Effectiveness of Case Management Versus Case Management Plus Problem-solving Therapy to Treat Depression in Low-income Elders

Depression is a common mental disorder that affects many low-income elders. Many elders
suffer from multiple chronic illnesses and often must deal with social and financial
hardships as they continue to age. Rates of diagnosis and treatment for depression within
the elderly population are low. This may be because elders are embarrassed to discuss their
symptoms with their doctor and assume sadness and anxiety are a normal part of the aging
process. However, depression is not a normal consequence of aging. Furthermore, it can
severely impact people's lives, sleep patterns, concentration, and energy levels. This study
will compare the effectiveness of case management combined with problem-solving therapy
(CM-PST) versus case management (CM) alone for assisting elderly people diagnosed with
depression.

CM involves identifying a person's particular needs and working with a case worker to plan
and implement specific resources and services that will meet those needs. PST emphasizes the
social context of an individual's situation through problem-solving and behavior change
techniques. Recent studies have suggested that combining CM with PST may have a mutually
beneficial effect on depressed, low-income elders. CM can help elders with their social and
financial needs, and PST can improve their ability to cope with stressful events and utilize
their new resources.

Participants in this open-label study will be randomly assigned to receive 12 sessions of
either CM or CM-PST. Both treatments will be delivered at the participant's home by a
trained case worker. Participants assigned to receive CM will focus on increasing their
resources and reducing adversity. The case worker will help participants determine the
causes of their unmet needs, create an action plan to meet those needs, encourage the use of
services, and possibly advise their family members and health care providers to help
facilitate the use of those services. Participants assigned to CM-PST will undergo a needs
assessment during the first session to develop a problem-solving plan that will be
implemented over the next 11 sessions. Each session will include instruction on how to use
the PST approach to solve problems identified by both the therapist and participant. All
participants will undergo a neuropsychological exam and complete psychological and physical
functioning questionnaires prior to treatment and at Weeks 3, 6, 12, and 24.

Inclusion Criteria:

- Receives home-delivered meal service

- Has at least one instrumental activity of daily living (IADL) impairment

- Meets Diagnostic and Statistical Manual of Mental Disorders (DSM)IV criteria for
unipolar major depression

- Considered low income (30% of the local median income)

- Has a need for social services

- Experiences problem-solving difficulties

- Speaks English

Exclusion Criteria:

- Diagnosis of psychotic depression or experiences delusions

- Suicidal

- Diagnosed with any Axis I psychiatric disorder other than unipolar major depression

- History of substance abuse

- Axis II diagnosis of antisocial personality

- History of psychiatric disorders other than unipolar major depression or generalized
anxiety disorder, such as bipolar disorder, hypomania, or dysthymia

- Diagnosed with dementia

- Acute or severe medical illness, such as delirium, metastatic cancer, major surgery,
stroke, heart attack, or decompensated heart, liver, or kidney failure within 3
months of study entry

- Use of drugs known to cause depression, such as steroids, reserpine,
alpha-methyl-dopa, tamoxifen, or vincristine

- Use of antidepressants

- Currently receiving psychotherapy

- Inability to perform any of the activities of daily living (ADLs) even with
assistance

- Aphasia interfering with communication