treating depression in prison nursing home

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2008 7: 555 originally published online 25 July 2008Clinical Case StudiesSuzanne Meeks, Robin Sublett, Irene Kostiwa, James R. Rodgers and Donna Haddix

Research-to-Practice TranslationTreating Depression in the Prison Nursing Home : Demonstrating

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Treating Depression in the PrisonNursing HomeDemonstrating Research-to-PracticeTranslationSuzanne MeeksUniversity of LouisvilleRobin SublettKentucky State ReformatoryIrene KostiwaJames R. RodgersUniversity of LouisvilleDonna HaddixKentucky State Reformatory

We describe a theoretically grounded and empirically developed intervention for depression witholder men in a state reformatory nursing home. As the number of prisoners “aging in place” rises,there is a critical need for research on mental health interventions in prison nursing homes whereinmates may be at high risk for depression and suicide. The participants in this project were fourmale residents in the Kentucky state prison system nursing home; all four had diagnoses of majordepressive episodes. BE-ACTIV, a behavioral treatment for depression, is a hybrid approach thatcombines one-to-one sessions with the depressed resident and work with staff. One-to-one ses-sions motivate the resident to engage in new activities, while meetings with nursing home staffbreak down barriers to completion of pleasant events. Over the 10-week treatment, depressivesymptoms declined, and global functioning increased an average of 13 points per participant. Twoof the participants showed improved self-reported negative affect. Study results suggest thatBE-ACTIV is feasible in the prison nursing home and has the potential to improve the quality oflife for medically frail prisoners by helping them to identify meaningful or pleasant activities. Thecases illustrate importance of therapeutic relationships in the context of improving depressivesymptoms, and the possibility of building effective relationships in a setting with multiple barri-ers to effective treatment.

Keywords: nursing homes; prisoners; depression; treatment

1 Theoretical and Research Basis

In this case study, we describe the application of a theoretically grounded and empiri-cally developed intervention for depression to a specific population of older adults: oldermen in a state reformatory nursing home. In recent years, researchers and funding agencies

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have increasingly recognized the importance of “translating” research findings to clinicalsettings as critical to the vitality and utility of any clinical science (e.g., National Institutesof Health [NIH], 2007; Vernig, 2007). From the perspective of funding agencies, suchtranslation ensures that investment in scientific research results in advancements in directpatient care; from the perspective of researchers, working in clinical settings stimulates newresearch questions and enables real-world tests of theoretical models. The evidence-basedtreatment movement encourages use of empirically tested interventions in practice settings,but often the process of developing evidence-based treatments does not address the manybarriers to translating those treatments to varied practice settings. Older adults in particularenter mental health treatment through a variety of settings that ranges from traditional men-tal health venues and outpatient medical practices to long-term care settings, such asassisted living and nursing homes. Each of these settings presents novel challenges to treat-ment delivery that must be tested and overcome if treatments are to be widely available.This study is part of a larger program of research for developing and testing the BE-ACTIVintervention specifically designed for nursing home clients. This small demonstration pro-ject came about following an inquiry by the second author regarding whether BE-ACTIVmight be applicable to the prison nursing home setting. A demonstration of this nature notonly provides information to meet site-specific clinical needs, but also adds to the founda-tion of ecological validation for a treatment approach.

Mental Health Needs Among Older Prisoners

Despite the fact that the elderly appear to be a rapidly growing segment of the prisonpopulation in the United States and other countries, there is relatively little work done todate addressing the mental health issues related to aging in place in prisons. The generalpopulation of prisoners in federal, state, and private facilities grew 28% between 1995 and2000 (Bureau of Justice Statistics, 2003), but although elderly prisoners are still a minorityof the corrections population, the rate of older prisoners is growing at a much higher rate(Aday, 1994). Little is known about these older prisoners; we found only a 1983 review offederal data, case reports, and other nonresearch reports compiled by Goetting describingthis population. Her review indicated that the majority of elderly prisoners were men withmultiple incarcerations who were likely to have histories of violence.

Data from the Bureau of Prison Statistics suggest that the rate of mental illness amongprisoners is very high, with approximately half reporting symptoms (James & Glaze,2006). Most symptoms were related to mood disorders. Prisoners with mental illness wereat higher risk than other prisoners for injury and victimization, as well as for longer prisonstays. Although rates of mental illness diminished with age, the percentage for older adultsremained significantly higher than for elders outside of prison. In one of the few epidemi-ological studies of psychiatric morbidity in prisons, Fazel, Hope, O’Donnell, and Jacoby(2001) surveyed 203 men over the age of 60 in 15 British prisons with populations of atleast 10 older prisoners. Diagnoses were determined by structured psychiatric interviews.Approximately one third of the sample had Axis I diagnoses from the Diagnostic andStatistical Manual of Mental Disorders (4th ed.) (DSM-IV; American PsychiatricAssociation, 1994), and nearly all of these had diagnoses of a depressive disorder. Risk fordepressive disorder was related to medical condition, similar to other populations of older

556 Clinical Case Studies



adults that have been studied, but because the overall risk was much higher than for com-munity-residing elders, it seems likely that older prisoners in nursing homes are at partic-ular risk for depressive illness. When treatment needs of this same sample were examined,it appeared that depressive disorders were medically undertreated (Fazel, Hope, O’Donnell,& Jacoby, 2004). Prisoners of all ages with mental illnesses are at risk for suicidal behav-ior (Senior et al., 2007), and suicide risk is correlated with age. Prisoners who have been inprison longer are at higher risk for suicide (Konrad et al., 2007). In their comparison ofBritish prisoners with and without charted suicide risk, Senior and colleagues (2007) foundthat those at risk had higher unmet support needs in the areas of safety, psychologicaldistress, and daily activities.

