Treatment Considerations for Depression Research in Older Married Couples: A Dyadic Case Study

Abstract

Objective

Critical gaps remain in understanding optimal approaches to intervening with older couples. The focus of this report is to describe the pros and cons of incorporating spousal dyads into depression-prevention research.

Methods

In an intervention development study, the authors administered problem-solving therapy (PST) dyadically to participants with mild cognitive impairment (MCI) and their caregivers. Dyads worked with the same interventionist in the same therapy session. The dyadic PST (highlighted in a case example of a husband with MCI and his wife/support person) and the potential feasibility of the program are described.

Results

The authors found that the wife of the individual with MCI could be trained as a PST coach to help her husband learn and use problem-solving skills. A decrease in depressive symptom severity was observed for the individual with MCI, which was sustained over 12 months of follow-up. Neither the husband nor wife experienced an incident episode of major depression over the course of the study.

Conclusion

Dyadic interventions need to be further developed in geriatric psychiatry; proven methods such as PST can be modified to include patients’ support persons. Recommendations are offered for developing randomized controlled trials that aim to recruit dyads and prevent depression in at-risk older married couples.

INTRODUCTION

Treatments for late-life depression are primarily focused on the patient. However, studies suggest that patient progress may be explained by spousal/partner involvement via support, participation, and collaboration.¹ Little is known about dyadic coping in the context of late-life depression and how older couples negotiate their experiences with depression or other neuropsychiatric disorders. For example, do couples make treatment decisions together; do they engage in joint coping efforts and appraise the situation as “our” stressor? A better understanding of these issues could lead to greater use of dyadic approaches. Dyadic treatments may have an advantage over patient-focused approaches because they not only address the patient’s symptoms but also promote effective support behaviors on the part of the spouse or support person, leading to a better and more durable response in the patient.² On the other hand, dyadic approaches may entail greater burden on the therapist and the couple and may not be reimbursed adequately. Critical gaps remain in understanding optimal approaches to intervening with older couples, which is the focus of this report.

An added challenge to working with older couples (in research and clinical treatment) may lie in depression prevention and identifying couples who are not currently depressed but exhibit risk factors that place one or both members of the dyad at high risk for major depressive disorder (MDD). In particular, individuals with mild cognitive impairment (MCI) function independently but are at high risk of developing dementia, depression, and becoming increasingly dependent, placing stress not just on the patient but on the significant other as well. MCI is frequently accompanied by mild depressive symptoms, which research suggests further increases risk of cognitive decline.³ Individuals with MCI are also at especially high risk of developing MDD that in addition to reducing quality of life, presumably serves to enhance risk of cognitive decline even further (individuals who have experienced even a single episode of MDD are at double the risk of developing dementia relative to those without a history of MDD).⁴

In individuals with MCI and their significant others, depression prevention efforts could target the long-term benefit and health of both members of the dyad, even if a couple does not view their health status as risky or either individual believes he or she needs help from their spouse or support person to manage their health. The goal of this report is to describe our experience incorporating spousal dyads into depression-prevention research. First, we describe why prevention of depression is important in older married couples. Second, we review a depression-prevention pilot study we conducted using problem-solving therapy (PST) in dyads, consisting of an MCI patient and spousal caregiver (Retaining Cognition While Avoiding Late-Life Depression [ReCALL]).⁵ We then discuss a case example of an older married couple participating in ReCALL and randomly assigned to learn PST for the prevention of major depression to illustrate the pros and cons of dyadic treatment.

