By Amanda Leggett and Steven H. Zarit
￼In the field of mental health, prevention efforts have the ability to decrease healthcare costs, reduce mental illness incidence, and enhance individuals’ well-being and functioning. The National Institute of Mental Health (NIMH) lists in its Strategic Objective 2.3 the goal “to develop and test novel interventions that are targeted at pre-symptomatic or prodromal stages of illness, [and] are designed to preempt syndrome development . . .” (NIMH, 2014). In some disciplines such as public health, prevention programs have been widely discussed and implemented, but innovations for preventing mental disorders lag behind, particularly for older adults, where the focus has been on sickness, disability, and disease treatment.
Traditionally, preventive efforts have focused on children and adolescents to promote positive health trajectories early in life (National Research Council and Institute of Medicine, 2009). However, mental health problems are common in older adults and associated with risk and protective factors that differ from those active in early life. Some factors, such as education and early-life socioeconomic advantage, cannot be modified in late life; however, more salient late-life factors, such as social support, sleep disturbance, and activity levels, are malleable in the later years.
As the global population of older adults expands, an increasingly large number will seek mental health care. We also know that current treatments are only partly successful. For example, approximately 20 percent to 30 percent of a person’s years lived with disability due to depression can be avoided by using existing treatments, and treatments do not prevent the full burden of anxiety disorders (Andrews et al., 2004). Prevention efforts to stop mental health problems before they start is a promising approach to lower overall disease burden.
This article presents encouraging findings from existing preventive interventions in pharmacotherapy, psychotherapy, and psycho-social efforts. Much of this work addresses depressive and anxiety disorders, and interrelated areas of health, such as sleeping patterns. We conclude by providing suggestions for future directions of research and practice in geriatric mental health prevention.
First, we will review prevention terminology. As opposed to treatment, prevention targets individuals before the development of a disorder. Gordon (1983) labeled preventive interventions as universal, selected, and indicated, depending upon risk level of the targeted population. Indicated interventions focus on individuals who already show preliminary signs or subsyndromal symptoms of a disorder, but not severe enough for diagnosis; selected interventions target those at high risk; and, universal programs are aimed at an entire population. The Institute of Medicine adopted Gordon’s terminology and added a category of more general mental health promotion (National Research Council and Institute of Medicine, 2009). We highlight some recent preventive interventions that fall into each of these categories, starting in the domain of pharmacological prevention.
Positive effects of antidepressants for the treatment of depression are well-documented, even among the oldest old (Trappler and Cohen, 1998). While the majority of older adults recover from depression, many will relapse, but current or prior antidepressant use has been associated with a better prognosis (Denihan et al., 2000). Prophylactic antidepressant use has been trialled primarily for treatment maintenance and relapse prevention in older adults recently recovered from a major depressive disorder episode.
Reynolds et al. (2006) examined adults ages 70 and older with major depressive disorder who responded to combined psychotherapy and paroxetine (brand name: Paxil) treatment. Patients were randomized into four groups receiving paroxetine or a placebo, combined with either interpersonal psychotherapy or clinical-management sessions for two years, or until a new major depressive disorder episode. Individuals who received two years of paroxetine were less likely to develop a new episode of major depressive disorder. Adjusting for the psychotherapy effect, individuals receiving the placebo had a 2.4 times greater relative risk of recurrence than individuals on paroxetine.
Robinson and colleagues (2008) assigned three randomized groups of adults, ages 50 to 90, who had suffered a stroke in the past three months, to escitalopram (brand name: Lexapro), problem-solving therapy, or placebo in a twelve-month trial. In that time period, 22.4 percent of individuals on a placebo developed depression, compared to only 8.5 percent of individuals taking escitalopram and 11.9 percent of individuals receiving problem-solving therapy. At six months following escitalopram discontinuation, participants who had received escitalopram exhibited significantly worse levels of depressive symptoms than the problem-solving therapy or placebo group (Mikami et al., 2011). In other work, Fournier and colleagues (2010) found the benefit of an antidepressant over a placebo rose with increasing severity of depression. The antidepressant had only a small effect for individuals with none to moderate symptoms, suggesting greater use for treatment than prevention.