In their 2005 review of research on mental disorders in prison, Fazel and Lubbe concludethat although epidemiological work and work on attention to interventions for violentbehaviors constitute a starting point, there is a critical need for research into what inter-ventions can be effectively implemented in prison settings. There is some evidence thatprisoners do receive antidepressant medication (Baillargeon, Black, Contreras, Grady, &Pulvino, 2002), although approximately 20% of prisoners diagnosed with major depressiondid not receive antidepressants in this study, and there were gender, racial, and ethnic dis-parities in who received antidepressants and what type of antidepressants were prescribed.Most state prisons, and all federal prisons, offer psychological and psychiatric services(Bureau of Justice Statistics, 2003). Although some therapists have written about treatingprisoners (e.g., Pollock, Stowell-Smith, & Göpfert, 2006; Saunders, 2001), there is virtu-ally no research on mental health interventions for this population, and the effectiveness ofinterventions used with prisoners, particularly older prisoners, is unknown.

The BE-ACTIV Program for Depression in Nursing Homes

The BE-ACTIV program has been described in two previous publications (Meeks,Looney, Van Haitsma, & Teri, 2008; Meeks, Teri, Van Haitsma, & Looney, 2006), and theconceptual basis was described in a third article (Meeks & Depp, 2002). Briefly,BE-ACTIV is a behavioral treatment that derives from the work of Lewinsohn and his col-leagues (Lewinsohn, Hoberman, Teri, & Hautzinger, 1985). In this work, the central fea-ture of depression is the combination of reduced positive reinforcement and positive impactthat arise in the context of disrupted routine, loss of control, and stress. The primary goalof treatment is to interrupt the cycle of high negative affect and low positivity by system-atically increasing opportunities for positive reinforcement. Empirical support for an activ-ity-related intervention in nursing homes comes from a body of evidence accumulated byLawton and his colleagues (e.g., Lawton, 1997) that links resident activity level, affectivetone of activities, and levels of positive and negative affect to depression. This researchstrongly suggests that participation in activities perceived as positive should be an impor-tant focus for intervention.

BE-ACTIV was adapted from a manualized treatment for depression in cognitivelyimpaired elders, developed and tested by Teri and colleagues (Teri, 1994, 1997; Teri,Logston, & Uomoto, 1991; Teri, Logsdon, Uomoto, & Curry, 1997). Their research demon-strated that a behavioral intervention can be used successfully with impaired elders, and thatcaregivers can learn to collaborate in increasing pleasant events and producing successful

Meeks et al. / Treating Depression in the Prison Nursing Home 557



outcomes for the elders they care for. Our preliminary work adapting this intervention tothe nursing home setting is summarized in two previous articles (Meeks et al., 2006; Meekset al., 2008). In place of family caregivers, BE-ACTIV requires that the therapist form aworking relationship with the activities staff of the nursing facility. This hybrid approachto mental health care involves a combination of one-to-one sessions with the depressed res-ident and involvement of staff in implementing the plan for increasing pleasant events. One-to-one sessions serve to motivate the resident to engage in new activities, while meetingswith nursing home staff help to break down barriers to the implementation of pleasantevents. In the pilot work, BE-ACTIV shows promise of improving depressive diagnoses,increasing positive affect, and increasing activity levels of nursing home residents as com-pared to residents randomly assigned to treatment as usual (Meeks et al., 2008). Given thatprisoners in a correctional nursing home environment are at high risk for depression and sui-cide, and the prison environment affords few opportunities for pleasant daily activities, itseems logical that BE-ACTIV could be a useful intervention for that setting.

2 Case Presentation

The participants in this demonstration project were four male prisoners who were resi-dents in the nursing facility for the Kentucky state prison system. The participants volun-teered to participate as part of a research project; the chief psychologist of the nursingfacility identified all residents who were presenting with depressed mood, had diagnoses ofdepression, or were being treated with antidepressants. Of the 78 inmates on the unit, thechief psychologist identified approximately 46 as potentially eligible (meeting criteria fora depressive disorder and having a Mini-Mental Status Exam [MMSE] score of 14 orabove). Of these, 21 consented to screening, but only 6 were found to meet criteria for thestudy after the initial research assessment. One of these men was transferred off the unitand another died before they could receive the intervention; we completed the interventionwith the other four.

Table 1 shows the ages, race, and diagnostic status of the participants at baseline assess-ment. The youngest participant was 47,1 the oldest was 81, but they all had considerablemedical morbidity and all but one had some mild cognitive impairment. After baselineassessment, they received weekly sessions of BE-ACTIV for 10 weeks, with a follow-upassessment at the end of the 10 weeks. The therapists were two doctoral students in clini-cal psychology, one male and one female, with prior clinical experience in both inpatientand nursing home settings, but with no prior experience in forensic settings. The staff mem-ber who collaborated in the treatment was a female recreational therapist assigned to thenursing unit for several hours per week. Prior to her participation, she received a 3-hrin-service training by the first author about the BE-ACTIV program, depression in general,and her role in implementing pleasant events (see Meeks & Burton, 2004).

The prison nursing unit is configured more like a nursing home than a prison ward, witha centrally located nursing station, semiprivate rooms, a mess hall, and a lounge area witha TV. There is also a fenced, secure, outdoor patio with a small garden. Inmates of the nurs-ing home are generally not allowed to be on the “yard” with the general prison population.Recreational activities are usually held in the mess hall. Weekly sessions were held either




in the resident’s room or in available office space on the nursing or psychiatric units. Carewas taken to optimize privacy but at times staff may have been within earshot of the sharedoffice space, or a roommate may have been present. During the 10 weeks of treatment,therapists recorded weekly self-reported mood ratings, pleasant events, and the time thatthe recreational therapist spent with the residents. The therapists completed diagnostic andsymptom assessments in the week following the tenth session for all except Mr. D, who wasin solitary confinement at the end of the treatment.

3 Presenting Complaints and History

All four participants were experiencing major depressive episodes (MDEs) at baseline,two severe and two in partial remission (see Table 1). We deliberately did not requestinformation about the participants’ criminal background or convictions aside from thelength of time they had been incarcerated, choosing instead to treat depressive symptomsin the context of the resident’s current situation. Individual presenting issues and history arepresented in the following paragraphs.

