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Ghesquiere AR, Aldridge MD, Johnson-Hürzeler R, Kaplan D, Bruce ML, Bradley E. Hospice Services for Complicated Grief and Depression: Results from a National Survey. J Am Geriatr Soc 2015; 63:2173-80. [PMID: 26456597 DOI: 10.1111/jgs.13656] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the prevalence of screening for complicated grief (CG) and depression in hospice and access to bereavement therapy and to examine whether screening and access to therapy varied according to hospice organizational characteristics or staff training and involvement. DESIGN Cross-sectional national survey conducted from 2008 to 2009. SETTING United States. PARTICIPANTS Hospices (N = 591). MEASUREMENTS Whether hospices screened for depression or CG at the time of death or provided access to bereavement therapy (individual or group). Organizational characteristics included region, chain status, ownership, and patient volume. Staffing-related variables included training length and meeting attendance requirements. RESULTS Fifty-five percent of hospices provided screening for CG and depression and access to bereavement therapy, 13% provided screening but not access to bereavement therapy, 24% provided access to bereavement therapy but not screening, and 8% neither screened nor provided access to bereavement therapy. Hospices with 100 patients per day or more were significantly more likely to provide screening and access to bereavement therapy. CONCLUSION Hospices appear to have high capacity to provide screening for CG and depression and to deliver group and individual therapy, but data are needed on whether screeners are evidence based and whether therapy addresses CG or depression specifically. Future work could build upon existing infrastructure to ensure use of well-validated screeners and evidence-based therapies.
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Affiliation(s)
- Angela R Ghesquiere
- Brookdale Center for Health Aging, Hunter College, City University of New York, New York, New York
| | - Melissa D Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rosemary Johnson-Hürzeler
- Connecticut Hospice and the Hospice Institute for Education, Training and Research, Branford, Connecticut
| | - Daniel Kaplan
- Department of Psychiatry, Graduate School of Medical Sciences, Weill Cornell Medical College, White Plains, New York
| | - Martha L Bruce
- Department of Psychiatry, Graduate School of Medical Sciences, Weill Cornell Medical College, White Plains, New York.,Clinical Epidemiology Program, Graduate School of Medical Sciences, Weill Cornell Medical College, White Plains, New York
| | - Elizabeth Bradley
- Global Health Initiative, Yale University, New Haven, Connecticut.,Global Health Leadership Institute, Yale University, New Haven, Connecticut.,Branford College, Yale University, New Haven, Connecticut.,School of Public Health, Yale University, New Haven, Connecticut
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A community-based walk-in screening of depression in Taiwan. ScientificWorldJournal 2014; 2014:184018. [PMID: 25133204 PMCID: PMC4124201 DOI: 10.1155/2014/184018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 07/02/2014] [Indexed: 11/17/2022] Open
Abstract
Depression is a crucial public health problem because of its relatively high association with suicidal attempts, prolonged social isolation, poor physical health, and dementia. However, the available data and study on the prevalence of depression in Taiwan were mostly completed within the previous 1 to 2 decades, and these studies were limited to certain areas or populations. Little is known regarding the current status of depression in Taiwan. We used a brief tool, the Center for Epidemiological Studies Depression Scale (CES-D), to screen depression in 4 areas among the general and aged population. The results showed a higher CES-D score in the southern area among general (mean ± SD: 7.8 ± 8.4) or aged participants (mean ± SD: 7.2 ± 8.0) compared with other areas. The ratio of suspected depression patients was 16.4% of all recruited participants and 13.3% of aged participants. These results may provide information for this public health issue.
