The Treatment Initiation Program: An Intervention to Improve Depression Outcomes in Older Adults

Depression is prevalent and, if left untreated, exacts tremendous personal, social, and economic costs. Older adults are especially vulnerable to the deleterious effects of depression. Elderly depression increases disability, mortality, and the risk of suicide (1–3). While most depressed adults do not receive treatment, older adults are even less likely to receive adequate care (4). Even when a referral is made, many treatments for depression end in treatment rejection.

To reduce nonadherence and poor acceptance of mental health care for depression in older adults, new initiatives have been launched in primary care settings. Many of these initiatives include interventions to supplement pharmacotherapy with a nonmedical clinician to monitor depression symptoms, side effects, and adherence. Encouragingly, these interventions improve depression outcomes (5, 6). However, often barriers still result in treatment refusal or discontinuation.

Recent work has explored the relation between attitudes and treatment participation. Depressed adults often are fearful, suspicious, or disparaging about care (7). In a prospective study of treatment participation, high perceived stigma and the minimizing of illness severity predicted medication nonadherence (8). Older adults with higher perceived stigma at the inception of treatment were more likely to discontinue treatment (9). Additionally, the cognitive symptoms of depression, most notably hopelessness, interfere with treatment participation. At its worst, hopelessness is associated with suicidal ideation and completed suicide (10).

The Treatment Initiation Program (TIP) is a brief, early intervention developed to target older adults’ attitudes about depression and treatment to reduce barriers and increase treatment acceptance. We conducted a pilot study to examine the usefulness of the TIP intervention in an outpatient geriatric clinic. We hypothesized that depressed older adults who receive the TIP intervention combined with antidepressant therapy would show a greater reduction of depressive symptoms than older adults who received antidepressant therapy alone.

Method

Consecutive admissions to an outpatient geriatric psychiatry clinic were approached and fully informed about the study procedures. All patients agreed to participate (N=59) and signed informed consent forms. A structured diagnostic interview (the Structured Clinical Interview for DSM-IV) confirmed the diagnosis of major depressive disorder. Seven patients were excluded (three had cognitive impairment defined as a Mini-Mental Health Examination score <24, three did not have major depressive disorder, and one patient already had begun antidepressant therapy). All study participants had a score of 17 or greater on the 24-item Hamilton Depression Rating Scale. The 52 participants who met study criteria were randomly assigned to either pharmacotherapy as usual or pharmacotherapy with the TIP intervention.

The study group was 54% women (N=28), mostly Caucasian (N=49), with a mean age of 73.2 years (SD=5.8, range=65–85). The majority of the patients were married (N=29, 56%) or lived with someone (N=33, 65%).

Research assistants who were unaware of group assignment assessed participants at admission and at 6, 12, and 24 weeks after admission to evaluate the impact of the intervention on depressive symptoms. Depression severity was rated with the Hamilton depression scale. Physical and mental functioning were assessed with the Medical Outcomes Study 12-item Short-Form Health Survey (11). Interim service use was recorded at 12 and 24 weeks with the Cornell Services Index (unpublished measure by Sirey et al.). At study completion, a chart review recorded the duration of treatment.

The TIP intervention begins with an assessment to identify specific barriers to care. Barrier domains reviewed included 1) misconceptions about depression and treatment, 2) perceived need for care, 3) perceived stigma, 4) cognitive distortions associated with depression, and 5) logistical barriers. Identified barriers are the focus of the TIP intervention. In addition, all patients received psychoeducation and identified personal treatment goals. The TIP clinician used cognitive behavior and nonspecific therapeutic techniques (e.g., empathy, support) to address barriers, activate older adults, and increase depression treatment self-efficacy.

The TIP intervention includes three 30-minute meetings with the patient alone during the first 6 weeks of pharmacotherapy, followed by two follow-up telephone calls at 8 and 10 weeks after admission. A “contact sheet” that lists barriers in each domain and specific intervention techniques is the guide for sessions and a record of the interventions administered. Two nonmedical clinicians (the principal investigator and a senior social worker) administered the TIP in this study. The second clinician learned the TIP by observing two full interventions conducted by the principal investigator, then the principal investigator observed the clinician conducting two full interventions. After training was completed, the principal investigator provided weekly supervision.

The study groups were compared to identify any sociodemographic, functional, or clinical differences with Student’s t tests and chi-square comparisons. An intent-to-treat mixed-effects model with all available cases and an autoregressive (1) covariance structure was employed to examine the changes in depression severity at each follow-up point. The autoregressive (1) covariance structure was chosen to reflect temporal correlations of repeatedly measured Hamilton depression scale scores within subjects. Baseline Hamilton depression scale score was included as a covariate to adjust for differences at admission between the two groups.