Mr. A

Mr. A was an African American male who had been in and out of the prison system in thepast and was incarcerated for a little more than a year at the time of the study because of aviolation of his parole. Staff reported that he was irritable, quiet, and withdrawn, rarely


Table 1Participant Baseline Characteristics

Mr. A Mr. B Mr. C Mr. D

Age 61 47 58 81Race African African White White

American AmericanDSM-IV diagnosis MDD recurrent, Bipolar disorder, MDD recurrent, in MDD, single

in partial current episode partial remission episode, severe,remission MDE, severe, without psychotic

without psychotic featuresfeatures

GAF 60 53 53 45GDS 18 21 25 22MMSE 24 29 26 23COOP 7 10 8 13Positive affecta 5 14 14 9Negative affecta 10 10 15 20

Note: COOP, Dartmouth COOP Scales of Functioning; DSM-IV, Diagnostic and Statistical Manual of MentalDisorders–fourth edition; GAF, global assessment of functioning; GDS, Geriatric Depression Scale; MDD,major depressive disorder; MDE, major depressive episode; MMSE, Mini-Mental Status Exam.a. Positive and negative affect are sums of five items for baseline week.



participating in activities, spending much of his time in his room watching television or sleep-ing. He admitted that he had been “hibernating” because of ongoing worries about his health,parole, and marriage. He also complained of “nerves” and said that he did not like being incrowds or around other people, especially his fellow inmates. Mr. A reported having strainedrelationships with most of his family members, although his aunt and cousin remained in con-tact with him. During the initial interview and early sessions, his speech was relatively quietand he appeared somewhat guarded in his responses. Mr. A was placed on the nursing unit fol-lowing the loss of his leg resulting from poorly controlled diabetes mellitus and peripheral vas-cular disease. He had triple bypass surgery approximately 4 years prior to treatment. Hesuffered a heart attack just a year before his incarceration, which he felt marked the beginningof his current depressive episode. His health status and access to adequate health care were keyconcerns for him; he feared dying in prison. Symptoms of depressed mood, weight gain,insomnia, lack of energy, and difficulty concentrating endorsed at the initial interview con-tributed to a diagnosis of recurrent major depressive disorder (MDD) in partial remission.

Mr. B

Mr. B was an African American who had been incarcerated for 2 years. He was referred tothe program because staff members reported that he rarely spoke, did not attend activities, andleft his room only to eat or when instructed to do so. He would constantly lie in bed and watchtelevision even though only one TV channel was available to him. During the initial assess-ment, Mr. B was reserved and quiet, rarely making eye contact or speaking except to answerdirect questions. He stated that he “didn’t have much energy” and that he felt “really down”almost all of the time. His medical record included a diagnosis of schizophrenia, but based onhis endorsements on the Structured Clinical Interview for DSM-IV (SCID), he met criteria fora history of mania and reported no psychosis outside of the context of affective episodes; so hereceived the diagnosis of bipolar disorder, most recent episode depressed. His current episodewas rated as severe, but there was no evidence of current psychotic features. He agreed to par-ticipate in the project in hopes that he would “feel better.”

Mr. B stated that he felt that he had a normal childhood and had played football in highschool but that he always felt different than other people. He had no immediate family andwas divorced from his only wife. This was his second time in prison and he was determinedthat his behavior would be such that he would be assured of parole at the earliest possibleopportunity. He reported that he had been moved to the prison nursing home to monitor andcare for his diabetes. Mr. B had many friends on the yard (in the general prison population),and the move to the nursing home had isolated him from these friends because visitsbetween units required a special request sanction by the warden’s office. Mr. B noted thatthe larger rooms in the nursing facility were “nice” but that he missed his friends.

Mr. C

Mr. C was a white man who had been incarcerated for approximately 13 years. Staff sug-gested that he might be a good candidate for the study because of ongoing difficulties withdepressed mood, sleep disruption, and irritability. Despite these symptoms, Mr. C maximizedhis daily routine by participating in available activities and remaining engaged with staff and




fellow inmates. He embodied the essence of behavioral activation even before his participationin the study, and often stated “I have to stay busy” and hinted of a looming deeper depression.Mr. C related a history of severe depressive episodes and alcohol abuse that began in his late20s; he had a history of at least one grave suicide attempt. Mr. C was on the nursing unit pri-marily because of visual impairment combined with other medical problems. During theinitial interview, he complained of visions of “bright lights” and images of arbitrary “floatingobjects,” which interfered with his concentration during the day and prevented him fromobtaining restorative sleep at night. He said these obtrusive visions began subsequent to a sur-gical procedure on his eyes. During the initial interview, his symptoms of depressed mood,weight gain, insomnia, fatigue, thoughts of death, and significant ongoing distress contributedto a diagnosis of MDD in partial remission. Interpersonally, Mr. C was very pleasant and agree-able but was noted to have a low frustration tolerance. He became visibly irritated when dis-cussing his lack of control in terms of an inability to accomplish certain tasks either becauseof his blindness or because of the restrictive environment of the prison.

Mr. D

Mr. D was a white man who had served more than 30 years in the prison system. Thestaff noted that Mr. D was not liked by other inmates on the unit and that his problematicand often oppositional behavior made him difficult to treat. Mr. D showed signs of mem-ory loss and his score on the MMSE was a 23, indicating significant cognitive impairment.He was often incontinent and resisted attempts by the staff to help him with self-care.Usually, such resistance was met by calling the prison guard who would order him to batheand change clothes on the threat of punishment involving solitary confinement and loss ofprivileges. On the SCID, Mr. D met threshold for all major depression items, earning hima diagnosis of MDE, severe, without psychotic features. He had no recollection of a priorepisode, nor were any documented in his medical record.

Mr. D reported that he was a self-taught engineer and that he designed heating and air con-ditioning systems. He had worked for many years in a supervisory position in the prisonmechanical shop and had been involved in training other prisoners in skilled trades that couldbe useful in and out of the prison system. Mr. D noted that because of his prison jobs, he feltthat his life had been useful. He put a great deal of emphasis on his ability to do “real work.”As his memory difficulties progressed he was gradually removed from the teaching positionsand then from the prison shop. Ultimately, (probably because of his cognitive decline) he wasplaced in the prison nursing home where he spent his time occasionally watching TV, eatingfood from the prison commissary, and sleeping. Because of the sale of his home and belong-ings following the death of his wife, Mr. D had some money in the bank; he believed thatother prisoners only talked to him so that they could borrow money or share in his food. Hedid not have any positive social relationships with other inmates on the unit.

