Three-Pronged Intervention Eases Caregivers' Depression

A program of sustained counseling and support significantly reduces depressive symptoms in spouse caregivers of people with Alzheimer's disease, according to a report in the May American Journal of Psychiatry.

Primary caregivers who received an intervention that consisted of six sessions of individual and family counseling, support group participation, and ongoing ad hoc counseling showed significantly greater improvement in depressive symptoms than did caregivers receiving usual care offered to family members of patients at the New York University (NYU) Alzheimer's Disease Center.

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Study author Mary Mittelman, Dr.P.H., told Psychiatric News that the intervention consisted of three components. The first of those—individual and family counseling—began at baseline. The second component was participation in a support group for caregivers, which began four months after baseline but was expected to be continuous. The third component consisted of ongoing “ad hoc counseling” with a counselor (the NYU team included social workers, psychologists, and a gerontologist). “Ad hoc” meant that the caregiver could call on a counselor for practical advice, support, and encouragement as often as necessary.

“People might call three or four times a day if there was a crisis and not call again for months,” Mittelman said. “And others never called but reported that they were comforted by knowing that the option was available.”

She is director of psychosocial research and support at the Silberstein Institute for Aging and Dementia at NYU School of Medicine.

While caregiver satisfaction ratings improved almost immediately in the treatment group, the effects on depressive symptoms were not seen until eight and 12 months after enrollment. This suggests the importance of the cumulative effect of all components of the intervention, Mittelman said.

Those effects were long lasting, and Mittelman believes it is attributable to the multifaceted nature of the intervention and the elements that were ongoing—participation in support groups with other caregivers and ad hoc counseling.

“We found that while the structured part of the intervention, including individual and family counseling, occurred in the first four months of the study, the effects on depression were statistically significant and clinically meaningful for more than three years after enrollment,” Mittelman said.

The intervention, “could have a major impact on health care costs, on the emotional distress associated with caregiving, and perhaps on factors related to depressive symptoms, including health, disability, and related health care utilization and costs,” Mittelman and colleagues reported.

The study was supported by grants from the National Institute on Mental Health and the National Institute on Aging. Additional resources were provided by the NYU Alzheimer's Disease Center.

In the study, 406 spouse caregivers of Alzheimer's patients who lived at home were randomly assigned to either a group receiving the enhanced intervention or a control group receiving usual care. The Geriatric Depression Scale was administered at baseline and at regular follow-up intervals for as long as the caregiver participated in the study.

Caregivers were interviewed every four months during the first year and every six months thereafter by telephone or in person. They were followed until two years after the patient's death or until they refused to or could no longer participate in the study.

After controlling for baseline differences, caregivers in the intervention group had significantly fewer depressive symptoms than the control group. Mittelman said that the effects were likely to have been understated since what constitutes usual care at the NYU Alzheimer's Disease Center may be more than what is typical in the community.

“Basically, when people [in the control group] called, they got the help they were looking for,” she told Psychiatric News.

Mittelman said that one of the strengths of the intervention is that it is tailored to the needs of the specific caregiver and family. She added that the elements of the intervention can be easily adopted and referred clinicians to a book published in 2002 by AMA Press, Counseling the Alzheimer's Caregiver: A Resource for Healthcare Professionals.

Yet she said that caregivers typically do not have access to the kind of intense, individualized, and multifaceted intervention analyzed in the study. She added that the caregiver can easily be overlooked by clinicians focusing on the Alzheimer's patient.

“It's really important to understand the toll that caring for a relative with dementia takes on a person,” Mittelman said. “When there is a patient, the clinician pays attention to the patient, but it's important not to ignore the caregiver at home.”

The study, “Sustained Benefit of Supportive Intervention for Depressive Symptoms in Caregivers of Patients With Alzheimer's Disease,” is posted online at<http://ajp.psychiatryonline.org/cgi/content/full/161/5/850?>.▪