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        Life review therapy for older adults with depressive symptoms in general practice: results of a pilot evaluation
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        Life review therapy for older adults with depressive symptoms in general practice: results of a pilot evaluation
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Abstract

Objective:

General practices play an important role in the detection and treatment of depressive symptoms in older adults. An adapted version of the indicated preventive life review therapy group intervention called Looking for Meaning (LFM) was developed for general practice and a pilot evaluation was conducted.

Design:

A pretest-posttest design was used. One week before and one week after the intervention participants filled out questionnaires.

Setting:

In six general practices in the Netherlands the adapted intervention was given.

Participants:

Inclusion criteria were > 60 years and a score of 5 or higher on the Center for Epidemiological Studies Depression Scale (CES-D).

Intervention:

The length and number of LFM sessions were shortened and the intervention was given by one mental health care nurse practitioner (MHCNP).

Measurements:

The impact on mental health was analyzed by depressive symptoms (CES-D) as the primary outcome and anxiety symptoms (HADS-A), psychological well-being (PGCMS) and mastery (PMS) as secondary outcomes. An evaluative questionnaire was included to evaluate the feasibility and acceptability.

Results:

Most participants were satisfied with the adaptations of the number (72%) and length (72%) of sessions. The overall sample showed a significant decrease in depressive symptoms after the intervention. No impact was found on psychological well-being, anxiety symptoms and mastery.

Conclusions:

The intervention is feasible and acceptable for older adults with depressive symptoms and has an impact on their depressive symptoms.

Depression is a serious health problem with a poor prognosis among older adults (Licht-Strunk et al., Reference Licht-Strunk, Beekman, de Haan and van Marwijk2009). Major depressive disorder (MDD) occurs in 1.8% of the general population aged 55 years and older and clinically relevant depressive symptoms (CRDS) occur in 9.8% (Beekman et al., Reference Beekman, Copeland and Prince1999). The major risk factor for developing MDD is the presence of CRDS (Cuijpers et al., Reference Cuijpers, Smit and Willemse2005), which is defined by a level of depressive symptoms that indicates a higher risk for developing MDD, yet not meeting the criteria for MDD (Beekman et al., Reference Beekman2002). Older adults with depressive symptoms often consult their general practitioner and receive treatment within their general practice (Licht-Strunk et al., Reference Licht-Strunk2005). In the Netherlands, these treatments in general practices are partly provided by mental health care nurse practitioners (MHCNPs). Therefore, general practices play a major role in the detection and treatment of depressive symptoms in older adults (Government of the Netherlands, 2013). However, evidence-based interventions for older adults with depressive symptoms in this setting are lacking (van Asch et al., Reference van Asch and Nuijen2010). Therefore, there is a need for effective, low-threshold preventive interventions for older adults applicable to general practices.

Life review therapy (LR) is an intervention effectively reducing depressive symptoms in older adults (Bohlmeijer et al., Reference Bohlmeijer, Roemer, Cuijpers and Smit2007) and could very well be provided in general practice by MHCNPs. LR may be especially appropriate for older adults, as its basic principle fits so well with the natural tendency of older adults to reminisce (Butler, Reference Butler1963). LR focuses on recollecting memories, evaluating one’s own life story, and reminiscence styles. Negative reminiscence styles (e.g., bitterness revival and boredom reduction) are more commonly used by older adults with depressive symptoms (Korte et al., Reference Korte, Bohlmeijer, Westerhof and Pot2011) and have a direct negative association with psychological well-being (O’Rourke et al., Reference O’Rourke, Cappeliez and Claxton2010). Therefore, transforming negative reminiscence styles and stimulating positive reminiscence styles may reduce depressive symptoms and promote mental health among older adults (Bohlmeijer et al., Reference Bohlmeijer, Roemer, Cuijpers and Smit2007; Cappeliez et al., Reference Cappeliez, Guindon and Robitaille2008; Webster et al., Reference Webster, Bohlmeijer and Westerhof2010).

