Problem-solving treatment for complicated depression in late life: a case study in primary care.

TOPIC. Treatment of depression in primary care. PURPOSE. To describe the application of problem-solving treatment for a person with complicated depression. SOURCES. Specific treatment details from audiotaped therapy sessions; published literature. CONCLUSION. This case demonstrates how an older person benefited from problem-solving treatment. Search terms: Depression, geriatrics, primary care, problem solving, therapy ********** Many older adults with depression have a chronic and recurrent course beginning in their younger years and complicated in late life by medical co-morbidity, cognitive impairment, and diminishing psychosocial resources. A number of studies have found that older adults who experience chronic or recurrent depression respond best to a combined treatment approach (Arean & Cook, 2002). While antidepressant treatment is a mainstay of therapy for chronic and recurrent depression in primary care, psychotherapeutic approaches enhance the therapeutic value of medication as well as the prevention of relapse in both younger (Fava, 1999) and older adults (Reynolds, Alexopoulos, Katz, & Lebowitz, 2001). Many older adults, however, seek help for depression in primary care where they have limited access to psychotherapy. In settings where psychological interventions are available, providers may be reluctant to administer brief and structured therapies for chronically depressed patients with complicated and long-standing psychosocial and interpersonal problems. In recent research with younger adults suffering from chronic and recurrent depression, those receiving antidepressant medication and a brief mood management program improved substantially and were less likely to suffer a relapse within a 2-year window (Fava). In this article we discuss the complex case of an older patient who was treated for chronic depression in primary care medicine, using an integrated medication and psychotherapeutic approach (Unutzer et al., 2001). Included are specific details regarding use of Problem Solving Treatment for Primary Care (PST-PC). We begin with a brief description of the model of care delivered--IMPACT. The IMPACT Collaborative Care Approach IMPACT (improving care for late life depression) is a research project that provided treatment to older adults in a primary care clinic (Katon et al., 2002). Patients are identified in primary care medicine either through primary care provider referral, clinic screening, or self-referral. Patients are then seen and followed by a care manager (either a nurse or a psychologist) in the primary care clinic who collaborates with the patient's primary care provider. Patients can be treated with antidepressant medication alone, psychotherapy alone, PST-PC psychotherapy alone, or a combination of the two treatments. The choice of treatment is arrived at jointly among the primary care provider, the patient, and the care manager, with consultation from a team psychiatrist. If antidepressant treatment is the treatment of choice, the team psychiatrist provides consultation to the care manager and the prescribing primary care provider concerning medication management. While most patients are started on and remain on either medication or psychotherapy, patients with chronic depression may be started on both treatments or started on an antidepressant and then given psychotherapy as an additional intervention if response to medication is minimal. A detailed description of this treatment model is provided elsewhere (Saur et al., 2002; Unutzer et al., 2001). The psychotherapy. Very few psychotherapies are designed specifically for primary care medicine. Problem Solving Treatment for Primary Care is one psychotherapy that has considerable empirical support for its efficacy (Catalan et al., 1991). PST-PC is an effective treatment for major depression (Mynors-Wallis, Gath, Day, & Baker, 2000; Mynors-Wallis, Gath, Lloyd-Thomas, & Tomlinson, 1995) and possibly dysthymia and minor depression in younger and older primary care patients (Barrett et al. …