Depression treatment in older adult veterans

Association of Caregiving Receipt With Mental Health Utilization in a National Cohort of Older Adults

OBJECTIVE

There exist significant age disparities in mental health (MH) utilization, such that older adults, including older veterans, are much less likely to use MH services. In-home caregivers represent a novel, yet understudied, pathway to increase appropriate utilization. We sought to examine the association between receiving caregiving assistance and MH utilization and test moderation effects of cognitive status and depression severity in a sample of older veterans.

METHODS

Cross-sectional, mixed effects logistic regression with moderation analyses was used with a unique data resource combining survey data from the 2000-2012 U.S. Health and Retirement Study with Veterans Affairs (VA) healthcare administrative records. The analytic sample included N=1,957 Community-dwelling veterans (mean age 68.2 [9.7]), primarily male (96.5%) and non-Hispanic white (77.0%). Measures included MH utilization extracted from VA records or self-report; CESD-8 for depressive symptoms; and the Langa-Weir cognitive status classification using the modified TICS.

RESULTS

After accounting for demographics, spousal caregiver availability, health factors, and socioeconomic status, caregiving receipt was associated with two-fold odds of MH utilization, compared to receiving no assistance (8,839 person-year observations; OR = 2.02; 95% CI 1.54-2.65) and remained similar following VA policy changes to enhance MH access. Exploratory analyses revealed that categories of cognition and depressive symptoms may moderate the association.

CONCLUSION

Receipt of any in-home caregiving is associated with increased likelihood of MH use by older adults. Caregivers may represent an underutilized resource to reduce age-related mental health access disparities.

Mental Health Care Use Among U.S. Military Veterans: Results From the 2019-2020 National Health and Resilience in Veterans Study

OBJECTIVE

Psychiatric and substance use disorders are prevalent among U.S. military veterans, yet many veterans do not engage in treatment. The authors examined characteristics associated with use of mental health care in a nationally representative veteran sample.

METHODS

Using 2019-2020 data from the National Health and Resilience in Veterans Study (N=4,069), the authors examined predisposing, enabling, and need factors and perceived barriers to care as correlates of mental health care utilization (psychotherapy, counseling, or pharmacotherapy). Hierarchical logistic regression and relative importance analyses were used.

RESULTS

Among all veterans, 433 (weighted prevalence, 12%) reported current use of mental health care. Among 924 (26%) veterans with a probable mental or substance use disorder, less than a third (weighted prevalence, 27%) reported care utilization. Mental dysfunction (24%), posttraumatic stress disorder symptom severity (18%), using the U.S. Department of Veterans Affairs as primary health care provider (14%), sleep disorder (12%), and grit (i.e., trait perseverance including decision and commitment to address one's needs on one's own; 7%) explained most of the variance in mental health care utilization in this subsample. Grit moderated the relationship between mental dysfunction and use of care; among veterans with high mental dysfunction, those with high grit (23%) were less likely to use services than were those with low grit (53%).

CONCLUSIONS

A minority of U.S. veterans engaged in mental health care. Less stigmatized need factors (e.g., functioning and sleep difficulties) may facilitate engagement. The relationship between protective and need factors may help inform understanding of veterans' decision making regarding treatment seeking and outreach efforts.

Mental Health Needs of Aging Veterans: Recent Evidence and Clinical Recommendations

Objectives: Large numbers of older Americans have a history of military service, which may be positively or negatively associated with mental health in late life. We reviewed literature with the aim of better understanding the mental health needs of older Veterans.Methods: Articles included those published in 2009-2018 and focused on prevalence/risk for mental illness and suicide among older Veterans; utilization of mental health services; effectiveness of evidence-based behavioral treatments; and pertinent care delivery models.Results: Older Veterans are generally resilient. A significant minority experience mental health concerns that are associated with poor outcomes including a substantial number of suicides. Most published research is based on the approximately one third of Veterans who use the Veterans Health Administration (VHA) for care. Older Veterans with mental health diagnoses are less likely to utilize mental health services compared to younger Veterans, but as likely to benefit once engaged. Integrated care models in primary and geriatric care settings are promising.Conclusions: Aging Veterans are a large subset of Americans whose mental health needs are complex and deserve attention.Clinical Implications: Clinicians should ask about history of military service (i.e., Veteran status) and utilize available resources when providing care for older Veterans.

