INTRODUCTION
Prevention in the mental health field has been seen, traditionally, as an area that has been implicitly restricted to issues in childhood and adolescence. If anything, prevention in geriatrics was seen as an oxymoron. Theory and research in prevention were, for a long time, restricted to issues of child development and intervention early in the life course. In an influential report, the Institute of Medicine (IoM) of the US National Academy of Sciences assessed the state of knowledge in prevention research in the 1990s, but could find hardly any studies aimed at prevention of mental disorders in older adults1. A more recent follow-up report on prevention of mental disorders by that same institute is aimed completely at children, youth and young adults, while prevention in older adults is not mentioned at all2.
At the same time, however, prevention of mental disorders in older adults has been the focus of a new line of research. This research has resulted in a growing body of knowledge on how to identify those with the highest risk of developing a mental disorder, several preventive interventions, and some randomized controlled trials showing that prevention may be possible and effective in older adults. Furthermore, considerable progress has been achieved in the field of prevention of mental disorders for younger adults in recent years. The growing number of randomized controlled trials has shown that prevention of depressive and anxiety disorders in adults in general is probably effective, and there is no reason to assume that interventions which are effective in younger adults would not be effective in older adults.
Why be concerned with prevention in late life? As is well covered in other sections of this text, there is the demographic imperative brought about by the overall ageing of the world population and in particular by the ageing of the older population. As pointed out in the classic paper by Kramer (1980)3, the same dynamics: public health measures, technological development and lifestyle changes, that created this growth in the overall population were also relevant to growth of the population of those with chronic illnesses and disabilities. They conclude that, in the absence of cures or effective preventive strategies, we will see an explosion in the number of older persons with serious and persistent disabling illnesses, particularly mental disorders. The availability of more efficacious treatments and the accessibility of appropriate services in the community combined to produce huge gains in the life expectancy of those with mental disorders, who in earlier times would have died long before reaching old age. This demographic imperative leads to the conclusion that prevention must be an important part of the agenda of geriatric psychiatry.
For example, major depression currently affects about 3.6–4.8% of persons of 60 years or older, and many more report clinically relevant depressive symptoms4,5. At this moment, major depression in all age groups is the fourth disorder worldwide in terms of disease burden, and it is expected to be the disorder with the highest disease burden in high-income countries by the year 20306. Furthermore, the prevalence of depressive disorders in older adults is projected to double from its present level by 20507. Depression is not only a highly prevalent disorder, but it is also associated with a huge loss of quality of life in patients and their relatives8,9, with increased mortality rates10, with high levels of service use and with enormous economic costs. The economic costs of depression in the United States were estimated to be $83 billion in 200011.
Another reason why prevention is important is that current treatments can reduce the disease burden of depression only to a limited extent. A recent study in Australia estimated that about 16% of the disease burden of major depression is averted in the current health system12. Because many patients do not receive an evidence-based treatment, this percentage could rise to 23% if all patients received such an evidence-based treatment. Furthermore, about 40% of all people with a depressive disorder do not receive any treatment. If it would be possible to deliver treatment to all patients with a depressive disorder, 34% of the disease burden of depression could be averted. So, although current treatments are usually considered to be effective in treating depressive disorders, it is estimated that these treatments can reduce the disease burden of depression by a maximum of 34%12. Prevention of the incidence of new cases of major depression has been suggested as an alternative for treatment which may reduce a part of the 66% of the disease burden which is not averted by current treatments13,14.
In the current chapter we will give an overview of the field of prevention of mental disorders in older adults. First, we will give a definition of prevention in the mental health field. Then we will focus on recently developed methods of identifying the optimal high-risk groups for preventive interventions. Finally, we will describe the interventions that have been developed and the results of research examining the effects of these interventions.
The traditional public health view derives from infectious disease and is divided into primary, secondary and tertiary prevention. Primary prevention is directed towards maintaining health by isolating the causes of disease and eliminating or counteracting them. Secondary prevention is directed towards enhancing recovery by case identification and prompt intervention early in the course of illness. Tertiary prevention is directed towards those already ill and emphasizes treatment and rehabilitation.
There is a growing consensus that the traditional public health view is not optimal in mental health. The components of this approach including, for example, concepts such as pathogens, risk factors, disease vectors and definitions of caseness do not translate easily into psychopathology or chronic disease. In the definition of depression which is currently used by most researchers and practitioners in the mental health field, prevention comprises all interventions which are conducted before subjects meet the formal criteria of a mental disorder (according to the DSM-IV1). Curative interventions are given to persons who suffer from acute disorders, and maintenance treatments are given to patients with chronic disorders. In this spectrum of interventions, three types of prevention can be distinguished:
Universal prevention is aimed at the general population or parts of the general population, regardless of whether they have a higher than average risk of developing a disorder. The best-known examples of universal prevention include school programmes aimed at all students, whether they have an increased likelihood of developing a mental disorder or not; and mass media campaigns, aimed at the general population.
