Blackburn J.A., Dulmus C.N. (Editors). Handbook of gerontology: evidence-based approaches to theory, practice, and policy

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• Improving communication between physician and patient

• Utilizing written instructions along with verbal instructions

• Timing the medication administration to match the patient’s daily schedule

• Using mechanical aids to assist in reminding or organizing drugs

• Specifying in prescriptions that medications should not be dispensed in

safety-cap containers (AMA, 2002)

Addressing compliance is an issue not only for the patient and the prescribing

physician; it is recommended that family members, caregivers, and even social

service providers receive training in medication management and education

about adverse drug reactions.

SYCHOTHERAPY

Several evidence-based therapeutic interventions for depression are available.

However, because late-life depression is complicated by an increase in the number

of comorbid medical conditions, changing developmental stages, transitioning

life events, and changing roles of older adults, and because older adults’ principal

service use is through primary care physicians (Areán et al., 2003; Blazer, 2003;

Oxman, Dietrich, & Schulberg, 2003), the intervention’s effectiveness must be

tested specifically with this age group. Fortunately, several models of effective

individual and group therapeutic interventions are recommended for work with

depressed older adults (Scogin, Welsh, Hanson, Stump, & Coates, 2005). As men-

tioned earlier, these interventions are primarily based on the psychological theo-

ries of what causes depression in late life. Furthermore, psychotherapy has been

indicated to be a highly effective alternative or addition to pharmacotherapy in

treating late-life depression (Mackin & Areán, 2005). Several variations of psy-

chotherapy have been used with depressed older adults; the literature provides

specific evidence for four specific approaches: (1) behavior therapy, (2) cognitive

therapy, (3) problem-solving therapy, and (4) interpersonal therapy.

Behavior Therapy Behavioral therapy approaches attempt to increase participa-

tion in pleasant activities so that mood will rise (Lewinsohn, Biglan, & Zeiss,

1976). By using baseline measurements, behavior contracts, monitoring, and eval-

uation of results, this therapy has also become structured. These intervention

tasks promote the client’s ability to recognize and alter the impact of events on

his or her mood by increasing involvement in pleasant events. There is even a list

of over 250 activities, called the Pleasant Event Schedule, to help the older adult

generate ideas (Lewinsohn & Libet, 1972). The effectiveness of behavior therapy

alone (Lewinsohn et al., 1976; L. W. Thompson, Gallagher, & Steinmetz Brecken-

ridge, 1987) and in conjunction with other therapies (Ciechanowski et al., 2004) is

supported in the literature. A practitioner can obtain skills in behavioral therapy

through coursework or continuing education programs.

Cognitive-Behavioral Therapy Cognitive theory has been used as a brief therapy

based on manualized steps to identify and alter negative thought processes

that can lead to depression. Sometimes referred to as cognitive-behavioral ther-

apy (CBT), it has an educational component of teaching clients about cognitive

Depression 287

distortions, about skills to evaluate their thought processes, and then about

how to correct the negative distortions—which may then lead to an elevated

mood (Beck et al., 1979). This therapy has been specifically modified for use in

treating late-life depression (Laidlaw, Thompson, Dick-Siskin, & Gallagher-

Thompson, 2003).

Cognitive-behavioral therapy has the largest evidence base for the treatment of

depression in older adults (Areán & Ayalon, 2005; Scogin et al., 2005). Alone, CBT

has been found to be a beneficial treatment for late-life depression (Campbell, 1992;

Floyd, Scogin, McKendree-Smith, Floyd, & Rokke, 2004). Areán, Gum, and col-

leagues (2005) have also reported the effectiveness of CBT combined with case

management in decreasing depression for low-income older adults. Empirical stud-

ies regarding depression interventions for older adults have supported the compa-

rable effectiveness of CBT with other psychotherapies (i.e., interpersonal therapy,

psychodynamic therapy; Gallagher-Thompson & Steffen, 1994; L. W. Thompson

et al., 1987). A combination of CBT and medication was more effective than CBT

alone or medication alone (L. W. Thompson, Coon, & Gallagher-Thompson, 2001).

Several versions of manualized cognitive therapy are available for both individual

and group treatment. More recently, Simon, Ludman, Tutty, Operskalski, and Von

Korff (2004) reported results from a randomized controlled trial that participation

rates are high for a telephone psychotherapy program using cognitive therapy; this

intervention resulted in lower depression severity of the adult participants. Spe-

cialized training to conduct cognitive therapy is available in professional schools

and through continuing education events.

