Mental health services use: Baltimore epidemiologic catchment area follow-up

Comparing Public Perceptions of Child and Adult Grief Responses to Familial Incarceration

Children of incarcerated parents may grieve this loss, yet perceptions of their grief are understudied. Using vignettes varying by age (adult/child) and grief response (prolonged/resilient), we examined differences between perceptions of adults and children grieving parental incarceration. Participants rated grief response appropriateness, comfort providing support, and grief therapy recommendations for the grieving person in the vignette. Participants perceived resilience as more appropriate than prolonged grief [F (1, 224) = 9.02, p = .003, η2 = .04]. Age did not predict outcomes. Recommending grief therapy was higher for prolonged grief, yet 53% of participants with resilient vignettes recommended the person should seek grief therapy, which is concerning given possible iatrogenic effects. Thus, laypeople may have stigma toward individuals grieving parental incarceration, regardless of age.

Older patients' perspectives on the therapeutic relationship with young psychotherapists

The current demographic change means that young psychotherapists and older patients will increasingly come into contact. Unique for this constellation is the intergenerational therapeutic relationship, which forms the basis of psychotherapy, but has not yet been the focus of empirical research. This qualitative study provides preliminary insights into how older patients (aged over 65) experience and perceive the therapeutic relationship with young psychotherapists (aged in their mid-20s to mid-30s). We conducted semi-structured interviews with twelve older patients (8 women, 4 men) and analysed their data using the grounded theory approach. We found a connection between the type of transference a participant demonstrated and their biographical as well as social experiences, desires, and fantasies. Overall, a tendency to seek harmony was observed among the participants, which was reflected in their behaviour towards young psychotherapists: (a) conflict avoidance, (b) (fantasised) therapy discontinuation, (c) adaption/subordination, and (d) solidarity, support, and protection. Our findings demonstrated that various intergenerational transference phenomena, including the roles in which young therapists are perceived, are associated with certain particularities and challenges, such as the topic of sexuality. It can be valuable for young psychotherapists to become aware of a potential role reversal that may result in older patients trying to support them.

Perceived Need, Mental Health Literacy, Neuroticism and Self- Stigma Predict Mental Health Service Use Among Older Adults

OBJECTIVES

Older adults are the least likely age group to seek mental health services. However, few studies have explored a comprehensive range of sociodemographic, psychological, and social barriers and facilitators to seeking treatment in later life.

METHODS

A cross-sectional, national sample of Canadian older adults (55+, N = 2,745) completed an online survey including reliable and valid measures of predisposing, enabling, and need characteristics, based on Andersen's behavioral model of health, as well as self-reported use of mental health services. Univariate and hierarchical logistic regressions predicted past 5-year mental health service use.

RESULTS

Mental health service use was most strongly and consistently associated with greater perceived need (OR = 11.48) and mental health literacy (OR = 2.16). Less self-stigma of seeking help (OR = .65) and greater neuroticism (OR = 1.57) also predicted help-seeking in our final model, although their effects were not as strong or consistent across gender, marital status, and age subgroups.

CONCLUSIONS

The need category was crucial to seeking help, but predisposing psychological factors were also significant barriers to treatment.

CLINICAL IMPLICATIONS

Interventions that target older adults high in neuroticism by improving perceptions of need for treatment, mental health literacy, and self-stigma of seeking help may be particularly effective ways of improving access to mental health services.

Older adults’ mental health information preferences: a call for more balanced information to empower older adults’ mental health help-seeking

A small minority of older adults seek psychological help when they need it. Barriers to mental health service use among older adults include low mental health literacy and reduced opportunities for shared decision-making in health care. There is a gap in the literature examining the mental health information preferences of older adults. The objectives of this study were to describe the information preferences and predictors of preferences among older adults. In total, 229 adults aged 50 years and older in central Canada responded to a questionnaire investigating socio-demographic, psycho-social and health-related characteristics, as well as mental health information preferences. Descriptive analysis quantified participants’ ratings of information preferences and hierarchical linear regression analysis determined predictors of their preferences. Older adults rated all mental health content items as very important. Most participants preferred detailed information (two to six pages) on all treatment options (psychological, pharmacological, combined and self-help). Older adults significantly preferred discussion with a heath-care provider and written information, in comparison to other formats. Older adults also significantly preferred to consult family, friends and heath-care professionals over other sources. Socio-demographic and psycho-social characteristics accounted for some of the variance in predicting older adults’ information preferences. Findings highlight older adults’ desire to be involved in decisions concerning mental health supports. Providing balanced information concerning mental health treatment may increase empowerment in mental health help-seeking.

Therapeutic alliance in vocational rehabilitation counseling: Assessing client factors and functioning

BACKGROUND: The therapeutic relationship is often acknowledged as one of the most significant factors in clinical process that influences client outcomes. OBJECTIVE: While considerable research has been conducted on the therapeutic relationship in psychotherapy, there is a paucity of research on the impact of the therapeutic relationship in vocational rehabilitation counseling settings. METHODS: This study explored the relationship between areas of client functioning (individual, interpersonal, social, and overall) and the therapeutic alliance among clients who receive services from the State vocational rehabilitation agency. RESULTS: In this study, younger clients (ages between 16 to 29) reported stronger therapeutic alliance. CONCLUSION: The findings of this study suggested that clients’ perceived individual, interpersonal and overall functioning have a significant positive relationship with the task and bond components of therapeutic relationship.

