Life Depression and Anxiety - Healio

Guest Editorial

Collaborative Care Models for LateLife Depression and Anxiety Roles for Nurses epression and anxiety are common problems in late life, occurring both as diagnosable disorders and as clinically significant symptoms that cause significant distress and dysfunction. Whether occurring alone or comorbidly, latelife depression and anxiety are regularly associated with increased levels of disability, pain, health service use, and reduced function and quality of life (Bair, Wu, Damush, Sutherland, & Kroenke, 2008; Löwe et al., 2008; Porensky et al., 2009; Strine et al., 2009; Teh et al., 2009). These outcomes are both regrettable and avoidable in light of recent advances in medication and talk therapies and, more recently, multifaceted collaborative care models in primary care settings where older adults regularly report depression and anxiety. The depression care model, Improving Mood: Increasing Access to Treatment (IMPACT), is widely recognized for improving health outcomes among older adults, including reduced levels of depression, pain, and functional impairment and improved physical function, quality of life, and satisfaction with care (Callahan et al., 2005; Lin et al., 2003; Unützer et al., 2002). Similar models have proven effective in improving outcomes associated with comorbid pain and mood disorders (Kroenke et al., 2007; Kroenke, Shen, Oxman, Williams, & Dietrich, 2008; Unützer

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et al., 2008) and anxiety disorders (Roy-Byrne et al., 2005). The value of IMPACT and other collaborative care models in helping older adults restore wellness is further underscored by data supporting the cost effectiveness of the approach (Katon et al., 2005) and its contribution to relapse prevention (Trivedi, Lin, & Katon, 2007). In short, the many positive outcomes associated with collaborative care provide huge impetus for all providers to examine ways these models, and/or the essential principles of care they address, may be greater utilized in daily care. The central components of successful collaborative care models regularly include use of a specially trained care manager (often a nurse)

Journal of Gerontological Nursing • Vol. 36, No. 9, 2010

who works directly with the depressed and/or anxious older adult in collaboration with the older adult’s primary care provider (PCP) and a psychiatrist. Key components of care provided by the nurse care manager (NCM) include: l Patient involvement and choice related to treatment, which may include medication or talking therapy. l Systematic monitoring of symptoms using standardized scales for depression/anxiety. l Patient education about depression/anxiety and its treatment. l Behavioral activation that includes scheduling pleasant events. l Communication among all care partners.



Problem-solving therapy provided by the NCM and medication interventions are also offered to the older adult on the basis of individualized needs and preferences. The initial assessment conducted by the NCM is used to develop a treatment plan that is guided by the older person’s preferences, developed in collaboration with the psychiatrist, and provided to the PCP for review. Treatment may be delivered in person or over the telephone, with an average of 12 sessions in a 3-month period and additional follow up as needed to promote optimal outcomes. During this time, the NCM documents progress, and care is adjusted to promote fullest recovery. The “stepped care” approach follows a treatment algorithm that recommends treatment changes based on outcomes achieved over time, and relapse prevention plans are used to help older adults recognize and act on early warning symptoms of relapse. Collaborative care offers nurses many opportunities to intervene with older adults, not just as NCMs, but also as specialty nurse practitioners who may collaborate in the provision of stepped care, as researchers who translate models to new settings and populations, and more widely, as partners in the identification of older adults who would benefit from referral for treatment. In addition, collaborative care offers nurses a number of valuable lessons for general practice. First, education is often the first and most important step in helping older patients get the treatment they need. Paying close attention to the older adult’s preferences for treatment increases adherence and satisfaction with care. Systematic monitoring of symptoms is critically important to full recovery and can be easily conducted with self-report scales. And while reducing depression and anxiety symptoms is important, an increase in enjoyable activities (i.e.,



behavioral activation) is essential to overcoming limitations caused by anhedonia and excessive worry. Clear, regular, and targeted communication with other providers offers another avenue for nurses to make sure older patients get the treatment they need and recover to the fullest extent possible. And certainly, use of relapse prevention plans that outline early warning symptoms unique to the person, as well as individualized plans for getting help, are clearly within the scope of nursing practice. In summary, nurses have many opportunities to increase positive outcomes for older adults with depression and anxiety, within the context of applying a collaborative care model or using essential principles to guide daily practice. The potential emotional, physical, and financial benefits for anxious and depressed older adults are clearly worth the investment of time to explore systems and practices to assure that the “evidence” is “evident” in daily care. References

