Colleen S. Brems ARNP Lynda Green RN, BA Department of Nursing University of Iowa Hospitals and Clinics Iowa City, Iowa

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 • Current Gero-Psych Clinic based on Medical Model • Is there a role for Psychotherapy with this population? • Little information on efficacy of psychotherapy with this population. • Clinical decision to be based on available evidence.

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

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

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

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

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

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

9. Pilot Change in Practice

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

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