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Using interpersonal psychotherapy to reduce depression among home-bound elders: a service-learning research collaboration.

The number of older adults with mental health needs is rapidly increasing, and yet this segment of the population is vastly underserved.

Estimates of major depression in older people living in the community range from less than 1 percent to about 5 percent, but rises to 13.5 percent in those who require home healthcare and to 11.5 percent in elderly hospital patients.

An estimated 5 million have subsyndromal depression, symptoms that fall short of meeting the full diagnostic criteria for a disorder.

Subsyndromal depression is especially common among older persons and is associated with an increased risk of developing major depression. (National Institute of Mental Health, 2007)

However, only 3 percent of older adults have ever sought assistance from mental health professionals (U.S. Department of Health and Human Services [DHHS], 2001). Potential barriers to seeking mental health services include lack of financial resources or inadequate medical insurance, medical issues that may interfere with ambulating or driving, inadequate mental health screening and referrals by primary care physicians, poorly integrated systems of care, ethnic disparities in access to care, and perceived social stigma associated with the need for mental health treatment (Borson, Bartels, Colenda, Gottlieb, & Meyers, 2001; Estes, 1995).

More important, another impediment to the adequate provision of mental health services to older adults suffering from depression concerns the paucity of mental health professionals with specialty training in geriatric mental health. Recently, efforts have been underway to recruit professionals to work specifically with geriatric populations, both because potential providers typically steer away from working with older adults, and also because the projected number of older adults with depression is expected to increase over the next two decades. Indeed, demographers predict that by the year 2030, 20 percent of the nation's population will be over age 65, with 25 percent having significant symptoms of mental illness, including anxiety, cognitive, and mood disorders (U.S. DHHS, 2001; Snowden, Steinman, & Frederick, 2008). Thus, in response to the national need to prepare social workers for careers in geriatrics, innovative collaborations between social work programs and community organizations are being formed. This article describes a collaboration that took place between the Binghamton University Department of Social Work and Faith-in-Action, a volunteer program of the Broome County Council of Churches that provides services to older adults in the community. This academic and community collaboration resulted in the development and launching of a master of social work (MSW) service-learning research class, in which students developed skills in an evidence-based mental health intervention, provided mental health services to home-bound older adults in the community, and contributed to the beginning evidence base for the efficacy of using interpersonal psychotherapy (IPT)-informed treatment to reduce depression among older adults in home-based settings.

The Benefits of Service-Learning Research Projects

Service learning is a method of teaching, learning, and reflecting that combines academic classroom curriculums with meaningful service within a community. Service-learning research projects provide benefits to community members, students, and instructors, alike. In an era where community resources are dwindling and needs are increasing, service-learning collaborations provide cost-effective ways to build capacity in human service organizations. That is, students-in-training may provide services in agencies that otherwise would not have the staffing to provide such services. In the case described herein, social work students provided clinical services to clients in agencies that did not have social workers on staff. Service-learning projects also provide hands-on opportunities for students to develop and master skill sets that are immediately beneficial both to their own professional development and to their communities. Faculty members are able to integrate simultaneously teaching, service, and research into their work, thus increasing their value to their institutions, communities, and profession. Thus, service-learning research projects achieve simultaneously three goals. Underserved populations in the community are provided needed services, students are provided opportunities for experiential learning, and research may be conducted to contribute to the current knowledge-base.

IPT with Older Adults Suffering from Depression

IPT is founded on the seminal contributions of Adolf Meyer, Harry Stack Sullivan, and John Bowlby, whose theoretical contributions include, respectively, social psychology, interpersonal psychiatry, and attachment theory. With regard to the latter theory, IPT is the only evidence-based, manualized approach that focuses on relationships as a cornerstone of the model, despite the fact that the quality of the therapeutic relationship has been found to be the most salient predictor of successful treatment outcomes across all approaches (Safran & Muran, 1994).

