Prognostic factors, course, and outcome of depression among older primary care patients: the PROSPECT study

Integrated Care Models for Older Adults with Depression and Physical Comorbidity: A Scoping Review

Objective

Multimorbidity is a growing challenge in the care for older people with mental illness. To address both physical and mental illnesses, integrated care management is required. The purpose of this scoping review is to identify core components of integrated care models for older adults with depression and physical comorbidity, and map reported outcomes and implementation strategies.

Methods

PubMed, EMBASE, CINAHL and Cochrane Library were searched independently by two reviewers for studies concerning integrated care interventions for older adults with depression and physical comorbidity. We used the SELFIE framework to map core components of integrated care models. Clinical and organisational outcomes were mapped.

Results

Thirty-eight studies describing thirteen care models were included. In all care models, a multidisciplinary team was involved. The following core components were mainly described: continuity, person-centredness, tailored holistic assessment, pro-activeness, treatment interaction, individualized care planning, and coordination tailored to complexity of care needs. Twenty-seven different outcomes were evaluated, with more attention given to clinical than to organisational outcomes.

Conclusion

The core components that comprise integrated care models are diverse. Future studies should focus more on implementation aspects of the intervention and describe financial parts, e.g., the cost of the intervention for the healthcare user, more transparently.

Transdiagnostic and functional predictors of depression severity and trajectory in the Penn state psychiatry clinical assessment and rating evaluation system (PCARES) registry

BACKGROUND

Timely, accurate diagnosis and subsequent identification of risk factors for depression that is difficult-to-treat can aid in decreasing the burden of depressive illness and reducing probability of future disability. We aimed to identify sociodemographic, clinical, and functional factors that predict depression severity over one year in a real-world, naturalistic, transdiagnostic clinical sample. A subset sample with moderate depression was examined to determine the magnitude of improvement.

METHODS

The Penn State Psychiatry Clinical Assessment and Rating System (PCARES) Registry houses data from systematically-structured patient-reported outcomes and clinical data from an Electronic Medical Record (EMR) gathered during routine clinical care of patients seeking mental health care at a mid-Atlantic clinic. Self-report symptom and functional measures were obtained, and sociodemographic features and clinical diagnoses were extracted from the EMR from 1,766 patients between 2/6/2016 to 9/30/2019. The Patient Health Questionnaire 9 (PHQ-9) depression scale was obtained at each visit. Using a discrete mixture clustering model, the study population was divided into five longitudinal trajectory groups, termed depression severity groups, based on intra-individual PHQ-9 score trajectories over one year. Multinomial logistic regression models were estimated to evaluate associations between characteristics and the likelihood of depression severity group membership. To determine the magnitude of improvement, predictors of the slope of the PHQ-9 trajectory were examined for patients with moderate depression.

RESULTS

The strongest predictors of high depression severity over one year were poor functioning, high transdiagnostic DSM-5 Level 1 crosscutting symptom score, diagnosis of Post-Traumatic Stress Disorder (PTSD), public/self-pay insurance, female gender, and non-White race. Among the subset of patients with moderate depression, strong predictors of improvement were commercial insurance and exposure to trauma; the strongest predictors of worsening were high functional impairment, high transdiagnostic Level 1 symptom score, diagnosis of PTSD, diagnosis of bipolar disorder, and marital status of single or formerly married; depression-specific symptom measures were not predictive.

LIMITATIONS

Limitations include inferring education and income status from zip code level-data, the non-random missingness of data, and the use of diagnoses collected from the electronic medical record.

CONCLUSION

Functional impairment, transdiagnostic measures of symptom burden, and insurance status are strong predictors of depression severity and poor outcome.

Trajectories of major depression in middle-aged and older adults: A population-based study

OBJECTIVES

This study aimed to examine depression trajectories and correlates in a nationally representative sample of middle-aged and older adults in the United States.

METHODS

The study sample consisted of 15 661 participants aged over 50 years from the US Health and Retirement Study. Major depression was assessed using the Composite International Diagnostic Interview (CIDI-SF). Depression trajectories were identified using a group-based trajectory modeling enhanced to account for nonrandom attrition. Multinomial logistic regression was conducted to investigate predictors of depression trajectories.