One criticism of CBT is that the exact mechanisms that make it effective are

unclear: It could be the therapeutic relationship, the metacognition development

of being able to step back prior to responding, or that CBT results in attitude

changes (Blazer, 2003). Another criticism is that CBT is as effective as other psy-

chotherapies, not more effective, as reported earlier. Therefore, other forms of

therapy can cause the same result of decreased depression; it is not clear, due to

spurious factors that result in similar outcomes of decreased depression, that cog-

nitions cause depression.

Problem-Solving Therapy for Primary Care This therapy, known by the acronym

PST-PC, incorporates components of both cognitive and behavioral theories into a

specific approach for the primary care setting (Catalan et al., 1991). It uses a part-

nership model and focuses on using clients’ strengths to improve on real-world

problems that matter to the client (e.g., loneliness, need to clean house, need to

schedule appointments). Repeated difficulties with these problems lead to

thoughts and feelings of hopelessness and helplessness. This therapy addresses

negative thought distortions by initially providing education on how problems

are a normal and predictable part of living, that depression is a sign that a prob-

lem is present, that the older adult has some degree of control over the problem,

and that effective solutions exist (Areán, Hegel, & Reynolds, 2001).

A session usually lasts about 30 minutes, with four to eight sessions total. De-

pressed older adults are instructed to use seven steps to solve problems: (1) clari-

fying and defining the problem, (2) setting a realistic goal, (3) generating

multiple solutions through brainstorming, (4) evaluating and comparing the solu-

tions using pro and con lists, (5) selecting a feasible solution, (6) implementing

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the solution through an action plan, and (7) evaluating the outcome. Additionally,

PST-PC incorporates behavior activation by planning weekly pleasant activity

schedules and monitoring the older adult’s activity level. Treatment has included

a step-down approach, using group therapy to conduct maintenance sessions

with older adults in partial remission of depression.

Problem-solving therapy for primary care has empirical support for use in

primary care clinics (Mynors-Wallis, 2003; Unützer, Katon, et al., 2002), senior

service agencies (Ciechanowski et al., 2004), and other community settings

(Alexopoulos, Raue, & Areán, 2003). This therapeutic approach has also in-

creased the positive treatment outcomes of minority patients (Areán, Ayalon,

et al., 2005). It is a highly structured, manualized therapy program that can be

conducted by non-mental health clinicians; however, research has shown that

mental health practitioners are more likely to maintain treatment fidelity to the

PST-PC model (Hegel et al., 2002).

Interpersonal Therapy Klerman, Weissman, Rounsaville, and Chevron (1984) de-

veloped interpersonal psychotherapy (IPT) as a time-limited, outpatient treat-

ment for depression that addresses difficulties with current interpersonal

relationships through active discussions. These difficulties are categorized into

four conflict areas: grief, interpersonal conflict with specific people, role transi-

tions, and interpersonal deficits that interfere when interacting with people in

general. The therapeutic process is divided into three phases. First, one to three

sessions focus on conducting an assessment of not only the depression but also

the client’s social functioning and close relationships and patterns and expecta-

tions of interacting in relationships. Second, over the course of the next 8 to 12

weeks, specific strategies to address the interpersonal problem area are enacted.

Third, the last four sessions involve increasing the client’s renewed sense of inde-

pendence and competence and preparing for termination (Feijo de Mello, Mari,

Bacaltchuk, Verdeli, & Neugebauer, 2005).

Interpersonal psychotherapy has been adapted to work specifically with de-

pressed older adults in primary care (IPT-PC; Bruce et al., 2004). The same four

conflict areas guide the treatment; however, Areán and colleagues (2001) have

identified that the main areas of conflict are grief and role transition. The adapta-

tion also follows the three phases of treatment, but alterations include increased

participation of family members and conducting sessions via the telephone. Re-

sults of testing IPT-PC specifically are not currently available. Used in conjunc-

ture with medications in a collaborative care approach IPT-PC does not appear to

adversely affect treatment outcomes (Bruce et al., 2004).

