I
I l
I

I

I fl I III "@I‘
H
HI 3 HI I II‘

’I
I

IIII
I ‘I'
I
[IV
I III

!
I
II

I l

I

II‘
‘I

“I
II

I

I
1,“; II:

I III
I

I
,I‘
I:

 

'HAA
Imw
_mom

PRACTICE GUIDELINES IN TIE USE ‘
0F COGNITIVE-BEHAVIORAL STRATEGIES WITH
DEPRESSED ELDERLY IN PRIMARY CARE

Scholarly Project for the Degree of M. S. N.-   ,
MICHIGAN STATE UNIVERSITY ‘
CATHERINE MORRIS
1998 ' _

‘I 1'}
0'4. "

 

 

LIBRARY
Michigan State
University

 

 

PLACE IN RETURN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

DATE DUE

DATE DUE

DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6/01 c:/ClFIC/DateDue.p65-p. 15

 

Practice Guidelines in the Use of Cognitive-Behavioral
Strategies with Depressed Elderly in Primary Care

by

Catherine Morris

A Scholarly Project

Submitted To
Michigan State University
College of Nursing
In Partial Fulfillment Of The Requirements
For the Degree Of

Master of Science

College of Nursing

1998

Acknowledgments

I would like to thank the many people in my life, especially my extended family, fiiends,
teachers, clients and peers, who have all in some way contributed to allowing me to complete
my scholarly project and thereby my MSN. It takes a community to complete a graduate
program!

My sincerest and heartfelt gratitude extends to my spiritual mentor Sant Darshan Singh
Ji who encouraged me in my decision to become a nurse, and acted as a role model and
inspiration in countless ways.

I would also like to thank my committee members Dr. Sharon King, chair person, Dr.
Linda Spence and Jacqueline Wright, MSN, committee members, for their encouragement,
support and expert guidance throughout the process of this project.

Further, my heart goes out to my parents Angela and Bernard Seiler who lovingly
believed in me and have shown their support in so many ways. Thank you so much!

A very special thank you goes to my husband Ray, the “Best Coach in the World”, for
his love, support (speak “push”) and patience. I couldn’t have done it without you!

I would also like to make a special mention of our unborn child and thank you for the
many blessings your presence has already brought into my life!

And last but not least merci beaucoup to Tobin Mellberg who patiently walked me
through the often treacherous and unpredictable computer mazes. Your guidance was
invaluable in the completion of this project.

December 15, 1998

TABLE OF CONTENTS
Abstract ................................................................................ l
The Problem ........................................................................... 2
Introduction .................................................................. 2
Purpose ......................................................................... 4
Conceptual Definitions ................................................................ 4
Depression ..................................................................... 4
Cognitive-Behavioral Therapy ............................................... 5
Conceptual Framework ................................................................ 7
Theory of Self-Care ............................................................ 9
Theory of Self-Care Deficit ................................................... 9
Theory of Nursing System ................................................... 10
Supportive-Educative System ................................................ 10
Review of Literature ................................................................... 12
Depression and the Elderly .................................................. 12
Cognitive-Behavioral Therapy and the Elderly ............................ l7

Adapting CBT to the Special Needs of the Elderly ........................ 23

Project Development .................................................................... 25
Methodology .................................................................... 25
Utilization of Practice Guidelines for CBS ................................... 26
Evaluation of Clinical Guidelines .............................................. 30

Implications for Advanced Nursing Practice .......................................... 32

References ................................................................................. 36

Appendices ................................................................................. 42

Abstract

Practice Guidelines in the Use of Cognitive-Behavioral
Strategies with Depressed Elderly in Primary Care

by
Catherine Morris

Depression is the leading psychiatric disorder in old age. Although it is one of the most
frequent diagnoses made in outpatient practice, late-life depression is underrecognized,
misdiagnosed and undertreated. The management of major depression in the elderly is affected
by several factors, including the presence of multiple medical conditions, polypharrnacy,
increased sensitivity to medication, atypical presentations of depression, and age-specific
psycho-social issues such as the stigma elderly attach to mental disorders, social isolation and
lack of financial resources. Since aged persons tend to refuse referral to mental health
specialists and psychosocial interventions are often an important aspect in the treatment plan
for depression, the integration of strategies based on brief, time-limited psychotherapies such as
cognitive-behavioral therapy into primary care visits can provide significant benefits for the
depressed elderly client. Due to advanced practice nursing’s holistic approach and comfort
level applying nonpharrnacologic modalities in the treatment of clients in primary care,
cognitive-behavioral strategies lend themselves well to their practice style. The focus of this
project is the development of practice guidelines in the use of select cognitive-behavioral

strategies with depressed elderly in primary care.

Practice Guidelines in the Use of Cognitive-Behavioral

Strategies for Depressed Elderly in Primary Care

The Problem

Introduction

Major depression is estimated to affect up to 4 % of older adults, while self-reports of
depressive symptoms in community surveys indicate a 15 - 65 % prevalence (Blixen &
Wilkinson, 1994; Miranda & Munoz, 1994; Thompson, Futterman & Gallagher, 1988).
Depression is the most common psychiatric disorder in old age (Hendrie & Crossett, 1990) and
is among the most common diagnoses made in outpatient practice (Richter, Barsky & Hupp,
1983). Major and minor depression in primary care clinics are found to affect 5 % of the
elderly population (NIH Consensus Development Panel on Depression in Late Life, 1992).
Although 90 % of people with major depression are treated in primary care, it is estimated that
only about 10 % of elderly in need of psychiatric service receive it. In spite of its prevalence,
depression in the elderly is underrecognized, misdiagnosed, and undertreated causing much
unnecessary suffering for the elderly (Badger et al., 1994; Banazak, 1996; Callahan, Dittus &
Tierney, 1996; NIH Consensus Development Panel on Depression in Late Life, 1992; Pierre,
Craven & Bruno, 1986; Ruegg, Zisook & Swerlow, 1988; Scott, Tacchi, Jones & Scott, 1997;

Steiner & Marcopulous, 199]).

The management of major depression in the elderly is affected by several factors including the
presence of multiple medical conditions, polypharmacy, increased sensitivity to medications,
masked or atypical presentations of depression, and age-specific psycho-social issues such as
the stigma elderly attach to mental disorders, social isolation, and lack of financial resources
(Flint, 1996). The NIH Consensus Development Panel on Depression in Late Life (1992)
determined that goals of treatment for geriatric depression should include symptom reduction,
decreased risk of relapse and recurrence, enhanced quality of life, amelioration of overall
health, cost-effectiveness and mortality reduction. The two major categories for the treatment
of depression include biological therapy, such as pharmaco-therapy, and psycho-therapy, such
as cognitive-behavioral therapy (CBT) (NIH Consensus Development Panel on Depression in
Late Life, 1992), which can either be used alone or in combination. The efficacy of these
therapies will be discussed in the literature review.

With primary care providers prescribing 80 % of all antidepressant medications used in
the United States (Robinson et al., 1995), it is important to recall that many of these
medications have significant side effects especially in the geriatric population. Despite
improved antidepressant medications being available and appropriate for the elderly, many
older persons cannot or will not take them (Callahan, Dittus & Tierney, 1996; NIH Consensus
Development Panel on Depression in Late Life, 1992; Oxman, 1996). Because growing data is
becoming available regarding the efficacy of brief psychotherapies in the treatment of late-life
depression, and the population is increasingly exposed to its principles through media and self-
help books, there is a growing trend to use cognitive-behavioral strategies (CBS) in the
primary care setting (Robinson et al., 1995). Since aged persons tend to I'CfUSC referral to

mental health specialists and psychosocial interventions are often an important aspect in the

treatment plan for depression, the integration of interventions based on brief, time-limited
psychotherapies such as the application of CBS into primary care visits can provide significant
benefits for the depressed client. Due to advanced practice nursing’s (APN) holistic approach
and comfort level applying nonpharmacologic modalities in the assessment and treatment of

clients in primary care, CBS lend themselves well to their practice style.

ngzose ef the Preject

The purpose of this paper is to develop clinical guidelines for the use of cognitive-
behavioral strategies with depressed elderly in primary care to be used alone or in conjunction
with other treatment modalities. The unique needs of the depressed geriatric client will be taken
into consideration and the goal of therapy will be to enhance the quality of life and improve the

rate of recovery.

Conceptual Definitions

Depression

Although geriatric patients often present with the classic symptoms in the DSM-IV
(1994), atypical presentations are equally common. The concept depression can be used to
refer to a “subclinical problem: a ‘blue’ mood state and general feelings of hopelessness and
demoralization” (Thompson, Futterman & Gallagaher, 1988, p. 557). Depression can also refer
to an acute or chronic disorder as specified in the DSM-IV (1994). Beck et al. (1979) state that

non-psychotic, unipolar depression is especially responsive to cognitive-behavioral therapy.

For the purpose of this project depression will be defined as a mild to moderate,
unipolar, non-psychotic (without hallucinations or delusions) major depressive disorder which
may present many or all of the following symptoms of depression. The classic symptoms of
unipolar affective disorder as listed in the DSM-IV (1994) include: depressed mood,
diminished interest or pleasure in activities, weight changes, insomnia/hypersomnia,
psychomotor change, fatigue/energy loss, low self-esteem/guilt, concentration
problems/indecision, and thoughts of death or suicide. McCullough (1991) makes additional
mention of the atypical presentations of depression in the elderly: cognitive deficit/pseudo-
dementia, pain syndromes, somatization, anxiety/irritability, and alcohol abuse. The DSM-IV
(1994) further differentiates the severity of depression (mild, moderate or severe) which is

detemiined by the number of symptoms. severity, level of functional disability and distress.

Cegnitive-Behfliorel Therepy

Cognitive-behavioral therapy (CBT) is a form of brief, time-limited psychotherapy
made up of cognitive and behavioral strategies that focus on the here and now rather than
exploring the distant past (Grant & Casey, 1995). Cognitive-behavioral therapy is among the
only structured therapeutic approaches created specifically to treat depression. It focuses on
eliminating distorted thought systems while striving to increase the number of pleasant events
in a client’s daily life (Moberg & Lazarus, I990).

