Assessment and Psychological Treatment of Depression in Older Adults with Terminal or Life-Threatening Illness

Depression decreases the quality of life and hinders efforts to palliate symptoms of adults with terminal or life-threatening illness. Nevertheless, depression often may go undetected and untreated in palliative care and hospice settings due to a number of factors, including the overlap of depressive symptoms with those of serious medical illness and concern that frail elderly patients cannot tolerate psychotherapy or antidepressant treatment. In this paper we review the available research regarding assessment and treatment of depression in older adults with terminal or life-threatening illness, focusing on patients who are seen in palliative care, cancer treatment, or hospice settings. Although the prevalence of depression is relatively high in these settings in mixed-age adult samples, studies focused exclusively on older adults are rare and there appear to be no randomized controlled trials of psychotherapy conducted to date that specifically address their needs. There are, however, promising psychological approaches featured in case reports and pilot studies that are consistent with empirically supported therapies for the general treatment of depression in older adults. Based on these preliminary findings and reports, we offer tentative recommendations for the assessment and treatment of depression in terminally ill older adults. We conclude that controlled research on psychotherapy for late-life depression is both feasible and urgently needed in palliative care, cancer care, and hospice settings.     

Training Psychologists for Service Delivery in Long-Term Care Settings

Population changes have resulted in a growing number of older individuals in long-term care settings, and an impetus for training professionals competent to meet their specialized needs. Working in the environment of long-term care requires the professional to be attuned to the unique needs of the patients and staff. Specific tasks, such as psychological assessment, competency determinations, work within the structure of an interdisciplinary team, and staff development, are reviewed here in relation to work in this setting. Guidelines for training at the various levels, along with resources are also discussed.     

Providing Interdisciplinary Geriatric Team Care: What Does It Really Take?

We concur with Speer and Schneider's arguments (2003 ; this issue) that more psychologists should offer mental health services to older adults and that the primary care system is a good focus of such efforts. Three issues deserve more prominence in their review. First, their argument that older adults are averse to mental health services seems incorrect, given research indicating that older adults prefer psychotherapy to medication for treatment of depression. Second, psychologists working in primary care need to be aware of new Current Procedural Terminology (CPT) codes that allow documentation of psychological work in medical settings. Third, Speer and Schneider allude to interdisciplinary team functioning, but provide little information about models of team care or issues in developing a well-functioning interdisciplinary team; this commentary expands on those topics.     

Identification of the palliative phase in people with dementia: a variety of opinions between healthcare professionals

Background

People with dementia can benefit from a palliative care approach. Recommendations, such as those of the EAPC have been proposed to strengthen the provision of palliative care for this group of patients. Yet, it remains challenging for professionals to identify when a person with dementia is in need of palliative care. The objective of this study therefore was to explore when professionals in long-term care settings consider a person with dementia in need of palliative care.

Methods

Teams with in total 84 professionals working in 13 long-term care settings from 6 countries (France, Germany, Italy, Norway, Poland and the Netherlands) received a case-vignette concerning a person with dementia recently admitted to a nursing home. Teams were asked to discuss when they considered people with dementia eligible for palliative care. The constant comparative method was used to analyse their answers.

Results

Three different time points in the disease trajectory when people with dementia were considered to be eligible for palliative care were extracted: (1) early in the disease trajectory; (2) when signs and symptoms of advanced dementia are present; and (3) from the time point that curative treatment of co-morbidities is futile. Yet, none of these time points was uniformly considered by the professional teams across Europe. In some cases, professionals working in the same nursing home didn’t even reach consensus when considering persons with dementia eligible for palliative care.

Conclusion

The results of the study identified that professionals across Europe have different opinions regarding the time point when to consider a person with dementia in need of palliative care.

     

Alcohol Assessment in Psychiatric Patients

Alcohol use disorders in persons with co-occurring psychiatric disorders are associated with high rates of psy-chosocial instability and poorer treatment outcomes. Thus, assessment of alcohol use and abuse should become an integral part of psychiatric care. Because setf-report-based measures are frequently used, issues of reliability and validity in this population should be critically examined. The purpose of this article is to review and critique the existing empirical literature that has evaluated the psychometric integrity of self- report-based measures in psychiatric settings, and to outline a research agenda that promises to enhance the accuracy of alcohol assessment by persons receiving psychiatric treatment.     