These results show that antidepressants may have some preventive benefit for relapse of depression in older adults, but results are mixed. There are also ethical concerns regarding prescription of antidepressants or other medications to individuals without a diagnosed disorder. Medications such as antidepressants and benzodiazepines (brand names: Valium, Zanax, Halcion, etc.) tend to be less effective for mild symptoms, are associated with a number of side effects (e.g., fall risk, cognitive impairment), add to a potential medication cascade effect in elders, and many older adults prefer non-pharmacological treatment (Fournier et al., 2010; Gum et al., 2006; Landi et al., 2005; Verdoux, Lagnaoui, and Begaud, 2005). While pharmacotherapy may be called for in some high-risk cases, or where it is helpful for individuals who had past depressive episodes, it should not be the initial choice for primary prevention efforts.
Baby boomers are high users of psychotherapy and thus demand may grow for non-pharmacological prevention. Few researchers have considered psychotherapy as a preventive intervention compared to treatment, however, several studies show promising results (see Lee et al., 2012, for a review). Below, we discuss a few recent efforts predominantly focusing on cognitive behavioral therapy and problem-solving therapy.
Cognitive behavioral therapy
Most psychotherapy studies use a cognitive behavioral framework, which targets dysfunctional thoughts and levels of activity, aiming to restructure one’s thoughts and ultimately change behavior. The most commonly used form is Lewinsohn’s “Coping with Depression” course, which is a psycho-educational form of cognitive behavior therapy (Lewinsohn et al., 1984). A therapist serves as instructor for a group of participants, teaching useful skills to manage depressive feelings such as scheduling and completing pleasant activities, developing social skills, relaxation, and techniques for restructuring one’s maladaptive thought processing.
Konnert, Dobson, and Stelmach (2009) trialled an adapted version of this course, geared specifically for prevention and called “Coping with Stress,” in nursing home residents (thirteen sessions over seven weeks). The course was modified to provide relevant examples and pleasant events that would be appropriate for older adults in nursing homes. Participants were assisted, where needed, to write in their treatment manuals and to get to the sessions. Scores on the Geriatric Depression Scale (a thirty-item questionnaire in which participants are asked to answer yes or no questions in reference to how they felt over the past week) (Yesavage et al., 1982) declined significantly over time (baseline to six months post-treatment) and were significantly better in comparison with the control group.
Over the six months of treatment and follow-up, no participants in the Coping with Stress course developed major depressive disorder (out of n=20), while two participants in the control group did (out of n=23). However, the intervention group did not differ significantly from the control group on two other depression symptom scales (The Center for Epidemiologic Studies Depression Scale and Dysfunctional Attitudes Scale for Medically Ill Elders) (Koenig et al., 1994; Radloff, 1977).
Problem-solving therapy is a behavioral approach that aims to reduce depression by targeting inaccurate problem appraisals and teaching skills to solve these problems adaptively. Rovner and colleagues (Rovner et al., 2007; Rovner and Casten, 2008) employed a problem-solving therapy selective intervention (six hour-long sessions across eight weeks) that targeted individuals with macular degeneration. Given that macular degeneration would modify an individual’s capability to perform some activities, problem-solving therapy presents a creative behavioral solution to address these visual challenges and potentially prevent depression.
At two months, the experimental group had half the incidence rate of depression compared to the control group (11.6 percent versus 23.2 percent). The researchers did not find differences in incidence at six months; however, activities were better maintained in the experimental group. This intervention may be effective in older adults with other chronic diseases where both depression and disability are common. Taken together, with findings from Robinson and colleagues (2008) problem-solving therapy and escitalopram comparison, results suggest that problem-solving therapy provided over only a few weeks may have long-term effects in preventing depression, particularly in individuals with a medical comorbidity.
Innovative and multi-component psychotherapy approaches
In a three-group randomized control trial, Spek et al. (2008) compared group participants in the ten-week Coping with Depression course and an eight-session Internet-based, cognitive-behavioral therapy self-help intervention with individuals in a wait-list control. Participants were adults ages 50 and older, with sub-threshold symptoms of depression. While both interventions had a large improvement effect size, the differences between the Coping with Depression course group and the wait-list control were negligible. While 62 percent of individuals in the Internet cognitive-behavioral intervention were below the threshold indicator for depression on the Beck Depression Inventory (a self-report scale that measures symptoms of depression) (Beck, Steer, and Brown, 1996), only 45 percent of the Coping with Depression course and 38 percent of the wait-list participants were below threshold one year following initiation of treatment. This reflects the natural course of improvement over time as well as the potential efficacy and desirability of Internet-based interventions.