Perceived need for treatment and non-utilization of outpatient psychotherapy in old age: two cohorts of a nationwide survey

BEACKGROUND

Older adults with mental health problems may benefit from psychotherapy; however, their perceived need for treatment in relation to rates of non-utilization of outpatient psychotherapy as well as the predisposing, enabling, and need factors proposed by Andersen's Model of Health Care Utilization that account for these differences warrant further investigation.

METHODS

We used two separate cohorts (2014 and 2019) of a weighted nationwide telephone survey in Germany of German-speaking adults with N = 12,197 participants. Across the two cohorts, 12.9% (weighted) reported a perceived need for treatment for mental health problems and were selected for further analyses. Logistic Generalized Estimation Equations (GEE) was applied to model the associations between disposing (age, gender, single habiting, rural residency, general health status), enabling (education, general practitioner visit) non-utilization of psychotherapy (outcome) across cohorts in those with a need for treatment (need factor).

RESULTS

In 2014, 11.8% of 6087 participants reported a perceived need for treatment due to mental health problems. In 2016, the prevalence increased significantly to 14.0% of 6110 participants. Of those who reported a perceived need for treatment, 36.4% in 2014 and 36.9%in 2019 did not see a psychotherapist - where rates of non-utilization of psychotherapy were vastly higher in the oldest age category (59.3/52.5%; 75+) than in the youngest (29.1/10.7%; aged 18-25). Concerning factors associated with non-utilization, multivariate findings indicated participation in the cohort of 2014 (OR 0.94), older age (55-64 OR 1.02, 65-74 OR 1.47, 75+ OR 4.76), male gender (OR 0.83), lower educational status (OR 0.84), rural residency (OR 1.38), single habiting (OR 1.37), and seeing a GP (OR 1.39) to be related with non-utilization of psychotherapy; general health status was not significantly associated with non-utilization when GP contact was included in the model.

CONCLUSION

There is a strong age effect in terms of non-utilization of outpatient psychotherapy. Individual characteristics of both healthcare professionals and patients and structural barriers may add to this picture. Effective strategies to increase psychotherapy rates in those older adults with unmet treatment needs are required.

Depressed Older Patients with Death Wishes: Experimental Evidence for Psychotherapists' Age and Health Bias

Objectives: When psychotherapists encounter an older patient with depression and death wishes, especially when burdened by physical illness, they may be subject to judgmental biases. This study investigates how this group of patients with highest suicide risk may experience discrimination both on age and health status. Methods: Using a 2 × 2 [chronological age x physical health status] vignette design, psychotherapists (N = 147) were randomly presented with one of the four variants of a case describing a patient with depression and death wishes (i.e., 78 years old + poor physical health; 78 years old + normal physical health; 48 years old + poor physical health; 48 years old + normal physical health). Afterward, participants' attitudes toward the case were assessed. Results: In case of the hypothetical patient's old age and poor health status, participants did not underestimate the pathological significance of his death wishes, but nevertheless showed less optimistic treatment attitudes and less confidence in psychotherapeutic treatment. Conclusions: Psychotherapists' age bias and health bias may serve as two potentially fatal factors influencing the provision of mental health services. Clinical Implications: Psychotherapists may contribute to better mental health-care provision of older adults with depression and the prevention of late-life suicide by increasing awareness of their age and health bias.

Evaluation of the Effects of an Intervention Intended to Optimize the Sleep Environment Among the Elderly: An Exploratory Study

Purpose

The objective of this exploratory study was to evaluate the effects of a brief intervention intended to optimize the sleep environment in older people living in the community and to examine the way these effects change over time.

Methods

The sample was made up of 44 participants (19 men and 25 women) aged 65-85 years, with a mean age of 71.4. The intervention consisted in a group training session that covered the reasons for and ways to ("why" and "how") optimize a sleep environment. It comprises six themes: air quality and odors, luminosity, noises and sounds, comfort of the mattress, comfort of the pillow, and temperature. Participants completed a set of questionnaires before the intervention, and one month and four months later.

Results

Four months after the intervention, the replies to the questionnaires showed that the participants experienced reduced severity of insomnia, sleep latency and anxiety. The subjective quality of the participants' sleep along with their sleep efficacy also increased significantly during the same period.

Conclusion

A brief intervention intended to optimize the sleep environment appears promising as an addition or alternative to the two other sleep improvement options generally offered to older people: medication and cognitive behavioral therapy.

EMDR in Older Adults With Posttraumatic Stress Disorder

Recognition of posttraumatic stress disorder (PTSD) in older adults is often difficult due to its complicated presentation. Once recognized, trauma symptoms can, in accordance with (inter)national guidelines, be successfully treated with eye movement desensitization and reprocessing (EMDR) therapy. However, limited empirical research has been done on the expression and treatment of PTSD in older adults. This article explains trauma and age in the context of psychotherapy. It discusses the interaction between age and pathology and summarizes the cognitive issues related to age, PTSD, and anxiety. It provides practical suggestions for how these can be addressed in treatment. Age-related challenges related to motivation are identified with practical suggestions for addressing them. The case illustrates the necessary additions and subtractions for older adults, with clear explanations and instructions. This article points the way for future research.