Bair, M.J., Wu, J., Damush, T.M., Sutherland, J.M., & Kroenke, K. (2008). Association of depression and anxiety alone and in combination with chronic musculoskeletal pain in primary care patients. Psychosomatic Medicine, 70, 890-897. Callahan, C.M., Kroenke, K., Counsell, S.R., Hendrie, H.C., Perkins, A.J., Katon, W., et al. (2005). Treatment of depression improves physical functioning in older adults. Journal of the American Geriatrics Society, 53, 367373. Katon, W.J., Schoenbaum, M., Fan, M.Y., Callahan, C.M., Williams, J., Jr., Hunkeler, E., et al. (2005). Cost-effectiveness of improving primary care treatment of late-life depression. Archives of General Psychiatry, 62, 1313-1320. Kroenke, K., Bair, M., Damush, T., Hoke, S., Nicholas, G., Kempf, C., et al. (2007). Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study: Design and practical implications of an intervention for comorbid pain and depression. General Hospital Psychiatry, 29, 506-517. Kroenke, K., Shen, J., Oxman, T.E., Williams, J.W., Jr., & Dietrich, A.J. (2008). Impact of pain on the outcomes of depression treatment: Results from the RESPECT trial. Pain, 134, 209-215.

Lin, E.H., Katon, W., Von Korff, M., Tang, L., Williams, J.W., Jr., Kroenke, K., et al. (2003). Effect of improving depression care on pain and functional outcomes among older adults with arthritis: A randomized controlled trial. Journal of the American Medical Association, 290, 2428-2429. Löwe, B., Spitzer, R.L., Williams, J.B., Mussell, M., Schellberg, D., & Kroenke, K. (2008). Depression, anxiety and somatization in primary care: Syndrome overlap and functional impairment. General Hospital Psychiatry, 30, 191-199. Porensky, E.K., Dew, M.A., Karp, J.F., Skidmore, E., Rollman, B.L., Shear, M.K., et al. (2009). The burden of late-life generalized anxiety disorder: Effects on disability, health-related quality of life, and healthcare utilization. American Journal of Geriatric Psychiatry, 17, 473-482. Roy-Byrne, P.P., Craske, M.G., Stein, M.B., Sullivan, G., Bystritsky, A., Katon, W., et al. (2005). A randomized effectiveness trial of cognitive-behavioral therapy and medication for primary care panic disorder. Archives of General Psychiatry, 62, 290-298. Strine, T.W., Kroenke, K., Dhingra, S., Balluz, L.S., Gonzalez, O., Berry, J.T., et al. (2009). The associations between depression, healthrelated quality of life, social support, life satisfaction, and disability in communitydwelling US adults. Journal of Nervous and Mental Disorders, 197, 61-64. Teh, C.F., Morone, N.E., Karp, J.F., Belnap, B.H., Zhu, F., Weiner, D.K., et al. (2009). Pain interference impacts response to treatment for anxiety disorders. Depression and Anxiety, 26, 222-228. Trivedi, M.H., Lin, E.H., & Katon, W.J. (2007). Consensus recommendations for improving adherence, self-management, and outcomes in patients with depression. CNS Spectrums, 12(8 Suppl. 13), 1-27. Unützer, J., Hantke, M., Powers, D., Higa, L., Lin, E., Vannoy, S.D., et al. (2008). Care management for depression and osteoarthritis pain in older primary care patients: A pilot study. International Journal of Geriatric Psychiatry, 23, 1166-1171. Unützer, J., Katon, W., Callahan, C.M., Williams, J.W., Jr., Hunkeler, E., Harpole, L., et al. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. Journal of the American Medical Association, 288, 2836-2845.

Marianne Smith, PhD, RN Assistant Professor University of Iowa College of Nursing Iowa City, Iowa The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. doi:10.3928/00989134-20100803-01

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