Transcript Treatments for individuals with depression who live in a long term

PREVALENCE OF INDIVIDUALS IN INSTITUTIONS
NEEDING TREATMENT.
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McDougall, et. al. (2007) found in their study of
the symptomatology of depression in individuals
living in institutions compared to those in the
community that the prevalence was 27% for those
in institutions and 9.3% for those living at home.
They stated that more than one quarter of older
people living in institutions suffer from depression
of a severity that warrants treatment.
McDougall, et. al. (2007).
TREATMENT
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Snowden, et. al. found in review of literature, peer-reviewed journal articles
found in nursing home settings, studies of non-pharmacological
interventions outnumbered studies of medication. Reports of several nonpharmacological trials indicate that subjects continued to take psychotropic
medications that were adjusted during the trial.
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According to Bartels et. al. (2002),combined pharmacologic and
psychosocial interventions have a “synergistic” effect in preventing relapse
of geriatric mental health conditions.
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Klausner & Alexopoulos (1999) found that psychosocial treatments were
found to be more effective than no treatment or placebo in the population of
older adults.
Klausner & Alexopoulos (1999).
Snowden, et. al.(2003).
CARE PLANNING
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Care staff in daily contact with older people in care facilities
provide a possible solution to reducing depression in their facility.
Lack of training, and management and peer pressure mean that
care staff give priority to practical tasks rather than talking to the
patients.
It was believed that care staff could be directly instrumental in
modifying depression, through their capacity to make meaningful
relationships with residents and provide a measure of therapeutic
relief that would go beyond keeping the resident comfortable.
Lyne, et. al. (2005) found that personalized care planning,
conducted by suitable trained and supported care staff, might be
an effective intervention for detecting and reducing depression in
long term care facilities for older people.
Lyne, et. al. (2005).
TYPES OF NON-PHARMACOLOGICAL TREATMENT
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Supportive therapy-central to the management of an depressive disorder is the presence of a
treating professional who attempts to and sustains an engagement with the person, a dialogue
based on understanding the depressed persons symptoms; helping the person feel
understood, empathy, the treatment ritual, success experiences, and therapeutic optimism. In
working with the participant, the therapist creates a supportive relationship and encourages
the participant to consider his/her strengths and abilities rather than focusing on negative
aspects of his/her character. It Allows that person to ventilate problems for discussion and
resolution. For best results, patients in long term care should be cognitively able to process
information
It must be given on a regular schedule, preferably for a set amount of time which allows the
health care staff (therapist) and the client time for questions from each party. The goal of this
process is for the therapist to provide support through encouragement and optimism in the
matters that are discussed.
This form of intervention can be performed in individual sessions or in a groups setting; the
main goal is for the patient to feel comfortable. Suitable locations may include, but are not
exclusive to the patients room, the therapist’s office or group room. helping the person feel
understood, empathy, the treatment ritual, success experiences, and therapeutic optimism. In
working with the participant, the therapist creates a supportive relationship and encourages
the participant to consider his/her strengths and abilities rather than focusing on negative
aspects of his/her character.
NSW Health, (2001).
TYPES OF NON-PHARMACOLOGICAL TREATMENT
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Cognitive therapy- focus in on questioning the rational basis for the
depressed person’s beliefs, which are often persistently and illogically
negative and generalized to everything in the person’s life.
This form of intervention may include questions such as:
 Why do you believe…?
 What evidence do you have …?
 What are other possible explanations or solutions…?
The desired outcome is to have the depressed person reduce their
tendency to generalize pessimistic ideas about their own actions/health.
This interventions can be offered individually or in a group setting. For best
results, the long term care patient would make the decision on intervention
setting.
Locations of service delivery may be in client’s room, in the therapist’s
office, or a group room if group therapy is offered and chosen by the patient.
NSW Health, (2001).
TYPES OF NON-PHARMACOLOGICAL TREATMENT
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Behavior therapy- the aim is to encourage the patient to engage in a series
of activities within their physical capabilities, which are most likely to be
pleasurable, and to minimize engaging in chores or disliked activities, based
on pre-depressed activity. Activities which give pleasure should positively
reinforce these same activities to occur more often and be encouraged.
The patient should be able to give feedback about what they are feeling
during and after the activities.
The goal is the activities that lift the mood of the patient should positively
reinforce these same activities to happen in greater frequency.
This intervention can be done in a individual or group setting. The patient
must feel comfortable to gain maximum benefits. Therapy locations may
include the patient’s room, the therapist’s office, or a group room in the long
term care facility.
NSW Health,(2001)
TYPES OF NON-PHARMACOLOGICAL TREATMENT
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Interpersonal therapy- consideration of the various important relationships in the
patient’s life, and the areas in which these have become less successful as
perceived by the depressed person, strategies can be discussed and enacted which
improve the depressed person’s views and the way the relationship works.
Interpersonal Therapy focuses on role disputes, role transitions and interpersonal
deficits. It can be especially meaningful for older adults given the multiple losses,
role changes, social isolation, and helplessness associated with late-life depression.
This type of therapy requires a level of cognitive competence on the part of the
patient and frequently some form of active participation in the form of diary keeping
and other forms of homework assignments.
Interpersonal psychotherapy for depression (IPT) is a brief psychotherapy that has
been found to be effective in treating major depressive disorder (MDD) and other
problems in younger adults. In recent years, IPT has been used as psychotherapy for
depressed elderly. With its emphasis on addressing interpersonally relevant
problems, IPT appears especially well suited to the life changes that many people
experience in their later years. Consistent with results of research studies, the author
has found in clinical practice that IPT is effective in treating depression in older
Hinrichsen, G.A. (1999).
adults.