Factors associated with the use of social workers for assistance with lifetime and 12-month behavioral health disorders

This study examined the use of social workers for assistance with a behavioral health disorder. Data were from the Collaborative Psychiatric Epidemiology Surveys. The analytic sample included respondents who reported using professional services for assistance with a behavioral health disorder during their lifetime (n = 5,585). Logistic regression was used to examine the use of a social worker during the respondent's lifetime or 12 months prior to the interview. Ten percent of respondents visited a social worker for help with a behavioral health disorder during their lifetime and 3% did so in the 12 months prior to the interview. Women were less likely than men to report using a social worker. Those who visited a social worker tended to also use other professionals for a behavioral health disorder although overall respondents reported visiting social workers less frequently for this reason than other types of professionals.

Relationship Between the Types of Insurance Coverage and Outpatient Mental Health Treatment Use Among Older Adults

Using the public use data files of the 2008 to 2012 National Survey on Drug Use and Health, this study examined (a) the payment sources for mental health treatment among those aged 50 to 64 years and those aged 65+ years and (b) the relationship between outpatient mental health treatment use and different types of insurance coverage among members of these two age groups. The results show that 16% of the 50 to 64 age group and 10% of the 65+ age group used inpatient or outpatient mental health treatment in the preceding year. Logistic regression analyses showed that mental health problem severity and public insurance programs (Medicare, Medicaid, and Department of Veterans Affairs [VA]/military insurance) significantly increased the odds of receiving outpatient treatment. Private insurance was not a significant factor for either age group. Older adults with mental health problems must be encouraged to seek treatment and need to be informed about mental health coverage included in their insurance(s).

The Barriers to Mental Health Services Scale Revised: Psychometric Analysis Among Older Adults

OBJECTIVES

Older adults underutilize mental health services suggesting that significant barriers are operating. This study presents reliability and validity data for a revised version of the self-report Barriers to Mental Health Services Scale (BMHSS) designed to quantify 10 barriers to mental health service use, so that barriers can be examined collectively.

METHODS

The Barriers to Mental Health Services Scale Revised (BMHSS-R) was revised to improve its reliability and validity, including adding items, eliminating poor items, and balancing the number of items across subscales. A sample of 100 older adults (M age = 72.1 years, SD = 17.8 years) completed the BMHSS-R, the Beliefs Toward Mental Illness Scale, and the Willingness to Seek Help Questionnaire.

RESULTS

Internal consistency for the 10 subscales of the BMHSS-R ranged between .63 and .87, with 8 of the 10 values greater than .70. Correlational analyses indicated that many of the subscales overlap considerably but are still distinct. Convergent validity of the BMHSS-R subscales of help-seeking and stigma was partially supported, although correlations were modest.

CONCLUSION

Revisions to the BMHSS resulted in improved reliability estimates for use as a measure of perceived barriers to mental health services. We recommend when using the BMHSS-R to combine results with other information (e.g., service utilization data) to characterize a profile of barriers. We discuss directions for future research and further refinement of the BMHSS-R.

Attitudes towards seeking mental health services among older adults: personal and contextual correlates

OBJECTIVES

Especially older adults underutilize professional mental health services. However, little is known about the factors associated with older adults' attitudes towards seeking mental health services (ATSMHS). We therefore investigated a wide range of contextual (e.g. physical access, residence) and personal (e.g. perceived social support, life satisfaction, openness to experience) predictors of ATSMHS in a sample of older community-dwelling adults in Germany. We predicted that representations of old age as well as perceptions of (younger) psychotherapists would be uniquely important for determining ATSMHS.

METHOD

A diverse sample of N = 156 older adults (Mage = 71.5 years, SD = 6.4, range: 60-92) completed questionnaire measures. We used hierarchical linear regression analyses to identify predictors of ATSMHS.

RESULTS

In the final saturated model, female gender, urban residence, personal and vicarious experience with psychotherapy, and higher perceived social support were each associated with more positive ATSMHS. In addition, more positive representations of old age and less negative perceptions of (younger) psychotherapists explained unique variance in ATSMHS over and above the other predictors. The overall model was significant and explained 49% of the variance in ATSMHS.

CONCLUSION

Our findings can be used to inform interventions to improve older adults' ATSMHS. Interventions that seek to improve older adults' representations of their own aging as well as of psychotherapists may be useful for reducing the treatment gap.

Mental health treatment use and perceived treatment need among suicide planners and attempters in the United States: between and within group differences

Background

Despite many previous studies of suicidal ideation and/or attempts, little research has examined mental health treatment use and perceived treatment need among and within groups of ideators and/or attemptors. We examined mental health treatment use and perceived treatment need in four groups of US adults who had serious suicidal ideation: (1) no suicide plan/no attempt; (2) planned/no attempt; (3) no plan/attempted; and (4) planned/attempted.

Methods

We compared ideators and nonideators using the 154,923 U.S. residents aged 21 and older who participated in the 2008–2012 National Survey on Drug Use and Health (NSDUH). We then employed logistic regression analyses to discern factors associated with treatment use and perceived treatment need among and within the four groups of ideators (N = 7,348).

Results

More than 30% of ideators who made suicide plans and/or attempted suicide received no treatment before or after planning or attempting. Racial/ethnic minorities had lower odds of treatment use in all four groups, but major depression significantly increased the odds in all but the no plan/attempted group. Treatment use and substance use disorder increased the odds of perceived need in all four groups.

