Department of Psychiatry, Medical Faculty, University of Groningen
EMGOInstitute, Free University Amsterdam
Department of Psychiatry, Medical Faculty, University of Groningen, The Netherlands
Correspondence: Ms Anne-Marie Eisses, Victorialaan 7, 5261AE Vught, The Netherlands. Tel: +31 736577422; Fax: +31 503619722; e-mail: A.M.H.Eisses{at}med.rug.nl
Declaration of interest None. Funding detailed in Acknowledgements.
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To determine the effects of staff training on the detection, treatment and outcome of depression in residents of ten homes.
Method We conducted a randomised controlled trialin ten residential homes. The intervention consisted of a training programme for staff and collaborative evaluation by staff and a mental health specialist of residents with possible depression.
Results Recognition of depression increased more in homes where staff received the training than in the control homes. Treatment rates also increased compared with control homes, but the increase was not significant. Residents with depressive symptoms had a more favourable course when staff had received training. Moreover, the prevalence of depressive symptoms decreased, but the decrease was not significant.
Conclusions Training of care staff resultsin the increased detection of depression in the elderly, a trend towards more treatment and better outcomes.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The main outcome measures referred to residents with depression (recognition, treatment and prognosis). The secondary outcome measure referred to the whole group of residents (prevalence). Written informed consent was obtained prior to the study. The medical ethics committee approved the study.
Intervention
The intervention was directed towards the care staff and consisted of two
components: (a) training in using a standardised screening instrument; (b)
review of the findings of screening at a staff meeting. The training focused
on the recognition of psycho-pathology in residents and the recording of
observations according to the Behaviour Rating Scale for Psychogeriatric
Inpatients (Dutch abbreviation GIP28). The GIP28 consists of
three reliable and valid scales: apathy, cognitive disturbance and affective
disturbance (Jonghe et al,
1997). The GIP28 has been used in the care of the elderly
for over 15 years. During daily care activities the care staff observe
specific behavioural aspects of residents. The staff later indicate how often
they have registered certain behaviours. The advantage of this instrument is
that active participation of the resident is not required. Trainers were
mental health specialists; trainees were the care staff of the residential
homes. The training consisted of two sessions of 2 h. During the training,
care staff learned how to observe specific behaviours, supported by video
material. Special attention was given to the basic differences in behavioural
manifestations of dementia and depression.
Evaluation of the intervention consisted of a discussion of the recorded observations by an experienced mental health nurse or psychologist with the care staff at a formal meeting to determine the course of action. Residents who were possibly depressed according to the GIP28 were identified and discussed. The discussion resulted in a decision on the course of action:
The effects of the intervention (e.g. successful detection) were assessed separately from the GIP recordings. Furthermore, no feedback was given by the researchers or anyone else to the care staff about the success of the detection of depression.
Selection of homes
In The Netherlands, residential homes provide daily care to the infirm
elderly over 65 years with significant limitations to daily living; if needed,
they also provide basic medical care. About 5% of all those over 65 years in
The Netherlands live in a residential home. Nursing homes, in which about 3%
of all Dutch residents over 65 years reside, provide more specialised medical
care to all ages, but mainly to the elderly.
Of the 42 residential homes in the province of Drenthe, 23 were eligible for the study. The 19 non-eligible homes were excluded because they met one or more of the following exclusion criteria:
The staff of five of these homes had no interest in participation, as they received adequate assistance from the attending psychologist of a nearby nursing home. Five homes were not interested in the study, and three homes indicated that the intervention took too much time. Ultimately, ten homes were willing to participate.
Residential homes in the province of Drenthe are comparable to those in other parts of The Netherlands: they have the same gender ratio of residents (1 male: 4 female); mean residents age (about 85 years); care methods; and admission criteria. However, homes in Drenthe are slightly smaller (about 85 beds) than those in other parts of the country (101 beds), and Drenthe itself consists of small towns (up to 150 000 inhabitants) and rural areas (Centraal Bureau voor de Statistiek, 1998).
Matching and randomisation
Since the intensity of existing care might constitute a major confounder if
not well balanced over both conditions, we matched the homes on care
intensity. Care intensity was defined as: (a) the presence of contact nursing
(one personal carer maintains intensive contact with the residents
family and general practitioner); and (b) care ratio (number of carers divided
by the number of residents in the home). The matched homes were randomly
assigned to the control or the experimental group. Control homes did not
implement the intervention; they continued with standard care, comprising
regular reports on residents by staff, without systematic observation or the
use of rating scales.