Social support and mental health among health care workers during Coronavirus Disease 2019 outbreak: A moderated mediation model

Purposes

During the outbreak of Coronavirus Disease 2019 (COVID-19) all over the world, the mental health conditions of health care workers are of great importance to ensure the efficiency of rescue operations. The current study examined the effect of social support on mental health of health care workers and its underlying mechanisms regarding the mediating role of resilience and moderating role of age during the epidemic.

Methods

Social Support Rating Scale (SSRS), Connor-Davidson Resilience scale (CD-RISC) and Symptom Checklist 90 (SCL-90) were administrated among 1472 health care workers from Jiangsu Province, China during the peak period of COVID-19 outbreak. Structural equation modeling (SEM) was used to examine the mediation effect of resilience on the relation between social support and mental health, whereas moderated mediation analysis was performed by Hayes PROCESS macro.

Results

The findings showed that resilience could partially mediate the effect of social support on mental health among health care workers. Age group moderated the indirect relationship between social support and mental health via resilience. Specifically, compared with younger health care workers, the association between resilience and mental health would be attenuated in the middle-aged workers.

Conclusions

The results add knowledge to previous literature by uncovering the underlying mechanisms between social support and mental health. The present study has profound implications for mental health services for health care workers during the peak period of COVID-19.

Patterns and predictors of self-reported clinical diagnosis and treatment for depression in prostate cancer survivors

Background

Appropriate depression care is a cancer‐care priority. However, many cancer survivors live with undiagnosed and untreated depression. Prostate cancer survivors may be particularly vulnerable, but little is known about their access to depression care. The goal of this study was to describe patterns and predictors of clinical diagnosis and treatment of depression in prostate cancer survivors.

Methods

Generalized estimating equations were used to evaluate indicators of self‐reported clinical diagnosis and treatment depression as a function of individual‐level characteristics within a longitudinal dataset. The data were from a population‐based cohort of North Carolinian prostate cancer survivors who were enrolled from 2004 to 2007 on the North Carolina‐Louisiana Prostate Cancer Project (N = 1,031), and prospectively followed annually from 2008 to 2011 on the Health Care Access and Prostate Cancer Treatment in North Carolina (N = 805).

Results

The average rate of self‐reported clinical diagnosis of depression was 44% (95% CI: 39%‐49%), which declined from 60% to 40% between prostate cancer diagnosis and 5‐7 years later. Factors associated with lower odds of self‐reported clinical diagnosis of depression include African‐American race, employment, age at enrollment, low education, infrequent primary care visits, and living with a prostate cancer diagnosis for more than 2 years. The average rate of self‐reported depression treatment was 62% (95% CI: 55%‐69%). Factors associated with lower odds of self‐reported depression treatment included employment and living with a prostate cancer diagnosis for 2 or more years.

Conclusion

Prostate cancer survivors experience barriers when in need of depression care.

An Evidence Map of the Women Veterans' Health Research Literature (2008-2015)

BACKGROUND

Women comprise a growing proportion of Veterans seeking care at Veterans Affairs (VA) healthcare facilities. VA initiatives have accelerated changes in services for female Veterans, yet the corresponding literature has not been systematically reviewed since 2008. In 2015, VA Women's Health Services and the VA Women's Health Research Network requested an updated literature review to facilitate policy and research planning.

METHODS

The Minneapolis VA Evidence-based Synthesis Program performed a systematic search of research related to female Veterans' health published from 2008 through 2015. We extracted study characteristics including healthcare topic, design, sample size and proportion female, research setting, and funding source. We created an evidence map by organizing and presenting results within and across healthcare topics, and describing patterns, strengths, and gaps.