Cognitive-behavioral therapy is based on Beck’s theory of the cognitive contribution to
depression and focuses on eliminating the following types of abnormal thinking: the cognitive
triad (the patient’s negative concept of him/herself as useless, a pessimistic view of the future

and the outside world as threatening); schemas (in which automatic negative thought patterns

result in occurrences being interpreted in an exclusively negative way); and faulty information
processing (in which dysfunctional thought processes, such as overgeneralization and
misattribution, result in fiirther negative interpretations of occurrences) (Beck et al., 1979).
Cognitive-behavioral therapy seeks to aid in recognizing the connection between negative
patterns of thought and depressed mood, and reversing these through the following five steps:
“ Monitoring negative thoughts; recognizing the connections between negative thoughts and
feelings of depression; examining the evidence for and against specific automatic negative
thoughts; learning to identify and alter the dysfunctional beliefs that sustain negative
cognitions, and developing more reality-oriented or adaptive views of the self, the world, and
the future” (Moberg & Lazarus, 1990, p. 94).

It is explained to the clients that this therapy can help them adjust to issues currently
occurring in their life, requires active participation, encourages the use of a therapy journal and
the practicing of techniques at home (Moberg & Lazarus, 1990). Beck et a1. (1979) view the
integration of behavioral techniques as an important factor in obtaining cognitive change.
Through the change of cognitive processes and behavior (increasing the occurrence of pleasant
activities) the client is shown that negative and overgeneralized thought patterns (i.e. “I’m
useless”, “this will never get any better”, “things just never seem to work out for me”) are not
accurate. The thoughts of helplessness, hopelessness or pessimism which had previously
seriously restricted the level of motivation and resulting behaviors are replaced by positive
thoughts and a positive mood. The client is taught to become aware of the relationship
between thought, activity and mood. Cognitive-behavioral therapy is very structured, and

teaches the client new skills through in-session exercises and homework assignments like

reading assignments or the utilization of imagery or relaxation techniques. It is a pragmatic

approach that focuses on problem solving using clear, measurable goals and reduces symptoms
in a collaborative relationship between the client and the facilitator (Grant & Casey, 1995).

Cognitive-behavioral therapy is indicated in the treatment of mild to moderate major
depression in the elderly and is especially effective with a specific problem or precipitating
event (although this is not essential). Clients with severe cognitive limitations, very severe
psychomotor agitation or depression, extreme medical frailty or instability, and severe sensory
loss may be too impaired to benefit from CBT (Casey & Grant, 1995). Yet Rybarczyk et a1.
(1992) stress that CBT can be adapted to special needs.

For the purpose of this project cognitive-behavioral strategies (CBS) will be defined as
interventions that are based on the idea that distorted thought processes and the absence of
pleasurable activities contribute greatly to the development and continuation of affective
disorders such as depression. Cognitive-behavioral strategies focus on eliminating distorted
thought systems, while striving to increase the number of pleasant experiences in one’s daily
life. In addition to being highly effective in treating depression, the client learns skills usefitl in
coping with a broad range of stressors (Thompson, 1996). The APN can either use CBS alone

or in combination with other modalities.

Conceptual Fremework
The issues related to major depression in the elderly and its resulting effects fit well into
the framework presented by theorist Dorothea E. Orem (1991) in her general theory of nursing

which provides the framework for this project (see Figure 1).

Nurse
action

Nurse
action

 

Accomplishes patient's
therapeutic self-care

 

Compensates for patient’s
inability to engage
in self.care

 

 

Supports and protects
patient

 

 

Wholly compensatory system

 

Performs some self-care
measures for patient

 

Compensates for self-care
limitations of patient

 

Assists patient as required

 

 

Performs some self-care
measures

 

Regulates self-care agency

 

Accepts care and assistance
from nurse

 

 

 

Partly compensatory system

 

Accomplishes self-care

 

 

 

 

Regulates the exercise and
development of

 

 

self-care agency

 

Patient
action

Figure 1. Basic Nursing Systems (Orem, 199])

Orem’s fi'amework consists of three interrelated theories: the theory of self-care, the theory of

self-care deficit, and the theory of nursing system.

Th f 1f-

Orem (1991) states that ‘self-care’ is an individual’s ability to respond to his/her
personal needs which are affected by age, stage of development, state of health, the
environment, and the result of medical treatments. She further explains that self-care is a
learned behavior and a deliberate action aimed at meeting ever-changing internal and external
factors through self-regulation. Self-care, which is learned through an intellectual process, is
developed through social interaction where recurring requisites for self-care lead to the

development of care habits. These vary from culture to culture and are situation specific.

Theory of Self-Care Deficit

In this context Orem (1991) defines ‘deficit’ as an individual’s inability to respond to
his/her personal needs. She stresses that this should not be interpreted as a human disorder,
although it may be indicative of a person’s functional or structural disorder. When self-care
abilities are less than those required to meet a self-care demand, such as frequently occurs in
depression, a client may require nursing care. A client’s self-care engagement is affected by the
(p. 71) “person’s limitations in knowing what to do under existent conditions and

circumstances or how to do it.” As a result the client’s therapeutic self-care demand requires a

10

usually time-limited, situation specific intervention which meets self-care requisites until the

ability to resume self-care is attained once again.

Theog of Nursing System

Orem’s (1991) theory of nursing system discusses the relationship between client and
nurse. The nursing interventions used in response to a therapeutic self-care demand seek either
to protect the client or facilitate the ability to once again respond to personal needs. The nurse
takes the client’s values into consideration while applying the nursing process. Nurse and client
mutually determine goals and the roles each are to assume in achieving these, in order to
reinstate self-care agency.

Orem (1991, p. 291) describes three types of nursing systems: wholly compensatory,
when the client is completely unable to engage in self-care and the nurse performs all necessary
care i.e. a comatose person; partly compensatory, when both client and nurse “perform care
measures involving manipulative tasks or ambulation,” i.e. medical rehabilitation nursing;

and lastly the supportive-educative nursing system.

Supportive-Educative System

Within this nursing system the client requires assistance to perform therapeutic self-
care, such as (Orem, 1991, p.291) “support, guidance, provision of a developmental
environment, and teaching.” Orem (1991) explains that this is a supportive-developmental
system where the nurse assists the client with the making of decisions, controlling behavior and
the learning of new knowledge and skills. The nurse’s role is primarily consultative, providing

periodic guidance and teaching (see Figure 2).

11

 

Accomplishes
self-care

 

 

 

 

 

Self-care deficit Patient action

A

 

 

 

 

 

 

 

 

Y Y

Regulates the
Depression exercise & development
of self-care agency

 

 

 

 

 

 

 

 

 

Nurse action

 

 

 

Figure 2. Application of Orem’s Supportive-Educative System to Treat
Depressed Elderly in Primary Care

The advanced practice nurse (APN) in the primary care setting assists the client within
this last nursing system. The elderly client experiencing depression displays a range of
symptoms which indicate that self-care demands exceed self-care abilities. The client seeks help
from the primary care provider (APN), who applies a personalized nursing process (nurse
action) to help regulate the exercise and development of self-care agency. The APN utilizes the
nursing process to assess self-care requisites, determine self-care demands and self-care
abilities of the client. This information is used in the process of making a diagnosis of the self-

care deficit and developing an individualized plan. The supportive-educative system provides

12

information and support to help achieve self-care agency once again. The implementation of
this system allows the APN to apply CBS either alone or in conjunction with medication. As
the client learns to adopt new coping techniques learned from CBS in his or her repertoire, s/he

once again resumes the independent management of self-care.

Review of Literature

Depression and the Elderly

Depression in old age is a major costly public health problem, burdening not only the
affected patient, but also their families and ultimately the whole community. It leads to
increased morbidity, decreased functional status, over-utilization of health care resources, and
possible occurrence of death (Badger et al., 1994; Jarret & Rush, 1994; Miranda & Munoz,
1994; NIH Consensus Development Panel on Depression in Late Life, 1992; Rothshild, 1996).

While depression can be precipitated by various general medical disorders (i.e.
endocrine disorders, cancers, infections, nutritional deficiencies, cardiovascular disease,
metabolic disorders, collagen disorders, alcoholism and neurologic disorders), it may also be
brought on by the use of certain medications (antihypertensives: clonidine, reserpine,
methyldopa, propranolol, guanethidine; diuretics; oral contraceptives; steroids/ACTH;
cimetidine; digitalis; disulfiram; barbiturates; benzodiazepines) (Steiner & Marcopulos, 1991).
One study cited by Rybarczyk et al. (1992) shows that older adults with a significant chronic
disease process are at double the risk of depression than someone without medical problems.
High rates of depression have been linked with patients with arthritis, stroke, Parkinson’s
disease, multiple sclerosis, and COPD (Rybarczyk et al., 1992). Risk factors for depression in

the elderly include a personal or family history of depression, other medical illnesses,

13

caregiving, being single (especially widowed), financial burden, loss of independence, social
isolation and being female (Hendrie & Crossett, 1990; Katona, 1994; Richter, Barsky & Hupp,
1983; Rothschild, 1996; Steiner & Marcopolous, 1991).

Due to the stigma the elderly attach to mental disorders, they fiequently deny
symptoms of depression or present with masked depression, characterized by “a condition in
which the mood component seems absent or inaccessible to the patient, although other
symptoms characteristic of (depression) are present” (Thompson, Futterrnan, & Gallagher,
1988, p. 578). This is particularly common in men. Elderly typically have a significantly lower
rate of seeking referrral for psychiatric care and of being referred by their primary care provider
(Hendrie & Crossett, 1996). One study by Richter et al. (1983) cites that less than 25 °/o of all
geriatric depressed patients were referred to mental health professionals. Of these twenty-five
percent, 5 % were seen by social services to confirm the diagnosis, 10 % were referred
specifically for counseling, 6 % were followed by nurse practitioners for supportive care, while
only 3 % regularly met a mental health professional for treatment of depression. All other
patients (75 %) were usually treated by their primary care physician with supportive counseling
during a 20 minute office visit while addressing issues of general medical care, and follow-up
visits were scheduled 8 weeks later.

Atypical symptoms of depression in the elderly complicate appropriate diagnosis of
affective illness. Therefore carefiil history taking is necessary (McCullough, 1991), possibly
including near family to aid in the process of gathering information for reliable diagnosis
(Hendrie & Crossett, 1990) such as obtaining the medical history, a current list of medications,
precipitating events (losses), and recent affective or behavioral changes for reliable diagnosis.

The family can also be invaluable in the treatment phase by facilitating accurate medication

14

intake, providing the client with emotional support, being supportive of the assigned
homework and providing the health care provider with pertinent feedback regarding the
client’s progress.

Usually depression is time-limited, resolving within 3-6 months if left untreated,
although relapse is frequent and 15 - 20 % result in chronic depression. Therefore the aim of
treatment is to accelerate recovery and reduce recurrence through learning depression
management skills (F ennell, 1995).

