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Treatment Considerations for Depression Research in Older Married Couples: A Dyadic Case Study
Accepted Manuscript Title: Treatment Considerations for Depression Research in Older Married Couples: a Dyadic Case Study Author: Sarah T. Stahl, Juleen Rodakowski, Ariel G. Gildengers, Charles F. Reynolds, Jennifer Morse, Kevin Rico, Meryl A. Butters PII: DOI: Reference:
S1064-7481(16)30343-8 http://dx.doi.org/doi: 10.1016/j.jagp.2016.12.013 AMGP 749
To appear in:
The American Journal of Geriatric Psychiatry
Received date: Revised date: Accepted date:
1-9-2016 19-12-2016 21-12-2016
Please cite this article as: Sarah T. Stahl, Juleen Rodakowski, Ariel G. Gildengers, Charles F. Reynolds, Jennifer Morse, Kevin Rico, Meryl A. Butters, Treatment Considerations for Depression Research in Older Married Couples: a Dyadic Case Study, The American Journal of Geriatric Psychiatry (2017), http://dx.doi.org/doi: 10.1016/j.jagp.2016.12.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 Treatment Considerations for Depression Research in Older Married Couples: A Dyadic Case Study
Sarah T. Stahl, PhD (1) Juleen Rodakowski, OTD, MS, OTR/L (2) Ariel G. Gildengers, MD (1) Charles F. Reynolds, MD (1) Jennifer Morse, PhD (3) Kevin Rico, LSW (1) Meryl A. Butters, PhD (1) (1) Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh PA (2) Department of Occupational Therapy, University of Pittsburgh School of Health and Rehab Sciences, Pittsburgh PA (3) Department of Counseling Psychology, Chatham University
AUTHOR’S NOTES Address correspondence to: Dr. Meryl A. Butters, Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O’Hara Street, Pittsburgh, PA 15213. Email: [email protected] Source of funding Preparation of this manuscript was supported in part by Grants from NIH P30 MH090333 (Project 8315), K01MH103467, KL2 TR000146, UL1 TR000005. Conflicts of Interest Dr. Reynolds reports being supported by the NIH, and the UPMC Endowment in Geriatric Psychiatry; having received medication supplies for investigator-initiated trials from Bristol Meyers Squibb, Forrest Labs, Lily, and Pfizer; and receives royalties for industry sponsored use of the Pittsburgh Sleep Quality Index (PSQI), to which he holds intellectual property rights. The other authors have nothing to disclose
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2 ABSTRACT Critical gaps remain in understanding optimal approaches to intervening with older couples. The focus of this report is to describe the pros and cons of incorporating spousal dyads into depression-prevention research. In an intervention development study, we administered Problem Solving Therapy (PST) dyadically –to participants with Mild Cognitive Impairment (MCI) and their caregivers. Dyads worked with the same interventionist in the same therapy session. We describe our dyadic PST (highlighted in a case example of a husband with MCI and his wife/support person) as well as the potential feasibility of the program. We found that the MCI individual’s wife could be trained as a PST coach to help her husband learn and use problem solving skills. A decrease in depressive symptom severity was observed for the MCI individual, which sustained over 12 months of follow-up. Neither the husband nor wife experienced an incident episode of major depression over the course of the study. We conclude that dyadic interventions need to be further developed in geriatric psychiatry; proven methods such as PST can be modified to include patients’ support persons. We offer recommendations for developing randomized controlled trials that aim to recruit dyads and prevent depression in at-risk older married couples.
Key words: depression, prevention, couples, dyads, problem-solving therapy
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3 Treatments for late-life depression are primarily focused on the patient. However, studies suggest that patient progress may be explained by spousal/partner involvement via support, participation, and collaboration. (1) Little is known about dyadic coping in the context of late-life depression and how older couples negotiate their experiences with depression or other neuropsychiatric disorders. For example, do couples make treatment decisions together; do they engage in joint coping efforts and appraise the situation as ‘our’ stressor? A better understanding of these issues could lead to greater use of dyadic approaches. Dyadic treatments may have an advantage over patient-focused approaches because they not only address the patient’s symptoms, but promote effective support behaviors on the part of the spouse or support person, leading to a better and more durable response in the patient. (2) On the other hand, dyadic approaches may entail greater burden on the therapist, the couple, and may not be reimbursed adequately. Critical gaps remain in understanding optimal approaches to intervening with older couples; that is the focus of this report. An added challenge to working with older couples (in research and clinical treatment) may lie in depression prevention and identifying couples who are not currently depressed, but exhibit risk factors that place one or both members of the dyad at high risk for Major Depressive Disorder (MDD). In particular, individuals with Mild Cognitive Impairment (MCI) function independently, but are at high risk of developing dementia, depression, and becoming increasingly dependent, placing stress not just on the patient, but on the significant other. MCI is frequently accompanied by mild depressive symptoms, which recent research suggests further increases risk of cognitive decline. (3) Individuals with MCI are also at especially high risk of developing MDD that in addition to reducing quality of life, presumably serves to enhance risk of cognitive decline even further (individuals who have experienced even a single episode of
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4 MDD are at double the risk of developing dementia relative to those without a history of MDD). (4) In individuals with MCI and their significant others, depression prevention efforts could target the long-term benefit and health of both members of the dyad, even if a couple does not view their health status as risky or either individual believes he or she needs help from their spouse or support person to manage their health. The goal of this report is to describe our experience incorporating spousal dyads into depression-prevention research. First, we describe why prevention of depression is important in older married couples. Second, we review a depression prevention pilot study we conducted using problem-solving therapy in dyads, consisting of an MCI patient and spousal caregiver (RECALL). (18) We then discuss a case example of an older married couple participating in RECALL and randomly assigned to learn problem solving therapy for the prevention of major depression to illustrate the pros and cons of dyadic treatment. Depression in Older Spouses Prior research shows that depressive symptoms are highly related in older spouses; depression in one partner increases the risk for depression in the other. (5, 6) Developing dyadic interventions for depression requires the identification of contextual factors that impact the extent to which spouses are affected by their partner’s depression. For example, dyadic interventions that focus on improving spousal support behaviors (e.g., help with symptom management or behavioral change) may work best in couples who report high relationship conflict, low marital quality, or a low level of partner support. (7) Another contextual factor to consider is relationship closeness. Couples who report greater relationship closeness or interconnectedness may be the most negatively affected by a partner’s depression because they
