Occupational Therapy Clinical Reference

for Older Adults with Depression

Task Group of Occupational Therapy Clinical Reference for

Older Adults with Depression
Coordinating Committee in Occupational Therapy
Hong Kong Hospital Authority
Convenor / Editor: SEZTO Ngai-wah, Helen, Occupational Therapist I,
United Christian Hospital
YEONG Yi-ling, Eileen, Occupational Therapist I,
Queen Mary Hospital
Core Group Members: CHIN Mei-huen, Annie, Occupational Therapist I,
Kowloon Hospital
Dr. LEE Yuet-ying, Grace, Senior Occupational Therapist
(Advanced Practitioner in Psychogeriatrics),
Kwai Chung Hospital
Ho-lam, Clifton, Occupational Therapist I,
North District Hospital
Support Members: CHAU Pui-chu, Menda, Occupational Therapist I,
Wong Chuk Hang Hospital
CHU Kam-chuen, Thomas, Occupational Therapist I,
Tung Wah Hospital
FUNG Man-lok, Ernest, Occupational Therapist II,
Pamela Youde Nethersole Eastern Hospital
LAI Yung-yung, Natalie, Occupational Therapist I,
Castle Peak Hospital
LAW Siu-tuen, Daphne, Occupational Therapist I,
Shatin Hospital
LEE Ching-kit, John, Occupational Therapist I,
Kwai Chung Hospital
LEUNG Suet-lai, Cammy, Occupational Therapist I,
North District Hospital
WONG Hung, Hester, Occupational Therapist I,
Wong Tai Sin Hospital
First Edition
November 2016
Occupational Therapy Clinical Reference for Older Adults with Depression is originated from
Occupational Therapy Clinical Guideline on Elderly Depression
First Edition: 2002
Second Edition: 2012
1. Background

Like other western developed countries, the proportion of the population aged over 65 in Hong Kong
is projected to rise markedly from 15% in 2014 to 33% in 2064. Among this group, people aged 80
and above is expected to rise from 4.4% in 2014 to 8.2% in 2034 (Census and Statistics Department,
2015). The ageing of population brings new demands and challenges to the local medical and social
services. From the research data in Hong Kong, the prevalence rates of depression in those aged 65
or above, 10.2% and 14.8% of older men and women are suffering from depression (Chiu, 2005).
A local study done (Yip at el., 2003) reveals that depression is a very significant risk factor to
suicidal ideation among Hong Kong Chinese aged 60 or above. According to a local report, the
suicide rate of the older adults aged 60 or above was 27.6 per 100,000 in 2006, which was 106%
higher than that of the total population (13.6 per 100,000) in that year. This report found that
depressive disorder had been the most prevalent among the 2006 suicide deceased with psychiatric
problems (Yip & Law, 2008). A local research (Chiu et al., 2004) also discovers that major
depressive episode is the commonest disorder found among the suicide elderly. Depressive disorders
including major depression, adjustment disorder with depressed mood and dysthymic disorder
significantly increases the risk of local elderly in committing suicide.

Depression and disability interact with each other in various ways, leading to potentially detrimental
consequences, such as complicating the treatment of concomitant physical illnesses, increasing the
risk of new medical problems, increasing mortality, and increasing burden on health care resources
(Apfeldorf & Alexopoulos, 2003). Besides, an overseas research (Cummings, Neff and Husaini,
2003) finds that higher level of depressive symptoms is associated with impairment in instrumental
activities of daily living (IADL). Older adults become at risk for depression when physical and/or
cognitive impairment threaten their independent operation within their home and community.
Having known the above adverse impact of depression on individuals and our community, there is
however ample evidence showing that this psychiatric illness is under-recognized in the primary and
secondary health care sectors, and is also under-treated when cases are recognised (Oslin et al.,
2002).

Depression in elderly can be prevented and is not incurable. Maximizing functional performance,
promoting meaningful life and positive cognition, and enhancing psychological well-being in this
population are of both clinical and research priority in the care service of Occupational Therapists.
This guideline aims to give the best available evidence based practice to local Occupational
Therapists to guide therapist to provide assessment and treatment of service to older adults with
depression in order to improve the quality and standard of service in the OT profession.

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2. Interpretation of Evidence

Once all evidence statements relating to a particular clinical aspect were finalized and agreed by the
members of the Task Group on Clinical Reference for Older Adults with Depression, Coordinating
Committee on Occupational Therapy, of the Hong Kong Hospital Authority, the associated
recommendations were produced and graded (Eccles & Mason, 2001; Mann, 1996).
Recommendations were graded A to C based on the level of associated evidence (see Table 1).
Therapists referring to this guideline should be aware that the ratings of the strength of evidence in
this guideline were based on the contemporary evidence available at the time it was compiled.

Table 1: Hierarchy of evidence and recommendations grading scheme.

