Treating depression and anxiety in older adults with physical comorbidities affecting functioning: systematic review and meta-analysis of non-pharmacological interventions

Problem

Depression and anxiety are common in later life, particularly when people have comorbid impairments affecting their functioning (e.g. mobility difficulties, mild cognitive impairment). This combination leads to reduced quality of life, increased disability and increased health/social care use. However, treatments are commonly not tailored to those with functional difficulties, who may face barriers in accessing and participating in non-pharmacological therapies such as psychological therapies. We aimed to review the effectiveness of non-pharmacological interventions for depression or anxiety in this population.

Approach

We searched MEDLINE, MEDLINE in Process & Other Non-Indexed Citations, EMBASE, AMED, Social Science Citation Index, CENTRAL, EED, PsycINFO, CINAHL, SocAbs, Social Care Online and ASSIA (inception-Jul 2017), supplemented by trials register searches, reference list screening and citation tracking. We included randomised controlled trials of non-pharmacological interventions targeted at depression or anxiety in older people aged 60+ with comorbid physical impairments affecting functioning (e.g. low functioning scores, frailty, use of home care services). We used random effects meta-analysis to pool study data where possible and narratively synthesised other data. Two authors assessed risk of bias using the Cochrane risk of bias tool.

Findings

We identified 14 eligible trials including 2099 randomised participants and two subgroup analyses. Problem-solving therapy reduced short-term clinician-rated depressive symptoms (n=5 trials, mean difference in Hamilton Depression Rating Scale score -4.94 (95% CI -7.90 to -1.98)) but not remission rates, with limited evidence for effects on quality of life and functioning. Collaborative care had mixed effects upon remission of depression and depressive symptoms, and no evidence of improvements in functioning or quality of life. Bibliotherapy and life review had only single, small studies. No intervention consistently affected service use, although trials were limited by small sample sizes and short follow-up periods. No interventions targeted at anxiety were identified in this population.

Consequences

In older people with depression and comorbid physical impairments affecting functioning, home-based problem-solving therapy may reduce depressive symptoms. The evidence for the effectiveness of collaborative care is conflicting, and little evidence exists for other therapies. Future research needs to evaluate cost-effectiveness, long-term outcomes and anxiety interventions for this population.