Originally developed collaboratively by Klerman, Weissman, Rounsaville, and Chevron (1984) for the treatment of acute depression, the principles of ITP integrate an environmental/social model and a disease model of depression. IPT is a manual-based, short term (twelve to sixteen sessions) therapeutic approach in which the therapist works simultaneously to reduce depressive symptoms and target interpersonal problem areas (i.e., grief, role disputes, role transitions, or interpersonal deficits) using flexible supportive techniques. IPT may be ideally suited for older adults because the interpersonal problem areas, especially role transition and grief, are compatible with the types of issues that older adults suffering from depression typically face. Also, IPT has a psychoeducational focus, is conversationally based, and collaborative, which bodes well for its use with older adults (Iselin & Hinrichsen, 2008). Moreover, IPT may be preferable, at times, to cognitive behavioral therapy (CBT), a well-validated approach because older adults may perceive CBT to be burdensome, in terms of homework assignments and to-do-lists (Miller, 2009). Finally, IPT is well suited to the goals of social work practice, in that it uses a biopsychosocial conceptual definition of depression.

IPT has been validated extensively through research studies and clinical trials and has been studied in a wide range of cultures and socioeconomic groups with adults and adolescents with mood disorders. IPT has also been found to be an effective treatment for late-life depression (Schulberg et al., 2007) as well as effective for the treatment of recurrent depression among older adults in combination with nortriptyline (Reynolds et al., 1992), as a monthly maintenance treatment to prevent recurrences of major depression in older adults dealing with role conflicts (Miller, Cornes, Houck, & Reynolds, 2003), and with older adults with varying rates of cognitive function (Carreira et al., 2008). Hinrichsen and Clougherty (2006) developed a manual that may be used by practitioners wishing to use IPT with older adults.

Overview of IPT

Relieving depressive symptoms is the main goal of IPT. Toward this end, interpersonal relationships are viewed as key to both the maintenance and also the remediation of depressive symptoms. Within IPT, there is no attempt to change the underlying personality structure. Indeed, the approach may be most effective for individuals who are experiencing acute or reactive depressive symptomatology, rather than chronic depression. ITP may be used concomitantly with psychotropic medication, and with better results that those obtained from medications alone. Although psychoeducation about the biopsychosocial basis of depression is emphasized, within the approach clients are typically given the "sick role" to emphasize parity with medical illnesses. This aspect can be somewhat disconcerting to social work students who have been trained in strengths-based approaches, but students who participated in the class also acknowledged that for some individuals a diagnostic label was a source of relief and a frame for understanding one's lack of motivation, energy, and interest in usual activities.

The focus within IPT is on current issues, rather than early childhood or past experiences, although an interpersonal inventory of significant lifetime relationships is an important aspect of the assessment. Also, the focus is on real, interpersonal relationships with others, rather than the development or analysis of the transference relationship. Miller (2008) described the therapeutic role as one of "benevolent facilitator" (p. 16). Termination is handled by reviewing the client's progress in developing coping strategies that result in decreased depressive symptoms and identifying ways of managing future life events.

As summarized by Miller (2008), the basic steps of IPT include "a thorough initial psychiatric evaluation, establishing a treatment contract for 12 to 16 weekly face-to-face individual sessions, assigning the patient the 'sick role,' and soliciting the interpersonal inventory" (p. 17). Early on, the therapist, in collaboration with the client, identifies which of four foci (unresolved grief, role transitions, role disputes, or interpersonal deficits) best characterize the client's main issues. Each of the four problem areas uses specific manualized strategies to reduce depressive symptoms. In addition, all problem foci use strategies of "encouraging affect, clarification, communication analysis, use of the therapeutic relationship, decision analysis, and role play to effect change" (Miller, 2008, p. 17).

Description of Class

The elective course, "Mental Health Treatment for Home Bound Elders," was offered to advanced MSW students in their final semester of the program. One first-year student was allowed to enter the course, with permission of the instructor. Students were informed about the opportunity to participate in a service-learning class in the semester before the class convened. One of the concerns raised initially by perspective students related to the extra time requirement necessitated by working with clients in the field. On a logistical level this concern was addressed by reducing the weekly in-class time to two hours, rather than the usually required three hours of class. The third hour was allotted to the time that students would spend in the field meeting weekly with clients.

The class was configured so that each student would have the opportunity to provide twelve weeks of interpersonal psychotherapy-informed treatment to seniors, with whom they were matched by the project coordinator, a volunteer staff member of the research partner, Faith-in-Action. Throughout the semester, each student received one hour of in-class didactic instruction in IPT and one hour of in-class clinical group supervision weekly. Two supervisory groups of seven students each were formed. To accommodate students' schedules, each student was required to attend two hours of class each week--an hour of lecture and an hour of group supervision. Students also were required to visit clients in their home weekly at a time that was mutually convenient.