RESULTS

We identified 2276 abstracts and assessed each for relevance. We excluded 1092 abstracts and reviewed 1184 full-text articles; 750 were excluded. Of 440 included articles, 208 (47%) were related to mental health, particularly post-traumatic stress disorder (71 articles), military sexual trauma (37 articles), and substance abuse (20 articles). The number of articles addressing VA priority topic areas increased over time, including reproductive health, healthcare organization and delivery, access and utilization, and post-deployment health. Three or fewer articles addressed each of the common chronic diseases: diabetes, hypertension, depression, or anxiety. Nearly 400 articles (90%) used an observational design. Eight articles (2%) described randomized trials.

CONCLUSIONS

Our evidence map summarizes patterns, progress, and growth in the female Veterans' health and healthcare literature. Observational studies in mental health make up the majority of research. A focus on primary care delivery over clinical topics in primary care and a lack of sex-specific results for studies that include men and women have contributed to research gaps in addressing common chronic diseases. Interventional research using randomized trials is needed.

Antidepressant Prescribing in Primary Care to Older Adults Without Major Depression

OBJECTIVE

The study compared distress levels among two groups of older adults who had been newly prescribed an antidepressant by their primary care physician, those with major depressive disorder (MDD) and those without MDD.

METHODS

This analysis used a convenience sample of participants (N=231) who had been newly prescribed an antidepressant in a randomized controlled trial of a program to improve antidepressant adherence and depression outcomes among older adults (≥55). After determining the proportion of participants with and without MDD (using the Structured Clinical Interview for DSM-IV), the authors compared groups on demographic, clinical, and psychosocial characteristics, including the 12-Item Short-Form Health Survey physical and mental component summary scores (PCS and MCS). Logistic regression was used to test the association of these characteristics with antidepressant use in the absence of MDD.

RESULTS

Most (57%) participants did not have MDD. This group was older (69.4 versus 64.7, p<.001), had a larger proportion of white participants (82% versus 56%, p<.001), and reported better physical (PCS, 43.4 versus 39.9, p=.03) and emotional (MCS, 40.2 versus 30.5, p<.001) well-being compared with the group with MDD. In the final regression model, white race (adjusted odds ratio [AOR]=3.11, p=.03) and better emotional well-being (AOR=1.16, p<.001) were associated with antidepressant use in the absence of MDD.

CONCLUSIONS

Older adults prescribed antidepressants in the absence of MDD did not report similar distress levels compared with their counterparts with MDD. Given the continued emphasis on screening for depression in primary care, it is important to consider the potential for overtreatment.

High Prevalence of Malnutrition among Elderly Veterans in Home Based Primary Care

INTRODUCTION

Elderly Veterans enrolled in VA Home Based Primary Care (HBPC) programs suffer from many diseases including malnutrition. Nutrition screening tools exist in the VA system but they are inconsistently utilized across ambulatory care programs and are neither research validated nor comparable with non-VA populations. The Mini-Nutritional Assessment short-form (MNA-SF) has been validated in international studies in a variety of settings. The primary aim of this study was to find the prevalence of malnutrition among Veterans enrolled in HBPC programs. The secondary objective was to determine the feasibility of adopting a validated nutrition screening tool (Mini-Nutritional Assessment short-form (MNA-SF)).

METHODS

2252 veterans age 65 and older from 18 HBPC programs from across the country participated in the study. The study period was between April and September 2012. WinPepi (version 11.25) was used for descriptive analysis.

RESULTS

We found that the prevalence of malnutrition was 15% (344/2252) and the prevalence of at risk for malnutrition was 40.3% (909/2252).

DISCUSSION

The MNA-SF is an efficient nutrition screening tool and it can be successfully used for the elderly veterans. The prevalence of malnutrition among veterans was high compared to the community dwelling U.S. civilian elderly population. By preventing and treating malnutrition, health care systems should be able to reduce overall health care costs.

Age as a predictive factor of mental health service use among adults with depression and/or anxiety disorder receiving care through the Veterans Health Administration

OBJECTIVE

This study compared mental health service utilization by treatment modality and determined predictive factors of use among younger-adult (18-35 years), middle-aged adult (36-64 years), and older-adult veterans (65+ years) with a newly recognized diagnosis of depression and/or anxiety disorder.

