Introduction
Depression is one of the most widespread mental illnesses in the world. Employees have to take sick leaves or even leave their positions due to the illness, especially if it remains untreated. More than 80% of people who have symptoms of clinical depression do not receive any help (Australian and New Zealand College of Psychiatrists, 2016). In the USA, 1 in ten Americans has experienced or exhibited signs of depression at least once in their life (Uher et al., 2012). Even though more than twenty different types of drugs exist to treat depression, patients’ responses to them can be insufficient or unsatisfactory.
According to Uher et al. (2012), in the USA depression can be defined by the following symptoms: feeling of sadness almost every day, loss of interest in hobbies, difficulty in making decisions, lack of enjoyment in activities that formerly were enjoyable, feeling of hopelessness and loss of meaning. If these guidelines are compared to the Australian and New Zealand guidelines on symptoms of depression, it is evident that there is little difference between them: Australian and New Zealand College of Psychiatrists (2016) also name feelings of emptiness or sadness, lack of interest in hobbies or other activities, changes in appetite or weight, restlessness or lack/excessive sleep as primary symptoms of depression. The guidelines can vary from organization to organization but generally have a similar scope of symptoms.
Even though depression is more prevalent in adults (35-45 years old), adolescents and young adults are diagnosed with this illness more often every year (Uher et al., 2012). Depression can significantly complicate one’s life, worsen its quality, and sometimes lead to suicide or other harmful behavior. Particular attention should be paid to intervention techniques in the treatment of vulnerable patients (older adults) with depression.
Study #1; Nursing Research Study in the USA
Kiosses, D. N., Ravdin, L. D., Gross, J. J., Raue, P., Kotbi, N., & Alexopoulos, G. S. (2015). Problem adaptation therapy for older adults with major depression and cognitive impairment: A randomized clinical trial. JAMA Psychiatry, 72(1), 22-30.
The purpose of the study was to compare the efficacy of the 12-week PATH program and supportive therapy in older adults diagnosed with major depression (hypothesis: PATH program more efficient than ST). The sample (74 individuals ≥65 years) was recruited using different collaborating community agencies of Weill Cornell Institute of Geriatric Psychiatry. Inclusion criteria in patients were these: they had nonpsychotic, unipolar MDD DSM-IV diagnosis, mild cognitive deficits, disability, and limited mobility. They were not taking antidepressants, memantine, or cholinesterase inhibitors (Kiosses, Ravdin, & Gross, 2015). They were not involved in psychotherapy and did not have advanced dementia. 85.1% of the sample size participated in the research.
Randomization was designed using SAS; raters worked as independent evaluators and collected data, whereas participants were asked not to reveal their randomization status. No information about the determination of the sample size is given. The effectiveness of the intervention was tested via a MADRS total score (≤7 or ≤10) for two weeks without disruptions. Patients were randomly assigned via SAS.
The results indicate that PATH participants experienced a greater reduction in depression and disability, and higher remission rates (both full and partial) than ST-CI participants did during the 12-week intervention.
JAMA-Psychiatry is a peer-reviewed journal, which supports research’s credibility. The design used provided detailed results to address the research question and was appropriate. The measuring instruments were reliable scores used for the assessment of depression and disability (Montgomery-Asberg Depression Rating Scale and the World Health Organization Disability Assessment Schedule II).
Extraneous variables were four therapists who administered both treatments; each of them was trained and supervised to avoid bias.
The intervention was created by the authors, and appropriate training was designed; all participants were randomized into two similar groups. Interventions continued throughout 12 weeks. The groups were treated equally, but the found difference could rely on other factors such as therapists’ allegiance (Kiosses et al., 2015).
The findings can be considered as credible, although the small sample size and possible bias indicate the need for further research. The target population is described clearly with necessary indications of disabilities, diagnoses, mean age, gender, and medications used or nor used by members before the research.
The treatment effect is impressive because it shows how a PATH intervention can significantly reduce depression in older adults and improve their partial or full remission; if it would be tested on a larger sample and show its efficiency, it could provide significant improvements in clinical practice of nurses working with patients with depression and physical/cognitive disabilities.
Further research should include a larger, less homogenous sample size and non-allegiant therapists who are at lower risk of creating bias. If the intervention is effective, it can be incorporated into the local recommendations for treating depression. Its further testing will show whether it can be used on a national level.
Study #2; Nursing Research Study Non-USA
Underwood, M., Lamb, S. E., Eldridge, S., Sheehan, B., Slower, A. M., Spencer, A.,… Diaz-Ordaz, K. (2013). Exercise for depression in elderly residents of care homes: A cluster-randomized controlled trial. The Lancet, 382(9886), 41-49.
The purpose of the research was to understand whether exercise programs of moderate-intensity would reduce depressive symptoms in elderly patients with depression in nursing homes in England.