IPT is a twelve- to sixteen-week protocol that is divided into three phases: (1) initial sessions (two to three weeks), (2) intermediate sessions (six to ten weeks), and (3) termination (two to three weeks). The students were provided an overview of the model in the first two weeks of the course, and then, coinciding with the scheduling of each of twelve sessions, students were introduced to the issues, goals and strategies, and specific techniques of each phase of the treatment. The main textbook used in the course was Interpersonal Psychotherapy for Depressed Older Adults by Hinrichsen and Clougherty (2006). The didactic portion of the course utilized PowerPoint presentations, video illustrations of the approach, and a discussion period where students could ask questions directly relevant to their work with their clients. The students were asked to turn in weekly process recordings and reflective analyses of their work. On a rotating basis, each student presented their work to their assigned supervision group. In addition, the instructor provided weekly written feedback on the students' process material. As a whole, the course required that each student complete three graded assignments--the weekly critical reflective analysis, worth 50 percent of the grade; active participation in class discussions and group supervision, worth 25 percent of the grade; and an integrative final paper, worth 25 percent of the final grade.

Integrating Research into the Service-Learning Class

In addition to achieving the joint goals of training students in an evidence-based psychotherapeutic approach, and providing needed services to an underserved population of older adults, this project also served as a feasibility study. A research proposal was submitted and approved by the University's Institutional Review Board. All students were required to take an online course in conducting research with human subjects and were then certified to participate as co-investigators. The research study was designed to evaluate the feasibility of using MSW students to provide a twelve-week trial of IPT-informed psychotherapy. The study also sought to evaluate the effectiveness of the approach in reducing depressive symptoms among fourteen home-bound older adults. Moreover, the study planned to identify barriers to providing home-based IPT-informed psychotherapy to older adults, which had not been examined previously in the extant literature.

The Instructor's/Primary Investigator's Qualifications

In addition to being an assistant professor in the department of social work, the instructor was a licensed clinical social work (LCSW) with over twenty-four years of clinical practice experience, including working with older adults with depression and anxiety. At the time the course was convened, the instructor was also providing IPT treatment to a number of older adults with depression and cognitive impairment in partnership with a county office of services for the aging in a suburb of Philadelphia. In addition to having received advanced training in interpersonal psychiatry, as developed by Harry Stack Sullivan, at a training institute in New York City, the instructor also received weekly phone supervision in the provision of IPT with older adults by a certified IPT trainer, who also had developed a modification for IPT for older adults with cognitive impairment (IPT-ci; Miller, 2009). The weekly supervision was conducted to strengthen the fidelity of the training offered to students. However, by the time the course was launched, the instructor had not yet been fully certified in IPT, as established by criteria set forth by the International Society for Interpersonal Psychotherapy (ISIPT). Therefore, both training and also treatment fidelity could not be assured. Thus, for accuracy's sake, it is stated that study participants received IPT-informed psychotherapy.

Research Questions

Two research questions were posed at the beginning of the study to determine efficacy: (1) Does the administration of IPT-informed treatment by MSW students in training decrease symptoms of depression in home-bound elders over the course of twelve weeks; and (2) does the administration of IPT-informed treatment result in improvements in any specific domain of cognitive functioning. Feasibility was assessed at the conclusion of the intervention, in part, by asking subjects a series of open-ended questions. These questions were posed by independent data collectors (not students of the course).

1. What was your overall experience of having the student come to your home?

2. What was most helpful about the experience?

3. Do you have any suggestions as to how the process may have gone more smoothly?

4. Would you recommend the experience to another person, why or why not?

5. Are there any additional thoughts you would like to share about the course?

The focus group (with students on the last day of class) included the following open-ended questions: (1) What benefits and/or challenges arose by seeing clients in their homes? and (2) What worked well in the course and what didn't work as well? The focus group was convened by the course instructor and the project manager, who was not a student in the course.

Description of Research Procedures

Potential participants were screened prior to the commencement of the course. The Faith-in-Action program of the Broome County Council of Churches initially identified clients who presented with depressive symptoms. These clients were contacted by a representative of the Faith-in-Action program who advised them of an opportunity to both receive cost-free mental health treatment by advanced MSW students from the Binghamton University Department of Social Work, and also to participate in a research study. Interested individuals were referred to the project coordinator to arrange an appointment. Forty-two individuals were referred for participation in the projects.

