Ability of nurses to identify depression in primary care, secondary care and nursing homes--a meta-analysis of routine clinical accuracy

Association between sociodemographic factors, clinic characteristics and mental health screening rates in primary care

BACKGROUND

Screening for mental health problems has been shown to be effective to detect depression and initiate treatment in primary care. Current guidelines recommend periodic screening for depression and anxiety. This study examines the association of patient sociodemographic factors and clinic characteristics on mental health screening in primary care.

DESIGN

In this retrospective cohort study, electronic medical record (EMR) data from a 14-month period from 10/15/2021 to 12/14/2022 were analyzed. Data were retrieved from 18 primary care clinics from the Corewell Health healthcare system in West Michigan. The main outcome was documentation of any Patient Health Questionnaire (PHQ-4/PHQ-9/GAD-7) screening in the EMR within the 14-month period at patient level. General linear regression models with logit link function were used to assess adjusted odds ratio (aOR) of having a documented screening.

RESULTS

In total, 126,306 unique patients aged 16 years or older with a total of 291,789 encounters were included. The prevalence of 14-month screening was 79.8% (95% CI, 79.6-80.0). Regression analyses revealed higher screening odds for patients of smaller clinics (<5,000 patients, aOR 1.88; 95% CI 1.80-1.98 vs. clinics >10.000 patients), clinics in areas with mental health provider shortages (aOR 1.69; 95% CI 1.62-1.77), frequent visits (aOR 1.80; 95% CI, 1.78-1.83), and having an annual physical / well child visit encounter (aOR 1.52; 95% CI, 1.47-1.57). Smaller positive effect sizes were also found for male sex, Black or African American race, Asian race, Latinx ethnicity (ref. White/Caucasians), and having insurance through Medicaid (ref. other private insurance).

DISCUSSION

The 14-month mental health screening rates have been shown to be significantly lower among patients with infrequent visits seeking care in larger clinics and available mental health resources in the community. Introducing and incentivizing mandatory mental health screening protocols in annual well visits, are viable options to increase screening rates.

District Nurses' Experiences of Practice in Caring for People with Mental Ill-Health in Swedish Primary Care

Mental ill-health is one of the greatest public health challenges in Sweden, and it is estimated that every third person seeking primary care in the country suffers from mental ill-health. Without proper treatment at an early stage, mental ill-health may lead to long-term illness and have a significant impact on functional ability. As district nurses are specialists in public health nursing, they have been pointed out as having a key role in the prevention and management of mental ill-health. The aim was to explore district nurses' practice in caring for people with mental ill-health within primary health care. Individual semi-structured interviews were conducted with district nurses (n = 18) and the transcribed text was subjected to qualitative content analysis. The result was formulated as several subthemes, eventually developed into three themes: Practicing within an organisation where traditional attitudes are impediments, Perceiving mental healthcare as not being an obvious part of district nursing, Working as fellow human beings rather than "professionals". The findings indicate that district nurses feel uncertainty in their practice in this area. Working independently with mental ill-health was not always considered socially acceptable among district nurses. Despite these challenges they tried to remain involved without becoming emotionally overwhelmed. They also strived to meet the needs of these patients with 'small things', that could be effective and a part of recovery-oriented practice, even if they might be defined as unprofessional, and their efficacy negated.

Trajectories of depressive symptoms among community-dwelling Korean older adults: findings from the Korean longitudinal study of aging (2006-2016)

BACKGROUND

Depression among older adults is an important public health concern associated with increased risk of suicide and decreased physical, cognitive, and social functioning. This study identified trajectories of depressive symptoms and investigated predictive variables of group-based trajectory modeling among Korean community-dwelling older adults.

METHODS

Participants comprised 2016 community-dwelling Korean adults over 65 years. Data from the years 2006-2016 of the Korean Longitudinal Study of Aging, a nationally representative panel survey that has been conducted every two years since 2006, were used. We employed a group-based trajectory modeling analysis to identify depressive symptom trajectories. Multinomial logistic regression analysis was conducted to identify predictors of each class of depressive symptoms.

RESULTS

Five depressive symptom trajectory groups were identified: Group 1, "None" (28.9%); Group 2, "Slowly worsening" (24.3%); Group 3, "Rapidly worsening" (17.5%); Group 4 "Improving" (12.4%); and Group 5, "Persistently severe" (16.9%). Older adults followed five distinct depressive symptom trajectories over 10 years. Mini-Mental State Examination scores, number of chronic diseases, educational level, and social activity were predictors associated with increasing depressive symptoms.