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Liebman LS, Nazarian RS, Kellner CH. Electroconvulsive Therapy (ECT) for Cognitive Impairment of Depression. Psychiatr Ann 2012. [DOI: 10.3928/00485713-20121203-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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4
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Naismith SL, Norrie LM, Mowszowski L, Hickie IB. The neurobiology of depression in later-life: Clinical, neuropsychological, neuroimaging and pathophysiological features. Prog Neurobiol 2012; 98:99-143. [DOI: 10.1016/j.pneurobio.2012.05.009] [Citation(s) in RCA: 169] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 05/03/2012] [Accepted: 05/09/2012] [Indexed: 02/07/2023]
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Metti AL, Cauley JA, Newman AB, Ayonayon HN, Barry LC, Kuller LM, Satterfield S, Simonsick EM, Yaffe K. Plasma beta amyloid level and depression in older adults. J Gerontol A Biol Sci Med Sci 2012; 68:74-9. [PMID: 22499763 DOI: 10.1093/gerona/gls093] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Older adults with depression have an increased risk of developing dementia. Low plasma beta-amyloid 42 (Aβ42) and Aβ42/Aβ40 have emerged as promising biomarkers of dementia. The association between depression and plasma Aβ is unclear. METHODS In this longitudinal study of 988 community-dwelling elders from the Health Aging and Body Composition study, depression was assessed with the Center for Epidemiologic Studies-Depression Scale 10-item version. We determined the association between Aβ42 and Aβ42/Aβ40 tertile and depression at baseline and over 9 years. We also stratified the models to determine if apolipoprotein E e4 allele status modified the associations. RESULTS Mean baseline age was 74.0 ± 3.0 years, 51 (5.2%) participants had depression, 545 (55.2%) were women, 531 (53.7%) were black, and 286 (30.7%) had one or more apolipoprotein E e4 allele. At baseline, there was no association between Aβ42/Aβ40 or Aβ42 and depression. Over 9 years, 220 (23.5%) participants developed depression. In adjusted Cox proportional hazards models, among those with one or more e4 allele, low Aβ42/Aβ40 was associated with an increased risk of developing depression over time (low 10.8% vs high 3.2%, hazard ratio = 2.38, 95% confidence interval: 1.15-4.92). Among those with no e4 allele, there was no association between Aβ42/Aβ40 and risk of depression over time (13.3% vs 17.5%, hazard ratio = 0.80, 95% confidence interval: 0.52-1.23; p value for interaction = .003). CONCLUSIONS The association between low plasma Aβ42/Aβ40 and increased risk of incident depression among those with one or more apolipoprotein E e4 allele implies a synergistic relationship similar to that found with dementia. Future work should investigate the interrelationships among plasma Aβ42/Aβ40, depression, and dementia.
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Affiliation(s)
- Andrea L Metti
- Center for Aging and Population Health, Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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Kobayashi T, Kato S. Depression-dementia medius: between depression and the manifestation of dementia symptoms. Psychogeriatrics 2011; 11:177-82. [PMID: 21951959 DOI: 10.1111/j.1479-8301.2011.00363.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Depression and dementia, among the most common conditions in clinical practice, sometimes coexist, sometimes succeed each other, and often confuse clinicians. In the present paper, the clinical concept of 'depression-dementia medius' (which includes pseudodementia and depression in Alzheimer's disease as exemplars) is proposed, in reference to Janet's concept of psychological tension. Because psychosomatically complex human lives are always in a state of dynamic equilibrium, it seems sensible to propose that pseudodementia and depression in Alzheimer's disease are located within a spectrum extending from depression without dementia symptoms to dementia without depression. From the Janetian viewpoint, pseudodementia is regarded as uncovered latent dementia as a result of reduced psychological tension. Dementia is more than a fixed progressive condition under this view, and is a manifestation of dynamic mental activities. Characterizing these entities through perspectives such as psychological tension may yield deep insights in clinical practice.
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7
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Prado-Jean A, Couratier P, Bénissan-Tevi LA, Nubukpo P, Druet-Cabanac M, Clément JP. Development and validation of an instrument to detect depression in nursing homes. Nursing homes short depression inventory (NH-SDI). Int J Geriatr Psychiatry 2011; 26:853-9. [PMID: 21744386 DOI: 10.1002/gps.2613] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Accepted: 07/06/2010] [Indexed: 11/10/2022]
Abstract
UNLABELLED Depression is often overlooked in elderly nursing home residents because symptoms may be masked or dismissed as an inevitable consequence of ageing. Current tools for the detection of depression in institutionalised older people are not always specific. AIMS To construct and verify an instrument with which to detect depression in elderly nursing home residents (NH-SDI). METHOD Firstly for the construction, 328 elderly people were selected at random from the residents of 17 nursing homes in France, and examined by a single investigator. The examination included a psychiatric assessment, an evaluation of cognitive function using the MMSE, an evaluation of depressive state using four different instruments (mini-GDS, Goldberg, DMAS, CSDD), and assessment of any changes in behaviour in those suffering from dementia, using the NPI. A second stage was to confirm NH-SDI in 99 institutionalised subjects. RESULTS Following the selection of items, we created a scale of 16 dichotomous items (NH-SDI). The internal consistency was satisfactory (α Cronbach = 0.85), as was its reliability with a sensitivity of 85.1% and a specificity of 86.5% for a cut-off score above 5. CONCLUSIONS The NH-SDI appears to be a useful instrument for the detection of depression in nursing homes and can easily be applied by healthcare staff as part of routine procedures.
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Affiliation(s)
- Annie Prado-Jean
- CMRR-The Limousin Center for Memory Research, University of Limoges, France; Institute of Epidemiology and Tropical Neurology, University of Limoges, France.