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5 include their partner in their own sense of self. (8, 9) Couples who are interconnected are likely heavily involved in each other’s daily routine and would likely benefit from a dyadic treatment plan. Finally, contagion of depression in older couples may be reduced by directly targeting spouses’ well-being. Findings from the caregiving intervention literature suggest that it is important to provide spouses with information about treatment, include them as active agents of support, and help them engage in self-care behaviors. (10) The importance of caregiver involvement is highlighted in a treatment study of depression and cognitive impairment by Miller et al (2007). In this study, interpersonal psychotherapy was modified to include both the patient and caregiver in order to include caregivers in the therapeutic process of treatment and target interpersonal stressors between patients and their caregivers. (11) Cross-sectional evidence shows that spouses/family members can be both beneficial and harmful to patients’ symptom severity. Increased emotional support behaviors from spouses and/or family members can increase treatment adherence (12), improve treatment response (13), and decrease relapse (14). On the other hand, lack of support from spouses and/or family members such as engaging in controlling behaviors (15), caregiver burden (11), and frequent couple conflict (16) can independently increase patients’ depressive symptom severity. A systematic review of randomized controlled trials shows that a dyadic treatment approach is superior to usual care in decreasing symptom severity among older patients with MDD. (2) However, only 4 treatment trials of MDD were identified in the review (the other papers included smaller proportions of patients with clinically significant levels of symptoms), indicating that remarkably few dyadic interventions have been attempted to treat depression in older adults. OUR RANDOMIZED DEPRESSION PREVENTION TRIAL
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6 Prevention of MDD in older adults is efficiently accomplished by targeting individuals who are mildly symptomatic because they are at the highest risk for converting to the full-blown clinical disorder (“indicated prevention”). (17,18) We conducted a pilot randomized control trial (ReCALL) to test the efficacy of Problem Solving Therapy (PST) for preventing the onset of MDD and anxiety and reducing depressive and anxiety symptom burden over 12 months in patients with MCI and their spousal/family caregiver (referred hereafter as ‘support person’) (19). The ReCALL trial focused on older adults with MCI and their support persons because depressive symptoms frequently co-occur with MCI (20), and spousal caregivers of individuals with MCI are at increased risk for MDD due to caregiving demands. (21) Participants were recruited from primary care physician (PCP) offices and the University of Pittsburgh Alzheimer’s Disease Research Center (ADRC), who referred appropriate participants (those diagnosed with (MCI) to our study. Participant Characteristics We enrolled individuals with MCI who were 60 years or older and scored >1 on the Patient Health Questionaire-9 (PHQ-9) with at least a score of 1 on question 1 or 2 (depressed mood or anhedonia). We administered the Structured Clinical Interview for DSM-IV (22) to rule out current MDD and anxiety disorder, except for specific phobia. Participants needed adequate physical and sensory functioning to undergo neuropsychological assessment. RECALL also tested whether moderate-intensity physical exercise might prevent major depression and anxiety; therefore; participants needed the ability to engage in moderately intense exercise (brisk walking) three times per week (for full report, see 19) Intervention
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7 Problem Solving Therapy (PST) is a cognitive-behavioral intervention approach in which the clinician and patient collaborate to identify and effectively manage negative events that a patient is experiencing. The goal of PST is to improve the patient’s ability to cope with stressful life experiences by teaching them a systematic approach for solving problems. Components of PST include psychoeducation, active problem solving in sessions, behavioral activation, and homework assignments where patients can apply problem-solving skills. PST entails 7 steps: defining a problem, generating solutions (brainstorming), evaluating solutions, comparing solutions, selecting a feasible solution, implementing the solution, and evaluating the outcome. The rationale for using PST in individuals with MCI is that the cognitive symptoms they experience, such as slowed information processing and impaired memory, compromise problem solving. (23) The underlying assumption of PST is that problem solving deficits lead to maladaptive coping, increased stress, and ultimately psychopathology like major depression. (24, 25) ReCALL focused on preventing depression and enhancing cognitive function in individuals with MCI and preventing depression in support persons. Therefore, we modified the traditional PST approach to slow down the presentation and provide extra repetition of information to the MCI participant and to include support persons. Both patients and support responses were consented participants in the intervention. After the PST model was presented, the patient gave permission to include a support person in each session. Some dyads often had sessions where the support person was present for the patient's PST session but occasionally a patient would have an individual session. Ten to twelve sessions of PST were delivered over 16 weeks. Each PST session lasted approximately 60-90 minutes. The primary motivation for including support persons was to help them serve as the MCI participant’s “coach,” meaning that the support person had to be sufficiently trained in PST so
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8 that s/he could assist the MCI individual to use PST effectively once the intervention ended. In traditional PST, the 7 steps are typically taught in the first session; in ReCALL, therapists presented 2 steps per session to ensure that the MCI participant understood the problem-solving model and was not overwhelmed by the amount of information that was presented. The support person was present during the teaching portion of these early sessions, which served several important functions: 1) the therapist modeled a non-judgmental stance towards both the MCI participant and support person and explicitly taught coaching to the support person along with PST skills; 2) the therapist reinforced to both the MCI individual and the support person that PST was not couples’ therapy; and 3) the therapist observed the interaction between the MCI participant and support person. Specifically, the therapist followed the PST principle that the intervention is driven by the patient by focusing on the pace of teaching the components of PST, problems and goals of the MCI participant, and demonstrating a different way for the support person to interact with the MCI participant. The therapist also modeled good coaching and invited the support person to try coaching; offering feedback about coaching that was related back to each step of PST rather than any marital dynamic or personal characteristic. The therapist praised both improved problem-solving skills and coaching skills. The timing of the session was also modified so that it included time to check-in (and/or teach) with both the MCI participant and support person together as well as separately. Individual time with each member of the dyad offered further opportunities for one-on-one teaching and feedback as well as space to discuss topics that either member did not want to bring up in front of the other (though often, after individual coaching, these concerns were raised when the dyad was together). Finally, the support person was offered a single session of PST for him/herself, to focus on a problem of his or her choosing. The goal of this session was to check
