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The treatment of depression in low-income older adults who live in poverty is complicated by several factors. Poor access to resources, disability, and mild cognitive impairment are the main factors that moderate treatment effects in this population. Interventions that not only address the depressive syndrome but also manage social adversity are sorely needed to help this patient population recover from depression.
This paper is a literature review of correlates of depression in late life. In the review we propose a treatment model that combines case management to address social adversity with problem solving treatment to address the depressive syndrome.
We present the case of Mr. Z, an older gentleman living in poverty who is also depressed and physically disabled. In this case we illustrate how the combination of case management and problem solving treatment can work together to ameliorate depression.
The combination of age, disability and social adversity complicates the management and treatment of depression. Case management and problem solving treatment are interventions that work synergistically to overcome depression and manage social problems.
10% of people over the age of 65 live at or below the poverty line (Census, 2004), and have higher rates of major depression (9%) than do community dwelling older adults (3.8%)(Gum, Arean, & Bostrom, 2007). Depression in older adults is treatable, particularly when access to these treatments is integrated into settings where older adults are most likely to use them. Studies integrating antidepressant medication management and psychotherapy into primary care settings find an increase in access to these treatments, as well as improved depression and function when compared to older adults who receive care as usual, with positive outcomes lasting as long as two years after treatment initiation (Hunkeler et al, 2006; Unutzer et al, 2002; Bruce et al, 2004). Additionally, data suggest that providing care in the home can reduce depression and increase functioning in older, disabled adults (Rabins et al, 2000; Ceichanowski et al, 2004; Van Critters & Bartels, 2004; Ell et al, 2007).
Although late life depression is a treatable illness in a variety of settings, low-income older adults benefit less from pharmacotherapy and psychotherapy than more affluent older adults (Cohen et al., 2006) Alexopoulos, 2001; Arean & Alexopoulos, 2007; Arean et al., 2005; Spillmann et al., 1997) (Gum et al., 2007). These individuals often experience financial strain, crime and violence and live in an unstable housing environment (Angel RJ, 2003; Gum et al., 2007; Krause, 1987), problems that antidepressant medication and psychotherapy cannot directly address. We argue that the care of depressed, low-income elders should offer direct help and advocacy to meet the social needs that these older adults cannot manage on their own, enhance their ability to utilize the resources that may become available to them, and address their depressive symptoms.
Poverty promotes depression by increasing the burden of medical illnesses contributing to depression because of poor health care and health related behaviors (Angel RJ, 2003; Arean & Alexopoulos, 2007; Bruce et al., 2004; Butler, 1991; Cairney & Krause, 2005; Corney, 1984; Dohan, 2002; Epping-Jordan, Bengoa, Kawar, & Sabate, 2001; Frojdh, Hakansson, Karlsson, & Molarius, 2003; Garrett, 2003; Gilman, Kawachi, Fitzmaurice, & Buka, 2003; Gum et al., 2007; Krause, 2005; Mellor & Milyo, 2003; Nunez, Armbruster, Phillips, & Gale, 2003; Ostir, Eschbach, Markides, & Goodwin, 2003). It exposes individuals to chronic adversity as even their basic needs are often unsatisfied (Bruce ML, 1994; Butler, 1991; Cairney & Krause, 2005; von Goeler, Rosal, Ockene, Scavron, & De Torrijos, 2003). Disability, whether it comes from depression or from other medical conditions, adds another layer of chronic adversity (Arean et al., 2005; Bruce et al., 2004; Butler, 1991; Fry, 1993; Garrett, 2003; Gilman et al., 2003; Gum et al., 2007). Research suggests that many people in poverty have limited problem solving skills (Krause, 1987, , 1993; Lorant et al., 2003), which further enhance the experience of adversity through difficulties in utilizing available resources(Kraaij, Arensman, & Spinhoven, 2002; Krause, 1995; Ostir et al., 2003). Adversity from unsatisfied needs or from repeated failures contributes to poor self-efficacy, hopelessness, and eventually negative affect(Ashby, Isen, & Turken, 1999; Kraaij et al., 2002; Pudrovska, Schieman, Pearlin, & Nguyen, 2005), thus further fueling the experience of adversity and promoting depression(Kraaij et al., 2002; Krause, 2005; Krause & Baker, 1992; Moos, Brennan, Schutte, & Moos, 2006).
