Implementation and Effectiveness of Cognitive Behavioral Therapy for Insomnia in Geriatric Primary Care.

OBJECTIVES: We evaluated a plan for implementation and effectiveness of cognitive behavioral therapy for insomnia (CBT-I) in geriatric primary care by a geropsychologist. METHODS: The flow of referrals to a geropsychologist was tracked and, among those eligible and interested in participating, success in deprescribing sleep medications and the effectiveness of CBT-I were documented. RESULTS: Seventy patients were referred for evaluation of whom 62 were eligible for CBT-I; 34 began CBT-I and 29 completed a full course of treatment. Almost two-thirds of treatment completers were the "old old" (76-84 years) and "oldest old" (85-93 years) with multiple medical problems. Most treatment completers taking sleep medications had them deprescribed at the beginning of treatment and, one year after treatment, did not have them re-prescribed. After CBT-I, two-thirds of patients met the insomnia severity index criteria for response; and three-fifths for remission from insomnia. Further, most patients had sustained improvement in their target insomnia symptom(s) and sleep efficiency. CONCLUSIONS: CBT-I can be implemented in geriatric primary care with successful deprescribing of sleep medications and meaningful improvement in symptoms of insomnia in a group of older adults of advanced age with multiple medical problems. CLINICAL IMPLICATIONS: Clinical gerontologists can play an important role in improving late life insomnia.

Treating depression in an urban primary care setting: Introducing an adapted therapeutic approach to improve behavioral health engagement in primary care.

Depression is common in patients attending primary care clinics especially for those in socioeconomically disadvantaged urban neighborhoods. A number of behavioral health collaborative care models exist to screen, assess, and treat patients within primary care clinics. This paper discusses the implementation of a behavioral health care program using the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) model within an urban primary care clinic setting in New York City, that serves a large population of ethnically diverse and socioeconomically disadvantaged patients. While elements of the structured IMPACT model in the clinic were effective, the therapeutic approaches did not always meet the needs of all the patients. Therefore, the article describes the challenges this program faced and highlights how the IMPACT model was modified to meet the specific needs of the patients by using an adapted version of Interpersonal Psychotherapy as an alternative psychosocial intervention to the traditional Problem Solving Treatment psychosocial treatment in IMPACT.

Pikes Peak model for training in professional geropsychology.

The aging of the population will increase demand for psychological services for older adults, which challenges the profession of psychology to provide those services. In response to that challenge, professional geropsychology has been developing over the past few decades to meet current and prepare for anticipated future demand. The development of a range of training opportunities is important to enable psychologists to work effectively with older adults. This article describes the Pikes Peak model for training in professional geropsychology. The model is an aspirational, competencies-based approach to training professional geropsychologists that allows for entry points at multiple levels of professional development.

The Mood Disorder Burden Index: a scale for assessing the burden of caregivers to adults with unipolar or bipolar disorder.

We present a brief measure of caregiver burden, the Mood Disorder Burden Index (MDBI), for use with family members and close friends of adults with major depressive disorder (MDD) or bipolar disorder (BD). The MDBI assesses burden in three core domains (patients' mood symptoms, caregivers' worry about the future, and caregivers' interpersonal difficulties with the patient) and includes an optional module that assesses caregiver burden associated with patients' pharmacotherapy or psychotherapy. The MDBI was administered to caregivers of older individuals (i.e., 58 years and older) with MDD (n=123) or BD (n=38) who were receiving treatment through a research study. Analyses indicated evidence of convergent and discriminant validity of the new measure well as internal consistency within both caregiver groups. It will be important for future research to administer the MDBI to caregivers of middle-aged and older patients as well as those receiving treatment through inpatient settings or community outpatient clinics.

Impact of close family members on older adults' early response to depression treatment.

This study of 130 depressed older adults and their spouses or adult children examined the impact of caregiver burden specific to patients' depressive symptoms on patients' response to antidepressant treatment. Primary care patients completed medical, psychiatric, and neuropsychological assessments prior to treatment, and interviews were conducted with their identified family member. As hypothesized, caregivers' depression-specific burden predicted greater depression severity for the patient at the 6th week of treatment after accounting for patients' pretreatment characteristics, caregivers' depressive symptoms, and caregivers' relationship satisfaction. Future research may identify family attitudes and behaviors that stem from burden and compromise older adults' ability to recover from depression.

[Interpersonal psychotherapy in the treatment of depression in older adults]. / La psychothérapie interpersonnelle (PTI) pour le traitement de la dépression chez les personnes âgées.

In this paper, the authors explain why Interpersonal Psychotherapy (PTI) is a particularly apt psychosocial treatment for depression in older adults ; they discuss issues that can emerge in the process of implementing PTI with older adults ; review the research conducted on older adults treated with PTI, and present two case summaries to illustrate the application of PTI to this population. PTI suits depressed older adults especially well because its foci match many of the issues that older adults face and that for some can trigger depression. In addition, PTI is a good fit for older adults because of its psychoeducational component, use of the medical paradigm, and collaborative, problem-focused, time-limited nature. PTI necessitates very little adaptation for older adults but should be informed by knowledge of gerontology and geropsychology. Some research and their clinical practice suggest that acute (i.e., weekly) PTI reduces depression symptoms in older adults but more research needs to be conducted. Interpersonal Counseling, a modified version of PTI, has been found to be effective in the treatment of depressive symptoms in older adults with medical problems. Continuation/Maintenance (i.e., monthly) PTI has been shown to be beneficial to some but not all older adults with major depression. Two cases are described that illustrate the implementation of PTI. One case focuses on interpersonal disputes and the other focuses on role transition.

