Archives of Gerontology and Geriatrics 55 (2012) 522529

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Archives of Gerontology and Geriatrics

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Review

Non-pharmacological prevention of major depression among community-dwelling older adults: A systematic review of the efcacy of psychotherapy interventions
Su Yeon Lee a,*, Mary Kathryn Franchetti a, Anuar Imanbayev a, Joseph J. Gallo a, Adam P. Spira a, Hochang B. Lee b
a b

Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States

A R T I C L E I N F O

A B S T R A C T

Article history: Received 29 January 2012 Received in revised form 1 March 2012 Accepted 2 March 2012 Available online 5 April 2012 Keywords: Older adults Subthreshold depression Indicated prevention Non-pharmacological prevention

Depression is a major public health burden among the aging population. While older adults prefer nonpharmacological treatment, few options for psychotherapy are available in primary care settings, which is where older adults tend to receive mental health services. Indicated prevention is a cost-effective, public health approach to prevent major depressive disorder among people with depressive symptoms who do not yet meet standard criteria for major depression. We critically reviewed randomized controlled trials (RCTs) that assessed the efcacy of psychotherapy among community-dwelling older adults with subthreshold depression (depressive symptoms that do not meet standard criteria for major depression). We examined the intervention types, results, internal validity, and external validity of ve studies. We used the United States Preventive Services Task Force (USPSTF) guidelines to rate the quality of the studies and to provide recommendations. Results suggest that psychotherapy is a safe and costeffective method to reduce the public health burden of depression among older adults with subthreshold depression. 2012 Elsevier Ireland Ltd. All rights reserved.

Contents 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Depression among older adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1. Psychotherapy as a preferred treatment for geriatric depression. . . . . . . . . . . . 1.2. Indicated prevention of depression among older adults . . . . . . . . . . . . . . . . . . . 1.3. The USPSTF guideline on depression prevention. . . . . . . . . . . . . . . . . . . . . . . . . 1.4. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Identication of studies and selection criteria . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Grading of each study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Internal validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Reliability and validity of the depression screening methods . . . . . . . 3.1.1. Training and educational attainment of mental health professionals . 3.1.2. Compliance among study participants . . . . . . . . . . . . . . . . . . . . . . . . . 3.1.3. External validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Grade of each study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523 523 523 523 523 523 523 524 525 526 526 526 526 527 527 527 527 528 528 528

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* Corresponding author. Tel.: +1 410 645 0103. E-mail address: sulee@jhsph.edu (S.Y. Lee). 0167-4943/$ see front matter 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2012.03.003

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1. Introduction 1.1. Depression among older adults Depression is a signicant global health burden, especially among older adults (Snowden et al., 2008). Geriatric depression is associated with increased health care costs, mortality, and reduced quality of life (Chapman and Perry, 2008; Snowden et al., 2008). The public health burden imposed due to poor physical and mental health associated with late-life depression is comparable to or even more severe than the burden observed in other common chronic medical conditions (Katon et al., 2007). The presentation of depression among older adults may be complex due to a wide range of severity and comorbid symptoms such as cerebrovascular disorders, anxiety disorders, and substance use disorders (Skoog, 2011). Subthreshold depression that does not meet the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; APA, 1994) criteria of major depression, including subsyndromal and minor depression, is a clinically meaningful concept in geriatric psychiatry. Subthreshold or minor depression is two to three times more prevalent than major depressive disorder among community-dwelling elders, with a median point prevalence of 9.8% (Meeks et al., 2011). Cuijpers et al. (2007) found that 20% of community-dwelling older adults with subthreshold depression subsequently developed major depression. In addition, subthreshold depression is associated with an increased risk of developing cognitive impairment and dementia (Han et al., 2008; Boyle et al., 2010), disability in activities of daily living (Hybels et al., 2009), physical ailments (Bremmer et al., 2006; Rafanelli et al., 2006), increased healthcare use (Koenig and Kuchibhatla, 1998), suicidal ideation (Waern et al., 2003; Wiktorsson et al., 2010), and decreased quality of life (Nirenberg et al., 2010). 1.2. Psychotherapy as a preferred treatment for geriatric depression While subthreshold depression is prevalent and has a clinically signicant impact among older adults, the current health care system provides few options to prevent worsening of depressive symptoms among older adults with subthreshold depression. With respect to treatment of depression, older adults prefer nonpharmacological treatment (e.g., counseling and psychotherapy) over pharmacotherapy (Gum et al., 2006; Hindi et al., 2011) and favor treatment in the primary care setting rather than the specialty care setting (Arean et al., 2001). Most primary care clinicians believe that the treatment of depression is more effective and less stigmatizing when counseling and psychotherapy are integrated into the primary care setting (Gallo et al., 2004). Reynolds et al. (1999) found that the combination of antidepressant treatment and interpersonal psychotherapy was effective in reducing depressive symptoms for older adults with recurrent depression. However, clinicians often prefer not to prescribe medication for frail elderly individuals with depression, especially when they are already taking multiple medications (Reynolds and Kupfer, 1999). In fact, a recent meta-analysis reported that the effect of pharmacological treatment compared to placebo among adults with subthreshold depressive symptoms (Hamilton Depression Rating Scale (HDRS) < 23) was minimal to non-existent (Fournier et al., 2010). In contrast, another meta-analysis reported that the psychosocial interventions reduced the onset of major depression among non-elderly subjects with subthreshold depression, and also that long-term effect of psychotherapy was minimal (Cuijpers et al., 2007). Yet, little is known of the value of psychotherapy in reducing depressive symptoms and preventing major depression among older adults with subthreshold symptoms.