NSW Health, (2001)..
TYPES OF NON-PHARMACOLOGICAL TREATMENT
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Reminiscence therapy /Life Review is a nurse-initiated intervention that has
the advantages of being cost-effective, therapeutic, social, and recreational
for the institutionalized older adult. As a communicative psychosocial
process, reminiscence therapy has proven to be a valuable intervention for
the depressed elderly client.
For those elders in a long term care facility, reminiscence therapy may
prove an extremely beneficial alternative to more traditional treatment
modalities in reducing the effects of depression and depressive symptoms.
Life review and reminiscence are probably efficacious in improvement of
depressive symptoms or in producing higher life satisfaction.
American Psychiatric Association (2008).
Haight, et. al. (1998).
TYPES OF NON-PHARMACOLOGICAL
TREATMENT
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Cognitive Therapy and Behavioral therapy (CBT) can be combined in order to
link an older persons thoughts, feelings, and behaviors. The goal is to
change thoughts, improve skills, and modify emotional states.
Brief, group-based cognitive-behavioral therapy can reduce symptom
severity in nursing home residents who are at risk for depression but who do
not yet meet criteria for major depression. This type of intervention can be
an important tool in treating and preventing depression in this population.
Studies have shown that long term care patients are at increased risk for
depression; those who have been relocated recently are at particularly high
risk.
CBT is shown to reduce depressive symptoms among 70% of older adult
patients (Klausner & Alexopoulos, 1999).
Llewellyn-Jones & Snowden (2007), stated that residents with major
depression without moderate or severe cognitive impairment may benefit
from individual or group cognitive behavioral therapy (CBT).
Mahoney, D. (2004)
Llewellyn-Jones, R., H. & Snowden, J. (2007)
Klausner,& Alexopoulous (1999)
OTHER FACTORS CONCERNING INTERVENTIONS
Types of psychosocial evidence-based interventions are:
 Supportive Therapy
 Cognitive Therapy
 Behavior Therapy
 Interpersonal Therapy
 Reminiscence/Life Review Therapy
 Cognitive Behavioral Therapy
The frequency and duration of interventions should be set on a
given schedule for a specific amount of time. The schedule
should be a time in which the patients are going to be at their
most alert state. The duration will depend on the cognitive
level of the individuals, the other activities that may be going
OTHER FACTORS CON’T
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on in the facility, the doctor rounds, the medications that the
patients are taking, and the physical condition of the patients.
Intervention sessions should be individualize to the patient as
much as possible to obtain maximum benefit.
Methods of evaluation may include:
the Geriatric Depression Scale (GDS)
Brief Assessment Schedule Depression Cards
Self-Report
Report of other’s who knew the patient before and either
during or after intervention—examples may be therapist report
or report from family and friends.
OTHER FACTORS CON’T
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Location of intervention for patients in a long-term facility will
take place on the facility grounds.
A place that is quiet and private will be best for patients that
want to participate in individual sessions. Locations for
individual session may include the patient’s room or the
therapist’s office.
Patient’s that chose to participate in groups sessions will need
a room that is large enough to accommodate other equipment
that the patient may need such as wheelchairs.
OTHER FACTORS CON’T
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Results will vary from individual to individual, some
interventions will work better for some than with other
depending on the individuals specific issues. All of the
previous interventions are evidence-based and may have better
results when coupled with medications.
Evaluation of effectiveness should be done on a monthly basis
to chart progress and make any adjustments that may be
necessary such as changing the frequency and duration of
sessions.
REFERENCES
The American Psychiatric Association,-Psychotherapy and Older Adults Resource Guide. Retrieved
from website www.apa.org/pi/aging/psychotherapy.html. on November 20, 2008.
Haight, B., K., Michel, Y., Hendrix, S. (1998). Life review: Preventing despair in newly relocated
nursing home residents. International Journal of Aging & Human Development, 47, 119-142.
Hinrichsen, G. A. (1999). Treating older adults with interpersonal psychotherapy of depression.
Journal of Clinical Psychology: In Session: Psychotherapy in Practice, 55, 949–960.
Klausner, E., J., Alexopolos, G., S. (1999). The future of psychosocial treatments for elderly
patients. Mental Health and Aging, 50(9): 1198-1204.
Llewellyn-Jones, R., H., Snowden, J. (2007). Depression in nursing homes. CNS Drugs, 21:627-640.
Lyne, K., J., Moxon, S., Sinclair, I., Young, P., Kirk, C., Ellison, S. (2005). Analysis of a care planning
intervention for reducing depression in older people in residential care. Aging & Mental Health,
10(4):394-403.
Mahoney, D. (2004). CBT can help at-risk nursing home residents. Clinical Psychiatry News, March
2004.
McDougall, F., A., Matthews, F., E., Kvaal, K., Dewey, M., E., Brayen, C. (2007). Prevalence and
symptomatology of depression in older people living in institutions in England and Wales. Age
and Ageing, 36: 562-568.
North Sydney Health Department. (2001). Consensus guidelines of assessment and management
of depression in the elderly. Faculty of Psychiatry of Old Age. Retrieved from website:
www.health.nsw.gov.au on November 18, 2008.
Snowden, M., Sato, K., Roy-Byrne, P. (2003). Assessment and treatment of nursing home residents
with depression or behavioral symptoms associated with dementia: a review of the literature.
The American Geriatrics Society, 51:1305-1317.