Conclusions

The four groups have different rates of treatment access and perceived treatment need that do not appear to be commensurate with their risk level. The findings underscore the importance of treatment access for all those at-risk of suicide, especially racial/ethnic minorities and those of lower SES.

Quantifying the importance of disease burden on perceived general health and depressive symptoms in patients within the Mayo Clinic Biobank

Background

Deficits in health-related quality of life (HRQOL) may be associated with worse patient experiences, outcomes and even survival. While there exists evidence to identify risk factors associated with deficits in HRQOL among patients with individual medical conditions such as cancer, it is less well established in more general populations without attention to specific illnesses. This study used patients with a wide range of medical conditions to identify contributors with the greatest influence on HRQOL deficits.

Methods

Self-perceived general health and depressive symptoms were assessed using data from 21,736 Mayo Clinic Biobank (MCB) participants. Each domain was dichotomized into categories related to poor health: deficit (poor/fair for general health and ≥3 for PHQ-2 depressive symptoms) or non-deficit. Logistic regression models were used to test the association of commonly collected demographic characteristics and disease burden with each HRQOL domain, adjusting for age and gender. Gradient boosting machine (GBM) models were applied to quantify the relative influence of contributors on each HRQOL domain.

Results

The prevalence of participants with a deficit was 9.5 % for perception of general health and 4.6 % for depressive symptoms. For both groups, disease burden had the strongest influence for deficit in HRQOL (63 % for general health and 42 % for depressive symptoms). For depressive symptoms, age was equally influential. The prevalence of a deficit in general health increased slightly with age for males, but remained stable across age for females. Deficit in depressive symptoms was inversely associated with age. For both HRQOL domains, risk of a deficit was associated with higher disease burden, lower levels of education, no alcohol consumption, smoking, and obesity. Subjects with deficits were less likely to report that they were currently working for pay than those without a deficit; this association was stronger among males than females.

Conclusions

Comorbid health burden has the strongest influence on deficits in self-perceived general health, while demographic factors show relatively minimal impact. For depressive symptoms, both age and comorbid health burden were equally important, with decreasing deficits in depressive symptoms with increasing age. For interpreting patient-reported metrics and comparison, one must account for comorbid health burden.

Images of Aging in the Psychotherapeutic Context

Both psychotherapists and their clients have mental representations of old age and the aging process. In this conceptual review, we draw on available research from gerontology, social and developmental psychology, and communication science to consider how these “images of aging” may affect the psychotherapeutic process with older clients. On the basis of selected empirical findings we hypothesize that such images may affect the pathways to psychotherapy in later life, therapist-client communication, client performance on diagnostic tests as well as how therapists select and apply a therapeutic method. We posit that interventions to help both older clients and therapists to reflect on their own images of aging may increase the likelihood of successful treatment. We conclude by making suggestions for future research.

Utilization of Hospice Bereavement Support by At-Risk Family Members

Approximately 10% of the bereaved are at risk of bereavement-related mental health disorders. Hospices' bereavement services could potentially address needs of many at risk, but little is known about their service use. We analyzed data from 6160 bereaved family members of hospice patients. Risk of mental health problems was identified by hospice providers postloss. Of those characterized as "at-risk," 52% used services compared to 18% of the "low risk." Factors associated with service use among at-risk were female gender and younger age of death. Those who lost a child used services less than other bereaved. Although hospices appear to be skilled at identifying and providing bereavement services to the at-risk, services do not reach almost half. Results suggest the need to improve care access, especially among men and those losing a child.

What factors determine disclosure of suicide ideation in adults 60 and older to a treatment provider?

Correlates of patient disclosure of suicide ideation to a primary care or mental health provider were identified. Secondary analyses of IMPACT trial data were conducted. Of the 107 patients 60 years of age or older who endorsed thoughts of ending their life at least "a little bit" during the past month, 53 indicated they had disclosed these thoughts to a mental health or primary care provider during this period. Multiple logistic regression was used to identify predictors of disclosure to a provider. Significant predictors included poorer quality of life and prior mental health specialty treatment. Among participants endorsing thoughts of suicide, the likelihood of disclosing these thoughts to a provider was 2.96 times higher if they had a prior history of mental health specialty treatment and 1.56 times higher for every one-unit decrease in quality of life. Variation in disclosure of thoughts of suicide to a mental health or primary care provider depends, in part, on patient characteristics. Although the provision of evidence-based suicide risk assessment and guidelines could minimize unwanted variation and enhance disclosure, efforts to routinize the process of suicide risk assessment should also consider effective ways to lessen potential unintended consequences.

“I was Just Trying to Stick it Out Until I Realized that I Couldn'T”: A Phenomenological Investigation of Support Seeking among Older Adults with Complicated Grief

Complicated Grief (CG) is a prolonged, impairing mental health condition affecting about 7% of the bereaved. CG may be especially prevalent in older adults. Though evidence-based treatments for CG have been developed, little is known about support-seeking in older adults with CG. This study used the descriptive phenomenological approach to explore the CG support-seeking process. In-depth interviews were conducted with 8 CG-positive older adults who had completed participation in a randomized clinical trial of CG treatment. Five primary themes arose: observing that grief was causing a great deal of distress and impairment; grief not meeting expectations of what grief “should be”; an important influence of social relationships on support-seeking; lack of effectiveness of grief support groups and/or care from mental health professionals prior to study enrollment; and strong reactions to the label of CG. Themes may hep inform efforts to engage older adults with CG in effective care.