METHODS

This retrospective study used data from the Veterans Health Administration National Patient Care Database outpatient and inpatient treatment files during the 2010 fiscal year (N = 583,692).

RESULTS

Younger adults were the most likely to use mental health services, followed by middle-aged adults and then older adults. Age was found to be one of the greatest predictors of utilization of mental health services, with odds of use being threefold among younger adults compared with older adults.

CONCLUSIONS

Continued efforts are needed to improve the awareness of, access to, and receipt of mental health services in veterans, particularly older adults, with depression and anxiety disorders. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.

Mental Health Treatment for Older Veterans Newly Diagnosed with PTSD: A National Investigation

OBJECTIVE

Older veterans are the largest cohort served by the U.S. Department of Veterans Affairs (VA). The aim of this study was to examine mental health service utilization among older veterans recently diagnosed with posttraumatic stress disorder (PTSD), with an interest in sociodemographic and clinical characteristics related to receipt and type of mental health treatment.

DESIGN

VA National administrative data set and pharmacy records.

SETTING

VA Healthcare System.

PARTICIPANTS

The sample comprised 96,249 veterans aged 50+ years who received a new diagnosis of PTSD between fiscal years 2008-2011.

MEASUREMENTS

Demographic/clinical characteristics and treatment variables (receipt of mental health treatment; number of days before first appointment; receipt of psychotherapy, medication, or combination treatment; type of medication; number of psychotherapy visits) were assessed and relations were examined using logistic, negative binomial, and Cox regressions.

RESULTS

The majority of older veterans with newly diagnosed PTSD received at least one follow-up mental health visit. Increasing age was associated with decreased odds of receipt of any type of mental health treatment, and psychiatric comorbidities and greater number of medical appointments were associated with increased odds of treatment. Among veterans who received treatment, increased age was associated with decreased odds of receiving both psychotherapy and pharmacotherapy, decreased number of psychotherapy visits, and increased waiting times.

CONCLUSION

Among older veterans recently diagnosed with PTSD in the VA healthcare system, older individuals, particularly those over 80 years old, are at risk of not receiving timely and appropriate mental health treatment, indicating targeted outreach to this population could be helpful in improving care.

Deconstructing Chronic Low Back Pain in the Older Adult: Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part IV: Depression

OBJECTIVE

To present the fourth in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of twelve important contributors to pain and disability in older adults with CLBP. This article focuses on depression.

METHODS

The evaluation and treatment algorithm, a table articulating the rationale for the individual algorithm components, and stepped-care drug recommendations were developed using a modified Delphi approach. The Principal Investigator, a three-member content expert panel, and a nine-member primary care panel were involved in the iterative development of these materials. The algorithm was developed keeping in mind medications and other resources available within Veterans Health Administration (VHA) facilities. As panelists were not exclusive to the VHA, the materials can be applied in both VHA and civilian settings. The illustrative clinical case was taken from one of the contributor's clinical practice.

RESULTS

We present an algorithm and supportive materials to help guide the care of older adults with depression, an important contributor to CLBP. The case illustrates an example of a complex clinical presentation in which depression was an important contributor to symptoms and disability in an older adult with CLBP.

CONCLUSIONS

Depression is common and should be evaluated routinely in the older adult with CLBP so that appropriately targeted treatments can be planned and implemented.

Perceptions of Determinants of Successful Aging Among Older U.S. Veterans: Results from the National Health and Resilience in Veterans Study

OBJECTIVE

To conduct a qualitative study of older American veterans' subjective perceptions of factors that contribute to successful physical, emotional, and cognitive aging.

METHODS

A nationally representative sample of 2,025 veterans aged 60 or older (range: 60-96; 96.9% male, 39.4% combat veterans) participated in the National Health and Resilience in Veterans Study. Using qualitative analysis software, the authors coded responses to three open-ended questions, inductively developed categories, aggregated similar categories into factors, and grouped factors into broader themes.