An intervention that addresses both access to services and improves problem solving skills may interrupt the spiral of interacting factors contributing to depression in low-income, disabled older adults. Case Management (CM) may improve access to health care and reduce the impact of medical disorders promoting depression, and through the provision of other services, reduce hardship. Problem Solving Treatment can make elders become better managers of their lives (Krause, Herzog, & Baker, 1992), reducing the experience of adversity(Fry, 1993; Kraaij et al., 2002; Krause & Shaw, 2000). An intervention enabling patients to manage the problems they can address while also improving access to services maximizes the chances of overcoming depression (Ashby et al., 1999).
Different types of case management exist but all share the theme of helping individuals cope with their illnesses through linkage to social services, advocacy, rehabilitation and ongoing support during recovery from illnesses(Moos et al., 2006). Mueser et al.(Nezu CM, 1998) have divided case management into rehabilitation models, intensive case management, and standard case management. Rehabilitation and intensive models are for patients with severe mental illness and involve an array of team-based services. Standard case management has largely been used for less severe mental illnesses, such as major depression, and for chronic health problems.
Standard case management is offered by case managers who are advocates for the client (Coleman & Newton, 2005). Problem resolution is achieved through a joint effort by clients and case managers, but the case managers do most of the problem solving on behalf of the client. Standard case management offers education about treatment, encouragement in utilizing resources, and crisis intervention. Case managers maintain long-term relationships with their clients so that they can monitor their changing needs and provide additional resources (Artistico, Cervone, & Pezzuti, 2003; Phillips, Smith, & Gilhooly, 2002). While CM has therapeutic ingredients (psychoeducation about depression, reduction of adversity, development of a relationship, encouragement, linkage to social and health services), we believe that case management is necessary but not sufficient to treat depression, and an active depression intervention should be part of CM.
Problem Solving Treatment (PST) is an intervention that has been found to be effective in treating depression in older adults (Arean et al., 2005; Johnsen M, 1999). The goal of PST is to teach clients how to objectively and systematically manage the problems that are either causing or exacerbating their depression. The goal of CM is to create a more favorable environment for its clients by addressing their social and health needs through linking clients to serves, and thus problem solving is implicit in its mission. PST approaches patient problems from a different, yet complementary, angle. Unlike CM that seeks to increase the availability and utilization of resources by its clients, PST focuses on the patients themselves and helps them develop skills in identifying, prioritizing, and solving problems, and thereby creates a sense of empowerment. Thus, although CM and PST have different theoretical premises, they both focus on the resolution of concrete problems promoting depression.
Integrating PST with CM produces a synergy by compensating for each approach’s limitations. A limitation of PST is that depressed low-income older adults often have problems that they cannot solve by themselves even after enhancement of their problem solving skills (Mueser, Bond, Drake, & Resnick, 1998). For example, accessing financial, legal, housing and medical services requires an understanding of the bureaucracy of these services that many low-income older adults do not have. Case managers can overcome some of the barriers through direct action. However, CM recipients rely on case managers and do not learn how to become their own advocates and feel empowered. Access to services alone is insufficient, because depressed elders may make limited use of them. Many depressed elders also have executive dysfunction, which leads to difficulties in planning, initiating, and sequencing their actions. PST has been found effective in such patients(Mueser et al., 1998). Thus it is logical to expect that helping depressed elders with their needs and improving their ability to cope with stressors and to utilize their new resources would have a synergistic effect. Beyond logic, there is preliminary empirical evidence suggesting that PST can be integrated in CM (Kanter, 1989; Simpson, Miller, & Bowers, 2003) and may even be effective in depressed elders.
UCSF and Cornell University have developed an intervention manual that combines the delivery of CM and PST together. This intervention has been studied on a small scale for feasibility in delivery by case managers who work for home-based meals programs, programs that are most likely to encounter low-income, disabled older adults, with promising results. Treatment consists of 12 weekly meetings in which the case manager teaches the patient the PST model and also updates him/her on case management activities during these sessions. Case management typically takes place between sessions and consists of service linkage, patient advocacy and support. PST consists of teaching seven steps in the problem solving process which includes generating a problem list, defining problems clearly and succinctly, setting a goal, generating solutions, picking the best solution and creating an action plan to implement the solution. CM activities and PST are delivered concurrently.
The first session consists of a needs assessment and education on the CM-PST process. The case manager explains the basic concepts of CM-PST and divides problems into those that the case manager will address and problems that the patient will work on using the PST model. During this introductory discussion, the case manager describes the PST process and indicates that both the case manager and client will use the same PST forms to solve problems. The next 10 minutes is devoted to needs assessment, prioritizing problems and dividing them into problems the case manager will work on and problems the client will work on. The remaining time is spent solving a problem using the PST forms and walking the client through the PST steps. By the end of the first session, both the case manager and the client each have a problem solving plan to implement. During the next 11 sessions clients are instructed how to use PST to solve jointly-identified problems. The case manager uses strategies described under CM to address problems determined to be above the client’s ability to solve.