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9 on caregiver burden and to ensure that the support person understood the principles of PST and the content of the steps well enough to act independently as a coach. It also served to provide the support person with a tool to help reduce their own level or stress. Assessments We assessed MCI participants and their support persons six times over a 15 month period: baseline, after the PST intervention (16 weeks from baseline), and 3, 6, 9, and 12 months post-intervention. The primary outcome was the time to onset of an episode of major depression or anxiety disorder as determined by the PRIME-MD/Mini. (26) We also assessed depressive symptom burden with the PHQ-9 (27) and anxiety symptom burden with the GAD-7 (28). We used the Dyadic Adjustment Scale (DAS) (29) to examine marital satisfaction in both the patient and support person and we used the 22-item Zarit Burden Interview (30) to examine caregiver burden in the support person. CASE REPORT 75-year-old white man with MCI and his 65-year-old wife are randomized to learn PST At the first (meet-and-greet) session, the boundaries for PST were discussed and the couple was informed that the PST intervention is not a form of marital therapy. The clinician discussed how the MCI participant and his wife would work on problems selected by the MCI participant. The role of the support person is to function as a "coach" and “auxiliary brain” who helps to keep the patient on track in learning the seven steps of PST. This understanding had to be reinforced throughout the intervention as the support person seemed to have her own agenda that she wanted her husband to work on, rather than supporting him in the problems he had selected to work on in each session. They both noted that problems in their relationship were significant sources of stress, particularly about their differences in how they each manage their
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10 finances. Psychoeducation was important in helping the wife understand her husbands’ MCI diagnosis and that he is not being ‘passive-aggressive’ when forgetting to do something, but that he really cannot remember. The MCI participant eventually selected ‘cleaning up his den’ as the focus of his first PST experience. Although it did not directly address their relationship, his selection of "cleaning up his den" seemed to be well received by his wife. He was able to experience the need to break down a larger problem into smaller, more manageable sections. The first section he chose to work on was to develop a list of creditors that he makes payments to each month. This goal was encouraged by his wife as it would immediately reduce the stress she experiences over not knowing how much money they owed to credit card companies. In the phase of PST where the support person has an opportunity to select a problem of their own to work on, she selected “(feeling) being patient and nonjudgmental in order to feel calm” as a goal. She indicated this would allow her to get along better with her husband. The couple also consistently completed the "pleasant daily activity" part of the intervention. The patient said that this part of PST was helpful to him in that it reminded him of all the things he enjoyed doing over the past week. The patient continued to work through the various steps necessary to "clean up his den" and his wife was supportive of his efforts in that area. The couple was seen for 11 sessions over four months. In session six, the husband expressed his desire to "stop being judgmental" as a means of improving his interaction with his wife. He articulated that he wanted to work on his mood and was looking for resources. After he brainstormed all the solutions he knew, the clinician described the Mind Over Mood (31) book that could be used both for himself and for the couple together. The clinician was careful to communicate that the information/resources offered are just that and that there is no pressure for
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11 the patient to select the therapist's solution. The patient was interested in getting and reading Mind over Mood. The patient's cognitive impairment was mild and not enough to make Mind over Mood inaccessible. The MCI participant indicated he was beginning to gain an awareness of times when he was more likely to become judgmental and reportedly was "able to catch myself" to keep from becoming so angry at those times. As the sessions progressed, the patient continued to work on the goals of cleaning his den and not being judgmental. His wife provided adequate support during the sessions to guide him in "working through" the steps of PST. She was able to state how his behavior had caused difficulty in their relationship and in his relationships with others. In brainstorming solutions, he was able to ask his wife for help in supporting him in his efforts to become more aware of when he was treating her in a manner that she considered to be disrespectful. They came to a mutually agreeable method of achieving this solution. Treatment Results At baseline, the husband reported that for several days he felt down, depressed, or hopeless; had trouble falling or staying asleep; felt tired/had little energy; and felt he moved or spoke slowly (PHQ-9 score = 4). After PST, his PHQ-9 score decreased by 2 points. At the 3 month post-intervention follow-up he reported no depressive symptoms; this effect sustained for the rest of the follow-up period (6 months). The support person reported little to no symptoms over the entire study. At baseline, marital satisfaction scores were similar for the MCI participant and support person (DAS score = 26 and 27 respectively). After PST, marital satisfaction increased for the patient (DAS = 29) and decreased for the support person (DAS = 23); these scores sustained across 12 months of follow-up. A closer look at the individual items shows that the MCI
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12 participant reported an increase in happiness over the course of the study (‘very happy’ at baseline and ‘extremely happy’ after PST and at the 12-month follow-up). The support person reported no change in marital happiness and felt ‘happy’ over the course of the study. The support person reported little or no caregiver burden at baseline (Zarit score = 7) (30). She reported that she sometimes felt angry and strained when she was around her husband. She felt that she did not have as much privacy as she would like because of the need to provide some degree of support for her husband. She also felt that her health had suffered because of her involvement with supporting her husband. At the 6- and 12-month follow-up interviews her burden score decreased from a 7 to a 4; she reported feeling less embarrassed over her husband’s behavior. While the cutoff for mild caregiver burden is 21 on the Zarit Interview, these scores highlight the ups and downs experienced by a spousal caregiver of an individual with MCI. LESSONS LEARNED This report describes a dyadic case study where Problem Solving Therapy (PST) – an efficacious treatment for the prevention of MDD in at-risk older adults (32-34) – was modified to include the MCI participant’s wife as a support person. We found that the wife could be trained as a PST coach to promote positive aspects of their relationship. A decrease in depression symptom severity was observed for the MCI participant, which sustained over time. Neither the husband nor wife experienced an incident episode of major depression over the course of the 12month follow-up. An increase in marital happiness was also observed for the MCI participant; while no change in happiness was observed for the support person. Based on our clinical experience and research findings, we offer the following recommendations for developing RCTs that aim to recruit dyads and prevent depression in at-risk older married couples: 1. It is crucial that the individual with MCI and support person understand the purpose