4 Assessment

Diagnoses were determined using a modified version of the SCID (First, Spitzer,Gibbon, & Williams, 2002). Either the first author or one of the therapists administered the




SCID 2 weeks prior to the first therapy session, and then again in the week following ses-sion 10. Depressive symptoms were also assessed using the Geriatric Depression Scale(GDS; Brink et al., 1982), a 30-item, self-report scale designed for use with older adults.We also administered the MMSE (Folstein, Folstein, & McHugh, 1975) as a screen for cog-nitive impairment, and the Dartmouth COOP Scales of Functioning (Nelson, Wasson,Johnson, & Hays, n.d.). The COOP chart method of assessing functional status was devel-oped by the Dartmouth Primary Care Cooperative Information Project (COOP) to provideresearchers and clinicians with a quick but valid means to assess adult and adolescent func-tioning in primary care (Nelson et al., 1987). COOP charts used included interference withdaily activities, interference with social activities, health changes, and overall self-ratedhealth, yielding a functional impairment scale ranging from 4 to 25 with higher scores indi-cating higher impairment. Participants rated their mood weekly using the PhiladelphiaGeriatric Center Positive and Negative Affect Rating Scale (PNAR; Lawton, Kleban, Dean,Rajagopal, & Parmelee, 1992). The PNAR produces positive and negative affect scaleseach with a possible range of 5-25. We obtained demographic information, medical diag-noses, and medications from the prison health records. Results of baseline assessments areshown in Table 1.

During the first session of BE-ACTIV, the therapist completes the initial version of thePleasant Events Schedule–Nursing Home Version (PES-NH; Meeks, Heuerman, Ramsey,Welsh, & White, 2005). This instrument helps the therapist and resident identify potentiallypleasant events that could be incorporated into the resident’s daily routine. An activity staffmember is invited to attend these first sessions. In this project, the recreational therapistwas present at all four first sessions to help the therapists determine what activities werefeasible within the prison nursing home. The follow-up version of the PES-NH was usedweekly during the therapy sessions to determine the number and pleasantness of the men’sactivities during the time between sessions.

5 Case Conceptualization

With the exception of Mr. C, each of these men presented with pronounced reduction indaily activities and a sense of hopelessness about the possibility of engaging in any activi-ties that might be pleasant. As a result of placement on the nursing unit, all the men hadexperienced significant losses related to meaningful social contact, including opportunitiesto interact with friends and relatives on the yard (A, B, and C), and the opportunity toengage in meaningful work including teaching others (D). They also reported reduction inopportunities for leisure activities such as access to a weight room and library, and loss ofcontrol over the availability of supplies or materials such as books, newspapers, art sup-plies, or television stations. Thus, each was experiencing reduced opportunities for positiveaffect, in combination with increasing experiences of negative affect related to increasedhealth problems and disability, worries about parole (for A and B), and family stressors (Aand C). Figure 1 depicts these circumstances within the context of the conceptual basis ofBE-ACTIV from the work of Lewinsohn and colleagues (Lewinsohn et al., 1985). Theshaded box indicates the primary target of the intervention to increase opportunities for, andcontrol over, pleasant events so that the participants will experience increased positive




affect. Note that although it is unavoidable that there will be some attention to reducingnegative affect and negative events associated therewith, this is not the focus of BE-ACTIVbecause many sources of negative affect in nursing homes, and particularly in a prison nurs-ing home, are unavoidable and largely immutable.

6 Course of Treatment and Assessment of Progress

Figure 2 shows increases in pleasant events for all participants over the course of ther-apy, with slight decreases apparent at therapy termination. Graphs of weekly mood ratings(Figures 3-6) over the 12 weeks of the study suggest that the participants’ mood was unsta-ble and highly reactive to environmental events, particularly at the beginning of the treat-ment period, but that as treatment progressed, around the fifth or sixth session, there was astabilization of negative affect for three out of four participants. The participants’ relation-ships with the staff recreational therapist showed both greater contact and greater trust overthe 10 weeks of treatment. Participants also reported a feeling of having more control overtheir moods and choices of activities. Tables 1 and 2 show characteristics of the participantsat pre- and posttreatment assessments. These data suggest, contrary to our expectations,that overall self-reported positive affect did not increase much over the course of treatment,but that at least in the case of two of the participants, negative affect declined. Levels of


Figure 1Conceptual Model of BE-ACTIV in the Prison Setting

Antecedents: Increased physical/cognitive disabilityMove to more restrictive prison unit

Reduced positivereinforcement

Reduced positive affect

Increased negativeself-awareness (negative cognitions)

Increased depression(Persistent Dysphoria)

Negative consequencesof Depression: Reduced activity, negative interpersonal interactions, poorer health, more need for care

Vulnerabilities

Reduced opportunities forsocial interaction and work

Loss of control over daily activities

Increased negative affect



physical disability remained stable across the 10 weeks. Depressive symptoms declined forall participants for whom we were able to assess outcomes, and global functioningincreased an average of 13 points per participant. Specific characteristics of treatmentcourse for the participants are summarized in the following paragraphs.

Course of Treatment for Mr. A

Gaining a sense of mastery over his daily routine appeared to be a major theme forMr. A over the course of therapy, who stated that his mood problems were “a matter of con-trol.” Control issues might be expected in a prison setting where inmates have few choices,but Mr. A in particular found great relief and pleasure in the notion that he had some con-trol, even if it was in the smallest facet of his daily routine. At the beginning of therapy, hisattention was largely focused on his upcoming parole hearing. Any excitement or positivefeelings concerning his possible release were undermined by significant worry aboutreturning to the free world with an amputated leg, that his marriage was deteriorating, andthat his former home and life would no longer be available to him. Thus, during the firstseveral sessions, Mr. A’s negative affect increased significantly reflecting his ongoing anx-iety about an upcoming parole hearing and intense disappointment and anger on denial ofparole. Despite his past tendency to withdraw and isolate in the face of such negative feel-ings, Mr. A identified and engaged in activities that he found pleasurable as a part of thestudy. Mr. A was highly creative and found pleasure in reading stories, writing, painting,and listening to music. He described in vivid detail the pleasure that he felt when paintingor taking a hot bath which involved a type of mental “escape” from the confines of theprison and an overall sense of well-being. He drew a strong connection between his chosenactivities and these positive feelings, and he often framed this in terms of a renewed senseof control. As a result, he became highly committed to participating in these activities, inde-pendently increased the frequency of his baths, and never missed an opportunity to paint.When faced with divorce from his wife around the Session 7, rather than follow his past