Level Type of evidence Grade Recommendation
I Evidence obtained from a single randomized A At least one randomized controlled trial as
controlled trial or a meta-analysis of part of a body of literature of overall good
randomized controlled trials quality and consistency addressing the
specific recommendation (evidence level I)
without extrapolation
IIa Evidence obtained from at least one B Well-conducted clinical studies but no
well-designed controlled study without randomized clinical trials on the topic of
randomization recommendation (evidence levels II or III); or
IIb Evidence obtained from at least one other extrapolated from level I evidence
well-designed quasi-experimental study
III Evidence obtained from well-designed
non-experimental descriptive studies, such
as comparative studies, correlation studies
and case-control studies
IV Evidence obtained from expert committee C Expert committee reports or opinions and/or
reports or opinions and/or clinical clinical experiences of respected authorities
experiences of respected authorities (evidence level IV) or extrapolated from level
I or II evidence. This grading indicates that
directly applicable clinical studies of good
quality are absent or not readily available

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3. Purpose and Scope

Occupational Therapy Clinical Reference in Older Adults with Depression is developed for assisting
our local Occupational Therapists in screening and providing appropriate assessment and
intervention to the depressed elderly. The main focus of this Clinical Reference is on the
evidence-based practice for providing comprehensive Occupational Therapy services to the
depressed elderly in the psychiatric settings by addressing their mood, cognitive and functional
performance and psychosocial functioning.

The selection and application of appropriate assessments and intervention suggested in the reference
will be varies according to different settings, client nature, stages of recovery and experience or
training of individual OT practitioners.

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4. Guiding Principles – Assumptions

It is the consensus of the task group members that the following assumptions are critical starting
points for Occupational Therapists working with depressed elderly, and therefore were used as a
framework for the development of this clinical reference.

4.1 Personal preferences, values and beliefs of our clients should be respected in case management.
All our clients shall lead a meaningful life of their choice.

4.2 Occupational Therapists should empower our clients to return to their valued life roles at home,
work and leisure by making the best use of their capabilities. Hence, the therapists should
examine the clients’ life roles that are meaningful to them. Obstacles hindering individual client
from fulfilling his/ her life roles should be identified. In addition, the therapist should provide
opportunities for them in fulfilling their roles and gaining sense of accomplishment.

4.3 Psychosocial background and lifestyle of clients are critical in their rehabilitation process and
therefore should be addressed. Occupational Therapists should facilitate the clients in
participating in balanced, meaningful and pleasant activities which can enhance their
psychological well-being.

4.4 Occupational Therapists should consider the cognitive, motor and psychological factors relating
to clients’ performance in Activities of Daily Living (ADL) and Instrumental Activities of
Daily Living (IADL), and assist clients to attain optimal functioning within their home and
community.

4.5 Occupational Therapists have an important role in planning safe discharge, providing ongoing
care options and making referrals to appropriate agencies and services for our clients.

4.6 Best practice in Occupational Therapy should be identified based on research evidence.

4.7 Three components of recovery were identified as being distinct to older people with mental
illness: the significance of an established and enduring sense of identity; coping strategies,
which provide continuity and reinforce identity; and the associated impact of physical illness.

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5. Practice Recommendations

The following diagram outlines the flow of information and recommendations that are included in
this clinical reference
Detection and Management of depression in the elderly

Identification of potential depression:


 Risk factors


Screening:
 Symptoms of depression
 Mood
 Cognitive Performance


Assessment:
 Mood Clients with suicidal risk:
 Suicidal Risk Assessment  Refer to Suicidal
 Functional performance Risk Management
 Psychosocial function (Chapter 9)
 Occupational Lifestyle

Non-pharmacological Intervention:
 Cognitive-behavioral Therapy
 Problem-solving Therapy
 Interpersonal Psychotherapy
 Reminiscence Therapy
 Life Review Therapy
 Health Qigong
 Music Therapy
 Occupational Lifestyle Redesign Program
 Self-management Support Programs
 Mindfulness-based Cognitive Therapy
 Relaxation Therapy
 Behavioral Activation
 Art Therapy
 Remotivation Therapy

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6. Identification of Potential Depression

6.1 Risk Factors for depression in the elderly

(Centre for Mental Health, NSW Health Department & Faculty of Psychiatry of Old Age, Royal
Australia and New Zealand College of Psychiatrists, 2001) (Level of evidence: IV,
Recommendation: C)

6.1.1 In the past

• Previous episodes of major depression, mania
• Previous sustained depressive responses to life events
• Personality disorder, or pronounced traits that are dysfunctional
• Previous psychiatric disorder
• Chronic physical illness

6.1.2 Recent
• New, potentially life-threatening or potentially chronic illness
• Substance dependence +/- abuse
• Major life event, especially losses (relationships, finance, position/role)
• Cognitive change
• Move to institutional accommodation (there is a higher incidence of depressive
disorders as a whole (25% +) and major depression (15%+) within the first year of
admission of people to a nursing home)

6.2 Risk factors of elderly depression in Hong Kong

Local community-dwelling older adults possessing the following characteristics are considered
as having higher risk of depression (Chi et al., 2005): (Recommendation: B)

• Living in Hong Kong less than 20 years

• Poor self-rated health status
• Long term pain
• Having visual problems
• Received less social support

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7. Screening

7.1 Symptoms of Depression

7.1.1 According to the tenth revision of the International Statistical Classification of Diseases and
Related Health Problems (ICD-10; World Health Organization, 2016), the followings are the
common symptoms of typical depressive episodes:
• Lowering of mood
• Reduction of energy
• Decrease in activity
• Reduced Capacity for enjoyment
• Reduced interest
• Reduced concentration
• Marked tiredness after even minimum effort
• Sleep is usually disturbed
• Appetite diminished
• Self-esteem and self-confidence are almost always reduced
• Ideas of guilt or worthlessness