Selection of residents
We visited all residents aged 65 years and above, except those receiving
day care for dementia. The researchers notified residents of the study by a
letter explaining the study and requesting their approval. Those who were
severely cognitively impaired, indicated by a score below 15 on the
Mini-Mental State Examination (MMSE)
(Folstein et al,
1975), and those with severe hearing problems or aphasia were
excluded. We reasoned that no valid assessments could be obtained from these
residents.
Assessments
Depression
We assessed residents at baseline and follow-up with the validated Dutch
version of the Geriatric Depression Scale (GDS), consisting of 30 yes/no
items, which measures clinically relevant depressive symptoms
(Yesavage et al,
1982; Kok, 1994).
The GDS was administered at an interview between resident and trained research
assistant, because many participants had serious difficulty with reading due
to visual problems. The GDS does not contain any items assessing physical
symptoms, hence it is an appropriate instrument for the elderly with physical
illness. The GDS has been validated as a screening tool in nursing homes
(McGivney et al,
1994). A score of over 10 on the GDS30 is indicative of
depression (Brink et al,
1982). Scores between 11 and 20 indicate moderate depression, and
scores above 20 indicate severe depression
(Brink et al,
1982).
Recognition of depression
Masked to the GDS results, the care staff were asked, at baseline and
follow-up, to rate each resident as probably depressed or probably not
depressed. The staffs ratings were compared with the scores of the
residents on the GDS (above/below threshold). The GDS was the gold
standard in this study. Both sensitivity and specificity were
calculated.
Treatment of depression
Treatment (yes/no) was defined as the prescription of antidepressant
medication or counselling by a professional (e.g. general practitioner,
psychologist or social worker). Interviews with care managers and medical
records were used to obtain such information.
Statistical analysis
To determine prognosis, we compared residents from both experimental and
control groups assessed as depressed (GDS410) at baseline. To examine whether
the intervention led to improvement of recognition, treatment and a lower
prevalence of depression, data were required on all residents present at
baseline and on all residents present at follow-up. Thus, for these analyses,
new residents were included at follow-up (new inhabitants, as
well as those who were ill or refused participation at baseline).
Sensitivity refers to the proportion of residents with depression
(GDS>10) correctly identified by the care staff. Specificity refers to the
proportion of residents without depression (GDS10) correctly identified by
the care staff.
For the statistical evaluation of differences in proportions between experimental and control homes, taking into account baseline differences, Newcombes method 10 for independent proportions was used (Newcombe, 2001). Differences in means were evaluated by t-tests. Where appropriate effect sizes were reported according to Cohen (1992).
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Residents
There were 426 residents included at baseline; 41 residents were excluded
because of severe cognitive impairment, 13 were physically too ill to
participate, 5 had died shortly before the interviews and 2 residents could
not be visited. There were 52 residents who refused to participate at
baseline. Table 1 describes the
baseline characteristics of the sample, divided into control and experimental
groups. Most respondents were female (74.2%). The mean age of the men was 84.8
years (s.d.=7.4, range 6598 years). The mean age of the women was 85.6
years (s.d.=6.1, range 69101 years). At baseline, 12.7% of the male
residents suffered from depressive symptoms and 14.9% of the female residents.
There were no significant baseline differences between the control and
experimental groups.
|
Table 2 shows the inclusion at baseline, the loss to follow-up and the inclusion of new residents. Figure 1 presents a flow chart of inclusion and attrition rates at baseline and follow-up. At follow-up, data were available on 173 residents in the experimental group and 187 in the control group. Most residents were female (76.9%). Of the men, 10.8% had a GDS score above 10; 11.9% of the women had a score above 10.
|
|
In the experimental group 27 residents had depressive symptoms at baseline. Of these, 12 residents were also investigated at follow-up (15 were lost to follow-up: 7 refused, 5 died, 2 were too ill and 1 was too deaf). In the control group, 19 of the 34 GDS-positive residents at baseline participated at follow-up (15 were lost to follow-up: 3 died, 7 refused, 2 were too cognitively impaired and 3 were too ill).
Analyses of those who dropped out (n=146) and those who were
assessed twice (n=280) revealed that the mean score on the GDS at
baseline was significantly higher in those who dropped out (7.29, s.d.=5.13)
compared with those who were assessed twice (5.60, s.d.=4.24,
t-test=3.422, P=0.001). There were no age and gender
differences between those who dropped out and those who were assessed twice.
At follow-up, the mean GDS score of those assessed twice and new participants
did not differ statistically (6.07, s.d.=4.36 . 5.60, s.d.=4.45,
t-test=0.843, P=0.400).
There was no difference in mean GDS score of those who dropped out from the
control and experimental groups (7.22, s.d.=5.24 . 7.36, s.d.=5.05;
t-test 0.161, P=0.871) or the mean score of those assessed
twice in the two groups (t-test=1.008, P=0.314).
There was, however, a difference in mean scores of newcomers.
The newcomers in the control group had a higher mean GDS score (6.91,
s.d.=4.895) than those in the experimental group (4.73, s.d.=3.95,
t-test=2.102, P=0.040).
The mean GDS scores did not differ between the groups (t-test=0.458, P=0.647). The average GDS scores at baseline did not differ among the ten homes (ANOVA F=1.645, P=0.100).
Care staff
The sample of staff at baseline (42 in the control and 43 in the
experimental group) included 10% nurses, 33% orderlies, 50% geriatric helpers
and 7% others. These care staff members are the first who might notice
depressive symptoms in residents and discuss their concern with colleagues.
All staff members except one were female. Their mean age was 37.7 years
(s.d.=7.5, range 2155) and they had worked on average 9.5 years in the
homes under study (s.d.=5, range 10 months to 23 years, median=10 years). The
samples are representative of the staff in Dutch homes for the elderly.
Effects of intervention
Effect on recognition
Table 3 shows the staff
ratings (depressed/not depressed) compared with the GDS scores (screen
positive, GDS>10/screen negative, GDS10).
Table 4 shows the recognition
rates (sensitivity and specificity). The improvement in sensitivity is
significantly greater in the experimental group than in the control group
where it actually decreased (Z=1.6722, P=0.0472).
|
|
Effect on treatment for depression
The treatment rate of residents with depressive symptoms showed a large
difference at baseline in favour of the control group: 33.3% (11 out of 33)
received treatment compared with 3.8% (1 out of 26) in the experimental group.
The treatment rate in the experimental group increased (up to 23.1%, 3 out of
13), but remained stable in the control group (31%, 9 out of 29). Although
substantial, the difference in increase of treatment rate was not
statistically significant (Table
4).
Effect on the course of depressive symptoms
We defined the course of depression as favourable if the GDS score at
follow-up fell into a less severe category than at baseline. In the
experimental group, 58.3% (7 out of 12) improved . 15.8% (3 out of 19) in
the control group (P=0.0068, Table
4).
We also examined the decrease in depressive symptoms for participants with a positive GDS score at baseline (GDS >10). In the experimental group the GDS decreased by a mean of 4.50 GDS units (s.d.=4.76) but increased by 0.684 GDS units (s.d.=4.12) in the control group. The corresponding effect size was 1.18 (95% CI 1.93 to 0.38) suggesting that the GDS scores of residents who were depressed at baseline (GDS >10) decreased significantly more in the experimental than in the control group.
Effect on the prevalence and incidence of depression
We also investigated whether the whole sample benefited from the
intervention. The prevalence of depressive symptoms (GDS >10) at baseline
was similar in both groups, with 13.6% in the experimental group and 14.9% in
the control group. At follow-up, the prevalence of depressive symptoms in the
experimental group decreased to 7.5% but remained at 15.5% in the control
group. Although substantial, the difference between the groups was not
significant (Table 4). We also
compared the decrease in depressive symptoms between baseline and follow-up.
The mean difference score was 0.1360 (s.d.=3.4) in the experimental group and
0.7419 (s.d.=3.2) in the control group. The effect size was 0.18 (95%
CI 0.42 to 0.005) (NS).
Moreover, the incidence of depressive symptoms (GDS >10) at follow-up in residents without depression at baseline was 3.5% in the experimental group and 5.9% in the control group. There is a suggestion that the intervention contributes to the prevention of depressive symptoms, but the difference was not statistically significant (Z=0.8593, P=0.1951).
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The two groups of care homes were well-balanced with respect to degree of care. However, we did not succeed in creating two equivalent groups at baseline with regard to recognition and treatment rates. Although we have carefully checked the procedures, we can not explain the difference. We are reassured that the baseline difference was coincidental, but would have preferred all baseline indices to be (roughly) equivalent. With ten homes there is a considerable probability of baseline inequality. In this type of intervention the number of randomisable units is by implication always lower than one would wish from a statistical and a design point of view. Unlike many studies at the institutional level we applied baseline assessments; by doing this we were able to correct for baseline non-equivalence and calculate the change in scores brought about by the intervention.
The study had high rates of loss to follow-up of residents with depression. Hence, only small numbers of residents with depression were available for analyses of improvement. The loss to follow-up reflects the vulnerability of residents with depression.
Newcomers in the control group were more depressed than those in the experimental group, but there was no overall difference in symptom rates between new participants and residents assessed twice. This may be a result of support of newly arrived residents by the care staff. An attentive and supporting attitude may be enhanced by training.
The effects we found were not large. This is because the number of residents with depression in our study was much smaller than expected from previous prevalence studies. Such a small number restricts the maximum effect attainable, through the phenomenon of restriction of range. The intervention may be more effective in populations with higher prevalences (Nunnally, 1976).
Furthermore, the sensitivity decreased in the control group at follow-up, probably because of a reduction in awareness or demoralisation owing to not having received the training. These phenomena are documented in the literature on research methodology of intervention studies (Cook & Campbell, 1979).
Effect on recognition
Recognition of depression in the elderly in residential homes is
undoubtedly difficult; difficulties result from the high prevalence of
multiple physical disorders and functional impairments in residents
(Koenig et al, 1993).
The intervention under study brought about an increase in the recognition
rates (sensitivity). At the same time, the specificity remained high and
stable, implying that the care staff improved their recognition of depression,
without wrongly rating non-depressed residents as depressed. Furthermore, the
positive predictive value of the judgements of care staff remained stable in
both groups between baseline and follow-up, whereas the negative predictive
value increased after the intervention.
Judgements of care staff are without doubt valuable in the recognition of depression, but before psychological or pharmacological treatment for the depression may be provided, screening instruments and clinical assessments by, for example, general practitioners are still mandatory.
Effect on treatment for depression
The treatment rate of residents with depressive symptoms increased after
the intervention. The increase was substantial but not statistically
significant. This supports the results of another recent randomised controlled
trial carried out in long-term care facilities: the frequency of treatment or
referral to mental health services by primary care physicians increased when
they were informed about the results of a depression screen (GDS)
(Soon & Levine, 2002).
Effect on the course of depressive symptoms
Residents with depressive symptoms improved more in the homes where the
intervention had been implemented than in the control homes. Our results are
in line with those reported by Cuijpers & van Lammeren
(2001), who applied a
quasi-experimental design. They reported favourable patient outcome as a
result of a comprehensive training programme in residential homes focusing on
caregivers, residents and relatives. Beneficial effects of training and
education of care staff on the course of depressive symptoms have also been
reported by Proctor and colleagues
(1999). Rabins et al
(2000) also found positive
effects of an intervention on the reduction of psychiatric symptoms in the
elderly. They taught staff to find cases, to perform assessment in the
residents apartments and to provide care if necessary. This method
compares well with that used in our study.
Effect on the prevalence and incidence of depression
Our findings suggest that the intervention contributes to the prevention of
depressive symptoms, since in the experimental group: (a) the prevalence rates
of depressive symptoms showed a greater decrease between baseline and
follow-up (NS); and (b) the incidence of depressive symptoms was lower
compared with the control group (NS).
In summary, we have found support for the beneficial effects of a programme of staff training in improving detection, treatment and the course of depression in normal practice. The care staff appreciated the training, the systematic observation procedures and the meetings with the mental health worker. They indicated that they received valuable tools to deal with vulnerable residents. The intervention has now been implemented successfully in several parts of The Netherlands.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Bagley, H., Cordingley, L., Burns, A., et al (2000) Recognition of depression by staff in nursing and residential homes. Journal of Clinical Nursing, 9, 445 450.[CrossRef][Medline]
Blazer, D. G. (1994) Epidemiology of depression: prevalence and incidence. In Principles and Practice of Geriatric Psychiatry (eds J. R. M. Copeland, M. T. Abou-Saleh & D.G. Blazer), pp. 519522. Chichester: Wiley.