Predictors of medication discontinuation by patients with first-episode schizophrenia and schizoaffective disorder.

BACKGROUND: Enhancing medication adherence early in the course of schizophrenia and schizoaffective disorder may substantially improve long-term course. Although extensively studied in multi-episode patients, little data exist on medication adherence by first-episode patients. METHOD: Medication adherence was assessed during the first year of treatment and following recovery from the first relapse in patients treated by a standardized medication algorithm. RESULTS: During the first year of treatment, patients with poorer premorbid cognitive functioning were more likely to stop antipsychotics (t=-2.54, df=75, p=0.01). Parkinsonian side effects increased the likelihood (hazard ratio=41.22; 95% CI=2.30, 737.89; p=0.01), and better executive function decreased the likelihood (hazard ratio=0.40; 95% CI=0.18, 0.88; p=0.02) that patients discontinued maintenance medication after a first relapse. CONCLUSION: Interventions to ameliorate cognitive deficits and Parkinsonian side effects may enhance treatment adherence.

National dissemination of interpersonal psychotherapy for depression in veterans: therapist and patient-level outcomes.

OBJECTIVE: To evaluate the effects of training in and delivery of interpersonal psychotherapy (IPT) for depression throughout the U.S. Department of Veterans Affairs health care system on therapists' competency and patients' clinical outcomes. METHOD: Participants included 124 therapists and 241 veteran patients. Therapists participated in a 3-day workshop followed by 6 months of weekly group consultation. Therapy session tapes were rated by expert IPT training consultants using a standardized competency rating form. Patient outcomes were assessed with the Beck Depression Inventory-II and the World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed with the Working Alliance Inventory-Short Revised. RESULTS: Of the 124 therapists receiving IPT training, 115 (93%) completed all training requirements. Therapist competence in IPT increased from their 1st patient to their 2nd for both initial (d = 0.36) and intermediate (d = 0.24) treatment phases. Of the 241 veteran patients treated with IPT, 167 (69%) completed ≥ 12 sessions. Intent-to-treat analyses indicated large overall reductions in depression (d = 1.26) and significant improvements in quality of life (d = 0.57 to 0.86) and the therapeutic alliance (d = 0.50 to 0.83). CONCLUSIONS: National IPT training in the VA health care system was associated with significant increases in therapist competencies to deliver IPT, as well as large overall reductions in depression and improvements in quality of life among veterans, many of whom presented with high levels of depression. RESULTS support the feasibility and effectiveness of broad dissemination of IPT in routine clinical settings.

Influencing public policy to improve the lives of older Americans.

Aging of the U.S. population raises numerous public policy issues about which gerontological researchers, policy experts, and practitioners have much to contribute. However, the means by which aging-related public policy is influenced are not always apparent. Drawing on experience working in the U.S. Senate and other settings as Health and Aging Policy Fellows, the authors outline the formal and informal processes by which public policy is shaped in the U.S. Congress. Many who seek to influence public policy do so by telling legislators what they want. A less obvious path to policy influence is for gerontologists to offer their expertise to legislators and their staff. The authors provide specific recommendations for how gerontologists can establish productive and ongoing relationships with key legislative players. The authors also emphasize the importance of collaboration with advocacy groups and with local and state stakeholders to advance aging-related public policy to improve the lives of older Americans.

Doctoral clinical geropsychology training in a primary care setting.

Most older adults diagnosed with a mental disorder receive treatment in primary care settings that lack personnel skilled in geropsychological diagnosis and treatment. The Ferkauf Older Adult Program of Yeshiva University endeavors to bridge this gap by providing training in geriatric psychology, through coursework and diverse clinical practica, to clinical psychology doctoral students within a large urban professional psychology program. In an innovative effort to provide the most disadvantaged elderly with comprehensive mental health treatment and maximize trainee exposure to an interdisciplinary treatment model, the program also pairs selected doctoral psychology trainees with medical residents to optimize integrated mental health service delivery for primary care elderly. The program has the following core objectives: (1) Infuse the mental health and aging knowledge base into the regular graduate curriculum; (2) Provide interdisciplinary training in geropsychological diagnostic and consultative services within an urban primary care setting; (3) Provide interdisciplinary training in the practice of psychological and neuropsychological evaluation of elderly; (4) Provide training in geropsychological psychotherapeutic intervention, including individual, couples/family, and brief/psycho-educational therapies with outpatient older adults. These objectives are achieved by pooling the resources of a graduate school of psychology, a local public hospital, and an academic medical center to achieve educational and clinical service goals.