Depression in the elderly can be assessed by using the Beck Depression Inventory
(Beck et al., 1961) or the Geriatric Depression Scale (Yesavage et al., 1983). Both are self-
report questionnaires and can be used for initial screening, to determine the level of depression,
and later to assess the effectiveness of interventions used (Thompson, Futterman & Gallagher,
1988).

Mortality rates by suicide in this age group are higher than any other, and careful
assessment of suicide potential is essential. Particularly for elderly white men suicide potential
increases steadily with growing age (Pierre, Craven & Bruno, 1986; NIH Consensus
Development Panel on Depression in Late Life, 1992). Men’s suicide rate peaks after age 75,
while women are at highest risk after age 45 (McCullough, 1991). The risk of suicide is greatly
enhanced when elderly are lonely and isolated (widowed, divorced or unmarried), experiencing
physical illness, or when facing the cumulative effect of a range of losses, especially a recent
relocation (Katona, 1994). Over 75 % of clients who complete suicide are seen by their
primary care provider within 30 days prior to their suicide, generally while experiencing a first

episode of major depression, the symptoms of which were not recognized or treated

15

appropriately (NIH Consensus Development Panel on Depression in Late Life, 1992), or the
diagnostic criteria for depression not appropriately applied.

Issues that appear to contribute to up to 50 % underrecognition of depression in
primary care include age bias, also known as ‘ageism’. Both terms refer to all prejudices and
negative views held about the elderly which lead to stereotyping the process of aging (Collins,
Katona and Orrell, 1995). Further factors that can lead to misdiagnosis and atypical
presentation of geriatric depression include lack of adequate office time, underutilization of
screening instruments, and the complexity of the diagnostic process in patients with psychiatric
and medical co-morbidity (Banazak, 1996; Hendrie & Crossett, 1990; Kalayam & Shamoian,
1990; McCullough, 1991). Also, the health care system adds to the problem of
underrecognition with poor or lack of reimbursement for mental health services overall
(Badger et al., 1994).

There is growing evidence that primary care providers recognize symptoms of late-life
depression more often than they document or treat them. Callahan, Dittus & Tierney (1996)
suggest that this may be due to inadequate knowledge regarding available treatments, client
refusal or deferral of therapy, and providers’ pessimism regarding the elderly client’s potential
to respond to therapy. The literature also mentions the ‘silent conspiracy’ between elderly
patients and their health care providers to deny symptoms related to mental illness fi'om fear of
potential treatment consequences (Collins, Katona & Orrell, 1995).

Banazak’s (1996) study reports that 41 °/o of primary care clinicians were unaware of
federally developed guidelines for detection, diagnosis and treatment of depression in primary
care (Depression Guideline Panel, 1993). This may play a key role in the high percentage of

antidepressant scripts written and the high rate of patient noncompliance to treatment. Her

16

study (1996) further supports the earlier finding that patient noncompliance is an important
barrier to treatment. Although health care providers in general lay more emphasis on using
antidepressant medication rather than psychotherapies, male providers are more prone to use
biological treatments, while female providers are more comfortable with their counseling and
activity therapy skills. Banazak’s (1996) recommendations include the need for primary care
providers to become more comfortable with using non-pharmacological treatment modalities.
Primary care providers prescribe the majority of all the antidepressant medication used
in the United States (Robinson et al., 1995). In the elderly population of those who take
pharrnacotherapy for the treatment of acute depression approximately 60 % improve clinically
although significant response often takes 6-12 weeks to manifest (unlike younger patients)
(NIH Consensus Development Panel on Depression in Late Life, 1992). It is therefore not
surpriSing that there are compliance difficulties with pharrnacotherapy. The high rate of adverse
dmg reactions in the elderly also contributes to non-compliance. Examples of adverse drug
reactions include cognitive impairments such as delirium, toxic antidepressant psychoses, and
memory impairment (Oxman, 1996), and cardiovascular problems. All of these drug reactions
ultimately increase the risk for resulting morbidity, such as the association of falls and hip
fractures in the elderly client from the use of antidepressant medication (Steiner & Marcopulos,
1991). Many side effects in the elderly are due to “age-related pharmacokinetic changes in
absorption, distribution, biotransforrnation and elimination of drugs” (Oxman, 1996, p. 39).
The single most important cause of adverse drug reactions in the elderly is polypharrnacy. The
average geriatric client takes between six to eight different medications daily. With medications
being metabolized and excreted less optimally in the geriatric client, s/he remains at increased

risk for side effects the longer the drugs remain in the body (Rothschild, 1996).

17

Cogm’tive-Behavioral Therapy and the Elderly

The elderly have been undertreated with psychotherapy in part due to a view influenced
by Freud who believed that clients over the age of 50 didn’t exhibit the necessary “elasticity of
mental processes” for psychoanalysis. He also feared that older adults’ life review would result
in never-ending analysis. As a result little research has been done studying psychotherapy with
older adults (Grant & Casey, 1995).

Another theory leading directly to age bias and the resulting undertreatment of the
elderly client is the misunderstanding of disengagement theory used to help explain the aging
process. This theory states that aging is a process of mutual withdrawal or disengagement
which results in reduced interaction between the aging person and others in the social systems
he belongs to. The theory continues by stating that disengagement results in the severing of
many relationships between the elderly person and other members of society, and the alteration
in the nature of those which remain (Henthom, 1979). In her article Henthom (1979) firrther
explains that this theory has been used by some (i.e. policy makers and health care
administrators) to accept ‘negligent practices’ and the lack of interventions and opportunities
to enhance the elders’ quality of life. However, in recent years several types of psychotherapies
have been proven successful with the elderly patient. This review will focus on the efficacy of
CBT in the treatment of the depressed elderly person.

Gallagher and Thompson (1982) report a study where the effects of cognitive or
behavioral therapy were compared to the efficacy of relational/insight therapy in the outpatient
treatment of depressed older adults. Cognitive and behavioral therapy proved superior not only
with regard to the outcomes achieved, but also with regard to the longer maintenance of

treatment gains. Almost two-thirds of subjects expressed regularly using specific skills they had

18

acquired in cognitive or behavioral therapy in a one year follow-up (such as the use of mood
monitoring and recording dysfunctional thoughts).

Fry (1984) discusses a fiirther study using CBT in the depressed elderly, comparing the
effects of immediate treatment versus delayed treatment. The outcome shows that CBT
alleviated depression in both groups. He notes that specific changes observed include “increase
in positive cognitions, decrease in irrational thoughts, reduction in beliefs of dependency, self-
criticism and inefiicacy”. However, Fry points out that improvements in depression cannot be
attributed to any specific cognitive-behavioral strategy employed.

Morris & Morris (1991) evaluated six controlled trials (between 1982 and 1987) using
outpatient CBT with the depressed elderly and concur that CBT is an effective treatment for
this population. They question the cost-effectiveness of CBT versus pharrnacotherapy (the
latter traditionally being considered especially usefiil because the elderly have more so-called
vegetative or physical signs of depression), and point out that more research is needed to
determine this. They caution that the results are limited in the generalizability and advocate a
treatment approach which provides equal attention to psychological and physical care. Further,
they note that issues related to rates of relapse and compliance still need more research.

Blackburn et al. (1981) compared the efficacy of cognitive therapy and pharmaco-
therapy, each alone and in combination, both in hospital out-patient clinics and general
practice. The subjects’ age ranged from 18 to 65 and were diagnosed with primary major
depression. Combination treatment was superior to drug treatment in both sites, while
cognitive therapy in general practice yielded better results than drug treatment alone. Similar
results were obtained in a study by Teasdale et al. (1984) comparing the effect of cognitive

therapy (in addition to treatment-as-usual) for major depressive disorder with treatment-as-

19

usual in primary care. The results indicate that patients receiving the addition of cognitive
therapy were significantly less depressed than the control group.

One factor that all the studies reviewed have in common is that the treatment sessions
lasted 60 to 90 minutes, for a period of 12 to 37 weeks, and were all facilitated by experienced
therapists such as clinical psychologists. Although the outcomes were positive, the fact that
patients were referred outside of the primary care setting will need to be taken into
consideration when developing the clinical guidelines, by adapting the contents of the sessions
to a format acceptable in primary care.

In contrast to the rather lengthy treatments mentioned above, Scott et al. (1997)
performed an acute and one-year randomized controlled trial of brief cognitive therapy for
major depressive disorder in primary care in a population aged 18-65. The intervention group
received six sessions, the first of which lasted 60 minutes and the subsequent ones were about
30 minutes duration along with written material and homework. The results imply that brief
cognitive therapy is usefiil in addition to treatment-as-usual and that patients in the intervention
group recovered earlier, with improvements remaining sustained at one-year follow-up. Yet the
researchers point out that brief therapy requires trained facilitators with a high level of
expertise. The same article discusses the results of three other studies using brief cognitive
therapy. Fennel] & Teasdale (1987) show that some depressed subjects display a significant
improvement within only four sessions of cognitive therapy. While Barkham et al. (1992) and
Mynors-Wallis et al. (1995) demonstrated that two cognitive therapy sessions plus a brief
problem-solving therapy for depression were beneficial in treating depression.

Mynors-Wallis et al. (1995) presented the randomized controlled trial comparing

problem solving treatment with amitriptyline and placebo for major depression in primary care.

20

They ofi’ered six treatment sessions over three months (weeks 1, 2, 3, 5, 7, and 11) to all three
treatment groups. Their study utilized three therapists: a psychiatrist and two general
practitioners who had been trained in the techniques used. The problem solving technique used
has several stages: “(a) identifying and clarifying the problem; (b) setting clear achievable goals;
(c) brain-storming to generate solutions; (d) selecting a preferred solution; (e) clarifying the
necessary steps to implement the solution; and (f) evaluating progress.” Problem solving was
significantly superior to placebo at weeks six and twelve. There was no significant difference
between problem solving and amitriptyline treatment.

The Leung and Orrel study (1993) looked at the outcome of brief cognitive behavioral
group therapy for depressed elderly. The seven sessions focused on helping participants
identify automatic negative thoughts and identify goals. This pilot study suggests that this form
of therapy can reestablish independence and enhance recovery from major depressive disorders
in older adults.

The last five studies mentioned are important in that they contrast the previous research
reviewed for this project and show that brief cognitive therapy is effective. The Mynors-Wallis
et al. (1995) study is significant in demonstrating that trained practitioners can effectively
provide treatments when instructed properly.

