Indicated Prevention

Recruitment

Target group

Definition of minD

Conditions

Intervention

For

Nse

Qual^a

Country

[8]

Community

Older adults (55+)

Self-reported depressive symptoms; no MDD

1. CBT

2. WL

Coping with depression course (CWD)

Grp

−

− − − +

[10]

Screening

Nursing home residents

GDS E 9; no MDD

1. CBT

2. CAU

Coping with stress course (CWD)

Grp

3, 6

− − + −

[22]

Through medical centers

Medically ill older adults

(60+)

GDS ≥ 11 at two occasions

1. IPC

2. CAU

Interpersonal counseling

Ind

−

− − + −

[25]

Community

Older adults (≥50 years)

CES-D ≥ 5; no MDD

1. Life review

2. Control

Life review therapy

Grp

−

+ + + +

[9]

Community

Older adults (50–75 years)

EDS ≥ 12, no MDD

1. internet CBT

2. Group CBT

3. Waiting list

102

100

Coping with depression course (CWD)

Grp

−

+ + + +

[28]

Screening in primary care

Older primary care patients

CES-D ≥ 16; no MDD

1. Stepped-care

2. CAU

Stepped-care protocol

Ind

–

6, 12, 24

−

+ + + +

[20]

Through primary care

Older adults

Minor depression (≥3 of 9 MDD symptoms, 4 weeks); no MDD

1. PST

2. Placebo

Problem-solving therapy

Ind

−

+ + + +

^a In this column a positive (+), or negative (−) sign is given for four quality criteria, respectively: allocation sequence; concealment of allocation to conditions; blinding of assessors; and intention-to-treat analyses.

Four studies were conducted among older adults in general, one in nursing home residents, one in medically ill older adults, and one among older primary care patients. There were eight comparisons between an indicated intervention and a control group (one study compared two treatments with a control group; [9]). The interventions in the six studies included the Coping with Depression course (3 studies), life review, problem-solving therapy, interpersonal counseling, and stepped-care (1 study each). In four interventions a group format was used, three used an individual format and one used an Internet-based intervention. The number of sessions ranged from 6 to 13. Four studies were conducted in the Netherlands, two in the United States, and one in Canada. The quality of the studies varied. Four studies met all four quality criteria, while the other three only met one of the four criteria. In three studies a care-as-usual control group was used, in two studies a waiting-list control group, in one study a pill placebo and in the final study a non-active intervention (a movie) control group.

The overall effect of the interventions on the level of depressive symptoms was g = 0.29 (95 % CI: 0.15–0.43), with almost no heterogeneity (I ² = 7; 95 % CI: 0–73). This effect size can be interpreted as small to moderate, and it corresponds to an NNT of 6.17.

There were some indications for publication bias. Duval and Tweedie’s trim and fill procedure indicated that the mean effect would drop from g = 0.29 to g = 0.22 (95 % CI: 0.07–0.38; number of imputed studies = 2) after adjustment for publication bias.

Only two studies examined the effects of indicated prevention on the incidence of major depressive episodes [10, 28]. However, the relative risk (RR) of developing a depressive episode at follow-up was RR = 0.37 (95 % CI: 0.15–0.91; p = 0.03), indicating that people who received the preventive intervention had 63 % less chance of developing a depressive episode than people in the control group. Heterogeneity (I ²) was zero. We also calculated the NNT (as the inverse of the risk difference). The NNT of indicated prevention compared with the control groups was 10.53 (95 % CI: 5.78–57.80; p = 0.02).

Because of the small number of studies we did not conduct any additional analyses.

7.6 Discussion

Although much research has focused on prevention of depressive disorders in children and adolescents, a growing number of studies have examined the possibilities to prevent depression in older adults. Furthermore, several manuals for evidence-based preventive interventions are now available, and prevention of depression has been established quite well. Seven randomized controlled trials have shown positive effects of these interventions on the level of depressive symptoms in older adults with subclinical depression, and there is some preliminary evidence that these interventions may also reduce the incidence of depressive disorders at 1–2 years follow-up.

There are several challenges for preventive interventions in older adults [38]. One important issue is to identify the optimal target groups for preventive interventions. Both indicated and selective preventive have been found to be effective in the prevention of depressive disorders. However, both types of prevention are aimed at high-risk groups and all known risk indicators of depressive disorders have the problem that their specificity is low. This low specificity implies that most subjects who are exposed to the risk factor do not develop the disorder and that one such risk factor by itself is not sufficient to produce the disorder. Recently, more sophisticated methods have been developed to identify ultra high-risk groups. These groups typically do not have only one high-risk indicators, but a combination of these factors. Furthermore, they are as small as possible (for efficiency reasons), but are responsible for the largest possible proportion of new incident cases [39, 40]. Although these epidemiological methods have been well-developed, they have not yet been translated into preventive intervention research. It may be possible that the use of biosignature data (e.g., inflammatory cytokines; [42]) may improve the identification of which persons with subsyndromal symptoms and may benefit from indicated preventive interventions.

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