CONCLUSIONS

This study showed that many older adults living in the community have depressive symptoms. To prevent and treat depression and aid successful mental health aging among older adults, the development of interventions should be tailored to target specific needs for each symptom trajectory. It is necessary to develop community-based interventions and strategies to identify and prevent depressive symptom trajectories among older adults.

A Methodological Quality Evaluation of Meta-Analyses on Nursing Home Research: Overview and Suggestions for Future Directions

(1) Background: The nursing home (NH) research field lacks quality reporting about meta-analyses (MAs), and most gradings of MA evidence are biased on analyzing the effectiveness of independent variables in randomized control trials. (2) Objectives: This study aimed to perform a critical methodological review of MAs in the NH research field. (3) Methods: We searched the articles from four databases (PubMed, MEDLINE, CINAHL, and PsycINFO) until 15th January 2021. We reviewed a total of 41 published review articles in the NH research field. (4) Results: The studies primarily fell into the following categories: medicine (17/41), nursing (7/41), and psychiatry or psychology (6/41); 36.6% of the reviewed studies did not use any validated MA guidelines. The lowest correctly reported PRISMA 2000 guideline item was protocol and registration (14.6%), and more than 50% of articles did not report risk of bias. Moreover, 78.0% of studies did not describe missing reports of effect size formula. (5) Discussion: NH researchers must follow appropriate and updated guidelines for their MAs in order to provide validated reviews, as well as consider statistical issues such as the complexity of interventions, proper grouping, and scientific effect-size calculations to improve the quality of their study. Future quality review studies should investigate more diverse studies.

Barriers to the Recognition of Geriatric Depression in Residential Care Facilities in Alberta

This study explored the barriers that regulated nurse professionals encountered in recognizing and assessing geriatric depression in residential care facilities in the Canadian province of Alberta. The study used a convergent parallel mixed methods design, including a cross-sectional survey (N = 635) and qualitative interviews (N = 14) with regulated nurse professionals. Findings revealed six major barriers to the recognition of geriatric depression in Alberta, including 1) insufficient clinical knowledge and training in geriatric depression; 2) misconceived beliefs about geriatric depression; 3) limited access to resources; 4) unclear depression assessment protocol and procedures in facilities; 5) characteristics of models of care and organizational culture in facilities; and 6) communication difficulties among all stakeholders in the process. Socio-cultural values and beliefs about geriatric depression played a key role in the complex interaction of the various structural and agential barriers to the effective recognition and assessment of depression in residential care facilities in Alberta.

How Do Regulated Nurse Professionals in Alberta Assess Geriatric Depression in Residential Care Facilities?

Although geriatric depression is a prevalent, serious, and under-recognized mental health condition in residential care facilities, there is a dearth of related research in Canada. This exploratory mixed methods study examines the perspectives and practices of regulated nurse professionals on assessment of geriatric depression in residential care facilities in Alberta. Findings from the quantitative surveys (n = 635) and qualitative interviews (n = 14) suggest that geriatric depression is not systematically assessed in these care settings due to multiple challenges, including confusing assessment protocol, inconsistent use and contested clinical utility of current assessment methods in facilities, limited availability of mental health professionals in facilities, and the varied views of regulated nurse professionals on who is responsible for depression assessment in facilities. Implications and future research directions are discussed.

Depression Among Elderly Users of Open and Closed Care Facilities in a Rural Region of Greece: an Important Public Health Issue

Introduction:

It is estimated that 5.7% of the total Greek population suffers from depressive disorders. Elderly may be particularly prone to depression compared to younger people. In Greece, there is a paucity of literature regarding the correlation between the existence of chronic diseases, sociodemographic features, participation in open/ closed structures, and the presence of depression or depressive symptoms, among seniors. The purpose of this study was to explore potential correlations between the above- mentioned variables, as a whole.

Methods:

This was a cross- sectional, questionnaire survey of 200 elderly aged 65 or above and were members of 12 Open Care Centers for the Elderly (OCCE) or residents in 2 nursing homes located in the rural region of Epirus, in Greece. Data collection took place in the form of structured individual interviews. For the identification of independent factors associated with the existence of depressive symptoms, stepwise logistic regression analysis was performed.