DEPRESSION IN OLDER SPOUSES

Prior research shows that depressive symptoms are highly related in older spouses; depression in one partner increases the risk for depression in the other.^6,7 Developing dyadic interventions for depression requires the identification of contextual factors that impact the extent to which spouses are affected by their partners’ depression. For example, dyadic interventions that focus on improving spousal support behaviors (e.g., help with symptom management or behavioral change) may work best in couples who report high relationship conflict, low marital quality, or a low level of partner support.⁸ Another contextual factor to consider is relationship closeness. Couples who report greater relationship closeness or interconnectedness may be the most negatively affected by a partner’s depression because they include their partner in their own sense of self.^9,10 Couples who are interconnected are likely heavily involved in each other’s daily routine and would likely benefit from a dyadic treatment plan. Finally, contagion of depression in older couples may be reduced by directly targeting spouses’ well-being. Findings from the caregiving intervention literature suggest it is important to provide spouses with information about treatment, include them as active agents of support, and help them engage in self-care behaviors.¹¹ The importance of caregiver involvement is highlighted in a treatment study of depression and cognitive impairment by Miller et al.¹² In this study interpersonal psychotherapy was modified to include both the patient and caregiver to include caregivers in the therapeutic process of treatment and target interpersonal stressors between patients and their caregivers.

Cross-sectional evidence shows that spouses/family members can be both beneficial and harmful to patients’ symptom severity. Increased emotional support behaviors from spouses and/or family members can increase treatment compliance,¹³ improve treatment response,¹⁴ and decrease relapse.¹⁵ On the other hand, lack of support from spouses and/or family members such as engaging in controlling behaviors,¹⁶ caregiver burden,¹² and frequent couple conflict¹⁷ can independently increase patients’ depressive symptom severity. A systematic review of randomized controlled trials shows that a dyadic treatment approach is superior to usual care in decreasing symptom severity among older patients with MDD.² However, only four treatment trials of MDD were identified in the review (the other articles included smaller proportions of patients with clinically significant levels of symptoms), indicating that remarkably few dyadic interventions have been attempted to treat depression in older adults.

OUR RANDOMIZED DEPRESSION PREVENTION TRIAL

Prevention of MDD in older adults is efficiently accomplished by targeting individuals who are mildly symptomatic because they are at the highest risk for converting to the full-blown clinical disorder (“indicated prevention”).^18,19 We conducted a pilot randomized control trial (ReCALL) to test the efficacy of PST for preventing the onset of MDD and anxiety and reducing depressive and anxiety symptom burden over 12 months in patients with MCI and their spousal/family caregiver (referred hereafter as “support person”).⁵ The ReCALL trial focused on older adults with MCI and their support persons because depressive symptoms frequently co-occur with MCI,²⁰ and spousal caregivers of individuals with MCI are at increased risk for MDD because of caregiving demands.²¹ Participants were recruited from senior centers, primary care physician offices and the University of Pittsburgh Alzheimer’s Disease Research Center, who referred appropriate participants (those diagnosed with MCI) to our study.

Participant Characteristics

We enrolled individuals with MCI who were 60 years or older and scored > 1 on the Patient Health Questionnaire-9 (PHQ-9) with at least a score of 1 on question 1 or 2 (depressed mood or anhedonia). We administered the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,²² to rule out current MDD and anxiety disorder, except for specific phobia. Participants needed adequate physical and sensory functioning to undergo neuropsychological assessment. ReCALL also tested whether moderate-intensity physical exercise might prevent major depression and anxiety; therefore, participants needed the ability to engage in moderately intense exercise (brisk walking) three times per week (for full report, see Gildengers et al.⁵).

Intervention

PST is a cognitive behavioral intervention approach in which the clinician and patient collaborate to identify and effectively manage negative events that a patient is experiencing. The goal of PST is to improve the patient’s ability to cope with stressful life experiences by teaching him or her a systematic approach for solving problems. Components of PST include psychoeducation, active problem solving in sessions, behavioral activation, and homework assignments where patients can apply problem-solving skills. PST entails seven steps: defining a problem, generating solutions (brainstorming), evaluating solutions, comparing solutions, selecting a feasible solution, implementing the solution, and evaluating the outcome.