7.1.2 The fifth edition of the Diagnostic and Statistical Manual for Mental Disorder (DSM-V;
American Psychiatric Association, 2013) also provides the following diagnostic criteria for
major depressive episode:

7.1.2.1 Five (or more) of the following symptoms have been present during the same two-week
period and represent a change from previous functioning; at least one of the symptoms is
either (1) depressed mood, or (2) loss of interest or pleasure.
• Depressed mood most of the day, nearly every day
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day,
nearly everyday
• Significant weight loss when not dieting or gain, or decrease or increase in appetite
nearly every day
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or retardation nearly every day
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt nearly every day
• Diminished ability to think or concentrate, or indecisiveness nearly every day
• Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a
suicidal attempt or a specific plan for committing suicide

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7.2 Screening Instrument

A systematic review of 18 studies evaluating nine screening instruments in patients older

than 65 years was done (Douglas 2012). The PHQ-2 has a sensitivity of 100 percent and
specificity of 77 percent in these patients (Li et al., 2007) whereas the 30-item and the
15-item Geriatric Depression Scales have a sensitivity of 74 to 100 percent and a
specificity of 53 to 98 percent (Watson & Pignone 2003). Both the 4- and the 5-item
versions are excellent alternatives to the 15-item version (Cheng et al., 2010).

7.2.1 Mood

7.2.1.1 Chinese Geriatric Depression Scale (4–item version)

Chinese Geriatric Depression Scale with 4-item version has been developed in Hong Kong
(Yeong & Chan, 2004). It does bring a “quicker, simpler and reliable” screening tool for
identification of elderly depression. With the cut-off score at 2, it yields a sensitivity of
84.6 %, specificity of 80.9%, positive predictive value of 66.7% and negative predictive
value of 91.9%.

7.2.1.2 Patient Health Questionnaire (PHQ)

The Patient Health Questionnaire PHQ-2 and PHQ-9 are validated screening tools for
screening of depression. The PHQ-2 has a sensitivity of 100 percent and specificity of 77
percent in the patients older than 65. PHQ-2 is a valid screening tool for major depression
in older people but should be followed by a more-comprehensive diagnostic process.
Although its specificity differs by age, sex, and racial and ethnic groups, these differences
appear to be of little clinical significance (Li, Friedman, Conwell et al., 2007). However,
there is no local validated chinese version.

7.2.2 Cognitive Performance

In the clinical setting, patients with late-life depression (LLD) frequently present with
cognitive complaints, and 20-50% of individuals with LLD are estimated to have
cognitive impairment greater than that of age-and education- matched comparators
(Sheline et al., 2006). Cognitive deficits have been associated with increased rates of
depression relapse, poorer antidepressant treatment response, greater overall disability and
functioning (Koenig, A. M., Bhalla, R. K., & Butters, M. A. 2014).

8
7.2.2.1 Cantonese version of Mini-Mental State Examination (CMMSE) (Chiu, Lee, Chung,
and Kwong, 1994)

The CMMSE is a widely used screening measure of global cognitive function among
older people and can be used to assess cognitive functioning of older adults who present
with depressive symptoms (Vinkers, D. J., Gussekloo, J., Stek, M. L., Westendorp, R. G.,
& Van der Mast, R. C. 2004). It is composed of five domains: orientation to time and
place, registration and immediate recall, attention and calculation, language and visual
construction.

9
8. Assessment

8.1 Mood

8.1.1 Cantonese version of Geriatric Depression Scale – Short Form (CGDS-SF)

The 15-item Geriatric Depression Scale is particularly useful for detecting late-life major
depression. In Hong Kong, Geriatric Depression Scale was translated into Chinese (Chiu et
al., 1994) and the Chinese GDS-Short Form (i.e. GDS-15) showed good psychometric
properties in a local population (Lee, Chiu, & Kwong, 1994). With the cut-off score of 8+,
the short form is able to correctly classify slightly over 90% of cases and non-cases in a
mixed group of community-dwelling normal and depressed subjects. A standardized
manual for verbal administration the Chinese Geriatric Depression Scale-Short Form has
been developed in order to improve the reliability of this tool (Wong et al., 2002). Both
the 4- and the 5-item versions are excellent alternatives to the 15-item version, and all are
reasonable tools for detecting the presence of suicide ideation also (Cheng et al., 2010).

8.1.2 The Hamilton Depression Rating Scale

The Hamilton Depression Rating Scale has become the most widely used depression
severity rating scale in the world (Williams, 2001). HRSD also provided a reliable
assessment of depression (Trajkovic et al., 2011). The symptoms are defined by
anchor-point descriptions that increase in intensity; clinicians are to consider both the
intensity and frequency of a symptom when assigning it a rating value.
The scale has a 17-item version that uses a 3-point to 5-point range to quantify data. The
higher the score on HDRS, it represents for more severity of the depression. With a score
greater than 17 (cut-off), it presents for mild to moderate depression. The Hamilton Rating
Scale is thought to be more accurately assessing the behavioral characteristics of
depression, rather than reduced concentration and anhedonia.