Physicians' detection of late-life depression: the roles of dysphoria and cognitive impairment

OBJECTIVE

To examine factors that impede or facilitate physicians' detection of depression in later life, including cognitive impairment and patients' endorsement of dysphoria.

METHODS

A population-based sample of 344 adults from the Swedish Adoption/Twin Study of Aging (SATSA) was utilized. Physician detection of depression was determined by (1) outpatient medical records, (2) antidepressant prescription, and/or (3) inpatient hospitalization. Depressive symptoms were measured by highest score on the Center for Epidemiologic Studies - Depression Scale (CES-D), administered on six occasions between 1986 and 1994. Endorsement of dysphoria was examined using two items on the CES-D. The Mini-Mental State Examination (MMSE) was used to indicate cognitive impairment.

RESULTS

One-hundred thirty-six individuals were above the cut-off on the CES-D on at least one occasion; however, only 14 of these individuals (10%) were detected as depressed by a physician. Higher CES-D total score was significantly related to physician detection. Furthermore, physicians were most likely to detect depression if the individual endorsed the single CES-D item regarding feeling depressed. A significant interaction was found, such that overall CES-D score was only associated with physician detection among those with higher endorsement of the depressed item. The association between total CES-D and physician detection was not affected by presence of cognitive impairment.

CONCLUSIONS

Depression in later life often goes undetected by physicians. Factors associated with detection include the frequency/severity of symptoms and patients' endorsement specifically of feeling depressed. Results suggest that physicians should routinely assess for other symptoms associated with late-life depression besides dysphoria (e.g., appetite loss, crying spells).

Depression and use of health care services in patients with advanced cancer

OBJECTIVE

To examine whether depression in patients with advanced cancer is associated with increased rates of physician visits, especially to primary care.

DESIGN

Retrospective, observational study linking depression survey data to provincial health administration data.

SETTING

Toronto, Ont.

PARTICIPANTS

A total of 737 patients with advanced cancer attending Princess Margaret Hospital, who participated in the Will to Live Study from 2002 to 2008.

MAIN OUTCOME MEASURES

Frequency of visits to primary care, oncology, surgery, and psychiatry services, before and after the depression assessment.

RESULTS

Before the assessment, depression was associated with an almost 25% increase in the rate of primary care visits for reasons not related to mental health (rate ratio [RR] = 1.23, 95% CI 1.00 to 1.50), adjusting for medical morbidity and other factors. After assessment, depression was associated with a 2-fold increase in the rate of primary care visits for mental health-related reasons (RR = 2.35, 95% CI 1.18 to 4.66). However, depression was also associated during this time with an almost 25% reduction in the rate of oncology visits (RR = 0.78, 95% CI 0.65 to 0.94).

CONCLUSION

Depression affects health care service use in patients with advanced cancer. Individuals with depression were more likely to see primary care physicians but less likely to see oncologists, compared with individuals without depression. However, the frequent association of disease-related factors with depression in patients with advanced cancer highlights the need for communication between oncologists and primary care physicians about the medical and psychosocial care of these patients.

Functional impairment, illness burden, and depressive symptoms in older adults: does type of social relationship matter?

OBJECTIVE

The nature of interpersonal relationships, whether supportive or critical, may affect the association between health status and mental health outcomes. We examined the potential moderating effects of social support, as a buffer, and family criticism, as an exacerbating factor, on the association between illness burden, functional impairment and depressive symptoms.

METHODS

Our sample of 735 older adults, 65 years and older, was recruited from internal and family medicine primary care offices. Trained interviewers administered the Hamilton Rating Scale for Depression, Duke Social Support Inventory, and Family Emotional Involvement and Criticism Scale. Physician-rated assessments of health, including the Karnofsky Performance Status Scale and Cumulative Illness Rating Scale, were also completed.

RESULTS

Linear multivariable hierarchical regression results indicate that social interaction was a significant buffer, weakening the association between illness burden and depressive symptoms, whereas perceived social support buffered the relationship between functional impairment and depressive symptoms. Family criticism and instrumental social support were not significant moderators.

CONCLUSIONS

Type of medical dysfunction, whether illness or impairment, may require different therapeutic and supportive approaches. Enhancement of perceived social support, for those who are impaired, and encouragement of social interactions, for those who are ill, may be important intervention targets for treatment of depressive symptoms in older adult primary care patients.

Course of depression and mortality among older primary care patients

CONTEXT

: Depression is a treatable illness that disproportionately places older adults at increased risk for mortality.

OBJECTIVE

: We sought to examine whether there are patterns of course of depression severity among older primary care patients that are associated with increased risk for mortality.

DESIGN AND SETTING

: Our study was a secondary analysis of data from a practice-based randomized controlled trial within 20 primary care practices located in greater New York City, Philadelphia, and Pittsburgh.

PARTICIPANTS

: The study sample consisted of 599 adults aged 60 years and older recruited from primary care settings. Participants were identified though a two-stage, age-stratified (60-74 years; older than 75 years) depression screening of randomly sampled patients. Severity of depression was assessed using the 24-item Hamilton Depression Rating Scale (HDRS).