RESULTS

Four depression trajectory groups were identified: "never" (85.8%), "increasing" (6.3%), "decreasing" (3.2%), and "persistently moderate/high" (4.7%). Baseline depressive symptom severity was a strong predictor of depression trajectories. Older age, male sex, and non-Hispanic African American race were associated with a lower risk of the three trajectories with small to high depression burden, whereas chronic disease count was associated with a higher risk of these trajectories. The risk of being on the increasing trajectory increased with mobility difficulties. Difficulties in household activities predicted membership in the persistently moderate/high group.

CONCLUSIONS

A small but nonignorable proportion of middle-aged and older adults have chronic major depression. Initial symptom severity and chronic disease burden are consistent risk factors for unfavorable depression trajectories and potential targets for screening and intervention.

Perceptions of patient-provider communication and receipt of mental health treatment among older adults with depressive symptoms

OBJECTIVES

This study aimed to: (1) determine if and how perceptions towards healthcare providers differ between older adults with and without clinically signifcant depressive symptoms (CSDS), and (2) assess whether perceptions towards providers are associated with receipt of mental health treatment among older adults with CSDS.

METHODS

Data from the 2013 and 2014 Medical Expenditure Panel Survey were used to examine CSDS prevalence, receipt of mental health treatment, and perceptions of provider communication among community-dwelling adults ≥ age 65 (N = 6,936) using four of the 'How Well Doctors Communicate' composite items from the Consumer Assessment of Healthcare Providers and Systems(CAHPS). Multivariate logistic regression was used.

RESULTS

CSDS are associated with greater odds of having 'poor' perceptions of provider communication on all four CAHPS communication measures. Perceptions of provider communication are similar among older adults with CSDS who received and did not receive mental health treatment, except on an item measuring a provider's ability to explain information in ways patients understand.

CONCLUSION

Older adults with CSDS have more negative perceptions of the quality of their communication with healthcare providers than their peers. Healthcare systems should consider how to accommodate these patients' unique needs and communication preferences to ensure receipt of quality care.

Predictors of treatment outcome in depression in later life: A systematic review and meta-analysis

BACKGROUND

Predictor analyses of late-life depression can be used to identify variables associated with outcomes of treatments, and hence ways of tailoring specific treatments to patients. The aim of this review was to systematically identify, review and meta-analyse predictors of outcomes of any type of treatment for late-life depression.

METHODS

Pubmed, Embase, CINAHL, Web of Science and PsycINFO were searched for studies published up to December 2016. Primary and secondary studies reported treatment predictors from randomised controlled trials of any treatment for patients with major depressive disorder aged over 60 were included. Treatment outcomes included response, remission and change in depression score.

RESULTS

Sixty-seven studies met the inclusion criteria. Of 65 identified statistically significant predictors, only 7 were reported in at least 3 studies. Of these, 5 were included in meta-analyses, and only 3 were statistically significant. Most studies were rated as being of moderate to strong quality and satisfied key quality criteria for predictor analyses.

LIMITATIONS

The searches were limited to randomised controlled trials and most of the included studies were secondary analyses.

CONCLUSIONS

Baseline depression severity, co-morbid anxiety, executive dysfunction, current episode duration, early improvement, physical illnesses and age were reported as statistically significant predictors of treatment outcomes. Only the first three were significant in meta-analyses. Subgroup analyses showed differences in predictor effect between biological and psychosocial treatment. However, high heterogeneity and small study numbers suggest a cautious interpretation of results. These predictors were associated with various mechanisms including brain pathophysiology, perceived social support and proposed distinct types of depressive disorder. Further investigation of the clinical utility of these predictors is suggested.

The two-year course of late-life depression; results from the Netherlands study of depression in older persons

BACKGROUND

We aimed to examine the course of depression during 2-year follow-up in a group clinically depressed older persons. Subsequently, we studied which socio-demographic and clinical characteristics predict a depression diagnoses at 2-year follow-up.

METHODS

Data were used from the Netherlands Study of Depression in Older persons (NESDO; N = 510). Diagnoses of depression DSM-IV-TR criteria were available from 285 patients at baseline and at 2-year follow-up. Severity of the depressive symptoms, as assessed with the Inventory of Depressive Symptoms (IDS), was obtained from 6-monthly postal questionnaires. Information about socio-demographic and clinical variables was obtained from the baseline measurement.