8.1.3 Visual Analog Scale (VAS)

Cantonese version of Geriatric Depression Scale – Short Form (CGDS-SF) and The
Hamilton Depression Rating Scale are highly recommended to be used. However, Visual
Analog Scale (VAS) can be considered as a quick assessment scale of mood.

8.1.4 Cornell Scale for Depression in Dementia (CSDD)

The Cornell Scale for Depression in Dementia (CSDD) was specifically developed to
assess signs and symptoms of major depression in patients with dementia. Because some
of these patients may give unreliable reports, the CSDD uses a comprehensive
10
 interviewing approach that derives information from the patient and the informant.
Information is elicited through two semi-structured interviews; an interview with an
informant and an interview with the patient. The interviews focus on depressive symptoms
and signs occurring during the week preceding the interview. Many of the items during the
patient interview can be filled after direct observation of the patient. If there are
discrepancies in ratings generated from the informant and the patient interviews, the rater
should re-interview both the informant and the patient to resolve the discrepancies. The
final ratings of the CSDD items represent the rater's clinical impression rather than the
responses of the informant or the patient. The CSDD takes approximately 20 minutes to
administer (Alexopoulos, 2002).

8.1.5 Depression Anxiety Stress Scales (DASS)

The DASS is a set of three self-report scales designed to measure the negative emotional
states of depression, anxiety and stress. The DASS was constructed not merely as another
set of scales to measure conventionally defined emotional states, but to further the process
of defining, understanding, and measuring the ubiquitous and clinically significant
emotional states usually described as depression, anxiety and stress. DASS-21 is a
theoretically relevant measure of negative emotions that include mixed symptoms of
depression, anxiety, and stress “over the past week.” However, to optimize its clinical
utility, instructions for completing the DASS-21 items might be revised to include
extended time frames (e.g. “over the past 2 weeks”) (Osman et al. 2012).

8.2 Suicidal Risk Assessment

The best intervention for suicide is prevention, which depends on prompt and thorough
evaluation of the potentially suicidal patients (Coordinating Committee, Psychiatry, 2006).

8.2.1 History Taking

i. The reason of the attempt or ideation, the degree of premeditation and perceived lethality
of suicide method considered or adopted.
ii. How the attempt or ideation surfaces to professional care (whether patient has motivation
to seek help).
iii. Whether logistics have been carried out by the patient to prepare for his/her sudden
absence should the attempt be successful.
iv. The presence of any vulnerable family members whose safety may be at risk in the context
of the patient’s suicidal or even violent ideation.
v. Risk factors
a. Demographic data (e.g. old age, male gender, single, divorced, widowed and
unemployment)
b. Predisposing conditions (e.g. chronic painful illness, alcohol related problem, drug
dependence and social isolation)
11
 vi. Problem leading to the self-harm behavior or idea and to see if patent could see differently
or handle more constructively the problem previously troubling him/her after the counseling.

8.2.2 Mental State Examination

i. Patient’s attitude (any evasive / uncooperative)
ii. Current suicidal intent
iii. Any features of depressive disorder
iv. Any concomitant symptoms (e.g. anxiety and insomnia)
v. Psychotic symptoms (especially those which result in agitation, distress and
helplessness)
vi. Own understanding of his/her potential risk with respect to the suicide idea or attempt
and the acceptance to professional help

8.2.3 Screening Question for Suicidal Risk

A single question like “Do you wish to end your life?” (Cheng et al., 2010) can be used for
assessing one’s suicidal tendency.

8.2.4 SAD PERSONS

(Level of evidence: IIa, Recommendation: B)
SAD PERSONS scale is recommended for assessing the likelihood of a suicidal attempt. It is
an easily learned scale utilizing a brief acronym (SAD PERSONS) and based on ten major
risk factors (Patterson, Dohn, Bird, & Patterson, 1983). They are: Sex, Age, Depression,
Previous attempt, Ethanol abuse, Rational thinking loss, Social support lacking, Organised
plan, No spouse and Sickness.
According to Modified SAD PERSONS Score (MSPS), the patient can be considered to be at
a higher risk for suicide if the total points  6.

8.3 Functional performance

Many patients with late-life depression have some problems with activities of daily living
(ADL) and that a substantial improvement in ADL occurs in association with temporal
improvement of depressive severity (Saito et al., 2008). Moreover, the impairment of
instrumental activities of daily living (IADL) is more frequent and strongly associated with
specific symptoms of the severity of depression. (Alexopoulos et al., 1996) Therefore,
assessment of BADL and IADL are essential throughout the treatment process. BADL could
be assessed by Modified Barthel Index, Chinese version (MBI-CV) (Leung, 2003). There are
10 assessment items with a total score of 100. Hong Kong Lawton Instrumental Activities
of Daily Living Scale (HKLIADL) could be used to assess the IADL of the patients (Tong &
Man, 2002). There is a full score of 27 points for rating of 9 items of community living skills.

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8.4 Psychosocial/ Occupational Lifestyle
Occupational lifestyle might affect the well being of a person. In evaluation of one’s life roles,
interests, occupational lifestyle and QOL, the following assessments are recommended:

8.4.1 WHO-5
The WHO-5 is developed to measure the psychological wellbeing of patient. There are a total
of 5 questions and each Question with a rating of 0 to 5 (World Health Organization, 1998).
The Cantonese version of WHO-5 is effective in measuring the well-being and the
effectiveness of the psychological intervention in people with severe mental illness (Kong et
al, 2016).