Selective prevention is aimed at high-risk groups, who have not yet developed a mental disorder. High-risk groups include people who have recently experienced a stressful life event or who experience a chronic stressor, such as divorce, losing a family member through death, caring for an ill family member, and unemployment.
Indicated prevention is aimed at individuals who have some symptoms of a mental disorder but do not meet diagnostic criteria.
In this chapter, we will give an overview of selective and indicated preventive interventions for older adults. Because universal interventions have not been developed systematically or examined in well-designed trials, we will not discuss these possibilities here. Then we will look at the research examining whether preventive interventions are actually capable of preventing the incidence of new cases of mental disorders, and we will describe new methods of identifying optimal target groups for prevention of mental disorders in older adults.
In the past decades, several indicated preventive interventions for older adults have been developed, including interventions aimed at widows and widowers, caregivers of frail older adults, older adults with a chronic general medical illness, and inhabitants of homes for the elderly and nursing homes. Several of these interventions are not specifically aimed at older adults, because there are also younger adults who lose their spouse or get a chronic general medical disorder, but the chance of belonging to such a high-risk group is much greater among older adults. Therefore, it seems reasonable to consider such interventions as prevention for older adults.
One important group of selective preventive interventions is aimed at widows and widowers. They are an important high-risk group for mental disorders15, and several preventive interventions have been developed, including social support groups and widow-to-widow programmes. In social support groups, widows and widowers come together in small groups to exchange experiences and emotions, with a clear preventive focus. However, research examining the effects of these groups has not resulted in strong evidence for their effectiveness16. Another preventive intervention developed for widows and widowers are the so-called ‘Widow-to-widow’ programmes17,18. In these programmes, widows who have recently lost their spouse are visited by another widow who lost their spouse some time earlier. Early research showed promising effects of these programmes, but a larger recent trial did not find any beneficial health effects of such a programme19.
Another group of selective preventive interventions is aimed at caregivers of frail older adults. Because of the stressful situation they live in and the burden of care, this is an important high-risk group for the development of mental disorders20. Several types of interventions have been developed for caregivers, many of which have a clear preventive goal in terms of preventing mental disorders or severe stress-related problems. Interventions for these caregivers include support groups and psycho-educational interventions21, respite care22, home visits23, and multi-component interventions in which different interventions are combined and adapted to the need of the caregiver24. Research examining these interventions has typically resulted in small to moderate effect sizes on mental health outcomes in caregivers, with limited clinical impact25,26, although multi-component interventions seem to be more effective27.
Several multifaceted interventions have been developed for the prevention of late-life depression in residential care28,29, where the prevalence of depressive disorders is very high30. Such interventions focus on the training of nurses and doctors, on consultation and on supportive interventions for the residents. A few trials have found encouraging effects of these interventions28,29. Another study found significant effects for screening and early intervention in residential homes for the elderly31, although this should be considered as indicated prevention or even treatment.
Older adults with chronic general medical illnesses are another important target group for selective prevention. In this area, several well-designed studies have been conducted, and these studies have actually examined whether preventive interventions are capable of preventing the onset of new cases of mental disorders. Rovner and colleagues (2007)32 screened older patients with neovascular macular degeneration, and found that problem-solving treatment resulted in a significantly lower incidence rate of new cases of depressive disorders at two and six months follow-up. Robinson and colleagues (2008)33 found that both problem-solving treatment and antidepressive medication resulted in a significantly lower incidence rate of major depressive disorders in stroke patients.
This overview of selective preventive interventions is not comprehensive, but it gives a good idea of the possibilities that are available for developing preventive interventions for older adults at risk of getting a mental disorder.
In the past decades, several indicated preventive interventions, aimed at older adults with sub-threshold symptoms but no mental disorder, have been developed. Until now, these interventions have focused mainly on depression. The first type of indicated prevention we want to present is the psycho-educational ‘Coping with Depression’ course (CWD). This intervention was originally developed as a group treatment for depression. However, because of its psycho-educational nature, it can also be applied relatively easy as a preventive intervention. As we will see later on, the CWD (for all age groups) has been used in 6 of the 19 randomized controlled trials which have examined the effects of prevention on the incidence of major depression in those who did not have a depressive disorder at baseline.
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Environmental Factors, Life Events and Coping Abilities Toni C. Antonucci and James S. Jackson
The Multidisciplinary Team and Day Care Provision Martin Orrell and Kunle Ashaye
Training Requirements for Old Age Psychiatrists in the UK Susan Mary Benbow and Aparna Prasanna
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