RESULT

From the 285 older persons who were clinically depressed at baseline almost half (48.4%) also suffered from a depressive disorder two years later. Patients with more severe depressive symptoms, comorbid dysthymia, younger age of onset and more chronic diseases were more likely to be depressed at 2-year follow-up. 61% of the persons that were depressed at baseline had a chronic course of depressive symptoms during these two years.

CONCLUSIONS

Late-life depression often has a chronic course, even when treated conform current guidelines for older persons. Our results suggest that physical comorbidity may be candidate for adjusted and intensified treatment strategies of older depressed patients with chronic and complex pathology.

The economic, public health, and caregiver burden of late-life depression

This article reviews the burden of late-life depression (LLD) from several perspectives, including costs of depression treatment and treatment of other comorbid psychiatric and medical conditions; the impact of LLD on job functioning, disability, and retirement; and how LLD influences others, such as family members and caregivers.

Course, risk factors, and prognostic factors in elderly primary care patients with mild depression: a two-year observational study

OBJECTIVE

The aim of this study was to observe course, risk factors, and prognostic factors in a primary care cohort aged > 60 with mild to moderate depression during two-year follow-up.

DESIGN

Observational study.

SETTING

Primary care.

SUBJECTS AND METHOD

During an 11-month period all (n = 302) consecutive patients aged 60 and above attending a primary care centre in Gothenburg, Sweden were screened by a nurse for depressive symptoms with the Primary Care Evaluation of Mental Disorders, Patient Questionnaire (PRIME-MD PQ) and the Montgomery-Åsberg Depression Rating Scale, self-rated version (MADRS-S) and by a GP with a patient-centred consultation model. In the second step, the GPs diagnosed depression in screen-positives by use of the PRIME-MD Clinical Evaluation Guide (PRIME-MD CEG). All patients with mild to moderate depression were followed up for two years to assess course with several MADRS-S score assessments. Main outcome measures. Risk factors, prognostic factors, and symptoms at baseline and after two years were tested with logistic regression, using the DSM-IV and MADRS-S (cut-off > 13) respectively. Course patterns were observed and described.

RESULTS

A total of 54 patients were diagnosed with depression. Follow-up revealed declining median MADRS-S scores and three course patterns: remitting, stable, and fluctuating. History of depression, significant life events, lacking leisure activities, and use of sedatives were risk factors for depression, all previously known. An important finding was that lacking leisure activities also increased the risk of depressive symptoms after two years (odds ratio 12, confidence interval 1.1-136).

CONCLUSION

It is desirable to identify elderly individuals with less severe depression. Three course patterns were observed; this finding requires further study of the clinical characteristics related to the different patterns. Awareness of risk factors may facilitate identification of those at highest risk of poor prognosis.

Chronic medical conditions and reproducibility of self-reported age at menopause among community-dwelling women

OBJECTIVE

The aim of this study was to examine the association between chronic medical conditions and reproducibility of self-reported age at menopause among community-dwelling women.

METHODS

Age at menopause was assessed in a population-based longitudinal survey of 240 women twice, in 1993 and 2004. Women who recalled age at menopause in 2004 within 1 year or less of age at menopause recalled in 1993 (concordant) were compared with women who did not recall age at menopause in 2004 within 1 year of age at menopause recalled in 1993 (discordant). Type of menopause (surgical or natural) and chronic medical conditions were assessed by self-report.

RESULTS

One hundred forty-three women (59.6%) reported surgical menopause, and 97 (40.4%) reported natural menopause. In all, 130 (54.2%) women recalled age at menopause in 2004 within 1 year or less of recalled age at menopause in 1994, whereas 110 (45.8%) women did not recall age at menopause in 2004 within 1 year or less of recalled age at menopause in 1994. Among the women with surgical menopause, the women with three or more medical conditions were less likely to have concordant recall of age at menopause than the women with less than three chronic medical conditions (adjusted odds ratio, 0.36; 95% CI, 0.15-0.91) in multivariate models controlling for potentially influential characteristics including cognition and years since menopause.

CONCLUSIONS

Among women who underwent surgical menopause, the presence of three or more medical conditions is associated with decreased reproducibility of self-reported age at menopause.