8.4.2 Chinese version of Personal Well Being Index

Chinese version of Personal Well Being Index (Lau et al, 2005) is a subjective rating of own
well being. There are a total of 8 questions, and each Question with a rating scale of 0 to
10.

8.4.3 Role Checklist / Interests Checklist / Activity Card Sort for Occupational Lifestyle
Assessment
An interview was done to assess patient’s occupational lifestyle including roles and interests,
using Role Checklist and Interests Checklist or leisure pattern using Activity Card Sort for
Older Persons – Hong Kong version (Chan, Chung & Parker, 2006).

13
9. Suicidal Risk Management

(Level of evidence: IV, Recommendation: C)

Clients with risk of suicide can follow the recommendation as below:

General Risk High Risk

 Need regular review or review daily  Patient not to be left alone

with set contact time  Seek urgent specialist help
 Establish safety net-contact person  Advice to Accident and Emergency
 Make a ‘keeping safe’ contract Department for urgent consultation if
 Establish a convincing set of steps needed
that a patient would take if suicidal
impulse became overwhelming
 Consider to refer Elderly Suicide
Prevention Service (ESPP). (Refer to
Appendix 1)

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10. Non-pharmacological Intervention

10.1 Cognitive-behavioral Therapy (CBT)

(Level of evidence: I, Recommendation: A)

CBT is one of the most popular psychotherapies treating depression. It based on the
assumption that depressive disorders are not a direct consequence of external events, but
rather a combination of coping skills deficits, problems with emotion regulation, and an
overly negativistic view of oneself and the world. In CBT, patients work collaboratively
with therapists to identify the types and adverse effects of their negative cognitions on
their mood problems. Therapists, by means of behavioral treatment procedures, assist
patients in developing a repertoire of skills in monitoring and countering these negative
cognition and increasing pleasant events in their daily lives. CBT is reported as an
effective treatment for older adult depression, both clinical and sub-clinical, with sound
evidence from many meta-analyses (Cuijpers, Karyotaki, Pot, Park, & Reynolds, 2014;
Krishna et al., 2013; Gould, Coulson, & Howard, 2012; Pinquart, Duberstein, & Lyness,
2006; Pinquart, Duberstein, & Lyness, 2007; Pinquart & Sorensen, 2001). The benefit of
CBT for depression is not limited to individual treatment but in group format for older
adults as well (Krishna et al., 2011). Its effectiveness can be observed from the improved
results in both clinician and self-rated depression (Gould et al., 2012; Pinquart et al.,
2006).

10.2 Problem-solving Therapy (PST)

(Level of evidence: I, Recommendation: A)

PST is actually a specialized form of CBT. It focuses on tackling patients’ ineffective

coping skills leading to them poor problem solving and subsequent depression. PST assists
patients in developing skills in identifying, defining and understanding a problem, setting
goal with regard to the defined problem, generating and evaluating alternative solutions
for it, and implementing and evaluating the efficacy of the chosen alternatives. The effect
of PST in improving mood of older adults suffering from clinical depression is supported
by both randomized controlled trials (Arean et al., 1993; Gellis, McGinty, Horowitz,
Bruce, & Misener, 2007) and meta-analysis (Cuijpers et al., 2014). Other than greater
reduction in depression level, older adults with clinical depression and executive
dysfunction showed greater response rate and greater remission rate after joining PST
group compared to their counterparts having joined supportive therapy group (Arean et al.,
2010).

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10.3 Interpersonal Psychotherapy (IPT)
(Level of evidence: I, Recommendation: A)

IPT focuses mainly on interpersonal issues relating to depression. It conceptualizes

patients’ social functioning problems as one or more of the four areas: interpersonal
disputes, role transitions, grief and interpersonal deficits. It aims at alleviating depressive
symptoms and assisting patients to improve social functioning. Role-playing,
communication analysis, clarification of wants and needs, and encouragement of affect are
some of the commonly used techniques. IPT is effective intervention for elderly
depression, especially for those suffering from moderate to severe major depressive
disorder (van Schaik et al., 2006).

10.4 Reminiscence Therapy (RT)

(Level of evidence: I, Recommendation: A)

According to Haight and Burnside (1993), RT is a kind of psychosocial intervention

widely used for older adults. The therapy enhances socialization, self-confidence and
increases pleasure of the participants. During RT, therapists guide patients to recollect and
share their past experiences, usually for providing patients’ pleasurable experience and
improving their quality of life. The therapy mainly focuses on positive recall and is
conducted under relaxed atmosphere. Themes and tangible prompts like photographs,
musical tapes, objects of the old days, etc are usually used to trigger patients’ recollection
of the past. Through guiding and encouraging patients to recall, relive and talk about past
events and experiences, therapist assists patients in achieving different goals, such as
decreasing level of depression, enhancing self-esteem and life satisfaction etc. The
effectiveness of RT in treating depressive symptoms of older adults has been supported by
meta-analyses (Bohlmeijer, Smit, & Cuijpers, 2003; Chin, 2007; Pinquart et al., 2007).
Moreover, the effect size is comparable to that of pharmacotherapy and CBT (Bohlmeijer
et al., 2003). Other than reducing depression level, a meta-analysis which did not confine
the subjects to older adults showed that reminiscence intervention brought in other
benefits regarding to purpose in life, preparation for death, sense of mastery, mental health
other than depression, positive well-being, social integration and cognitive performance;
and the levels of change in depressive symptoms and positive well-being did not vary by
age (Pinquart & Forstmeier, 2012).