Robinson et al. (1995) describe a study of primary care physicians’ use of cognitive-
behavioral techniques with depressed patients. Patients reported that on average their primary
care physician recommended between 2 to 5 cognitive-behavioral techniques in the
antidepression prescription visit, although more younger than older patients reported mention
of the use of cognitive behavioral techniques. The psychological coping techniques identified

were ( p. 354): “planning regular participation in activities that (l) are pleasurable, (2) boost

21

confidence, (3) help with relaxation, and (4) are with other people; (5) using problem-solving
techniques for problems in life and (6) recognizing negative thoughts and replacing them
with more positive thoughts”. One possible reason the researchers mention for this result is the
greater difficulty elderly have in accepting the diagnosis of depression and of less interest and
familiarity in psychological treatments of depression. Also, older physicians are less likely to
discuss counseling as a treatment option (which may be reflective of their training) and also
tend to have older patients. It also may reflect older physicians not being familiar with the
newer and briefer psychotherapeutic approaches and belief that psychotherapy is equal to
psychoanalysis. This may confirm the stigma earlier mentioned which elderly attach to mental
disorders, and possibly be a reflection of client and provider age bias affecting treatment
Options for the depressed elderly. Significantly, higher rates of utilizing cognitive-behavioral
techniques resulted in higher adherence to pharmacotherapy.

Scogin et al.’s (1989) study recommends the use of select cognitive-behavioral
bibliotherapy in the treatment of mildly and moderately depressed older adults as an alternative
or adjunct to traditional treatments. The authors mention that its cost-effectiveness and non-
invasive nature make it attractive to older adults. Participants in the one treatment group
obtained a copy of Control Your Depression (Lewinsohn et al., 1986), a 24l-page presentation
of behavioral therapy for depression, while the second treatment group received a copy of
Feeling Good (Burns, 1980), a 398-page presentation of cognitive therapy for depression. The
participants were given 4 weeks to complete the book and the researchers made weekly 5-
minute phone calls to the participants. The control consisted of a delayed treatment group. The

results indicate that both cognitive and behavioral bibliotherapies are effective self-help

22

depression treatments yet require active monitoring (p. 407) “because of the risks to emotional
and physical health that can result from a deepening affective disorder”.

These findings are confirmed by Robinson et al. (1997) whose study of behavioral
bibliotherapy concludes that older depressed primary care patients benefit fiom written
information in addition to psychological treatments during primary care visits, which has also
been found to help patients adhere to antidepressant treatment in the period until the results .
can be observed. The authors conclude that older depressed patients benefit from brief,
interactive, age- and need-specific, written information on medication and behavioral strategies,
coupled with either longer office visits or ancillary phone contacts from the primary care
provider. Written infonnation/ booklets are also useful in providing structure for interactions
between physician and client during office visits. This study is supported by the findings of
Brown & Lewinsohn (1984).

Although there is relatively little research specifically adapting psychotherapy to
primary care, Salazar (1996) mentions a national survey of family practitioners treating mental
health illnesses which shows that over 80 % regularly provided advice, reassurance, or
supportive problem solving, while 25 % regularly provided insight-oriented verbal therapy;
and over 15 % regularly provided behavior modification. The survey estimates that more than
25 % of the total amount of time devoted to psychotherapy in the United States occurs in
general medical settings. That is promising yet surprisingly low considering that 90 % of
depression is treated in primary care. Salazar (1996) and Shearer & Kaplin Adams (1993) both
mention CBT for use in primary care, while the latter extensively mention bibliotherapy to

supplement the treatment of depression.

23

Salazar (1996) states that the standard of care with less severe depression recommends
beginning with psychotherapy alone and only if required adding medication later. He also
recommends adding psychotherapy to severely depressed patients once pharmacologic
treatment has improved the patient’s condition.

In reviewing the available literature on depression in the elderly and the use of
cognitive-behavioral strategies in primary care, it is striking to note that nursing generated data
is conspicuous by its absence. This is surprising since the holistic perspective nurse
practitioners apply in their approach to client assessment and treatment would lead one to
expect the APN to study firrther nonpharmacological approaches in primary care. This author
hopes that in the future nurse researchers will focus on this population and its unique

treatment issues and thereby enrich the literature with its contributions.

Adapting CBT to the Specie] Needs of the Elderly

Gallagher and Thompson (1981) have adapted CBT to the treatment of depression in
the elderly. Thompson (1996) makes specific recommendations for adapting CBT to optimize
the effects in treating late-life depression. He recommends administering the Mini-Mental State
Examination (Folstein, Folstein & McHugh, 1975) to assess the level of cognitive function, in
addition to a brief assessment of depression (using the Beck Depression Inventory and the
Geriatric Depression Scale). He further suggests adapting material for reduced cognitive
processing if necessary, presenting new ideas slowly and in a variety of ways, asking the patient
to summarize materials frequently, and maintaining a notebook.

Grant and Casey (1995) adapt CBT to the frail depressed elderly by stressing the

importance of socializing the client to therapy using simple, commonsense terms, mutually

24

agreeing on modest therapy goals to allow the client to have an early sense of accomplishment,
while creatively individualizing the process. They firrther suggest using a family system context
in approaching the elderly patient’s problems, and recommend utilizing family members as a
resource in compliance with homework assignments whenever possible. They also stress the
importance of the provider being aware of and confionting his/her own beliefs and biases about
the ability of elderly to function effectively.

Rybarczyk et al. (1992) specify the use of CBT to treat chronically ill clients with late
life depression. They stress the importance of helping the client understand that s/he is indeed
depressed and that a chronic medical illness is a problem separate from depression which is
reversible. The client may need help understanding what depression is, its symptom profile,
and that it is not merely a “side effect” of a medical condition (as is commonly believed). Also,
any feelings about being stigmatized by a psychological label should be addressed. The authors
also indicate the importance of dealing with issues of loss of social roles and autonomy as a
result of chronic illness, and challenging the perception of being a “burden” by addressing three
commonly used forms of distorted thinking (p. 134): negative filtering (“I’m nothing but
trouble for my family”), mindreading (“my wife is getting tired of taking care of me”), and
negative forecasting (“before long, my daughter will have to transport me everywhere and will

end up resenting me”).

25

Project Development

M h l

The structure of the practice guidelines in the use of CBS with depressed elderly in
primary care will be evolved from the conceptual fiamework, while the content of the
guidelines will be drawn fi'om the review of literature. The goal of the practice guidelines is to
allow the depressed elderly client to accomplish self-care once again. The practice guidelines
include a self-care deficit assessment, recommendations for diagnosis of depression and how to
develop a personalized treatment plan, educational intervention modules, and a section on how
to evaluate outcomes.

The self-care deficit assessment (see Appendix A) addresses the client’s bio-psycho-
social spheres. It includes a bio-medical and medication history, a psycho-social history
assessing for typical and atypical signs of depression, as well as risk factors for depression,
suicide and the assessment of suicidal ideation and social support systems. These assessment
guidelines firrther assess specific potential issues relevant to CBS and include relaxation,
pleasant activities, problems with people (social skills), troublesome thoughts, problem solving
skills and self-control problems, the need for a personalized problem list, an assessment of
barriers to participating in CBS and lastly the ability to perform ADL/IADLs. The purpose of
this assessment is to determine the level of self-care deficit in the client and is used as a
foundation for choosing appropriate treatment interventions for the individual client.

The section on diagnosis (see Appendix B) recommends the instruments the literature
discusses for diagnosing depression in the elderly (the Beck Depression Inventory and the

Geriatric Depression Scale) and the level of cognitive functioning (the Mini-Mental State

26

Examination). The plan section (see Appendix C) guides the APN through the process of
personalizing the treatment plan and explaining the principles of CBS to the client. Based on
the literature review and the research results on the use of bibliotherapy with depressed elderly
the book Contrel Your Depression (1992) by Lewinsohn, PM. et al. was chosen as a tool to
apply the proposed practice guidelines for CBS in primary care. It is a readily available and
relatively inexpensive paperback book written by four psychologists, providing self-help
techniques to people with depression using principles of cognitive-behavioral therapy. Their
approach reflects the content of research reviewed for this project. The book is written at
about a high school education level.

The section on interventions (see Appendix D) provides educational modules on
medication teaching, relaxation, pleasant activities, problems with people (social skills)
regarding assertiveness, personal style and isolation, controlling thoughts, problem solving
skills, self-control problems, and relapse prevention.

And finally, the practice guidelines propose a means of evaluating outcomes (see
Appendix E). The NIH Consensus Development Panel on Depression in Late Life (1992)
determined that the goals of treatment for geriatric depression should include symptom
reduction, decreased risk of relapse and recurrence, enhanced quality of life, amelioration of

overall health, cost-effectiveness, and mortality reduction.

UtilizeLion of the Practice Guidelines for CBS
The practitioner working with a depressed client needs to make an in-depth assessment
of the numerous factors that can lead to depression or present depressive symptoms.

Therefore a thorough medical history and physical examination are critical, as well as a review

27

of the medications taken including prescription and non-prescription agents (see Section A).
Further, an assessment of the client’s psychosocial history (see Section B) regarding typical
and atypical signs and symptoms of depression, risk factors for depression and suicide, as well
as an assessment of current suicidal ideation will all help determine the level of acuity and crisis
a client is experiencing. A client displaying active suicidal ideation with a plan needs to be
hospitalized immediately to regain personal stability. Cognitive-Behavioral Strategies can be
applied subsequently as indicated. An assessment of social support systems including family
and fiiends, professional agencies, counselors and therapists, gives the practitioner insight into
the social network of a client (or the lack thereof). With the client’s written permission key
persons may be contacted for firrther information or to ask for ongoing support.

What follows is an assessment of specific issues (see Section C) which all can
contribute to depression and gives the practitioner a basis for the personalized CBS and
relevant educational modules which are to follow. The practitioner is advised to be familiar
with the content of Control Your Depression ( 1992) by Lewinsohn, PM. et al. and can refer to
chapter four for further guidance on this section. Section D allows the APN to develop a
problem list for CBS based on the assessment done in Section C (for which subsequent
educational modules have been developed).

An assessment of potential barriers or challenges (see Section E) to participating in
CBS looks at various issues which either require adapting CBS to the special needs of the
elderly (i.e. loss of hearing or vision, weakness or pain) or may even prevent a client fiom
benefiting from CBS such as the literacy level or education. Special adaptations used to
overcome barriers might include using large print, audio-taping the contents of select chapters,

recommending the use of tape recorders for joumaling, or working with family members,

28

fiiends or volunteers on homework assignments. The client’s cultural background and
perceived needs can give the practitioner an idea about how to further personalize the
guidelines to obtain greater efficacy and improved compliance with the proposed process.