The project coordinator then spoke by phone with potential participants. She explained the study and answered any questions posed by the potential participants. She spoke with thirty-seven potential participants and six caregivers (e.g., a child or friend). Of this group, eighteen were not screened for further participation--nine due to lack of interest or time, two due to seeing other therapists, one due to youthful age, four due to obvious cognitive problems, and two for other unknown reasons. She met individually with nineteen individuals. During these meetings the consent for participation was reviewed, and the potential participants were asked to sign the consent form. In cases where the participant was unable to sign the form for themselves, a legal guardian or other designated individual was asked to sign the form. In this latter case, the potential study participant was also asked to sign an assent form.

On acceptance into the study, baseline measures of functional impairment of depression, using the Hamilton Depression Rating Scale-24 (HAM-D; Hamilton, 1960), were collected. The HAM-D was chosen to measure pre- and postdepression scores, as it is an outcome measure that is primarily used in clinical trials. The HAM-D has been validated for diagnostic accuracy, reflecting good sensitivity and specificity across genders and with older depressed community residents (Mottram, Wilson, & Copeland, 2001). Two independent data collectors, who were not students in the course, received formal training in the HAM-D by a certified trainer in the administration of the Hamilton Depression Scale at the University of Pennsylvania's Center for Mental Health Policy and Services Research. Data collectors also administered the Mini-Mental State Examination (Kurlowicz & Wallace, 1999), based on Folstein's Mini-Mental Status Examination (MMSE; Folstein, Folstein, & McHugh, 1975) to ascertain subjects' suitability for admission into the study. Any potential subject who scored below twenty four on the MMSE was excluded from the study. Inclusion criteria included mild to moderate depression, as measured by the HAM-D-21, and a score of twenty four or above on the MMSE.

Demographic data were collected via a demographic survey form. Home-bound older adults admitted into the study were administered a twelve-week trial of IPT-informed treatment by MSW students enrolled in the service-learning class. All students had proof of malpractice insurance on file with the university. Following completion of the intervention, posttreatment measures using the HAM-D and the MMSE were gathered by data collectors. During the postintervention data collection phase, clients also were asked by the independent data collectors to complete a satisfaction questionnaire, in which they were asked about their subjective experiences of the project and invited to provide feedback. All questionnaire responses were independently coded for themes by the course instructor and the project manager. A focus group was convened with students on the last day of class to identify the barriers and benefits of providing home-based services to clients, and to solicit feedback about the class structure and any future course modifications. The focus group was tape recorded by the project manager, and a resulting transcript was transcribed by the first author's graduate assistant and independently coded for relevant themes, after first using an open-coding technique (Padgett, 1998) by both the instructor and the project manager to ensure interrater reliability.

Quantitative Results

Study Sample

The analysis for effectiveness included those individuals who both completed the intervention and also two waves of data collection (pre- and posttests; N = 10). Among initial participants, seven individuals were excluded from the study due to their incomplete intervention status. The reasons for not completing the intervention included the following: four had changes in health conditions that prevented their continuation, one unexpectedly moved from the area, another dropped out because she reported that the student was "too young and intrusive," and a third was excluded due to the short length of intervention (four weeks). No difference was found in terms of their demographic characteristics and their scores on the baseline MMSE and HAM-D (one person with missing Wave 1 MMSE score was not considered a "drop-out" because she was not regarded eligible for the study--the MMSE was used as one of the inclusion criteria). The mean age of the sample was seventy years. The majority of our sample was female (90%), living alone (80%). All participants were Caucasian.

Data Analysis

Pre-and posttest results of the total MMSE and HAM-D scores were compared by using Wilcoxon signed ranks tests, nonparametric equivalent of paired-sample t tests. Nonparametric tests were conducted due to a small sample size and non-normal distributions of the HAM-D and MMSE total scores at baseline. To identify in which subdimensions of the HAM-D the differences are observed, scores on the subscales were calculated according to Cole et al. (2004) and the pre- and posttest results were compared using the Wilcoxon signed ranks tests. Data entry, clearing, and analyses were conducted using SPSS 17.0 by the second author.

