The future of clinical research in mental disorders of late life

Engaging in Late-Life Mental Health Research: a Narrative Review of Challenges to Participation

Purpose of review

This narrative review seeks to ascertain the challenges older patients face with participation in mental health clinical research studies and suggests creative strategies to minimize these obstacles.

Recent findings

Challenges to older adults’ engagement in mental health research include practical, institutional, and collaboration-related barriers applicable to all clinical trials as well as more personal, cultural, and age-related patient barriers specific to geriatric mental health research. Universal research challenges include (1) institutional barriers of lack of funding and researchers, inter-researcher conflict, and sampling bias; (2) collaboration-related barriers involving miscommunication and clinician concerns; and (3) practical patient barriers such as scheduling issues, financial constraints, and transportation difficulties. Challenges unique to geriatric mental health research include (1) personal barriers such as no perceived need for treatment, prior negative experience, and mistrust of mental health research; (2) cultural barriers involving stigma and lack of bilingual or culturally matched staff; and (3) chronic medical issues and concerns about capacity.

Summary

Proposed solutions to these barriers include increased programmatic focus on and funding of geriatric psychiatry research grants, meeting with clinical staff to clarify study protocols and eligibility criteria, and offering transportation for participants. To minimize stigma and mistrust of psychiatric research, studies should devise community outreach efforts, employ culturally competent bilingual staff, and provide patient and family education about the study and general information about promoting mental health.

Comorbidity of late-life depression in the United States: a population-based study

OBJECTIVES

This study sought to determine the clinical and sociodemographic correlates and the treatment-seeking rate of major depressive disorder (MDD), diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, among older adults and its association with comorbid psychiatric disorders and perceived health status.

METHODS

Data were drawn from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions, a large cross-sectional survey (N = 43,093) representative of the US population.

RESULTS

Compared with participants aged 65 years and older without a 12-month diagnosis of MDD, those with MDD were more likely to have lifetime and 12-month comorbid psychiatric disorders. Except for lifetime dysthymia, we found no significant interaction between rates of current somatic comorbidity, lifetime and 12-month psychiatric comorbidity, and age groups. Compared with younger participants with a 12-month MDD, they had an older age at onset, reported a similar number of lifetime major depressive episodes and perceived health status, and had lower mental health service utilization rates.

CONCLUSIONS

Current major depression in the elderly seems to be as disabling as in younger adults in terms of comorbid psychiatric disorders and impaired quality of life. Poorer prognosis of MDD in older adults might be explained by a lower perceived need of treatment, resulting in a lower rate of treatment-seeking behavior.

Clinical trials: bridging the gap between efficacy and effectiveness

The need for clinical psychiatry research to provide practical information to clinicians, families, and consumers has led to the development of new approaches to clinical trials. Efficacy trials, the historical backbone of clinical research, have many shortcomings in delivering practical information to stakeholders. The 'effectiveness' or 'public-health' model of intervention research targets a diverse group of patients across multiple settings that are outside of academic medical centres, with study design and outcomes that are selected on the basis of their potential to produce clinically meaningful information. The National Institute of Mental Health has funded three such clinical trials in recent years, respectively targeting schizophrenia and Alzheimer's disease, depression, and bipolar disorder. Each of these studies has made a major impact, and provided new insights into the challenges of public health orientated trials in psychiatry. In this review, we describe the underlying principles and practical considerations in efficacy and effectiveness-orientated trials.