RESULTS

A total of 53, 56, and 61 categories of responses was identified in response to questions about successful physical, cognitive, and emotional aging, respectively, with 10 aggregate factors linking these categories. The most prominent theme overall was "What you do," which received 2,295, 2,210, and 1,247 mentions for each of these domains of successful aging, with health behaviors the most common factor for both successful physical and cognitive aging and social engagement the most common for successful emotional aging. The theme "Who you are" was the second-most common factor (discerned from 376, 247, and 943 total mentions, respectively), with the factors that comprise this theme-personality and explanatory style, moral compass, and emotional dispositions-more commonly endorsed for successful emotional aging. External factors such as healthcare were least commonly endorsed across all domains.

CONCLUSION

Older U.S. Veterans emphasize health behaviors, social engagement, and dispositional characteristics as key determinants of successful aging. Prevention and treatment initiatives that target these potentially modifiable factors may help promote successful aging in this growing segment of the population.

Mental health utilization among older Veterans with coexisting depression and dementia

OBJECTIVE

We compared mental health service utilization among older, depressed Veterans (60 years or older) with and without coexisting dementia.

METHODS

This retrospective study examined data from the 2010 Veterans Health Administration National Patient Care Database outpatient treatment files of Veterans with a newly recognized diagnosis of depression (N = 177,710).

RESULTS

Approximately 48.84% with coexisting depression and dementia and 32.00% with depression only received mental health services within 12 months of diagnosis (p < .0001). Veterans with coexisting depression and dementia were more likely to receive medication-management appointments (33.40% vs 20.62%), individual therapy (13.39% vs 10.91%), and family therapy (3.77% vs 1.19%) than depressed Veterans without dementia.

CONCLUSION

In general, Veterans with recently diagnosed depression are significantly underusing Veterans Affairs mental health treatment services. Those Veterans who have comorbid dementia are more likely than those with just depression to be enrolled in mental health treatments. Systemic improvements are needed to increase use of mental health services for older, depressed Veterans.

Hospital outcomes in major depression among older adults: differences by alcohol comorbidity

OBJECTIVE

The prevalence of depression in older adults has been increasing over the last 20 years and is associated with economic costs in the form of treatment utilization and caregiving, including inpatient hospitalization. Comorbid alcohol diagnoses may serve as a complicating factor in inpatient admissions and may lead to overutilization of care and greater economic cost. This study sought to isolate the comorbidity effect of alcohol among older adult hospital admissions for depression.

METHODS

We analyzed a subsample (N = 8,480) of older adults (65+) from the 2010 Nationwide Inpatient Sample who were hospitalized with primary depression diagnoses, 7,741 of whom had depression only and 739 of whom also had a comorbid alcohol disorder. To address potential selection bias based on drinking and health status, propensity score matching was used to compare length of stay, total costs, and disposition between the two groups.

RESULTS

Bivariate analyses showed that older persons with depression and alcohol comorbidities were more often male (59.9% versus 34.0%, p <.001) and younger (70.9 versus 75.9 years, p <.001) than those with depression only. In terms of medical comorbidities, those with depression and alcohol disorders experienced more medical issues related to substance use (e.g., drug use diagnoses, liver disease, and suicidality; all p <.001), while those with depression only experienced more general medical problems (e.g., diabetes, renal failure, hypothyroid, and dementia; all p <.001). Propensity score matched models found that alcohol comorbidity was associated with shorter lengths of stay (on average 1.08 days, p <.02) and lower likelihood of post-hospitalization placement in a nursing home or other care facility (OR = 0.64, p <.001). No significant differences were found in overall costs or likelihood of discharge to a psychiatric hospital.

CONCLUSIONS

In older adults, depression with alcohol comorbidity does not lead to increased costs or higher levels of care after discharge. Comorbidity may lead to inpatient hospitalization at lower levels of severity, and depression with alcohol comorbidity may be qualitatively different than non-comorbid depression. Additionally, increased costs and negative outcomes in this population may occur at other levels of care such as outpatient services or emergency department visits.

Associations between vascular risk and mood in euthymic older adults: preliminary findings

OBJECTIVES

Vascular risk has been associated with late-life depression, but it is less certain whether it is also associated with the endorsement of depressive symptoms among euthymic older adults. We explore whether vascular risk is associated with endorsement of depressive symptoms among euthymic older adults and examine associations with cognitive function.