10.5 Life Review Therapy (LRT)

(Level of evidence: I, Recommendation: A)

Life review refers to a critical analysis of one’s past life. LRT is a kind of directive and
structured intervention conducted on one-to-one basis. During the therapy, patients recall and
review their entire life, covering all developmental phases. Therapists listen to patients with
16
 empathetic understanding and guide patients to report their feelings towards different life
events, evaluate the events. Individual difficult life event will be worked over until it is
acceptable to the patient before progression to another event. Therefore patients need to recall,
reorganize, re-evaluate and re-interpret their past, resolve conflicts at different life stages and
identify new significance and meaning to their life. The ultimate goal of the therapy is to
facilitate patients to achieve integrity (Haight & Burnside, 1993), which, according to Erikson
(1950), is characterized by attainment of life satisfaction and contentment, and coming to
terms with death. The efficacy of LRT in reducing depression among older adults is also
supported by meta-analysis (Cuijpers et al., 2014; Bohlmeijer et al., 2003).

10.6 Heath Qigong--Eight-Section Brocades (Baduanjin)

(Level of evidence: I, Recommendation: A)

Qigong, with a history of around 5000 years, is an ancient Chinese art for improving
personal health and promoting longevity. It is a system of “breathing” or “vital energy”
mind control exercises with positive effects on health (Dong & Esser, 1990). Through the
practice of specific body postures, relaxation exercises, breathing exercises, mental
activities and concentration exercises, exercisers can achieve regulation of their body,
breathing and mind, which in turn improves their health status, strengthens their resistance
against and enhances recovery from diseases. Tsang, Cheung and Lak (2002) speculate
that Qigong, on one hand, alleviates the self-perceived functional limitations of chronic
physical illness sufferers; and on the other hand, raises their sense of mastery and self
efficacy. Such reduction in disability and increase in psychosocial resources will then
reduce the sufferers’ depression and enhance their self-esteem and quality of life.
Eight-Section Brocades is one of the many forms of health-promoting Qigong. It is
comparatively less demanding on the exercisers’ physical and cognitive abilities.
Eight-Section Brocades can be practiced in sitting-style and standing-style. The former
one is more suitable for people who are chair-bound or with poor standing balance to
adopt. Eight-Section Brocades is found effective in relieving depression, improving
self-efficacy and personal wellbeing among elderly suffering from chronic physical
illnesses. It may also affect neuroendocrine system that results in alleviation of
depressive symptoms. Ongoing practice is essential to bring the beneficial effects more
long-lasting. (Tsang, Fung, Chan, et al., 2006 and Tsang, Tsang, Jones et al., 2013). In a
recent meta-analysis conducted by Wang, Chan, Ho, et al. in 2013, although not confined
to older people with depression, the authors suggested that there is a preliminary evidence
that qigong may be potentially beneficial in management of depressive symptoms.

17
10.7 Music Therapy
(Level of evidence: I, Recommendation: A)

Music therapy, according to Bruscia (1991), is “an interpersonal process in which the
therapist uses music and all of its facets to help patients to improve, restore or maintain
health”. It can be regarded as a kind of psychotherapeutic method where musical
interaction is used as a means of communication and expression. In mental health, music
therapy assists patients in socialization and addressing issues which they find difficult to
deal with by words. The approaches of music therapy can be broadly categorized as active
and receptive. In active approach, therapists use clinical techniques to stimulate and guide
patients to compose, re-create or improvise music with their voices or musical instruments.
During the process, therapists help patients to explore their inner feelings and gain insight
into their relational and emotional problems in order to achieve personal growth. In
receptive approach, therapists, through presenting appropriate types of music, assist
patients to relax, reflect, reminisce and change their mood state. Usually the receptive
approach involves an adjunctive activity, such as relaxation practice, meditation and
reminiscence, performed with the playing of the selected music. Stress reduction strategy
incorporated with appropriate music listening is found to be an effective treatment to
reduce level of depression and distress among elderly suffering from major and minor
depressive disorder. (Hanser & Thompson, 1994).

10.8 Occupational Lifestyle Redesign Program (OLSR)

(Level of evidence: I, Recommendation: B)

OLSR is developed basing on the science of occupation and, especially, occupational

therapy theories on personal causation, value, interest, habit and role formation, and
growth trajectory in the Model of Human Occupation. The whole program works within
the realm of positive psychology and occupational therapy, in which both gear towards the
concepts of developing personal strength, fostering personal growth, and pursuing quality
of life. The ultimate goal is leading a pleasant, engaged and meaningful life. Occupational
therapy process plays an important role to help people with physical or psychological
limitations to overcome their internal or external barriers of pursuing happiness. It is
believed that happiness fosters and supports both mental and physical health. Through
individual and group coaching, the program helps clients to make active and conscious
effort in exploring, experimenting, habituating and internalizing old and/or new
occupations, including self care, home maintenance, work, leisure, social and spiritual
activities; and prioritizing and organizing them into a new occupational lifestyle in which
physical and mental health can be maintained; spirit can be nurtured, personal growth can
be facilitated, and meaning and happiness can be fostered. The key therapeutic component
of OLSR includes:

