While many people maintain positive emotional wellbeing as they age, around half of older Australians living in residential aged care have significant levels of depression. Symptoms such as low mood, lack of interest or pleasure in life and difficulty sleeping are common.

Rates of depression in aged care appear to be increasing, and without adequate treatment, symptoms can be enduring and significantly impair older adults’ quality of life.

But only a minority of aged care residents with depression receive services specific to the condition. Less than 3% of Australian aged care residents access Medicare-subsidised mental health services, such as consultations with a psychologist or psychiatrist, each year.

Instead, residents are typically prescribed a medication by their GP to manage their mental health, which they often take for several months or years. A recent study found six in ten Australian aged care residents take antidepressants.

While antidepressant medications may help many people, we lack robust evidence on whether they work for aged care residents with depression. Researchers have described “serious limitations of the current standard of care” in reference to the widespread use of antidepressants to treat frail older people with depression.

Given this, we wanted to find out whether psychological therapies can help manage depression in this group. These treatments address factors contributing to people’s distress and provide them with skills to manage their symptoms and improve their day-to-day lives. But to date researchers, care providers and policy makers haven’t had clear information about their effectiveness for treating depression among older people in residential aged care.

The good news is the evidence we published today suggests psychological therapies may be an effective approach for people living in aged care.

We reviewed the evidence

Our research team searched for randomised controlled trials published over the past 40 years that were designed to test the effectiveness of psychological therapies for depression among aged care residents 65 and over. We identified 19 trials from seven countries, including Australia, involving a total of 873 aged care residents with significant symptoms of depression.

The studies tested several different kinds of psychological therapies, which we classified as cognitive behavioural therapy (CBT), behaviour therapy or reminiscence therapy.

CBT involves teaching practical skills to help people re-frame negative thoughts and beliefs, while behaviour therapy aims to modify behaviour patterns by encouraging people with depression to engage in pleasurable and rewarding activities. Reminiscence therapy supports older people to reflect on positive or shared memories, and helps them find meaning in their life history.

The therapies were delivered by a range of professionals, including psychologists, social workers, occupational therapists and trainee therapists.

In these studies, psychological therapies were compared to a control group where the older people did not receive psychological therapy. In most studies, this was “usual care” – the care typically provided to aged care residents, which may include access to antidepressants, scheduled activities and help with day-to-day tasks.

In some studies psychological therapy was compared to a situation where the older people received extra social contact, such as visits from a volunteer or joining in a discussion group.

What we found

Our results showed psychological therapies may be effective in reducing symptoms of depression for older people in residential aged care, compared with usual care, with effects lasting up to six months. While we didn’t see the same effect beyond six months, only two of the studies in our review followed people for this length of time, so the data was limited.

Our findings suggest these therapies may also improve quality of life and psychological wellbeing.

Psychological therapies mostly included between two and ten sessions, so the interventions were relatively brief. This is positive in terms of the potential feasibility of delivering psychological therapies at scale. The three different therapy types all appeared to be effective, compared to usual care.

However, we found psychological therapy may not be more effective than extra social contact in reducing symptoms of depression. Older people commonly feel bored, lonely and socially isolated in aged care. The activities on offer are often inadequate to meet their needs for stimulation and interest. So identifying ways to increase meaningful engagement day-to-day could improve the mental health and wellbeing of older people in aged care.

Some limitations

Many of the studies we found were of relatively poor quality, because of small sample sizes and potential risk of bias, for example. So we need more high-quality research to increase our confidence in the findings.

Many of the studies we reviewed were also old, and important gaps remain. For example, we are yet to understand the effectiveness of psychological therapies for people from diverse cultural or linguistic backgrounds.

Separately, we need better research to evaluate the effectiveness of antidepressants among aged care residents.

What needs to happen now?

Depression should not be considered a “normal” experience at this (or any other) stage of life, and those experiencing symptoms should have equal access to a range of effective treatments. The royal commission into aged care highlighted that Australians living in aged care don’t receive enough mental health support and called for this issue to be addressed.

While there have been some efforts to provide psychological services in residential aged care, the unmet need remains very high, and much more must be done.

The focus now needs to shift to how to implement psychological therapies in aged care, by increasing the competencies of the aged care workforce, training the next generation of psychologists to work in this setting, and funding these programs in a cost-effective way.