Table 2Posttreatment Outcomes


DSM-IV diagnosis MDD recurrent, BPI, most recent MDD recurrent, Unable to in partial episode depressed, in partial complete remission in partial remission final

remission SCIDGAF 70 60 75 NAGDS 12 18 10 NAMMSE 25 26 26 NACOOP 7 10 5 NAPositive affecta 5 16 14 NANegative affecta 13 7 10 NA

Note: See note to Table 1. NA, not available; SCID, Structured Clinical Interview for DSM-IV.a. Positive and negative affect are sums of the final week of therapy.




Figure 2Change in Pleasant Activities (Frequency × Pleasantness)

Over 12 Weeks for Each Prisoner

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Figure 3Change in Positive and Negative Affect Over 12 Weeks for Mr. A

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Figure 4Change in Positive and Negative Affect Over 12 Weeks for Mr. B

Mr. D Pos Affect Mr. D Neg Affect

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Figure 5Change in Positive and Negative Affect Over 12 Weeks for Mr. C

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pattern of withdrawal, he continued to participate in activities and his negative affectremained low. Nonetheless, as he felt better about himself, Mr. A also engaged in a plea-surable activity that had negative consequences for his health: eating sweets and high fatsnacks. With diabetes and cardiovascular problems, this increased snacking affected hisblood sugar and physical health. As he experienced physical discomfort, his worry abouthis health and negative affect increased around Session 9. Despite the physical illness, hecontinued to increase the frequency of his baths and also identified additional activities ofinterest, such as writing a novel.

Course of Treatment for Mr. B

At baseline, Mr. B rarely participated in any activities or left his room. Figure 4 showsthat Mr. B experienced a relatively small range of both positive and negative affect. As theintervention progressed, he found interests in numerous events including attending the reg-ular Monday afternoon unit coffee, going to bingo games, taking a second weekly shower,sitting outside, and listening to nature. Mr. B discovered an avid interest in listening to thesounds of nature. During the sessions, he would describe in detail the appearance of the birdsthat landed in the prison yard and would occasionally attempt to whistle like them. At theconclusion of these exchanges, a rare smile would appear on his face. Toward the end of theintervention, Mr. B was beginning to spend a small amount of time each day out on the patiounder a shady overhang attempting to hear whatever sounds were available including thecows in the pasture beyond the wall, men working in the yard, and the blowing of the wind.


Figure 6Change in Positive and Negative Affect Over 12 Weeks for Mr. D

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Mr. B Pos Affect Mr. B Neg Affect



The weekly visit from the therapist appeared to become a pleasant event in itself. Hisresponse to the therapist is evident in both activity level (Figure 2) and negative affect(Figure 4). Mr. B noted that he “looked forward” to the meeting each week. Early in theintervention, his compliance with planned activities seemed to be mainly the result of hisstated desire to fulfill the therapist’s requests, illustrating how the one-to-one relationshipcan serve as a motivator to encourage depressed residents to try activities that they other-wise would not. As time progressed, the pleasure Mr. B gained from activity participationappeared to become the impetus for his continued activity participation, even resulting inparticipation in spontaneous activities such as talking to people on the unit, attending movienight, and going outside more often than requested.

Course of Treatment for Mr. C

From the outset of the therapy, Mr. C emphasized his need to “stay busy” and engagedin all available activities, except those that required vision, such as crafts, because of hisvisual impairment. Rather than focusing on the enjoyment he received from these activi-ties, however, he attributed his high level of engagement in activities and with others as anavoidance of being alone in an empty room, where he believed he would inevitably focuson his problems and become deeply depressed. Over the course of therapy, discussion ofactivities as “pleasant events” and a source of positive affect appeared to help him derivemore satisfaction from the activities in which he already engaged. Identification of addi-tional activities was challenging because he was so highly active, therefore much of thework at baseline focused on increasing simple interactions with the staff and advocating forhis own needs. Like Mr. A, Mr. C expressed feelings of frustration regarding his lack ofcontrol. For Mr. C this related to his inability to meet his own needs, in part because of hisvisual impairment. He reported frustration regarding his unfulfilled requests of staff mem-bers. For example, he requested that his tape recorder be fixed so that he could listen tobooks on tape, requested visits from his brother who was also an inmate but who residedin the general population, and he requested that he be baptized. In the past, his requestswere largely passive, wherein he would ask once and then wait for it to be fulfilled. Hebecame quickly impatient when these things did not happen, and his negative feelings pre-vented him from further pursuing his needs. Thus, pleasant events identified at the begin-ning of the therapy involved interacting with staff and checking on the status of hisrequests. Mr. C was generally very social in that he enjoyed talking to other inmates and tostaff. He was personable and appreciative of others, therefore the staff responded well tohim, further establishing these interactions as pleasant events. Thus, the activity of “check-ing in” with staff members helped him build better relationships and provided reminders tostaff about his needs, both of which gave him a sense of control. He often expressed hisgenuine positive regard and respect for the recreational therapist, and in building this rela-tionship, expressed a feeling of being supported, which he previously lacked. As a result ofhis “activity” of checking in with staff regularly, he received a new tape recorder, receivedapproval for regularly scheduled visitation with his brother, and was baptized. Thus, hisinteractions with staff led to further reinforcement via fulfillment of his requests, and inturn an increase in other events, such as listening to books on tape and visiting with hisbrother. A sharp increase in negative affect was noted in sessions 3 and 4, wherein Mr. C




discussed frustrations with unfulfilled needs such as not being able to get his laundry done,not finding a chair to sit in at church, and most importantly his worry about his brother’slegal issues. These setbacks were addressed by focusing Mr. C on those things that werewithin his control, such as the activities that he scheduled and in which he engaged.

