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Lay counseling effective for reducing late-life depression

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Study contributes to existing evidence

Depression occurring later in life is the most common mental health issue in the elderly and has been shown to have a negative impact on comorbidities and contribute to the risk for dementia and mortality. There is no doubt later-life depression poses a significant public health challenge. Low-income countries with limited resources can experience those challenges at a deeper level.

The current study contributes to the existing evidence, which shows that interventions carried out by nonhealth care professionals can be effective for addressing mental health conditions in low-resource settings. In addition, previous studies have shown that task sharing as a method is effective in tackling other health conditions such as HIV, hypertension, and tuberculosis in such settings.

However, it should be noted that, in the current study, the intervention was delivered by workers who received regular support. A logical next step, therefore, would be to examine the efficacy of interventions delivered by public health workers. Organizations that currently provide counseling services should be encouraged to adopt a structured approach demonstrated in the current study.

Jagadisha Thirthalli, MD, Palanimuthu T. Sivakumar, MD, and Bangalore N. Gangadhar, MD, are affiliated with the department of psychiatry at the National Institute of Mental Health and Neurosciences in Bengaluru, India. These comments are taken from an accompanying editorial (JAMA Psychiatry. 2018 Nov 7. doi: 10.1001/jamapsychiatry.2018.2898). No conflicts of interest were reported.



Counseling delivered by trained lay community members can effectively treat depression and anxiety in older adults in low- and middle-income countries, a study shows.

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“The [depression in later life] intervention, is to our knowledge, the first randomized clinical trial of indicated depression prevention in older adults living in a [low- and middle-income country] and as such addresses a previously unmet need in global health,” wrote Amit Dias, MD, and his colleagues. The findings show that the intervention could be a viable prevention option for older people living in those countries, which often lack the resources to provide prevention services for this population.

The study randomized 181 adults aged 60 years and older with subsyndromal depressive symptoms who attended rural and urban primary care clinics in Goa, India, to an intervention arm (n = 91) or to usual care (n = 90), reported Dr. Dias and his colleagues. The intervention arm was delivered by lay counselors (LCs) who were members of the local community, aged over 30 years, and graduates of any nonhealth-related field. The LCs, who received training, had weekly supervision and support from experts in the United States via Skype, reported Dr. Dias, of the department of preventive and social medicine at Goa Medical College in Bambolim, India, and his colleagues.

The intervention was a learning-based approach rooted in problem-solving therapy for primary care and brief behavioral treatment for insomnia. People in the intervention group also were given assistance with accessing medical and social programs. Six sessions lasting 30-40 minutes were delivered either in the patients’ homes or at a local center over a 6-10 week period.

Patients randomized to the control group received care as usual together with the same outcome assessments as the intervention group. Depressive episodes were measured using the Mini-International Neuropsychiatric Interview.

Results showed that 4.4% of participants in the intervention group had a major depressive episode, compared with 14.4% of those in the usual care group (number needed to treat, 9.95; 95% confidence interval, 5.12-182.43; P = 0.04), Dr. Dias and his colleagues wrote in JAMA Psychiatry. Kaplan-Meier estimates showed that 95.1% of patients in the intervention group were free of depression at 12 months, compared with 87.4% of those in the control arm.

The incidence of depression, as measured by General Health Questionnaire12 scores, also was lower in the intervention group (12-month mean difference, –1.18; 95% CI, –2.03 to –0.31; P less than .001). The intervention also was associated with lower systolic blood pressure at 12 months (difference, –6.98; 95% CI, –11.96 to –2.01; group x time interaction, P less than 0.001) and a change in body mass index (difference, 0.23; 95% CI, –0.97 to 1.43; P = 0.04).

However, the intervention did not affect measures of functional status or cognition.

The researchers concluded that their findings extend earlier work (Lancet. 2010;376[9758]:2086-95)(Lancet. 2017:389[10065]:176-85), which also showed that LCs could effectively treat prevalent cases of depression and anxiety in primary care practice. “If the success of the [depression in later life] intervention in depression prevention can be replicated in other [low- and middle-income countries], then its utility and scalability would be further supported,” they concluded.

Dr. Dias and his colleagues cited several limitations. One is that people with mild cognitive impairment or dementia were excluded from the study.

The study was supported by grants from the U.S. National Institute of Mental Health. The authors reported no conflicts of interest.

SOURCE: Dias A et al. JAMA Psychiatry. 2018 Nov 7. doi: 10.1001/jamapsychaitry.2018.3048.

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