The last section (see Section F) allows the practitioner to ask questions about the
current level of Activities of Daily Living (ADL) and Independent Activities of Daily Living
(IADL) which may have been impacted by the depression (or the decline thereof which may
have contributed to depression). Questions can include ability to wash self, dress, do laundry,
prepare food, do groceries, transportation (does s/he still drive), ability to do house work and
take medications.

The next section (see Appendix B) instructs the practitioner to either use the Beck
Depression Inventory or the Geriatric Depression Scale to make the final diagnosis of major
depression in the elderly client. The level of depression should not exceed mild to moderate,
and the client should not be psychotic (the APN should rule out visual or auditory
hallucinations or delusions) or bipolar (by ruling out previous episodes of manic-depressive
occurrences or diagnosis) to optimally benefit from CBS. The Mini-Mental State Examination
is used to assess the level of cognitive status (and can indicate the existence of dementia or
pseudodementia).

After the self-care deficit assessment (see Appendix A) and the diagnosis (see Appendix
B) have been completed, the practitioner reviews the findings of the assessment with the client
and explains the diagnosis of depression (see Appendix C). It is important to assess the client’s
fear of stigma or level of denial regarding a mental health diagnosis, and allow for feedback or
verbalization of feelings. The problem list for CBS is also discussed and priorities are mutually

established. What follows is an explanation of the principles of CBS, the need to commit to

29

homework assignments and practicing of exercise techniques learned using the book Cempl
Yeur Depreeeien (1992) by Lewinsohn, P. M. et al. Once the client agrees to learn CBS the
homework assignment is discussed and a follow-up appointment is detemtined based on the
client’s level of acuity. The practitioner may periodically follow-up with a brief phone
conversation as deemed appropriate.

The interventions (see Appendix D) are made up of ten educational modules:
Medication Teaching, Relaxation, Pleasant Activities, Problems with People (Social Skills) and
includes Assertiveness, Personal Style, and Isolation, Controlling Thoughts, Problem Solving
Skills, Self-Control Problems and Relapse Prevention. The individual modules are only initiated
if indicated and in the order that appears appropriate for the respective client (with
recommendations made by the APN and by mutual consent). For example the module for
Medication Teaching is only used if the practitioner chooses to prescribe psychotropic
medications. The client goal is that s/he verbalizes understanding of the proper medication
purpose and use. The practitioner documents whether or not the goal was met and documents
relevant responses and issues in the comment section.

At the beginning of each new session the practitioner reviews the homework
assignment allowing for feedback and assesses the mood before discussing the goal for the
visit. It is important to work at the client’s pace, although the practitioner may occasionally
need to redirect the client and refocus on the task at hand. The practitioner is advised to
prepare for the intended module by reading the relevant chapter(s) in the book ontrol Your
Depression (1992) by Lewinsohn, P. M. et al. Forms may be photocopied from the book and

enlarged for the client’s homework assignment. The homework assignment might include daily

3O

exercises from a previous module (i.e. relaxation exercise) in addition to the one indicated by
the module currently being covered.

Each client should end the program with the module entitled Relapse Prevention. This
module acts as a review of the material covered and further emphasizes techniques that can be
practiced to help prevent firrther relapses or to detect a new episode of depression in its early
stages and seek help (or utilize the techniques learned).

The educational sessions are intended to be used in the primary care setting and last 20
to 30 minutes each. Thorough documentation is indicated with regard to responses and
outcomes obtained, and the practice guideline sheets can become a part of the client’s

permanent record.

Eyglpetion of Clinical Guidelines

The goals of the clinical guidelines are (see Appendix E): symptom reduction,
decreased risk of relapse and recurrence, enhanced quality of life, amelioration of overall
health, cost-effectiveness and mortality reduction and were drawn from the recommendations
of the NIH Consensus Development Panel on Depression in Late Life (1992). Symptom
reduction may be assessed through the client’s use of effective coping skills (as evidenced by
the appropriate use of CBS learned under the supervision of the APN) , and the comparison of
the initial scores of the Beck Depression Inventory or the Geriatric Depression Scale with
those at the end of the program. Also the Mini-Mental State Examination may be applied and
the scores compared to the initial ones obtained.

Decreased risk of relapse and recurrence may be evaluated by periodically assessing the

client for typical and atypical signs and symptoms of depression, the length of remission of

31

symptoms, and any precipitation of relapse. In addition, the use of effective coping skills
(CBS), the number of relapses and recurrences now as compared to prior to the use of CBS,
and the periodic application of the Beck Depression Inventory or Geriatric Depression Scale
can be used to monitor the client’s well-being emotionally.

Enhanced quality of life can be assessed by applying the Beck Depression Inventory or
the Geriatric Depression Scale and the Mini-Mental State Examination. Also the number of
pleasant activities engaged in as well as the presence of negative thoughts can be monitored by
questioning the client, in addition to assessing the use of effective coping skills.

Amelioration of overall health can be assessed by reviewing the utilization of healthcare
resources and by comparing the use prior to the utilization of CBS as opposed to after its use.
The goal for a client whose depression is controlled or cured is a decreased use of healthcare
resources, whereas a client who is still actively suffering from depression should seek
appropriate help (which may represent an increased use of resources but may indicate a
positive change as opposed to denial or immobilization). Further, a periodic physical and
mental functional status examination can evaluate the overall state of health.

Cost-effectiveness can directly be measured by looking at the utilization of healthcare
resources such as number of and reasons for visits to the healthcare provider, hospitalizations,
referrals and level of compliance with treatment. Here also, a periodic physical and mental
functional status examination can give feedback on the client’s overall wellbeing.

And lastly, mortality reduction can be assessed in a twofold way. The practitioner can
evaluate the number of suicide attempts or threats after use of CBS, or the occurrence of death

by suicide.

32

Impligtiens fer Advaneed Nursing Pragice

The APN in primary care is at the float line of encountering depressed elderly clients. It
is of great importance that s/he be able to assess, diagnose and treat depression effectively in
this population. The ability to establish a therapeutic relationship with a client overtime will
help provide the trust that is helpful and often necessary in overcoming the stigma and denial
the elderly frequently attach to mental health illnesses. A long-term therapeutic relationship can
also benefit the provider in recognizing depression especially when it presents atypically.
Further, it is important that the health care provider confront his/her own biases about aging,
grief and loss, and depression so as to more effectively recognize and treat this potentially fatal
condition in the elderly client. Due to the APN’s holistic approach and tendency to apply non-
pharmacologic modalities in the treatment of clients in primary care, CBS lend themselves well
to their practice style. Therefore, it is important that the prospective APN become familiar
incorporating brief, time-limited psychotherapies such as CBS into his/her practice style.

As the health care arena is changing rapidly it is important that clients learn to assume
ever more responsibility in the process of health maintenance and illness prevention. The APN
can gently and sensitively guide the elderly population away from the traditional “fix me”
attitude to develop more of an equal partnership with the provider. In this partnership the APN
functions as a clinician, educator, expert, guide and sounding board offering options and
allowing the client to make educated decisions.

The educational setting should help make prospective APNs aware of the practice
guidelines (such as the Depression Guideline Panel, 1993) available to treat a complex disease
process such as depression. Also, the student should further be instructed and encouraged to

use these protocols and learn when it is wise to seek a consultation or to make referrals to a

33

mental health specialist. The prospective APN greatly benefits fi'om developing research and
theory based protocols during the educational process as this author certainly has. S/he thereby
becomes sensitized to the complexity of issues impacting treatment, and are helped in applying
clinical guidelines or protocols in the future clinical setting. The educational setting is an
important arena where age-related biases can be uncovered, challenged, and reality-based
information imparted to refine the clinical skills of the prospective APN. With the curriculum of
programs for APNs becoming increasingly laden with material needing to be covered, the APN
increasingly needs to turn to continuing education to expand the knowledge base. The
experience gained in the clinical setting will provide the necessary motivation to learn ever
more effective treatment modalities, or simply to have more options for treatment available.

The APN in the primary care setting needs to be aware of the prevalence of
depression, its typical and atypical signs and symptoms in the elderly person, methods of
diagnosis using appropriate diagnostic criteria mentioned in the DSM-IV (1994), treatment and
outcome evaluation, and help the elderly client express feelings about the stigma regarding a
mental health problem to enhance compliance with treatment. The APN in his or her role as an
educator needs to become comfortable discussing depression in simple and understandable
terms for the lay person, emphasizing what depression is, how it affects feelings, as well as
mental abilities and physiological firnctions, how common it is, and the high rate of successfirl
treatment.

When introducing the proposed clinical guidelines for CBS into a practice setting, the
APN is advised to hold an orientation meeting with his or her colleagues. The discussion can
include a brief review of the literature on depressed elderly in primary care, the use of

cognitive-behavioral therapy, bibliotherapy and the elderly depressed client, and an explanation

34

of the proposed clinical guidelines for CBS. As the APN obtains results and gains new
experiences , she should keep the colleagues updated while concisely documenting outcomes.

The treatment of depressed elderly with non-pharmacological modalities in the primary
care setting certainly requires more research in general, and specifically nursing generated
research. This is becoming all the more important as a growing segment of our population is
aging, facing specific age-related issues. This scholarly project could be used as a basis for a
pilot study collecting pertinent data by using specific evaluation criteria fiom Appendix E.
Possible research questions might include: What is the relationship between the use of CBS
with depressed elderly in primary care and cost-effectiveness (as evidenced by utilization of
health care resources and compliance with treatments) as compared to using only
pharmacological interventions? Or: What is the relationship between the use of CBS with
depressed elderly in primary care and the rate of relapse and recurrence of major depression as
compared to using only pharmacological interventions? The APN can then publish the results
obtained or use the results as a basis for negotiating improved coverage of CBS in primary care
with insurance companies.

An other area which this author has found lacking in the literature deals with spiritual
and existential issues the aging client faces and how to integrate these in the assessment and
treatment phase of cognitive-behavioral therapy. It is interesting that the literature discussing
CBS adapted to the depressed elderly client doesn’t address this. One can only imagine that as
the aging client faces issues of mortality and while reviewing his/her life seeks to impart
meaning to especially painful experiences of the past, crises can arise which may contribute to

the development of major depression. Although other forms of therapy have been developed to

35

deal with these issues outside of the primary care setting, perhaps research can indicate a way
of integrating a usefirl approach for the APN to use in the primary care setting.