Interpretation of Quantitative Findings: Effectiveness of the Intervention

As can be seen in table 1, significant decreases in the total HAM-D scores were observed among participants after the twelve-week intervention (p < .05). As can be seen in table 2, among other subscales, the insomnia subscale on the HAM-D yielded a significant decrease in the symptoms postintervention. No differences were found on the overall scores of the MMSE.

Qualitative Results

Client Responses: Participant Satisfaction

Positive experience. The recipients uniformly found the experience to be worthwhile. One woman spoke about the difference it made in her life: "This got me started on taking care of myself. It made a difference in my life, absolutely." Another woman echoed this sentiment: "It was wonderful. It was like having a special friend meet with me. It was great to talk with someone who was not family." Another woman summed up her experience this way: "It worked out beautifully. It was an incredible experience. I enjoyed his company.... It has strengthened me in so many ways." All participants stated that they would recommend the project to other seniors. "One-to-one made all the difference in the experience. Before ... I blamed myself ... I thought I should do it on my own." Another said: "I spoke to everyone about it ... priest, friends. I spoke with another woman who was asked to participate but did not. She was sorry she didn't once she learned of my experience. My kids thought it was wonderful for me."

Suggestions for improvement. Several suggestions were offered by participant to extend the intervention: "Have it continue," stated one. "Keep it going," echoed another. One participant suggested that a follow-up group be formed with participants. Indeed, these suggestions corroborate findings that demonstrate that maintenance treatment, where clients continue to be seen monthly for a period of time following the initial treatment protocol, is effective in maintaining positive treatment effects (Hinrichsen & Clougherty, 2006).

Student Responses: Benefits and Barriers to Providing Home-Based Services

Benefits

Comfort of clients. One of the major benefits to seeing clients in their homes related to the fact that clients were often more comfortable than they might otherwise be meeting in a clinical setting. One student responded, "It was more personal. I felt the connection was easier to build and maintain because it was in their comfort space." Another student said, "I liked the fact that we went to them. Started literally where the client was at." Another remarked, "You also get the sense of the person in the environment.... I got a sense of all the different ... issues she dealt with on a day-to-day basis." Another student said, "I think it showed them that they had control of the relationship. If they don't want us in the home, they had a voice to say so."

Students also remarked on the importance of heeding the client's wishes when they did not feel comfortable meeting in the home. One student explained, "She didn't feel comfortable doing the therapy in the home because I don't think she wanted her husband to know about it. " Another student elaborated, "Going to the home where the husband might be there and you're working with a female might be an issue. That might make a person feel uncomfortable, especially if part of the problem is with the relationship."

Barriers

Discomfort of students. On the other hand, a common theme that emerged from the students was their greater discomfort meeting clients in the home. One student stated, "For my client, she and her husband are ill, so sometimes I felt like I was invading their space." Another student noted, "I think there could be a lot of distractions, like people coming to the door." Another student offered, "Maybe one of the problems is familiarity with the environment. Having someone get up and do things in the house there while you're trying to have a session can be a distraction ... like trying to show you a picture or something."

Maintaining professional boundaries. Students also noted the challenges of maintaining professional boundaries while being inside someone's home: "Being blind, she would climb on her table to hang her curtains, but she couldn't get them down, so I helped. I knew I shouldn't be doing things like that, but I didn't want her to get hurt. I took it upon myself to do a lot of things I knew I shouldn't have been doing. In a clinical setting, things like that wouldn't have come up." Conversely, another student observed, "In that same scenario, I didn't do some of the things I felt I should have done, such as putting things away in boxes. I thought that maybe I could bring some friends over and help, but I didn't. I don't think I would have had those feelings if I didn't visit the home."

Student Responses: Evaluation of Class

What worked well. In terms of what worked well in the class and what did not, several students stated that they enjoyed the weekly reflective papers, "I think that put a lot of things in perspective. Going back to my client the following week, it helped my strategy as to what approach to use and how to stay focused." Other students appreciated the group supervision. "Getting everyone's feedback and what was going on with them and how they were using the approach." "I liked the group supervision because you learn from each other. There were a lot of things I was able to pick up from those intimate sessions. You can take from here and go out and work with the client and have new ideas about what to ask her. It's never too late to go back and address those questions." "One of the benefits of being in these supervisory groups was that it was open to opinions. It worked out nicely. Even though some of the feedback wasn't always positive, no one took it personally, which was good."