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13 of depression prevention or treatment and the expectations of the intervention protocol (PST). The purpose for the use of PST in working with couples is to teach the skills to both the individual with MCI and their support person so that the support person can provide beneficial feedback in order to facilitate the MCI individual in their attempt to learn PST. By empowering the MCI individual with the tools of PST, it is hoped that they will have reduced stress, decreased depression burden, and increased ability to function independently. We found that it was very important to set the duties of the support person as being a "coach" to the MCI individual in the first "meet and greet" session. We also found that psychoeducation was important in helping the coach understand their spouses’ diagnosis. 2. It is important to emphasize that PST is not marital therapy that uses couple counseling to intervene in any relationship issues that may be present between the patient and their support person. It is necessary to adhere to intervention principles (descriptions of the problem are factual and non-judgmental) and guidelines (learning is optimized when the problem is not too emotional) so that sessions do not become an opportunity for the couple to become stuck in a series of complaints about their relationship. Working with the individual with MCI during the initial PST session to select a personal goal related to having a daily pleasant activity may help alleviate a couple’s urge to discuss marital problems. It is also a less complicated goal that allows the opportunity for the dyad to experience success thus increasing their motivation and confidence for addressing more difficult problems over the course of the intervention. 3. When screening potential participants, we found that many older adults lived alone
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14 and/or did not have a support person who could participate with them. We edited our intervention protocol in order to include patients with and without support persons. Future research should determine whether PST can be administered to patient-friend or patient-adult child dyads. 4. Some individuals disliked being coached by their spouses, especially when the spouse was the dominant figure in the relationship. In situations whether the patient's and support person’s ideas about treatment goals differed, the therapist referred back to the PST model and say that the patient's goals would be the focus. The overall PST framework clearly puts the patient's treatment goals as primary. If the patient was excessively dependent, that was addressed by reminding the patient that successful PST depends on the patient's expertise in their own life along with the therapist's expertise in the model. So the patient would be encouraged to come up with each of the steps independently as much as possible. If the coach was excessively dependent, that was addressed by explicitly talking about the coach's role in learning PST and supporting the patient. Often our therapists talked about as the coach being an "extra brain" for the patient. The individual session with the coach was focused on ensuring that the coach fully understood and could apply PST and also provided an opportunity to address a problem specific to the coach, including caregiver burden, coach's selfcare, and potential coaching dynamics. We also believe it is crucial to collect information about the marital relationship in order to determine who might benefit best from being coached by their spouse. This information would also help describe potential mechanisms of change. For example, greater marital happiness or low caregiver burden might be important mediators or moderators of treatment effects in
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15 dyadic treatment studies of depression. Conclusions This report describes the pros and cons of incorporating spousal dyads into depressionprevention research. When intervening with older married couples, it is important to collect information about the marital relationship, as these variables may be important moderators or mediators of treatment effects. Dyadic interventions need to be further developed for prevention of depression in individuals with MCI and their support persons. Our experiences in RECALL suggest that proven patient-centered interventions like PST can be adapted to the include patient’s support person.
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16 References 1. Berg CA, Upchurch R: A developmental-contextual model of couples coping with chronic illness across the adult life span. Psychol Bull. 2007; 133: 920-54. 2. Stahl ST, Rodakowski J, Saghafi E, et al: Systematic review of dyadic and family-oriented interventions for late-life depression. Int J Geriatr Psychiatry 2016; 31: 963-973. 3. Diniz BS, Sibille E, Ding Y, et al: Plasma biosignature and brain pathology related to persistent cognitive impairment in late-life depression. Mol Psychiatry 2015; 20: 594–601. 4. Diniz B, Butters MA, Albert SM, et al: Late-life depression and risk of vascular dementia and Alzheimer’s disease: a systematic review and meta-analysis of population-based cohort studies. Br J Psychiatr 2013; 202(5): 329-35. 5. Monin J, Doyle M, Levy B, et al: Spousal Associations Between Frailty and Depressive Symptoms: Longitudinal Findings from the Cardiovascular Health Study. J Am Geriatr Soc 2016: 64: 824–830. 6. Townsend AL, Miller B, Guo S: Depressive symptomatology in middle-aged and older married couples a dyadic analysis. JGerontol Ser B Psychol Sci Soc Sci. 2001; 56(6): S352S364. 7. Kiecolt-Glaser JK, Newton TL: Marriage and health: His and hers. Psychol Bull 2001: 127: 472–503 8. Aron A, Aron EN, Smollan D: Inclusion of Other in the Self Scale and the structure of interpersonal closeness. J Pers Soc Psychol 1992; 63(4): 596. 9. Monin JK, Martire LM, Schulz R. et al: Willingness to express emotions to caregiving spouses. Emot 2009: 1: 101-106.
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17 10. Martire LM, Schulz R: Involving family in psychosocial interventions for chronic illness. Current Dir Psychol Sci 2007: 16(2): 90-94. 11. Miller MD, Richarards V, Zuckoff A, Martire LM, Morse J, Frank E, Reynolds CF. A Model for Modifying Interpersonal Psychotherapy (IPT) for Depressed Elders with Cognitive Impairment. Clin Geron 2007; 30: 79-101. 12. Bolka CR, Bonner LM, Campbell DG, et al: Family involvement, medication adherence, and depression outcomes among patients in veterans affairs primary care. Psychiatric Serv 2013; 64: 472-478. 13. Martire LM, Schulz R, Reynolds CF, et al: Impact of close family members on older adults’ early response to depression treatment. Psyc Aging 2008; 23: 447-452. 14. Miklowitz DJ, George EL, Richards JA, et al: A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder, Archiv Gen Psychiatry 2003; 60: 904-912. 15. Martire LM, Schulz R, Wrosch C, et al: Perceptions and implications of received spousal care: Evidence from the Caregiver Health Effects Study. Psyc Aging 2003; 18: 593-601. 16. Park M, Unützer J. Hundred forty eight more days with depression: the association between marital conflict and depression-free days. Int J of Geriatr Psychiatry 2014; 29(12): 12711277. 17. Reynolds CF, 3rd, Cuijpers P, Patel V, et al: Early intervention to reduce the global health and economic burden of major depression in older adults. Annu Rev Public Health. 2012; 33: 123–135 18. Schoevers RA, Smit F, Deeg DJH, et al: Prevention of late-life depression in primary care: do we know where to begin? Am J Psychiatry 2006; 163:1611–1621.
