A Model for Modifying Interpersonal Psychotherapy (IPT) for Depressed Elders with Cognitive Impairment

Mark D. Miller, M.D.

Valerie Richards, Ph.D.

Allan Zuckoff, Ph.D.

Lynn M. Martire, Ph.D.

Jennifer Morse, Ph.D.

Ellen Frank, Ph.D.

Charles F. Reynolds III, M.D.

From the Intervention Research Center and the Advanced Center in Interventions and Services Research for Late-Life Mood Disorders, University of Pittsburgh School of Medicine

Corresponding Author:Mark D. Miller, M.D., Bellefield Towers; Room 742; Pittsburgh, PA 15213; Phone: 412-246-6009, Fax: 412-246-6030; millermd@upmc.edu

Versions of this paper have been presented at the 2004 American Association for Geriatric Psychiatry, the 2004 International Society for Interpersonal Psychotherapy, and the 2004 International Congress of Geriatric Psychiatrists. This research is supported by T32 MH19986, K01 MH065547, R01 MH37869, R37 MH43832, P30 MH52247, and P30 MH071944.

For submission to Clinical Gerontologist August 26, 2005

The authors wish to acknowledge the contribution of other IPT therapists who have contributed to this work including Lin Ehrenpreis, Jill Houle, Scott Kaper, Julie Marx, MaryAnn Schlernitzauer, Barbara Tracey, Lee Wolfson, Diane Hanlon, Mary McShea and especially Rebecca Silberman Ph.D. and Stanley Imber, Ph.D. both of whom passed away in 2005. The authors dedicate this paper to the memory of Dr. Silberman and Dr. Imber.

Abstract:

The authors review the psychological and emotional aspects of late-life depression complicated by cognitive impairment and propose a treatment model for modifying interpersonal psychotherapy (IPT) to better serve this group of patients and their family caregivers. The key component of this modification, named IPT-CI (for Cognitive Impairment) is a combined patient/caregiver approach that provides psychoeducation for both parties, opportunity for problem solving for both parties individually, and a forum for role dispute resolution through joint meetings. Caregivers thus have regular input into the therapeutic process and are encouraged to extend the therapeutic work between meetings to help the patient to maintain progress despite memory loss and/or impairments in insight, judgment or executive function. A detailed case vignette provides an illustration of the use of this modified form of IPT.

Keywords: Depressed, elders, cognitive, impairment, late-life

Introduction:

This report proposes modifications to Interpersonal Psychotherapy (IPT, Klerman et al., 1984) that are designed to better serve the needs of depressed elders with mild to moderate cognitive impairments as well as those family members who give them care. The major modification of IPT is the systematic incorporation of caregivers into the treatment process.

We review the literature on the challenges of treating depression in elders who are also cognitively impaired, the psychological and emotional aspects of this combination, the impact on caregivers and their link to successful treatment outcome. The basic tenets of IPT are briefly reviewed with emphasis upon the rationale for the proposed changes, particularly the profound social and interpersonal role transitions that can occur with cognitive impairment in the identified patient and the role transitions that occur in the caregiver.

Cognitive Impairment in Late Life Depression

Depression in later life is a serious public health concern associated with high rates of suicide, nonadherence to existing medical treatments, a negative impact on quality of life and health, and amplification of functional disability. Cognitive impairment adds increased disability to the clinical presentation and complicates the course of treatment of depressed elders. Patients with both depression and cognitive impairment display greater symptom severity including significantly more dysphoric mood, vegetative signs, feelings of guilt and worthlessness, suicidal ideation, loss of motivation and social withdrawal. Depressed patients with executive dysfunction also experience psychomotor retardation, reduced insight, suspiciousness (Alexopoulos, 2002) and pronounced behavioral disability (Kiosses et al., 2000). The negatively affected cognitive domains include: information processing speed, executive function, visuospatial ability attention and inhibition, working memory and both verbal and visuospatial memory (Butters et al., 2004). Cognitive impairment has been identified as a marker for delayed depression treatment response, incomplete response to antidepressants, and greater risk of recurrence of depressive symptoms (Alexopoulos et al., 2000; Alexopoulos, 2002).

Our own preliminary studies in non-demented elderly subjects with remitted major depression indicate, on the basis of cognitive impairment alone, that about 60% may qualify for a diagnosis of Mild Cognitive Impairment (MCI), primarily the Petersen Criteria defined MCI-other rather than MCI-amnestic subtype (Peterson, 1995; Peterson & Schmidt, 1999). The MCI literature suggests that depression in old age often accompanies but does not cause MCI (Meyer et al., 2002; Reischies & Neu, 2000; Goldman et al., 2001). More recently however, amnestic MCI is increasingly thought to be a risk a factor for or precursor to either Alzheimers dementia or, less commonly, vascular dementia (Peterson & Schmidt, 1999; Bozoki et al., 2001). Moreover, in the first population-based study of neuropsychiatric symptoms in MCI, the CHS cognition study, 20% of MCI participants exhibited depression, 15% apathy, and 15% irritability (Lyketsos et al., 2002). While 58% of our non-demented, remitted depressed patients meet cognitive criteria for MCI in general, only 2% are impaired exclusively in the memory domain. There is also evidence that executive dysfunction, including difficulties with initiation and preservation, amplifies disability associated with depression in old age, decreases response to acute antidepressant treatment, and increases the risk of depression relapse during continuation/maintenance treatment (Kalayam & Alexopoulos, 1999; Alexopoulos et al., 2000; Alexopoulos et al., 2002). Thus, our preliminary studies suggest that cognitive impairments are highly prevalent, pleomorphic, and persistent in older depressed patients even after their mood disorder has responded to antidepressant medications.