Van’t Veer-Tazelaar and colleagues (2009) provide an example of a stepped-care program for older adults in primary care that reduced the odds of developing an anxiety or depressive disorder by more than half and showed long-term effects. Stepped-care interventions start with no intervention but progress to more involved interventions if an individual is not improving. This method aims to make the best use of clinical and economical resources by only giving intervention as needed. Van’t Veer-Tazelaar and colleagues’ stepped-care program consists of four three-month periods, starting with watchful waiting as many individuals’ symptoms spontaneously remit without treatment. If significant symptoms lasted after an initial three months, participants were randomized to either a usual care control group or cognitive-behavioral therapy bibliotherapy (a self-help book version of the Coping with Depression course) intervention. A nurse first visited to provide information about anxiety and depression and basic advice on coping skills. In a second visit, the Coping with Depression (and Anxiety) course was provided and the nurse made several follow-up visits or calls to monitor progress. If participants were still symptomatic three months later, they would progress to a seven-session problem-solving therapy.
Finally, symptomatic participants at three months later would be referred to their primary care physician for antidepressant treatment. At the end of any period, if participants’ symptom scores were below threshold, they would enter or remain in a watchful waiting period. The twelve-month incidence of anxiety and depressive disorders was 0.12 in the stepped-care group and 0.24 in the control group. Participants in this study were ages 75 and older, suggesting that a stepped-care intervention was tolerable for individuals in late-life and primary care was an effective setting for recruitment and intervention.
Sleep Problems Prevention.
Sleep disturbance and mood are strongly associated, and as circadian rhythms and sleep patterns change with age, these associations are pivotal in older adults (Buysse, 2004). Targeting the treatment of late-life insomnia, Germain and colleagues (2006) conducted a Brief Behavioral Treatment of Insomnia intervention, including one forty-five minute session and a short booster session two weeks later.
The Brief Behavioral Treatment includes education about sleep regulation, what influences sleep, and behaviors that can inhibit or promote sleep. In particular, participants were asked to follow four instructions for the four-week intervention: spend only the amount of time in bed one expects to sleep; wake up at the same time each day; only go to bed when sleepy; and get out of bed if not sleeping. Individuals with “unstable” or untreated psychiatric diagnoses were excluded from the study, and so the mean Hamilton Rating Scale for Depression and Anxiety (Hamilton, 1959, 1960) scores at baseline were well below accepted cut scores. Compared to a control group, participants receiving the Brief Behavioral Treatment of Insomnia intervention improved in their number of nighttime awakenings after falling asleep; sleep latency, quality, and efficiency; and, in symptoms of anxiety and depression. More research is needed to see whether sleep interventions can reduce incidence of mental health disorders or be useful in multi-component interventions.
Other Prevention Programs
Other prevention programs, such as psychosocial or exercise interventions, are less standardized than pharmacotherapy and psychotherapy interventions, yet have an opportunity to address specific risk factors in a way that may be more tolerable and less stigmatizing to older adults. Most psychosocial studies are targeting mental health promotion in samples of community-dwelling older adults, as opposed to indicated or selective prevention for a specific disorder. These programs provide some promising efforts that may be replicated, modified, or incorporated in a multifaceted way in indicated or selected randomized control trials. We consider some recent and promising examples (see Forsman, Schierenbeck, and Wahlbeck, 2011, for further review).
Pot and colleagues (2010) trialled an indicated preventive intervention of “life review.” Participants ranged from ages 50 to 90 and had sub-syndromal symptoms (symptoms that are not severe enough for an actual depression diagnosis) of depression. Participants were randomized to a control group that watched an educational video on aging successfully, or an intervention called “Looking for Meaning,” which consisted of twelve, two-hour sessions in which participants performed various life-review activities (discussing life experiences, sensory recall, or other creative activities) on various topics such as former dwellings or smells from the past. Pot et al. reported a significant improvement in depression scores in the intervention compared to the control group, which translated into a large-effect size for the between group difference in pre- and post-assessment (Δd=0.58). Both the intervention and control groups declined in anxiety, so there was not a significant between-group change-effect. A meta-analysis found similar effects of reminiscence and life-review programs in reducing depressive symptoms in individuals with mild to moderate symptomatology (d=0.37) (Bohlmeijer, Smit, and Cuijpers, 2003).