1.3. Indicated prevention of depression among older adults Two of the main purposes of preventing depression include delaying the onset of the disorder, thereby decreasing the length of morbidity, and protection from other health conditions associated with depression (Hindi et al., 2011). Several types of preventive interventions are available for different target populations with varying mental health needs. Universal prevention targets the whole population who may or may not have risk factors and symptoms of depression (i.e. the general population), while selective prevention interventions target a population at elevated risk of depression (e.g. the recently widowed; Mrazek and Haggerty, 1994). In order to prevent depression that meets DSM-IV criteria, indicated prevention interventions target individuals who report some depressive symptoms but have not developed clinically diagnosable depression (Mrazek and Haggerty, 1994). The goals of indicated prevention are to reduce the incidence of disorders that meet DSM-IV criteria, to delay the onset of disorder, to reduce the severity and persistence of symptoms experienced at a subthreshold level, and to protect from co-morbidities associated with the disorder. Schoevers et al. (2006) suggested that indicated prevention of depression older adults with subthreshold depressive symptoms had a greater impact on the burden of depression and was more cost-effective than selective prevention targeting older adults with risk factors only (e.g. loss of a spouse). Schoevers and colleagues and others (Grabovich et al., 2010) recommended indicated prevention over selective prevention when screening methodologies are available. 1.4. The USPSTF guideline on depression prevention The USPSTF focuses on maintenance of health and quality of life as the major benet of clinical preventive services, and not simply the identication or treatment of disease. The USPSTF recommendations highlight the opportunities for improving delivery of effective services and have helped others provide preventive care in different populations (U.S. Preventive Services Task Force, 2010). In 2009, the USPSTF gave a B recommendation for screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up (http://www.uspreventiveservicestaskforce.org/ uspstf09/adultdepression/addeprrs.htm). A grade denition of B indicates that the USPSTF has moderate to high certainty that the net benet of the service is moderate to substantial, and indicates that the USPSTF suggests offering or providing the service in primary care settings. The USPSTF grade denitions can be found on the website (http://www.uspreventiveservicestaskforce.org/ uspstf/grades.htm). Currently, however, we are unaware of published guidelines regarding which interventions are effective for the prevention of major depressive disorder in older adults with subthreshold depressive symptoms. The purpose of our study was to evaluate the efcacy of non-pharmacological interventions of depression among community-dwelling older adults with subthreshold depression. Based on the critical review of methodology, internal validity, and external validity, we reviewed previous studies on the indicated prevention of depression among older adults with subthreshold depressive symptoms. 2. Methods 2.1. Identication of studies and selection criteria Studies were identied by searching titles and abstracts in PubMed, PsycINFO, and SCOPUS in September, 2011. We identied relevant abstracts by combining the concept terms of psychotherapy and prevention of depression with the AND Boolean term