In order for research to enhance its efforts and utilize limited fimds for issues benefiting
the elderly population, our society needs to releam how to honor and value its aging (and
aged) members, learn to receive the manifold gifts they have to impart, and in return assist
them as they face their challenges and metamorphoses. We will certainly all benefit fi'om this

partnership.

36

References

Badger, L. W., DeGruy, F. V., Hartman, J ., Plant, M. A., Leeper, J., Anderson, R.,
Ficken, R., Gaskins, S., Maxwell, A., Rand, E., & Tietze, P. (1994). Patient Presentation,
Interview Content and the Detection of Depression by Primary Care Physicians. Psychogmatic
Medieine, 56, 128-135.

Banazak, D. A. (1996). Late Life Depression in Primary Care: How Well Are
We Doing? .10qu of Genefll IntemaL Medicine, fl(3), 163-167.

Barkham, M., Moorey, J., Brown, C. , et al. (1992). Cognitive-Behavioural Therapy in
Two-Plus -One Sessions: A Pilot Field Trial. B_eh_aviour;gfl’grchothmpy, 29, 147-154.

Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive Therapy of
Depression. New York: The Guildford Press.

Beck , A.T., Ward, C.H., Mendelsohn, M., Mock, J.E. & Erbaugh, J. (1961). An
Inventory Measuring Depression. Archives of Generel Psychim 5, 561-571.

Blackburn, 1. M., Bishop, 5., Glen, A. I. M., Whalley, L. J. & Christie, J. E. (1981).
The Efficacy of Cognitive Therapy in Depression: A Treatment Trial Using Cognitive Therapy
and Pharmacotherapy, each Alone and in Combination. British JouLnel of Psychia_try, _32,
181-189.

Blixen, C. E. & Wilkinson, L. K. (1994). Assessing and Managing Depression in the

Older Adult: Implications for Advanced Practice Nurses. Nurse Prectitioner. I2 (7), 66-69.

37

Brown, R. A. & Lewinsohn, P. M. (1984). A Psychoeducational Approach to the
Treatment of Depression: Comparison of Group, Individual, and Minimal Contact Procedures.
mm of Consultingend Clinical Psycholegy, 2(5), 774-783.

Burns, D. (1980). Fgling mod. New York: Guilford Press.

Callahan, C. M., Dittus, R. S., & Tierney, W. M. (1996). Primary Care Physicians’
Medical Decision Making for Late-Life Depression. J oumgl of General InteLnel Medicine.
1_l_(4), 218-225.

Collins, E., Katona, C. & Orrell, M. (1995). Management of Depression in the Elderly
by General Practitioners: II. Attitudes to Ageing and Factors Affecting Practice. My
P_rae_tjce, 12(1),12-17.

Depression Guideline Panel. (1993). Depression in Primary Care: Volume 1, Detection
and Diagnosis; Volume 2, Treatment of Major Depression. Clinical Practice Guidelines,
Number 5. AHCPR Publication No. 93-0051. Rockville, MD: US. Department of Health and
Human Services, Public Health Service, Agency for Health Care Policy and Research.

Eggnostic aLnd Stflticel Miguel of Mentel Disorders IV. (1994).(4"’ ed.) American
Psychiatric Association.

Fennell, M.J.V. (1995). Depression Edited by Hawton, K., Salkovskis, P.M., Kirk, J.
& Clark, D.M. Cegnitive-Beheviour Therapy for Psychiatric Problems: A Practical Guide.
Oxford: Oxford University Press.

Fennell, M. J. V. & Teasdale, J. D. (1987). Cognitive Therapy for Depression:
Individual Differences and the Process of Change. C gpjtive Therapy and Research 11 253-

,—,

271.

38

Flint, A. J. (1996). Treatment of Depression in the Elderly. Edited by Schulman, K.I.,
Tohen, M. & Kutcher, S.P. Mood Disorders Across the Life Span. New York: Wiley-Liss &
Sons, Inc.

Folstein, M., Folstein, S. & McHugh, P. (1975). Mini-Mental State: A Practical
Method for Grading the Cognitive Status of Patients for the Clinician. Journel of Psyehiatric
Reggie _1_2, 189-198.

Fry, P. S. (1984). Cognitive Training and Cognitive-Behavioral Variables in the
Treatment of Depression in the Elderly. Clinicel Gerontologi_s_t, 3(1), 25-45.

Gallagher, D. & Thompson, L. W. (1981). Depression in the Elderly: A BehevirLal
Treatment Manual. The University of Southern California Press.

Gallagher, DE. & Thompson, L.W. (1982). Treatment of Major Depressive Disorder
in Older Adult Outpatients with Brief Psychotherapies. Psychotherapy: Theory, Research and
Bgetjee, _1_9_(4), 482-490.

Grant, R. W. & Casey, D. A. (1995). Adapting Cognitive-Behavioral Therapy for the
Frail Elderly. Interngtionel Psychogeriatrics, 2, 561-571.

Hendrie, H. C., & Crossett, H. W. (1990). An Overview of Depression in the Elderly.
Psychiatric Annals, 29(2), 64-70.

Henthom, B. S. (1979). Disengagement and Reinforcement in the Elderly. Research in
Nursing and Health, _2_(l), 1-8.

Jarrett, R. B., & Rush, A. J. (1994). Short-Tenn Psychotherapy of Depressive
Disorders: Current Status and Future Directions. Psychiatg, 2, May, 115-132.

Kalayam, B., & Shamoian, C. A. (1990). Geriatric Psychiatry: An Update. Journal of

Clinicel Psychiatgg, 51(5), 177-183.

39

Katona, C. L. E. (1994). Depression in 91d Age. John Wiley & Sons, Chichester.

Leung, S.N.M., & Orrell, MW. (1993). A Brief Cognitive Behavioral Therapy Group
for the Elderly: Who Benefits? International Jouml of Geriatric Psychjgg, 9, 593-598.

Lewinsohn, P., Munoz, R.,Youngren, M. A. & Zeiss, AM. ( 1986). ntrol Y ur
Depression. Fireside, New York, NY.

Lewinsohn, P., Munoz, R., Youngren, M. A. & Zeiss, A. M. (1992). Control Your
Depressien, Fireside, New York, NY.

McCullough, PK. (1991). Geriatric Depression: Atypical Presentations, Hidden
Meanings. Geriatrics, @(10), 72-76.

Miranda, J. & Munoz, R. (l994).lntervention for Minor Depression in Primary Care
Patients. Pavchosomatic Medicine, _5_6, 136-142.

Moberg, P.J. & Lazarus, L.W. (1990). Psychotherapy of Depression in the Elderly.
Psychiatric Annale, 29, 2, 92-96.

Morris, R. G. & Morris, L. W. (1991). Cognitive and Behavioural Approaches with the
Depressed Elderly. International Journal of Gerigmic Psychiapry, 9, 407-413.

Mynors-Wallis, L.M., Gath, D.H., Lloyd-Thomas, A. R & Tomlinson, D. (1995).
Randomized Controlled Trial Comparing Problem Solving Treatment with Amitriptyline and
Placebo for Depression in Primary Care. British Medical Journal, 3_19, 441-445.

NIH Consensus Development Panel on Depression in Late Life (1992). Diagnosis and
Treatment of Depression in Late Life. Joumflf the American Medical Association. 268(8),
1018-1024.

Orem, D. E. (1991). Nursiraggoncepts of Practice (4‘h ed.) St. Louis: Mosby.

40

Oxman, T. E. (1996). Antidepressants and Cognitive Impairment in the Elderly. Jeumal

pf elinieaI Psyehiatfl, $6), 38-44.

Pierre, J. St., Cravan, R. F ., & Bruno, P. (1986). Late Life Depression: A Guide for
Assessment. Journal of Gerontological Nuraing, _1_2_(7), 5-10.

Richter, J. M., Barsky, A. J., & Hupp, J. A. (1983). The Treatment of Depression in
Elderly Patients. The Jeumal of ligatily Praem, 11(1), 43-47.

Robinson, P., Bush, T., Von Korff, M., Katon, W., Lin, E., Simon, G. E., & Walker, E.
(1995). Primary Care Physician Use of Cognitive Behavioral Techniques with Depressed
Patients. The Journal of Family Praaztice, 19(4), 352-357.

Robinson, P., Katon, W., Van Korff, M., Bush, T., Simon, 6., Lin, B, & Walker, E.
(1997). The Education of Depressed Primary Care Patients: What Do Patients Think of
Interactive Booklets and a Video? The Journal of Family Practice. fl, 6, 562-571.

Rothschild, A. J. (1996). The Diagnosis and Treatment of Late-Life Depression.
Journal of Clinical Psychim, fl, suppl. 5, 5-11.

Ruegg, R. G., Zisook, S., & Swerdlow, NR. (1988). Depression in the Aged: An
Overview. Paychiatric Clinics on North America, _1_1(1), 83-99.

Rybarczyk, B., Gallagher-Thompson, D., Rodman, J ., Zeiss, A. Gantz, F. E. &
Yesavage, J. (1992). Applying Cognitive-Behavioral Psychotherapy to the Chronically Ill
Elderly: Treatment Issues and Case Illustration. International Psychogeriatrics, 3(1), 127-140.

Salazar, W. H. (1996). Management of Depression in the Outpatient Office. M_ec_1_ieal

Clinics of North America, 89(2), 431-455.

41

Scogin, F ., Jamison, C. & Gochneaur, K. (1989). Comparative Efficacy of Cognitive
and Behavioral Bibliotherapy for Mildly and Moderately Depressed Older Adults. Jeamal ef
Qensulting and clinical Psycholegy, fl(3), 403-407.

Scott, C., Tacchi, M. J., Jones, R., & Scott, J. (1997). Acute and One-Year Outcome
of a Randomised Controlled Trial of Brief Cognitive Therapy for Major Depressive Disorder in
Primary Care. Britisa Journal of Psychiam, I7_1, 131-134.

Shearer, S. L. & Kaplin Adams, G. (1993). Nonpharmacologic Aids in the Treatment
of Depression. American Family Physician, 2, 435-441.

Steiner, D. & Marcopulos, B. (1991). Depression in the Elderly: Characteristics and
Clinical Management. maaiag Clinics of North America, EB), 585-600.

Teasdale, J. D., Fennell, M. J. V., Hibbert, G. A. & Amies, P. L. (1984). Cognitive
Therapy for Major Depressive Disorder in Primary Care. British Journal of Psychiaa'y, _1_451,
400-406.