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8
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Skoog I. Psychiatric disorders in the elderly. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2011; 56:387-97. [PMID: 21835102 DOI: 10.1177/070674371105600702] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Recent research has shown that depression, anxiety disorders, and psychosis are more common than previously supposed in elderly populations without dementia. It is unclear whether the frequency of these disorders increases or decreases with age. Clinical expression of psychiatric disorders in old age may be different from that seen in younger age groups, with less and often milder symptoms. Concurrently, comorbidity between different psychiatric disorders is immense, as well as comorbidity with somatic disorders. Cognitive function is often decreased in people with depression, anxiety disorders, and psychosis, but whether these disorders are risk factors for dementia is unclear. Psychiatric disorders in the elderly are often related to cerebral neurodegeneration and cerebrovascular disease, although psychosocial risk factors are also important. Psychiatric disorders, common among the elderly, have consequences that include social deprivation, poor quality of life, cognitive decline, disability, increased risk for somatic disorders, suicide, and increased nonsuicidal mortality.
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Affiliation(s)
- Ingmar Skoog
- Institute of Neuroscience and Physiology, Section for Psychiatry Section, Unit of Neuropsychiatric Epidemiology, University of Gothenburg, Sweden.
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9
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Novelli MMPC, Nitrini R, Caramelli P. Validation of the Brazilian version of the quality of life scale for patients with Alzheimer's disease and their caregivers (QOL-AD). Aging Ment Health 2010; 14:624-31. [PMID: 20480421 DOI: 10.1080/13607861003588840] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Quality of life (QOL) has been extensively studied in clinical trials and in research on chronic degenerative diseases and dementia. The aim of this study was to assess the reliability and construct validity of the Brazilian version of the QOL scale in Alzheimer's disease (AD; QOL-AD). The QOL-AD was administered to 60 patients with mild or moderate AD and to their caregivers. The construct validation was accomplished through correlations amongst total scores of patients' and caregivers' reports on patients' quality of life (PQOL and C-PQOL, respectively), and data related to cognitive impairment, depressive symptoms, functional performance, behavioral disturbances and a generic instrument of quality of life (WHOQOL-brief), as well as correlation of total score of caregivers' reports on their own quality of life (CQOL) with the measurements cited above, QOL-AD patient reports, and depressive symptoms. The reliability was high for PQOL, C-PQOL, and CQOL versions (Cronbach's alpha = 0.80, 0.83, and 0.86, respectively). We observed significant correlations in the construct validity of all three versions regarding the variables associated with the disease and also with WHOQOL-brief. The scale took, on average, six min for each version. The results indicate reliability and construct validity of the Brazilian version of the QOL-AD in the studied sample.
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10
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Novelli MMPC, Caramelli P. The influence of neuropsychiatric and functional changes on quality of life in Alzheimer's disease. Dement Neuropsychol 2010; 4:47-53. [PMID: 29213660 PMCID: PMC5619530 DOI: 10.1590/s1980-57642010dn40100008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
To investigate the influence of neuropsychiatric manifestations and functional
performance on quality of life (QOL) of AD patients and their caregivers/family
members.
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Affiliation(s)
- Marcia M P C Novelli
- Occupational Therapy Course, Department of Health Sciences, Federal University of São Paulo, Santos SP, Brazil.,Behavioral and Cognitive Neurology Unit, Department of Neurology, University of São Paulo School of Medicine, São Paulo SP, Brazil
| | - Paulo Caramelli
- Behavioral and Cognitive Neurology Unit, Department of Neurology, University of São Paulo School of Medicine, São Paulo SP, Brazil.,Behavioral and Cognitive Neurology Unit, Department of Internal Medicine, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte MG, Brazil
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12
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Carthery-Goulart MT, Areza-Fegyveres R, Schultz RR, Okamoto I, Caramelli P, Bertolucci PHF, Nitrini R. [Brazilian version of the Cornell depression scale in dementia]. ARQUIVOS DE NEURO-PSIQUIATRIA 2008; 65:912-5. [PMID: 17952308 DOI: 10.1590/s0004-282x2007000500037] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2006] [Accepted: 06/18/2007] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Translating and adapting the Cornell scale for depression in dementia to the Portuguese language and verifying the interrater and test-retest reliability of the translated and adapted version. METHOD The Cornell scale was translated into Portuguese and back translated into English. Divergences of translation were identified and discussed, resulting in a version which was submitted to a pre-test for cross-cultural adaptation. The final version was administered to a sample of 29 patients with probable AD and to their caregivers. RESULTS The Cornell Scale presented good interrater (Kappa=0,77; p<0,001) and test-retest reliability (Kappa=0,76; p<0,001). The final version was easy to administer and well understood by the caregivers. CONCLUSION The Brazilian version of the Cornell Scale is an instrument with good reliability to evaluate depression in patients with dementia. This tool will contribute to the evaluation and follow-up of depressed patients with dementia in our population and may also be used in multicentric studies with Brazilian population.