Course of Treatment for Mr. D

Because of his dementia, although Mr. D could remember the majority of activities inwhich he participated he had difficulty remembering the affect associated with those activ-ities. He often lived in the moment and would interpret the past in light of his present mood.However, there were a few activities about which he would give account in great detail andwhich seemed to supersede his mood-specific interpretation. He consistently perceivedsocial activities such as coffees and bingo as negative events and felt they were unworthyof his time. The one exception was whenever the activities director would place a cookie inhis mouth during coffee. He would remember this with great pleasure and enjoyed recount-ing this event. He appeared to enjoy going outside but reported that he was “too old” tostand the summer heat. Mr. D attached great importance to events or activities that he con-sidered “worth his time.” Attending religious services fell into this category, not so muchfor the religious content as for the musical content. Mr. D described himself as a formermusician and attending religious service with the accompanying music seemed to restorethe affect associated with his memories of those days. Prior to the intervention, he rarelyassociated with other residents in a positive manner and rarely took part in any activities.Near the end of his time in the study, there was a rare live musical concert and hamburgercookout that produced a spike of positive affect for Mr. D (see T6 in Figure 6) because itcombined, food, going outside, and his love of music.

As with Mr. B, the weekly therapy meetings appeared to become a pleasant event forMr. D. He enjoyed and responded to one-on-one interactions with both the therapist and therecreational therapist. Along with his determination of activity meaningfulness, this type ofinteraction seemed to underlie his compliance with therapy and his willingness to partici-pate in any activity. Despite his bitter skepticism about participating in anything meaning-ful, Mr. D made an effort seemingly just to please the therapists, and his positive affectappears to have increased somewhat over the course of treatment. However, Mr. D’s cog-nitive decline within a prison nursing home setting significantly affected the outcome of histreatment. As an example, on two occasions, Mr. D initially refused his scheduled sessionsbecause of incontinence and a lack of clean clothing. Prisoners are issued a uniform and ifthe uniform becomes soiled it is sometimes difficult to acquire new clothing. This may bebecause clothing is limited and the necessary articles may not be readily available or itcould be because the unit is understaffed and certified nursing assistants (CNAs) have othermore pressing duties. In the first instance, the therapist was able to resolve the issue by find-ing new clothing for Mr. D, and in the second instance, Mr. D agreed to continue therapywithin the confines of his room. The other issue brought about by Mr. D’s cognitive declinewas his behavioral infractions on the unit and with the staff. These were often combativeand sometimes viewed as vindictive. In a prison population, problematic behaviors may bedealt with in a punitive fashion and according to accepted prison protocols and standards. InMr. D’s case, his behavioral infractions resulted in segregation from the prison population.




Segregation takes place in a small cell where the prisoner is kept for 23 hr per day, with lit-tle contact with others and only few possessions (Bender, 2005). Mr. D was in segregationduring the final week of treatment and was unable to have his final assessment or meetingwith his therapist, as it was expected that he would be there for some time.

7 Complicating Factors

Clearly, prison nursing homes have characteristics that pose unique barriers to success-ful treatment of and recovery from depressive disorders. Some of the barriers we encoun-tered are shared with other nursing homes. For example, the recreational therapist had verylittle access to or budget for supplies that might enhance activities such as art projects, read-ing, and movies. Frequently this lack of an activities budget is found in nursing homes inthe private sector as well, although not surprisingly we found the lack of supplies to bemore extreme in the correctional setting. The limited amount of time the recreational ther-apist could be on the unit was also a problem, and staff shortages are frequently found inprivate sector nursing homes as well. Lack of a private place to hold therapy sessions is aproblem that frequently occurs in all nursing homes, but this is significantly more of anissue in the prison because of security considerations. Such lack of privacy may, especiallyin prisons, impede open communication between the therapist and the client, and thereforelimit the power of the therapy relationship to effect change through motivating the client.Nevertheless, all four of these men appear to have developed good working relationshipswith their therapists, and all commented on the importance of the visits to them and formotivating them to try new activities.

As nursing home patients are typically medically at risk and struggle with multiplechronic health problems, the threat of illness events may have an impact on fluctuations inmood, therapy compliance, and outcomes. We saw this in the prison setting as well. Mr. A,B, and C were younger than the average nursing home resident, but all three suffered frommultiple chronic illnesses and disabilities and were significantly impaired in their ability tonavigate in their environments. Mr. A was particularly sensitive to changes in his health andworried extensively about dying in prison. All four perceived, and complained of, poorermedical care than they believed they would have received outside of prison. AlthoughMr. B and C had relatively stable health over the time we worked with them, both Mr. Aand especially Mr. D showed medical instability that affected their mood and activity par-ticipation. Mr. D’s declining cognitive capacity was especially problematic because itresulted in behavioral symptoms that within the prison context were interpreted and dealtwith as disciplinary infractions. This more punitive response was probably exacerbated byboth Mr. D’s premorbid personality and the type of crime for which he had been convicted;simply put, he was not an easy person to like. His case, however, illustrates the effective-ness of individual therapy sessions for building a positive relationship that can lead to pos-itive change against this backdrop of unstable or declining health.

Other life stressors also complicated the course of treatment for these men. Perhaps themost powerful of these was the worry about parole hearings; in the case of Mr. A, denial ofparole constituted a major challenge to his improving mood, but he was able to use the




treatment process to work through his disappointment and manage his mood following thedenial. Additionally, Mr. A and C reported multiple family stressors, including legal prob-lems of other family members, family illness, and the limited access to see or talk to fam-ily members. The presence of ongoing life stressors of this nature potentially not onlyimpedes the progress of therapy, but also provides opportunities to test the capacity of theresident to use skills taught in the treatment to improve mood.

