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Clinician Article

Sustained benefit of supportive intervention for depressive symptoms in caregivers of patients with Alzheimer's disease.



  • Mittelman MS
  • Roth DL
  • Coon DW
  • Haley WE
Am J Psychiatry. 2004 May;161(5):850-6. doi: 10.1176/appi.ajp.161.5.850. (Original)
PMID: 15121650
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Disciplines
  • Family Medicine (FM)/General Practice (GP)
    Relevance - 6/7
    Newsworthiness - 6/7
  • General Internal Medicine-Primary Care(US)
    Relevance - 6/7
    Newsworthiness - 6/7
  • FM/GP/Mental Health
    Relevance - 6/7
    Newsworthiness - 5/7
  • Geriatrics
    Relevance - 6/7
    Newsworthiness - 4/7

Abstract

OBJECTIVE: The long-term effect of counseling and support on symptoms of depression was examined in spouse-caregivers of patients with Alzheimer's disease.

METHOD: The participants were 406 spouse-caregivers of Alzheimer's disease patients who lived at home at baseline. The caregivers were randomly assigned to either a group receiving enhanced counseling and support treatment or a group receiving usual care (control group). Caregivers in the enhanced treatment group were provided with six sessions of individual and family counseling, agreed to join support groups 4 months after enrollment, and received ongoing ad hoc counseling. The Geriatric Depression Scale was administered at baseline and at regular follow-up intervals for as long as the caregiver participated in the study.

RESULTS: After baseline differences were controlled for, caregivers in the enhanced treatment group had significantly fewer depressive symptoms after the intervention than did the control subjects. These effects were sustained for 3.1 years after baseline, similar across gender and patient severity level, and sustained after nursing home placement or death of the patient.

CONCLUSIONS: Counseling and support lead to sustained benefits in reducing depressive symptoms in spouse-caregivers of Alzheimer's disease patients and should be widely available to provide effective, evidence-based intervention for family caregivers.


Clinical Comments

Family Medicine (FM)/General Practice (GP)

A good topic, and an often forgotten patient population. Often most of our care and attention is focused on the patient with Alzheimer`s disease, and the caregiver is neglected.

FM/GP/Mental Health

Well powered RCT of a practical skills-based and supportive intervention for care-givers. Both intervention and usual care control group showed a small decrease in depression scores of care-givers over five years of study. However, the intervention group showed a modest clinically significant improvement within the first year, and maintained a slight benefit over the control until the end of five years, independent of other study factors. This intervention is probably beneficial, acceptable to patients, and likely to be cost effective. The only question is whether family physicians in other regions have referral access to such a counseling service.

General Internal Medicine-Primary Care(US)

Evidence of efficacy may help mobilize efforts to start a program to proactively identify patients` caregivers and plan preventive strategies, especially if cost-effectiveness is addressed specifically.

Geriatrics

Spouse caregivers randomized to usual care vs. enhanced counseling/support. Outcome: depressive symptoms measured using GDS. Unfortunately, major methodological flaws. A few examples: -Adherence to CONSORT guidelines for RCTs would have helped - esp. flow diagram, clearly identifying a primary outcome, sample size rationale (MCID of GDS?), consideration of issues like allocation concealment, contamination/need for blinding at least the outcome assessors, etc etc -randomization failed to balance the groups in terms of sex (more females in control group) and baseline depression ratings -intervention wasn’t blinded - would have been difficult, but could have used other strategies (eg. blinding outcome assessors, cluster randomization) -co-interventions? (eg. antidepressant use, support from other agencies/family) I support dementia caregiver counseling, but this study adds little. It`s a shame given the amount of effort (time-consuming intervention, large N, duration of follow-up).

Geriatrics

The issue of caregiver burden in patients with Alzheimer`s disease is extremely important, yet proven ways to alleviate some of the burden have yet to be defined. Impact of physician visits, counseling, resource referral, support groups, and even drug therapy for caregiver depression have not been rigorously studied or applied in actual practice settings. This article provides much needed data supporting the value of a 3- phase intervention. The success of this intervention is impressive and should prompt a change in practice. This will require both payors and health care providers to re-evalute and improve their commitment to such important services. The impact of reduced caregiver depression can have a national impact on health care utilization, particularly if this would lead to reduced LTC utilization. This latter assumption needs to be tested in additional studies.

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