Depression in Long-Term Care: Contrasting a Disease Model with Attention to Environmental Impact

The preceding review of depression in long-term care (LTC settings recognizes the prevalence of depression in LTC, addresses problems in assessment of depression, and examines empirical literature on the effectiveness of psychotherapy for depression. This commentary expands on the preceding review by focusing on a theoretical understanding of depression and how that understanding can inform treatment recommendations. The basic argument presented is that psychologists could best serve older adults in LTC settings by extending beyond traditional approaches to treatment of individuals who are depressed; psychologists can become good observers of the relationship of environmental factors in LTC to the internal emotional experience of depression, and then help to serve as change agents by collaborating in designing and implementing change in LTC environments. Such a radical shift could improve the quality of life for LTC residents. It also offers the possibility of defining theoretical linkages among external environmental variables, cognitive understanding of them, and emotional experience that could inform depression theory generally.     

Differences in clinical characteristics between patients assessed for NHS specialist psychotherapy and primary care counselling

Objectives . Although several studies have described patient populations in primary care counselling settings and NHS (National Health Service) specialist psychotherapy settings, there is a paucity of studies specifically comparing differences in clinical characteristics between the two groups of patients. The aim of this study is to ascertain if specialist psychotherapy referrals represent a more challenging client group than primary care counselling patients. Design . We compare the socio‐demographic features and severity of presentation in the symptomatic, interpersonal problems and global adjustment dimensions of a sample of patients (N=384) assessed by a primary care counselling service located in North London and a sample of patients (N=853) assessed in eight NHS psychotherapy centres located within urban settings in England. Methods . Both the groups completed the Brief Symptom Inventory, the Inventory of Interpersonal Problems and Clinical Outcomes in Routine Evaluation Outcome Measure. Results . Patients referred for specialist psychotherapy services were more dysfunctional than those referred for primary care counselling. The linear function constructed to discriminate the groups showed that a combination of more psychotic symptoms, social inhibitions and higher risk of self‐harm effectively identified those referred to psychotherapy services, while patients exhibiting greater levels of somatic and anxiety symptoms and non‐assertiveness were more likely to be seen in primary care settings. However, similarities between the two samples were also marked, as shown by the overlap in the distribution of clinical outcomes in routine evaluation clinical scores in the two samples. Conclusions . The findings are discussed in terms of their implications for policy and service delivery of these two types of psychological therapy services.     

Differential efficacy of group and individual/couple psychotherapy with infertile patients

BACKGROUND: The diagnosis of infertility and concurrent medical treatment may inflict an array of negative emotional symptoms in infertile persons. Evidence for the positive effects of psychotherapy on negative affect and also possible influence on conception rates has been discussed in several studies. METHOD: Meta-analyses were conducted in order to evaluate the efficacy of group and individual/couple therapies on (i) the reduction of negative emotional symptoms, and (ii) the possible promotion of pregnancy. RESULTS: Group and individual/couple psychotherapy led to a decrease in feelings of anxiety. Upon termination of psychotherapy, a reduction of depressive symptoms in patients was greater after 6 months. Psychotherapy accompanying IVF treatment yielded similar conception success rates to psychological interventions administered to patients not in specific medical care. CONCLUSION: Results are suggestive of positive effects of psychotherapy for infertile patients. However, these results must be viewed with caution due to methodological and informational bias within the studies analysed.     

Psychologists in Long-Term Care: Overview of Practice and Public Policy: Introduction to the Special Series

With the overall aging of the population and the concomitant need for the provision of mental health care for older adults, professional psychology in long-term care has come of age. Psychologists are now increasingly practicing in such traditional long-term care settings as nursing homes and in less traditional ones such as rehabilitation units, day centers, partial hospitaliza-tion programs, and hospices. The practice of psychology in long-term care is strongly influenced by public policy issues relating to Medicare, such as conditions of reimbursement, the rise of managed Medicare, and the continued disparity between payment for mental health and medical diagnoses. Ceropsychologists must be flexible in the form of their healthcare delivery to continue to provide quality services. The following articles in this special section on long-term care summarize the research on assessment and interventions for long-term care patients, outline the training opportunities available, and provide a decision-making framework for the common professional ethical/legal issues encountered in long-term care settings.     

