 McDougall, et. al. (2007) found in their study of the symptomatology of depression in individuals living in institutions compared to those in the community that the prevalence was 27% for those in institutions and 9.3% for those living at home. They stated that more than one quarter of older people living in institutions suffer from depression of a severity that warrants treatment. McDougall, et. al. (2007).

 Snowden, et. al. found in review of literature, peer-reviewed journal articles found in nursing home settings, studies of non-pharmacological interventions outnumbered studies of medication. Reports of several non- pharmacological trials indicate that subjects continued to take psychotropic medications that were adjusted during the trial.  According to Bartels et. al. (2002),combined pharmacologic and psychosocial interventions have a “synergistic” effect in preventing relapse of geriatric mental health conditions.  Klausner & Alexopoulos (1999) found that psychosocial treatments were found to be more effective than no treatment or placebo in the population of older adults. Klausner & Alexopoulos (1999). Snowden, et. al.(2003).

 Care staff in daily contact with older people in care facilities provide a possible solution to reducing depression in their facility.  Lack of training, and management and peer pressure mean that care staff give priority to practical tasks rather than talking to the patients.  It was believed that care staff could be directly instrumental in modifying depression, through their capacity to make meaningful relationships with residents and provide a measure of therapeutic relief that would go beyond keeping the resident comfortable.  Lyne, et. al. (2005) found that personalized care planning, conducted by suitable trained and supported care staff, might be an effective intervention for detecting and reducing depression in long term care facilities for older people. Lyne, et. al. (2005).

 Supportive therapy-central to the management of an depressive disorder is the presence of a treating professional who attempts to and sustains an engagement with the person, a dialogue based on understanding the depressed persons symptoms; helping the person feel understood, empathy, the treatment ritual, success experiences, and therapeutic optimism. In working with the participant, the therapist creates a supportive relationship and encourages the participant to consider his/her strengths and abilities rather than focusing on negative aspects of his/her character. It Allows that person to ventilate problems for discussion and resolution. For best results, patients in long term care should be cognitively able to process information  It must be given on a regular schedule, preferably for a set amount of time which allows the health care staff (therapist) and the client time for questions from each party. The goal of this process is for the therapist to provide support through encouragement and optimism in the matters that are discussed.  This form of intervention can be performed in individual sessions or in a groups setting; the main goal is for the patient to feel comfortable. Suitable locations may include, but are not exclusive to the patients room, the therapist’s office or group room. helping the person feel understood, empathy, the treatment ritual, success experiences, and therapeutic optimism. In working with the participant, the therapist creates a supportive relationship and encourages the participant to consider his/her strengths and abilities rather than focusing on negative aspects of his/her character. NSW Health, (2001).

 Cognitive therapy- focus in on questioning the rational basis for the depressed person’s beliefs, which are often persistently and illogically negative and generalized to everything in the person’s life.  This form of intervention may include questions such as:  Why do you believe…?  What evidence do you have …?  What are other possible explanations or solutions…?  The desired outcome is to have the depressed person reduce their tendency to generalize pessimistic ideas about their own actions/health. This interventions can be offered individually or in a group setting. For best results, the long term care patient would make the decision on intervention setting.  Locations of service delivery may be in client’s room, in the therapist’s office, or a group room if group therapy is offered and chosen by the patient. NSW Health, (2001).

 Behavior therapy- the aim is to encourage the patient to engage in a series of activities within their physical capabilities, which are most likely to be pleasurable, and to minimize engaging in chores or disliked activities, based on pre-depressed activity. Activities which give pleasure should positively reinforce these same activities to occur more often and be encouraged.  The patient should be able to give feedback about what they are feeling during and after the activities.  The goal is the activities that lift the mood of the patient should positively reinforce these same activities to happen in greater frequency.  This intervention can be done in a individual or group setting. The patient must feel comfortable to gain maximum benefits. Therapy locations may include the patient’s room, the therapist’s office, or a group room in the long term care facility. NSW Health,(2001)

 Interpersonal therapy- consideration of the various important relationships in the patient’s life, and the areas in which these have become less successful as perceived by the depressed person, strategies can be discussed and enacted which improve the depressed person’s views and the way the relationship works.  Interpersonal Therapy focuses on role disputes, role transitions and interpersonal deficits. It can be especially meaningful for older adults given the multiple losses, role changes, social isolation, and helplessness associated with late-life depression.  This type of therapy requires a level of cognitive competence on the part of the patient and frequently some form of active participation in the form of diary keeping and other forms of homework assignments.  Interpersonal psychotherapy for depression (IPT) is a brief psychotherapy that has been found to be effective in treating major depressive disorder (MDD) and other problems in younger adults. In recent years, IPT has been used as psychotherapy for depressed elderly. With its emphasis on addressing interpersonally relevant problems, IPT appears especially well suited to the life changes that many people experience in their later years. Consistent with results of research studies, the author has found in clinical practice that IPT is effective in treating depression in older adults. Hinrichsen, G.A. (1999). NSW Health, (2001)..