The sample was obtained in two regions in England: northeast London, and Coventry and Warwickshire (Underwood et al., 2013). Inclusion criteria were the following: participants were aged 65 years or older, we’re able to participate in the study, had given their written consent, were English speaking, and permanent residents. Participants with severe communication problems, a terminal illness, or those who were asked not to be approached by the care manager were excluded from the study. 891 participants contributed data to researchers before randomization; when the six-month follow-up was conducted, 114 of the participants died. Thus, the sample size decreased.
To collect data, MMSE, EQ-5D, and SPPB were used to measure cognitive function, quality of life, and functional performance respectively. The geriatric depression scale-15 (GDS-15) was used to measure depressive symptoms among the participants.
The sample size was recruited only via those care homes where more than six residents were able to take part in the study, and all residents could communicate and speak English.
An independent statistician was recruited to randomize each home after the baseline data collection at that home. However, researchers who collected follow-up data from participants and participants themselves were aware of home randomization due to physiotherapists’ activities within it.
The main findings indicate that group exercise classes that were conducted for 12 months had no effect on depressive symptoms among care home residents with no regard to participants’ present or absent depression at baseline.
The Lancet is a weekly peer-reviewed journal, one of the oldest journals dedicated to problems in healthcare and healthcare research; it can be considered credible.
The design was appropriate because it allowed the researchers to test the efficiency of interventions in a cluster-randomized controlled trial that reduced bias but targeted the primary population (older adults). Obtained data and analysis answer the research question by indicating that exercise interventions are not effective in reducing depressive symptoms in older adults.
The measuring instrument (the geriatric depression scale-15 or GDS-15) was appropriate because it is an accurate and sensitive tool for the measurement of depressive mood (Underwood et al., 2013). No extraneous variables were discussed.
Participants were not randomly assigned; instead, randomization targeted care homes, which were minimized into intervention and control groups depending on the home provider. The intervention was well-defined and included staff training for the intervention group, as well as 45-minutes exercise sessions (two days per week) that lasted 12 months. All groups were treated equally. The sample size was large enough to indicate the difference (891 at the beginning of the intervention and 679 at the end of the follow-up), but it was not found.
Despite the researchers’ and participants’ awareness of the randomization, these findings can be considered credible since they were tested in more than 20 care homes. The findings can be used for further interventions with elderly citizens that will not include exercising as primary intervention often used in clinical practice. The results are clinically applicable because they indicate that nurses might use other types of interventions (therapy, medicine) to reduce depressive symptoms.
Study #3; Nursing Research Study Non-USA
Haugan, G., Innstrand, S. T., & Moksnes, U. K. (2013). The effect of nurse-patient interaction on anxiety and depression in cognitively intact nursing home patients. Journal of Clinical Nursing, 22(15-16), 2192-2205.
The purpose of the study is to test the effect of nurse-patient interaction on depression and anxiety symptoms among nursing home patients. The hypotheses: nurse-patient interaction influences depression positively, influences anxiety, and depression influences anxiety negatively.
The sample was obtained via 44 nursing homes in Norway (250 patients). Patients who were provided with long-term NH care lived in NH for more than six months, provided informed consent, and were able to participate in interviews met the inclusion criteria. The total sample consisted of 202 participants. A questionnaire was used to collect data. The intervention was not tested, and no patients were assigned to groups randomly. The main findings of the study indicate that good relationships between nurses and patients were negatively associated with depression, whereas the indirect influence of nurse-patient relationships on anxiety (mediated by depression) was also detected. A significant relationship between anxiety and depression was also found.
The study was published in a peer-reviewed journal; the design of the study (cross-sectional design and statistical analysis of data provided by participants) was appropriate to answer the research question, but it provided information relatable to a particular point of time. The measuring instrument (The Nurse-Patient Interaction Scale NPIS) was developed by the authors of the research and is valid. Important extraneous variables were the quality of nursing care and the patient’s attitude toward nurses; the variables were introduced either by NH’s staff or by residents during the research.
The target population is clearly described (elderly patients who live in nursing homes in Norway). The finding would establish a more holistic approach to nursing care, thus resulting in improved quality of nursing care and reduction of depressive symptoms in patients. If this intervention becomes policy-based, it can significantly lower depression rates in residents of nursing homes; further research is needed to demonstrate whether these findings apply to larger, more diverse populations.
Study #4; Nursing Research Study in the USA
Choi, N. G., Marti, C. N., Bruce, M. L., Hegel, M. T., Wilson, N. L., & Kunik, M. E. (2014). Six‐month postintervention depression and disability outcomes of in‐home telehealth problem‐solving therapy for depressed, low‐income homebound older adults. Depression and Anxiety, 31(8), 653-661.
