Depressed older adults being treated in primary care settings do better with psychosocial therapies than with antidepressant medicines, suggests a new review of evidence. //
Furthermore, older adults with depression have the best response when these cognitive-behavioral therapies are delivered by interdisciplinary health teams, say reviewers led by psychologist Karyn Skultety.
The review recommends this integrated approach instead of the more conventional focus on antidepressant medications.
The suggestion is based on only eight studies, yet, “We think the findings give us some valuable information on what works,” says Skultety, who works in the Veterans Administration Palo Alto Health Care System in California.
The reviewers also note that older adults prefer to seek help for depression from primary care physicians, and that many prefer psychosocial treatments. “They’re on a lot of medications already, and usually they’re trying to work with their doctors to reduce the number of medications they’re on, not increase,” Skultety said.
The review, part of a new series, appears in the November issue of the journal Health Psychology. Each evidence-based review centers on a specific psychological assessment or treatment conducted in the context of a physical disease process or risk reduction effort.
The review comprised eight randomized controlled trials comparing psychosocial treatments in primary care to “usual care” for patients aged 55 and older. The number of participants ranged from 96 in the smallest study to 1,801 in the largest.
Usual care in all the studies involved allowing primary care physicians to assess depression and offer treatment as they deemed appropriate.
Psychosocial interventions included education and counseling provided by nurses, social workers, psychologists, counselors, or physicians.
The strongest treatment effects appeared in the two
studies that incorporated interdisciplinary teams, in which mental health providers worked in collaboration with medical providers to develop plans for care. These models resulted in “consistently significant improvements in depressive symptoms,” the reviewers found.
The reviewers note that they could not combine results across the studies, because of large variations in study populations, interventions and providers involved. Clear guidelines for future projects are a must, said Skultety, so that results can be compared and combined to reveal the most effective treatments.
Furthermore, she said, all future studies need to report the number of patients who drop out of each treatment program. “Just showing that [a treatment] works isn’t quite enough. You also have to show that you can actually get people to stay engaged in it over time.”
“Even at this point I think there’s enough evidence to say this is a desired model if you’re going to work in primary care,” said Forrest Scogin, president-elect of the Clinical Geropsychology Section of the American Psychological Association.
Interdisciplinary teams have become commonplace in treating diabetes and other chronic conditions, Scogin said. “You’re involving more professionals in the treatment, so really it becomes more of a fiscal issue.”
While Skultety said that involving interdisciplinary teams can be time-consuming initially, she added “You’re actually looking at saving yourself time down the road because you’re addressing everything at once. Otherwise, a lot of older adults present depression with just vague physical complaints, and they come back again and again and again.”
Estimates of depressive symptoms among older adults in community and primary care settings range from 10 percent to 25 percent, say the authors. Depression exacerbates physical health problems in seniors and vice versa.
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