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Noyes K, Liu H, Temkin-Greener H. Cost of Caring for Medicare Beneficiaries with Parkinson's Disease: Impact of the CMS-HCC Risk-Adjustment Model. ACTA ACUST UNITED AC 2006; 9:339-48. [PMID: 17115881 DOI: 10.1089/dis.2006.9.339] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Previous studies have demonstrated that Medicare risk-adjusted capitation models do not adequately compensate programs serving primarily disabled or frail populations. Using the Medicare Current Beneficiary Survey, we demonstrate that the Centers for Medicare and Medicaid Services-Hierarchical Condition Categories (CMS-HCC) model calculates Medicare capitation payments for Parkinson's patients more accurately than for the general population. The discrepancies between the predicted and actual expenditures estimated at various disability levels were smaller for Parkinson's patients than for other beneficiaries. If the CMS-HCC payment model were to apply to programs that draw a significant percentage of their participants from the Parkinson's disease community, these programs likely would be compensated fairly.
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Affiliation(s)
- Katia Noyes
- Department of Community and Preventive Medicine, University of Rochester School of Medicine, Rochester, New York 14620, USA.
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Geron SM, Keefe B. Moving Evidence-Based Interventions to Populations: A Case Study Using Social Workers in Primary Care. Home Health Care Serv Q 2006; 25:95-113. [PMID: 16803740 DOI: 10.1300/j027v25n01_06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This article describes a study to expand a proven evidence- based practice for depression to a population-based intervention for frail older adults. Problem-Solving Therapy (PST) has been proven effective in reducing depression and other mental health conditions in cognitively intact adults in many studies. The current study employs a randomized controlled trial to test the effectiveness of a social work intervention for frail older adults that uses PST to address depression and other psychosocial issues. The intervention employs Master's trained social workers integrated into a large primary care practice. The study population is comprised of home-dwelling older adults with multiple chronic conditions, a recent history of unnecessary hospitalizations, and no more than mild cognitive impairment.
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Affiliation(s)
- Scott Miyake Geron
- Institute for Geriatric Social Work, Boston University School of Social Work, 232 Bay State Rd, Boston, MA 02215, USA
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15
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Dal Forno G, Palermo MT, Donohue JE, Karagiozis H, Zonderman AB, Kawas CH. Depressive symptoms, sex, and risk for Alzheimer's disease. Ann Neurol 2005; 57:381-7. [PMID: 15732103 DOI: 10.1002/ana.20405] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Depression associates with increased risk for dementia and Alzheimer's disease (AD), although it is unclear whether it represents an actual risk factor or a prodrome. To determine the relative hazard of premorbid depressive symptomatology for development of dementia and AD, we studied risk for incident dementia and AD over a 14-year period in 1,357 community-dwelling men and women participating in the 40-year prospective Baltimore Longitudinal Study of Aging. Screening for depressive symptoms, comprehensive medical and neuropsychological evaluations were prospectively collected every 2 years. Time-dependent proportional hazards of development of AD or dementia were calculated separately for men and women, with symptoms of depression detected at 2-, 4-, and 6-year intervals before onset of dementia symptoms. Vascular risk factors were analyzed as covariates. Premorbid depressive symptoms significantly increased risk for dementia, particularly AD in men but not in women. Hazard ratios were approximately two times greater than for individuals without history of depressive symptoms, an effect independent of vascular disease. We conclude that the impact of depressive symptoms on risk for dementia and AD may vary with sex. Further studies assessing separately the role of depression as a risk factor in men and women are necessary.
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Affiliation(s)
- Gloria Dal Forno
- Clinical Neurosciences, University Campus BioMedico and Associazione Fatebenefratelli per la Ricerca (A.Fa.R.), Via dei Compositori 130-132, 00128 Rome, Italy.
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Mojtabai R, Olfson M. Cognitive Deficits and the Course of Major Depression in a Cohort of Middle-Aged and Older Community-Dwelling Adults. J Am Geriatr Soc 2004; 52:1060-9. [PMID: 15209642 DOI: 10.1111/j.1532-5415.2004.52302.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine associations between cognitive deficits and persistent significant depressive symptoms at baseline and 2- and 4-year follow-ups in a sample of community-dwelling middle-aged and older adults. DESIGN Prospective cohort study. SETTING A U.S. national prospective cohort study of middle-aged and older adults, the Health and Retirement Study. PARTICIPANTS A sample of 661 participants of the 1996 wave of the Health and Retirement Study who met criteria for 12-month Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised major depression (MD). MEASUREMENTS MD was assessed using the World Health Organization Composite International Diagnostic Interview-Short Form. Persistent significant depressive symptoms were assessed using an eight-item version of the Center for Epidemiological Studies Depression scale. RESULTS Cognitive deficits were associated with persistent significant depressive symptoms at follow-up. In a latent state-trait analysis, two stable and strongly correlated traits best explained variations in cognitive functioning and depressive symptoms across assessment points. CONCLUSION Trait-like cognitive deficits commonly complicate the course of MD in community-dwelling middle-aged and older adults and may help to explain the persistent course of depressive symptoms in a large subgroup of adults with MD in this age range.