To implement LR in mental health care for older people with depressive symptoms, an indicated preventive intervention was developed, called Looking for Meaning (LFM) (Franssen and Bohlmeijer, Reference Franssen and Bohlmeijer2003). This group intervention consists of both verbal and non-verbal exercises in which reminiscence, dialogue and creative expression alternate (Bohlmeijer et al., Reference Bohlmeijer, Valenkamp, Westerhof, Smit and Cuijpers2005). The intervention is guided by a psychologist and creative therapist. Studies on different versions of LFM showed promising results for the mental health of different older target groups, including community-dwelling older adults, older adults with chronic psychiatric disorders, and older adults living in residential care (Bohlmeijer et al., Reference Bohlmeijer, Valenkamp, Westerhof, Smit and Cuijpers2005, Pot et al., Reference Pot, Bohlmeijer, Onrust, Melenhorst, Veerbeek and de Vries2010, Willemse et al., Reference Willemse, Depla and Bohlmeijer2009, van Asch et al., Reference van Asch, de Lange, Smalbrugge and Pot2011). Considering the current lack of suitable interventions in general practices for older adults with depressive symptoms (van Asch et al., Reference van Asch and Nuijen2010), LFM would be a good option as an indicated preventive intervention for older general practice attendees with depressive symptoms. To make LFM feasible for general practices, several adjustments were made to the intervention, including a reduction of the length and number of sessions, and the number of course leaders.

In compliance with the guidelines for testing new complex interventions by Campbell et al. (Reference Campbell2000), we conducted a pilot study. The first phase of intervention development can be used to test and optimize the intervention within the relevant context. This often involves testing the feasibility of delivering the intervention and its acceptability to participants (Campbell et al., Reference Campbell2000). In the current study, we were therefore interested in the following questions:

  1. (1) Feasibility and acceptability: What are the dropout and attendance rates? How do the participants evaluate the intervention?

  2. (2) Impact: Is an impact found on depressive symptoms (primary outcome), anxiety symptoms, psychological well-being, and mastery (secondary outcomes)?

  3. (3) Is impact on depressive symptoms predictable by the presence of clinically relevant depressive symptoms?

Methods

Design

The intervention was evaluated in a one-group pretest-posttest study. A questionnaire on depressive symptoms, anxiety symptoms, psychological well-being, and mastery was administered by telephone within one week prior to and one week after the intervention. The pretest questionnaire contained additional questions on demographic variables and at posttest an evaluative questionnaire on how the participants evaluated the course was added. Finally, the course leaders were asked to keep track of attendance of the participants.

Sample and setting

The pilot project was conducted in September – December 2017 in six general practices in the Netherlands. Subjects were eligible when they were over 60 years, community-dwelling, and when they had depressive symptoms, yet not exceeding the threshold for MDD (Beekman et al., Reference Beekman2002). Eligible persons who were willing to participate gave their written informed consent to participate in the study. The consent procedure was approved by the Medical Ethics Committee (CCMO).

Intervention

The group intervention Looking for meaning is a well-structured type of LR that is based on the underlying assumption that reminiscence styles influence coping with depressive symptoms and can be alternated or transformed, thereby reducing depressive symptoms (Franssen and Bohlmeijer, Reference Franssen and Bohlmeijer2003). Various memories are activated through different themes per session and both verbal and non-verbal exercises in which reminiscence, dialogue and creative expression alternate (Bohlmeijer et al., Reference Bohlmeijer, Valenkamp, Westerhof, Smit and Cuijpers2005). To make LFM feasible for general practices, several adjustments were made to the intervention. LFM originally consisted of twelve 2.5-hour sessions, led by a psychologist and creative therapist (Franssen and Bohlmeijer, Reference Franssen and Bohlmeijer2003). The adjusted LFM consisted of eight weekly sessions of 1.5h, led by one MHCNP. Each session had a structure of an introduction, working phase, and a closing phase. Each session focused on a theme (own name, childhood houses, own roots, hands, friendship, turning points, desires, and making up a balance). The participating MHCNP received a 1.5 day training conducted by a psychologist/researcher specialized in LR, a health psychologist specialized in group dynamics, and a creative therapist.