Results:

A total of 81 (40.5%) seniors experienced depressive symptoms, though only 39 of them (19.5%) had been diagnosed for depression. Depression rates were higher for those with more chronic diseases (p=0.01) and at divorced, widowed and single seniors compared to married ones (50.5% vs. 28.1% respectively, p=0.002). The prevalence of depression was higher among the elderly who lived in nursing homes compared to the participants who were registered members of the OCCE (50% vs. 35.6% respectively, p=0.049), while elderly who often participated in the social activities of OCCE, had significantly lower rates of depressive symptoms compared to those who scarcely were involved in these activities (23% vs. 46.2% respectively, p=0.019). Participants who suffered from osteoporosis were more likely of displaying depressive symptoms compared to those who didn’t; OR (95% Confidence Interval) = 2.61 (1.28-5.33), p=0.009.

Conclusions:

The existence of an action plan that includes education and training of health professionals on mental health of the elderly and the satisfactory operation of public facilities to promote the wellbeing of seniors and offer more incentives for activity participation, may reduce depression rates and the under-diagnosis of the disease.

Registered nurses experiences of managing depressive symptoms at care centres for older people: a qualitative descriptive study

BACKGROUND

Depressive symptoms and/or depression are commonly experienced by older people. Both are underdiagnosed, undertreated and regularly overlooked by healthcare professionals. Healthcare facilities for people aged ≥75 years have been in place in Sweden since 2015. The aim of these care centres, which are managed by registered nurses (RNs), is to offer care adjusted to cater to the complex needs and health problems of older people. Although the mental health of older people is prioritised in these centres, research into the experience of RNs of depressive symptoms and/or depression in older people in this setting is limited. Therefore, this study aimed to illuminate RNs, working at care centres for older people, experience of identifying and intervening in cases of depressive symptoms.

METHODS

The data for this qualitative descriptive study were collected through interviews (n = 10) with RNs working at 10 care centres for older people in southern Sweden. The transcribed texts were analysed using inductive content analysis.

RESULTS

The participants' experiences could be understood from four predominant themes: (1) challenging to identify, (2) described interventions, (3) prerequisites for identification, and (4) contextual influences. Key findings were that it was difficult to identify depression as it often manifested as physical symptoms; evidence-based nursing interventions were generally not the first-line treatment used; trust, continuity and the ability of RNs to think laterally; and the context influenced the ability of RNs to manage older people's depressive symptoms and/or depression.

CONCLUSIONS

The process of identifying depressive symptoms and performing an appropriate intervention was found to be complex, especially as older people were reluctant to present at the centres and provided obscure reasons for doing so. A nurse-patient relationship that was built on trust and was characterised by continuity of care was identified as a necessary prerequisite. Appropriate nursing interventions-afforded the same status as pharmacological treatment-are warranted as the first-line treatment of depression. Further research is also needed into efficacious nursing interventions targeting depressive symptoms and/or depression.

[Functional Health Pattern Model Based Care Plan for a Depression Diagnosed Patient]

Depression is the most frequent disorder among mental disorders, with frequent attacks, high suicidal risks, causing loss of labour-force, as well as to loss of serious physical and psycho-social skills, and also is economically and socially overcosting. The aim of nursing care for depression diagnosed patients is to provide security, to support their independence as much as possible, to help the patient rebuild the harmony at pre-diagnosis level, and to continue their well-being. This case applied to the hospital after an attempt to commit suicide, having continuous thoughts of suicide, guilt feelings, unhappiness, unwillingness, and was hospitalised with a diagnosis of medium depressive seizure. The patient was evaluated via nursing care model of Gordon's Functional Health Patterns on the second day of hospitalisation, and was diagnosed with 'Nutrition, imbalanced: less than body requirements, hopelessness, decrease in self-esteem, impaired social interaction, risk of self-harm, ineffective individual coping'. Nursing care was applied to the medication administered patient within the framework of nursing diagnosis. It was seen that the applied care provided positive support to the healing process of the patient.

The effect of a training programme on school nurses' knowledge, attitudes, and depression recognition skills: The QUEST cluster randomised controlled trial

BACKGROUND

Mental health problems in children and young people are a vital public health issue. Only 25% of British school children with diagnosed mental health problems have specialist mental health services contact; front-line staff such as school nurses play a vital role in identifying and managing these problems, and accessing additional services for children, but there appears limited specific training and support for this aspect of their role.

OBJECTIVES

To evaluate the effectiveness of a bespoke short training programme, which incorporated interactive and didactic teaching with printed and electronic resources. Hypothesized outcomes were improvements in school nurses' knowledge, attitudes, and recognition skills for depression.

DESIGN

A cluster-randomised controlled trial.

PARTICIPANTS AND SETTING

146 school nurses from 13 Primary Care Trusts (PCTs) in London were randomly allocated to receive the training programme.