A final complication that we encountered in this project was the low participation byinmates identified as potentially eligible. The refusal rate for this project was not notice-ably different than refusal rates we have encountered for depressed residents in nursinghomes outside of prison. However, despite the fact that the mental health staff at the facil-ity used their own knowledge of the inmates to nominate them for participation, themajority of inmates who consented to be screened did not meet criteria for major orminor depressive episodes when interviewed with the SCID. This led us to wonderwhether there was a reluctance among the residents to admit to depression, particularlyto strangers. It is possible that, had the screenings been conducted with staff memberswith whom inmates had already developed some form of relationship, we would haveidentified more depression.

8 Follow-Up

Participants continued to be monitored by the prison’s chief psychologist, with the fol-lowing outcomes approximately 6 months after termination of therapy.

Mr. A

Unfortunately, Mr. A’s worries about dying in prison were borne out. Approximately 1month after the completion of the program, Mr. A died as a result of complications follow-ing a fall. Mr. A had been medically unstable for some time. However, prior to his death,Mr. A’s mood improved noticeably, he was happier, and he shared more. In addition, hecontinued to participate in arts and crafts as well as bingo.

Mr. B

At the beginning of the program Mr. B only rarely left his room. Though he has notregressed to that level, Mr. B continues to spend an excessive amount of time in his roomsleeping and staring at the television. His participation in group activities has declined buthe does attend bingo. Another previously identified pleasurable activity that he has main-tained is taking regular showers. His church attendance and writing have declined thoughnot to preprogram levels. His affect remains primarily flat though he does occasionallysmile and his eye contact has improved from what it was at the beginning of the study. Aparticular pleasurable activity for Mr. B was to go outside and observe nature.Unfortunately, he has not been able to engage in this for some time because of a prolongedperiod of inclement weather.




Mr. C

Mr. C continues to come to bingo and enjoys his books on tape. He has had some visits fromhis brother which is another identified pleasurable event. He has maintained his previous levelof high activity and has added a “job” of wiping down the hand rails in the nursing care unit.He has a roommate with whom he gets along and he continues to be social, visiting with otherinmates on a regular basis. Mr. C appears upbeat and describes his mood as good.

Mr. D

Mr. D has significantly decreased in cognitive functioning since the end of the program.In addition, his health has declined. He spends most of his time in his room sleeping. Henow requires a wheel chair for ambulation. He continues to be disliked by staff and otherinmates and is now serving segregation time for displaying threatening behavior toward hisroommate. Despite this, Mr. D can respond pleasantly when treated with compassion.

9 Treatment Implications of the Cases

These four cases suggest that, once cases are identified, BE-ACTIV is feasible in the prisonnursing home and has the potential to improve the quality of life for medically frail prisonersby helping them to identify meaningful or pleasant activities. The cases illustrate how the rela-tionship with the therapist is an important aspect of the intervention, despite its behavioralemphasis. In addition, BE-ACTIV encourages the development of a productive and positiverelationship with recreational staff members, giving them explicit tasks that can help structuretheir work with prisoners and allowing prisoners to have an ally within the prison system. Thecases show how relatively few resources can be brought to make a difference in the activitylevels and satisfaction of inmates, and that increases in activity levels can lead to improvementsin negative affect, depressive symptoms, and psychiatric functioning. The intervention uses rel-atively few resources that are already available in most prison settings, and therefore, to theextent that treatment for depression may reduce morbidity, activities of daily life (ADL) depen-dency, and excess mortality, such a treatment may be seen as a cost-effective means of pre-venting other problems that might arise for depressed inmates. The cases studies presentedhere, therefore, suggest that it may be appropriate to further evaluate BE-ACTIV in the prisonsetting in a larger, controlled research study.

10 Recommendations to Clinicians and Students

Clinicians working in prison settings face numerous barriers that have been explored inrecently published books (Pollock et al., 2006; Saunders, 2001). Despite these barriers, ourcases illustrate that a useful therapist–inmate relationship can be established relatively quicklyin the context of a structured, manualized, behavioral treatment. We found that it was not nec-essary to explore the prisoners’ past experiences or criminal activity to treat their depressioneffectively. A working partnership with nonmental health staff in the prison unit is a critical




part of BE-ACTIV and serves two purposes: (a) to ensure that pleasant events are imple-mented and (b) to provide the inmate with an ally whose function extends beyond mentalhealth care to enjoyment of day-to-day life. Furthermore, the alliance with a recreational ther-apist helps increase the likelihood that activities will be maintained once active mental healthtreatment is ended, although we did not test this assumption in the present project.

Note

1. To protect the anonymity of the participants, inmates’ actual ages are not given in the case descriptions.

References

Aday, R. (1994). Golden years behind bars: Special programs and facilities for elderly inmates [Electronic ver-sion]. Federal Probation, 58(2), 47.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.).Washington, DC: Author.

Baillargeon, J., Black, S. A., Contreras, S., Grady, J., & Pulvino, J. (2002). Anti-depressant prescribing patternsamong prison inmates with depressive disorders. U.S. Department of Justice Document #194054. RetrievedJanuary 16, 2008, from the National Criminal Justice Reference Service Web site: http://www.ncjrs.gov/pdf-files1/nij/grants/194054.pdf

Bender, E. (2005). Prison punishment exacerbates inmates’ psychiatric illness. Psychiatric News, 40, 15-16.Bureau of Justice Statistics. (2003). Census of state and federal correctional facilities, 2000. Revised 2003.

Retrieved January 16, 2008, from http://www.ojp.usdoj.gov/bjs/pub/pdf/csfcf00.pdfBrink, T. L., Yesavage, J. A., Owen, L., Heersema, P., Aey, M., & Rose, T. L. (1982). Screening tests for geri-

atric depression. Clinical Gerontologist, 1, 37-43.Fazel, S., Hope, T., O’Donnell, I., & Jacoby, R. (2001). Hidden psychiatric morbidity in elderly prisoners

[Electronic version]. British Journal of Psychiatry, 179, 535-539.Fazel, S., Hope, T., O’Donnell, I., & Jacoby, R. (2004). Unmet treatment needs of older prisoners: A primary

care survey. Age and Ageing, 33, 396-398.Fazel, S., & Lubbe, S. (2005). Prevalence and characteristics of mental disorders in jails and prisons. Current

Opinion in Psychiatry, 18, 550-554.First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (2002, November). Structured Clinical Interview

for DSM-IV-TR Axis I disorders, research version, patient edition (SCID-I/P). New York: BiometricsResearch, New York State Psychiatric Institute.