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Table 1 PubMed concept terms and search terms used in this review. Concept terms Search terms Psychotherapy (Psychotherapy [mesh] or psychotherapy [tiab] or psychotherapies [tiab] or Non-pharmacological therapy [tiab] or Non-pharmacological intervention [tiab] or Non-pharmaceutical intervention* [tiab] or Problem Solving Therapy [tiab] or problem-solving treatment [tiab] or Life Review [tiab] or Aromatherapy [tiab] or Art Therapy [tiab] or Behavior Therapy [tiab] or Cognitive Therapy [tiab] or Bibliotherapy [tiab] or Color Therapy [tiab] or crisis Intervention [tiab] or Dance Therapy [tiab] or Gestalt Therapy [tiab] or Horticultural Therapy [tiab] or Imagery (Psychotherapy) [tiab] or Music Therapy [tiab] or Nondirective Therapy [tiab] or Play Therapy [tiab] or Psychoanalytic Therapy [tiab] or Free Association [tiab] or Psychotherapeutic Processes [tiab] or Reality Therapy [tiab] or Socioenvironmental Therapy [tiab] or Cognitive Psychotherapy [tiab] or Cognitive Psychotherapies [tiab] or Cognitive Therapies [tiab] or Cognition Therapy [tiab] or Cognition Therapies [tiab] or Cognitive Behavior Therapy [tiab] or Cognitive Behavior Therapies [tiab]) Prevention of depression Depression/prevention & control* [mesh] or depressive disorder, major/prevention & control [mesh] or dysthymic disorder/therapy* [mesh] or ((Depression/diagnosis [mesh] or depression/psychology [mesh] or dysthymic disorder [mesh] or dysthymia [tiab] or depressive disorder [mesh] or depressive disorder [tiab] or depressive symptom [tiab] or depressive symptoms [tiab] or subsyndromal depression [tiab] or subthrehold depression [tiab] or minor depression [tiab]) AND (indicated prevention [tiab] or prevention [tiab] or prevent [tiab] or indicated intervention [tiab] or intervention [tiab] or indicated [tiab])) [(prevention) AND (diagnosis) AND (cognitive behavioral therapy OR CBT) AND (depression OR depressive symptoms)]

(see Table 1 for detailed PubMed search terms). We limited our search results to studies with the MeSH terms human, randomized controlled trial, controlled clinical, English, Aged: 65+ years, and 80 and over: 80+ years. This search yielded 280 titles and abstracts of studies that focused on psychotherapy for community dwelling older adults with depressive symptoms not meeting DSM-IV criteria for depression. We reviewed these studies and the reference list of retrieved articles, and identied studies for review that met the following criteria: (1) psychotherapy was used as a major arm of intervention to prevent depression; (2) depressive symptoms were measured with reliable and valid tools, permitting the identication of participants with subthreshold depressive symptoms; (3) the study sample included only community-dwelling individuals; (4) participants were at least 50 years of age at entry; and, (5) the type of study was a RCT. In Tables 24, we have summarized each study, reporting the type of intervention (Table 2), control condition, duration and/or
Table 2 Evidence table of the intervention/results in the included studies. Author Ciechanowski et al. (2004) Intervention The PEARLS intervention (n = 72) of PST, social and physical activation, and referral to physicians Control Usual care (n = 66)

frequency of the intervention, outcome, factors related to internal validity (Table 3; i.e., sampling type, power parameters, compliance rate, and level of mental health professional training), and factors related to external validity (Table 4; sample demographics, location of the sample, exclusion criteria, follow-up interval, and handling of missing data). The USPSTF procedure manual served as a guide for the assignment of a grade for each study, and our nal recommendation regarding the use of psychotherapy to reduce depressive symptoms among older adults. 2.2. Grading of each study The Recommendation Grid provided by the USPSTF rates the net benet of each study as either substantial, moderate, small, or zero/negative (http://www.uspreventiveservicestaskforce.org/ uspstf/grades.htm). Net benet is determined by the results of a given study such as effect size of the outcome measure, which in the present review are depressive symptoms. In addition, the

Duration/frequency 12 months

Outcome Compared to the control, PEARLS group had greater reduction in depressive symptoms (43% vs 15%; (OR) 5.21; (95% CI) 2.0113.49), achieved complete remission (36% vs 12%; (OR) 4.96; (95% CI) 1.7913.72), and had greater quality-of-life improvements in functional (p = 0.001) and emotional well-being (p = 0.048). The life review course reduced depressive symptoms that were retained during follow-up. Found a signicant between-group effect size in depressive symptoms (d = 0.58). Pre-treatment to follow-up effect size was 0.69 in the control group, 0.62 in the group CBT group, and 1.22 in the Internet-based treatment group. Difference in control vs Internet CBT group was signicant (p = 0.08). The intervention halved the 12-month incidence of depressive and anxiety disorders, from 0.24 (20 of 84) in the usual care group to 0.12 (10 of 86) in the stepped-care group (relative risk, 0.49; 95% condence interval, 0.240.98). Paroxetine showed moderate benet for depressive symptoms and mental health function in participants with dysthymia and more severely impaired patients with minor depression. The benets of PST were smaller, slower in onset, and more subject to site differences.