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 • Weekly action plan for exploring, implementing, and reinforcing happiness, flow or
meaning inducing occupations, which are compatible with the physical and mental
capabilities, personal resources, and environmental constraints of the clients
• Provision of a variety of activities and a platform (environment) to facilitate
formulation, implementation and reporting of the weekly action plan
• Task analysis, problem solving, and activity scheduling are techniques for
overcoming barriers and ensuring successful implementation of the weekly action plan
• Emphasis on positive feelings (emotions) generated from successful implementation
of action plan. Such feelings act as the driving force for further activity engagement
• Facilitation for incorporating satisfying occupations into habits and lifestyle
(Leung, 2009)
OLSR has been found effective in lowering the depression level, and promoting vitality,
mental health, social functioning and life satisfaction among older adults who did not
demonstrate overt sign of psychosis and dementia (Clark et al., 2012).

10.9 Self-management Support Programs

(Level of evidence: I, Recommendation: B)

Self-management support, according to Adams, Greiner and Corrigan (2004), is the

“systematic provision of education and supportive interventions by health care staff to
increase patients’ skills and confidence in managing their health problems, including
regular assessment of progress and problems, goal setting, and problem-solving
support.”(p.57). The main goal of self-management support is to prevent relapse by helping
patients to recognize and plan action to tackle the signs of deterioration, and get familiar to
the resources available (Houle, Gascon-Depatie, Bélanger-Dumontier, & Cardinal, 2013).
Like many other chronic illnesses, programs adopting self-management support approach
have been developed for patients suffering from depression, a mental illness with high
recurrence rates. A systematic review done by Houle et al. (2013) had identified 11
intervention components of depression self-management support programs:
• Action plan for changing behaviors
• Behavioural activation for scheduling pleasant activities
• Improving communication with health professionals and social network
• Coping with negative emotions related to suffering from a chronic illness
• Patient education on the prevalence, symptoms, course, treatment options, effective
management and treatment of depression
• Initiating or enhancing positive physical habits, and understanding the link between
healthy habits and mental health
• Personal relapse prevention plan
• Personal emergency plan listing things to do if a new phase of depression is detected
• Learning various skills such as problem-solving, relaxation techniques, coping skills, etc.,
to self-manage the disease,
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 • Self-monitoring of symptoms to identify the early warning signs of recurrence
• Stressing the importance of adherence to medication and psychotherapy to avoid a relapse
or recurrence

Depression program adopting self-management support approach was found associating

with a significant decrease in depressive symptoms and a significant improvement in
antidepressants adherence among patients with recurrent major depression or dysthymia
(Katon et al., 2001); and less severe symptoms among people with chronic or recurrent
depressive symptoms (Ludman et al., 2016).

10.10 Mindfulness-based Cognitive Therapy (MBCT)

(Level of evidence: I, Recommendation: B)

Mindfulness training was firstly introduced by Kabat-Zinn as an 8-session course named

“Mindfulness-based Stress Reduction programme”. In the programme, participants were
taught to become more aware of their mental processes and to develop attentional control
through repeated meditation exercise which includes: body-focused attention, shifting focus
between different kinds of mental content, mindful movement and mindful walking. It also
emphasized to extend mindfulness to everyday activities and practice self-compassion and
acceptance. Later, it was further developed with combination of cognitive therapy to a
treatment programme for preventing recurrence of depression, named “Mindfulness-based
Cognitive Therapy” (MBCT). The MBCT incorporates some of the principles and
techniques of cognitive therapy with mindfulness practice. Selection of cognitive therapy
elements was based on the understanding that at times of lowered mood, people who have
experienced multiple depressive episodes undergo reactivation of ‘modes of being’ that
embraced thoughts, emotions and bodily reactions. It was also based on understanding that
“de-centring” may be a crucial aspect of successful cognitive therapy, particularly effective
when combined with an attitude that is self-accepting and open to experience. MBCT was
designed to be undertaken between depressive episodes, as it might be too demanding for
people who were severely depressed. To prevent recurrence, MBCT incorporates cognitive
therapy techniques such as identifying “signs of relapse” and developing self-coping
strategies when relapse occurs. The strategies included mindfulness meditation which
reduces psychological process resulting depressive ruminations through increase awareness
of present-moment and enhance experience of positive reinforcement in the present moment.
A qualitative study was conducted by Smith, Graham & Senthinathan in 2007, it suggested
that MBCT was a promising intervention for addressing depression in old age and it had
high level of acceptance among the older population. A recent systematic review and
meta-analysis of systematic reviews on standardized mindfulness-based interventions were
conducted to investigate their effectiveness in different patient categories (Gotink, Chu,
Busschbach, et al., 2015). Although the reviews were not confined to older adult population,
it was found that MBCT reduced depressive symptoms and relapse rate significantly when
20
 compared with treatment as usual especially in patients with at least 3 episodes of
diagnosed depression.

