Evidence-based treatments identified for geriatric depression identified
By Paula Hartman-Stein, Ph.D.
With antidepressant medication as the first line of treatment in protocols endorsed by insurance companies, and Medicare requiring proof of medical necessity for all services, the identification of research- based psychological treatments for depressed older adults has arrived none too soon.
Five different psychological interventions have recently been identified as evidence-based treatments (EBTs) in managing geriatric depression, according to Forrest Scogin, Ph.D., of Tuscaloosa, Alabama, who is coordinator of a task force on older adults organized through Division 12 of APA.
These include behavior therapy, cognitive-behavioral therapy, problem-solving group therapy, cognitive bibliotherapy, and reminiscence group therapy. A treatment close to EBT status is interpersonal therapy.
The task force reviewed 107 studies on geriatric depression, coding 33 studies to determine whether they met the criteria as an evidence-based treatment. To qualify, the study needed a minimum of 30 participants, have a control or comparison group, and use subjects 60 years or older. Two independent raters evaluated each study, with 99% coding reliability.
"These kinds of efforts that identify evidence- based treatments and show that what we do works is absolutely critical," said Scogin. "EBTs guide professionals in their choice of treatment and can influence future research. In addition, identifying treatments with solid empirical support may facilitate insurance coverage of these services," he said. Reminiscence groups are one example of services that have been denied coverage by some Medicare carriers.
The task force chose to not include studies with combination treatments of antidepressant medication and psychotherapy because they were unable to tease out the specific effects of psychotherapy. The committee agrees that studies using combination treatments deserve recognition. Improved methods for coding may be developed in the future, Scogin said.
Former APA President, Nicholas Cummings, Ph.D., of Reno, Nevada predicts the inevitability of requiring EBTs in the future. "It won’t be long before they are the standard of care in malpractice suits," he said. "Soon the beleaguered malpractice insurers will cover only EBTs. The problem is that the research is usually directed at systems that are easy to quantify, and not on the need in the field."
Cummings and Scogin agree that implementing EBTs in real-world practice is difficult because patients are characterized by co-morbidities, or multiple health and behavioral problems. EBTs often exclude co-morbid conditions and have stringent measurements of therapist adherence to treatment protocols that are not always realistic in actual practice.
Ronald Levant, Ed.D., of Fort Lauderdale, Fla. president-elect of APA, points out the problem that many EBTs use homogeneous samples of white, middle class clients. In the geriatric EBTs that were reviewed, Scogin found that "subjects tended to be on the young-old side, with few studies of the old-old who often live in long term care settings."
The older adult task force is currently focusing on identifying additional EBTs for anxiety, sleep disorders, behavior problems in dementia, caregiver stress, and memory training. Regardless of the drawbacks, Scogin emphasized that EBTs enhance the credibility of psychology as a discipline that integrates science with practice. The present body of scientific evidence is not developed enough to serve as the sole foundation for clinical practice, according to Levant. He suggests a broader definition of evidence-based practice that contains best research evidence, clinical expertise, and patient values.
"Such a model that values all three components equally will better advance knowledge related to best treatment and provide better accountability," said Levant. Cummings points out that all EBTs need to be subjected to field-testing in large delivery systems, but he said no one is doing that ... yet.
The National Psychologist, 2004, vol. 13. No. 2, P. 9