MEASUREMENTS

: Longitudinal analysis via growth curve mixture modeling was carried out to classify patterns of course of depression severity across 12 months. Vital status at 5 years was ascertained via the National Death Index Plus.

RESULTS

: Three patterns of change in course of depression severity over 12 months were identified: 1) persistent depressive symptoms, 2) high but declining depressive symptoms, 3) low and declining depressive symptoms. After a median follow-up of 52.0 months, 114 patients had died. Patients with persistent depressive symptoms were more likely to have died compared with patients with a course of high but declining depressive symptoms (adjusted hazard ratio 2.32, 95% confidence interval [1.15-4.69]).

CONCLUSIONS

: Persistent depressive symptoms signaled increased risk of dying in older primary care patients, even after adjustment for potentially influential characteristics such as age, smoking status, and medical comorbidity.

A crisis resolution and home treatment team in Norway: a longitudinal survey study Part 1. Patient characteristics at admission and referral

Background

Crisis resolution and home treatment (CRHT) is an emerging mode of delivering acute mental health care in the community. There is a paucity of knowledge regarding the workings of CRHT in the literature. This is the first paper in a series of three from the longitudinal survey of patients of a CRHT team in Norway, which was aimed at describing the characteristics of patients served, professional services provided, and clinical outcomes. This report focuses on describing the characteristics of the patients at admission.

Methods

The study was a descriptive, quantitative study based on the patient data from a longitudinal survey of one CRHT team in Norway. The participants of the survey, a total of 363 patients, were the complete registration of patients of this team in the period from February 2008 to July 2009.

Results

Although diverse in their characteristics, the patients were over represented by females, young to middle aged, and people on public support. The patients were mostly referred to the team by self/family members and primary care physicians. At admission, depression was the most prevalent symptom, the overall intensity level of mental health problems was low, and most of the patients had long-standing mental health problems.

Conclusions

Self/family referral seems to be a critical route to receive services by CRTH teams as shown in our study, suggesting a need to examine policies that disallow this form of referral in some communities. The findings from our study show that the patients of the CRHT team, while mostly having long-standing mental health problems and had been receiving healthcare for them, did not have severe mental health problems at admission, although could have been in crises. There is a need for further studies to examine how people with severe mental health problems obtain services in time of crises, and to address the need to gain a greater understanding of the role of CRHT.

Self-reported estrogen use and newly incident urinary incontinence among postmenopausal community-dwelling women

OBJECTIVE

The aim of this study was to examine the relationship between self-reported estrogen use and newly incident urinary incontinence (UI) among community-dwelling postmenopausal women.

METHODS

The study was a population-based longitudinal survey of postmenopausal women who did not report UI in 1993 and for whom complete data were available. Women were classified as having newly incident UI if they reported uncontrolled urine loss within 12 months of the 2004 interview. Condition-specific functional loss secondary to UI was assessed using questions on the participants' inability to engage in certain activities because of UI. The duration of hormone therapy containing estrogen was obtained in 1993 using a structured questionnaire.

RESULTS

Among the 167 postmenopausal women who did not report UI in 1993, 47 (28.1%) reported newly incident UI, and 31 (18.6%) reported newly incident UI with condition-specific functional loss in 2004. Of the 167 postmenopausal women, 46 (27.5%) reported using hormone therapy containing estrogen ever, and 14 (8.3%) women reported using hormone therapy containing estrogen for 5 years or more in 1993. Estrogen use for 5 years or more was significantly associated with newly incident UI with condition-specific functional loss compared with estrogen use for less than 5 years or having no reported history of estrogen (adjusted relative odds, 3.97; 95% CI, 1.02-15.43) in multivariate models controlling for potentially influential characteristics.

CONCLUSIONS

Postmenopausal community-dwelling women with a history of estrogen use for 5 years or more were more likely to report newly incident UI with condition-specific functional loss after 10 years of follow-up.

Primary care-mental health integration programs in the veterans affairs health system serve a different patient population than specialty mental health clinics

OBJECTIVE

To assess whether Primary Care-Mental Health Integration (PC-MHI) programs within the Veterans Affairs (VA) health system provide services to patient subgroups that may be underrepresented in specialty mental health care, including older patients and women, and to explore whether PC-MHI served individuals with less severe mental health disorders compared to specialty mental health clinics.

METHOD

Data were obtained from the VA National Patient Care Database for a random sample of VA patients, and primary care patients with an ICD-9-CM mental health diagnosis (N = 243,806) in 2009 were identified. Demographic and clinical characteristics between patients who received mental health treatment exclusively in a specialty mental health clinic (n = 128,248) or exclusively in a PC-MHI setting (n = 8,485) were then compared. Characteristics of patients who used both types of services were also explored.

RESULTS

Compared to patients treated in specialty mental health clinics, PC-MHI service users were more likely to be aged 65 years or older (26.4% vs 17.9%, P < .001) and female (8.6% vs 7.7%, P = .003). PC-MHI patients were more likely than specialty mental health clinic patients to be diagnosed with a depressive disorder other than major depression, an unspecified anxiety disorder, or an adjustment disorder (P < .001) and less likely to be diagnosed with more severe disorders, including bipolar disorder, posttraumatic stress disorder, psychotic disorders, and alcohol or substance dependence (P < .001).