The rationale for using PST in individuals with MCI is that the cognitive symptoms they experience, such as slowed information processing and impaired memory, compromise problem solving.²³ The underlying assumption of PST is that problem-solving deficits lead to maladaptive coping, increased stress, and, ultimately, psychopathology like major depression.^24,25 ReCALL focused on preventing depression and enhancing cognitive function in individuals with MCI and preventing depression in support persons. Therefore, we modified the traditional PST approach to slow down the presentation and provide extra repetition of information to the MCI participant and to include support persons.

Both patients and support persons were consented participants in the intervention. After the PST model was presented, the patient gave permission to include a support person in each session. Some dyads often had sessions where the support person was present for the patient’s PST session, but occasionally a patient would have an individual session. Ten to 12 sessions of PST were delivered over 16 weeks. Each PST session lasted approximately 60–90 minutes.

The primary motivation for including support persons was to help them serve as the MCI participant’s “coach,” meaning the support person had to be sufficiently trained in PST so that she or he could assist the MCI patient to use PST effectively once the intervention ended. In traditional PST the seven steps are typically taught in the first session; in ReCALL therapists presented two steps per session to ensure the MCI participant understood the problem-solving model and was not overwhelmed by the amount of information presented. The support person was present during the teaching portion of these early sessions, which served several important functions: (1) the therapist modeled a nonjudgmental stance toward both the MCI participant and support person and explicitly taught coaching to the support person along with PST skills, (2) the therapist reinforced to both the individual with MCI and the support person that PST was not couples’ therapy, and (3) the therapist observed the interaction between the MCI participant and support person. Specifically, the therapist followed the PST principle that the intervention is driven by the patient by focusing on the pace of teaching the components of PST, the problems and goals of the MCI participant, and demonstrating a different way for the support person to interact with the MCI participant. The therapist also modeled good coaching and invited the support person to try coaching, offering feedback about coaching that was related back to each step of PST rather than any marital dynamic or personal characteristic. The therapist praised both improved problem-solving skills and coaching skills.

The timing of the session was also modified so it included time to check-in (and/or teach) with both the MCI participant and support person together as well as separately. Individual time with each member of the dyad offered further opportunities for one-on-one teaching and feedback and the space to discuss topics that either member did not want to bring up in front of the other (although often, after individual coaching, these concerns were raised when the dyad was together). Finally, the support person was offered a single session of PST for him- or herself to focus on a problem of his or her choosing. The goal of this session was to check on caregiver burden and to ensure the support person understood the principles of PST and the content of the steps well enough to act independently as a coach. It also served to provide the support person with a tool to help reduce his or her own level or stress.

Assessments

We assessed MCI participants and their support persons six times over a 15-month period: baseline; after the PST intervention (16 weeks from baseline); and at 3, 6, 9, and 12 months postintervention. The primary outcome was the time to onset of an episode of MDD or anxiety disorder as determined by the Primary Care Evaluation of Mental Disorders/The Mini International Neuropsychiatric Interview (PRIME-MD/MINI).²⁶ We also assessed depressive symptom burden with the PHQ-9²⁷ and anxiety symptom burden with the Generalized Anxiety Disorder-7 item Scale (GAD-7).²⁸ We used the Dyadic Adjustment Scale²⁹ to examine marital satisfaction in both the patient and support person and the 22-item Zarit Burden Interview³⁰ to examine caregiver burden in the support person.

CASE REPORT

A 75-year-old white man with MCI and his 65-yearold wife were randomized to learn PST. At the first (meet-and-greet) session, the boundaries for PST were discussed and the couple was informed that the PST intervention is not a form of marital therapy. The clinician discussed how the MCI participant and his wife would work on problems selected by the MCI participant. The role of the support person is to function as a “coach” and “auxiliary brain” who helps to keep the patient on track in learning the seven steps of PST. This understanding had to be reinforced throughout the intervention, because the support person seemed to want her husband to work on problems she believed were important rather than supporting him in the problems he had selected to work on in each session. They both noted that problems in their relationship were significant sources of stress, particularly about their differences in how they each manage their finances. Psychoeducation was important in helping the wife understand her husband’s MCI diagnosis and that he is not being “passive-aggressive” when forgetting to do something but really could not remember.