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18 19. Gildengers AG, Butters MA, Albert SM, et al: The design and implementation of an intervention development study: Retaining cognition while avoiding late-life depression (ReCALL). Am J Geriat Psychiat. 2016; 24(6) 444-454. 20. Lingler JH, Nightingale MC, Erlen JA, et al: Making sense of mild cognitive impairment: a qualitative exploration of the patient's experience. The Gerontologist 2006; 46:791-800 21. Garand L, Dew MA, Eazor LR, et al: Caregiving burden and psychiatric morbidity in spouses of persons with mild cognitive impairment. Int J Geriatr Psychiat 2005; 20:512-522 22. American Psychiatric Association. American Psychiatric Association. Task Force on DSMIV.: Diagnostic and statistical manual of mental disorders : DSM-IV-TR, 4th. Washington, DC, American Psychiatric Association, 2000 23. Alexopoulos GS, Raue P, Arean P. Problem-solving therapy versus supportive therapy in geriatric major depression with executive dysfunction. Am J Geriatr Psychiatry. 2003; 11: 46–52. 24. Arean PA, Perri MG, Nezu AM, et al: Comparative effectiveness of social problem-solving therapy and reminiscence therapy as treatments for depression in older adults. J Consult Clin Psych 1993; 61(6):1003-10. 25. Nezu AM, Perri MG. Social problem-solving therapy for unipolar depression: an initial dismantling investigation. J Consult Clin Psych 1989; 57(3): 408-13. 26. Spitzer RL, Williams JB, Kroenke K, et al: Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA 1994; 272: 1749-1756 27. Kroenke K, Spitzer RL, Williams JB: The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002; 64:258-266
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19 28. Spitzer RL, Kroenke L, Williams JBW, et al: A brief measure for assessing generalized anxiety disorder. Arch Intern Med 2006; 166: 1092-1097 29. Spanier GB. Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. J Marriage Fam 1976; 38: 15-28. 30. Zarit SH, Reever KE, Bach-Peterson J: Relatives of the impaired elderly: correlated of feelings of burden. Gerontologist 1980; 20: 649-655. 31. Greenberger, D. Mind over mood: Change how you feel by changing the way you think. New York: Guilford Press; 1995. 32. Cuijpers P, van Straten A, Smit F: Psychological treatment of late life depression: a metaanalysis of randomized controlled trials. Int J Geriatr Psychiatry 2006; 21:1139–1149 33. Reynolds CF, Thomas SB, Morse JQ et al., Early intervention to preempt major depression in older black and white adults. Psychiatric Services 2014; 65: 765 -773 34. Robinson RG, Jorge RE, Moser DJ, et al. Escitalopram and problem-solving therapy for prevention of post-stroke depression: a randomized controlled trial. JAMA. 2008; 299:2391– 2400.
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S1064-7481(16)30343-8 http://dx.doi.org/doi: 10.1016/j.jagp.2016.12.013 AMGP 749
To appear in:
The American Journal of Geriatric Psychiatry
Received date: Revised date: Accepted date:
1-9-2016 19-12-2016 21-12-2016
Please cite this article as: Sarah T. Stahl, Juleen Rodakowski, Ariel G. Gildengers, Charles F. Reynolds, Jennifer Morse, Kevin Rico, Meryl A. Butters, Treatment Considerations for Depression Research in Older Married Couples: a Dyadic Case Study, The American Journal of Geriatric Psychiatry (2017), http://dx.doi.org/doi: 10.1016/j.jagp.2016.12.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 Treatment Considerations for Depression Research in Older Married Couples: A Dyadic Case Study
Sarah T. Stahl, PhD (1) Juleen Rodakowski, OTD, MS, OTR/L (2) Ariel G. Gildengers, MD (1) Charles F. Reynolds, MD (1) Jennifer Morse, PhD (3) Kevin Rico, LSW (1) Meryl A. Butters, PhD (1) (1) Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh PA (2) Department of Occupational Therapy, University of Pittsburgh School of Health and Rehab Sciences, Pittsburgh PA (3) Department of Counseling Psychology, Chatham University
AUTHOR’S NOTES Address correspondence to: Dr. Meryl A. Butters, Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O’Hara Street, Pittsburgh, PA 15213. Email: [email protected] Source of funding Preparation of this manuscript was supported in part by Grants from NIH P30 MH090333 (Project 8315), K01MH103467, KL2 TR000146, UL1 TR000005. Conflicts of Interest Dr. Reynolds reports being supported by the NIH, and the UPMC Endowment in Geriatric Psychiatry; having received medication supplies for investigator-initiated trials from Bristol Meyers Squibb, Forrest Labs, Lily, and Pfizer; and receives royalties for industry sponsored use of the Pittsburgh Sleep Quality Index (PSQI), to which he holds intellectual property rights. The other authors have nothing to disclose
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2 ABSTRACT Critical gaps remain in understanding optimal approaches to intervening with older couples. The focus of this report is to describe the pros and cons of incorporating spousal dyads into depression-prevention research. In an intervention development study, we administered Problem Solving Therapy (PST) dyadically –to participants with Mild Cognitive Impairment (MCI) and their caregivers. Dyads worked with the same interventionist in the same therapy session. We describe our dyadic PST (highlighted in a case example of a husband with MCI and his wife/support person) as well as the potential feasibility of the program. We found that the MCI individual’s wife could be trained as a PST coach to help her husband learn and use problem solving skills. A decrease in depressive symptom severity was observed for the MCI individual, which sustained over 12 months of follow-up. Neither the husband nor wife experienced an incident episode of major depression over the course of the study. We conclude that dyadic interventions need to be further developed in geriatric psychiatry; proven methods such as PST can be modified to include patients’ support persons. We offer recommendations for developing randomized controlled trials that aim to recruit dyads and prevent depression in at-risk older married couples.