METHODS

School nurses from 7 PCTs (n = 81) were randomly allocated to receive the training intervention and from 6 PCTs (n = 65) for waiting list control. Depression detection was measured by response to vignettes, attitudes measured with the Depression Attitude Questionnaire, and knowledge by the QUEST knowledge measure. These outcomes were measured at baseline and (following training) 3 months and nine months later, after which nurses in the control group received the training programme.

RESULTS

At 3 months, 115 nurses completed outcome measures. Training was associated with significant improvements in the specificity of depression judgements (52.0% for the intervention group and 47.2% for the control group, P = 0.039), and there was a non-significant increase in sensitivity (64.5% compared to 61.5% P = 0.25). Nurses' knowledge about depression improved (standardised mean difference = 0.97 [95% CI 0.58 to 1.35], P < 0.001); and confidence about their professional role in relation to depression increased. There was also a significant change in optimism about depression outcomes, but no change in tendency to defer depression management to specialists. At 9-month follow-up, improved specificity in depression identification and improved knowledge were maintained.

CONCLUSIONS

This school nurse development programme, designed to convey best practice for the identification and care of depression, delivered significant improvements in some aspects of depression recognition and understanding, and was associated with increased confidence in working with young people experiencing mental health problems.

Oncology Nurses' Attitudes Toward the Edmonton Symptom Assessment System: Results From a Large Cancer Care Ontario Study

PURPOSE/OBJECTIVES

To examine oncology nurses' attitudes toward and reported use of the Edmonton Symptom Assessment System (ESAS) and to determine whether the length of work experience and presence of oncology certification are associated with their attitudes and reported usage.
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DESIGN

Exploratory, mixed-methods study employing a questionnaire approach.
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SETTING

14 regional cancer centers (RCCs) in Ontario, Canada.
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SAMPLE

Oncology nurses who took part in a larger province-wide study that surveyed 960 interdisciplinary providers in oncology care settings at all of Ontario's 14 RCCs.
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METHODS

Oncology nurses' attitudes and use of ESAS were measured using a 21-item investigator-developed questionnaire. Descriptive statistics and Kendall's tau-b or tau-c test were used for data analyses. Qualitative responses were analyzed using content analysis.
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MAIN RESEARCH VARIABLES

Attitudes toward and self-reported use of standardized symptom screening and ESAS.
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FINDINGS

More than half of the participants agreed that ESAS improves symptom screening, most said they would encourage their patients to complete ESAS, and most felt that managing symptoms is within their scope of practice and clinical responsibilities. Qualitative comments provided additional information elucidating the quantitative responses. Statistical analyses revealed that oncology nurses who have 10 years or less of work experience were more likely to agree that the use of standardized, valid instruments to screen for and assess symptoms should be considered best practice, ESAS improves symptom screening, and ESAS enables them to better manage patients' symptoms. No statistically significant difference was found between oncology-certified RNs and noncertified RNs on attitudes or reported use of ESAS.
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CONCLUSIONS

Implementing a population-based symptom screening approach is a major undertaking. The current study found that oncology nurses recognize the value of standardized screening, as demonstrated by their attitudes toward ESAS.
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IMPLICATIONS FOR NURSING

Oncology nurses are integral to providing high-quality person-centered care. Using standardized approaches that enable patients to self-report symptoms and understanding barriers and enablers to optimal use of patient-reported outcome tools can improve the quality of patient care.

Depression recognition and capacity for self-report among ethnically diverse nursing homes residents: Evidence of disparities in screening

AIMS AND OBJECTIVES

To examine agreement between Minimum Data Set clinician ratings and researcher assessments of depression among ethnically diverse nursing home residents using the 9-item Patient Health Questionnaire.

BACKGROUND

Although depression is common among nursing homes residents, its recognition remains a challenge.

DESIGN

Observational baseline data from a longitudinal intervention study.

METHODS

Sample of 155 residents from 12 long-term care units in one US facility; 50 were interviewed in Spanish. Convergence between clinician and researcher ratings was examined for (i) self-report capacity, (ii) suicidal ideation, (iii) at least moderate depression, (iv) Patient Health Questionnaire severity scores. Experiences by clinical raters using the depression assessment were analysed. The intraclass correlation coefficient was used to examine concordance and Cohen's kappa to examine agreement between clinicians and researchers.

RESULTS

Moderate agreement (κ = 0.52) was observed in determination of capacity and poor to fair agreement in reporting suicidal ideation (κ = 0.10-0.37) across time intervals. Poor agreement was observed in classification of at least moderate depression (κ = -0.02 to 0.24), lower than the maximum kappa obtainable (0.58-0.85). Eight assessors indicated problems assessing Spanish-speaking residents. Among Spanish speakers, researchers identified 16% with Patient Health Questionnaire scores of 10 or greater, and 14% with thoughts of self-harm whilst clinicians identified 6% and 0%, respectively.