Pot et al. (2010)

Spek et al. (2008)

Looking for meaning, a life-review designed to cope with depression (n = 83) Coping with Depression course (1) Internet-based CBT (n = 67); (2) group CBT (n = 56) Stepped-care (n = 86): (1) watchful waiting, (2) CBT-based bibliotherapy, (3) CBT-based PST, (4) referral to physicians (1) PST (n = 138); (2) medication treatment of paroxetine (n = 137)

Watched the 20 min video, The Art of Growing Older (n = 88) Waiting-list group (n = 66)

12 sessions

1 year

Vant Veer-Tazelaar et al. (2009)

Usual care group (n = 84) received unrestricted access to usual care Placebo (n = 140)

Each step lasted 3 months for 1 year

Williams et al. (2000)

6 visits over 11 week period

Abbreviations: CBT, Cognitive Behavior Therapy; PEARLS, Program to Encourage Active Rewarding Lives for Seniors; PST, Problem Solving Therapy.

S.Y. Lee et al. / Archives of Gerontology and Geriatrics 55 (2012) 522529 Table 3 Evidence table of the recruitment/internal validity in the included studies. Author Ciechanowski et al. (2004) Sampling Community & home-based thru senior service agencies or public housing Seattle, WA Open recruitment through media and 11 mental health care institutions n/power calc Effect size 0.30; power 0.95; alpha 0.05; 64 participants Compliance 92% by 12-month follow up Missing data Mixed-effects regression analysis Depression instrument 2-item PRIME-MD during routinely scheduled visits or telephone calls Training of MH professional Trained research associates

525

Pot et al. (2010)

Effect size 0.35; power 0.80; alpha 0.05; 80 participants

88.9% follow up by 3 months; 84.2% follow-up by 9 months

Regression imputation

Dutch version of CES-D  5 or <10 cutoff

Spek et al. (2008)

Open recruitment through letters and then clinical interview

Vant Veer-Tazelaar et al. (2009)

Primary care setting (n = 170)

Control ES 0.69, CBT ES 0.62, internet CBT ES 1.22; power 0.78; alpha 0.05; 301 participants Effect size 0.25; power 0.90; 2-sided alpha 0.05; 65 participants per group

Follow-up at 12 months: Internet CBT (57%); group CBT (67%); control (66%) Dropout signicantly higher in the intervention group (p = 0.009)

37%; multiple imputation

BDI, CIDI, EDS  12

Regression imputation

MINI

Williams et al. (2000)

Community, Veterans Affairs, and academic-afliated primary care clinics.

Effect size 0.20; power 0.80; alpha 0.05; 126 participants at each site, 63 for each of the two diagnoses

PST group (83.1%) completed all 6 treatment sessions

None

Depressive symptoms (by the HSCL-D-20 and the HDRS) and functional status (SF-36)

Therapists had therapeutic backgrounds or in behavioral sciences or social work; received 2-day training by psychotherapist; booster training Internet CBT is a self-help intervention; group CBT therapists are psychologists or trained social workers Trained community psychiatric nurses trained during a 2-day PST workshop and had received monthly supervision Medication therapists were general internists and psychiatrists. PST therapists were psychologists and social workers with a masters degree

