Mental health care program helps older adults with depression

Researchers in Brazil and the United Kingdom have developed a novel approach that includes training non-specialist health workers to deliver care to the elderly.

By Diego Freire  |  Agência FAPESP – A group of researchers developed an experimental program of care for older adults with depression. After five months of home-delivered care, 87% of enrolled subjects displayed a significant improvement in symptoms, and some even recovered completely.

The pilot program included training for primary care professionals and the development of a computer-based system for interacting with older adults. 

The program involved 33 elderly people with depression enrolled in a local health center in the city of São Paulo, Brazil. The study was conducted by researchers affiliated with Hospital das Clínicas (HC), the general hospital run by the University of São Paulo’s Medical School (FM-USP), and the London School of Hygiene & Tropical Medicine (LSHTM). It was funded by FAPESP and the United Kingdom’s Medical Research Council.

Called ProActive, the approach was developed during the FAPESP Thematic Project “Cluster randomized controlled trial for late-life depression in socioeconomically deprived areas of São Paulo, Brazil”, led by Marcia Scazufca at HC’s Institute of Psychiatry.

“Late-life depression is a serious problem,” Scazufca said. “It’s underdiagnosed and undertreated owing to the scarcity of professionals who specialize in mental health, the high cost of specialized services, and the difficulty of early diagnosis, ideally at the primary care level.”

Scazufca explained that ProActive was designed to be used as part of the Family Health Strategy implemented by the Unified Health System (SUS), Brazil’s national health service, deploying teams typically comprising a general practitioner, a nurse, two nursing assistants and six community health workers. These teams are responsible for family healthcare in specific areas covered by the service.

ProActive is based on four principles: collaborative care, treatment in stages, use of technology, and task shifting, an approach recommended by the World Health Organization (WHO) that consists of training non-specialists to play a new role. The community health workers were trained to act as front-line deliverers of care to older people in their homes.

“There are no other studies of this kind with the elderly in Latin America. It’s a groundbreaking approach and a model that can be adapted by other countries in need of more appropriate methods of delivering healthcare to older citizens,” said Ricardo Araya, Professor of Global Mental Health at LSHTM, who is responsible for the study on the UK side.

ProActive’s use of technology is one of its innovations. A tablet app gives health workers a digital support platform with resources that help them with decision making, keeping records of home visits, participating in clinical supervisions and contacting supervisors in emergencies, among other functions.

The care sequence starts with the collection of information on symptoms of depression and other health problems using a questionnaire built into the app. This information is used in the subsequent stages. Subjects are also invited to watch educational videos that suggest ways of dealing with depression and motivate them to participate actively in their own care.

“The psycho-education and behavioral activation techniques we use are simple, but the literature shows they’re effective for treating depression in short home visits,” Scazufca said.

One such technique is a “wellness-illness wheel” presented in a video by an actress as a way of showing how different kinds of behavior in response to symptoms of depression can help or hinder. Two cartoon characters with depression are then introduced. When sad or apathetic, they choose opposite ways of behaving: one calls a friend or goes for a walk and feels better, whereas the other does nothing and feels worse. The presenter suggests thinking with the health worker about behavioral choices that can “turn the wheel toward wellness.”

Non-specialists

The app is also used to plan patient activities between meetings. The patient’s response in the initial stage determines the frequency of visits, ranging from eight to eleven during the entire intervention, which typically lasts five months.

Home visit logs and other patient records are curated and posted to a secure online platform that doctors and other health professionals can access via a web interface. 

“Our main concern in developing the app was that its main users are not specialists in mental health,” Scazufca said. “They go in to people’s homes with a very important tool to support their delivery of care and to help standardize the actions taken or recommended.”

According to Scazufca, the approach would enable the health system to optimize the cost of treatment by facilitating the delivery of care to more people and preventing the development of other health problems.

“Depression has a very significant negative impact on the quality of life, on relationships, on functional capacity, and on the use of health services,” she said. “In addition, it’s associated with chronic conditions frequently found in older adults, such as diabetes and hypertension. Health systems aren’t prepared to provide for the needs of older people with depression, not just in Brazil but also in many other countries.”

Following the success of the pilot program, the researchers are preparing a clinical trial to evaluate the cost effectiveness of implementing ProActive on a large scale and the feasibility of its incorporation by the SUS.