Psychosocial treatment research with ethnic minority populations: ethical considerations in conducting clinical trials.

Because of historical mistreatment of ethnic minorities by research and medical institutions, it is particularly important for researchers to be mindful of ethical issues that arise when conducting research with ethnic minority populations. In this article, we focus on the ethical issues related to the inclusion of ethnic minorities in clinical trials of psychosocial treatments. We highlight 2 factors, skepticism and mistrust by ethnic minorities about research and current inequities in the mental health care system, that researchers should consider when developing psychosocial interventions studies that include ethnic minorities.

Ethical considerations in psychotherapy effectiveness research: choosing the comparison group.

The primary purpose behind effectiveness research is to determine whether a treatment with demonstrated efficacy has utility when administered to the general population. The main questions these studies are meant to answer are these: Can the typical patient respond to treatment? Is the treatment acceptable to the typical patient? Can the treatment be administered safely and in its entirety in the typical treatment setting? Is the treatment under study significantly better than the community standard of care both from and a cost and outcome perspective? Answering these questions is meant to provide sufficient information to providers and policymakers so that effective interventions can be adopted and become the new community standard. For this research to make a meaningful impact on a provider and policymaker's decision to change the status quo, study interventions should be compared to the existing community standard of treatment, often referred to as treatment as usual (TAU). From an ethical perspective, this decision may not always be the safest choice. In some populations, TAU may mean no treatment at all, and in others TAU may be worse than withholding treatment. The effectiveness researcher is then caught between the pull to do no harm and the need for research to have an impact on change. The purpose of this article is to highlight certain conditions when TAU is ethically acceptable and to discuss alternatives when TAU may be an unethical treatment condition. For purposes of precision, we focus exclusively on psychotherapy effectiveness research rather than system-intervention research or medication-intervention research.

The prevalence of psychiatric disorders and subsyndromal mental illness in low-income, medically ill elderly.

OBJECTIVE: This study estimated the past and current prevalence of psychiatric illness and subsyndromal mental illness (both pre-relapse and new onset) in a sample of low-income, medically ill older adults. METHOD: A convenience sample of 95 public sector medical patients aged 55 and older were assessed for the presence of psychiatric diagnosis and symptoms using the Geriatric Depression Scale, Beck Anxiety Inventory, the Short Michigan Alcohol Screening Test, and the Computerized Diagnostic Interview Schedule (DIS-C). RESULTS: Dysthymia and Major Depression were the most prevalent current disorders and Alcohol Dependence the most prevalent past disorder. Overall, 25 percent met criteria for at least one Axis I disorder. An additional 44 percent of patients had subsyndromal mental illness: 14 percent had subsyndromal depression, 17 percent were significantly anxious, and 30 percent were problem drinkers. A prior model predicting current Axis I disorder in younger people was found to be predictive of current Axis I but did not predict to subsyndromal disorder. CONCLUSIONS: The rates of psychiatric disorders and symptoms in this older, low-income population were similar to those in other samples of older medical patients. The findings from this research suggest the need for larger epidemiological studies of the prevalence of psychiatric disorders in this disadvantaged aging population. The complexities of this type of research are also discussed.

Treating depressive disorders: who responds, who does not respond, and who do we need to study?

Numerous studies show that pharmacotherapy and psychotherapy are efficacious and effective in treating depression. Even though that is true for many people, there are some who do not respond to these therapies, whether it is because they possess characteristics that make them resistant to treatment or because the treatment is not acceptable to them. Also, there are other populations for whom research has yet to determine if guideline-level treatment is effective. People with comorbid Axis I disorders, certain minority groups, and children have been under-represented in treatment research. Future research should focus on treatment-resistant depression and special populations that have been understudied.

Symptom differences between older depressed primary care patients with and without history of trauma.

OBJECTIVE: The current study explored the relationship between past traumatic experiences and current depression in a sample of depressed older adult primary care patients. METHOD: Sixty-six patients were referred from primary care to a psychogeriatric clinic that specialized in the treatment of unipolar depressive disorders. All patients received an extensive psychological assessment. RESULTS: Twenty-one percent had a history of trauma reported in their medical charts. Despite no differences found on a clinician-rated measure of depression, those with a trauma history had more depressive symptoms on a self-report measure. CONCLUSIONS: Although older patients with a history of trauma may not appear more depressed than a non-trauma comparison group, they may be in more psychological distress. The clinical implications of these findings and recommendations for mental health professionals are discussed.

