Effects of Problem-Solving Therapy and Clinical Case Management on Disability in Low-Income Older Adults

• Published in: The American journal of geriatric psychiatry 2015-12, Vol.23 (12), p.1307-1314
• Main Authors: Areán, Patricia A., Ph.D, Raue, Patrick J., Ph.D, McCulloch, Charles, Ph.D, Kanellopoulos, Dora, Ph.D, Seirup, Joanna K., Ph.D, Banerjee, Samprit, Ph.D, Kiosses, Dimitris N., Ph.D, Dwyer, Eleanor, L.C.S.W, Alexopoulos, George S., M.D
• Format: Article
• Language: English
• Subjects: Aged; case management; Case Management - statistics & numerical data; Disability; Disability Evaluation; Disabled Persons - psychology; Disabled Persons - statistics & numerical data; Humans; Internal Medicine; late-life depression; Poverty; Problem Solving; Psychiatric Status Rating Scales; Psychotherapy - methods; Treatment Outcome
• ISSN: 1064-7481; 1545-7214; 1545-7214
• DOI: 10.1016/j.jagp.2015.04.005

Objective To test the following hypotheses: (1) Clinical case management integrated with problem-solving therapy (CM-PST) is more effective than clinical case management alone (CM) in improving functional outcomes in disabled, impoverished patients and (2) improvement in depression, self-efficacy, and problem-solving skills mediates improvement of disability. Methods Using a randomized controlled trial with a parallel design, 271 individuals were screened and 171 were randomized to 12 weekly sessions of either CM or CM-PST at 1:1 ratio. Raters were blind to patients' assignments. Participants were at least age 60 years with major depression, had at least one disability, were eligible for home-based meals services, and had income no more than 30% of their counties' median. The WHO Disability Assessment Scale was used. Results Both interventions resulted in improved functioning by 12 weeks (t = 4.28, df = 554, p = 0.001), which was maintained until 24 weeks. Contrary to hypothesis, CM was noninferior to CM-PST (one-sided p = 0.0003, t = −3.5, df = 558). Change in disability was not affected by baseline depression severity, cognitive function, or number of unmet social service needs. Improvements in self efficacy (t = −2.45, df = 672, p = 0.021), problem-solving skill (t = −2.44, df = 546, p = 0.015), and depression symptoms (t = 2.25, df = 672, p = .025) by week 9 predicted improvement in function across groups by week 12. Conclusion CM is noninferior to CM-PST for late-life depression in low-income populations. The effect of these interventions occur early, with benefits in functional status maintained as long as 24 weeks after treatment initiation ( clinicaltrials.gov ; NCT00540865 ).