The primary hypothesis of the second Maintenance Therapies Trial in Late-Life Depression (MTLD-II 3/1/99 - 6/30/03) (MTLD-II) is that combined treatment with paroxetine and monthly interpersonal maintenance IPT will be superior to either active treatment alone and to clinical management with placebo in prolonging recovery and minimizing the burden of residual depressive symptoms. Interim survival analyses show an effect for paroxetine on duration of recovery (i.e., time to recurrence) but not for traditional IPT (unpublished data from C.F. Reynolds III, 7/20/05)., indicated by a significant Wilcoxon chi-square for paroxetine versus placebo of 4.76 (df=1; p<.03). Mean time to recurrence for paroxetine-randomized subjects was 77 weeks versus 43 weeks for placebo randomized subjects. We detected no difference in the four-group survival analysis (Wilcoxon chi-square = 4.84, df=3, p=.18). These data partly confirm the primary study hypothesis of MTLD-II, with support for the hypothesized effect of paroxetine maintenance therapy on prolonging recovery from major depression but fail to confirm the value of traditional IPT in prolonging recovery. We believe that failure to show the added value of maintenance IPT in MTLD-II could reflect differences in the sample compared with MTLD-I (Reynolds et al., 1999), where IPT maintenance was shown to prolong recovery and enhance social functioning in non-demented elders with recurrent depression. The MTLD-II study group had a greater burden of cognitive impairment. Many subjects had difficulties with achieving and maintaining a focus in IPT sessions. Our therapists reported that therapy sessions with cognitively impaired patients were often like supportive psychotherapy, rather than being specifically focused on interpersonal issues. As IPT has many user-friendly strengths we asked ourselves how it might be modified to better serve this group of patients.

Psychological and Emotional Aspects of Depression with Cognitive Impairment

Patients with both depression and cognitive impairment tend to display greater levels of both psychosocial and functional impairments than patients with depression alone. These neuropsychological deficits are accompanied by psychological, emotional, and behavioral changes. For example, decreasing attention span can lead to a loss of interest in activities and make it difficult for the person to participate in the flow of everyday events and master new skills. Difficulty modulating affect and responding empathically to emotional stimuli strains relations with others and can be perceived as a personality change by others. Impaired recall may lead to confabulation or confusion, further separating the person from meaningful engagement with others. Word finding difficulty impedes communication with others and contributes to a decline in interpersonal problem solving ability, which can lead to impaired coping, lowered stress tolerance, apprehension, social withdrawal, hopelessness, and suicidal ideation/behavior.

The Impact on Family Caregivers and their Link to Treatment

Depressed elders with cognitive impairment present with problems that are uncommon among younger adults. Late-life depression can lead not only to excess social and physical disability, but also to excess burden for their caregiving family members. A vast literature documents that family members of physically or cognitively impaired older adults often experience poorer mental and physical health themselves as a result of providing ongoing assistance (Schulz & Beach, 1999; Schulz et al., 1995; Wright et al., 1993; Mahoney, Hons, Regan et al, 2005; Vitaliano, Young, Russo et al, 1991; Russo, Vitaliano, Brewer et al 1995). Interpersonal tensions associated with late-life depression have been shown to complicate caregiver efforts to provide physical assistance to the patient (Hinrichsen & Zweig,1994). Caregivers of older adults who are both depressed and cognitively impaired may be at high risk for clinical depression themselves (Teri et al.,1997, Mohoney et al 2005).

Family caregivers for depressed older adults, in turn, can have a potentially positive impact on the physical and emotional well being of these patients. Family members frequently initiate treatment for depressed elders and are often crucial in maintaining treatment adherence and follow-up by convincing ambivalent patients of the merits of treatment and by providing transportation and logistical support. Family members play a critical role in the older patients adherence to a medication or psychotherapy regimen and in the reporting of medication side effects (National Institutes of Health, 1992). Moreover, family caregivers may significantly impact the patients response to depression treatment and his or her ability to stay well (Hinrichsen & Hernandez, 1993).

Caregiving family members often begin to feel compelled to provide more supervision and problem-solving assistance as cognitive decline and functional impairments become more obvious. Interpersonal role disputes can arise between the subject and the caregiver(s) over issues of safety, driving, nutrition, hygiene, sexual behavior, compliance with medical treatment, socially inappropriate behavior, and financial issues. Given the links between late-life depression and family caregiver stress, psychiatric treatments that specifically engage the primary caregiver(s) may increase the odds of patient recovery from depression (Joiner & Coyne, 1999; Keitner et al., 1995). Previous research on clinically depressed, cognitively impaired older adults has shown that behavioral treatment of the patient through the family caregiver (e.g. enhancement of problem-solving skills) resulted in decreased depression for both patient and family caregiver (Teri, 1997; Teri. Mckenzie and Lafazia 2005). Our own findings also suggest that it is beneficial to target family members of older depressed patients using psychoeducational strategies. Patients whose family members received education and support were less likely to drop out of continuation treatment than patients whose family members did not receive these interventions (Sherrill et al., 1997).

What is IPT and How is it Relevant to Depressed Elders with Cognitive Dysfunction?

Interpersonal psychotherapy is based on the premise that although depression has multiple causes it is always expressed in an interpersonal context