Bibliotherapy as an adjunct to psychotherapy for depression in older adults

Bibliotherapy, reading a self-help book for the treatment of psychological problems, has been shown to be effective as a "stand-alone" treatment for depression. Many practitioners recommend self-help books as an adjunct to treatment. This article offers some guidelines for the use of bibliotherapy as an adjunct to individual psychotherapy with depressed older adults. Two clinical cases demonstrate how bibliotherapy can be used effectively in conjunction with individual psychotherapy.     

Assessment and treatment of persistent pain in persons with cognitive and communicative impairment

Pain management is a challenge when working with persons who have cognitive impairment that affects their ability to understand and communicate. This article focuses on pain assessment and treatment in persons who have dementia, but the challenges and principles are relevant to the spectrum of cognitive impairment. Fundamental principles guiding pain assessment and treatment in this population are (1) that behavioral disturbance is the result of an unmet need that causes discomfort, (2) that the behavioral disturbances that result from the unmet need of uncontrolled pain may be identical to those caused by other unmet needs (e.g., thirst, needing to toilet, understimulation, overstimulation, depression, psychosis, uncomfortable clothing), and therefore (3) that any pain treatment protocol for this population must target discomfort behaviors in general and then attempt to determine their causes. Pain assessment and treatment approaches based on these principles are outlined, and then two cases are presented to illustrate the application of these approaches.     

Depression in Long-Term Care

The assessment and treatment of depression in long-term care (LTC) settings poses unique challenges to both clinicians and researchers. In this review we discuss the variety of forms depression can take among LTC residents and the influence the LTC environment can play on the development and maintenance of depression. We describe instruments that can be used to assess depressive symptoms, along with their strengths and liabilities. Additionally, we summarize treatment approaches, with an emphasis on the relatively limited number of empirically informed interventions. Throughout, we describe modifications that may improve the accuracy of assessment and the effectiveness of psychological treatments. Depression, while common among LTC residents, appears amenable to psychological intervention, although the field is far from identifying empirically supported treatments in the LTC setting.     

Therapeutic communication training in long-term care institutions: recommendations for future research

Objective

The purpose of this review is to critique contemporary experimental research and to recommend future directions for research interventions on nursing aides’ therapeutic communication with older adults who have cognitive impairment and/or dementia in institutional long-term care settings.

Methods

This literature review covers 13 journal articles (1999–2006) and focuses on the strengths and weaknesses of experimental research interventions to improve nursing aides’ therapeutic communication with older adults who have cognitive impairment and/or dementia in long-term care settings.

Results

Based on this review, recommendations for improved experimental designs include a minimum of two groups with one being a control and randomization of subjects at the care unit level, an average 3–5 h of total training, a minimum of a 6-month total evaluation period, and objective outcomes relevant to both nursing aides and residents. Findings from studies in this review indicate that the following therapeutic communication techniques can be taught and can benefit staffs and older adults’ quality of life: verbal and non-verbal communication behaviors including open-ended questions, positive statements, eye contact, affective touch, and smiling.

Conclusions

Some evidence exists to support that nursing aides can improve their therapeutic communication during care.

Practice Implications

Nursing aides need not only more training in therapeutic communication but also ongoing, dedicated supervision in psychosocial aspects of care.     

Improving outcomes for poorly responding clients: the use of clinical support tools and feedback to clients

We present two methods of enhancing outcome and preventing treatment failure in psychotherapy. The first involves providing therapists with a decision tree and several assessment measures for clients who are not having a positive response to psychotherapy. The organization of the decision tree and the selection of measures were based on results from psychotherapy outcome studies. The second method involves providing clients with feedback on their progress throughout the course of treatment. Both methods of providing feedback enhanced treatment outcomes and representative studies are reviewed. Use of these methods is recommended for application in routine practice.     