CONCLUSION

This study advances the field of depression recognition in long-term care by identification of possible challenges in assessing Spanish speakers.

RELEVANCE TO CLINICAL PRACTICE

Use of the Patient Health Questionnaire requires further investigation, particularly among non-English speakers. Depression screening for ethnically diverse nursing home residents is required, as underreporting of depression and suicidal ideation among Spanish speakers may result in lack of depression recognition and referral for evaluation and treatment. Training in depression recognition is imperative to improve the recognition, evaluation and treatment of depression in older people living in nursing homes.

Guidelines for Reporting Articles on Psychiatry and Heart rate variability (GRAPH): recommendations to advance research communication

The number of publications investigating heart rate variability (HRV) in psychiatry and the behavioral sciences has increased markedly in the last decade. In addition to the significant debates surrounding ideal methods to collect and interpret measures of HRV, standardized reporting of methodology in this field is lacking. Commonly cited recommendations were designed well before recent calls to improve research communication and reproducibility across disciplines. In an effort to standardize reporting, we propose the Guidelines for Reporting Articles on Psychiatry and Heart rate variability (GRAPH), a checklist with four domains: participant selection, interbeat interval collection, data preparation and HRV calculation. This paper provides an overview of these four domains and why their standardized reporting is necessary to suitably evaluate HRV research in psychiatry and related disciplines. Adherence to these communication guidelines will help expedite the translation of HRV research into a potential psychiatric biomarker by improving interpretation, reproducibility and future meta-analyses.

[Comparative effectiveness and safety of screening and counselling interventions conducted by non-physicians and physicians: a systematic review]

BACKGROUND

Current forecasts project a future shortage of physicians which might compromise the quality of health care if not addressed adequately by health policy decisions. One proposed measure is to shift selected tasks and responsibilities from physicians to other medical staff, a strategy that has proven successful in some areas (e. g., chronic disease management). To date, no studies have systematically and objectively assessed whether the application of a similar strategy to screening and counselling in preventive medicine compromises patients' health outcomes and experiences.

METHODS

A systematic search was conducted in MEDLINE, the Cochrane Library, CINAHL, and EMBASE (January 2000 - June 2014). We dually reviewed articles and assessed the risk of bias.

RESULTS

3,315 citations were identified and five relevant articles located. Overall, the available evidence indicated that there were no substantial differences in benefits and harms of screening (colon cancer screening, sexual transmitted diseases, and mammography) and counselling (genetic breast cancer risk) between non-physicians and physicians. The quality of evidence, however, is very low for most comparisons. Reported statistically significant differences for some outcomes need to be viewed cautiously.

CONCLUSION

Shifting tasks from physicians to other medical staff for screening and counselling could be a viable strategy to address the shortage of practicing physicians. Adequate training by a physician, however, is a prerequisite for the safe and beneficial screening and counselling conducted by non-physicians.

Health professionals' detection of depression and anxiety in their patients with diabetes: The influence of patient, illness and psychological factors

This study examines how often depression and anxiety, in patients with diabetes, are detected by health professionals; and whether detection is influenced by patient characteristics (age, gender), illness factors (duration of illness, diabetes control), and self-reported levels of depression and anxiety. Prevalence rates of clinically significant depression and anxiety were high (57% and 36%, respectively); however, of those identified, only 44 and 36 per cent, respectively, were detected by staff as depressed or anxious. The only significant predictors of detection were severity of depressive and anxious symptoms. Patient and illness characteristics did not influence whether professionals identified emotional problems in their patients.

Bariatric psychology in the UK National Health Service: input across the patient pathway

BACKGROUND

Providers of bariatric surgery within the National Health Service (NHS) are required to provide psychological assessment and intervention, yet operational definitions regarding the purpose and scope of this input are lacking. This has led to significant variation in the provision of psychology, with some providing an assessment-only service and others providing a more comprehensive package of intervention throughout the patient pathway. The aims of this paper are to document the current psychology provision and service models of National Health Service (NHS) bariatric surgery services in the UK. Psychologists belonging to a bariatric psychology forum completed a survey. This focused on provision of psychological assessment and intervention throughout the bariatric pathway as well as the ratio between psychology resources and number of bariatric procedures per year. We obtained information from 22 NHS services which provide 3691 procedures per year.

