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.

Fluoride is a common natural element found in water, soil, rocks and food. For the past several decades, fluoride has also been a cornerstone of dentistry and public health, owing to its ability to protect against tooth decay.

Water fluoridation is a population-based program where a precise, small amount of fluoride is added to public drinking water systems. Water fluoridation began in Australia in the 1950s. Today more than 90% of Australia’s population has access to fluoridated tap water.

But a recently published review found higher fluoride exposure is linked to lower intelligence quotient (IQ) in children. So how can we interpret the results?

Much of the data analysed in this review is poor quality. Overall, the findings don’t give us reason to be concerned about the fluoride levels in our water supplies.

Not a new controversy

Tooth decay (also known as caries or cavities) can have negative effects on dental health, overall health and quality of life. Fluoride strengthens our teeth, making them more resistant to decay. There is scientific consensus water fluoridation is a safe, effective and equitable way to improve oral health.

Nonetheless, water fluoridation has historically been somewhat controversial.

A potential link between fluoride and IQ (and cognitive function more broadly) has been a contentious topic for more than a decade. This started with reports from studies in China and India.

But it’s important to note these studies were limited by poor methodology, and water in these countries had high levels of natural fluoride when the studies were conducted – many times higher than the levels recommended for water fluoridation programs. Also, the studies did not control for other contaminants in the water supply.

Recent reviews focusing on the level of fluoride used in water fluoridation have concluded fluoride is not linked to lower IQ.

Despite this, some have continued to raise concerns. The United States National Toxicology Program conducted a review of the potential link. However, this review did not pass the quality assessment by the US National Academies of Sciences, Engineering and Medicine due to significant limitations in the conduct of the review.

The authors followed through with their study and published it as an independent publication in the journal JAMA Paediatrics last week. This is the study which has been generating media attention in recent days.

What the study did

This study was a systematic review and meta-analysis, where the researchers evaluated 74 studies from different parts of the world.

A total of 52 studies were rated as having a high risk of bias, and 64 were cross-sectional studies, which often can’t provide evidence of causal relationship.

Most of the studies were conducted in developing countries, such as China (45), India (12), Iran (4), Mexico (4) and Pakistan (2). Only a few studies were conducted in developed countries with established public water systems, where regular monitoring and treatment of drinking water ensures it’s free from contaminants.

The vast majority of studies were conducted in populations with high to very high levels of natural fluoride and without water fluoridation programs, where fluoride levels are controlled within recommended levels.

The study concluded there was an inverse association between fluoride levels and IQ in children. This means those children who had a higher intake of fluoride had lower IQ scores than their counterparts.

Limitations to consider

While this review combined many studies, there are several limitations that cast serious doubt over its conclusion. Scientists immediately raised concerns about the quality of the review, including in a linked editorial published in JAMA.

The low quality of the majority of included studies is a major concern, rendering the quality of the review equally low. Importantly, most studies were not relevant to the recommended levels of fluoride in water fluoridation programs.

Several included studies from countries with controlled public water systems (Canada, New Zealand, Taiwan) showed no negative effects. Other recent studies from comparable populations (such as Spain and Denmark) also have not shown any negative effect of fluoride on IQ, but they were not included in the meta-analysis.

For context, the review found there was no significant association with IQ when fluoride was measured at less than 1.5mg per litre in water. In Australia, the recommended levels of fluoride in public water supplies range from 0.6 to 1.1 mg/L.

Also, the primary outcome, IQ score, is difficult to collect. Most included studies varied widely on the methods used to collect IQ data and did not specify their focus on ensuring reliable and consistent IQ data. Though this is a challenge in most research on this topic, the significant variations between studies in this review raise further doubts about the combined results.

No cause for alarm

Although no Australian studies were included in the review, Australia has its own studies investigating a potential link between fluoride exposure in early childhood and child development.

I’ve been involved in population-based longitudinal studies investigating a link between fluoride and child behavioural development and executive functioning and between fluoride and IQ. The IQ data in the second study were collected by qualified, trained psychologists – and calibrated against a senior psychologist – to ensure quality and consistency. Both studies have provided strong evidence fluoride exposure in Australia does not negatively impact child development.

This new review is not a reason to be concerned about fluoride levels in Australia and other developed countries with water fluoridation programs. Fluoride remains important in maintaining the public’s dental health, particularly that of more vulnerable groups.

That said, high and uncontrolled levels of fluoride in water supplies in less developed countries warrant attention. There are programs underway in a range of countries to reduce natural fluoride to the recommended level.

Loc Do, Professor of Dental Public Health, The University of Queensland

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