Thompson, L. W. (1996). Cognitive-Behavioral Therapy and Treatment for Late-Life
Depression. Journal of Clinical Paychiatgg, 91, suppl. 5, 29-37.

Thompson, L. W., Futtennan, A., & Gallagher, D. (1988). Assessment of Late-Life
Depression. Psychopharrnacology Bulletin. 2_4(4), 577-586.

Yesavage, J ., Brink, T., Rose, T. Lum, 0., Huang, 0., Adey, V. & Leirer, V. (1983).
Development and Validation of a Geriatric Screening Scale: A Preliminary Report. Journal of

Psychiatric Research 17 37-49.

9—9

42

Appendix A

Clinical Guidelines in the Use of Cognitive-Behavioral Strategies

with Depressed Elderly

I. Self-Care Deficit Assessment (bio-psycho-soeial)

 

Objective Assessment

Subjective Findings

 

A) Wm

Evaluate client with complete medical history and physical
examination; specifically rule out endocrine disorders,
cancers, infections, nutritional deficiencies, cardiovascular
disease, metabolic disorders, collagen disorders, alcoholism
and neurological disorders.

Medication tfistegy:

Prescription drugs, OTC; specifically antihypertensives,
clonidine, reserpine, methyldopa, propanolol, guanethidine,
diuretics, oral contraceptives, steroids/ACTH, cimetidine,
digitalis, disulfiram, barbiturates, benzodiazepines.

 

 

B) Paycho-Social Histog:

- Assess for grpical s/s of depression (as per DSM-IV):
depressed mood, anhedonia, weight changes,
insomnia/hypersomnia, psychomotor changes,
fatigue/energy loss, low self-esteem/guilt, concentration
problems/indecision, and thoughts of death or suicide nearly
daily, for most of day, for at least 2 weeks and assess
severity of depression (mild, moderate or severe).

- Assess for agpical s/s of depression: cognitive
deficit/pseudodementia, pain syndromes, somatization,

anxiety/irritability and alcohol abuse.

- Assess for risk factors for depression: personal or family
history of depression, other medical illnesses, caregiving,
being single (esp. widowed), financial burden, loss of
independence, social isolation, gender (esp. female), and
recent precipitating events/losses

- Assess for suicide risk factors: hopelessness, caucasian
race, male gender, advanced age, living alone, prior suicide
attempts, family history of suicide attempts, family history
of substance abuse.

- Assess suicidal ideation, passive or active, plan, frequency
of thoughts (note: refer client if you assess suicidal ideation
with plan)

- Assess Social Suppert Systems: i.e. level of near family or
friend involvement, professional agencies,
counselors/therapists, and get permission to contact any of
them as nwded for further information.

 

 

 

43

 

Objective Assessment

Subjective Findings

 

 

C) Assess Saific Issues:

1) m: Assess current level of relaxation,
tension, anxiety, muscle tension, headaches, trouble
sleeping, stomachaches, jitteriness or shakiness.

2) Pleasant Activities: Assess for current involvement
in pleasant activities: any changes since depression
occurred, doing less compared to peers/friends, list
daily or regular pleasant activities involved in.

3) Problems with People (Social Skills):

a. Assertiveness: Assess current style of anger
management, level of self-disclosure (thoughts and
feelings), ability to say “no”.

b. Personal Style: Assess current interpersonal style:
criticism of others, grooming, eye contact, content of
speech (negativity), responsiveness to others.

c. Isolation: Assess current degree of interaction with
family and friends, feeling cut off from old friends.
ability to initiate conversations or initiate activities.
ability to actively interact socially.

4) Troublesome Thoughts:

Assess for current types of abnormal thinking:

- cognitive triad: the client‘s negative concept of
him/herself as useless, a pessimistic view of the future
and the outside world as threatening

- schemas: assess for automatic negative thought
patterns which result in occurrences being interpreted
in an exclusively negative way

- faplty information procemg: in which
dysfunctional thought processes (i.e.
overgeneralization and misattribution) result in
negative interpretations of occurrences.

5) Problem Solving Skills:

Assess current ability to problem-solve, coping skills.
feeling victimized by problems, tendency to overreact.
6) Self-Control Problems:

Assess current self-control problems, ability to
persevere or tendency to procrastinate.

D) Develop Problem List for CBS based on above
assessment (note: cover Relapse Prevention for
everyone).

E) Barriers to m'cigting in CBS:

Assess for physical problems (loss of hearing/vision.
weakness, pain), literacy level, education, client’s
perceived needs, cultural issues. and ability to perform

F) Ability to perform ADL/IADL.

 

 

 

44

Appendix B

1]. Diagnosis

 

Objective Assessment

Subjective Findings

 

Note: Appropriate diagnosis for CBS: mild to
moderate major depression, non-psychotic
(rule out visual or auditory hallucinations or
delusions) and unipolar (no previous episodes
of manic-depressive symptoms). Apply either
BDI or GDS for diagnosis of depression.

- Beck Depression Inventory:

 

- Geriatric Depression Scale:

 

 

- Mini-Mental State Examination:

 

 

 

45

 

Appendix C
III. Plan
Content Client Goal :2" m Comments

 

 

Develop a personalized treatment plan
based on assessment of self-care
deficits:

1) Explain results of assessment,
diagnosis of depression (assess fear of
stigma and denial), and discuss
problem list for CBS and prioritize
with client.

2) Explain principles of CBS:

- explain concepts ‘cognitive’ and
‘bchavioral’

- explain that the idea upon which CBS
is based believes that depression is a
learned behavior (social learning
theory) and teaches how to change
negative thought patterns and enhance
pleasant activities in order to minimize
depressed mood

- explain use of homework assignments
(readings and exercise) based on book

Control Your Depression (1992) by
Lewinsohn, PM. et al.

3) Ask if client agrees to learn CBS
under guidance and supervision of APN
over the next few weeks. If so:

4) Homework assignment:

- read chapters 1-3

5) Set up F/U appointment

 

1) Client will verbalize
understanding assessment,
diagnosis of depression
(incl. verbalize fears of
stigma or denial as
applicable), and prioritize
problem list for CBS

2) Client will verbalize
understanding principles of
CBS, understand
importance of exercise
techniques learned, agree
to buy book Control Your
Depression (1992) by
Lewinsohn, P. M. et al.,
and agree to do homework
assignments

3) Client will agree to learn
CBS under guidance and
supervision of APN

4) Client will verbalize
understanding of
homework assignment

5) Client will make new
PM appointment

 

 

 

 

 

46

Appendix D

IV. Interventipng

 

Content

Client Goal

Goal
met

Comments

 

 

Medication Teaching (if
applicable):

1) Review homework and
mood

2) Discuss goal for the visit

3) Instruct client on new
psychotropic medications
prescribed: name, dose,
frequency, action of
medication, potential side
effects and ways of coping
with them, warn about
interactions with Rx drugs,
OTC and ETOH, stress
importance of adherence to
regimen, advise client not
to discontinue medications
independently, explain that
full therapeutic effect may
take up to 6-12 weeks, give
written info on new meds,
explain that side effects are
a way to monitor the
medication and to know
that it is working in his/her
body.

4) No homework
assignment

5) Set up F/U appointment

 

1) Client will review
homework and give
feedback, as well as
express feelings/thoughts
re: mood

2) Client will verbalize
understanding goal

3) Client will verbalize
understanding purpose
and proper medication
use

4) none

5) Client will make new
F/U appointment

 

 

 

 

 

47

 

 

 

 

- Goal Goal
Content Client Goal m not me, Comments
Relaxation:
1) Review homework and mood 1) Client will review
homework and give
feedback, as well as express
feelings/thoughts re: mood
2) Discuss goal for the visit 2) Client will verbalize
understanding goal
3) Review personal s/s of 3) Client will verbalize
tension, inability to relax, personal s/s of tension and
techniques used in past relaxation techniques used in
the past
4) Discuss use of Daily 4) Client will verbalize
Relaxation Matitoring Form to understanding use and
assess stress purpose of Daily Relaxation
Monitoring F orm

5) Discuss “Learning to Relax”:
- preliminary steps

- procedure (have client practice
relaxation in ofl'rce 5-10
minutes) and allow client to give
feedback

- stress importance of daily
practice

6) Discuss common problems
relaxing and nwd to record
practice sessions

7) Discuss applying relaxation
exercise to specific situations

8) Discuss homework
assignment:

- Chapter 5

- other relevant exercises

9) Set up F/U appointment

 

 

5) Client will verbalize and
demonstrate under-

standing relaxation
technique and will verbalize
understanding importance of
daily practice

6) Client will verbalize
understanding common
problems relaxing and need
to record practice sessions

7) Client will verbalize
understanding application of
relaxation exercise to specific
situations

8) Client will verbalize
understanding homework
assignment

9) Client will make new PM
appointment

 

 

 

 

 

48

 

 

 

Content Client Goal 3 gym Comments
Wm

1)Reviewhomeworkand mood

2) Discuss goal for visit

3) Discuss how number of pleasant
activities and level of enjoyment
contribute to depression

4) Discuss development of if?
change plan to increase number of
pleath activities

5) Discuss inverse relationship
between pleasant activities and
depression

6) Discuss Mood-Related Activities
i.e. social interactions, activities
allowing us to feel useful/capable,
intrinsically pleasant activities

7) Discuss Pleasant Events
Schedule as an assessment tool

8) Discuss writing own Activity
Schedule (homework) & use this to
self observe your mood & rate of
engagement in pleasant activities
(give examples)

9) Discuss Antecedents (reasons for
low numbers of pleasant activities):
pressure from activities which must
be done; poor choice of activities
with high pleasantness potential;
anxiety and discomfort during
activity

10) Discuss developing a balanced
weefly plan (between ‘must’ and

‘fun’ activities)

1 1) Discuss homework assignment:
- Chapter 6

- other relevant exercises

12) Set 1m F/U mintment

 

1) Client will review homework
and give feedback, as well as
express feelings/thoughts re:
mood

2) Client will verbalize
understanding goal

3) Client will verbalize
understanding of how pleasant
activities affect mood

4) Client will verbalize
understanding self-change plan
to increase number of pleasant
activities

5) Client will verbalize
understanding relationship
between pleasant activities and
depression

6) Client will verbalize
understanding of Mood-Related
Activities and how they vary

7) Client will verbalize
understanding of Pleasant
Events Schedule

8) Client will verbalize

understanding personal
Activity Schedule

9) Client will verbalize
understanding Antecedents

10) Client win verbalize

understanding balanced weekly
plan

ll) Client will verbalize
understanding homework
assignment

12) Client will make F/U appt.