The MCI participant eventually selected “cleaning up his den” as the focus of his first PST experience. Although it did not directly address their relationship, his selection of “cleaning up his den” seemed to be well received by his wife. He was able to experience the need to break down a larger problem into smaller, more manageable sections. The first section he chose to work on was to develop a list of creditors that he makes payments to each month. This goal was encouraged by his wife because it would immediately reduce the stress she experienced over not knowing how much money they owed to credit card companies.

In the phase of PST where the support person has an opportunity to select a problem of his or her own to work on, she selected “(feeling) being patient and nonjudgmental in order to feel calm” as a goal. She indicated this would allow her to get along better with her husband. The couple also consistently completed the “pleasant daily activity” part of the intervention. The patient said that this part of PST was helpful to him in that it reminded him of all the things he enjoyed doing over the past week. The patient continued to work through the various steps necessary to “clean up his den,” and his wife was supportive of his efforts in that area.

The couple was seen for 11 sessions over 4 months. In Session 6 the husband expressed his desire to “stop being judgmental” as a means of improving his interaction with his wife. He articulated that he wanted to work on his mood and was looking for resources. After he brainstormed all the solutions he knew of the clinician described a book, Mind Over Mood,³¹ that could be used both for himself and for the couple together. The clinician was careful to communicate that the information/resources offered are just that and there is no pressure for the patient to select the therapist’s solution. The patient was interested in getting and reading the suggested book, and his cognitive impairment was mild and not enough to make the book inaccessible. The MCI participant indicated he was beginning to gain an awareness of times when he was more likely to become judgmental and reportedly was “able to catch myself” to keep from becoming so angry at those times. As the sessions progressed the patient continued to work on the goals of cleaning his den and not being judgmental. His wife provided adequate support during the sessions to guide him in “working through” the steps of PST. She was able to state how his behavior had caused difficulty in their relationship and in his relationships with others. In brainstorming solutions he was able to ask his wife for help in supporting him in his efforts to become more aware of when he was treating her in a manner that she considered to be disrespectful. They came to a mutually agreeable method of achieving this solution.

Treatment Results

At baseline the husband reported that for several days he felt down, depressed, or hopeless; had trouble falling or staying asleep; felt tired/had little energy; and felt he moved or spoke slowly (PHQ-9 score: 4). After PST, his PHQ-9 score decreased by 2 points. At the 3-month postintervention follow-up he reported no depressive symptoms; this effect was sustained for the rest of the follow-up period (6 months). The support person reported little to no symptoms over the entire study.

At baseline, marital satisfaction scores were similar for the MCI participant and support person (Dyadic Adjustment Scale score: 26 and 27, respectively). After PST, marital satisfaction increased for the patient (Dyadic Adjustment Scale: 29) and decreased for the support person (Dyadic Adjustment Scale: 23); these scores were sustained across 12 months of follow-up. A closer look at the individual items showed that the MCI participant reported an increase in happiness over the course of the study (“very happy” at baseline and “extremely happy” after PST and at the 12-month follow-up). The support person reported no change in marital happiness and felt “happy” over the course of the study.

The support person reported little or no caregiver burden at baseline (Zarit score: 7).³⁰ She reported she sometimes felt angry and strained when she was around her husband. She believed she did not have as much privacy as she would like because of the need to provide some degree of support for her husband. She also believed her health had suffered because of her involvement in supporting her husband. At the 6- and 12-month follow-up interviews her burden score decreased from a 7 to a 4; she reported feeling less embarrassed over her husband’s behavior. Although the cut-off for mild caregiver burden is 21 on the Zarit Interview, these scores highlight the ups and downs experienced by a spousal caregiver of an individual with MCI.