Abbreviations: BDI, Beck Depression Inventory; CES-D, Center for Epidemiologic Studies Depression Scale; EDS, Edinburgh Depression Scale; CIDI, The World Health Organization Composite International Diagnostic Interview; ES, Effect Size; HDRS, Hamilton Depression Rating Scale; HSCL-D-20, 20-item Hopkins Symptom Checklist Depression Scale; MINI, Mini International Neuropsychiatric Interview; PRIME-MD, Primary Care Evaluation of Mental Disorders; SF-36: Medical Outcomes Study ShortForm 36. Table 4 Evidence table of the external validity in the included studies. Author Ciechanowski et al. (2004) Pot et al. (2010) Age/demographics 60 with DSM-IV minor depression or dysthymia >50 (mean age 64); 5 CES-D; no depressive diagnosis or psychotropic or psychological treatment Mean age 55 years, S.D. = 4.6 years 75; CES-D score 16; no depressive disorder 60 Location Seattle, Washington, U.S. Netherlands Exclusion No depression; major depression; bipolar disorder; psychosis; and substance abuse Major depression, moderate-high suicide risk; 9 in CES-D; taking anti-depressant/benzodiazepines; receiving psychological treatment Any other psychiatric disorder in immediate need of treatment and suicidal ideation Elderly individuals with serious cognitive decline according to the self-rated IQCODE No depression diagnosis; major depression; depression with an HDRS score < 10 Follow-up interval Baseline, 6, and 12 months.

Baseline, 3, 6, and 12 months.

Spek et al. (2008)

Eindhoven, Netherlands

Baseline, at 10-week, and at 1 year. 3, 6, and 9 month.

Vant Veer-Tazelaar et al. (2009) Williams et al. (2000)

Primary care in Netherlands Primary care practices in the U.S.: (1) Lebanon, PA; (2) Pittsburgh, PA; (3) San Antonio, TX; (4) Seattle, WA

Baseline, at 6, and 11 weeks for patients assigned to receive PST.

Abbreviations: IQCODE, Informant Questionnaire on Cognitive Decline in the Elderly.

USPSTF denes the quality of evidence as either good, fair, or poor = I, i.e. insufcient evidence to make a recommendation and is determined by the quality of the study methodology, such as the validity of the screening tools used to identify depressive symptoms and the generalizability of results. In the present study, three raters independently assessed and assigned grades for the studies. Rater discrepancies regarding nal grades for

each study were resolved through discussion until a consensus was reached. 3. Results Results are detailed in Tables 24. Studies included in this review used psychotherapy to reduce depressive symptoms

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among participants with subthreshold depression, with the caveat that Williams et al. (2000) treated one of the arms of participants with medication and another arm with problem-solving therapy (PST). Participants were recruited in community settings, such as senior service agencies, public housings, primary care settings, mental health care centers, and primary care settings. Study participants included a substantial proportion of racial/ethnic minorities in Ciechanowski et al. (2004) and Vant Veer-Tazelaar et al. (2009); other study participants were from the Netherlands and racial/ethnic composition was not provided (Spek et al., 2008; Vant Veer-Tazelaar et al., 2009; Pot et al., 2010). The interventions used a range of approaches to treat depressive symptoms. Three of the ve interventions (Williams et al., 2000; Ciechanowski et al., 2004; Vant Veer-Tazelaar et al., 2009) used elements of PST, social and behavioral activation, and Cognitive behavior therapy (CBT)-based bibliotherapy in conjunction with referral to primary care for medication, if participants had continuously elevated depressive symptoms. The Vant VeerTazelaar et al. (2009) study intervention used a stepped-care model, which is an approach that employs a lower-cost intervention rst and subsequently use more costly and intensive interventions if participants do not respond to the initial intervention (Haaga, 2000). In both Ciechanowski et al. (2004) and Vant Veer-Tazelaar et al. (2009), participants in control conditions had unrestricted access to usual care. Spek et al. (2008) administered a highly structured cognitive behavioral therapy in the form of group-based and Internet-based therapy compared to the wait-listed group. Pot et al. (2010) utilized the life-review protocol that incorporated reminiscence, such as recalling sensory experiences from the past and reecting on poems, and problemsolving techniques. Participants in the control condition watched a video called The Art of Growing Older (Parnassia, 2003) for 20 min to learn about factors and skills that promote successful aging. Williams et al. (2000) compared PST, paroxetine treatment, and a placebo pill control condition. In terms of the outcome, the intervention arms of Ciechanowski et al. (2004), Vant Veer-Tazelaar et al. (2009), Pot et al. (2010), and Spek et al. (2008) reduced depressive symptoms by about a half. This contrasts sharply with the Williams et al. (2000) study, which demonstrated a very small effect of the PST intervention on depressive symptoms, compared to other studies (i.e., Ciechanowski et al., 2004: OR = 5.21, 95% CI = 2.0113.49, p < 0.001; Vant Veer-Tazelaar et al., 2009; RR = 0.24, 95% CI = 0.240.98; p = 0.04). With a highly signicant between-group effect size (d = 0.58), life-review intervention condition of the Pot et al. (2010) study showed signicantly reduced depressive symptoms that continued through follow-up. Overall, all three studies support the efcacy of psychotherapy in reducing depressive symptoms, despite utilizing different psychotherapy protocols. However, in Williams et al. (2000), the benets of PST were smaller, slower to show the effect, and more subject to site differences than those of paroxetine, a pharmacological intervention. 3.1. Internal validity 3.1.1. Reliability and validity of the depression screening methods Ciechanowski et al. (2004) screened participants for depression with a two-item Primary Care Evaluation of Mental Disorders (PRIME-MD; Spitzer et al., 1994) scale, a screening tool for depression in a primary care setting. For detection of dysthymia in adult patients in the primary care settings, this measure has a sensitivity of 51%, specicity of 96%, and 56% positive predictive value, yielding an overall accuracy of 92% (Spitzer et al., 1994). The inter-rater reliability was kappa of 0.46 (Spitzer et al., 1994). For detection of minor depressive disorder in the same sample, this measure had a sensitivity of 22%, specicity of 94%, and 19%