 

 

 

 

 

 

49

 

 

 

interaction, and that depression
affects how we interact socially:
decreased social activity, increased
difficulty initiating contact,
giving/receiving fewer positive
statements, less socially skillful and
comfortable etc.

4) Discuss what assertiveness is:
ability to express one’s thoughts
openly, sharing hopes and fears, is
of central importance for close and
fulfilling relationships, helps avoid
unpleasant encounters with others,
decreases isolation and exploitation
by others

5) Discuss use of Assertion
Questionnaire which rates frequency
of assertion

6) Discuss learning how to develop
assertiveness: creating a personal
problem list, plan and reward

7) Discuss using Self Monitoring of
Assertion Form to monitor progress
in asserting self

8) Discuss practicing assertiveness
imagery to explore numerous
responses and refine personal style

9) Discuss homework assignment:
- Chapter 7 (p. 107-1 19)
- other relevant exercises

10) Set up F/U appointment

 

between depression and altered
social behavior

4) Client will verbalize
understanding assertiveness
and its importance in fulfilling
relationships and enhancing
mood

5) Client will verbalize
understanding use and purpose
of Assertion Questionnaire

6) Client will verbalize
understanding of how to develop
assertiveness by creating a
personal problem list complete
with plan and reward

7) Client will verbalize
understanding use and purpose
of Self Monitoring of Asaertion

‘ Form

8) Client will verbalize
understanding use and purpose
of assertiveness imagery

9) Client will verbalize
understanding homework
assignment

10) Client will make new F/U
appointment

 

 

 

 

° Goal Goal
Content Client Goal m m, M Comments
s t e
W
W
1) Review homework and mood 1) Client will review homework
and give feedback, as well as
express feelings/thoughts re:
mood
2) Discuss goal for the visit 2) Client will verbalize
understanding goal
3) Discuss that many mood-related 3) Client will verbalize
pleasant actiVities involve social under-stariding the relationship

 

 

50

 

 

 

- Gael Goal
Content Client Goal M M M Comments
Wok
(Social Skills)
I]. Pemnal Sale:
1) Review homework and mood 1) Client will review
homework and give
feedback, as well as express
feelings/thoughts re: mood
2) Discuss goal for the visit 2) Client will verbalize
understanding goal

3) Do and discuss Pemnal Sgle
Assessment (p. 120)

with client and explain the
impact our style has on others

4) Discuss making personal
problem list, setting specific
goals and keeping track of
targeted behavior (monitor
progress) and rewarding success

5) Discuss homework
assignment:

- Chapter 7 (p. 119+)

- other relevant exercises

6) Set up F/U appointment

 

3) Client will assess personal
style and verbalize
understanding its impact on
others

4) Client will verbalize
understanding the process of
making a personal plan to
change desired personal
habits

5) Client will verbalize
understanding homework
assignment

6) Client will make new F/U
appointment

 

 

 

 

 

51

 

Content

Client Goal

Goal
not met

Comments

 

 

Problems with People
(Social Skills)

1]]. Elation:
1) Review homework and mood

2) Discuss goal for the visit

3) Discuss how depression can
cause us not to use our social
skills or causes us to be socially
anxious

4) Discuss §ocial Am'vities
Qaestionnaire to evaluate level
of social participation

5) Discuss problems interfering
with social participation:

- inadequate stimulation and

how to develop plan to overcome ‘
this (Social Activitiesar Increase
form, and Interferences:

Activities ta Decrease form)

- inadequate reward and
appropriate ways to reward
oneself for positive outcomes

6) Discuss homework
assignment:

- Chapter 8

- other relevant exercises

7) Set up F/U appointment

 

1) Client will review
homework and give
feedback, as well as express
feelings/thoughts re: mood

2) Client will verbalize
understanding goal

3) Client will verbalize
understanding how
depression affects use of
social skills and causes social
anxiety

4) Client will verbalize
understanding use and
purpose of Social Activities

Questionnaire

5) Client will verbalize
understanding problems
interfering with social
participation and how to
develop personal plan to
overcome these

6) Client will verbalize
understanding homework
assignment

7) Client will make new PM
appointment

 

 

 

 

 

52

 

 

 

- Goal Goal

Content Client Goal m m m Comments
W
1) Review homework and mood 1) Client will review homework

and give feedback, as well as

express feelings/thoughts re:

mood
2) Discuss goal for the visit 2) Client will verbalize

understanding goal
3) Discuss how thoughts affect 3) Client will verbalize
feelings and actions, and how we understanding relationship
can use thoughts to improve mood between thoughts, feelings and

(and number of pleasant activities)

4) Discuss use of Self-Assessment
of Thinking Patterns questionnaire
to enhance awareness of thought
patterns

5) Discuss daily use of Inventog of
Thoughts inventory to identify
positive and negative personal
thoughts

6) Discuss techniques to manage
thoughts and decrease negative
thinking (thereby enhancing mood):
- thought interruption (3 techniques)
- worrying time

- the blow-up technique

7) Discuss techniques to manage
thoughts and increase positive

1 . l . g:

- priming

- using cues

- noticing what you accomplish

- positive self-rewarding droughts
- time projection

8) Discuss homework assignment:
- Chapter 9
- other relevant exercises

9) Set up F/U appointment

 

actions

4) Client will verbalize
understanding Self-Assessment

Wm
questionnaire and its purpose

5) Client will verbalize

understanding use and purpose
of Inventory of Thoughts

6) Client will verbalize
understanding techniques to
decrease negative thoughts

7) Client will verbalize
understanding techniques to
increase positive thinking

8) Client will verbalize
understanding homework
assignment

9) Client will make new F/U
appointment

 

 

 

 

 

 

53

 

Content

Client Goal

3?

Comments

 

 

Problem Solving Skills:
1) Review homework and mood

2) Discuss goal for the visit

3) Discuss how the way we think
about problems (overreact)
affects how we deal with them
and ultimately affects our mood

4) Discuss nonconstructive self-
talk:

- using highly evaluative words
- catastrophizing

- overgeneralizing

5) Discuss use of

The A-B-C M_ethod (Activating
event, fielief or self-talk about
A, emotional Qansequences) to
help develop constructive
thinking

6) Discuss use of 1%
Monitoring Form to recognize
non-constructive self-talk and
enhance problem solving skills

7) Discuss homework
assignment:

- Chapter 10

- other relevant exercises

8) Set up F/U appointment

 

1) Client will review
homework and give
feedback, as well as express
feelings/thoughts re: mood

2) Client will verbalize
understanding goal

3) Client will verbalize
understanding how
overreacting to problems
affects how we deal with
them and how we feel

4) Client will verbalize
understanding
nonconstructive self-talk

5) Client will verbalize
understanding
The A-B-C Method and its

purpose

6) Client will verbalize
understanding the use of the
Daily Monitoring Form and

its purpose

7) Client will verbalize
understanding homework
assignment

8) Client will make new PM
appointment

 

 

 

 

 

54

 

Content

Client Goal

3?

Comments

 

 

glffiongrol Pppplems: (Self-
Instructional Techniques)

1) Review homework and mood

2) Discuss goal for the visit

3) Discuss self-talk and its
benefits:

- anticipating accomplishments,
situations and actions

- keeps you on track

- helps you handle good or bad
situations

- motivates

4) Discuss Using Self-
Instruction to help achieve
goals:

- understand your objective
- develop your plan

- write down steps

- use your plan

- change plan as necessary
- integrate plan into routine
- reward yourself

5) Discuss homework
assignment:

- Chapter 11

- other relevant exercises

6) Set up F/U appointment

 

1) Client will review
homework and give
feedback, as well as express
feelings/thoughts re: mood

2) Client will verbalize
understanding goal

3) Client will verbalize
understanding self-talk and
its benefits

4) Client will verbalize
understanding Using Self-
Instruction to help achieve
goals

‘ 5) Client will verbalize

understanding homework
assignment

6) Client will make new F/U
appointment

 

 

 

 

 

55

 

Content

Client Goal

3?

Goal
notmet

Comments

 

 

 

Relapse Prevention:
1) Review homework and mood

2) Discuss goal for the visit

3) Review with client what has been
done so far:

enhanced knowledge about personal
signs and symptoms of depression;
ability to recognize depression;
ability to understand causes of
depression; ability to know
situations, behaviors and thoughts
contributing to depression; ability to
apply self-change plan; ability to
recognize reduction of s/s of
depression ; ability to understand
psychotropic medications; other (as
relevant to individual client)

4) Discuss importance of early
recognition of depression and
regular reassessment of mood

5) Discuss importance of
prevention by preparing for stressful
life events that could lead to
depression

6) Discuss importance of

using coping techniques learned and
seeking support system for
depression prevention or symptom
reduction

7) Discuss homework assignment:
- Chapter 12
- other relevant exercises

8) Set up F/U appointment

 

1) Client will review homework
and give feedback, as well as
express feelings/thoughts re:
mood

2) Client will verbalize
understanding goal

3) Client will verbalize
recognizing accomplishments
made

4) Client will verbalize
understanding importance of
early recognition of depression
and regular reassessment of
mood

5) Client will verbalize
importance of prevention by
preparing for stressful life
events that could lead to
depression

6) Client will verbalize
understanding importance of
using coping techniques learned
and support system for
depression prevention or
symptom reduction

7) Client will verbalize
understanding homework
assignment

8) Client will make new F/U
appointment

 

 

 

 

 

Appendix E

V. Depression Evaluation

 

Expected Outcomes

Evaluation Criteria

 

l. Symptom reduction

- Effective coping skills

- Beck Depression Inventory and
Geriatric Depression Scale

- Mini-Mental State Examination

 

2. Decreased risk of relapse and recurrence

- Typical and atypical s/s of depression

- Effective c0ping skills

- Number of relapses and recurrences

- Beck Depression Inventory and Geriatric
Depression Scale

 

3. Enhanced quality of life

- Beck Depression Inventory and
Geriatric Depression Scale

- Mini-Mental State Examination

- Number of pleasant activities and
negative thoughts

- Effective coping skills

 

4. Amelioration of overall health

- Utilization of health care resources
- Physical and mental functional status

 

5. Cost-effectiveness

- Utilization of health care resources
- Compliance to treatments

 

 

6. Mortality reduction

 

- Suicide attempts
- Death

 

 

MIN
Ii‘i