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. 2024 Mar 19;3(3):CD013059.
doi: 10.1002/14651858.CD013059.pub2.

Psychological therapies for depression in older adults residing in long-term care settings

Tanya E Davison  1   2   3 , Sunil Bhar  4 , Yvonne Wells  5 , Patrick J Owen  6 , Emily You  7 , Colleen Doyle  8 , Steven J Bowe  9   10 , Leon Flicker  11
Affiliations

Psychological therapies for depression in older adults residing in long-term care settings

Tanya E Davison et al. Cochrane Database Syst Rev. .

Abstract

Background: Depression is common amongst older people residing in long-term care (LTC) facilities. Currently, most residents treated for depression are prescribed antidepressant medications, despite the potential availability of psychological therapies that are suitable for older people and a preference amongst many older people for non-pharmacological treatment approaches.

Objectives: To assess the effect of psychological therapies for depression in older people living in LTC settings, in comparison with treatment as usual, waiting list control, and non-specific attentional control; and to compare the effectiveness of different types of psychological therapies in this setting.

Search methods: We searched the Cochrane Common Mental Disorders Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, five other databases, five grey literature sources, and two trial registers. We performed reference checking and citation searching, and contacted study authors to identify additional studies. The latest search was 31 October 2021.

Selection criteria: We included randomized controlled trials (RCTs) and cluster-RCTs of any type of psychological therapy for the treatment of depression in adults aged 65 years and over residing in a LTC facility.

Data collection and analysis: Two review authors independently screened titles/abstracts and full-text manuscripts for inclusion. Two review authors independently performed data extraction and risk of bias assessments using the Cochrane RoB 1 tool. We contacted study authors for additional information where required. Primary outcomes were level of depressive symptomatology and treatment non-acceptability; secondary outcomes included depression remission, quality of life or psychological well-being, and level of anxious symptomatology. We used Review Manager 5 to conduct meta-analyses, using pairwise random-effects models. For continuous data, we calculated standardized mean differences and 95% confidence intervals (CIs), using endpoint data, and for dichotomous data, we used odds ratios and 95% CIs. We used GRADE to assess the certainty of the evidence.

Main results: We included 19 RCTs with 873 participants; 16 parallel group RCTs and three cluster-RCTs. Most studies compared psychological therapy (typically including elements of cognitive behavioural therapy, behavioural therapy, reminiscence therapy, or a combination of these) to treatment as usual or to a condition controlling for the effects of attention. We found very low-certainty evidence that psychological therapies were more effective than non-therapy control conditions in reducing symptoms of depression, with a large effect size at end-of-intervention (SMD -1.04, 95% CI -1.49 to -0.58; 18 RCTs, 644 participants) and at short-term (up to three months) follow-up (SMD -1.03, 95% CI -1.49 to -0.56; 16 RCTs, 512 participants). In addition, very low-certainty evidence from a single study with 82 participants indicated that psychological therapy was associated with a greater reduction in the number of participants presenting with major depressive disorder compared to treatment as usual control, at end-of-intervention and short-term follow-up. However, given the limited data on the effect of psychological therapies on remission of major depressive disorder, caution is advised in interpreting this result. Participants receiving psychological therapy were more likely to drop out of the trial than participants receiving a non-therapy control (odds ratio 3.44, 95% CI 1.19 to 9.93), which may indicate higher treatment non-acceptability. However, analyses were restricted due to limited dropout case data and imprecise reporting, and the finding should be interpreted with caution. There was very low-certainty evidence that psychological therapy was more effective than non-therapy control conditions in improving quality of life and psychological well-being at short-term follow-up, with a medium effect size (SMD 0.51, 95% CI 0.19 to 0.82; 5 RCTs, 170 participants), but the effect size was small at postintervention (SMD 0.40, 95% CI -0.02 to 0.82; 6 RCTs, 195 participants). There was very low-certainty evidence of no effect of psychological therapy on anxiety symptoms postintervention (SMD -0.68, 95% CI -2.50 to 1.14; 2 RCTs, 115 participants), although results lacked precision, and there was insufficient data to determine short-term outcomes.

Authors' conclusions: This systematic review suggests that cognitive behavioural therapy, behavioural therapy, and reminiscence therapy may reduce depressive symptoms compared with usual care for LTC residents, but the evidence is very uncertain. Psychological therapies may also improve quality of life and psychological well-being amongst depressed LTC residents in the short term, but may have no effect on symptoms of anxiety in depressed LTC residents, compared to control conditions. However, the evidence for these effects is very uncertain, limiting our confidence in the findings. The evidence could be strengthened by better reporting and higher-quality RCTs of psychological therapies in LTC, including trials with larger samples, reporting results separately for those with and without cognitive impairment and dementia, and longer-term outcomes to determine when effects wane.

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Conflict of interest statement

TD: reports publishing a literature review and opinion piece with relevance to the topic of the effectiveness of psychological therapies in long‐term care in Australian Psychologist which advocates for increased access to psychologists in this setting, and involvement in an ongoing trial that is eligible for this review (Bhar 2023).