Even though IPT in general has supporting evidence for treatment of depres-

sion in adults of all ages (Feijo de Mello et al., 2005), few studies report specifi-

cally on the effectiveness of IPT with depressed older adults. Reynolds and

colleagues (1999) did present evidence that IPT is most effective when combined

with pharmacotherapy and is particularly helpful to patients with chronic de-

pression, which supports previous evidence of IPT for late-life depression (Sloane,

Staples, & Schneider, 1985). However, monthly maintenance IPT sessions were not

as effective as maintenance pharmacotherapy in preventing recurrent depression

(Reynolds et al., 2006). Miller and colleagues (2001) also reported initial findings

that IPT was beneficial for depressed elders with cognitive impairment.

Depression 289

In summary, several forms of evidence-based psychotherapy are available for

intervening with depressed older adults (Scogin et al., 2005). Psychotherapy is

recommended as a stand-alone treatment for mild depression or as an addition to

providing pharmacological therapy for major depression (Shanmugham et al.,

2005). In their recent review of treatment options for late-life depression in pri-

mary care, Areán and Ayalon (2005) found that there is not sufficient research ev-

idence to conclusively state which therapeutic approach is best. Again, paying

attention to the specific setting and administrative needs and to the client’s char-

acteristics should guide treatment selection. Otherwise, selection of the psy-

chotherapeutic approach should take into consideration the assessment of client

needs, client treatment preferences, and the practitioner’s skills and competency

for any specific therapeutic approach.

LECTROCONVULSIVE

HERAPY

For some older adults with depression electroconvulsive therapy (ECT) has

demonstrated effectiveness in alleviating depression when other treatments

have failed or when a rapid response is needed due to the severity and immedi-

ate risks of untreated depression. Electroconvulsive therapy requires a medical

doctor to administer an electrical induction of seizures to the brain in a series of

6 to 12 treatment sessions on an inpatient or outpatient basis (U.S. Department

of Health and Human Services, 1999). Often treatments are initiated while a pa-

tient is hospitalized to monitor for effect and then may be continued on an out-

patient basis under the supervision of a psychiatrist. Because depression seems

to be prevalent among people in old age and the use of prescription medication

may be less effective and safe for this particular population, ECT serves as an

important alternative. It appears to be effective for short-term outcomes and safe

(Tew et al., 1999; van der Wurff, Stek, Hoogendijk, & Beekman, 2003). In fact,

older adults constitute more than half of patients with depression who receive

ECT (Tew et al., 1999).

As mentioned, the use of medication to treat depression may exacerbate prob-

lems among older adults due to a tendency for slower response and medical co-

morbidities (U.S. Department of Health and Human Services, 1999). Furthermore,

older adults presenting with depression may have more immediate needs due to

the fact that their illness may be accompanied by serious health concerns such as

dehydration, disability, malnutrition, and immobility (Anderson, 2001; Tew et al.,

1999; U.S. Department of Health and Human Services, 1999). As stated by Tew

et al., “The degree of impairment associated with severe geriatric depression [war-

rants] rapid intervention” (p. 1868), which ECT may be better able to provide than

medication. Reasons for selecting ECT as a first-line treatment for older adults

with severe depression include the following: (a) ECT can promote a faster re-

sponse than pharmacotherapy, (b) drug interactions are infrequent, and (c) early

intervention is beneficial to treatment response (Tew et al., 1999).

The effectiveness of ECT in acute treatment of depressed older adults is sup-

ported by systematic reviews, naturalistic follow-up studies, and retrospective

studies (van der Wurff et al., 2003). Tew et al. (1999) offered support of the previ-

ous statement with findings illustrating the effectiveness of ECT among multiple

populations, including the oldest old (75+) despite their cognitive impairments

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and large physical illness burdens. A study by Rao and Lyketsos (2000) also found

ECT to be effective among depressed older adults with dementia; 40% of the sam-

ple responded positively to ECT treatment. Examining the efficacy of ECT among

older adults in 14 studies, van der Wurff et al. (2003, p. 897) found, “The immedi-

ate outcome figures are superior for ECT in all studies, varying from 48% com-

plete recovery to 92% improvement on ECT.”

Immediate results are promising, but the long-term results are much more ten-

tative. Benbow (1987) cautions that ECT-treated patients suffered from increased

readmission rates, with 36% of the patients having a readmission within 6

months. These results may imply that although ECT seems to elicit a positive

acute response to depression in older age, caution should be used when attempt-

ing to predict long-term recovery. A study undertaken by Tew et al. (1999) points

to this issue as an area in need of further study.