Suggestions for improvement. Students suggested the need for more in-class practice exercises so that assessment strategies and intervention techniques may be better understood and mastered prior to students going into the field. Also, a student suggested that a more in-depth overview of the approach be provided earlier on. "Maybe doing the first two classes as a crash course.... Here's an abbreviated version of what it looks like from start to finish so we're not waiting for the next class to find out what comes next."

Limitations of Study

Because this was a feasibility study using a prepost design methodology, it was not possible to ascertain whether outcome effects were based solely on the intervention or the result of other extraneous factors. Perhaps the simple act of interacting with students was sufficient to improve depressive symptoms among the study sample. The HAM-D subscale area that revealed a significant difference was insomnia. Again, it is impossible to assert that these two effects resulted specifically from the IPT-informed protocol. A randomized control study is now underway to better screen for extraneous variables.

Moreover, although the overall scores on the postintervention HAM-D were reduced significantly, and there was reduction in all but one of the subscale area (Visceral); significant decrease in depressive symptoms was achieved on only one of the subscale area--insomnia. The small sample size (N = 10) may account for this result. In future studies, a larger sample size may be used to increase statistical power and to better identify possible interaction effects between reduction in depressive symptoms and cognitive functioning. The small sample size used in this study and the research design were not sufficient to assess the effectiveness of IPT in reducing depressive symptoms or improving specific domains of cognitive functioning, such as attention and orientation. Also the sample size was not sufficient to identify barriers to providing IPT in the home. The predominance of women subjects was also a potential limitation to determining efficacy of the approach with men. The sample was drawn from a population that had actively requested assistance in the home from the partnering agency. That population was predominately female. Particularly due to higher rates of suicide among older Caucasian men (McIntosh, Santos, Hubbard, & Overholser, 1994), it is important to find ways to access male subjects in future studies.

One of the participants was enrolled late in the study to accommodate for participants who dropped out, was only seen four times, and was thus excluded from the study. In a few cases, individuals did not meet the scoring criteria for depression, as measured by the HAM-D, but a decision was made to include them in the service-learning project both because they had requested specifically that a student visit them and also to provide each student with a client for the purposes of learning.

Plans for Further Research, Practice, and Education

Plans are currently underway to launch a second service-learning research project to study the effectiveness of providing IPT to older adults with depression and/or cognitive impairment. The new study will include a larger sample size of participants (n = 60), and will provide randomization of subjects into an intervention (n = 30) or control group (n = 30). The intervention group will receive twelve weeks of IPT provided by graduate social work, nurse practitioner, and psychology students enrolled in the service-learning course. The control group will receive twelve weeks of psychoeducational visits by nursing students in participants' homes. Pre- and postintervention measures of depression and cognitive impairment will be collected by independent, trained data collectors using the HAM-D (Hamilton, 1960), and the Montreal Cognitive Assessment Scale (Nasreddine et al., 2005). A decision was made to use the HAM-D-24 (longer version) for this population because the IPT intervention is related to reducing a symptom that is only available on the longer version. At the study's conclusion, control group participants will be offered the opportunity to receive the mental health intervention. Opportunities to provide monthly maintenance treatment to interested participants are also being initiated. All participants will be administered six-month and twelve-month follow-up measures on depression and cognitive impairment.

In terms of pedagogical improvements, course modifications will include providing individual and group supervision to students, and more in-class exercises and video illustrations of intervention techniques to support students' mastery of the approach and strengthen the fidelity of the intervention provided to participants. Additional methods of better assuring treatment fidelity will be incorporated, such as the use of audio taping of sessions by students, which may then be examined within individual supervision. Moreover, by the time the new study is underway, the course instructor will be fully certified as an IPT trainer, thus increasing the fidelity of the approach taught by the instructor. Also, students will receive additional instruction and supervision on how to manage professional boundaries while visiting with someone in their home.

Conclusions

This service-learning research project was a feasibility study designed to both examine the efficacy of using MSW students to provide mental health services to older adults in the community, and also to identify potential barriers to providing IPT-informed treatment to older adults in their homes. Preliminary results found decreased depressive symptoms postintervention, and thus provided justification for moving forward with a more rigorous study designed to test the effectiveness of using IPT in home-based setting with older adults suffering from depression.

