Effects of Problem-Solving Therapy and Clinical Case Management on Disability in Low-Income Older Adults.

OBJECTIVE: To test the following hypotheses: (1) Clinical case management integrated with problem-solving therapy (CM-PST) is more effective than clinical case management alone (CM) in improving functional outcomes in disabled, impoverished patients and (2) improvement in depression, self-efficacy, and problem-solving skills mediates improvement of disability. METHODS: Using a randomized controlled trial with a parallel design, 271 individuals were screened and 171 were randomized to 12 weekly sessions of either CM or CM-PST at 1:1 ratio. Raters were blind to patients' assignments. Participants were at least age 60 years with major depression, had at least one disability, were eligible for home-based meals services, and had income no more than 30% of their counties' median. The WHO Disability Assessment Scale was used. RESULTS: Both interventions resulted in improved functioning by 12 weeks (t = 4.28, df = 554, p = 0.001), which was maintained until 24 weeks. Contrary to hypothesis, CM was noninferior to CM-PST (one-sided p = 0.0003, t = -3.5, df = 558). Change in disability was not affected by baseline depression severity, cognitive function, or number of unmet social service needs. Improvements in self efficacy (t = -2.45, df = 672, p = 0.021), problem-solving skill (t = -2.44, df = 546, p = 0.015), and depression symptoms (t = 2.25, df = 672, p = .025) by week 9 predicted improvement in function across groups by week 12. CONCLUSION: CM is noninferior to CM-PST for late-life depression in low-income populations. The effect of these interventions occur early, with benefits in functional status maintained as long as 24 weeks after treatment initiation (clinicaltrials.gov; NCT00540865).

Treating depression in disabled, low-income elderly: a conceptual model and recommendations for care.

BACKGROUND: 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. METHODS: 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 (CM) to address social adversity with problem solving treatment (PST) to address the depressive syndrome. RESULTS: 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 CM and PST can work together to ameliorate depression. CONCLUSIONS: The combination of age, disability, and social adversity complicates the management and treatment of depression. CM and PST are interventions that work synergistically to overcome depression and manage social problems.

Treatment of depression among impoverished primary care patients from ethnic minority groups.

OBJECTIVE: The aim of this study was to determine whether supplementing traditional cognitive-behavioral therapy for depression with clinical case management would reduce the rate of dropout from care and improve outcomes for ethnically diverse, impoverished medical outpatients. METHODS: The study was a randomized trial that compared cognitive-behavioral group psychotherapy alone (N=103) with the same therapy supplemented by clinical case management (N=96). RESULTS: The patients who received supplemental case management had lower dropout rates than those who received cognitive-behavioral group therapy alone. Supplemental case management was associated with greater improvement in symptoms and functioning than cognitive-behavioral therapy alone for patients whose first language was Spanish (N=77) but was less effective for those whose first language was English (N=122). CONCLUSIONS: Supplemental case management improves retention in traditional mental health outpatient care and can improve outcomes for Spanish-speaking patients.