Research That Matters (January 17 - 20, 2008)

Background and Purpose: Subthreshold depression (SD) is a serious mental health disorder in medically ill homebound older adults. Prevalence estimates of depression in home care elderly are 13.5% and 27.5% for severe depressive symptomatology. However, few medically ill elderly patients receive adequate or effective treatment for depression. Subthreshold depression is accompanied by significant functional decline, increased health care use, and is a risk factor for mortality from medical conditions as well as suicide. Randomized controlled trials in primary care settings have examined the effectiveness of recommended treatments for this disorder, yet none have been tested in home health care settings. Our research group describes the results of an ongoing pilot study of brief Problem Solving Therapy in Home Care (PST-HC) designed to decrease depressive symptoms in medically ill homebound elderly.

Methods: The study involved a pilot randomized field trial comparing the impact of PST-HC to UC (usual care) augmented with depression education in a sample of 62 older medically ill home care patients with subthreshold depression. Participants were recruited through home care intake assessment screens from a university-affiliated agency. Primary inclusion criteria were 65 yrs or older, English speaking, CES-D depression score of 22 or greater, no cognitive impairment (MMSE=24 or greater), not currently receiving treatment for depression, and signed informed consent. Exclusion criteria included acute suicidal behavior, diagnosis of psychosis, bipolar disorder, personality disorder, or substance abuse within the past 6 month. Trained clinical social workers provided six weekly sessions of home-based PST-HC to participants in the experimental condition. PST-HC was based on an empirically-validated model developed for adult depression. Control group participants received six weeks of home care services plus one session of depression education. All participants received a primary care referral for antidepressant medication. The main outcome measure was depression and secondary outcomes were problem-solving abilities, quality of life, and satisfaction with treatment. Data analyses included descriptive statistics and random effects regression models for condition and time.

Results: No differences between the two groups were found on any demographic variables. At baseline, all participants were experiencing clinically significant levels of depressive symptoms when compared with normative samples. Outcome data suggested significant reduction in depression symptomatology and improvement in problem-solving abilities after PST-HC intervention relative to Usual Care. Positive effects of the intervention protocol were maintained 3 and 6 months after treatment ended. At posttest, the PST-HC group was also more satisfied with treatment as compared to the control condition.

Conclusions and Implications: PST-HC provides encouraging findings as an emerging psychosocial intervention that may improve the care for medically ill elderly with subthreshold depression. Researchers discuss results in terms of "real-world" social work applicability of this behavioral treatment and present implications for social work practice and research in this setting.