 Reminiscence therapy /Life Review is a nurse-initiated intervention that has the advantages of being cost-effective, therapeutic, social, and recreational for the institutionalized older adult. As a communicative psychosocial process, reminiscence therapy has proven to be a valuable intervention for the depressed elderly client.  For those elders in a long term care facility, reminiscence therapy may prove an extremely beneficial alternative to more traditional treatment modalities in reducing the effects of depression and depressive symptoms.  Life review and reminiscence are probably efficacious in improvement of depressive symptoms or in producing higher life satisfaction. American Psychiatric Association (2008). Haight, et. al. (1998).

 Cognitive Therapy and Behavioral therapy (CBT) can be combined in order to link an older persons thoughts, feelings, and behaviors. The goal is to change thoughts, improve skills, and modify emotional states.  Brief, group-based cognitive-behavioral therapy can reduce symptom severity in nursing home residents who are at risk for depression but who do not yet meet criteria for major depression. This type of intervention can be an important tool in treating and preventing depression in this population. Studies have shown that long term care patients are at increased risk for depression; those who have been relocated recently are at particularly high risk.  CBT is shown to reduce depressive symptoms among 70% of older adult patients (Klausner & Alexopoulos, 1999).  Llewellyn-Jones & Snowden (2007), stated that residents with major depression without moderate or severe cognitive impairment may benefit from individual or group cognitive behavioral therapy (CBT). Mahoney, D. (2004) Llewellyn-Jones, R., H. & Snowden, J. (2007) Klausner,& Alexopoulous (1999) TYPES OF NON-PHARMACOLOGICAL TREATMENT

Types of psychosocial evidence-based interventions are:  Supportive Therapy  Cognitive Therapy  Behavior Therapy  Interpersonal Therapy  Reminiscence/Life Review Therapy  Cognitive Behavioral Therapy The frequency and duration of interventions should be set on a given schedule for a specific amount of time. The schedule should be a time in which the patients are going to be at their most alert state. The duration will depend on the cognitive level of the individuals, the other activities that may be going

on in the facility, the doctor rounds, the medications that the patients are taking, and the physical condition of the patients. Intervention sessions should be individualize to the patient as much as possible to obtain maximum benefit. Methods of evaluation may include:  the Geriatric Depression Scale (GDS)  Brief Assessment Schedule Depression Cards  Self-Report  Report of other’s who knew the patient before and either during or after intervention—examples may be therapist report or report from family and friends.

 Location of intervention for patients in a long-term facility will take place on the facility grounds.  A place that is quiet and private will be best for patients that want to participate in individual sessions. Locations for individual session may include the patient’s room or the therapist’s office.  Patient’s that chose to participate in groups sessions will need a room that is large enough to accommodate other equipment that the patient may need such as wheelchairs.

 Results will vary from individual to individual, some interventions will work better for some than with other depending on the individuals specific issues. All of the previous interventions are evidence-based and may have better results when coupled with medications.  Evaluation of effectiveness should be done on a monthly basis to chart progress and make any adjustments that may be necessary such as changing the frequency and duration of sessions.

The American Psychiatric Association,-Psychotherapy and Older Adults Resource Guide. Retrieved from website on November 20, on November 20 Haight, B., K., Michel, Y., Hendrix, S. (1998). Life review: Preventing despair in newly relocated nursing home residents. International Journal of Aging & Human Development, 47, Hinrichsen, G. A. (1999). Treating older adults with interpersonal psychotherapy of depression. Journal of Clinical Psychology: In Session: Psychotherapy in Practice, 55, 949–960. Klausner, E., J., Alexopolos, G., S. (1999). The future of psychosocial treatments for elderly patients. Mental Health and Aging, 50(9): Llewellyn-Jones, R., H., Snowden, J. (2007). Depression in nursing homes. CNS Drugs, 21: Lyne, K., J., Moxon, S., Sinclair, I., Young, P., Kirk, C., Ellison, S. (2005). Analysis of a care planning intervention for reducing depression in older people in residential care. Aging & Mental Health, 10(4): Mahoney, D. (2004). CBT can help at-risk nursing home residents. Clinical Psychiatry News, March McDougall, F., A., Matthews, F., E., Kvaal, K., Dewey, M., E., Brayen, C. (2007). Prevalence and symptomatology of depression in older people living in institutions in England and Wales. Age and Ageing, 36: North Sydney Health Department. (2001). Consensus guidelines of assessment and management of depression in the elderly. Faculty of Psychiatry of Old Age. Retrieved from website: on November 18, Snowden, M., Sato, K., Roy-Byrne, P. (2003). Assessment and treatment of nursing home residents with depression or behavioral symptoms associated with dementia: a review of the literature. The American Geriatrics Society, 51: