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Behavioral Activation in Nursing Homes to Treat Depression (BAN-Dep): Results From a Clustered, Randomized, Single-Blinded, Controlled Clinical Trial

      Highlights

      • What is the primary question addressed by this study?
        Can we decrease the proportion of older adults living with depression in residential aged care facilities by training staff on how to use behavioral activation?
      • What is the main finding of the study?
        Training residential aged care staff on how to use behavioral activation has fleeting and nonsustainable effects on symptoms of depression and anxiety.
      • What is the meaning of the finding?
        Interventions that require activities to be added to usual routine practices of staff working in residential aged care facilities produce non-sustainable results, particularly in the context of competing demands such as the COVID-19 pandemic.

      Abstract

      Objectives

      To determine if behavioral activation (BA) delivered by trained staff decreases prevalence of clinically significant symptoms of depression among older adults living in residential aged care facilities (RACFs).

      Methods

      Clustered, randomized, single-blinded, controlled trial of BA for adults aged over 60 years living permanently in a RACF with symptoms of depression (Patient Health Questionnaire, PHQ-9 ≥ 5). BA was delivered over 8–12 weeks using a structured workbook. The proportion of residents with PHQ-9 ≥ 10 at weeks 12, 26, and 52, as well as anxiety symptoms (GAD-7), physical (PCS), and mental (MCS) quality of life, loneliness, and loss to follow-up were main outcomes of interest

      Results

      We recruited 54 RACFs (26 intervention) and 188 of their residents (89 intervention). Participants were aged 61–100 years and 132 (70.2%) were women. PHQ-9 ≥ 10 interacted with BA at week 12 (OR = 0.34, 95%CI = 0.11–1.07), but differences between the groups were not statistically significant at any time-point. GAD-7 ≥ 10 interacted with BA at week 26 (OR = 0.12, 95%CI = 0.02–0.58), but not at any other time-point. Overall, the intervention had no effect on the scores of the PHQ-9, GAD-7, PCS, MCS, and loneliness scale. Loss to follow-up was similar between groups. Adherence to all stages of the intervention was poor (36.2%).

      Conclusions

      Disruption by the COVID-19 pandemic and staffing issues in RACFs undermined recruitment and adherence. In such a context, a BA program delivered by RACF staff was not associated with better mental health outcomes for residents over 52 weeks.

      Key Words

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      Linked Article

      • The Problem With Maslow's Hammer
        The American Journal of Geriatric PsychiatryVol. 30Issue 12
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          Somewhere between 15% and 65% of elders living in nursing homes and residential care facilities have significant depression and anxiety1 and these symptoms have only intensified during the COVID-19 pandemic.2 Depression and anxiety are major contributors to decreased quality of life for older adults and are associated with poor health outcomes, social isolation, functional decline including premature death and increasing the burden on nursing home staff and caregivers.3,4 Mood disorders in late life are also often unrecognized clinically and more likely to have a complicated clinical course and incomplete recovery and.
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      • The Promise of Behavioral Activation to Treat Depression in Nursing Homes
        The American Journal of Geriatric PsychiatryVol. 30Issue 12
        • Preview
          Hundreds of randomized trials have shown that psychological interventions are effective in the treatment of depression.1 That is also true in older adults. Although the effects of psychological treatments are significantly less effective in children and adolescents, there are no significant differences in effects between age groups when patients have reached adulthood.2 Psychotherapy is as effective in older adults as it is in younger adults, and there is now enough evidence that it also works equally well in older old adults (75 and older).
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