Key words: depression, prevention, couples, dyads, problem-solving therapy
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3 Treatments for late-life depression are primarily focused on the patient. However, studies suggest that patient progress may be explained by spousal/partner involvement via support, participation, and collaboration. (1) Little is known about dyadic coping in the context of late-life depression and how older couples negotiate their experiences with depression or other neuropsychiatric disorders. For example, do couples make treatment decisions together; do they engage in joint coping efforts and appraise the situation as ‘our’ stressor? A better understanding of these issues could lead to greater use of dyadic approaches. Dyadic treatments may have an advantage over patient-focused approaches because they not only address the patient’s symptoms, but promote effective support behaviors on the part of the spouse or support person, leading to a better and more durable response in the patient. (2) On the other hand, dyadic approaches may entail greater burden on the therapist, the couple, and may not be reimbursed adequately. Critical gaps remain in understanding optimal approaches to intervening with older couples; that is the focus of this report. An added challenge to working with older couples (in research and clinical treatment) may lie in depression prevention and identifying couples who are not currently depressed, but exhibit risk factors that place one or both members of the dyad at high risk for Major Depressive Disorder (MDD). In particular, individuals with Mild Cognitive Impairment (MCI) function independently, but are at high risk of developing dementia, depression, and becoming increasingly dependent, placing stress not just on the patient, but on the significant other. MCI is frequently accompanied by mild depressive symptoms, which recent research suggests further increases risk of cognitive decline. (3) Individuals with MCI are also at especially high risk of developing MDD that in addition to reducing quality of life, presumably serves to enhance risk of cognitive decline even further (individuals who have experienced even a single episode of
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4 MDD are at double the risk of developing dementia relative to those without a history of MDD). (4) In individuals with MCI and their significant others, depression prevention efforts could target the long-term benefit and health of both members of the dyad, even if a couple does not view their health status as risky or either individual believes he or she needs help from their spouse or support person to manage their health. The goal of this report is to describe our experience incorporating spousal dyads into depression-prevention research. First, we describe why prevention of depression is important in older married couples. Second, we review a depression prevention pilot study we conducted using problem-solving therapy in dyads, consisting of an MCI patient and spousal caregiver (RECALL). (18) We then discuss a case example of an older married couple participating in RECALL and randomly assigned to learn problem solving therapy for the prevention of major depression to illustrate the pros and cons of dyadic treatment. Depression in Older Spouses Prior research shows that depressive symptoms are highly related in older spouses; depression in one partner increases the risk for depression in the other. (5, 6) Developing dyadic interventions for depression requires the identification of contextual factors that impact the extent to which spouses are affected by their partner’s depression. For example, dyadic interventions that focus on improving spousal support behaviors (e.g., help with symptom management or behavioral change) may work best in couples who report high relationship conflict, low marital quality, or a low level of partner support. (7) Another contextual factor to consider is relationship closeness. Couples who report greater relationship closeness or interconnectedness may be the most negatively affected by a partner’s depression because they
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5 include their partner in their own sense of self. (8, 9) Couples who are interconnected are likely heavily involved in each other’s daily routine and would likely benefit from a dyadic treatment plan. Finally, contagion of depression in older couples may be reduced by directly targeting spouses’ well-being. Findings from the caregiving intervention literature suggest that it is important to provide spouses with information about treatment, include them as active agents of support, and help them engage in self-care behaviors. (10) The importance of caregiver involvement is highlighted in a treatment study of depression and cognitive impairment by Miller et al (2007). In this study, interpersonal psychotherapy was modified to include both the patient and caregiver in order to include caregivers in the therapeutic process of treatment and target interpersonal stressors between patients and their caregivers. (11) Cross-sectional evidence shows that spouses/family members can be both beneficial and harmful to patients’ symptom severity. Increased emotional support behaviors from spouses and/or family members can increase treatment adherence (12), improve treatment response (13), and decrease relapse (14). On the other hand, lack of support from spouses and/or family members such as engaging in controlling behaviors (15), caregiver burden (11), and frequent couple conflict (16) can independently increase patients’ depressive symptom severity. A systematic review of randomized controlled trials shows that a dyadic treatment approach is superior to usual care in decreasing symptom severity among older patients with MDD. (2) However, only 4 treatment trials of MDD were identified in the review (the other papers included smaller proportions of patients with clinically significant levels of symptoms), indicating that remarkably few dyadic interventions have been attempted to treat depression in older adults. OUR RANDOMIZED DEPRESSION PREVENTION TRIAL
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6 Prevention of MDD in older adults is efficiently accomplished by targeting individuals who are mildly symptomatic because they are at the highest risk for converting to the full-blown clinical disorder (“indicated prevention”). (17,18) We conducted a pilot randomized control trial (ReCALL) to test the efficacy of Problem Solving Therapy (PST) for preventing the onset of MDD and anxiety and reducing depressive and anxiety symptom burden over 12 months in patients with MCI and their spousal/family caregiver (referred hereafter as ‘support person’) (19). The ReCALL trial focused on older adults with MCI and their support persons because depressive symptoms frequently co-occur with MCI (20), and spousal caregivers of individuals with MCI are at increased risk for MDD due to caregiving demands. (21) Participants were recruited from primary care physician (PCP) offices and the University of Pittsburgh Alzheimer’s Disease Research Center (ADRC), who referred appropriate participants (those diagnosed with (MCI) to our study. Participant Characteristics We enrolled individuals with MCI who were 60 years or older and scored >1 on the Patient Health Questionaire-9 (PHQ-9) with at least a score of 1 on question 1 or 2 (depressed mood or anhedonia). We administered the Structured Clinical Interview for DSM-IV (22) to rule out current MDD and anxiety disorder, except for specific phobia. Participants needed adequate physical and sensory functioning to undergo neuropsychological assessment. RECALL also tested whether moderate-intensity physical exercise might prevent major depression and anxiety; therefore; participants needed the ability to engage in moderately intense exercise (brisk walking) three times per week (for full report, see 19) Intervention
