CBT for Preventing Depression in Nursing Home Residents: Ethical, Clinical, and Training Issues

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CBT for Preventing Depression in Nursing Home
Residents Ethical, Clinical, and Training Issues
Candace Konnert March 16, 2005 Queensland
Psychology of Ageing Interest Group
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Overview

• To describe the results of a RCT of a prevention
  of depression program with nursing home residents
  (Konnert Dobson, in prep.).
• To discuss ethical issues such as informed
  consent and confidentiality in the context of a
  group nursing home intervention.
• To discuss clinical and training issues.

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Purpose of the research

• To evaluate the outcomes associated with a
  short-term group cognitive-behavioural prevention
  program for depression in nursing home residents.

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Why is this study important?

• 12-26 of residents meet full diagnostic criteria
  for depression, up to 50 show significant
  symptoms.
• Subsyndromal depression is a risk factor for MDD
  and suicide.
• Review of diagnostic patterns indicated that
  among elderly suicide victims, minor depression
  was a common diagnosis (Conwell, 1994).

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Prevention of depression

• Preventing depression is both more humane and
  potentially cost-effective.
• Prevention of depression programs with other age
  groups have been shown to be successful.
• Yet, there is no research indicating whether
  groups for preventing depression are effective in
  helping residents.

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The CBT Intervention

• Coping with Stress in Seniors (adapted from
  Clarke Lewinsohn, 1995)
• 13 sessions over 7 weeks, 60 minutes each
• Groups of 4 residents or more, 2 therapists
• Integrated groups (new admissions with
  established residents)
• Delivered by doctoral candidates in clinical
  psychology

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Sessions

• 1. Getting acquainted
• 2. Mood diary
• 3. Coping with stress
• 4. Changing your thinking Negative thoughts
• 5. Stressful situations and negative thinking
• 6. The power of positive thinking
• 7. Changing negative thoughts to positive thoughts

• 8.Introduction to pleasant events Controlled
  breathing/visual imagery
• 9. Identifying pleasant events
• 10.Scheduling pleasant events
• 11.Scheduling pleasant events Problems/ planning
• 12.Planning for stressful situations
• 13.Preventing the blues

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Standard Structure of the Sessions

• Review homework and key information from previous
  session
• Introduce new skill(s)/topic(s)
• Practice new skills(s)
• Assign and practice homework

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Study Design

• New admissions and current residents were
  recruited over a 3-year interval
• 258 residents were screened for depression
• 129 had elevated GDS scores
• 65 RA (in blocks, within site) to treatment
  versus TAU conditions
• Matched new admissions/long-stay

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Inclusionary Criteria

• 60 years of agePhysically able to attend
  groupCommunicative abilityEnglish speakingMMSE
  of 21At risk for depression (GDS of 9, did
  not meet criteria for Major Depression on the
  SCID-IV)

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Assessment

• Pre-, post-, 1-month, 3 months, 6 months
• Indices of physical health, MMSE, GDS, CES-D,
  Penn State Worry Questionnaire, Perceived Social
  Support from Family and Friends, Dysfunctional
  Attitudes Scale for Medically Ill Elders,
  satisfaction
• Collateral data from staff - MOSES

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Sample Characteristics

• N43 (20 in TX, 23 in TAU)
• 77 (n33) women, 23 (n10) men
• 100 Caucasian/White
• Mean age 80 years
• Mean MMSE 26.5 (range 21-30)
• Mean chronic conditions 4 (range 1-11)
• (predominantly cardiovascular)

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Changes in GDS Scores
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Changes in CES-D Scores
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Residents mean satisfaction ratings
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Conclusions

• Brief, group-based CBT can reduce symptoms of
  depression.
• With training, staff from a variety of
  disciplines could implement this treatment at a
  relatively low cost.
• Alternatives to CBT?

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Ethical Issues

• Lichtenberg et al. (1996). Standards of practice
  for psychologists in long term care settings.
  The Gerontologist, 38(1), 122-129.
• APA. (2004). Guidelines for psychological
  practice with older adults. American
  Psychologist, 59(4), 236-260.

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Case Study

• Mrs. Brown, 80, widowed, duration of residence, 6
  weeks.
• Medical conditions stroke, diabetes, HBP
• GDS 14, MMSE 22
• Staff reports withdrawn, dependent, care
  resistant
• Daughter is primary caregiver

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Case Study - continued

• On assessment, Mrs. B is unsure about whether she
  wants to participate in group. She is concerned
  that it might conflict with her hair appointment
  and doesnt really see the need. If only she
  could go back to her her own home. What would
  group involve? She should discuss it with her
  daughter. How wo/uld she get there? How long
  would it take? She really isnt feeling well and
  is very tired but you seem like such a nice
  person.

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Ethical Issues

• What recruitment strategies are most appropriate
  in a nursing home?
• What constitutes free and informed consent?
• Disclosure Risks and benefits. How much
  information? How is it best conveyed?
• Voluntariness What is the balance between
  encouraging/discouraging and coercing?
• Competency (Patrick Dulin April, 2004)
• Confidentiality and privacy

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Confidentiality in LTC (M. Norris)

• Informing residents at the outset regarding
  access to information (e.g., team meetings,
  progress notes).
• Obtaining agreements about what information will
  and will not be shared.
• Practice of providing general versus specific
  information to staff.
• Adopt a need to know policy.

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Clinical Issues Program Delivery

• Relaxation
• Pleasant events
• Cognitive Restructuring
• The Group Experience
• Program adaptations (content and process)
• Resident reluctance
• Sharing personal information

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Sensory, motor, and cognitive impairments

• Paraphrasing contributions of others, large font,
  magnifying glasses, hearing aids, everything in
  print was verbally presented
• Slower pacing, repetition
• Multimodal (say it, show it, do it)
• Memory aids (written assignments, notebooks)
• Strategies for staying on track (refocusing,
  written agenda)

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Attendance and Homework

• Attendance
• Notices, calendars, neon reminders
• Staff assistance
• Homework
• Each resident had a personal workbook
• Placed flags in residents workbooks marking the
  homework
• Homework kept in visible place
• Complete homework in head
• Assistance from family/friends

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Resident Reluctance

• Strategies
• Build rapport with therapists
• Deal directly with concerns
• Normalize feelings, education around mental
  health issues
• Outlines benefits (to self and others) and
  instilling hope
• Emphasizing strengths
• Develop group cohesion

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Sharing personal information

• Guidelines for confidentiality
• Rapport with therapists
• Pointing out commonalities among residents
• Initially discussing topics that were not
  personal
• Encouraging self-disclosure but not pushing
  residents to talk

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Training More than just fidelity!

• Molinari, V. et al. (2003). Recommendations
  about the knowledge and skills required of
  psychologists working with older adults
  Professional Psych. Research and Practice,
  34(4), 435-443.
• Working within a medical model
• Groundwork clarify needs of the setting, provide
  education about psychology, clarify trainees
  relationship to the team (Karel et al, 2000)
• Transference and countertransference
• Death

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Systemic Issues

• Administrative support and changes
• Staff and family Collecting collateral
  information
• Translating research into practice

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Helpful Resources

• Molinari, V. (2000). Professional psychology in
  long-term care A comprehensive guide. New York
  Hatherleigh.
• Norris, M. P., Molinari, V., Ogland- Hand, S.
  (2002). Emerging trends in psychological
  practice in long-term care. New York Haworth.