Common side effects for all recipients of ECT include confusion, temporary

memory impairment, head and muscle aches, and nausea (Anderson, 2001; U.S.

Department of Health and Human Services, 1999). In extreme instances, ECT has

been known to lead to death; Kelly and Zisselman (2000) reported 2 to 4 deaths

per 100,000 ECT treatments. Despite the possibility of side effects, ECT appears

to be a relatively safe treatment option for older adults. Tew et al. (1999) found the

oldest old (75+) to be just as tolerant of the treatment as those in the lower age

ranges. Van der Wurff et al. (2003) reported a small number of serious events, but

the majority of side effects tend to be mild and/or short-lived. The surgeon gen-

eral concluded that “there are no absolute medical contraindications to ECT”

(U.S. Department of Health and Human Services, 1999, p. 355). Some heart condi-

tions may require doctors to exercise caution (U.S. Department of Health and

Human Services, 1999); however, the regularly occurring cardiovascular compli-

cations are of the less severe and shorter-lasting kind (van der Wurff et al., 2003).

Thus, ECT, when administered over a limited time period under controlled con-

ditions, is considered safe. Evidence supports its short-term effectiveness as a

treatment for severe depression in late life.

ISEASE

ANAGEMENT

ROGRAMS AND

OLLABORATIVE

ARE

Due to the knowledge that a large portion of depressed older adults do not receive

many of the evidence-based depression treatments just described or specialty

mental health services (Charney et al., 2003), a new focus has been on integrating

evidence-based depression treatment into non-mental health settings. In particu-

lar, disease management programs were adapted to improve depression treatment

for younger and older adults. The theory for the disease management programs

was derived from the evidence-based model for treating chronic illness: the

chronic care model (Bodenheimer, Wagner, & Grumbach, 2002). By assessing how

provider-patient interactions are enhanced or hindered by community resources,

policies, and organization of the health care system (e.g., self-management sup-

port, delivery system design, decision support, and clinical information systems),

this model synthesizes system and practice changes associated with better out-

comes in chronic illness (Austin, Wagner, Hindmarsh, & Davis, 2000; Boden-

heimer, Wagner, & Grumbach, 2002). These disease management programs

incorporated evidence-based guidelines, patient self-management, systematic

Depression 291

screening, routine follow-up care, interdisciplinary teams, and, in some studies, a

designated staff member (i.e., depression care manager) to manage the patients’

depression treatment and interactions with service providers (Austin et al., 2000;

Oxman et al., 2003). Systematic reviews have supported the effectiveness of dis-

ease management programs for treating depression in adults (Badamgarav et al.,

2003; Neumeyer-Gromen, Lampert, Stark, & Kallischnigg, 2004).

In late-life depression treatment, these disease management programs have

also become known as collaborative care models. Several randomized controlled

trials of various collaborative care components have demonstrated the usefulness

of providing accessible and effective treatment in a variety of settings, such as in

primary care settings (Boult et al., 2001; Bruce et al., 2004; Oslin et al., 2003; Un-

utzer et al., 2001), hospitals (Oslin et al., 2004; Shah, Odutoye, & De, 2001), com-

munity senior services settings and public housing (Ciechanowski et al., 2004;

Rabins et al., 2000), and home health care (Blanchard, Watereus, & Mann, 1999).

Furthermore, several of these studies demonstrated positive outcomes associated

with collaborative care treatment, decreased depression severity and symptoma-

tology (Boult et al., 2001; Bruce et al., 2004; Ciechanowski et al., 2004; Rabins

et al., 2000; Unutzer, Katon, et al., 2002), and decreased functional impairment

(Boult et al., 2001; Ciechanowski et al., 2004; Unutzer, Katon, et al., 2002).

In general, these studies vary in the different collaborative components in-

cluded, but they typically involved a nurse or social worker acting as a dedicated

depression care manager with psychiatric clinical supervision, a stepped-care al-

gorithm, and a systematic tracking system to assess depression severity. As this

is a multifaceted approach that incorporates several evidence-based intervention

components, what constitutes required features is still being debated. In particu-

lar, the depression care manager has been highlighted as a key element for future

research to clarify the practicality and fiscal feasibility of transferring this inter-

vention to practice settings (Oxman et al., 2003).