Data collection

Participant demographics

Demographic variables collected were: gender, age, having children, living arrangement (living alone or in a shared household) and educational level (low, average, or high) according to the educational level classification of Statistics Netherlands (2016).

Feasibility and acceptability

To evaluate the feasibility of LFM, the MHCNPs kept track of attendance. We measured the acceptability of LFM with an evaluative questionnaire at posttest, containing the following questions and the corresponding response possibilities:

  1. (1) What did you think of the length of the sessions? (too long, exactly right, or too short)

  2. (2) What did you think of the number of sessions? (too much, exactly right, or too little)

  3. (3) What did you think of the MHCNP leading the course? (good, average, or bad)

  4. (4) What did you think of talking about your memories? (pleasant, neutral, or unpleasant)

  5. (5) What did you think of the creative exercises? (pleasant, neutral, or unpleasant)

  6. (6) Would you recommend the course to others? (yes, neutral, or no)

  7. (7) How satisfied are you about the course? (grading on a scale of 1 to 10)

  8. (8) What was the (additional) value of the course? (open-ended)

Primary outcome measures

To evaluate the effects of the intervention on the primary outcome depressive symptoms, the Center for Epidemiological Studies Depression Scale (CES-D) was used (Bouma et al., Reference Bouma, Ranchor, Sanderman and van Sonderen2012). The CES-D is a self-assessment list that measures the number of symptoms of depression the participant has had over the week preceding the assessment. Responses are given on a 4-point scale, ranging from 0 (rarely or none of the time, less than one day) to 3 (most or all the time, five to seven days). A sum score, ranging 0 to 60, is computed across the 20 items to assess the level of depressive symptoms (α = 0.93). A score of 16 or higher is considered indicative of CRDS (Beekman et al., Reference Beekman2002). For older adults, a score of 25 or higher is considered indicative for MDD (Haringsma et al., Reference Haringsma, Engels, Beekman and Spinhoven2004). The Dutch translation has good reliability and validity (Bouma et al., Reference Bouma, Ranchor, Sanderman and van Sonderen2012) and the scale is appropriate for older populations (Radloff and Teri, Reference Radloff and Teri1986).

Secondary outcome measures

The Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety symptoms (Zigmond and Snaith, Reference Zigmond and Snaith1983). The HADS is a self-report screening scale comprising two scales, measuring depression and anxiety. For this study, we only used the 7-item anxiety scale (HADS-A; Zigmond and Snaith, Reference Zigmond and Snaith1983). Participants are instructed to indicate whether they experienced feelings of restlessness, tension, or panic during the past four weeks on a 4-point scale, ranging from 0 (rarely or never) to 3 (always or most of the time). The final score ranges from 0 to 21 (α = 0.98; Spinhoven et al., Reference Spinhoven, Ormel, Sloekers, Kempen, Speckens and van Hemert1997), with higher scores indicating a higher level of anxiety symptoms.

The Philadelphia Geriatric Center Morale Scale (PGCMS) was used to measure psychological well-being (Lawton, Reference Lawton1975). The PGCMS has been validated for older adults in the Netherlands (van Campen et al., Reference van Campen, Kerkstra and Taes1997). The PGCMS contains three subscales: Agitation (6 items; α = 0.81), attitude towards own aging (5 items; α = 0.79), and lonely dissatisfaction (6 items; α = 0.74). The overall score is computed by summing the affirmative answer to positively worded questions and the negative answers to negative questions, ranging from 0 (dissatisfied) to 17 (satisfied) (α = 0.92).

Mastery was measured with the Pearlin Mastery Scale (PMS) (Pearlin and Schooler, Reference Pearlin and Schooler1978), abbreviated to 5 items (α = 0.80) and phrased in a negative way. The PMS measures beliefs of perceived control over one’s life in general or beliefs regarding one’s ability to control an event. Responses are given on a 5-point scale, ranging from 1 (strongly disagree) to 5 (strongly agree). The total mastery score is calculated by summing all answers, ranging from 5 to 25, with higher scores corresponding to lower levels of perceived control.