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Affiliation(s)
- Ramin Mojtabai
- Department of Psychiatry, Columbia University, New York, NY, USA.
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Unützer J, Katon W, Callahan CM, Williams JW, Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noel PH, Lin EHB, Tang L, Oishi S. Depression treatment in a sample of 1,801 depressed older adults in primary care. J Am Geriatr Soc 2003; 51:505-14. [PMID: 12657070 DOI: 10.1046/j.1532-5415.2003.51159.x] [Citation(s) in RCA: 150] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To examine rates and predictors of lifetime and recent depression treatment in a sample of 1,801 depressed older primary care patients DESIGN Cross sectional survey data collected from 1999 to 2001 as part of a treatment effectiveness trial. SETTING Eighteen primary care clinics belonging to eight organizations in five states. PARTICIPANTS One thousand eight hundred one clinic users aged 60 and older who met diagnostic criteria for major depression or dysthymia. MEASUREMENTS Lifetime depression treatment was defined as ever having received a prescription medication, counseling, or psychotherapy for depression. Potentially effective recent depression treatment was defined as 2 or more months of antidepressant medications or four or more sessions of counseling or psychotherapy for depression in the past 3 months. RESULTS The mean age +/- standard deviation was 71.2 +/- 7.5; 65% of subjects were women. Twenty-three percent of the sample came from ethnic minority groups (12% were African American, 8% were Latino, and 3% belonged to other ethnic minorities). The median household income was $23,000. Most study participants (83%) reported depressive symptoms for 2 or more years, and most (71%) reported two or more prior depressive episodes. About 65% reported any lifetime depression treatment, and 46% reported some depression treatment in the past 3 months, although only 29% reported potentially effective recent depression treatment. Most of the treatment provided consisted of antidepressant medications, with newer antidepressants such as selective serotonin reuptake inhibitors constituting the majority (78%) of antidepressants used. Most participants indicated a preference for counseling or psychotherapy over antidepressant medications, but only 8% had received such treatment in the past 3 months, and only 1% reported four or more sessions of counseling. Men, African Americans, Latinos, those without two or more prior episodes of depression, and those who preferred counseling to antidepressant medications reported significantly lower rates of depression care. CONCLUSION The findings suggest that there is considerable opportunity to improve care for older adults with depression. Particular efforts should be focused on improving access to depression care for older men, African Americans, Latinos, and patients who prefer treatments other than antidepressants.
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Affiliation(s)
- Jürgen Unützer
- Center for Health Services Research, UCLA Neuropsychiatric Institute, Los Angeles, California 90024, USA.
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Abstract
This article provides an overview of current challenges in the diagnosis and treatment of depressed older adults in primary care and considers suggestions for clinicians, researchers, and policy makers to improve care for this population. Despite the enormous toll of depression on individuals and society and the availability of effective treatments, depressed older adults remain largely untreated or undertreated. They rarely see mental health professionals, but have relatively frequent contact with primary care providers. In primary care, the chronic and recurrent nature of depression and a number of patient, provider, and policy-related barriers interfere with effective depression treatment. Recent research suggests that improving care for individuals with late life depression will require education and engagement of older adults and their primary care providers as active partners in caring for depression. It will also require additional human resources and systematic models of care dedicated to proactively managing depression as a chronic illness. Finally, it will require training of mental health professionals to effectively collaborate with their colleagues in primary care in treating depressed older adults. Further improvement in depression care would likely result from the implementation of true parity for mental health treatments for older adults.