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7 Problem Solving Therapy (PST) is a cognitive-behavioral intervention approach in which the clinician and patient collaborate to identify and effectively manage negative events that a patient is experiencing. The goal of PST is to improve the patient’s ability to cope with stressful life experiences by teaching them a systematic approach for solving problems. Components of PST include psychoeducation, active problem solving in sessions, behavioral activation, and homework assignments where patients can apply problem-solving skills. PST entails 7 steps: defining a problem, generating solutions (brainstorming), evaluating solutions, comparing solutions, selecting a feasible solution, implementing the solution, and evaluating the outcome. The rationale for using PST in individuals with MCI is that the cognitive symptoms they experience, such as slowed information processing and impaired memory, compromise problem solving. (23) The underlying assumption of PST is that problem solving deficits lead to maladaptive coping, increased stress, and ultimately psychopathology like major depression. (24, 25) ReCALL focused on preventing depression and enhancing cognitive function in individuals with MCI and preventing depression in support persons. Therefore, we modified the traditional PST approach to slow down the presentation and provide extra repetition of information to the MCI participant and to include support persons. Both patients and support responses were consented participants in the intervention. After the PST model was presented, the patient gave permission to include a support person in each session. Some dyads often had sessions where the support person was present for the patient's PST session but occasionally a patient would have an individual session. Ten to twelve sessions of PST were delivered over 16 weeks. Each PST session lasted approximately 60-90 minutes. The primary motivation for including support persons was to help them serve as the MCI participant’s “coach,” meaning that the support person had to be sufficiently trained in PST so
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8 that s/he could assist the MCI individual to use PST effectively once the intervention ended. In traditional PST, the 7 steps are typically taught in the first session; in ReCALL, therapists presented 2 steps per session to ensure that the MCI participant understood the problem-solving model and was not overwhelmed by the amount of information that was presented. The support person was present during the teaching portion of these early sessions, which served several important functions: 1) the therapist modeled a non-judgmental stance towards both the MCI participant and support person and explicitly taught coaching to the support person along with PST skills; 2) the therapist reinforced to both the MCI individual and the support person that PST was not couples’ therapy; and 3) the therapist observed the interaction between the MCI participant and support person. Specifically, the therapist followed the PST principle that the intervention is driven by the patient by focusing on the pace of teaching the components of PST, problems and goals of the MCI participant, and demonstrating a different way for the support person to interact with the MCI participant. The therapist also modeled good coaching and invited the support person to try coaching; offering feedback about coaching that was related back to each step of PST rather than any marital dynamic or personal characteristic. The therapist praised both improved problem-solving skills and coaching skills. The timing of the session was also modified so that it included time to check-in (and/or teach) with both the MCI participant and support person together as well as separately. Individual time with each member of the dyad offered further opportunities for one-on-one teaching and feedback as well as space to discuss topics that either member did not want to bring up in front of the other (though often, after individual coaching, these concerns were raised when the dyad was together). Finally, the support person was offered a single session of PST for him/herself, to focus on a problem of his or her choosing. The goal of this session was to check
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9 on caregiver burden and to ensure that the support person understood the principles of PST and the content of the steps well enough to act independently as a coach. It also served to provide the support person with a tool to help reduce their own level or stress. Assessments We assessed MCI participants and their support persons six times over a 15 month period: baseline, after the PST intervention (16 weeks from baseline), and 3, 6, 9, and 12 months post-intervention. The primary outcome was the time to onset of an episode of major depression or anxiety disorder as determined by the PRIME-MD/Mini. (26) We also assessed depressive symptom burden with the PHQ-9 (27) and anxiety symptom burden with the GAD-7 (28). We used the Dyadic Adjustment Scale (DAS) (29) to examine marital satisfaction in both the patient and support person and we used the 22-item Zarit Burden Interview (30) to examine caregiver burden in the support person. CASE REPORT 75-year-old white man with MCI and his 65-year-old wife are randomized to learn PST At the first (meet-and-greet) session, the boundaries for PST were discussed and the couple was informed that the PST intervention is not a form of marital therapy. The clinician discussed how the MCI participant and his wife would work on problems selected by the MCI participant. The role of the support person is to function as a "coach" and “auxiliary brain” who helps to keep the patient on track in learning the seven steps of PST. This understanding had to be reinforced throughout the intervention as the support person seemed to have her own agenda that she wanted her husband to work on, rather than supporting him in the problems he had selected to work on in each session. They both noted that problems in their relationship were significant sources of stress, particularly about their differences in how they each manage their
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10 finances. Psychoeducation was important in helping the wife understand her husbands’ MCI diagnosis and that he is not being ‘passive-aggressive’ when forgetting to do something, but that he really cannot remember. The MCI participant eventually selected ‘cleaning up his den’ as the focus of his first PST experience. Although it did not directly address their relationship, his selection of "cleaning up his den" seemed to be well received by his wife. He was able to experience the need to break down a larger problem into smaller, more manageable sections. The first section he chose to work on was to develop a list of creditors that he makes payments to each month. This goal was encouraged by his wife as it would immediately reduce the stress she experiences over not knowing how much money they owed to credit card companies. In the phase of PST where the support person has an opportunity to select a problem of their own to work on, she selected “(feeling) being patient and nonjudgmental in order to feel calm” as a goal. She indicated this would allow her to get along better with her husband. The couple also consistently completed the "pleasant daily activity" part of the intervention. The patient said that this part of PST was helpful to him in that it reminded him of all the things he enjoyed doing over the past week. The patient continued to work through the various steps necessary to "clean up his den" and his wife was supportive of his efforts in that area. The couple was seen for 11 sessions over four months. In session six, the husband expressed his desire to "stop being judgmental" as a means of improving his interaction with his wife. He articulated that he wanted to work on his mood and was looking for resources. After he brainstormed all the solutions he knew, the clinician described the Mind Over Mood (31) book that could be used both for himself and for the couple together. The clinician was careful to communicate that the information/resources offered are just that and that there is no pressure for