Tanya Davison, Adjunct professor, Health & Ageing Research Group, Swinburne University of Technology and Sunil Bhar, Professor of Clinical Psychology, Swinburne University of Technology

This article is republished from The Conversation under a Creative Commons license. Read the original article.

At least one in ten people have depression at some point in their lives, with some estimates closer to one in four. It’s one of the worst things for someone’s wellbeing – worse than debt, divorce or diabetes.

One in seven Australians take antidepressants. Psychologists are in high demand. Still, only half of people with depression in high-income countries get treatment.

Our new research shows that exercise should be considered alongside therapy and antidepressants. It can be just as impactful in treating depression as therapy, but it matters what type of exercise you do and how you do it.

Walk, run, lift, or dance away depression

We found 218 randomised trials on exercise for depression, with 14,170 participants. We analysed them using a method called a network meta-analysis. This allowed us to see how different types of exercise compared, instead of lumping all types together.

We found walking, running, strength training, yoga and mixed aerobic exercise were about as effective as cognitive behaviour therapy – one of the gold-standard treatments for depression. The effects of dancing were also powerful. However, this came from analysing just five studies, mostly involving young women. Other exercise types had more evidence to back them.

Walking, running, strength training, yoga and mixed aerobic exercise seemed more effective than antidepressant medication alone, and were about as effective as exercise alongside antidepressants.

But of these exercises, people were most likely to stick with strength training and yoga.

Antidepressants certainly help some people. And of course, anyone getting treatment for depression should talk to their doctor before changing what they are doing.

Still, our evidence shows that if you have depression, you should get a psychologist and an exercise plan, whether or not you’re taking antidepressants.

Join a program and go hard (with support)

Before we analysed the data, we thought people with depression might need to “ease into it” with generic advice, such as “some physical activity is better than doing none.”

But we found it was far better to have a clear program that aimed to push you, at least a little. Programs with clear structure worked better, compared with those that gave people lots of freedom. Exercising by yourself might also make it hard to set the bar at the right level, given low self-esteem is a symptom of depression.

We also found it didn’t matter how much people exercised, in terms of sessions or minutes a week. It also didn’t really matter how long the exercise program lasted. What mattered was the intensity of the exercise: the higher the intensity, the better the results.

Yes, it’s hard to keep motivated

We should exercise caution in interpreting the findings. Unlike drug trials, participants in exercise trials know which “treatment” they’ve been randomised to receive, so this may skew the results.

Many people with depression have physical, psychological or social barriers to participating in formal exercise programs. And getting support to exercise isn’t free.

We also still don’t know the best way to stay motivated to exercise, which can be even harder if you have depression.

Our study tried to find out whether things like setting exercise goals helped, but we couldn’t get a clear result.

Other reviews found it’s important to have a clear action plan (for example, putting exercise in your calendar) and to track your progress (for example, using an app or smartwatch). But predicting which of these interventions work is notoriously difficult.

A 2021 mega-study of more than 60,000 gym-goers found experts struggled to predict which strategies might get people into the gym more often. Even making workouts fun didn’t seem to motivate people. However, listening to audiobooks while exercising helped a lot, which no experts predicted.

Still, we can be confident that people benefit from personalised support and accountability. The support helps overcome the hurdles they’re sure to hit. The accountability keeps people going even when their brains are telling them to avoid it.

So, when starting out, it seems wise to avoid going it alone. Instead:

• join a fitness group or yoga studio

• get a trainer or an exercise physiologist

• ask a friend or family member to go for a walk with you.

Taking a few steps towards getting that support makes it more likely you’ll keep exercising.

Let’s make this official

Some countries see exercise as a backup plan for treating depression. For example, the American Psychological Association only conditionally recommends exercise as a “complementary and alternative treatment” when “psychotherapy or pharmacotherapy is either ineffective or unacceptable”.

Based on our research, this recommendation is withholding a potent treatment from many people who need it.

In contrast, The Royal Australian and New Zealand College of Psychiatrists recommends vigorous aerobic activity at least two to three times a week for all people with depression.

Given how common depression is, and the number failing to receive care, other countries should follow suit and recommend exercise alongside front-line treatments for depression.

I would like to acknowledge my colleagues Taren Sanders, Chris Lonsdale and the rest of the coauthors of the paper on which this article is based.

If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.

Michael Noetel, Senior Lecturer in Psychology, The University of Queensland

This article is republished from The Conversation under a Creative Commons license. Read the original article.