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Affiliation(s)
- Jürgen Unützer
- University of California, Los Angeles Neuropsychiatric Institute, 90024, USA
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20
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Alexopoulos GS, Katz IR, Reynolds CF, Carpenter D, Docherty JP, Ross RW. Pharmacotherapy of depression in older patients: a summary of the expert consensus guidelines. J Psychiatr Pract 2001; 7:361-76. [PMID: 15990550 DOI: 10.1097/00131746-200111000-00003] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Depression in older adults increases disability, medical morbidity, mortality, suicide risk, and healthcare utilization. Most studies of antidepressants are conducted in younger adults, and clinicians often have to extrapolate from findings in populations that do not present the same problems as older patients. Older patients often have serious coexisting medical conditions that may contribute to or complicate treatment of depression; they tend to take multiple medications, some of which may contribute to depression or interact with antidepressants; and they metabolize medications slowly and are more sensitive to side effects than younger patients. To address clinical questions not definitively answered in the research literature, the authors surveyed 50 experts on the pharmacotherapy of depressive disorders in older patients. The survey contained 64 questions with 857 options: 618 of the options were scored using a modified version of the RAND 9-point scale for rating appropriateness of medical decisions; for the other 239 options, the experts were asked to write in answers or check a box. The experts reached consensus on 89% of the options rated on the 9-point scale. Categorical rankings (first line/preferred, second line/alternate, third line/usually inappropriate) were assigned to each option based on the 95% confidence interval around the mean rating. Guideline tables indicating preferred treatment strategies were then developed for common and important clinical scenarios. The authors summarize the expert consensus methodology and the experts' recommendations and discuss how they relate to research findings. The experts recommend including both antidepressant medication and psychotherapy in treatment plans for nonpsychotic unipolar major depressive disorder of any severity, as well as for dysthymic disorder or persistent minor depressive disorder. They would also consider using either medication or psychotherapy alone for milder depression. For unipolar psychotic major depression, the treatment of choice is an antidepressant plus one of the newer atypical antipsychotics, with electroconvulsive therapy another first-line option. If the patient has a comorbid medical condition that is contributing to the depression, the experts recommend treating both the depression and the medical condition from the outset. The SSRIs were the top-rated antidepressants for all types of depression, with highest ratings for efficacy and tolerability given to citalopram and sertraline. Paroxetine was another first-line option, and fluoxetine was rated high second line. The preferred psychotherapy techniques for treating depression in older patients are cognitive-behavioral therapy, supportive psychotherapy, problem-solving psychotherapy, and interpersonal psychotherapy. The experts also recommended use of psychosocial interventions (e.g., psychoeducation, family counseling, visiting nurse services) in addition to pharmacotherapy and psychotherapy. Within limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide direction concerning common clinical dilemmas in older patients. They cannot address the complexities of each individual patient's care and can be most helpful in the hands of experienced clinicians.
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Affiliation(s)
- G S Alexopoulos
- Cornell Institute of Geriatric Psychiatry, White Plains, NY 10605, USA
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Schulberg HC, Bryce C, Chism K, Mulsant BH, Rollman B, Bruce M, Coyne J, Reynolds CF. Managing late-life depression in primary care practice: a case study of the Health Specialist's role. Int J Geriatr Psychiatry 2001; 16:577-84. [PMID: 11424166 DOI: 10.1002/gps.470] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Complexities in the diagnosis and treatment of late-life depression have stimulated various strategies for assisting the primary care physician to fulfil these tasks more effectively. The role of Health Specialist was developed for this purpose in a study to reduce suicidality among older depressed patients. This role includes clinical and case management tasks which aim to provide the physician with timely, patient-specific information and recommendations. Evolution of this role and its rewards/stressors during the study's first year are described.
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Affiliation(s)
- H C Schulberg
- Intervention Research Center for Late-Life Mood Disorders, Department of Psychiatry, University of Pittsburgh School of Medicine Pittsburgh, PA, USA.
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Unützer J, Simon G, Belin TR, Datt M, Katon W, Patrick D. Care for depression in HMO patients aged 65 and older. J Am Geriatr Soc 2000; 48:871-8. [PMID: 10968289 DOI: 10.1111/j.1532-5415.2000.tb06882.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To examine treatment for depression among older adults in a large staff model health maintenance organization (HMO). DESIGN A 4-year prospective cohort study (1989-1993). SETTING Four primary care clinics of a large staff model HMO in Seattle, Washington. PATIENTS A total of 2558 Medicare enrollees aged 65 and older. MAIN OUTCOME MEASURES Treatment of depression was defined as primary care visits resulting in depression diagnoses, use of antidepressant medications, or specialty mental health services. MAIN RESULTS The older adults in our sample had low rates of treatment for depression, ranging from 4 to 7% in the entire sample and from 12 to 25% among those with probable depressive disorders. Predictors of treatment included female gender, severity, and persistence of depressive symptoms, and severity of comorbid medical illness. Even when patients were treated for depression, the intensity of treatment was very low. Overall likelihood of treatment for depression increased somewhat from 1989 to 1993, but among those treated, the rate of adequate antidepressant use remained below 30%. CONCLUSIONS There is still considerable need to improve care for older adults with depression in primary care.