positive predictive value, yielding 89% overall accuracy and kappa of 0.15 (Spitzer et al., 1994). Both Pot et al. (2010) and Vant Veer-Tazelaar et al. (2009) used the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977), a 20-item, self-report scale developed to measure depressive symptoms in the general population. The items in the CES-D have been found to have high internal consistency and adequate test-retest reliability in a meta-analysis based on a wide range of samples across age and ethnicity (Shafer, 2006). For major depressive disorder, a commonly used cut-off score is 25, yielding a sensitivity of 85%, specicity of 64%, and 63% positive predictive value (Roberts, 1980). Spek et al. (2008) used the 10-item Edinburgh Depression Scale to assess eligible participants at entry, with the internal consistency of a = 0.80 and correlation with the Beck Depression Inventory (BDI; Beck et al., 1996) of G = 0.64. Spek and colleagues used the Dutch version of the 21-item BDI to measure the change in depressive symptoms from pre-treatment to post-treatment follow-up. Internal consistency of the Dutch version of the BDI is high, with a Cronbachs alpha of a = 0.92 (Van der Does, 2002). Vant Veer-Tazelaar et al. (2009) used the computer-assisted Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998; Dutch version developed by Edwin de Beurs, Netherlands Institute of Forensic Psychiatry and Psychology) to measure the incidence of DSM-IV major depression. The MINI is a short diagnostic structured interview that, compared to the Composite International Diagnostic Interview (CIDI), displays a sensitivity of 94%, specicity of 79%, positive predictive value of 83%, and negative predictive value of 93% when detecting major depressive disorder (Lecrubier et al., 1997). Inter-rater reliability measured by kappa was acceptable (kappa = 0.73) in the combination of psychiatric and non-psychiatric patients (Lecrubier et al., 1997). Williams et al. (2000) used the 20-item Hopkins Symptom Checklist Depression Scale (HSCL-D-20; Lipman et al., 1979) and the HDRS (HDRS; Hamilton, 1960) to measure both the presence of depressive symptoms at baseline and the primary outcome of depressive symptoms. Depressive symptoms were measured by 13 items from the HSCL-D-20 and 7 additional depression-related items added to increase responsiveness to the change of depressive symptoms (Williams et al., 2000). HSCL-D-20 is sensitive to patients change in depressive symptoms and has good internal consistency in adult populations including older adults (Cronbachs alpha = 0.84) (Williams et al., 2004). 3.1.2. Training and educational attainment of mental health professionals The varying levels of training and educational attainment of mental health professionals administering psychotherapy may have affected the quality of the interventions. The highest effect size was seen in Pot et al. (2010), which employed therapists with therapeutic and behavioral sciences backgrounds and in Spek et al. (2008), which used self-administrated Internet-based CBT method as an intervention. The effect size was average for Ciechanowski et al. (2004) and Spek et al. (2008), which employed research associates, psychologists, and social workers. The lowest effect size was seen in the Vant Veer-Tazelaar et al. (2009) study which employed psychiatric nurses. In the Williams et al. (2000) study, varying experience and skills among the therapists in administering high-quality PST may explain between-site variability in response to treatment. At the site with the best response, the primary therapist was a behavioral therapist with a doctorate degree who trained other therapists (Williams et al., 2000). 3.1.3. Compliance among study participants In terms of compliance or dropout rates, three of the ve studies had low rates of attrition except for the Vant Veer-Tazelaar et al.

