The University of York’s Kate Bosanquet provides a closer look at the CASPER Trial in collaborative care for depression in older adults.

Why?

There is currently very little in the way of psychological treatment offered for older adults. Some NHS services are leading the way in this, with real progress being made towards improving access to psychological therapies; however, there is a clear disparity across the UK when it comes to levels of care and access.

What?

Aimed at improving the lives of older adults throughout the UK, the CASPER Trial was conducted by researchers at the University of York. Using PCMIS (Patient Case Management Information System) to record patient data, CASPER was the largest-ever UK study in collaborative care for depression in older adults.

CASPER provided evidence that a psychosocial intervention improved the mental health and wellbeing of participants. It also showed that older adults were open to communicating with NHS therapists over the telephone, which means it can be rolled out across the NHS at low cost.

How?

Each participant was assigned a case manager who visited them at their home, in the first instance, before conducting subsequent sessions over the telephone. The case manager used Behavioural Activation within a collaborative care framework to support the participant. Often older adults do not see themselves as depressed, so it was important for case managers to handle this sensitively to establish a good connection with the person.

Some of the key aspects of the intervention were:

• Supporting people to re-establish connections with things they value and with the outside world
• Assessing current resources - family, friends, communication methods - telephone, internet
• Harnessing local knowledge - services, transport, groups - directory of services, sharing knowledge
• Respecting and accommodating personal values - previous work or life roles
• Providing Support to make the first step and regain confidence
• Revisiting what they used to like to do
• Helping to find other ways to be active or get what they need out of life
• Setting small targets or breaking jobs down
• Keeping a balance between routine, necessary and pleasurable activities, using a diary

Below are a few examples which show positive moves made by participants in response to working with the case manager. One lady talked about how she had always been the one to help everyone else and this made her reluctant to seek help from others, as she did not see this as something she did. The case manager suggested becoming a telephone befriender to help others.

"I'd not thought of becoming a befriender myself. I really enjoyed it and i'm helping people. I've always liked helping people."

Another participant volunteered at a hospice.

"...another thing I've started doing which I told (the case manager) about...and she thought it was wonderful. I'd always wanted to do voluntary work...and somebody gave me the name of the lady (at the Hospice) that deals with the volunteers and so I phoned her. Anyway...they've taken me on...and I just go and sit and talk to people."

Another participant become more physically active.

"I started going walking and things that I had not done for two or three years. And I think that was helpful. You know, just making up your mind to do things instead of sat there looking at the telly 24/7...just to move yourself and get on with it."

Functional equivalence

Another key aspect of the intervention was functional equivalence. Often older adults have physical health conditions which prevent them doing things they had previously enjoyed. The case managers were able to encourage participants to think about alternative ways of doing things which would provide similar satisfaction. "It is not what we do that is the most important thing, it is what we get out of doing it or what function it has for us." Case managers worked with people to identify what they got out of an activity they could no longer do, to look at other activities which could replace those functions and provide similar positive rewards to help them stay well.

What's next?

The study team, which also included researchers from the NHS, other universities, and the Hull York Medical School, are now planning to train NHS therapists in Collaborative Care to ensure that older adults all over the UK can benefit from this low cost intervention. It is also hoped that the CASPER findings will form part of the next iteration of NICE guidance on the management of depression/subthreshold depression.

Regarding further studies...

An extended follow-up has just begun where participants will be contacted to do a second diagnostic interview (a brief set of questions over the telephone to establish the participant's current psychological state/level of depression) about four or five years after their initial interview, along with completing a final questionnaire to see if the intervention is effective in the longer term.

The study extension is due to complete in June 2018, so we won't have to wait too long for the results.

For further information on the CASPER Trial please contact Dr Dean McMillan of the Mental Health & Addiction Research Group (MHARG) on dean.mcmillan@york.ac.uk or 01904 321 359.