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Affiliation(s)
- J Unützer
- Center for Health Services Research, UCLA Neuropsychiatric Institute, Los Angeles, California 90024, USA
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Kales HC, Blow FC, Copeland LA, Bingham RC, Kammerer EE, Mellow AM. Health care utilization by older patients with coexisting dementia and depression. Am J Psychiatry 1999; 156:550-6. [PMID: 10200733 DOI: 10.1176/ajp.156.4.550] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Few studies have examined the course of coexisting dementia and depression. The purpose of this study was to compare elderly patients who had coexisting dementia and depression with elderly patients who had either disorder alone in terms of their utilization of inpatient and outpatient services. METHOD The study group included 7,115 veterans aged 60 years or older who had been discharged from Department of Veterans Affairs inpatient units in 1992 with diagnoses of major depression, dementia, or both. Outcome measures were analyzed for a 2-year period following the index hospitalization for each diagnostic study group. RESULTS Patients with coexisting dementia and depression had significantly more psychiatric inpatient days than the other two study groups and more medical inpatient days and nursing home readmissions than patients with depression alone. Patients with coexisting dementia and depression had significantly more total inpatient days than the other two groups. Notably, patients with coexisting dementia and depression did not utilize more outpatient resources than the other study groups; in fact, they had significantly fewer medical, psychiatric, and total visits than patients with depression alone. CONCLUSIONS The findings suggest that patients with coexisting dementia and depression are high utilizers of inpatient services, with a course of illness that may resemble dementia in terms of nursing home and inpatient medical care utilization and depression in terms of inpatient psychiatric care utilization; however, these patients utilized significantly fewer outpatient resources than the group with depression alone. Aggressive outpatient treatment approaches might reduce utilization of inpatient care for patients with coexisting depression and dementia.
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Affiliation(s)
- H C Kales
- Psychiatry Service, Ann Arbor VA Medical Center, MI 48105, USA.
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Abstract
Older adults are an important segment of the population that has specific health care needs. Their unique biopsychosocial characteristics impact the presentation, evaluation, and management of psychiatric illnesses. This article describes how common psychiatric disorders present in an aging population. Research in this area is relatively new and much more information is still needed. Close attention should be paid to new knowledge as it emerges about this growing population.
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Affiliation(s)
- B D Bair
- Salt Lake City VA Medical Center GRECC, Utah, USA
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Silverman M, McDowell BJ, Musa D, Rodriguez E, Martin D. To treat or not to treat: issues in decisions not to treat older persons with cognitive impairment, depression, and incontinence. J Am Geriatr Soc 1997; 45:1094-101. [PMID: 9288017 DOI: 10.1111/j.1532-5415.1997.tb05972.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To examine decisions not to treat problems identified during outpatient geriatric assessment, particularly problems of cognitive impairment, depression, or urinary incontinence. DESIGN A descriptive study using patients' medical charts and survey data and interviews with clinical staff. SETTING Four hospital-based, ambulatory, geriatric assessment clinics in Allegheny Country, PA. PARTICIPANTS The sample comprised 128 older adults, recruited to a randomized, controlled clinical trial, who had problems associated with cognitive impairment, depression, or urinary incontinence. RESULTS Although treatment was recommended for most of the problems relating to cognitive impairment, depression, and/or incontinence experienced by this group, slightly more than one-third of cognitive impairment and depression problems and nearly one-half of incontinence did not receive treatment recommendations. Treatment rates varied considerably by condition and combination of comorbidity. Decisions not to treat are classified into six categories: patient or family refused treatment, the assessment was not completed, an intervention was already in place, concurrent problems or comorbities might have interfered with treatment, there was no documented diagnosis or there was a documented consideration and rule out of the problem, or no documented reason. CONCLUSION Outpatient geriatric assessment units are designed to deal with the multiple problems experienced by their geriatric patients, and they identify successfully most problems presented by their frail constituents. However, identification of the patient's problems is only the first step in the assessment process and does not necessarily lead to either a documented diagnosis or to a treatment recommendation. Multiple social, cultural, environmental, and medical factors complicate the assessment process and, hence, the decision clinicians face when they decide whether to make recommendations to treat. These clinicians must weigh all medical and non-medical factors, including the patient's receptivity to treatment, when prioritizing the problems they deem to be treatable and making recommendations to treat.
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Affiliation(s)
- M Silverman
- University of Pittsburgh Graduate School of Public Health, PA 15261, USA
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Abstract
We wish to stress the importance of remaining alert to the possibility of both depression and suicidality in the geriatric population. There is also a need for flexibility in assessing the elderly who may present with atypical symptoms of depression and who may not express their distress directly. The interaction of risk factors may be instrumental in determining the risk for suicide in a particular patient. In our case, we have identified an impaired ability to communicate, intractable tinnitus, and feelings of helplessness.
