In contrast to younger patients, older adults with depression more commonly have several concurrent medical disorders and cognitive impairment. Depression occurring in older patients is often undetected or inadequately treated. Antidepressants are the best-studied treatment option, but psychotherapy, exercise therapy, and electroconvulsive therapy may also be effective.
CBT indicates cognitive behavior therapy. Depression care management The DCM model is a systematic team approach to treating depression in older adults, which is based on the model for treating chronic diseases Common elements of DCM include diagnosing depression through a validated screening instrument and providing psychotherapy or antidepressants according to evidence-based guidelines.
A trained social worker, nurse, or other practitioner sometimes called a "depression care manager" or "care manager" educates patients, tracks outcomes, facilitates psychotherapy, and monitors antidepressants prescribed by a primary care provider.
The care manager works in consultation with a psychiatrist who supervises care but typically does not see the patients.
The goal is to improve rates of adherence to treatment and to improve recognition of, and treatment for, patients not responsive to their initial treatment.
Managing depression in primary care clinics is effective: The therapist teaches clients to recognize and modify these thoughts and behaviors in order to reduce symptoms of depression. CBT usually consists of weekly therapy sessions and daily exercises to help older adults apply CBT skills every day.
The therapists are supervised by, and may consult with, professionals with a PhD or an MD. Real-World Experience Several groups of experts recognize DCM and CBT as proven treatments for depression in many older adults 2223yet numerous obstacles prevent these interventions from being used by public health and healthy aging programs.
Next we describe several efforts to implement the recommended evidence-based depression interventions in various communities. PEARLS began as a 5-year study of subjects, during which research funds and administrative support were available for selecting and training interventionists, recruiting and funding a supervising psychiatrist, recruiting research subjects, collecting data, and assessing outcomes.
After the study ended, community agencies began funding and supporting the program. The researchers continued their support through regular meetings with the agency staff and administrators to solve problems and to provide education and training. As of April35 community-dwelling older adults had completed treatment through a social service agency that serves homebound and frail older adults.
These 35 were the first to complete treatment after the 5-year study ended. Their depression was diagnosed through the Patient Health Questionnaire PHQ-9 a nine-item, validated instrument for screening and diagnosing depressionand their initial average score A score of After treatment, the average PHQ-9 score of the 35 had decreased to 4.
Unfortunately, the number of community-dwelling older adults treated 35 is small in comparison with the number of older adults enrolled in the social services program and the number of enrollees who have mild depression at least This situation shows that implementing the PEARLS intervention in a real-world setting rather than a research setting is difficult even when the obstacles of screening, funding, training, and staffing are overcome.
During a discussion among the researchers, administrators, and staff involved in PEARLS about the barriers to implementing the program more widely, several factors became evident. First, without research staff to recruit older adults with depression, the in-home case managers must identify older adults with depression and refer them to the PEARLS counselors.
In addition, many clients, because of stigma or other reasons, do not see the need for treatment or are not interested in receiving treatment.
Lastly, the research intervention protocol excluded people with moderate or high levels of cognitive impairment and people who did not speak English. The current PEARLS program has many such clients but does not have a blueprint for modifying and adapting the program to meet the needs of these diverse, real-world patients.
Although the number of people who received the intervention outside the research study is unclear, several states are collaborating with the study team to implement the program on a large scale.
First, although primary care providers are comfortable using measurement-based care, primary care clinics do not usually screen for depression.
Therefore, getting primary care providers to incorporate instruments such as PHQ-9 into routine care can be challenging. Second, although evidence clearly shows that nurses who are not health care specialists or nurse practitioners can function as care managers, most third-party insurance providers, including Medicare and Medicaid, do not reimburse expenses when registered nurses serve as care managers.
Similarly, Medicare and Medicaid do not pay for a supervising psychiatrist. Finally, although the Internet has greatly reduced the challenges of training diverse audiences all across the country, it is unclear how much actual training is delivered through this mode of communication.
Cognitive behavioral therapy Cognitive behavior therapy is the oldest of the interventions recommended by the expert panel. Although some studies have been done on CBT 25none were done in primary care settings or as part of community-based geriatric programs.
However, since CBT is a single intervention technique, it does not face some of the challenges of multifaceted programs, which require several people to implement. CBT is usually taught during the intern and residency programs for psychiatrists, psychologists, and licensed clinical social workers.
Because numerous self-help texts 26 are available detailing the theory and practice of CBT, many other mental health providers are familiar with its use. However, most of these practitioners work in specialty mental health settings removed physically from primary care or community-based programs that serve older adults.
Therefore, linking the patient and the provider is a challenge because many older adults are reluctant to go to mental health specialists. In addition, the interventions that we determined were effective through the literature review were based on depression screening with quantitative instruments to guide and evaluate the therapy.
This quantitative-based approach to delivering psychotherapy is not common in many mental health settings.Evidence based guidelines for the general population, older adults and people with co-morbid physical conditions are presented at the conclusion of this article.
Allied health journals typically include evidence from the non-scientific genres of literature review, critical analysis, opinion, practice reports and narrative case studies. Hope, as a concept, may differ for older adults than for younger adults, which adds important insight into the tailoring hope interventions for this population.
For example, ways to foster hope with older adults with chronic illness may include strategies for finding meaning and . Enhanced Existential Relationship in Light of Eudaemonic Well-Being and Preoperative Religious Coping of Cardiac Patients.
middle-aged and older adults, controlling for Preoperative. An inverse relationship existed among hope and depression (Shi, Liu Hope in psychiatry: A review of the literature. Acta challenges among older adolescents and young adults.
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