To further exemplify the strengths of collaborative care, it is helpful to discuss

one prominent study. Unützer, Katon, et al. (2002) report on a multisite study

basedinprimarycarecalledIMPACT.TheIMPACTstudyusedaspecificcollabo-

rative care model to integrate evidence-based depression treatments into primary

care clinics. This collaborative care model used a depression care manager to:

• Conduct systematic assessments using standardized depression screens.

• Educate older adults about depression and prompt behavior activation.

• Provide brief psychotherapy using PST-PC.

• Facilitate consultation with primary care physicians and psychiatrists to

promote evidence-based medication management.

• Ensure follow-up to track depression outcomes, which would inform pa-

tient’s progression through the stepped-care treatment algorithm.

Several articles regarding IMPACT’s results report significant findings on the fol-

lowing outcomes: long-term decrease in depression severity and improved func-

tioning (Katon et al., 2002), improved arthritis outcomes and pain management

(Lin et al., 2003), improved diabetes management (Williams et al., 2004), de-

creased medical expenditures (Simon et al., 2001), and decreased racial and eth-

nic disparities in treatment outcomes (Areán, Gum, et al., 2005).

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In conclusion, disease management programs (i.e., collaborative care) are effec-

tive in treating late-life depression in a variety of settings when using a depression

care manager to coordinate the multiple evidence-based practice interventions, in-

cluding screening, pharmacotherapy, psychotherapy, and referral to specialty

mental health care as needed.

UICIDE

REVENTION

Several recent articles have detailed recommendations for suicide prevention

specifically for older adults, and they all highlight the importance of adequate de-

pression detection and treatment for this population (Heisel & Duberstein, 2005;

Pearson & Brown, 2000; Schulberg et al., 2004). Following the evidence-based

practices for depression treatment just described (psychotherapy, pharmacother-

apy, and ECT), this section details evidence-based interventions that go above

and beyond depression treatment to promote suicide prevention. In particular,

several suicide prevention efforts have targeted increasing the knowledge and

skills of primary care physicians and other practitioners to detect and address

suicide risk among their general client population (“National Strategy for Suicide

Prevention: Goals and Objectives for Action,” Public Health Service, 2001).

Even though systematic or standardized screening has not been recommended

for suicide prevention in primary care settings, training primary care physicians

to conduct suicide assessments and follow management algorithms has been sup-

ported (Schulberg et al., 2004). For example, the Respect Engineering Systems for

Primary Care Treatment of Depression treatment trial used an item from a stan-

dardized depression screener to trigger a systematic inquiry about the patient’s

suicide risk and specified proper management plans for implementation (Bartels

et al., 2004). The PROSPECT trial, mentioned earlier, demonstrated that a collabo-

rative care approach with a treatment algorithm incorporating pharmacotherapy

and/or interpersonal therapy resulted in decreased suicidal ideation and depres-

sion for older primary care patients when compared to usual primary care prac-

tice (Bruce et al., 2004).

Assessment of suicidal thoughts should include attention to known unmodifi-

able risk factors (i.e., age and sex); the clinical presentation of mental disorders,

substance abuse, and pain; and direct questions about the severity of the older

adult’s suicidal ideations and plans and the feasibility of the plans. For older

adults, an opening for the clinician to pursue this line of questioning would be

through more general end-of-life discussions (Schulberg et al., 2004).

Another avenue of suicide prevention is to ensure that crisis intervention ser-

vices are trained to address the specific risks and needs of older adults. However,

few studies address the effectiveness of crisis interventions, such as crisis hot-

lines, or older adults’ use of these services (Pearson & Brown, 2000). McIntosh

(1995) did provide a review of telephone outreach programs that demonstrated

some promise in reducing psychological distress and suicidal ideation. Overall,

multiple evidence-based treatment components are useful for addressing both de-

pression and suicide risk. Using treatment algorithms and collaborative care ap-

proaches, such as PROSPECT, can increase not only the use of efficacious

pharmacological and psychotherapeutic interventions, but also improve access to

treatment for older adults who are at risk for suicide.