Effect-predictors

The level of depressive symptoms is considered clinically relevant on the base of a cut-off score for possible cases on the CES-D (≥ 16) at T0 (Beekman et al., Reference Beekman2002).

Data analyses

For the analysis of the feasibility and acceptability, the dropout and attendance rates and the frequencies of the evaluative questionnaire were calculated. To analyze impact only data of completers were taken into account. To analyze the impact of LFM, we calculated the means and standard deviations for CES-D, HADS-A, PGCMS, and PMS at pre- and posttest and we executed a parametric paired-samples t-test to test for significant changes. To determine the clinical relevance of changes, we expressed the mean differences as Cohen’s d = (M 1M 0) / SD 0 (Lipsey and Wilson, Reference Lipsey and Wilson1993). Effect sizes ranging from 0 to 0.32 are considered small, moderate effect sizes range from 0.33 to 0.55, and large effect sizes range from 0.56 to 1.2 (Lipsey and Wilson, Reference Lipsey and Wilson1993). Univariate linear regression analysis was used to examine whether participants with CRDS especially benefited from LFM. For this, significant effect sizes were used as dependent variable and CES-D ≥ 16 at T0 as prognostic factor. SPSS 22 was used for all analyses.

Results

Sample

Initially, eight MHCNPs were selected and trained to lead the adapted LFM course. However, before starting the course, two MHCNPs withdrew from the study due to difficulties with recruiting participants. The number of general practices in the region often complicated the recruitment, limiting the number of eligible participants. Other complicating factors included limited availability of time parallel to their daily jobs as MHCNP, unfavorable location of the practice in a younger populated area, and insufficient referrals for eligible older adults by colleagues. Subsequently, six interested older adults could not participate in the study and the intervention was carried out by six MHCNPs. In total, 47 people were interested in participating in the study (Figure 1).

Figure 1. Flow chart of the participants.

Ten of them were not included as: they did not meet the inclusion criteria (n = 2, scoring above 30 on the CES-D); they refused to participate after receiving more extensive information about the study (n = 6); they did not respond after the screening (n = 1); or the person passed away (n = 1). Thirty-seven participants completed pretest and started LFM. The group sizes varied from five to seven participants per group. Thirty of them completed LFM (81%) and 29 participants completed posttest. The mean age of the participants who completed the pretest and posttest was 76.8 years (Table 1). The majority of the participants was female (72%), lived alone (79%), had children (90%), and had a low educational level (62%). Nineteen of the participants currently had CRDS according to their CES-D score at baseline (66%). Demographics of the participants who dropped out did not differ significantly from the completers.

Table 1. Demographics of participants who completed the study (N = 29) and dropped out (n = 8)

Note. CES-D = Center for Epidemiological Studies Depression Scale; *p < 0.05.

a CRDS = participants with clinically relevant depressive symptoms (CES-D ≥ 16) at T0 (Beekman et al., Reference Beekman2002).

Feasibility and acceptability

Thirty out of 37 participants completed the course (81%). On average, these participants attended seven out of eight sessions (SD = 0.68). The reasons for drop out during LFM varied: they did not fit well within their intervention group (n = 2), the course was too demanding (n = 1), support or grief counseling was expected (n = 1), reviewing life was not as pleasurable as expected (n = 1), and personal circumstances (n = 2). One person completed the intervention, but could not complete the posttest due to personal circumstances.

Most participants thought that the course had the right number of sessions (72%; see Table 2), that the duration of the sessions was right (72%), and were positive about their MHCNP (93%). Overall, twenty-one participants would recommend the course to others (72%). The mean grade of the adapted LFM course was 7.31. The open answers revealed that a minority of the participants (14%) found talking about memories too painful and that there was not enough emphasis on positivity during the course. Most participants stated they liked the course, among other reasons, because the participants “learned to reach out to other people and learned from other people’s stories, ” “found comfort in learning that they were not alone in their problems, ” and “developed a more positive outlook on life.”