Results

There were no differences between study groups in sociodemographic characteristics (e.g., age, gender, education) or physical and mental functioning. The intervention group had a lower Hamilton depression scale score at admission than the nonintervention group (mean=23.1, SD=6.1, versus mean=26.4, SD=5.1) (t=2.12, df=50, p<0.05). The two groups did not differ in their levels of hopelessness on the Hamilton depression scale. There were no differences in gender, education, race, or admission Hamilton depression scale scores between patients interviewed at follow-up and patients who were unavailable.

All patients were recommended for antidepressant therapy and attended an average of seven sessions over the 24 weeks. There were no differences in the number of pharmacotherapy visits attended (t=0.55, df=38, p=0.59). Similar proportions of patients in both groups received supportive psychotherapy provided by the clinic social worker (χ²=0.66, df=1, p=0.42), and there was no difference in the number of psychotherapy visits attended (t=0.07, df=38, p=0.94).

The mixed-effects model demonstrated a group effect on depression outcome such that the intervention group showed greater improvement in depression than the nonintervention group (F=8.67, df=1, 61.54, p=0.005). At the study completion (28 weeks), 71% (N=15) of the 21 intervention patients achieved remission (Hamilton depression scale score ≥10) compared to 42% (N=10) of the 24 nonintervention subjects (χ²=4.10, df=1, p=0.04). Potential confounders (Medical Outcomes Study 12-item Short-Form Health Survey, supportive psychotherapy) were not significantly associated with depression outcome at study completion and did not change the TIP effect.

A post hoc chi-square comparison examined the impact of the TIP on treatment engagement. At both 12 and 24 weeks after seeking treatment, more intervention patients remained in treatment than patients in the nonintervention group (12 weeks: p=0.05, two-tailed Fisher’s exact test; 24 weeks: p=0.04, two-tailed Fisher’s exact test).

A mixed-effects model examined group differences in Hamilton depression scale hopelessness scores. The intervention group had significantly lower hopelessness scores (F=8.12, df=1, 49.92, p=0.006). Only 14% (N=3) of the 21 intervention patients reported any hopeless ideation at study completion compared to 63% (N=15) of the 24 nonintervention patients.

Conclusions

The study findings offer preliminary support for the usefulness of the TIP interventions to address older adults’ attitudes and beliefs in the early stages of pharmacotherapy for depression. Older adults who participated in the intervention had a greater decrease in depression severity and hopelessness and were more likely to remain in treatment compared to older adults receiving usual care.

These pilot data suggest that providing personalized psychoeducation and support and addressing the personal and social barriers to initiating treatment may increase older adults’ knowledge and support for treatment self-efficacy. While the study group size limits analyses of the mediating variables to illustrate the mechanisms of action, the intervention may offer empowerment and hope. This may account for the decrease in hopelessness, which is a significant barrier to patient decision making and participation in care. The decrease in hopelessness is notable since hopelessness is viewed as one of the more intractable symptoms of depression and is associated with suicidal ideation. Future studies could recruit a larger study group, which would offer the opportunity to explore the links between specific barriers, mechanisms of change, and intervention techniques.

Further investigation of the usefulness of the TIP intervention is warranted. Future work could examine the impact of the TIP on a larger, more representative group. This would improve the generalizability of the effect and could explore the usefulness of the intervention to address stigma or personal illness models in a minority population. The TIP seeks to close the gap between the availability and use of efficacious treatments for depression in older adults by targeting empirically demonstrated barriers to care.

Received Oct. 19, 2003; revision received March 30 and April 8, 2004; accepted May 3, 2004. From the Geriatric Outpatient Clinic, Westchester Division, Weill Medical College of Cornell University. Address correspondence and reprint requests to Dr. Sirey, Westchester Division, Weill Medical College of Cornell University, 21 Bloomingdale Rd., White Plains, NY 10605; [email protected] (e-mail). Support provided by a grant from the National Alliance for Research in Schizophrenia and Affective Disorders and a grant from NIMH (K23 MH-66381) to Dr. Sirey. The authors thank the patients who participated in this study, the research staff on the Treatment Initiation Program Project, the clinical staff of the Geriatric Outpatient Clinic, and Patrick Raue, Ph.D., for his critical review of an earlier version of this report.