Logo: to the web site of Uppsala University

The COVID-19 pandemic prompted the use of telehealth interventions for treating depression in older adults. We conducted a pilot study of a telephone-based brief psychological intervention, Behavioral Activation with Mental Imagery (BA-MI), for the treatment of depression in isolated older adults during the COVID-19 pandemic. We achieved promising results regarding a reduction in depressive symptoms. The purpose of the present study was to investigate the participants' experiences of the intervention and provide insight into how the intervention could be improved. Fourteen participants aged 67-85 years that completed the BA-MI intervention were purposively selected and interviewed. The interviews were analyzed using thematic analysis with a descriptive phenomenological approach. BA was experienced as a good way of increasing activities and improving mood, but the opinions on MI were divided. Telephone delivery reduced barriers due to pandemic restrictions but felt less personal and lacking non-verbal communication. Being recognized and talking to a therapist every week was described as healing. When using manual-based psychological interventions, one should aim to make them as person-centered as possible by making room for the patients as individuals with both a past and a present, rather than just focusing on intervention delivery.

Background

Physical inactivity is a major public health concern worldwide. Psychological distress is linked to physical inactivity, which increases the risk of several diseases. Women tend to be more physically inactive than men. Moreover, physical inactivity increases with age in both sexes. Therefore, this study aimed to investigate the association between psychological distress and physical inactivity in adults aged ≥ 65 years, the role of psychosocial factors and explore sex-based differences.

Methods

This study included 14,213 older adults, comprising 7,069 women (52%) (median age = 75 years), who responded to a survey questionnaire sent to a random population sample in Mid-Sweden in 2022. The response rate in the population aged ≥ 65 years was 61%. The association between psychological distress as defined by the Kessler-6 and physical inactivity (< 150 min/week of physical activity) was analyzed using binary logistic regression, adjusting for sex, age, country of birth, educational level, and psychosocial factors.

Results

Overall, 30% of the participants reported psychological distress, and 45% were physically inactive. Psychological distress and physical inactivity were significantly associated (p < 0.001), being more common among women (p < 0.001). In the fully adjusted model, the Odds Ratio (OR) for physical inactivity was 1.46 (95% confidence interval (CI) 1.43–1.50) for women and 1.70 (95% CI: 1.65–1.74) for men regarding moderate psychological distress and 2.87 (95% CI: 2.72–3.04) for women and 2.43 (95% CI: 2.28–2.58) for men regarding serious psychological distress. Not participating in social activities in the last 12 months was associated with physical inactivity in both women and men.

Conclusions

Psychological distress is significantly associated with physical inactivity among older adults. Participation in social activities was identified as an essential factor in addressing physical inactivity. Social connections and physical inactivity are important factors to consider when supporting older adults’ mental health. Public health interventions should promote and raise awareness of physical and mental health as well as the social dimensions of aging, while also considering age and sex-based differences.

Geriatric anxiety scale 10 (GAS-10) är ett självskattningsformulär för ångestsymptom hos äldre vuxna. Syftet med denna studie var att beskriva översättningsprocessen och göra en inledande utvärdering av reliabiliteten och den konvergenta validiteten hos den svenska versionen av GAS-10.

Vi översatte och anpassade GAS-10 till svenska med hjälp av en översättnings- och återöversättningsprocedur. 84 deltagare som var 65 år eller äldre deltog i utvärderingen. Deltagarna fyllde i GAS-10, Hospital anxiety and depression scale (HADS) och Geriatric depression scale 15 (GDS-15), och vi mätte reliabilitet och konvergent validitet, samt undersökte den diagnostiska träffsäkerheten jämfört med HADS-Å.

Den interna konsistensen var hög (0,873). En stor korrelation uppmättes mellan GAS-10 och HADS-Å, och måttliga korrelationer uppmättes med HADS-D och GDS-15. Diagnostisk träffsäkerhet var utmärkt.

Denna studie indikerar att GAS-10 Swe har god reliabilitet och konvergent validitet. Fler studier behövs för att utvärdera den diagnostiska träffsäkerheten i kliniska populationer.

Objectives The Frontal Assessment Battery (FAB) is a screening test for executive functions. The purpose of this study was to describe the translation process and to make an initial evaluation of the reliability and convergent validity of the Swedish version of the FAB, the FAB-Swe.

