1. Using an Evidence Based Practice Approach to Plan Treatment for Individuals over 65 Seeking Treatment for Depression in an Adult Psychiatry Clinic Colleen S. Brems ARNP Lynda Green RN, BA Department of Nursing University of Iowa Hospitals and Clinics Iowa City, Iowa

2. Goal/ Problem Focused Trigger 2002 Re-evaluation of Adult Psych. Clinic Treatment Strategies 2002 Re-evaluation of Adult Psych. Clinic Treatment Strategies Current Gero-Psych Clinic based on Medical Model Current Gero-Psych Clinic based on Medical Model Is there a role for Psychotherapy with this population? Is there a role for Psychotherapy with this population? Little information on efficacy of psychotherapy with this population. Little information on efficacy of psychotherapy with this population. Clinical decision to be based on available evidence. Clinical decision to be based on available evidence.

3. Evidence Based Practice to Promote Quality Care Evidence Based Practice to Promote Quality Care Iowa Model Theoretical framework Iowa Model Theoretical framework Questions: Questions: Is psychotherapy appropriate modality for treatment of depression in this age group? Is psychotherapy appropriate modality for treatment of depression in this age group? Is one type of psychotherapy more effective than another? Is one type of psychotherapy more effective than another? Are adaptations needed for older population? Are adaptations needed for older population?

4. Literature Review Criteria Criteria Research Literature - English Language 1974-2004 Research Literature - English Language 1974-2004 Subjects Subjects 60y/o or older 60y/o or older MMSE > 24 MMSE > 24 Community Dwelling Community Dwelling Individual Psychotherapy Individual Psychotherapy Other Psychiatric Disorders excluded Other Psychiatric Disorders excluded BPAD, GAD, Psychosis BPAD, GAD, Psychosis

5. Relevant Research and Related Literature Class I : Random/Placebo Control (positive outcome) Class I : Random/Placebo Control (positive outcome) Acute Phase of Treatment Acute Phase of Treatment CBT alone 3 studies n = 75, 91, 30 Delayed wait list CBT alone 3 studies n = 75, 91, 30 Delayed wait list CBT with antidep 2 studies n = 102, 53 CBT with antidep 2 studies n = 102, 53 IPT with antidep 1 study Acute phase of Maintain. Study IPT with antidep 1 study Acute phase of Maintain. Study Bibliotherapy 2 studies n = 30,51 Bibliotherapy 2 studies n = 30,51 CBT, Behav, BDT 1 study n = 30 CBT, Behav, BDT 1 study n = 30 Meta-analysis 1974-1999 Meta-analysis 1974-1999

6. Relevant Research and Related Literature Maintenance Maintenance CBT with Antidep more effective than CBT, antidep, or placebo alone CBT with Antidep more effective than CBT, antidep, or placebo alone 1 study (2 years) + remission, but CBT alone poor prophylactic. Almost 50% dropout 1 study (2 years) + remission, but CBT alone poor prophylactic. Almost 50% dropout IPT w antidep > than IPT, antidep, or placebo, alone IPT w antidep > than IPT, antidep, or placebo, alone 1 study (3 years) n = 187 1 study (3 years) n = 187

7. Research /Related Lit Cont. Class II and III Class II and III Case Studies Case Studies CBT – Increased rate of homework completion demonstrated improved response CBT – Increased rate of homework completion demonstrated improved response IPT Descriptive Report w Case Vignettes IPT Descriptive Report w Case Vignettes Expert Guideline Expert Guideline “Guidelines for Management of Late Life Depression for Primary Care” “Guidelines for Management of Late Life Depression for Primary Care”

8. Implications of Review Of Literature Direct Comparisons limited because of size, different criteria. Direct Comparisons limited because of size, different criteria. Limited Modification Needed for Older Pop. Limited Modification Needed for Older Pop. Change is slower, Change is slower, Slower pace with increased reinforcement each session Slower pace with increased reinforcement each session Acute Phase Acute Phase CBT and IPT research has strongest support, CBT and IPT research has strongest support, Manual based, w supervised therapists, Manual based, w supervised therapists, CBT, IPT, BDT, PST, Bibliotherapy all > placebo CBT, IPT, BDT, PST, Bibliotherapy all > placebo CBT or IPT + Antidep effective for Mod - Severe CBT or IPT + Antidep effective for Mod - Severe Maintenance Maintenance CBT, IPT may be effective for mild- mod CBT, IPT may be effective for mild- mod Maintenance CBT, IPT + Antidep effective for mod - severe Maintenance CBT, IPT + Antidep effective for mod - severe

9. Pilot Change in Practice 07/02 – 12/02 07/03 – 12/03 Diagnosis MDD 2928 MMSE > 24 1011 MMSE Not rated 1616 MMSE < 24 31 Psycho Therapy 12 Med Management 2826 No. of Improve 610 Ave. Visits 2.131.82

10. Evaluation Data Limitations Data Limitations Tertiary Care Clinic – limited follow-up Tertiary Care Clinic – limited follow-up Small number of individuals with depression without dementia seeking ongoing treatment Small number of individuals with depression without dementia seeking ongoing treatment Clinic Reputation Medical Model Clinic Reputation Medical Model Bias against being seen in Psychiatry. Bias against being seen in Psychiatry.

11. Conclusions Psychotherapy is appropriate based on review of literature. Psychotherapy is appropriate based on review of literature. CBT or IPT effective for acute and maintenance treatment consistent with AHCPR guidelines for Adults. CBT or IPT effective for acute and maintenance treatment consistent with AHCPR guidelines for Adults. Alternative Strategies to identify and treat individuals are needed. Alternative Strategies to identify and treat individuals are needed. Education of Clinicians in Psychiatry, Primary Care, Geriatrics Education of Clinicians in Psychiatry, Primary Care, Geriatrics Education of General public Education of General public Efforts to minimize barriers to treatment Efforts to minimize barriers to treatment Ease of Access to appropriate resources Ease of Access to appropriate resources Challenge bias associated with depression Challenge bias associated with depression