10.11 Relaxation Therapy

(Level of evidence: I, Recommendation: B)

Relaxation Therapy refers to a number of techniques designed to teach clients to relax

voluntarily so as to decrease their physical and mental tension. The most common
techniques are the variant of Jocabson’s progressive muscle relaxation training. Others
include guided imagery, biofeedback, controlled breathing, etc. Most of these techniques
involve repetition of a specific word, phrase and muscular activity, and encourage a
passive attitude toward intruding thoughts. A recent systematic review shows that there
are positive effects of relaxation interventions on older adults with depression and anxiety.
Among those interventions examined, progressive muscle relaxation training, music
intervention, and yoga had the strongest intervention effects on depression.
(Klainin-Yobas, Suzanne Yew, & Lau, 2015).

10.12 Behavioral Activation (BA)

(Level of evidence: I, Recommendation: B)

Behavioral Activation views depression as an understandable response to difficult life

circumstances. Depression is maintained if a person experiences low rate of positive
reinforcement and higher rate of negative reinforcement in his/her daily life. BA
hypothesizes that actions, such as avoidance and withdrawal, taken by a person for some
short-term relief from depressive symptoms are actually detrimental in long-run. These
maladaptive behaviors will be negatively reinforced and make the person feel sad, find
fewer activities pleasurable and reduce engagement in pleasurable activities; hence obtain
less positive reinforcement. BA assists patients to identify activities which may provide
them experience of pleasure or mastery. Through Activity Scheduling (AS), patients set
out short term goals and timetable to gradually increase participation in meaningful and
pleasurable activities and increase positive reinforcement in daily life. A meta-analysis
with 16 randomized controlled trails has been done to study the clinical effects of activity
scheduling (AS) on depression in adults and finds that it is an effective treatment for
reducing depression level; and its efficacy is comparable to cognitive therapy and other
psychological treatments (Cuijpers, van Straten, & Warmerdam, 2007a). Moreover, the
beneficial effects of AS is retained for at least at 6 months after treatment. AS is also
regarded as a useful means for recovery by some depressed inpatients (Iqbal & Bassett,
2008)

21
10.13 Art Therapy
(Level of evidence: IIb, Recommendation: B)

“Art therapy is a meeting of the therapeutic process and the creative process.” (Wadeson,
1980). Art making is a form of communication that can be felt, seen and heard. It is an
assertive act, giving the client a sense of control, allowing creative discoveries and
possibilities for change. It brings healing and hopes to clients, helps them to make meaning
of their lives. (Johnson and Sullivan-Marx, 2006) In a review of art therapy for clients with
depression (Blomdahl et al., 2013), the authors examine the healing mechanisms of art
therapy and identified eight therapeutic factors, including self-exploration, self-expression,
communication, understanding and explanation, integration, symbolic thinking, creativity,
and sensory stimulation. Although, there were still limited studies to conclude its
effectiveness on clients with depression, it was suggested that art therapy could be
performed successfully in a wide variety of clinical situations. A local pilot study has been
conducted in Psychogeriatric Day Hospital of Kwai Chung Hospital (Wong et. al, 2015),
positive results were found in participants’ mood and psychological wellbeing, further
randomized control study was in progress.

10.14 Remotivation Therapy

(Level of evidence: III, Recommendation: B)

Remotivation Therapy (RT) is the use of a non-threatening group therapy, which aimed to
satisfy three innate psychological needs of the depressed elderly includes: competence,
autonomy and relatedness. This further help to enhance self-motivation, mental health and
sense of well-being of the depressed elderly and promote contact with reality and facilitate
community re-integration as the ultimate goal. (Sezto & Wan, 2008). A pilot study has
been conducted to a group of older adults in 2016, results showed significant improvement
in social cognition and wellbeing. (Ng, Wong, Lee, et al., 2016).

22
 Appendix. 1

Elderly Suicide Prevention Service

Scope of Service

The Hospital Authority launched an Elderly Suicide Prevention Programme in Oct., 2002 to provide
psychogeriatric service to prevent elderly suicide in partnership with relevant community
organizations, GPs and related health care professionals.

Mode of Service
The service operates as a two-tier model. The first tier is mainly a referral network with NGOs,
DSW, volunteers, GPs, GOPD and other general hospitals within the Mega-cluster. The second tier
consists of Fast Track Clinic, Home visits supplemented with telecheck and elderly suicide early
intervention for assessment and management of suicidal elderly.

Target Client Group

 All elderly clients aged 65 above

 Now not receiving any psychiatric service provided by the Hospital Authority
 Referred by related referrers

Guideline for GP and other medical referral to Fast Track Clinic as recommended by Steering
Committee on Elderly Suicide Prevention Programme is as follows:

When the client:

 Expresses suicidal thought or
 Has plan for suicide or
 Likely to attempt suicide (GP's clinical judgement) or
 Previous attempt of suicide or Moderate to severe depression at risk of suicide.

Consultation at Fast Track Clinic would be arranged within 7 working days. And nurses would
make use of home visits supplemented with telecheck process for monitoring the clients’ progress
and condition.

If the referrer considers the client needed immediate intervention, they are advised to refer the case
to nearby A & E Dept. for urgent consultation.

Referring System

Details please refer to the Internet Site on Elderly Suicide Prevention Service (ESPP) of the Hospital
Authority. Available at: http://www.ha.org.hk/espp/

23
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