Overall, the service-learning research project was a success. Students learned a set of skills that they can take with them on graduation, and older adults experienced a reduction in their overall depressive symptoms. Also, the groundwork was laid for the development of a collaborative infrastructure between the department of social work and a community agency, making it easier for further collaborations and research endeavors to be initiated in the future. Institutions of higher education may consider fostering the development of service-learning research projects in gerontology and other classes to provide students with experiential opportunities to acquire specialized skill sets, to provide needed services to underserved populations, and to contribute to the evidence base for the development of efficacious and innovative ways to reduce depression among vulnerable populations.

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U.S. Department of Health and Human Services Administration on Aging. (2001). Older adults and mental health: Issues and opportunities, executive summary-2001. Washington, DC: Department and Health and Human Services Administration on Aging.

Cassandra L. Bransford and Sunha Choi

Cassandra Bransford, PhD, LCSW-R, is associate professor at Binghamton University. Sunha Choi, PhD, is lecturer and the Hartford Geriatric Social Work faculty scholar at University of Tennessee. Direct correspondence to Cassandra Bransford, College of Community and Public Affairs, PO Box 6000, Binghamton University, Binghamton, NY 13902-6000; e-mail: cbrans@binghamton.edu.
Table 1 Pre-and Posttest Results on the Mini-Mental State
Examination (MMSE), Hamilton Rating Scale-24 Items (HAM-D-24), and
Hamilton Rating Scale-17 Items (HAM-D-17): Mean (SD), Median (Mdn),
and Wilcoxon Signed Ranks Test (N = 10)

Instrument     Pretest      Posttest      P

HAM-D-24     16.1 (7.28)   9.50 (5.99)   .024
             Mdn = 13.5     Mdn = 9.5
HAM-D-17     11.7 (5.85)   7.70 (4.47)   .050
             Mdn = 10.5      Mdn = 8
MMSE         24.4 (1.58)   26.3 (3.13)   .270
             Mdn = 27.5    Mdn = 27.0

Table 2 Pre-and Posttest Results on Four Subscales of the Hamilton
Depression Rating Scale (a) (HAM-D-17): Mean (SD), Median (Mdn), and
Wilcoxon Signed Ranks Test (N = 10)

Subscale     Item number on the HAM-D        Pretest     Posttest

Core         1. Depressed mood (0-4)         2.9 (1.8)   1.7 (1.9)
Depression   2. Feeling of guilt (0-4)       Mdn = 2.5   Mdn = 1.0
             3. Suicide (0-4)

Insomnia     4. Insomnia: Early (0-2)        1.8 (2.1)   0.5 (0.7)
             5. Insomnia: Middle (0-2)       Mdn = 1.0   Mdn = 0
             6. Insomnia: Late (0-2)

Anxiety      9. Agitation (0-4)              4.3 (2.8)   2.7 (1.7)
             10. Anxiety: Psychic (0-4)      Mdn = 4.0   Mdn = 3.0
             11. Anxiety: Somatic (0-4)
             12. Somatic symptoms:
               Gastrointestinal (0-2)
             13. Somatic symptoms:
               General (0-2)
             15. Hypochondriasis (0-4)

Visceral     7. Work and activities (0-4)    2.7 (1.6)   2.8 (2.1)
             8. Retardation: Psychomotor     Mdn = 3.0   Mdn = 2.0
               (0-4)
             14. Genital symptoms (0-2)
             16. Loss of weight (0-2)
             17. Loss of insight (0-2)

Subscale     Item number on the HAM-D        P

Core         1. Depressed mood (0-4)
Depression   2. Feeling of guilt (0-4)       .159
             3. Suicide (0-4)

Insomnia     4. Insomnia: Early (0-2)
             5. Insomnia: Middle (0-2)       .039
             6. Insomnia: Late (0-2)

Anxiety      9. Agitation (0-4)
             10. Anxiety: Psychic (0-4)
             11. Anxiety: Somatic (0-4)
             12. Somatic symptoms:
               Gastrointestinal (0-2)
             13. Somatic symptoms:
               General (0-2)
             15. Hypochondriasis (0-4)

Visceral     7. Work and activities (0-4)
             8. Retardation: Psychomotor     .855
               (0-4)
             14. Genital symptoms (0-2)
             16. Loss of weight (0-2)
             17. Loss of insight (0-2)

(a) The four dimensions were based on the validity study conducted
by Cole et al. (2004).
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Publication:Best Practices in Mental Health
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Date:Jan 1, 2012
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