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11 the patient to select the therapist's solution. The patient was interested in getting and reading Mind over Mood. The patient's cognitive impairment was mild and not enough to make Mind over Mood inaccessible. The MCI participant indicated he was beginning to gain an awareness of times when he was more likely to become judgmental and reportedly was "able to catch myself" to keep from becoming so angry at those times. As the sessions progressed, the patient continued to work on the goals of cleaning his den and not being judgmental. His wife provided adequate support during the sessions to guide him in "working through" the steps of PST. She was able to state how his behavior had caused difficulty in their relationship and in his relationships with others. In brainstorming solutions, he was able to ask his wife for help in supporting him in his efforts to become more aware of when he was treating her in a manner that she considered to be disrespectful. They came to a mutually agreeable method of achieving this solution. Treatment Results At baseline, the husband reported that for several days he felt down, depressed, or hopeless; had trouble falling or staying asleep; felt tired/had little energy; and felt he moved or spoke slowly (PHQ-9 score = 4). After PST, his PHQ-9 score decreased by 2 points. At the 3 month post-intervention follow-up he reported no depressive symptoms; this effect sustained for the rest of the follow-up period (6 months). The support person reported little to no symptoms over the entire study. At baseline, marital satisfaction scores were similar for the MCI participant and support person (DAS score = 26 and 27 respectively). After PST, marital satisfaction increased for the patient (DAS = 29) and decreased for the support person (DAS = 23); these scores sustained across 12 months of follow-up. A closer look at the individual items shows that the MCI
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12 participant reported an increase in happiness over the course of the study (‘very happy’ at baseline and ‘extremely happy’ after PST and at the 12-month follow-up). The support person reported no change in marital happiness and felt ‘happy’ over the course of the study. The support person reported little or no caregiver burden at baseline (Zarit score = 7) (30). She reported that she sometimes felt angry and strained when she was around her husband. She felt that she did not have as much privacy as she would like because of the need to provide some degree of support for her husband. She also felt that her health had suffered because of her involvement with supporting her husband. At the 6- and 12-month follow-up interviews her burden score decreased from a 7 to a 4; she reported feeling less embarrassed over her husband’s behavior. While the cutoff for mild caregiver burden is 21 on the Zarit Interview, these scores highlight the ups and downs experienced by a spousal caregiver of an individual with MCI. LESSONS LEARNED This report describes a dyadic case study where Problem Solving Therapy (PST) – an efficacious treatment for the prevention of MDD in at-risk older adults (32-34) – was modified to include the MCI participant’s wife as a support person. We found that the wife could be trained as a PST coach to promote positive aspects of their relationship. A decrease in depression symptom severity was observed for the MCI participant, which sustained over time. Neither the husband nor wife experienced an incident episode of major depression over the course of the 12month follow-up. An increase in marital happiness was also observed for the MCI participant; while no change in happiness was observed for the support person. Based on our clinical experience and research findings, we offer the following recommendations for developing RCTs that aim to recruit dyads and prevent depression in at-risk older married couples: 1. It is crucial that the individual with MCI and support person understand the purpose
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13 of depression prevention or treatment and the expectations of the intervention protocol (PST). The purpose for the use of PST in working with couples is to teach the skills to both the individual with MCI and their support person so that the support person can provide beneficial feedback in order to facilitate the MCI individual in their attempt to learn PST. By empowering the MCI individual with the tools of PST, it is hoped that they will have reduced stress, decreased depression burden, and increased ability to function independently. We found that it was very important to set the duties of the support person as being a "coach" to the MCI individual in the first "meet and greet" session. We also found that psychoeducation was important in helping the coach understand their spouses’ diagnosis. 2. It is important to emphasize that PST is not marital therapy that uses couple counseling to intervene in any relationship issues that may be present between the patient and their support person. It is necessary to adhere to intervention principles (descriptions of the problem are factual and non-judgmental) and guidelines (learning is optimized when the problem is not too emotional) so that sessions do not become an opportunity for the couple to become stuck in a series of complaints about their relationship. Working with the individual with MCI during the initial PST session to select a personal goal related to having a daily pleasant activity may help alleviate a couple’s urge to discuss marital problems. It is also a less complicated goal that allows the opportunity for the dyad to experience success thus increasing their motivation and confidence for addressing more difficult problems over the course of the intervention. 3. When screening potential participants, we found that many older adults lived alone
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14 and/or did not have a support person who could participate with them. We edited our intervention protocol in order to include patients with and without support persons. Future research should determine whether PST can be administered to patient-friend or patient-adult child dyads. 4. Some individuals disliked being coached by their spouses, especially when the spouse was the dominant figure in the relationship. In situations whether the patient's and support person’s ideas about treatment goals differed, the therapist referred back to the PST model and say that the patient's goals would be the focus. The overall PST framework clearly puts the patient's treatment goals as primary. If the patient was excessively dependent, that was addressed by reminding the patient that successful PST depends on the patient's expertise in their own life along with the therapist's expertise in the model. So the patient would be encouraged to come up with each of the steps independently as much as possible. If the coach was excessively dependent, that was addressed by explicitly talking about the coach's role in learning PST and supporting the patient. Often our therapists talked about as the coach being an "extra brain" for the patient. The individual session with the coach was focused on ensuring that the coach fully understood and could apply PST and also provided an opportunity to address a problem specific to the coach, including caregiver burden, coach's selfcare, and potential coaching dynamics. We also believe it is crucial to collect information about the marital relationship in order to determine who might benefit best from being coached by their spouse. This information would also help describe potential mechanisms of change. For example, greater marital happiness or low caregiver burden might be important mediators or moderators of treatment effects in
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15 dyadic treatment studies of depression. Conclusions This report describes the pros and cons of incorporating spousal dyads into depressionprevention research. When intervening with older married couples, it is important to collect information about the marital relationship, as these variables may be important moderators or mediators of treatment effects. Dyadic interventions need to be further developed for prevention of depression in individuals with MCI and their support persons. Our experiences in RECALL suggest that proven patient-centered interventions like PST can be adapted to the include patient’s support person.
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