![]() ![]() Implementing and testing such complex interventions entails substantial methodological and logistic challenges this is especially the case among older adults in whom individual variability is high and, often intervention tolerance may be low because of frailty or other geriatric-specific syndromes. Since the clinical approach for non-responders to an intervention usually involves continued exposure or a switch, testing sequences of interventions is indicated to inform care. Indeed, exposure to EXERCISE before CBT may engage participants who are otherwise not psychologically minded, preparing them to be more open to a psycho-behavioral intervention such as CBT. This order effect, however, is not established. Initial exposure to CBT may enhance attention to psychological health, motivation, and problem solving, thus enabling individuals who are first exposed to CBT to make better use of EXERCISE (compared with those exposed to EXERCISE followed by CBT). ![]() The order effect of these interventions on preventing MDD and anxiety disorders is also not known. 15 These qualities make them rational choices for a prevention study of new episode MDD and anxiety disorders. Both CBT and EXERCISE are behaviorally activating, improve self-efficacy, and reduce learned helplessness. Learning-based interventions such as Cognitive Behavioral Therapy (CBT) 13 or a knee-specific physical therapy (Manual Therapy and Supervised Exercise 14 EXERCISE) are routinely prescribed along with analgesics for both pain control and improved functioning. Since anxiety disorders increase risk for MDD 5 and both conditions worsen comorbid medical burden and disability 6, prevention interventions should aim to reduce the risk of developing both depression and anxiety in late-life. 4 It is plausible that reducing pain and disability could actually prevent new onset cases of MDD and anxiety disorders, although this has not yet been tested. 3 Patients living with both conditions also have significantly worse health-related quality of life, greater somatic symptom severity, and higher prevalence of other pain disorders than chronic pain patients without depression. 2 Indeed, among older adults with MDD, a significantly higher proportion report pain that is disabling compared to those without MDD. Osteoarthritis (OA) pain and associated disability are risk factors for a major depressive episode and possibly anxiety disorders, 1 and treating OA pain and disability may reduce the severity of comorbid MDD and anxiety. Medical illness, functional disability, family and personal histories of mood disorders, social isolation, life stressors, bereavement, and neurodegenerative disorders are all putative risk factors for new onset major depressive disorder (MDD) and anxiety disorders in older adults. ![]()
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