Table 2. Results of the evaluative questionnaire on feasibility and acceptability of the adapted LFM course (completers n = 29)

Impact

Regarding the primary outcome, completers reported significantly less depressive symptoms at posttest (M = 14.28, SD = 9.41; see Table 3) compared to pretest (M = 18.72, SD = 6.71), t (28) = 2.67, p = .012 (two-tailed) with an effect size of −0.66. Regarding secondary outcome measures no impact was found on anxiety, psychological well-being, and mastery. The scores on Lonely dissatisfaction decreased significantly (t (28) = −2.14, p = .041 two-tailed, d = 0.32), yet were not interpreted due to low internal consistency (α = 0.48).

Table 3. Effect sizes of the differences between posttest and pretest scores

Note. HADS-A = Anxiety subscale of the Hospital Anxiety and Depression Scale; PGCMS = the Philadelphia Geriatric Center Morale Scale with three subscales: Agitation, Attitude towards own aging, and Lonely dissatisfaction; PMS = the Pearlin Mastery Scale; Dif. = difference between pretest and posttest; CI = confidence interval; LL = Lower limit; UL = Upper limit; p = significance value; d = effect size of t-test denoted by Cohen’s d. For CES-D, HADS-A, and PMS, a negative effect size means improvement.

Prognostic factors

No predictive value of CRDS at T0 on the effect size of depressive symptoms was found (Table 4).

Table 4. Prognostic factors in a univariate regression model for change in depressive symptoms (n = 29)

aCRDS at T0 = Clinically relevant depressive symptoms (CES-D ≥ 16) at baseline (1 = CRDS; 0 = CES-D < 16).

Discussion

In this pilot study the feasibility, acceptability, and impact of Looking for Meaning in older general practice attendees with depressive symptoms were evaluated.

Generally, the results indicate that LFM is feasible and acceptable to older general practice attendees with depressive symptoms. First, low drop-out rates were found: 81% of the participants completed LFM. On average they missed only one out of eight sessions. Similar percentages were found by Bohlmeijer et al. (Reference Bohlmeijer, Roemer, Cuijpers and Smit2007) for older adults with moderate depressive symptoms. Most participants were positive about the number and length of sessions, despite the alterations made to the number and length of sessions. In addition, most participants were positive about their MHCNP as course leader. The majority of the participants (72%) would recommend the course to others. A minority of the participants stated that they did not like talking about memories and that there was not enough emphasis on positivity. Nevertheless, all of these participants finished the course. Overall, the results of the evaluation suggest that the adapted LFM is acceptable and feasible to older general practice attendees with depressive symptoms.

Regarding impact, after finishing LFM the participants reported significantly less depressive symptoms. According to the norms set by Lipsey and Wilson (Reference Lipsey and Wilson1993), the decrease of depressive symptoms is considered a large effect (d = −0.66). This finding is in line with earlier studies on previous versions of the LFM course (Bohlmeijer et al., Reference Bohlmeijer, Valenkamp, Westerhof, Smit and Cuijpers2005; Pot et al., Reference Pot, Bohlmeijer, Onrust, Melenhorst, Veerbeek and de Vries2010; van Asch et al., Reference van Asch, de Lange, Smalbrugge and Pot2011; Willemse et al., Reference Willemse, Depla and Bohlmeijer2009) and other studies on the effectiveness of LR in older adults (Bohlmeijer et al., Reference Bohlmeijer, Roemer, Cuijpers and Smit2007). On the secondary outcomes (anxiety symptoms, psychological well-being, and mastery) no significant changes were found.

A reduction of anxiety symptoms was found in an earlier study on LFM (Pot et al., Reference Pot, Bohlmeijer, Onrust, Melenhorst, Veerbeek and de Vries2010). An explanation for this discrepancy could be that the participants in the current study experienced relatively less anxiety symptoms at baseline compared to the sample studied by Pot et al. (Reference Pot, Bohlmeijer, Onrust, Melenhorst, Veerbeek and de Vries2010), so there may have been a floor effect. Also, the small sample size may have caused effects to go undetected (see Limitations). Since anxiety symptoms are frequently associated with depressive symptoms in older adults (Beekman et al., Reference Beekman, de Beurs, van Balkom, Deeg, van Dyck and van Tilburg2000), an intervention designed to treat depression would ideally also result in improvement in anxiety.