Methods The FAB-Swe was translated and adapted to Swedish using a translation and back-translation procedure. Seventy community-dwelling participants aged 65 years or older participated. Participants completed the FAB-Swe, the Mini-Mental State Examination – Swedish Revision (MMSE-SR), three established tests of executive functions (FAS, Trail Making Test—part B [TMT-B] and Stroop), and self-ratings of executive abilities. Reliability of the FAB-Swe was measured using Cronbach’s alpha. Convergent validity was measured using Spearman’s rank correlation.

Results Internal consistency was moderately high (.675). Statistically significant correlations were found between the FAB-Swe and MMSE-SR, FAS, TMT-B, Stroop, and education. No significant correlations were found between the FAB-Swe and age or self-rated executive functioning.

Conclusions This study indicates that the FAB-Swe has acceptable reliability and convergent validity. Further normative studies are needed to further investigate the effect of age and educational level. Studies are also needed to evaluate the diagnostic accuracy in clinical populations.

Background

Depression is common in older adults and is related to reduced quality of life and functional ability as well as increased mortality and morbidity. Current guidelines recommend psychological treatments for the treatment of depression in adults. Studies show that about 30% of older adults with depression in Sweden receive pharmacological treatment and about 3% receive psychological treatment. However, a majority receive no treatment at all. There is a need for effective and scalable psychological treatment options for older adults with depression in primary care. Behavioural activation is an extensively evaluated, effective, and relatively simple treatment for depression that can be delivered by health care professionals without comprehensive training in psychological treatment.

Methods

We will conduct a randomised controlled 2-armed parallel group multicentre trial comparing treatment as usual in primary care to a five-session telephone-delivered behavioural activation treatment as add on to treatment as usual. The current trial is open labelled. In all, 250 older adults (>= 65 years) with depression will be recruited from primary healthcare centres in three Swedish regions. The primary outcome is depressive symptoms measured with the Montgomery Åsberg Depression Rating Scale - Self rating version (MADRS-S) after treatment and at 3- and 6-month follow-up. Secondary outcomes include depression diagnoses, activity level (self-rated and measured with accelerometer), and self-rated anxiety, daily functioning, quality of life, self-efficacy, and loneliness.

Discussion

There is a need for fully powered studies of brief behavioural activation for older adults with depression delivered by telephone in a primary care context. This study has the potential to improve first-line treatment of depression in older adults in primary care, consequently reducing morbidity and mortality within this population. Increasing the availability and accessibility to effective psychological treatment for depression in older adults is needed to meet future demographic changes.

Trial registration

ClinicalTrials.gov: NCT06284889. Registered February 28, 2024.

Depression is one of the leading causes of disability in older adults worldwide. Many older adults with depression are undetected, and there is a need for brief, scalable psychological treatments for depression that can be delivered remotely.

The aims of this thesis were 1) to investigate the diagnostic accuracy of two rating scales (PHQ-9 and GDS-15) for the detection of depression in older adults, and 2) to investigate the feasibility, preliminary efficacy and patients’ experiences of a telephone-based psychological intervention, Behavioral activation with mental imagery (BA-MI), for the treatment of depression in older adults in the context of the covid-19 pandemic. 

Study I showed that a cutoff of ≥6 on the GDS-15 and ≥5 on the PHQ-9 were optimal to identify major depressive disorder. When identifying both major depressive disorder and subthreshold depression, the optimal cutoff on the GDS-15 was ≥5. Study II was a randomized clinical pilot trial, CoviDep, with a treatment group receiving the BA-MI intervention, and a control group. The drop-out rate was low. Compared to the control group, the treatment group reported a decrease in depressive symptoms throughout the treatment, with a large effect-size at posttreatment. Study III was a long-term follow-up of participants in CoviDep that received the BA-MI intervention. The drop-out rate over time was low, and compared to baseline, decreases in depressive symptoms were observed with a medium effect-size at posttreatment that was maintained 1- and 3 months post-treatment but lower after 6 months. Study IV was a qualitative study. The BA-MI intervention in CoviDep was described as increasing activities and improving mood. Telephone-delivery reduced barriers due to pandemic restrictions but felt less personal and lacking non-verbal communication. Being recognized and talking to a therapist every week was healing, but the manualized mode of treatment seemed to impair the relationship.