CONCLUSIONS

Primary Care-Mental Health Integration within the VA health system reaches demographic subgroups that are traditionally less likely to use specialty mental health care. By treating patients with less severe mental health disorders, PC-MHI appears to expand upon, rather than duplicate, specialty care services.

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

OBJECTIVES

We sought to examine whether there are patterns of evolving depression symptoms among older primary care patients that are related to prognostic factors and long-term clinical outcomes.

METHOD

Primary care practices were randomly assigned to Usual Care or to an intervention consisting of a depression care manager offering algorithm-based depression care. In all, 599 adults 60 years and older meeting criteria for major depression or clinically significant minor depression were randomly selected. Longitudinal analysis via growth curve mixture modeling was carried out to classify patients according to the patterns of depression symptoms across 12 months. Depression diagnosis determined after a structured interview at 24 months was the long-term clinical outcome.

RESULTS

Three patterns of change in depression symptoms over 12 months were identified: high persistent course (19.1% of the sample), high declining course (14.4% of the sample), and low declining course (66.5% of the sample). Being in the intervention condition was more likely to be associated with a course of high and declining depression symptoms than high and persistent depression symptoms (OR = 2.53, 95% CI [1.01, 6.37]). Patients with a course of high and persistent depression symptoms were much more likely to have a diagnosis of major depression at 24 months compared with patients with a course of low and declining depression symptoms (adjusted OR = 16.46, 95% CI [7.75, 34.95]).

CONCLUSION

Identification of patients at particularly high risk of persistent depression symptoms and poor long-term clinical outcomes is important for the development and delivery of interventions.

Low use of mental health services among older Americans with mood and anxiety disorders

OBJECTIVE

It is unclear why late-life mood and anxiety disorders are highly undertreated, despite being common among older adults. Thus this study examined prevalence of and key factors associated with nonuse of mental health services among older community-dwelling adults with these disorders.

METHODS

The sample included 348 participants aged 55 years or older who met 12-month criteria for DSM-IV mood and anxiety disorders and responded to the National Comorbidity Survey Replication (NCS-R), a population-based probability sample. Analyses included frequency measures and logistic regression with weights and complex design-corrected statistical tests. Key factors associated with not using mental health services were determined in a final multivariable model based on a systematic approach that accounted for a comprehensive list of potential predictors.

RESULTS

Approximately 70% of older adults with mood and anxiety disorders did not use services. Those who were from racial-ethnic minority groups, were not comfortable with discussing personal problems, were married or cohabitating, and had middle- versus high-income status had increased odds of not using mental health services. In addition, respondents with mild versus serious disorders, no chronic pain complaints, and low versus high perceived cognitive impairment had greater odds of nonuse.

CONCLUSIONS

Results indicate that improvements are needed in the following areas to combat the very high number of mood and anxiety disorders that go untreated in older Americans: awareness of need, comfort in discussing personal problems with a health care professional, and screening and other prevention efforts.

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.

Telephone-based behavioral health assessment for older adults starting a new psychiatric medication

OBJECTIVES

The purpose of this study is to explore behavioral health symptoms and characteristics of noninstitutionalized older adults newly started on an antidepressant, anxiolytic, or antipsychotic agent by nonpsychiatrist physicians.

DESIGN

Naturalistic cohort study of older adults participating in the Pharmaceutical Assistance Contract for the Elderly (PACE) of the state of Pennsylvania.

SETTING/PARTICIPANTS

Noninstitutionalized adults in Pennsylvania.

MEASUREMENTS

Standardized scales including the Blessed Orientation-Memory-Concentration (BOMC) test, Mini International Neuropsychiatric Interview (including Psychosis, Mania, Generalized Anxiety Disorder [GAD], Panic Disorder, and Alcohol Abuse/Dependence modules), Patient Health Questionnaire-9 (PHQ-9), Paykel Scale for suicide ideation, and Medical Outcomes Survey (SF-12).

RESULTS

Participants were mostly women (83.7%) with a mean age of 79.2 years (SD 7.1). The average PHQ-9 score for those on antidepressants was 5.8 (5.2), with no statistically significant difference between medication groups (F[2, 409] = 1.48, p = 0.23); just seven (4.9%) of those receiving anxiolytics met criteria for an anxiety disorder, which was not significantly different than other medication classes (χ (2) = 0.83, p = 0.66). Overall, 197 (47.8%) of the sample did not meet criteria for a mental health disorder. Just 69 (28.8%) of those on antidepressants reported depression as the self-reported reason for taking the medication, while 91 (22.8%) of the total reported poor sleep or stressful life events as the reason.

CONCLUSIONS

In this sample, many older persons received psychotropic medications despite low symptomatology, increasing the costs of care and possible exposure to unnecessary side effects. It is important to understand perceived benefit to both patient and provider of such prescribing patterns and work towards minimizing unnecessary use.

Shared conceptualizations and divergent experiences of counseling among African American and white older adults

Research findings suggest that older adults prefer counseling for depression treatment; however, few older adults use counseling services. In this article we present the results of our analysis of semistructured interviews with 102 older adults to explore conceptualizations of counseling and impediments to use among African American and White older adults. We found that older adults believe counseling is beneficial; however, use was hindered in multiple ways. Older adults were skeptical about establishing a caring relationship with a professional. African American older adults did not mention social relationships to facilitate depression care, whereas White older adults described using personal relationships to navigate counseling services. African American older men were least familiar with counseling. Our findings suggest that African American and White older adults share a strong cultural model of counseling as beneficial; however, significant impediments exist and affect older adults differentially based on ethnicity.