METHODS

Fifty-seven adults (50-89 years), were assessed for: 1) vascular risk (Framingham Stroke Risk Profile, FSRP); 2) depressive mood (Center for Epidemiologic Studies Depression, CESD self-rating questionnaire; Hamilton Depression Rating Scale, HDRS clinical interview); and 3) cognitive domains, (Learning and Memory, L-M; Attention and Information Processing, AIP; Executive Function, EF; Semantic Language, SL).

RESULTS

Significant correlations were observed between FSRP and both depression scales, independent of age. No significant correlations were observed between HDRS and any cognitive domain; in contrast, CESD correlated significantly with L-M, AIP and EF but not SL. FSRP correlated significantly with L-M and EF measures only. Regression analyses revealed that 11.5% of the variance in HDRS scores was explained by FSRP, whereas CESD scores were explained by EF (20.8% of variance).

CONCLUSIONS

Vascular risk was associated with endorsement of depressive symptoms in euthymic older adults. However, the patterns of associations with the two depression scales are distinct and may reflect both differences in administration and item characteristics. A limitation of this study was the exclusion of individuals with subclinical depression, leading to a restricted range on depression scales; future studies should include a full population sample to more fully explore low mood in late-life.

Psychiatric disorders and pain treatment in community nursing homes

OBJECTIVE

Effective pain assessment and pain treatment are key goals in community nursing homes, but residents' psychiatric disorders may interfere with attaining these goals. This study addressed whether (1) pain assessment and treatment obtained by nursing home residents with psychiatric disorders differs from that obtained by residents without psychiatric disorders; (2) this difference is found consistently across the four types of psychiatric disorder most prevalent in nursing homes (dementia, depression, serious mental illness, and substance use disorder); and (3) male gender, non-white, and longer length of stay add to psychiatric disorders to elevate risk of potentially adverse pain ratings and pain treatments.

METHODS

In this cross-sectional study, we examined relationships among National Nursing Home Survey 2004 residents' demographic, diagnostic, pain, and pain treatment characteristics.

RESULTS

Compared with residents without psychiatric disorders, those with psychiatric disorders were less likely to be rated as having pain in the last 7 days and had lower and more "missing" or "don't know" pain severity ratings. They also were less likely to obtain opioids and more likely to be given only nonopioid pain medications, even after statistically adjusting for demographic factors, physical functioning, and pain severity. These effects generally held across all four types of psychiatric disorders most prevalent in nursing homes and were compounded by male, non-white, and longer-stay status.

CONCLUSION

Psychiatric disorders besides dementia may impact pain assessment and treatment in nursing homes. Nursing home residents with psychiatric disorders, especially male, non-white, and longer-stay residents, should be targeted for improved pain care.

Racial and ethnic differences in receipt of antidepressants and psychotherapy by veterans with chronic depression

OBJECTIVE

This study characterized racial-ethnic differences in treatment of veterans with chronic depression by examining antidepressant and psychotherapy use among non-Hispanic black, non-Hispanic white, Hispanic, Asian, and American Indian-Alaska Native (AI/AN) veterans.

METHODS

Logistic regression models were estimated with data from the U.S. Department of Veterans Affairs (VA) medical records for a sample of 62,095 chronically depressed patients. Data (2009-2010) were from the VA External Peer Review Program. Three primary outcome measures were used: receipt of adequate antidepressant therapy (≥80% medications on hand), receipt of adequate psychotherapy (at least six sessions in six months), and receipt of guideline-concordant treatment (either of these treatments).

RESULTS

Compared with whites, nearly all minority groups had lower odds of adequate antidepressant use and guideline-concordant care in unadjusted and adjusted models (antidepressant adjusted odds ratio [AOR] range=.53-.82, p<.05; guideline-concordant AOR range=.59-.83, p<.05). Although receipt of adequate psychotherapy was more common among veterans from minority groups in unadjusted analyses, differences between Hispanic, AI/AN, and white veterans were no longer significant after covariate adjustment. After adjustment for distance to the VA facility, the difference between black and white veterans was no longer significant.

