the power of a two-sample t-test. Because we will use analysis of covariance to adjust for baseline values, we expect to have adequate precision and power. We planned to recruit an additional 20 participants for a total of participants 96 per group. To obtain the necessary sample size of , we needed to enroll study participants.

Although we did not conduct power calculations for exploratory aims, these analyses are important in order to refine research questions and hypotheses worthy of future consideration, refinement of the intervention and its dissemination. The focus of the primary analysis is to examine the effect of the intervention on symptom severity based on the principle of "intention to treat. This approach tests the effects of the intervention without accounting for the extent to which study participants actually receive the intervention.

It effectively penalizes the intervention if subjects are not willing to receive it or if subjects receive different doses or exposure to treatment. We will calculate adjusted mean differences in treatment effects on the outcome measure at 4-months using analysis of covariance. We will include as covariates the baseline value of the outcome measure and the stratification variable recruitment source.

Other background characteristics may also be used as covariates if large or statistically significant differences between initial treatment and wait-list control group participants are found for those variables in analyses conducted prior to any efficacy analyses. Prior to conducting the ANCOVA, we will test the normality assumption for the dependent measure by examining the distribution of the residuals. If the residual distribution is skewed, we will use a transformation of the data.

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For purposes of reporting results, we will also compute proportions improved. We will use two definitions of improvement: any reduction in PHQ-9; a reduction sufficient to move the patient at least one severity category lower. Note that we do not have to worry about the no symptom at baseline group in this definition, as that group is not eligible. We will also examine clinical significance by conducting subsidiary analyses that examine the proportion of individuals in treatment compared to controls who change diagnostic categories.

This is for reporting purposes and we are not powering for these alternative endpoints. As to our second aim, we seek to evaluate whether participants in the initial treatment group maintain reduced symptom presentation from 4 to 8 months. We view retention as a one-sided concept such that any beneficial effect of the intervention at four months is improved or at least maintained at 8 months.

Lack of retention is then considered a non-trivial loss of benefit. In the language of clinical treatment trials, this is a "clinical equivalence" or "non-inferiority" hypothesis. Thus, our analyses for our second aim will focus on estimating the amount of 4-month benefit that is retained at 8 months for the treatment group only. We will use confidence intervals in reporting results in order to understand how much loss of benefit is consistent with the data we obtain.

For exploratory aims, we seek to evaluate the mediational role of behavioral activation. We will use separate regressions in which the first regression will evaluate the relationship between 4 month values of the behavioral activation scale the mediator and symptom severity as measured by the PHQ-9 at 4 months.

The second regression will evaluate the relationship between group assignment the independent predictor variable and symptom severity at 4-months PHQ-9, the criterion. The third regression will evaluate the relationship of treatment assignment predictor to PHQ-9 severity scores criterion after entering behavioral activation values mediator.

To evaluate the strength of the mediation effects, we will compute the ratio of the unstandardized betas for treatment assignment beta from regression III divided by beta from regression II with values less than 1. We will repeat these analyses using 8-month values of the PHQ To evaluate differential treatment effects at 4-months, we will use a similar analytic strategy as for the main effect model. ANCOVAs will be used in which the covariates will be the baseline value and specific participant characteristic e. It may give you thoughts of suicide. Seeing a specialist for depression. Although most people get better at home with these treatments, some people do not.

That does not mean that people think you are 'mad'. If you are depressed, you may find it difficult to remember some of the details of how it all began. It can also help to write down your ideas before the interview. Going into hospital If you are very unwell - perhaps unable to eat or drink, or have tried to kill yourself - you may need the safety of a hospital. Staying well. Nobody wants their depression to come back again. There's a chance of the depression returning if you stop taking your tablets too soon.

If your general health is good and this is your first depression, you will probably need to stay on the tablets for 6 to 12 months. If you have already had depression several times, your doctor may recommend that you stay on an antidepressant for longer. Talking treatments, like Cognitive Behavioural Therapy, can also help to prevent depression coming back. Do go through the section on 'self-help' above. These things will all help you to stay well - and to feel that you have some control over what is happening.

How can friends and relatives help someone with depression? You may be the first person to notice the depression. Encourage them to get help. Tell them that depression is quite common, it can be treated and that they will get better. They may need to be reassured that they are not "going mad". You can suggest that they see their GP - and offer to go with them. People with depression get tired easily. Try to offer some practical help, like shopping or cleaning for them. They may need reminding to eat properly. Don't force them to talk.

Just being with someone is often helpful. In fact, people will often dig their heels in if they feel they are being put under too much pressure. It may be more acceptable for you to offer to go with them to something they want to do - a lunch club, a day centre, library or interest group.

Integrated Management of Depression in the Elderly

Be patient. Depression can make someone constantly ask for reassurance or become convinced that they've got something physically wrong with them. It's often because they are frightened or don't understand what is happening to them. Reassure them as much as you can and try to spend time listening. You may need to reassure them that they are not "losing their mind". Don't be embarrassed to ask if they have felt suicidal.

Most people who feel like this are just relieved when someone asks about it. Talking about it will help. You can become exhausted while caring for someone with depression - and then it is important to ask for help yourself. They are also there for you to talk to. They may put pressure on you and say that how they feel is all to do with where they live. But things are not usually that simple. People who move when they are depressed may regret it once they are better.

Integrated Management of Depression in the Elderly

Remember that social services may be able to help with self-care, meals and finances. Don't judge and do be supportive - depression is an illness which can be helped. Further help. The scheme is endorsed by health professionals, including the Royal College of Psychiatrists, and is supported by public libraries. Age UK Tel: Gives support to families by linking them through membership and provides information on Alzheimer's Disease and dementia.

Aware : your supporting light through depression Ireland Helpline: Assists and supports those suffering from depression and their families in Ireland. A helpline is available as well as support groups, lectures, and current research on depression. Offers a service of counselling, advice and opportunities for social contact to all bereaved people.


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Information on the grieving process, and how to help children grieve are included. Information, support and understanding for people who suffer with depression, and for relatives who want to help. Self-help groups, information, and raising awareness for depression. In: The Cochrane Library, Issue 4,