Mr. Z was a 75 year old, widowed Caucasian man who suffered from macular degeneration and diabetes, which had resulted in above the knee amputation and subsequently difficulty getting from place to place. He was treated with insulin, the beta blocker atenolol, aspirin, and vitamins. Because of poor income, poor eyesight and limited mobility, Mr. Z had become increasingly depressed. His depressed mood was noted by his social worker who was unable to get him motivated to use the resources available to him. Psychiatric assessment of Mr. Z revealed that he met DSM-IV criteria for major depression, with impairment in day-to-day functions. According to his physician, Mr. Z should be able to manage his day-to-day activities, despite his illnesses. A case worker trained in case management and problem solving therapy (CM-PST) visited Mr. Z at his home and worked with him to identify problems that were above Mr. Z’s ability to deal with as well as problems that Mr. Z could work on using a problem solving approach. Mr. Z’s case worker was able to link him to paratransit, which enabled him to go to his senior citizen center and to his medical appointments. The case worker also made arrangements for Mr. Z to obtain a new prosthesis.
Furthermore, Mr. Z and the case worker used the PST approach to identify problems that Mr. Z could address. The case worker helped Mr. Z with decisions related to his daily routine and some of his affairs, including setting limits with his son. Mr. Z identified the series of steps he needed to take prior to his visit to the senior citizen center, i.e. notify paratransit and prepare his clothes a day ahead of his visit, get up from bed well ahead of the time of his departure, and establish a routine for his personal hygiene. He used a similar approach for his medical visits and developed a plan for injecting his insulin and for taking his medication. Mr. Z also prepared a written list of contingency actions that he could undertake if challenged by his son. Twelve weeks after this intervention, Mr. Z’s depressive symptoms subsided and his HDRS dropped to 7 from a baseline of 32. Mr. Z reported feeling connected with the world, supported by the services he had received, and empowered by his increased ability to prioritize his problems, think of alternatives, and decide on a course of action.
Depression afflicts 9% of low-income elders and occurs in the context of high medical burden and disability. Beyond personal suffering, family disruption, and exacerbation of disability, depression worsens the outcome of medical illnesses and increases the risk of suicide. The clinical context in which late-life depression occurs coupled with the limitations imposed by financial problems creates a formidable challenge for care. While pharmacotherapy can be efficacious, its benefits may be limited in depressed, low-income elders, who often experience executive dysfunction, a clinical state associated with poor treatment response. Very few older adults consistently take antidepressants, which even when taken regularly only results in a 35–40% remission rate. Psychotherapy alone may not be feasible or adequate for depressed, low income elders who have to struggle for their next meal, are distressed over the loss of their home, or live with pain and disability because of limited access to care. Case management (CM) facilitates access to social services and medical care and offers to its client’s education about their treatment needs, and encouragement and support in utilizing their resources, especially those related to their treatment and rehabilitation. The resources offered by CM are critically needed by depressed, low-income elders. However, CM may be insufficient because it does not enrich its clients’ behavioral repertoire with problem solving skills needed to negotiate adversity and to overcome the inertia created by depression. Clinical logic and emerging empirical data suggest that integrating CM with PST may have a synergistic effect in depressed low-income elders, as CM can help them with their social needs and PST can improve their ability to cope with chronic stressors and utilize their new resources. Case workers are often social workers, whose professional orientation is focused on problem solving approaches, including case management. We have documented that social workers can be trained in PST. Like CM, PST when delivered in patients’ homes has been well accepted. Thus, CM-PST has the potential to be an efficacious and efficient clinical intervention addressing the complex socioeconomic and clinical problems of the most disadvantaged and suffering elderly population.
Authors have no conflict of interests to report
Patricia A. Areán, University of California, San Francisco.
Scott Mackin, University of California, San Francisco.
Eleanor Vargas-Dwyer, University of California, San Francisco.
Patrick Raue, Weill Cornell Institute of Geriatric Psychiatry, Weill Cornell Medical College.
Jo Anne Sirey, Weill Cornell Institute of Geriatric Psychiatry, Weill Cornell Medical College.
Dora Kanellopoulos, Weill Cornell Institute of Geriatric Psychiatry, Weill Cornell Medical College.
George S. Alexopoulos, Weill Cornell Institute of Geriatric Psychiatry, Weill Cornell Medical College.