Urinary incontinence (UI) and new psychological distress among community dwelling older adults

This study aimed at determining whether UI is associated with increased risk for the onset of psychological distress. This was a population based longitudinal survey of adults aged 50 and older who did not report psychological distress in 1993 and for whom complete data were available. Participants were classified as having UI if they reported uncontrolled urine loss within 12 months of the 1993 interview. Condition-specific functional loss secondary to UI was assessed by questions on participants' ability to engage in certain activities due to UI. Psychological distress was assessed using the General Health Questionnaire (GHQ) in 2004. The continuing participants were living in East Baltimore, Maryland in 1981. Persons with UI in 1993 were more likely to experience new psychological distress in 2004 than were persons without UI in 1993 adjusting for potentially influential covariates (relative odds (RO)=2.18, 95% confidence interval (CI)=1.19-4.01). Persons with condition-specific functional loss secondary to UI were more likely to experience new psychological distress than were persons without UI adjusting for potentially influential covariates (RO=7.57, 95%CI=2.92-19.62). We conclude that UI, especially when associated with condition-specific functional loss, predicted the onset of psychological distress among community dwelling older adults.

The temporal relationship between anxiety disorders and urinary incontinence among community-dwelling adults

OBJECTIVE

The purpose of this paper was to carefully examine the temporal relationships between anxiety disorders and urinary incontinence among community-dwelling adults.

METHOD

In all, 1071 persons aged 30 and over were the continuing participants in a population-based longitudinal study of community-dwelling adults. Participants were classified as incontinent if any uncontrolled urine loss within the 12 months prior to the interview was reported. Condition-specific functional loss secondary to urinary incontinence was further assessed based on a series of questions relating directly to participants' inability to engage in certain activities due to their urinary incontinence. Anxiety disorders were assessed with standardized interviews keyed to the diagnostic criteria.

RESULTS

In multivariate models that controlled for potentially influential characteristics the association between urinary incontinence with condition-specific functional loss and newly-incident anxiety disorders was statistically significant (adjusted relative odds (RO)=2.55, 95% confidence interval (CI) [1.05, 6.20]).

CONCLUSIONS

Urinary incontinence with condition-specific functional loss predicted onset of newly-incident anxiety disorders among community-dwelling adults.

The treatment of Common Mental Disorders across age groups: results from the 2007 Adult Psychiatric Morbidity Survey

BACKGROUND

We investigated for the first time in a national survey whether older people were less likely than younger adults with the same symptom severity to receive treatment for Common Mental Disorders (CMD).

METHOD

We analysed data from the 2007 English Adult Psychiatric Morbidity Survey, representative of people living in private homes. 7461 (57%) people approached took part. We used the revised Clinical Interview Schedule to measure CMD symptom severity.

RESULTS

Older participants were less likely than younger adults to receive talking therapy and to have seen their GP in the last year about mental health, and more likely to receive benzodiazepines, after adjusting for CMD symptoms. Adults aged 35-74 were the most likely to take antidepressants. There was also preliminary evidence that people from non-white ethnicities were less likely to be taking antidepressants and to have seen their GP in the last year about their mental health.

LIMITATIONS

We only recorded current treatment, and it is possible that older adults were less likely to be receiving treatments they had found unhelpful earlier in their lives. We asked people whether they had seen their GP about a mental health problem in the last year, but this question may not have detected those who attended for somatic manifestations of their anxieties.

CONCLUSIONS

Older people are less likely to receive evidence-based treatment for CMD. Managers and clinicians should prioritize reducing this inequality.

Correlates of perceived need for and use of mental health services by older adults in the collaborative psychiatric epidemiology surveys

OBJECTIVES

Older adults are especially unlikely to seek mental health services, but little is known about whether their perceptions of need for help contribute to this problem. The objectives of this study were to compare perceived need across the lifespan and to examine sociodemographic and mental health correlates of whether older adults sought professional help, perceived the need for help without seeking it, and sought help from specialty mental health professionals.

METHODS

The authors examined help-seeking and perceived need with the Collaborative Psychiatric Epidemiology Surveys, focusing on 3,017 adults aged 55 years and older. Logistic regressions predicted help-seeking and perceived need from sociodemographic factors, past-year psychiatric disorders, and past-year suicidal behaviors. Individuals who perceived the need for help without receiving it also reported barriers to help-seeking.

RESULTS

Levels of perceived need were highest among 25-44 year olds and lowest among adults aged 65 years and older. Among older adults with psychiatric disorders, 47.1% did not perceive a need for professional help. Diagnoses and suicidal behaviors were strong predictors of whether individuals perceived need, whereas among those who perceived the need for help, only older age was positively associated with help-seeking. Few factors clearly distinguished those who did and did not seek help from specialty mental health professionals with the exception of having three or more psychiatric diagnoses. Finally, the most common barrier to help-seeking was a desire to handle problems on one's own.

CONCLUSIONS

A lack of perceived need for mental health services and self-sufficiency beliefs are significant barriers to older adults' use of mental health services.