Meeting the Mental Health Needs of Older Adults in Primary Care: How Do We Get the Job Done?

Most elderly persons in the United States with mental health problems such as depression receive no attention or care. Those who receive treatment generally do so in primary care settings, where disorders like depression have a hard time competing with other common and chronic medical problems. Typically, mental illnesses are under-recognized and under-treated in elderly persons attending primary care clinics. The experience of the PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) study is briefly described, indicating that depression, for example, can be treated successfully in primary care elderly using the type of multidisciplinary collaborative care model advocated by Speer and Schneider (2003 ; this issue). The challenge now facing all of us is to create a consumer- and family-driven demand for good mental health services in geriatric clinics and a political consensus to reimburse such services fairly. Recent improvement in Medicare reimbursement for mental health services to victims of Alzheimer's dementia provides a basis for hope.     

In Pursuit of Empirically Supported Assessment for Use in Medical Settings

Psychological assessment in the medical setting presents many opportunities and challenges. On the question of what constitutes empirically supported assessment practice, there are few clear answers and perhaps fewer exemplars. The goal of this article was not to review the current status of empirically supported assessment in medical settings, but rather to highlight some areas of measurement innovation that may move this field toward its promise of a more stable evidence base supporting the use of patient‐reported outcome measures for clinical research, patient education, and clinical care. In addition, assessment in the medical setting provides one very unique opportunity that many psychologists are not honed in on: the use of psychological assessment to assess quality health care. This is an emerging reality that poses significant methodological puzzles and opens doors for those committed to psychological assessment.     

Depression indicators in a national sample of older community and care home patients: applying the Quality and Outcomes Framework

In a national primary care database sample of older people (≥65 years), 81% (83 588/103 821) of community and 58% (1702/2940) of care home residents with diabetes or heart disease had depression case finding recently recorded; 66% (1418/2145) of community and 22% (26/118) of care home residents with a new depression episode had a depression-severity assessment recorded. Age, sex, and higher care home dementia prevalence did not explain these differences. Case finding and assessment of depression need to be improved in older people, particularly care home residents.     

Effects of psychotherapy for anxiety in children and adolescents: a meta-analytic review

This paper provides a comprehensive quantitative review of high quality randomized controlled trials of psychological therapies for anxiety disorders in children and young people. Using a systematic search for randomized controlled trials which included a control condition and reported data suitable for meta-analysis, 55 studies were included. Eligible studies were rated for methodological quality and outcome data were extracted and analyzed using standard methods. Trial quality was variable, many studies were underpowered and adverse effects were rarely assessed; however, quality ratings were higher for more recently published studies. Most trials evaluated cognitive behavior therapy or behavior therapy and most recruited both children and adolescents. Psychological therapy for anxiety in children and young people was moderately effective overall, but effect sizes were small to medium when psychological therapy was compared to an active control condition. The effect size for non-CBT interventions was not significant. Parental involvement in therapy was not associated with differential effectiveness. Treatment targeted at specific anxiety disorders, individual psychotherapy, and psychotherapy with older children and adolescents had effect sizes which were larger than effect sizes for treatments targeting a range of anxiety disorders, group psychotherapy, and psychotherapy with younger children. Few studies included an effective follow-up. Future studies should follow CONSORT reporting standards, be adequately powered, and assess follow-up. Research trials are unlikely to address all important clinical questions around treatment delivery. Thus, careful assessment and formulation will remain an essential part of successful psychological treatment for anxiety in children and young people.     

Internal medicine/primary care reminder: What are the standards of care for HIV-positive patients aged 50 years and older?

The demographics of HIV-positive persons in the United States signal a steady shift toward an older population. The relationship between aging and HIV infection suggests that there is an additive and possibly synergistic effect increasing the risk for numerous common medical conditions, including heart disease, cancer, osteoporosis, frailty, depression, and dementia. Given the current crisis in the US health care system regarding universal access to quality primary and geriatric care, the aging of the HIV-positive population will pose numerous challenges to providers and policy makers. This review summarizes key areas of knowledge and concern regarding the care of HIV-positive persons aged 50 years and older.