SBh: reports involvement in an ongoing trial that is eligible for this review (Bhar 2023).

YW: none.

PO: none.

EY: none.

CD: receives funding from the National Health & Medical Research Council to investigate the effect of a social intervention on depression in nursing home residents but the trial is ongoing and not eligible for inclusion in this review.

SBo: none.

LF: reports being a Cochrane Editor (specifically in the Cochrane Dementia and Cognitive Improvement Group), with no involvement in the editorial process of the article, and also reports involvement in an ongoing trial that is eligible for this review (Velasquez Reyes 2019).

Figures

1
1
PRISMA flow diagram
2
2
3
3
4
4
Figure 4. Funnel plot of comparison 1: Any psychological therapy versus any non‐therapy comparator, Outcome 1: Depressive Symptomatology, Follow‐up: End‐of‐intervention.
1.1
1.1. Analysis
Comparison 1: Any psychological therapy versus any non‐therapy comparator, Outcome 1: Depressive symptomatology
1.2
1.2. Analysis
Comparison 1: Any psychological therapy versus any non‐therapy comparator, Outcome 2: Treatment non‐acceptability
1.3
1.3. Analysis
Comparison 1: Any psychological therapy versus any non‐therapy comparator, Outcome 3: Quality of life and psychological well‐being
1.4
1.4. Analysis
Comparison 1: Any psychological therapy versus any non‐therapy comparator, Outcome 4: Anxious symptomatology
2.1
2.1. Analysis
Comparison 2: Subgroup 1: baseline depression severity: psychological therapies versus non‐therapy comparators, Outcome 1: Depressive symptomatology (end‐of‐intervention)
3.1
3.1. Analysis
Comparison 3: Subgroup 2: type of psychological therapy: psychological therapies versus non‐therapy comparators, Outcome 1: Depressive symptomatology (end‐of‐intervention)
4.1
4.1. Analysis
Comparison 4: Subgroup 3: type of non‐therapy comparator: psychological therapies versus non‐therapy comparators, Outcome 1: Depressive symptomatology (end‐of‐intervention)
5.1
5.1. Analysis
Comparison 5: Subgroup 4: level of cognitive function: psychological therapies versus non‐therapy comparators, Outcome 1: Depressive symptomatology (end‐of‐intervention)
6.1
6.1. Analysis
Comparison 6: Subgroup 5: long‐term care facility staff involvement in therapy: psychological therapies versus non‐therapy comparators, Outcome 1: Depressive symptomatology (end‐of‐intervention)
7.1
7.1. Analysis
Comparison 7: Subgroup 6: therapeutic contact: psychological therapies versus non‐therapy comparators, Outcome 1: Depressive symptomatology, therapeutic contact (weeks)
7.2
7.2. Analysis
Comparison 7: Subgroup 6: therapeutic contact: psychological therapies versus non‐therapy comparators, Outcome 2: Depressive symptomatology, therapeutic contact (number of sessions)
7.3
7.3. Analysis
Comparison 7: Subgroup 6: therapeutic contact: psychological therapies versus non‐therapy comparators, Outcome 3: Depressive symptomatology, therapeutic contact (total treatment dose)
8.1
8.1. Analysis
Comparison 8: Sensitivity analysis 1: missing data: psychological therapies versus non‐therapy comparators, Outcome 1: Depressive symptomatology (end‐of‐intervention)
9.1
9.1. Analysis
Comparison 9: Sensitivity analysis 2: treatment fidelity: psychological therapies versus non‐therapy comparators, Outcome 1: Depressive symptomatology (end‐of‐intervention)
10.1
10.1. Analysis
Comparison 10: Sensitivity analysis 3: bias: psychological therapies versus non‐therapy comparators, Outcome 1: Depressive symptomatology
11.1
11.1. Analysis
Comparison 11: Sensitivity analysis 4: attrition: psychological therapies versus non‐therapy comparators, Outcome 1: Depressive symptomatology
12.1
12.1. Analysis
Comparison 12: Sensitivity analysis 5: omit Luo 2020: psychological therapies versus non‐therapy comparators, Outcome 1: Depressive symptomatology
12.2
12.2. Analysis
Comparison 12: Sensitivity analysis 5: omit Luo 2020: psychological therapies versus non‐therapy comparators, Outcome 2: Quality of life and psychological well‐being
13.1
13.1. Analysis
Comparison 13: Sensitivity analysis 6: omit Tsai 2008: psychological therapies versus non‐therapy comparators, Outcome 1: Depressive symptomatology
14.1
14.1. Analysis
Comparison 14: Sensitivity analysis 7: omit Daleo 1999: psychological therapies versus non‐therapy comparators, Outcome 1: Depressive symptomatology
15.1
15.1. Analysis
Comparison 15: Funnel plot: psychological therapies versus non‐therapy comparators, Outcome 1: Depressive symptomatology
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