Depression 293

Case Studies

To illustrate the use of the evidence-based practices in treating late-life depres-

sion, two case studies are presented next. First is a description of an elderly

woman who has had long-standing major depression. Her case study exemplifies

the multiple domains of causes and treatment needs related to managing her

chronic depression. The second case study provides an overview of an implemen-

tation study of the IMPACT collaborative care model in a community-based prac-

tice setting, thus highlighting the bench-to-trench process of integrating

evidence-based depression treatment. All identifying information has been al-

tered to protect the confidentiality of the individuals.

Mrs. J

As an 84-year-old widowed woman living on her own in the community, Mrs. J

prides herself on her independence and persistence. As a participant in a study

on depression in community long-term care, Mrs. J was excited to contribute her

knowledge and preferences to help inform future depression treatments for older

adults. Mrs. J openly described how she has experienced depression since her 20s,

when a series of traumatic events led to a “breakdown.” Since that time, she has

experienced a cycle of depressive episodes that has included at least one remis-

sion lasting over a decade. However, because Mrs. J has aged with a combination

of changes in roles, increased physical health problems that have made it more

difficult for her to leave her home, and financial difficulties, she reports a more

chronic duration of her depressive symptoms. Medical comorbidities of arthritis

and diabetes affect not only her health and functioning, but also her ability to

“get out” like she used to. Thus, she describes how her isolation leads to escalat-

ing depression due to boredom and loneliness. Mrs. J, who has previously re-

ceived extensive education on depression through prior specialty mental health

care, including hospitalizations, and her own self-learning through reading,

clearly identifies her current symptoms of low mood, loss of interest, fatigue,

trouble sleeping, overeating, and persistent thoughts of hopelessness. Though

adamant about not thinking about suicide, she does admit increased passive

thoughts of her eventual death.

To address her depression, Mrs. J works with a psychiatrist to obtain pharma-

cotherapy; however, she acknowledges not maintaining regular appointments due

to her difficulties with transportation. She does report that she adheres closely to

the medications prescribed and has a home health nurse who assists in setting up

her pill box. She has previously worked with both a cognitive-behavioral therapist

and an interpersonal therapist, but due to her current physical limitations and

low finances, she reports not receiving any therapy at this time. When asked

about her therapeutic experiences, she described how the specific techniques to

increase her coping skills were helpful, but what she really cared for was having

someone take the time to listen to her problems. The other current support Mrs. J

receives is from a home health care agency that provides in-home assistance 3

times a week for personal care and chore-worker tasks, which Mrs. J describes as

invaluable to maintaining her independent household and as a way to get social

contact during the week.

With her chronic depression and medical comorbidities, Mrs. J’s case demon-

strates how evidence-based practices could be integrated for someone who is

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already actively receiving treatment to further alleviate and monitor her depres-

sion. For example, introducing a systematic screening of her depression severity

may be necessary to help inform the effectiveness of the current pharmacother-

apy regimen, along with helping her to identify that change does occur in the

level of her depression. Evidence-based psychotherapy such as problem-solving

therapy may be conducted in-home or over the telephone to help her address

some of her problems of boredom and isolation. Also, having someone collaborat-

ing with Mrs. J to increase her behavior activation through scheduling feasible

pleasant activities may further break up her monotony. Finally, by integrating

collaborative care into her treatment, Mrs. J may experience a more streamlined

system of care for not only her depression but also her arthritis and diabetes. Col-

laborative care would also introduce a care manager to do proactive tracking of

depression, assist with coordinating the multiple professionals involved, and en-

sure that active treatment is pursued until the depression is alleviated through a

stepped-care algorithm.

The Delta “Collaborative Care” Project

The second case study overviews not a specific older adult’s experience with

obtaining evidence-based depression treatment, but how a system that is

overly burdened by depression is attempting to incorporate collaborative care

to promote the use of evidence-based treatments for its clients. In a pilot proj-

ect in a small region of a midwestern state’s public community long-term care

agency, steps to incorporate the key elements of the IMPACT model are cur-

rently under way. The clients were at increased risk for depression due to the

characteristics of the client population, which has eligibility requirements of

below poverty-level income and high functional impairment. This agency first

recognized the burden of depression through a clinical epidemiologic study

that reported that 1 in 4 of their new clients experienced depression (Morrow-

Howell et al., 2005).