S.Y. Lee et al. / Archives of Gerontology and Geriatrics 55 (2012) 522529 Table 5 Grade of each study. Author (year) Ciechanowski et al. (2004) Grade I-Good-A Description

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Pot et al. (2010)

I-Fair-B

Spek et al. (2008)

I-Fair-A

Vant Veer-Tazelaar et al. (2009) Williams et al. (2000)

I-Fair-B

I-Good-C

Overall, the net benet of the study was considered to be substantial (A) because the odds ratio of reduced depressive symptoms in the PEARLS group compared to the control was high and statistically signicant while the quality of evidence was identied as good due to the high compliance rate (93% at 12 months follow-up in the intervention group). Overall, the net benet of the study was considered moderate (B) because the between group effect size was considered high (0.58); however, the quality of evidence was considered fair due to the weak control group and the inclusion of younger individuals between 50 and 60 years of age. Overall, the net benet of the study was considered substantial (A) because the Internet-based and group-based CBT effect sizes were highly signicant, the power was strong, and the sample size of 301 participants was commendable for the Internet- and group-based intervention; however, the quality of evidence was considered fair due to the large amount of attrition (37% of participants did not provide follow up data) especially affecting the lower compliance in the Internet treatment group. Additionally, some selection bias is associated with only recruiting participants with the Internet access and individuals over 50 years old. Overall, the net benet of the study was considered moderate (B) because of signicantly decreased depressive symptoms comparing intervention group to the control group; however the quality of evidence was identied as fair due to the differential drop-out within the intervention group. Overall, the net benet of the study was considered small (C) because the effects of the PST-PC intervention were found to be small, slow in onset, and varied depending on site location. The reasons for the good quality of evidence are (1) the high sample size, (2) the use of two measurements in order to evaluate the presence of depressive disorder; and (3) the relatively high compliance rate (83.1%) with non-differential drop out.

(2009) and Spek et al. (2008) studies which experienced greater attrition rates in the intervention group compared to the control condition. Ciechanowski et al. (2004) had the highest retention of 93.0% by 12 months in the intervention group. Pot et al. (2010) had an average of 84.9% at 9-month follow-up; Williams et al. (2000) were the lowest at 83.1% retention at the nal 11-week assessment. 3.2. External validity The Pot et al. (2010) and Vant Veer-Tazelaar et al. (2009) studies were conducted in primary care settings in the Netherlands. Study participants in the Spek et al. (2008) study were recruited by postings in the regional newspapers and letters sent by the Municipal Health Care Service in the Netherlands. The Ciechanowskis et al. (2004) study was conducted among participants recruited through senior service agencies and public housings in Seattle, WA. The Williams et al. (2000) recruited participants from the primary care clinics in Lebanon, PA, Pittsburgh, PA, San Antonio, TX, and Seattle, WA. Across the studies, participants ages were homogeneous, with the average of approximately 65 years of age. Spek et al. (2008) had the lowest mean age of 55 years. All studies shared similar exclusion criteria, such as major depression, psychosis, bipolar disorder, and substance abuse. A commonality among most of the studies analyses was that missing data were handled using some form of multiple imputation; Williams et al. (2000) did not mention handling of missing data. The factors that tended to differ among the studies were specic intervention strategy, duration and/or frequency of the intervention, outcome on the level of depression, setting and geographic location of the sample, retention rate, follow-up interval, depression instrument, and level of mental health professional training (Table 2). Most studies included assessment at baseline, three months and six months into the intervention, and 12 months after baseline. 3.3. Grade of each study See Table 5. 3.4. Recommendation All ve studies included in the present review received a I (as in Roman numeral one) in the hierarchy of research design rating