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Affiliation(s)
- M Johnston
- Department of Psychiatry, Ottawa General Hospital, Ontario, Canada
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Methodology of Treatment Studies in Geriatric Depression. Am J Geriatr Psychiatry 1995; 3:280-289. [PMID: 28531061 DOI: 10.1097/00019442-199503040-00002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/1994] [Revised: 11/21/1994] [Accepted: 01/25/1995] [Indexed: 11/26/2022]
Abstract
Treatment studies of geriatric depression should focus not only on recovery and remission but also on relapse, recurrence, disability, quality of life, cognitive impairment, and exacerbation of medical morbidity. Each of these outcomes appears to have different predictors. Medical burden may influence geriatric depression, response to antidepressants, and overall disability, as well as specific conditions underlying geriatric depression (e.g., Alzheimer's disease, stroke, or parkinsonism). Measures of medical morbidity, cognitive impairment, and perhaps structural brain abnormalities should be considered as possible influences on treatment response. Studies of geriatric depression associated with specific disease entities are necessary, using instruments that avoid rating symptoms and signs that are part of a concurrent dementia syndrome or result from a medical illness. However, there should also be ratings with an "all-inclusive" approach that disregards the origin of depressive symptoms-whether from depression, dementia, or the medical illness. This strategy will reduce the risk of underdiagnosing depression.
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Becker T, Retz W, Hofmann E, Becker G, Teichmann E, Gsell W. Some methodological issues in neuroradiological research in psychiatry. J Neural Transm (Vienna) 1995; 99:7-54. [PMID: 8579809 DOI: 10.1007/bf01271468] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
An outline is given of some of the methodological issues discussed in neuroradiological research on psychiatric illness. Strengths and shortcomings of magnetic resonance imaging (MRI) in depicting and quantifying brain structures are described. Temporal lobe anatomy and pathology are easily accessible to MRI, whereas limits on anatomical delineation hamper approaches to frontal lobe study. White matter hyperintense lesions are sensitively depicted by MRI, but specificity is limited. Distinction of vascular and primary degenerative dementia is considerably improved by CT and MRI analysis. Computed tomography (CT) and MRI have enhanced the understanding of treatable organic psychiatric disorders, e.g., normal pressure hydrocephalus. Subcortical and white matter pathology has been replicated in CT and MRI studies of late-onset psychiatric disorders, clinical overlap with cerebrovascular disease or neurodegeneration may be of import. Transcranial sonography findings of brainstem structural change specific to unipolar depression may contribute to the understanding of affective psychoses. Magnetic resonance spectroscopy and functional MRI are likely to stimulate psychiatric research in the future.
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Affiliation(s)
- T Becker
- Department of Psychiatry, University of Würzburg, Federal Republic of Germany
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Ernst C, Angst J. Depression in old age. Is there a real decrease in prevalence? A review. Eur Arch Psychiatry Clin Neurosci 1995; 245:272-87. [PMID: 8527464 DOI: 10.1007/bf02191869] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The discrepancy between the constancy or increase of the prevalence of depressive symptoms and dysphoria in old age on one hand, and the decrease in the prevalence of the DSM-III diagnoses of major depression and dysthymia on the other, is discussed in light of the most frequent explanatory hypotheses such as memory defects, interpretation of depressive as somatic symptoms, higher risk of institutionalization as well as higher mortality of depressives and a mitigated course of depression in old age. We conclude that higher mortality, mitigation and the rarity of true late-onset depression are arguments for a real decline in prevalence, which occurs in accordance with the decline in all psychiatric disorders that are connected with emotional upheavals and substance ingestion. On the other hand, the connection of depressive states with somatic illness is strengthened, and according to preliminary validation studies, clinically relevant depressive states not reaching the threshold of DSM-III diagnoses may be typical for the depressive psychopathology of old age.
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Affiliation(s)
- C Ernst
- Psychiatric University Hospital, Zürich, Switzerland
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Quantitative EEG Correlates of Outcome in Older Psychiatric Patients: Part II: Two-Year Follow-Up of Patients With Depression. Am J Geriatr Psychiatry 1994; 2:290-299. [PMID: 28530979 DOI: 10.1097/00019442-199402040-00004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/1993] [Revised: 01/26/1994] [Accepted: 02/07/1994] [Indexed: 11/26/2022]
Abstract
The authors examined quantitative electroencephalographc (QEEG) coherence in 37 depressed elderly patients and performed 2-year follow-up evaluations. All subjects had equivocal cognitive impairment, but none had delirium or dementia. More than 40% (16/37) recovered from depression, and 38% (14/37) remained well for 2 years. Twenty-four percent (n = 9) had died within 2 years, most from cardiac causes. Low trans-Rolandic coherence from the left hemisphere was strongly associated with mortality: 44% (7/16) of those with low coherence died, and 78% (7/9) of those who died had low coherence. Among survivors (n = 28) at follow-up, low coherence was significantly associated with lower functional status. These findings suggest that the coherence variable measures actual neurophysiology differences between groups of depressed patients and these differences are associated with the heterogeneous outcomes of depression in elderly patients.
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