RESULTS

There is significant variation in the ratio between psychology resources and number of bariatric procedures undertaken per service. Whilst all services offer pre-surgery psychology assessments, less than one-third routinely assess all potential bariatric surgery candidates. Over 90% of services offer pre-surgery individual interventions and 41% offer pre-surgery groups. None of the services routinely offer post-surgery assessments but 68% offer post-surgery assessment and intervention following referral. None offered post-operative structured psychological group interventions.

CONCLUSION

There are significant disparities and inconsistencies in the provision of psychology resources in relation to surgery volume in the NHS. Most of these resources are directed at pre-surgery assessment and this raises issues regarding the function of these assessments. Rather than focusing on assessing psychological (un)suitability for surgery, an evidence-based approach involves psychologists offering pre-operative interventions to improve readiness for surgery and post-operative interventions to address recurring or emerging difficulties which impact on outcomes.

An interprofessional nurse-led mental health promotion intervention for older home care clients with depressive symptoms

Background

Depressive symptoms in older home care clients are common but poorly recognized and treated, resulting in adverse health outcomes, premature institutionalization, and costly use of health services. The objectives of this study were to examine the feasibility and acceptability of a new six-month interprofessional (IP) nurse-led mental health promotion intervention, and to explore its effects on reducing depressive symptoms in older home care clients (≥ 70 years) using personal support services.

Methods

A prospective one-group pre-test/post-test study design was used. The intervention was a six-month evidence-based depression care management strategy led by a registered nurse that used an IP approach. Of 142 eligible consenting participants, 98 (69%) completed the six-month and 87 (61%) completed the one-year follow-up. Outcomes included depressive symptoms, anxiety, health-related quality of life (HRQoL), and the costs of use of all types of health services at baseline and six-month and one-year follow-up. An interpretive descriptive design was used to explore clients’, nurses’, and personal support workers’ perceptions about the intervention’s appropriateness, benefits, and barriers and facilitators to implementation.

Results

Of the 142 participants, 56% had clinically significant depressive symptoms, with 38% having moderate to severe symptoms. The intervention was feasible and acceptable to older home care clients with depressive symptoms. It was effective in reducing depressive symptoms and improving HRQoL at six-month follow-up, with small additional improvements six months after the intervention. The intervention also reduced anxiety at one year follow-up. Significant reductions were observed in the use of hospitalization, ambulance services, and emergency room visits over the study period.

Conclusions

Our findings provide initial evidence for the feasibility, acceptability, and sustained effects of the nurse-led mental health promotion intervention in improving client outcomes, reducing use of expensive health services, and improving clinical practice behaviours of home care providers. Future research should evaluate its efficacy using a randomized clinical trial design, in different settings, with an adequate sample of older home care recipients with depressive symptoms.

Trial registration

Clinicaltrials.gov identifier: NCT01407926.

A structural multidisciplinary approach to depression management in nursing-home residents: a multicentre, stepped-wedge cluster-randomised trial

BACKGROUND

Depression in nursing-home residents is often under-recognised. We aimed to establish the effectiveness of a structural approach to its management.

METHODS

Between May 15, 2009, and April 30, 2011, we undertook a multicentre, stepped-wedge cluster-randomised trial in four provinces of the Netherlands. A network of nursing homes was invited to enrol one dementia and one somatic unit per nursing home. In enrolled units, nursing-home staff recruited residents, who were eligible as long as we had received written informed consent. Units were randomly allocated to one of five groups with computer-generated random numbers. A multidisciplinary care programme, Act in Case of Depression (AiD), was implemented at different timepoints in each group: at baseline, no groups were implenting the programme (usual care); the first group implemented it shortly after baseline; and other groups sequentially began implementation after assessments at intervals of roughly 4 months. Residents did not know when the intervention was being implemented or what the programme elements were; research staff were masked to intervention implementation, depression treatment, and results of previous assessments; and data analysts were masked to intervention implementation. The primary endpoint was depression prevalence in units, which was the proportion of residents per unit with a score of more than seven on the proxy-based Cornell scale for depression in dementia. Analyses were by intention to treat. This trial is registered with the Netherlands National Trial Register, number NTR1477.

FINDINGS

16 dementia units (403 residents) and 17 somatic units (390 residents) were enrolled in the course of the study. In somatic units, AiD reduced prevalence of depression (adjusted effect size -7·3%, 95% CI -13·7 to -0·9). The effect was not significant in dementia units (0·6, -5·6 to 6·8) and differed significantly from that in somatic units (p=0·031). Adherence to depression assessment procedures was lower in dementia units (69% [SD 19%]) than in somatic units (82% [15%]; p=0·045). Adherence to treatment pathways did not differ between dementia units (43% [SD 33%]) and somatic units (38% [40%]; p=0·745).