Through guidance and support from the IMPACT investigators, this agency

collaborated with local researchers on adapting collaborative care for their

agency. Agency stakeholders, researchers, and the depression care managers at-

tended training sessions conducted by the original IMPACT investigators and

followed the IMPACT training manuals. Agency caseworkers then referred their

clients with depression to the depression care manager to receive a full assess-

ment, which included a standardized screen for depression, the PHQ-9. Under

the supervision of a local mental health specialist, the depression care manager

established a treatment plan that included either pharmacotherapy or brief

problem-solving therapy. Treatment choice was guided by the client’s prefer-

ence, previous effective use of each modality, and the acuity of the depression.

Through in-home visits by the depression care manager, all clients received

psychoeducation by watching an educational video on depression and discus-

sion, behavior activation in weekly pleasant activities, and systematic tracking

of outcomes by completing the PHQ-9 on a regular basis. The depression care

manager used a stepped-care algorithm and consultation with the client’s pri-

mary care physician and the consulting specialty mental health clinician to ad-

just treatment as needed. Although early in its implementation, this study has

already shown promise as a means of offering evidence-based interventions to

vulnerable, home-bound older adults with depression.

Depression 295

EVIDENCE-BASED POLICY RECOMMENDATIONS

Currently, older Americans can obtain coverage for mental health diagnosis and

treatment from Medicare, Medicaid, and private insurance. In general, insurance

coverage for mental health care is less than coverage for physical health care, and

often coverage is exhausted in the face of ongoing mental health needs (Unützer,

Schoenbaum, Druss, & Katon, 2006). In 1996, Congress passed the Mental Health

Parity Act, which required that most plans offer similar limits on mental and

physical health coverage; 30 states have laws requiring comparable coverage for

mental and physical health (Smyer & Shea, 2003). Yet these laws have not resulted

in meaningful changes (Frank, Goldman, & McGuire, 2001).

Almost all Americans over the age of 65 have Medicare Part A, which will pay

for up to 190 days of psychiatric inpatient days during a person’s lifetime (there is

no lifetime limit on psychiatric stays in general hospitals). Partial hospitalization

is also covered, with no day limits, but there is a 20% copayment. Postacute care

in skilled nursing facilities is covered, but this coverage is for rehabilitative, not

long-term, care (Cano & Hennessy, 1997). Medicare Part B pays for outpatient

mental health care provided by physicians, psychiatrists, clinical psychologists,

clinical social workers, and other mental health specialists. If these providers

serve an older patient who is hospitalized, 80% of allowed charges are covered.

However, in the outpatient setting, 50% of allowed charges are covered (Rosen-

bach & Ammering, 1997). The new Medicare Part D now covers the cost of psy-

chotropic drugs. It is not yet clear how different formularies available to older

adults will affect their use of psychotropic medications.

Although lack of parity in the Medicare program has long been recognized, it

is less widely acknowledged that current policy fails to support the adaptation of

evidence-based practice models. Policy initiatives that are currently being advo-

cated by geriatric mental health experts are based on evidence that collaborative

care models (e.g., IMPACT) are effective and adaptable to care settings that reach

a large number of older adults (e.g., primary care clinics and public housing). Re-

search on effective depression intervention programs points to two key ingredi-

ents: (1) systematic case management by a trained clinical staff to facilitate case

identification, assessment, education, coordination of a treatment plan, monitor-

ing, and follow-up; and (2) consultation between the care manager, primary care

provider, and consulting psychiatrist (Unützer et al., 2006). Yet these key compo-

nents are not currently covered by Medicare. That is, many of the case manage-

ment and consultation functions, including any contact made over the telephone,

are not covered. Further, regulations prevent a primary care visit and a mental

health visit at a single clinic on the same day, limiting the coordination of care re-

quired in effective treatment programs. Thus, revisions of Medicare policies are

necessary to advance the integration of evidence-based practice.

Medicaid varies by state, but by federal law, state programs must cover inpa-

tient and outpatient services, physician services, and skilled nursing home ser-

vices for the mental health needs of older adults. Only the poorest of older adults

qualify, and low reimbursement rates discourage providers from serving this pop-

ulation (Smyer & Shea, 2003). The Balanced Budget Act of 1997 permitted states to

further reduce outpatient payments (L. Murray & Eppig, 2002). In the past decade,

strained state budgets have led to mental health service provision for only the

most severely mentally ill older adults (National Alliance for the Mentally Ill