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-mental state”: A practical method for gradingthe cognitive state of patients for the clinician. Journal of Psychiatry Research, 12, 189-198.

Goetting, A. (1983). The elderly in prison. Journal of Research in Crime and Delinquency, 20, 291-309.James, D. J., & Glaze, L. E. (2006). Mental health problems of prison and jail inmates. U. S. Department of

Justice, Bureau of Justice Statistics, NCJ 213600, September. Retrieved January 16, 2008, fromhttp://www.ojp.usdoj.gov/bjs/pub/pdf/mhppji.pdf

Konrad, N., Daigle, M. S., Daniel, A. E., Dear, G. E., Frottier. P., Hayes, L. M., et al. (2007). Preventing sui-cide in prisons, Part I. Recommendations from the International Association for Suicide Prevention TaskForce on Suicide in Prisons. Crisis, 28, 113-131.

Lawton, M. P. (1997). Positive and negative affective states among older people in long-term care. In R. L.Rubinstein & M. P. Lawton (Eds.), Depression in long-term and residential care (pp. 29-54). New York:Springer.

Lawton, M. P., Kleban, M. H., Dean, J., Rajagopal, D., & Parmelee, P. A. (1992). The factorial generality ofbrief positive and negative affect measures. Journal of Gerontology: Psychological Sciences, 47, 228-237.




Lewinsohn, P. M., Hoberman, H., Teri, L., & Hautzinger, M. (1985). An integrative theory of depression. In S. Reiss& R. R. Bootzin (Eds.), Theoretical issues in behavior therapy (pp. 331-359). New York: Academic Press.

Meeks, S., & Burton, E. G. (2004). Nursing home staff characteristics and knowledge gain from a didacticworkshop on depression and behavior management. Gerontology and Geriatrics Education, 25, 57-66.

Meeks, S., & Depp, C. A. (2002). Pleasant-events based behavioral intervention for depression in nursing homeresidents: A conceptual and empirical foundation. Clinical Gerontologist, 25, 125-148.

Meeks, S., Heuerman, A., Ramsey, S., Welsh, D., & White, K. (2005, November). The Pleasant EventsScale–Nursing Home Version: Development and validation. Paper presented at the Annual Meeting of theGerontological Society of America, Orlando, FL.

Meeks, S., Looney, S. W., Van Haitsma, K., & Teri, L. (2008). BE-ACTIV: A staff-assisted, behavioral inter-vention for depression in nursing homes. The Gerontologist, 48, 105-114.

Meeks, S., Teri, L., Van Haitsma, K., & Looney, S.W. (2006). Increasing pleasant events in the nursing home:Collaborative behavioral treatment for depression. Clinical Case Studies, 5, 287-304.

Nelson, E. C., Wasson, J., Johnson, D. J., & Hays, R. D. (n.d.). Dartmouth COOP functional health assessmentcharts: Brief measures for clinical practice. Retrieved June 16, 2005, from the Dartmouth University COOPProject Web site: http://www.dartmouth.edu/~coopproj/more_charts.html

Nelson, E. C., Wasson, J., Kirk, J., Keller, A., Clark, D., Dietrich, A., et al. (1987). Assessment of function inroutine clinical practice: Description of the COOP chart method and preliminary findings. Journal ofChronic Diseases, 40, 55S-63S.

National Institutes of Health. (2007). Re-engineering the clinical research enterprise. Retrieved January 9,2008, from http://nihroadmap.nih.gov/clinicalresearch/overview-translational.asp

Pollock, P. H., Stowell-Smith, M., & Göpfert, M. (Eds.). (2006). Cognitive analytic therapy for offenders.London: Routledge.

Saunders, J. W. (Ed.). (2001). Life within hidden worlds. Psychotherapy in prisons. London: Karnac Books.Senior, J., Hayes, A. J., Pratt, D., Thomas, S. D., Fahy, T., Leese, M., et al. (2007). The identification and man-

agement of suicide risk in local prisons. Journal of Forensic Psychiatry and Psychology, 18, 368-380.Teri, L. (1994). Behavioral treatment of depression in patients with dementia. Alzheimer’s Disease and

Associated Disorders, 8, 66-74.Teri, L. (1997). The relation between research on depression and a treatment program: One model. In R. L. Rubinstein

& M. P. Lawton (Eds.), Depression in long-term and residential care (pp. 129-153). New York: Springer.Teri, L., Logsdon, R., & Uomoto, J. (1991). Treatment of depression in patients with Alzheimer’s disease.

Therapist Manual. Seattle: University of Washington School of Medicine.Teri, L., Logsdon, R. G., Uomoto, J., & McCurry, S. M. (1997). Behavioral treatment of depression in demen-

tia patients: A controlled clinical trial. Journal of Gerontology: Psychological Sciences, 52B, P159-P166.Vernig, P. M. (2007). From science to practice: Bridging the gap with translational research. APS Observer, 20(2).

Retrieved January 19, 2008, from http://www.psychologicalscience.org/observer/getArticle.cfm? id=2133

Suzanne Meeks, PhD, is a professor of clinical psychology in the Department of Psychological and BrainSciences at the University of Louisville. She has been involved in clinical work and research in nursing homesfor more than 20 years as part of her broader research focus on mental illness in late life.

Robin Sublett, PhD, is the chief psychologist at the Kentucky State Reformatory. She currently provides clin-ical services in the Nursing Care Facility as well as supervises the General Psychological Services.

Irene Kostiwa, MA, is a doctoral student in clinical psychology at the University of Louisville. Her researchinterests include sleep and mood problems among long-term care residents.

James R. Rodgers, MA, is a doctoral student in clinical psychology at the University of Louisville, complet-ing his internship at the Southwest Texas Veterans Health Center during the 2008-2009 academic year. Hisresearch and clinical interests focus on end-of-life care.

Donna Haddix is a recreation leader at the Kentucky State Reformatory. She supervises recreation services inthe Correctional Psychiatric Unit as well as the Nursing Care Facility.




treating depression in prison nursing home

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