indicating a properly designed RCT (http://www.uspreventivese rvicestaskforce.org/uspstf08/methods/procmanual.htm). RCTs receive the highest mark of I because the RCT is considered the gold standard of intervention study design. Based on the results of our review, we determined that a B recommendation was appropriate for the use of psychotherapy among older adults. Specically, we determined that psychotherapy is an effective and safe intervention for the prevention of major depression in the primary care setting. 4. Discussion Based the USPSTF reporting guideline, we conducted a critical review on the indicated prevention of depression among older adults using psychotherapy. We provided an overall recommendation of B for the psychotherapy intervention for older adults who display depressive symptoms in the primary care setting. The results of the methodologically rigorous, randomized controlled studies included in this review suggest that major depression is a preventable condition when proper screening tools and an effective psychotherapy intervention are used. Our results suggest that the effect size for depressive symptoms reduction is large (Ciechanowski et al., 2004; Spek et al., 2008; Vant Veer-Tazelaar et al., 2009; Pot et al., 2010), and that older adults assigned to intervention conditions tended to have lower depressive symptoms, higher remission rates, and lower incidence of major depression at 12-month follow-up compared to control conditions. Overall, non-pharmaceutical, psychotherapy-based interventions have the potential to lower the onset of major depressive disorders among older adults. Our interpretation of the study results should be taken with caution, with the understanding of the limitations of the studies we reviewed and our analysis. First, there is substantial heterogeneity in the geographic location of the studies, measurement of the outcome, severity of depressive symptoms, and administration of psychotherapy. In particular, two of the ve studies (Williams et al., 2000; Ciechanowski et al., 2004) included half of the study participants with dysthymia, while dysthymia has distinct diagnostic criteria (having depressive symptoms for two years) than subthreshold depressive symptoms. Because those two studies assessed the intervention effect on participants with both dysthymia and subthreshold depressive symptoms without dysthymia, it is challenging to evaluate the overall effect of

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S.Y. Lee et al. / Archives of Gerontology and Geriatrics 55 (2012) 522529 Fournier, J.C., DeRubeis, R.J., Hollon, S.D., Dimidjian, S., Amsterdam, J.D., Shelton, R.C., Fawcett, J., 2010. Antidepressant drug effects and depression severity: a patient-level analysis. J. Am. Med. Assoc. 303, 4753. Gallo, J.J., Zubritsky, C., Maxwell, J., Nazar, M., Bogner, H.R., Quijano, L.M., Syropoulos, H.J., Cheal, K.L., Chen, H., Sanchez, H., Dodson, J., Levkoff, S.E., the PRISM-E investigators, 2004. Primary care clinicians evaluate integrated and referral models of behavioral health care for older adults: results from a multisite effectiveness trial (PRISM-E). Ann. Fam. Med. 2, 305309. Grabovich, A., Lu, N., Tang, W., Tu, X., Lyness, J.M., 2010. Outcomes of subsyndromal depression in older primary care patients. Am. J. Geriatr. Psychiatry 18, 227235. n, P.A., Hunkeler, E., Tang, L., Katon, W., Hitchcock, P., Steffens, D.C., Gum, A.M., Area tzer, J., the IMPACT investigators, 2006. 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psychotherapy on non-dysthymic subthreshold depression. Second, since psychotherapy was administered along with other types of interventions in studies that used the stepped-care model, we are not able to isolate the specic contributions of each type of intervention within a stepped-care program. Third, the frequency and length of the psychotherapy may not have been sufcient to achieve greater impact in decreasing depressive symptoms. Fourth, due to the variety of available depression screening methods, it is difcult to compare the validity and reliability of the measurement across the studies. However, our current analysis has considerable strengths. To our knowledge, this is the rst critical review to assess the efcacy of non-pharmacological, indicated prevention of depression for older adults with subthreshold depression. We included studies with high quality of methodology and generalizability. All ve studies included were RCTs, and participants were recruited in community-based settings. In addition, study participants represented diverse racial/ethnic groups in the United States as well as participants from the Netherlands. 5. Conclusion The studies reviewed suggest that psychotherapy is an effective, safe, and cost-effective method to reduce the public health burden of depression among older adults with subthreshold depression. Future studies should ensure adequacy of length and frequency of the intervention, in order to test the effect of psychotherapy over a longer time period. It is also necessary to include follow-up evaluation, in order to examine if the effect of the intervention holds even after a substantial time lapse and to decide if or when the booster session is needed. We also encourage examining the cost-effectiveness of psychotherapy intervention, in order to provide a more practical recommendation to the policy makers to incorporate psychotherapy for depressive symptoms in the primary care setting. Conict of interest statement All authors report no conict of interest. Acknowledgments Doctoral training of Su Yeon Lee, the corresponding author, is sponsored by the Hopkins Sommer Scholars program at the Johns Hopkins Bloomberg School of Public Health. Sommer Scholars program has no involvement in the study design, collection, analysis, and interpretation of data, or the writing of the manuscript. References
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