A feasibility study for NOn-Traditional providers to support the management of Elderly People with Anxiety and Depression: The NOTEPAD study Protocol

Anxiety and depression are prevalent among older people, with up to 20% reporting symptoms of depression [1, 2]. Demographic changes mean that even if prevalence rates were to remain stable, the growing numbers of older people will translate into large increases in the demand for treatment for these disorders in this population [3]. This will place an increasing burden on health and social care.

Untreated anxiety and depression lead to increased use of health and social care services, and raised mortality [4]. Depression and anxiety are more prevalent in people with long-term physical conditions. The prevalence of depression in people with diabetes may be as high as 30% [5], and the prevalence of anxiety in people with chronic obstructive pulmonary disease is up to 25% [6]. Depression is more than seven times more common in those with two or more chronic physical conditions [5]. Thus, mental and physical health problems tend to become entwined and manifest in complex co-morbidity [7]. As co-morbidities are common in later life (36% of people aged 65–74 and 47% of those aged 75 and over have a limiting chronic illness), they constitute a serious risk factor for developing depression and/or anxiety. Treatment of depression has the potential to improve outcomes for diabetes [7] and to improve mortality from all causes in older adults [8].

Depression and anxiety in older people are poorly detected and managed in primary care [9]. This is particularly the case in people with chronic physical ill health problems [10]. One impediment to detection is that older people may not present to their general practitioner (GP) with depression because of the stigma they perceive about mental health problems [11, 12]. In addition, older people express a preference for talking treatments rather than antidepressants [13].

A one-to-one intervention for older people with depression may be insufficient. According to a systematic review of interventions for isolated and depressed older people [14], nine of the ten effective interventions included were group activities with an educational or support input, whereas six of the eight ineffective interventions provided one-to-one social support, advice and information, or a health-needs assessment. There is a body of evidence demonstrating the beneficial effects of social connectedness on psychological and physical well-being [15‐17]. Indeed, a meta-analysis [15] showed that stronger social relationships were associated with longer life expectancy and the magnitude of the effect was comparable to ceasing smoking, and it exceeded that for obesity, high blood pressure and physical inactivity (the random effects weighted average effect size had an odds ratio of 1.50 with a 95% confidence interval of 1.42 to 1.59), indicating a 50% increased likelihood of survival for participants with stronger social relationships. Forsman’s systematic review [18] suggests that meaningful social activities, tailored to the older individual’s abilities and preferences, should be considered in aiming to improve mental health and well-being among older people. A further argument for increasing social participation is that loneliness and depression are strongly associated in older people [19, 20] and loneliness is an independent risk factor for depression [21]. Evidence from the United States [22] suggests that for lonely older people, there is a potential benefit from group social or educational activities. Thus, it is reasonable to postulate that group activity might be a useful adjunct to treatment for mild to moderate depression. Wicke et al. [23] demonstrate that social support influences health-related quality of life and that this association is strongly mediated by depressive mood, and they suggest that interventions for patients with depression and multi-morbidities should address social dimensions.

Further evidence from a systematic review of social interventions targeting loneliness in older people [24] suggests that the most successful interventions for loneliness, measured by improvement in the domains of physical, mental and social health, tend to be group based, participatory and offering some activity [25‐27]. Such community-based interventions have been shown to have additional benefits in terms of social inclusion and social cohesion [28‐30]. Despite the growing call for a diverse range of support for older people, there remains a paucity of evidence on what works best in reaching those who are most vulnerable [31] and it is clear that better designed studies, and in particular randomised controlled trials (RCTs), are needed to improve the evidence base [24].

Behavioural activation (BA) (a short-term intervention based on cognitive behavioural therapy) is a talking treatment known to be effective in the management of depression [32, 33]. BA focuses on activity scheduling to encourage participants to engage in activities that they may have previously enjoyed but are currently avoiding. In addition, it helps participants to develop new activities that can accommodate changes in life circumstances such as losses (e.g. spousal bereavement). Also, BA encourages participants to be aware of the presence and effects of cognitive processes (e.g. rumination) that may serve to reinforce avoidance and/or lack of engagement. Participants are, thus, supported to refocus on their goals and valued directions in life. The main advantage of BA-oriented interventions over traditional cognitive behavioural therapy for depression is that it may be easier to train non-clinical staff in it [34]. In addition, behavioural therapies have been shown to be effective in older people [35, 36]. BA forms the cornerstone of a number of recent trials where the intervention is delivered by psychological well-being practitioners. Richards et al. [37] found that the intervention for adults of all ages, within a collaborative care model, was effective.

The proposed project is a feasibility study determining whether it is possible to train third-sector workers to deliver a psychosocial intervention to depressed and/or anxious older people and whether this is acceptable to patients.

The target population (older people with anxiety and/or depression) means that this study is of strategic importance to the NHS and social care, and given the existing evidence and changes in demography, has the potential to have a significant impact on many people across the UK. By including the public, service users, the voluntary sector and clinicians in its development, the proposed intervention will likely have a high degree of acceptability and validity, and the findings of any definitive trial will have a higher probability of being commissioned than might otherwise be the case.

This study will inform a definitive multi-centre RCT, which has the potential to contribute to an innovative reorganisation of existing resources across health and social care, including the third or voluntary sector, and more effectively target resources to early intervention, to prevent the deterioration of mental health symptoms in older people.

Screening for potentially eligible participants commenced in January 2017. Recruitment has completed. The follow-up for this study is due to be completed in August 2017.