An improvement in psychological well-being was also reported in previous studies (van Asch et al., Reference van Asch, de Lange, Smalbrugge and Pot2011; Willemse et al., Reference Willemse, Depla and Bohlmeijer2009). The smaller sample size in the current study may have played part in that no significant impact of psychological well-being was found, since the current data were close to significant (p-value 0.08).

No improvement in mastery was found in earlier studies on LFM (Pot et al., Reference Pot, Bohlmeijer, Onrust, Melenhorst, Veerbeek and de Vries2010; Willemse et al., Reference Willemse, Depla and Bohlmeijer2009), indicating that LFM may not improve perceived control over one’s life evidently.

Limitations and strengths

We have to place our findings in the context of the limitations of our study. The first limitation concerns the study design. The open, unblinded and uncontrolled nature of study may have caused bias in favour of improvement in depressive symptoms. This means that there is a possibility that the impact found on depressive symptoms cannot be attributed to the LFM course. However, as the current study is a pilot-study, a pretest-posttest design without a control group is a suitable first step in intervention development (Campbell et al., Reference Campbell2000).

A second limitation concerns the small sample size. A small sample size may cause effects to remain undetected. In addition, a small sample size results in unstable estimates of the effect size.

The pilot study was pragmatic, meaning that compliance with the protocol and the quality of the therapy provided were not controlled, which may have led to an underestimation of the effects. To compensate for the pragmatic character of the study, MHCNPs were asked to report deviations from protocol and researchers observed one session per group.

Since follow-up measurements were not taken, it is uncertain whether the effects that were found last over a longer period.

Finally, it was not possible to assess effects of general practice or specific MHCNP on the observed effects.

This pilot-study also has a number of strengths. The pragmatic character of the study strengthens the generalizability to general practices. Another strength of the current study is that the study gained insight into the feasibility of the LFM course and its acceptability to participants. The evaluation provides an inventory of the strengths and weaknesses of the LFM course, which enables us to develop the LFM course to its full potential. Finally, this pilot-study yielded significant added value to solving the shortage of treatments in general practices for older adults with depressive symptoms.

Recommendations

This study indicates that LFM can improve mental health in older general practice attendees with depressive symptoms. To further examine the effectiveness of LFM, a randomized control trial (RCT) with a wait-list control group would be a suitable next step (Campbell et al., Reference Campbell2000). To control for positive attention as a contributing factor of effect, it is recommended that the control condition involves a group activity as well, omitting the life review aspects. Another recommendation is to conduct follow-up measures to provide insight into the long-term effects of LFM on depressive symptoms.

For the implementation of LFM in general practices, we have some recommendations. Although the adjusted LFM course was targeted at older general practice attendees with different degrees of depressive symptoms, general practices could focus on older adults with CRDS in particular, given that older adults with CRDS have a greater risk at developing an MDD (Cuijpers et al., Reference Cuijpers, Smit and Willemse2005). To anticipate on dropouts, it is recommended that special attention be given to providing accurate and extensive information to interested older adults on the process of life review therapy. In addition, it is of great importance to inform the participants that at any given time during the course they can choose whether or not to discuss certain memories.

Considering the promising results of the current study, LFM could offer a solution to the lack of evidence-based treatments for older adults with depressive symptoms that can be implemented in Dutch general practices.

Conflict of interest declaration

None.

Description of authors’ roles

Lotte Hendriks and Lindsay Veenendaal carried out the study and analyzed the data. Lotte Hendriks wrote the paper. Marjolein Veerbeek designed and supervised the study and the writing of the paper. Daniëlle Volker supervised the carrying out of study and statistical analyses. Bernadette Willemse designed the study and supervised the writing of the paper.

Acknowledgments

This work was supported by ZonMw, The Netherlands Organisation for Health Research and Development.

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