Brink, T. L., Yesavage, J. A., Lum, O., et al (1982) Screening tests for geriatric depression. Clinical Gerontologist, 1, 37 49.
Centraal Bureau voor de Statistiek (1998) Bevolking der gemeenten van Nederland op 1 januari 1998. Voorburg/Heerlen, The Netherlands: Centraal Bureau voor de Statistiek.
Cohen, J. (1992) A power primer. A power primer. Psychological Bulletin, 112, 155 159.[CrossRef]
Cook, T. D. & Campbell, D. T. (1979) Quasi-Experimentation: Design and Analysis for Field Settings. Chicago, IL: Rand McNally.
Cuijpers, P. & van Lammeren, P. (2001) Secondary prevention of depressive symptoms in elderly inhabitants of residential homes. International Journal of Geriatric Psychiatry, 16, 702 708.[CrossRef][Medline]
Folstein, M.F., Folstein, S.E. & McHugh, P.R. (1975) Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189 198.[CrossRef][Medline]
Jackson, R. & Baldwin, B. (1993) Detecting depression in elderly medically ill patients: the use of the Geriatric Depression Scale compared with medical and nursing observations. Age and Ageing, 22, 349 353.[Abstract]
Jonghe, J. F. M. de, Ooms, M. E. & Ribbe, M.W. (1997) Verkorte Gedragsobservatieschaal voor de Intramurale Psychogeriatrie (GIP-28). 28). Tijdschrift voor Gerontologie en Geriatrie, 28, 119 123.[Medline]
Koenig, H.G. & Blazer, D.G. (1992) Epidemiology of geriatric affective disorders. Clinics in Geriatric Medicine, 8, 235 251.
Koenig, H. G., Meador, K. G., Cohen, H. J., et al (1988) Detection and treatment of major depression in older medically ill hospitalized patients. International Journal of Psychiatry In Medicine, 18, 17 31.[Medline]
Koenig, H. G., Cohen, H. J., Blazer, D. G., et al (1993) Profile of depressive symptoms in younger and older medical inpatients with major depression. Journal of the American Geriatric Society, 41, 1169 1176.
Kok, R. M. (1994) Zelfbeoordelingsschalen voor depressie bij ouderen. Tijdschrift voor Gerontologie en Geriatrie, 25, 150 155.[Medline]
McGivney, S. A., Mulvihill, M. & Taylor, B. (1994) Validating the GDS depression screen in the nursing home. Journal of the American Geriatric Society, 42, 490 492.
Newcombe, R. G. (2001) Estimating the difference between differences: measurement of additive scale interaction for proportions. Statistics in Medicine, 20, 2885 2893.[CrossRef][Medline]
Nunnally, J. C. (1976) Psychometric Theory. New York: McGraw-Hill.
Pond, C. D., Mant, A., Bridges-Webb, C., et al (2002) Recognition of depression in the elderly: a comparison of general practitioner opinions and the geriatric depression scale. Family Practice, 7, 190 194.
Proctor, R., Burns, A., Stratton Powell, H., et al (1999) Behavioural management in nursing and residential homes: a randomised controlled trial. Lancet, 354, 26 29.[CrossRef][Medline]
Rabins, P. V., Black, B. S., Roca, R., et al
(2000) Effectiveness of a nurse-based outreach program for
identifying and treating psychiatric illness in the elderly.
JAMA, 283, 2802
2809.
Rovner, B.W., German, P. S., Brant, L. J., et al (1991) Depression and mortality in nursing homes. JAMA, 265, 993 996.[Abstract]
Soon, J. A. & Levine, M. (2002) Screening for depression in patients in long-term care facilities: a randomized controlled trial of physician response. Journal of the American Geriatrics Society, 50, 1092 1099.[CrossRef][Medline]
Yesavage, J. A., Brink, T. L., Rose, T. L., et al (1982) Development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research, 17, 37 49.[CrossRef][Medline]
Received for publication February 24, 2004. Revision received November 1, 2004. Accepted for publication November 5, 2004.