In sum, this thesis shows that both the GDS-15 and the PHQ-9 are useful tools for the detection of depression in older adults, and adds to the support for telephone-delivered BA for the treatment of depression and indicates that MI-interventions are feasible as an augmentation of BA in older adults.

Objectives: The covid-19 pandemic has highlighted the need for psychological interventions for depression that can be delivered remotely to older adults. Pellas et al. (2022) conducted a pilot trial on the preliminary effectiveness of a four-week telephone-delivered Behavioral Activation with Mental Imagery (BA-MI) intervention to N= 38 adults 65 years and older with clinically significant depressive symptoms living in isolation due to covid-19 in Sweden. This study assessed the feasibility of follow-up assessments and within-group symptom change over a six-month post-intervention period.

Methods: Retention rates at post-intervention and follow-up assessments of depressive symptoms (MADRS-S) at five time points were assessed (baseline, post-intervention, 1-, 3-, and 6-month follow- up). Effect sizes (Hedges' g) for within-group change scores were calculated between each time point.

Results: Retention rates over time were 95, 82, 89, and 84%. Mean MADRS-S score was 18.26 at baseline, 13.69 at post-intervention (g= .68), 13.42 at 1 month (g= .74), 13.82 at 3 months (g= .74), and 15.59 at 6 months (g= .41).

Conclusions: Long-term follow-ups were feasible. Within-group decreases in depressive symptoms were maintained with medium effect sizes at 6 months post-intervention.

Clinical implications: Telephone-based BA-MI may be a feasible intervention for depressive symptoms in older adults in isolation with maintained effects over time.

Introduction: To shield older adults during the COVID-19 pandemic, governments around the world have recommended social distancing. This can lead to social isolation and increase the risk for mental health problems such as depression. There is a need for brief, easy-accessible psychological treatments for depressive symptoms that can be delivered remotely. The aim of this study was to investigate the feasibility, acceptability, and preliminary efficacy of telephone-delivered Behavioral Activation with Mental Imagery (BA-MI) for the treatment of depressive symptoms in individuals 65 years and older living in isolation during the COVID-19-pandemic.

Materials and methods: In this open-label pilot randomized clinical trial, n = 41 individuals aged 65 years or older with clinically significant symptoms of depression were assigned to either a BA-MI treatment condition or an Attention control condition delivered over the telephone over a four week period.

Results: Depressive symptoms decreased in the treatment condition but not the control condition. The results in the treatment group were maintained 3 months post intervention. After treatment, 2 out of 16 participants in the treatment condition met diagnostic criteria for depression compared with 9 out of 13 in the control condition. Most participants in the treatment condition were satisfied with the treatment.

Conclusions: This pilot study suggests that BA-MI delivered over the telephone is feasible, acceptable, and potentially efficacious for the treatment of depressive symptoms in older individuals living in isolation. Replication in larger samples in different healthcare settings is needed.

Background and aims: Among older adults, the prevalence of anxiety disorders is 5 – 10 %, and one third report anxiety symptoms.  Assessment of anxiety in older adults is complicated by age-related differences in anxiety symptoms, high rates of medical and psychiatric comorbidities, and cognitive impairment.  The Geriatric Anxiety Scale – 10 item (GAS-10) is a self-rating scale designed to capture anxiety specifically in older adults, with items reflecting affective-, cognitive- and somatic anxiety symptoms. The aim of this study was to make an initial evaluation of the reliability and concurrent validity of the Swedish version of the GAS-10. 

Methods: The GAS-10 was translated and adapted to Swedish using a translation and back-translation procedure. The final version was reviewed by an expert panel of researchers and clinicians. Seventy-two community-dwelling participants 65 years or older (range 65 – 92 years) then completed the GAS-10 and the Hospital Anxiety and Depression Scale (HADS). Reliability of the GAS-10 was measured with Cronbach’s alpha, and concurrent validity was measured using Spearman’s rank correlation between the GAS-10 and the HADS anxiety (HADS-A) and depression (HADS-D) subscales. 

Results: Reliability was excellent (.88). Statistically significant moderate correlations were found between the GAS-10 and HADS-A (rs = .653, p = < .001) and HADS-D (rs = .527, p = < .001). 

Conclusions: This pilot study suggests that the Swedish GAS-10 has acceptable reliability as well as acceptable concurrent validity compared to the HADS-A. Further full-scaled psychometric studies are needed as well as studies evaluating the diagnostic accuracy in clinical populations.