INTERPRETATION

A structural approach to management of depression in nursing homes that includes assessment procedures can reduce depression prevalence in somatic units. Improvements are needed in depression screening in dementia units and in implementation of nursing-home treatment protocols generally.

FUNDING

The Netherlands Organization for Health Research and Development.

Including nurses in care models for older people with mild to moderate depression: an integrative review

AIMS AND OBJECTIVES

The aim of this integrative literature review was twofold: (1) to investigate different collaborative programmes for older people with depression living at home with diverse access to care and (2) to describe conceptualisation of the nurses' role and interventions within these care models.

BACKGROUND

One in four older people who visits a General Practitioner suffers from depression. Depression is a concern for 15% of all older home-care service clients. Detecting and managing depression in older people is highlighted as a key role of nurses. A literature review has been conducted to investigate collaborative models of care, aimed at ensuring low-threshold access to care and exploring the scope of nurse practice within these models.

METHODS

Literature review comprising 14 studies and reviews.

RESULTS

Three different collaborative care programmes (Collaborative Care Model, Community Mental Health Team and Psychogeriatric Assessment and Treatment in City Housing programme) were identified. In all programmes, the essential aspects were complex and multifaceted interventions, provided by a variety of healthcare professionals, but the access to care differed. All studies described the role of nurses differently and with wide variations.

CONCLUSIONS

Despite a broad scope of practice, nurses play a pivotal role within the different models of care. Nurses have to have the educational background and expertise in mental health issues to recognise depression and eventually be able to provide more comprehensive interventions to alleviate depression in older people.

RELEVANCE TO PRACTICE

Collaboration is needed to meet the needs of older people with depression. New forms of work divisions are pivotal to achieve this objective.

The development and first use of the QUEST measures to evaluate school nurses' knowledge and skills for depression recognition and management

BACKGROUND

Depression affects around 5% of adolescents and its identification and management is an important part of front-line professionals' roles. There are few validated measures of knowledge and skills in this area. We describe a multiple-choice question set to test nurses' depression knowledge and vignettes to examine case recognition skills.

METHODS

A 24-item knowledge test and 12 vignettes were developed based on relevant literature and expert panel review. Three rounds of panel review assessed face and content validity and expert agreement of vignette depression status. The measures were piloted with 26 school nurses. Following amendments, administered to 146 school nurses. A depression attitude scale was used concurrently so that associations among knowledge, attitudes, and condition recognition could be explored.

RESULTS

Readability for the knowledge test and vignettes was satisfactory. Item difficulty and discrimination indices for most knowledge questions were acceptable; overall, participants scored 50% correctly, with less than 5% unanswered. The panel reached 89% agreement about vignette depression status, and nurse participants' judgments of the vignettes achieved 65% sensitivity and 47% specificity.

CONCLUSION

The study produced psychometrically tested instruments for measuring depression recognition and knowledge. There was evidence for content validity, and limited evidence of convergent validity from associations among measures. Some of the items may be modified, and a smaller set of vignettes having the best expert agreement may be useful in future research.

Testing the PHQ-9 interview and observational versions (PHQ-9 OV) for MDS 3.0

OBJECTIVES

To test the feasibility and validity of the Patient Health Questionnaire-9 item interview (PHQ-9) and the newly developed Patient Health Questionnaire Observational Version (PHQ-9 OV) for screening for mood disorder in nursing home populations.

METHODS

The PHQ-9 was tested as part of the national Minimum Data Set 3.0 (MDS 3.0) evaluation study among 3822 residents scheduled for MDS 2.0 assessments. Residents from 71 community nursing homes (NHs) in eight states were randomly included in a feasibility sample (n = 3258) and a validation sample (n = 418). Each resident's ability to communicate determined whether the PHQ-9 interview or the PHQ-9 OV was initially attempted. In the validation sample, trained research nurses administered the instruments. For residents in the validation sample without severe cognitive impairment (3 MS ≥30) agreement between PHQ-9 and the modified Schedule for Affective Disorders and Schizophrenia (m-SADS) was measured with weighted kappas (κ). For residents with severe cognitive impairment (3MS <30), agreement between PHQ-9 interview or PHQ-9 OV and the Cornell Scale for Depression in Dementia (Cornell Scale) was measured using correlation coefficients. Staff impressions were obtained from an anonymous survey mailed to all MDS assessors.