The purpose of the study was to determine whether telehealth problem-solving therapy (tele-PST) was more effective than in-person PST and to report long-term outcomes of tele-PST. The hypothesis: tele-PST is cost-effective and efficient for low-income, homebound older adults in treating depression. Participants were served by a large home-delivered model (HDM) and recruited with the help of their case managers. Exclusion criteria were a high suicide risk, bipolar disorder, possible dementia, and psychotic disorder (Choi et al., 2014). 158 participants participated in the study. The 24-item Hamilton Rating Scale for Depression was used to assess participants’ depression, and different types of PST were used as tools of intervention and data collection.
Mixed-effects regression analysis was used to assess depression severity and disability in participants. Patients were randomly assigned to different treatment groups: tele-PST, PST, and care call.
The main findings indicate that both tele-PST and in-person PST (if compared to care calls) were effective for the treatment of depression in low-income homebound older adults. The effects of tele-PST were sustained longer than those of in-person PST (Choi et al., 2014). Reciprocal and indirect effects between disability outcomes and depression were also noted.
The study was published in a peer-reviewed journal; the study design (randomized controlled trial) was appropriate to evaluate the effect of tele-PST and avoid possible bias. The obtained data answer the research question by indicating that tele-PST had both short- and long-term effects and was efficient. HAM-D is an effective scale for the measurement of depressive symptoms and is widely used in clinical care and research. The study could be influenced by extraneous variables, e.g. participants’ context (relationships with family, low economic status, etc.).
Participants were assigned to different groups with a different number of members (tele-PST: 56; in-person PST: 63, care call: 39). All parts of the intervention (tele-PST, PST, and care calls) are explicitly defined by the authors. Six sessions (60 minutes each) were provided to participants with a 24- and 36-week follow-up; care calls were provided twice a week (30 minutes each). The groups were not treated equally (although this inequality relates to the intervention): participants who received care calls only communicated with therapists for 30 minutes, while in-person and tele-PST sessions were longer (60 min.). The found difference indicates that it was due to the intervention because the authors previously conducted a similar study on the short-term impact of tele-PST, which also provided positive results (Choi et al., 2014).
The findings are credible because the intervention was tested twice (in a previous and current study). The target population (homebound elderly adults (50+ with disabilities and depressive symptoms) is clearly described. The treatment effect can make PST therapy more cost-effective both for medical facilities and patients if it used as the basis for care. The findings are clinically significant: they indicate that the unmet needs of homebound older adults can be addressed by the use of technologies. Further research is needed to understand why tele-PST was so effective in a long-term perspective.
Conclusion
Depression in older adults has to be addressed due to their particular vulnerability. As the research shows, interventions, designed and led by medical professionals (PATH and tele-PST) are exceptionally efficient. Physical activities did not affect depressive symptoms in patients, which indicates that other interventions are necessary. The nurse-patient relationship can significantly affect depression; good relationships was negatively associated with depression but had to impact on anxiety. However, anxiety was mediated by depression. The findings of the studies indicate that a well-designed, evidence-based holistic intervention would provide more successful treatment for elderly patients with depression.
References
Australian and New Zealand College of Psychiatrists. (2016). Clinical practice guidelines team for depression. Australian & New Zealand Journal of Psychiatry, 38(6), 389 – 407.
Choi, N. G., Marti, C. N., Bruce, M. L., Hegel, M. T., Wilson, N. L., & Kunik, M. E. (2014). Six‐month postintervention depression and disability outcomes of in‐home telehealth problem‐solving therapy for depressed, low‐income homebound older adults. Depression and Anxiety, 31(8), 653-661.
Haugan, G., Innstrand, S. T., & Moksnes, U. K. (2013). The effect of nurse–patient interaction on anxiety and depression in cognitively intact nursing home patients. Journal of Clinical Nursing, 22(15-16), 2192-2205.
Kiosses, D. N., Ravdin, L. D., Gross, J. J., Raue, P., Kotbi, N., & Alexopoulos, G. S. (2015). Problem adaptation therapy for older adults with major depression and cognitive impairment: A randomized clinical trial. JAMA Psychiatry, 72(1), 22-30.
Uher, R., Perlis, R. H., Henigsberg, N., Zobel, A., Rietschel, M., Mors, O.,… & Maier, W. (2012). Depression symptom dimensions as predictors of antidepressant treatment outcome: Replicable evidence for interest-activity symptoms. Psychological Medicine, 42(5), 967-980.
Underwood, M., Lamb, S. E., Eldridge, S., Sheehan, B., Slowther, A. M., Spencer, A.,… Diaz-Ordaz, K. (2013). Exercise for depression in elderly residents of care homes: A cluster-randomised controlled trial. The Lancet, 382(9886), 41-49.