Findings Underscore Value of Support in Late-Life Depression

Abstract

LOS ANGELES – Several types of psychotherapy are effective for late-life depression, studies show. However, the type of control used in those studies plays an important role in the magnitude of the effect size, findings from a systematic review and meta-analysis suggest. The findings underscore the value of the supportive aspects of care and the importance of good clinical management in late-life depression, regardless of whether medication is used as part of treatment, Dr. Alice X. Huang said at the annual meeting of the American Association for Geriatric Psychiatry. Prior reviews supported various types of psychotherapy for late-life depression. But interestingly, no review has looked at the impact of the type of control group used in clinical trials, including waitlist, treatment as usual, attention control, supportive therapy, and placebo, said Dr. Huang, a psychiatry resident at the University of California, San Francisco. In their own review and meta-analysis of 27 trials, she and her team found that the type of control group used in trials of psychotherapy was related to the effect size of the psychotherapy being tested. The standard mean differences (SMDs) were statistically significant between psychotherapy and waitlist control, treatment-as-usual control, attention control, and supportive therapy control but not placebo control. The SMDs were lower for the supportive therapy, placebo control, and treatment-as-usual groups, compared with the waitlist control and attention-control groups. The findings are in line with the hypothesis that effect sizes would be larger when psychotherapy is compared with less active treatments than with significant clinical management, she explained. Supportive therapy as a control, and placebo, which included extensive clinical management in the studies that were reviewed, both captured many of the elements of psychotherapy that are effective, Dr. Huang noted. Studies included in the current review and meta-analysis involved 2,229 patients of mean ages 66-81 years. The studies lasted anywhere from 4 to 28 weeks (median, 8 weeks). Psychotherapies included cognitive-behavioral therapy, cognitive therapy, behavioral therapy, problem-solving therapy, interpersonal therapy, brief dynamic therapy, bibliotherapy, and reminiscence therapy. The findings suggest that many nonspecific elements of psychotherapy, which previous studies have estimated to account for a large percentage of the effect of psychotherapy in older adults, are captured by supportive psychotherapy, and this provides evidence for improved clinical management and supportive care in this population, regardless of whether a specific psychotherapy is indicated, Dr. Huang concluded. She reported having no financial conflict of interest. Editor's NoteWe need to be aware of depression and treat it appropriately in our patients, because it can have tremendous quality-of-life implications. As a geriatrician, I categorically believe that less medicine is better, but I am also a realist. Antidepressants are generally highly effective in treating depression, and I can be sure my patients get these when I order them.Psychotherapy is great when it can be provided consistently and appropriately, but that's not always the case in our buildings. Sadly, Medicare reimbursement for psychotherapy is pretty dismal and Medicaid reimbursement is downright pathetic: A physical therapist working with a patient for 45 minutes is reimbursed considerably more than a board-certified psychiatrist providing 45 minutes of intensive psychotherapy in a nursing home.Anyway, let's try to do whatever we need to do to identify and treat our depressed patients. Actually take the time to look at your residents' PHQ-9 scores on the MDS. You may be surprised. People sometimes put on a brave face for their doctor, when in fact they may be profoundly depressed.—Karl Steinberg, MD, CMD, Editor in Chief We need to be aware of depression and treat it appropriately in our patients, because it can have tremendous quality-of-life implications. As a geriatrician, I categorically believe that less medicine is better, but I am also a realist. Antidepressants are generally highly effective in treating depression, and I can be sure my patients get these when I order them. Psychotherapy is great when it can be provided consistently and appropriately, but that's not always the case in our buildings. Sadly, Medicare reimbursement for psychotherapy is pretty dismal and Medicaid reimbursement is downright pathetic: A physical therapist working with a patient for 45 minutes is reimbursed considerably more than a board-certified psychiatrist providing 45 minutes of intensive psychotherapy in a nursing home. Anyway, let's try to do whatever we need to do to identify and treat our depressed patients. Actually take the time to look at your residents' PHQ-9 scores on the MDS. You may be surprised. People sometimes put on a brave face for their doctor, when in fact they may be profoundly depressed. —Karl Steinberg, MD, CMD, Editor in Chief