The effectiveness of nonpharmacological interventions in older adults with depressive disorders: a systematic review.

BACKGROUND: It is widely acknowledged that mental disorders are common in old age and that depression is one of the most serious threats to the mental health of older adults. The lives of older adults are adversely affected both by major depression and subsyndromal depression. Depression should be approached with both pharmacotherapy and complementary therapies. The disadvantages posed by psychopharmacotherapy may be more prominent among older adults and there is a greater probability of drug interference. Different nonpharmacological interventions have been reported to reduce depressive symptoms in older adults with no adverse side effects.

OBJECTIVES: This review aimed to identify and synthesize the best available evidence on the effectiveness of nonpharmacological interventions for older adults with depressive disorders.

TYPES OF PARTICIPANTS: This review considered studies that included older adults: adult patients, aged over 65 years with any type of depressive disorder, regardless of comorbidities and any previous treatments, but excluded those with manic or psychotic episodes/symptoms. Patients receiving pharmacological treatment for depression or other illnesses were included. TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST: This review considered studies that used nonpharmacological interventions for older adults with depressive disorders. TYPES OF STUDIES: This review considered any experimental study design, including randomized controlled trials, non-randomized controlled trials, or other quasi-experimental studies, including before and after studies. TYPES OF OUTCOMES: This review considered studies that included the following outcome measures: depressive symptomatology. The secondary outcomes were the level of autonomy in activities of daily living, cognitive function, health-related quality of life and wellbeing.

SEARCH STRATEGY: An initial search of MEDLINE and CINAHL was undertaken, followed by a second search for published and unpublished studies from January 2000 to March 2012 of major healthcare-related electronic databases. Studies in English, Spanish and Portuguese were included in the review.

METHODOLOGICAL QUALITY: Methodological quality was assessed by two independent reviewers using the standardized critical appraisal instrument from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. Two independent reviewers assessed 23 studies. There was general agreement among the reviewers to include six of the studies in this review.

DATA EXTRACTION: Data were extracted using the Joanna Briggs Institute data extraction form for experimental studies and included participant characteristics, intervention characteristics and methods of the study.

DATA SYNTHESIS: The impact of interventions on depression outcomes was described in a narrative format for each specific intervention. Data from two studies were pooled in a meta-analysis.

RESULTS: Twenty-three studies met the inclusion criteria. Of those, 17 studies were excluded after assessment of their methodological quality. The remaining six original articles, which included 520 participants, were included in this review. Five were randomized clinical trials and one was a quasi-experimental study. The interventions included in this systematic review were: cognitive behavior therapy, competitive memory training, reminiscence group therapy, problem-adaptation therapy, and problem-solving therapy in home care. Evidence suggests that all of these interventions reduce depressive symptoms. Data from two studies reporting the effectiveness of problem-solving therapy in home care were pooled in a meta-analysis. The meta-analysis showed homogeneity (heterogeneity Chi-squared=2.83, p=0.09). The analysis estimated a statistically significant reduction (z= 11.19; p< 0.0001) of -10.23 points (CI: -12.03, -8.44) in the 17-item Hamilton Depression Rating Scale (HAM-D-17).

CONCLUSIONS: Evidence suggests that all of these interventions reduce depressive symptoms and, therefore, may be useful in practice. However, due to the diversity of interventions and the low number of studies per intervention included in this systematic review, evidence is not strong enough to produce a best practice guideline.