Implementing Evidence-Based Practices in Geriatric Mental Health

At a time when information on new treatments is rapidly growing, yet clinical resources and reimbursement appear to be shrinking, clinicians are challenged to identify the interventions that are best supported by the research literature. This challenge is particularly daunting in the field of geriatric mental health primarily because the number of well-designed treatment studies is relatively small, and treatments generally designed for younger people must be applied to a geriatric population, which may respond in a very different way For example, psychotherapeutic interventions may function differently in older people because of age-related changes in cognition and psychological development. Also, pharmacological response rates are known to vary in response to a variety of age-associated physiological changes and the complications of medication side-effects associated with concurrent medical conditions and interactions between drugs (Banerjee and Dickinson, 1997). Relying on reports of individual studies is risky, as it is often difficult to evaluate the quality of specific studies without training in research methodology. Evaluating the potential value of a given treatment becomes even more complex when considering multiple studies that together may present conflicting results and often have different samples, methods, and outcome measures. Fortunately, the challenge of sorting out the quality and significance of the research literature is well-recognized, and new techniques have been developed to summarize data from different studies and sources. When multiple studies of a specific treatment are evaluated, research findings can be aggregated and analyzed according to standardized methods and criteria to identify "evidence-based practices." While criteria vary, the underlying principles that define such practices include empirical support from randomized, controlled, well-designed studies with replication by different investigators using large, generalizable study samples (ACPR, 1993; Chambless and Ollendick, 2001). However, simply identifying evidence-based practices and developing guidelines is not sufficient to change what clinicians actually do. Innovative approaches must support the dissemination and implementation of these treatments in everyday practice, or "usual care." The following discussion includes a brief overview of evidence-based reviews of the treatment literature, challenges and strategies for implementing evidence-based practices in routine clinical settings, and issues requiring further attention. EVIDENCE-BASED REVIEWS Treatments for major depression are the most frequently studied interventions in geriatric mental health and have the most empirical support. A number of evidence-based reviews, including estimates of effects based on multiple studies, have established effectiveness for both pharmacological and psychosocial therapies (Gatz et al., 1998; Gerson et al., 1999; Pinquart and Soerensen, Zoos; Thorpe et al., 2001; Wilson et al., 2001). More than half of older adults treated with antidepressants for major depression experience at least a So-percent reduction in depressive symptoms. Comparable efficacy and tolerability in older people have been reported for a number of antidepressants-tricyclic antidepressants, selective serotonin re-uptake inhibitors (ssRis), and non-ssi norepinephrine reuptake inhibitors (NSSRIS) (Wilson et al., 2001). Reviews of the psychosocial research literature establish cognitive behavioral therapy and interpersonal therapy as effective treatment modalities for geriatric depression. Other potentially effective interventions now emerging are individual behavior therapy, problem-solving therapy, brief psychodynamic therapy, and reminiscence therapy (Gatz et aL., 1998). When pharmacological and psychosocial interventions are used together, they are potentially more effective than either intervention alone in preventing the recurrence of major depression (U. …