RESULTS

The PHQ-9 was completed in 86% of the 3258 residents in the feasibility sample. In the validation sample, the agreement between PHQ-9 and m-SADS was very good (weighted κ = 0.69, 95% CI = 0.61-0.76), whereas agreement between MDS 2.0 and m-SADS was poor (weighted κ = 0.15, 95% CI = 0.06-0.25). Likewise, in residents with severe cognitive impairment, PHQ correlations with the criterion standard Cornell Scale were superior to the MDS 2.0 for both the PHQ-9 (0.63 vs 0.34) and the PHQ-9 OV (0.84 vs 0.28). Eighty-six percent of survey respondents reported that the PHQ-9 provided new insight into residents' mood. The average time for completing the PHQ-9 interview was 4 minutes.

DISCUSSION

Compared with the MDS 2.0 observational items, the PHQ-9 interview had greater agreement with criterion standard diagnostic assessments. For residents who could not complete the interview, the PHQ-9 OV also had greater agreement with a criterion measure for depression than did the MDS 2.0 observational items. Moreover, the majority of NH residents were able to complete the PHQ-9, and most surveyed staff reported improved assessments with the new approach.

Adherence to Canadian best practice recommendations for stroke care: assessment and management of poststroke depression in an Ontario rehabilitation facility

BACKGROUND AND PURPOSE

Although Canadian best practice recommendations regarding assessment and management of poststroke depression (PSD) have been established, the degree to which these evidence-based guidelines have been translated into practice is not known. The objectives of the present study are to compare current and recommended best practice and examine possible reasons for identified care gaps.

METHODS

Practice audit by chart review was performed to identify recorded screening, assessment, and treatment for PSD in patients discharged from a specialized inpatient rehabilitation program over a 6-month period. A questionnaire was administered to all clinical staff addressing current screening practices as well as opinions regarding the importance and feasibility of identification and treatment of PSD.

RESULTS

Of 123 patients, 40 (32.5%) had been prescribed antidepressants at discharge. However, evidence of screening was found for 4.9% of patients; another 9.8% were referred for psychological consult. Treatment was associated with previous antidepressant use or history of depression, but not screening or assessment. Of the survey respondents, 56.2% were not aware of best practice recommendations. However, most felt screening and assessment to be important and treatment was regarded as both simple and effective.

CONCLUSIONS

Despite potential benefit associated with identification and treatment of PSD and the availability of evidence-based best practice recommendations, PSD may remain unrecognized and undertreated. Given the juxtaposition of perceived importance with the lack of documented best practice, education regarding standardized screening and the development of consistent clinical protocols including roles and responsibilities in the identification, diagnosis, and treatment of PSD are underway.

Reducing depression in older home care clients: design of a prospective study of a nurse-led interprofessional mental health promotion intervention

BACKGROUND

Very little research has been conducted in the area of depression among older home care clients using personal support services. These older adults are particularly vulnerable to depression because of decreased cognition, comorbid chronic conditions, functional limitations, lack of social support, and reduced access to health services. To date, research has focused on collaborative, nurse-led depression care programs among older adults in primary care settings. Optimal management of depression among older home care clients is not currently known. The objective of this study is to evaluate the feasibility, acceptability and effectiveness of a 6-month nurse-led, interprofessional mental health promotion intervention aimed at older home care clients with depressive symptoms using personal support services.

METHODS/DESIGN

This one-group pre-test post-test study aims to recruit a total of 250 long-stay (> 60 days) home care clients, 70 years or older, with depressive symptoms who are receiving personal support services through a home care program in Ontario, Canada. The nurse-led intervention is a multi-faceted 6-month program led by a Registered Nurse that involves regular home visits, monthly case conferences, and evidence-based assessment and management of depression using an interprofessional approach. The primary outcome is the change in severity of depressive symptoms from baseline to 6 months using the Centre for Epidemiological Studies in Depression Scale. Secondary outcomes include changes in the prevalence of depressive symptoms and anxiety, health-related quality of life, cognitive function, and the rate and appropriateness of depression treatment from baseline to 12 months. Changes in the costs of use of health services will be assessed from a societal perspective. Descriptive and qualitative data will be collected to examine the feasibility and acceptability of the intervention and identify barriers and facilitators to implementation.

DISCUSSION

Data collection began in May 2010 and is expected to be completed by July 2012. A collaborative nurse-led strategy may provide a feasible, acceptable and effective means for improving the health of older home care clients by improving the prevention, recognition, and management of depression in this vulnerable population. The challenges involved in designing a practical, transferable and sustainable nurse-led intervention in home care are also discussed.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01407926.