LESSONS LEARNED

This report describes a dyadic case study where PST, an efficacious treatment for the prevention of MDD in at-risk older adults,^32–34 was modified to include the MCI participant’s wife as a support person. We found that the wife could be trained as a PST coach to promote positive aspects of their relationship. A decrease in depression symptom severity was observed for the MCI participant, which was sustained over time. Neither the husband nor wife experienced an incident episode of major depression over the course of the 12-month follow-up. An increase in marital happiness was also observed for the MCI participant, but no change in happiness was observed for the support person.

Based on our clinical experience and research findings, we offer the following recommendations for developing randomized controlled trials that aim to recruit dyads and prevent depression in at-risk older married couples:

1. It is crucial that the individual with MCI and support person understand the purpose of depression prevention or treatment and the expectations of the intervention protocol (PST). The purpose for the use of PST in working with couples is to teach the skills to both the individual with MCI and his or her support person so the support person can provide beneficial feedback to facilitate the MCI individual in his or her attempt to learn PST. By empowering the MCI patient with the tools of PST, it is hoped he or she will have reduced stress, decreased depression burden, and increased ability to function independently. We found that it was very important to set the duties of the support person as being a “coach” to the MCI participant in the first “meet and greet” session. We also found that psychoeducation was important in helping coaches understand their spouses’ diagnosis.

2. It is important to emphasize that PST is not marital therapy that uses couples counseling to intervene in any relationship issues that may be present between the patient and his or her support person. It is necessary to comply with intervention principles (descriptions of the problem are factual and nonjudgmental) and guidelines (learning is optimized when the problem is not too emotional) so sessions do not become an opportunity for the couple to become stuck in a series of complaints about their relationship. Working with the individual with MCI during the initial PST session to select a personal goal related to having a daily pleasant activity may help alleviate a couple’s urge to discuss marital problems. It is also a less complicated goal that allows the opportunity for the dyad to experience success, thus increasing their motivation and confidence for addressing more difficult problems over the course of the intervention.

3. When screening potential participants, we found that many older adults lived alone and/or did not have a support person who could participate with them. We edited our intervention protocol to include patients with and without support persons. Future research should determine whether PST can be administered to patient–friend or patient–adult child dyads.

4. Some individuals disliked being coached by their spouses, especially when the spouse is the dominant figure in the relationship. In situations whether the patient’s and support person’s ideas about treatment goals differed, the therapist referred back to the PST model of focusing on the patient’s goals. The overall PST framework clearly puts the patient’s treatment goals as primary. If the patient was excessively dependent, that was addressed by reminding the patient that successful PST depends on the patient’s expertise in his or her own life along with the therapist’s expertise in the model. The patient was therefore encouraged to come up with each of the steps independently as much as possible. If the coach was excessively dependent, that was addressed by explicitly talking about the coach’s role in learning PST and supporting the patient. Often, our therapists talked about the coach as being an “extra brain” for the patient. The individual session with the coach was focused on ensuring that the coach fully understood and could apply PST and also provided an opportunity to address a problem specific to the coach, including caregiver burden, coach’s self-care, and potential coaching dynamics. We also believe it is crucial to collect information about the marital relationship to determine who might benefit best from being coached by their spouse. This information would also help describe potential mechanisms of change. For example, greater marital happiness or low caregiver burden might be important mediators or moderators of treatment effects in dyadic treatment studies of depression.

CONCLUSIONS

This report describes the pros and cons of incorporating spousaldyads into depression-prevention research. When intervening with older married couples, it is important to collect information about the marital relationship, because these variables may be important moderators or mediators of treatment effects. Dyadic interventions need to be further developed for prevention of depression in individuals with MCI and their support persons. Our experiences in ReCALL suggest that proven patient-centered interventions like PST can be adapted to the include a patient’s support person.