CONCLUSIONS

A better understanding of how patient preferences and provider and system factors interact to generate differences in depression care is needed to improve care for patients from racial-ethnic minority groups. It will become increasingly important to differentiate between health service use patterns that stem from genuine differences in patient preferences and those that signify inequitable quality of depression care.

Associations among indicators of depression in Medicaid-eligible community-dwelling older adults

PURPOSE

The purpose of this research was to examine associations among 2 separate Minimum Data Set-Home Care (MDS-HC) depression measures (the Depression Rating Scale [DRS] and medical diagnosis of depression) with billed antidepressant medications in Medicaid paid claim files.

DESIGN AND METHODS

The sample for this cross-sectional research included 3,041 Medicaid-eligible older adult participants in a Home and Community Based Waiver Program and used data from the MDS-HC, Version 1 and Medicaid Paid Claim Files. Sensitivity and specificity analyses, receiver operating characteristic (ROC) curve analysis, and t tests were utilized.

RESULTS

DRS scoring indicated that 15.4% of participants had behaviors indicative of depression, whereas 42% had a medical diagnosis of depression noted in the MDS-HC. Of those with a medical diagnosis of depression, 51% had a prescribed antidepressant medication. ROC analysis suggested that the DRS was a poor distinguisher of participants with and without a medical diagnosis of depression or prescribed antidepressant medications.

IMPLICATIONS

Approximately half of Medicaid-eligible older adults medically diagnosed with depression were treated pharmacologically. Longitudinal research is recommended to assess responsiveness of the DRS over time to pharmacological and psychotherapeutic interventions for depression.

After the drinking stops: completed suicide in individuals with remitted alcohol use disorders

A substantial minority of suicide victims have remitted alcohol use disorders. The authors hypothesized that psychiatric disorders are likely to be present in this group to create the necessary conditions for suicide. They compared suicide victims with active alcohol use disorders and those with remitted alcohol use disorders. Using data on a community sample of suicide victims (N=141), it was determined that 39% (N=55) had a history of alcohol misuse. These subjects were categorized by alcohol use disorder status (remitted versus active) and by age (<50, > or =50), creating four cells: younger remitted (N=8), older remitted (N=9), younger active (N=22), and older active (N=16) alcohol misusers. Results comparing proportions of DSM-III-R Axis I disorders in the four groups indicated that suicide victims with remitted alcohol use disorders were predominantly younger victims with psychotic disorders or older victims with major depression. These findings have implications for identifying those at risk for suicide even after the cessation of alcohol misuse. Case examples of suicide victims with remitted alcohol use disorders-a younger woman victim with a psychotic disorder and an older man with major depression-are presented.

The effect of alcohol abuse on the health status of older adults seen in the emergency department

OBJECTIVE

To examine the effect of alcohol abuse on the subsequent health status of elderly patients seen in an emergency department (ED).

PATIENTS AND METHODS

A sample of 966 patients aged 65 or older who presented to one urban academic ED between the hours of 8 A.M. and 12 midnight was followed for 1 year. A personal interview was administered during the ED visit. Current problem drinkers had a score of 1 or greater on the CAGE questionnaire at ED presentation and drank within the prior 6 months; former problem drinkers had a score of 1 or greater on the CAGE questionnaire at ED presentation and a last drink more than 6 months previously. We used 13 items from the Medical Outcomes Study short form adapted to the ED setting and 6 items from the Index of Activities of Daily Living (ADL) to measure health status.

RESULTS

In multivariate models for repeated-measures controlling for potential confounding factors, current problem drinkers had worse overall health (parameter estimate beta -3.6; 95% CI -7.1 to -0.04), and former problem drinkers had worse mental health (beta -3.6; CI -6.9 to -0.24) on follow-up. We could find no effect of problem drinking on physical health or social function.

CONCLUSIONS

Current problem drinking is associated with worse self-perceived health among elderly patients in the year following presentation to an ED. The magnitude of decline in health perception may approximate the effect of having back pain, sciatica, or other musculoskeletal complaints. Elderly former problem drinkers suffer from more severe mental health problems over that same period.