While physical exercise long has been associated with improvements in mood, few interventions have focused on prevention and promotion, as opposed to treatment of clinical disorders. Baker et al. (2007) randomly assigned retirement community residents having none to mild depressive symptoms to a ten-week exercise program (approximately one-hour sessions, three days a week) of high-intensity resistance training, moderate-intensity aerobic training, and balance training, or, alternately, to a wait-list control group. Since depressive symptoms were already low, there were no significant differences between treatment and control groups, but participants who had more depressive symptoms at baseline improved most. Rosenberg et al. (2010) examined a twelve-week Nintendo Wii Sports “exergame” intervention in older adults with sub-syndromal depression (three thirty-five-minute sessions a week; no control group). Participants’ depressive symptoms significantly declined with the reduction maintained at a twenty-four-week follow-up and 37 percent of participants’ symptom scores declined by 50 percent or more. Anxiety scores declined across the intervention, but not significantly.
These studies highlight the opportunity, yet also the paucity and lack of development, in prevention studies. Many of the described prevention studies only discussed improvement in symptoms or a comparison between an intervention and control group over time. When symptoms are low or absent, however, the goal cannot be to reduce depression or anxiety, but rather to demonstrate reduced risk or lower incidence of new disorder over time.
Conclusion and Future Directions
The above studies provide an overview of the potential for prevention and also challenges and limitations of this work. Pharmacotherapy has shown efficacy in preventing the recurrence of depression, yet antidepressants and benzodiazepines are associated with a number of negative side effects for older adults. Psychotherapy has been shown to reduce the incidence of depressive and anxiety disorders; but therapy sessions are lengthy and may require older adults to travel to a therapist. Finally, psychosocial prevention has shown success in promoting mental health, however, more indicated and selective studies are needed to show whether psychosocial prevention can reduce incidence of disorder in at-risk individuals.
The greatest challenge with selected and indicative prevention trials is the need for an adequate follow-up period. If everyone has low or no symptoms at the initial time point, it is difficult to detect effects over the short term, and given the uncertain risk of increased depression or anxiety in samples, it would be necessary to have a very large sample to detect differences in new cases of clinical disorders or even increases in sub-syndromal symptoms. Thus, indicated trials targeting specific risk and protective factors in older adults with beginning signs of disorders may be most effective. Besides the need for more selective and indicated prevention trials in geriatric mental health, other new directions for innovation in research and practice may be proposed.
It is important to take into account the disabilities, mobility, and cognitive capabilities, in addition to the resiliencies, wisdom, and strengths of the older population in preventive designs. In line with the growth of patient-centered outcomes research, new initiatives that consider specific preferences and needs of older adults relating to mental health care may be particularly beneficial to prevention work. To further increase participation, it might be helpful to work through primary care physicians, or through social services used by older adults with depressive or anxiety symptoms, and consider how programs can reach rural elders or those who cannot pay for mental health services.
Innovations in technology may help to reach older adults with mobility, transportation, or economic difficulties. Internet-based prevention programs have a number of benefits in that there is no need for appointment scheduling and travel, they allow individuals to work at their own pace, they may be shared globally, are inexpensive, and are reusable (in contrast to a therapist’s time—or a pill). Interventions powered through mobile phones, tablet computers, or applications such as Skype may be a particularly fertile area for growth (Muñoz et al., 2010). However, as Internet programs do not offer crisis assistance, the ethics of these interventions must be considered (Reynolds, 2009).
A best-case scenario for prevention research would be the ability to target the etiology of mental disorder. The biological underpinnings of disorders are beginning to be understood. For example, the stress hormone cortisol has been associated with depression and melatonin levels are related to insomnia (Burke et al., 2005; Wade et al., 2007). With increasing knowledge, bio-markers may help better target individuals for prevention so resources are not used on individuals who, while at risk, are not likely to develop a disorder. Ultimately, biomarkers may help individualize programs and make them more efficient, and might be measured when assessing response to an intervention.
In conclusion, the prevention of geriatric mental disorders is a field laden with challenges, yet ripe for growth, holding potential for great health and economic payoffs. This brief overview of the domains of geriatric prevention can provide clinicians with strategies for helping older adults at risk for disorders, and with examples of successful interventions from which researchers can build new ideas and trials. Disorders can be stopped before they begin and, as our population ages, prevention work promises to have increasing salience.
Amanda Leggett, Ph.D., is a National Institute of Mental Health Geriatric Mental Health Services postdoctoral research fellow in the Department of Psychiatry, at the University of Michigan Medical School in Ann Arbor, Michigan. Steven H. Zarit, Ph.D., is distinguished professor, and head of the Department of Human Development and Family Studies, at Pennsylvania State University, in University Park, Pennsylvania.
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