Physicians are less willing to treat suicidal ideation in older patients.

OBJECTIVE: Older adults have the highest rate of suicide of any age group, and reducing the number of late-life suicides has become a national priority. The objective of this study was to determine if an age bias exists among primary care physicians when they contemplate treating suicidal patients. DESIGN: Primary care providers were mailed one of two case vignettes of a suicidal, depressed patient. The only difference between the two vignettes was the age of the patient (38 or 78 years old) and employment status (employed vs retired as a factory worker). A questionnaire was included to determine provider recognition of suicidal ideation, and a scale was designed to detect willingness to treat the vignette patient. SETTING/PARTICIPANTS: Physicians were selected randomly from the University of California, San Francisco physician roster and invited to participate in the study. A total of 342 physicians (63% response rate), including specialists, responded to the mailings. For this study, the responses of 215 primary care physicians were analyzed. INTERVENTION: The randomly assigned experimental group received a vignette of a geriatric, retired patient who was depressed and suicidal (n = 100 participants). The control group received an identical but younger, employed patient (n = 115 participants). MEASUREMENTS: A 21-item Suicidal Patient Treatment Scale measured willingness to treat the suicidal patient. RESULTS: The physicians in this study recognized depression and suicidal risk in both the adult and the geriatric vignette, but they reported less willingness to treat the older suicidal patient compared with the younger patient. The physicians were more likely to feel that suicidal ideation on the part of the older patient was rational and normal. They were less willing to use therapeutic strategies to help the older patient, and they were not optimistic that psychiatrists or psychologists could help the suicidal patient. CONCLUSIONS: This study suggests that primary care physicians are capable of recognizing suicidal ideation but are less willing to treat it if the patient is older and retired. Future research needs to determine etiologic factors for this age bias.

Issues and recommendations for the recruitment and retention of older ethnic minority adults into clinical research.

A burgeoning literature indicates that treatment of mental disorders offsets mortality, morbidity, and poor quality of life in senior citizens. Unfortunately, ethnic minority senior citizens, who are in most need of mental health services, have not been well represented in psychosocial research. This lack of attention is due, in large part, to difficulties that may arise in recruitment and retention of older ethnic minority adults in research studies. The purpose of this article is to discuss successful methods for recruiting older ethnic minority adults into psychosocial research and to offer specific suggestions for keeping this population involved in longitudinal studies. Also included is a discussion of past research and present data from treatment studies that used the methods discussed in this article.

Do primary care patients accept psychological treatments?

Most individuals seeking care for psychological distress go to primary care physicians rather than to mental health professionals. Many have symptoms of distress that do not meet criteria for psychiatric disorders; pharmacotherapies are generally not available for these subsyndromal problems. Preliminary studies suggest that psychosocial therapies may be useful. The aim of this paper was to learn whether medical patients would accept psychological treatments for 1) depression, an explicit psychopathology; 2) stress, a nonpathological, but psychological, problem; and 3) medical problems, a nonpsychological issue. Respondents were 131 primary care patients at San Francisco General Hospital, a public sector hospital. The results show that most of the patients (107 of 131) found psychological interventions acceptable. In addition, the vast majority were willing to have the treatments focus on psychological issues such as depression and stress. This study demonstrates that primary care patients find psychological interventions acceptable.

Comparative effectiveness of social problem-solving therapy and reminiscence therapy as treatments for depression in older adults.

Compared the effects of 2 psychotherapies based on divergent conceptualizations of depression in later life. Seventy-five older adults diagnosed with major depressive disorder were assigned randomly to problem-solving therapy (PST), reminiscence therapy (RT), or a waiting-list control (WLC) condition. Participants in PST and RT were provided with 12 weekly sessions of group treatment. Dependent measures, taken at baseline, posttreatment, and 3-month follow-up, included self-report and observer-based assessments of depressive symptomatology. At posttreatment, both the PST and the RT conditions produced significant reductions in depressive symptoms, compared with the WLC group, and PST participants experienced significantly less depression than RT subjects. Moreover, a significantly greater proportion of participants in PST versus RT demonstrated sufficient positive change to warrant classification of their depression as improved or in remission at the posttreatment and follow-up evaluations.