Depression interventions among racial and ethnic minority older adults: a systematic review across 20 years

"How's your mood": Recorded physician mental health conversations with Chinese and Latino patients in routine primary care visits

OBJECTIVE

Patient-physician communication patterns may influence discussions around depressive symptoms and contribute to engagement in depression care among racial/ethnic minority adults. We examined patient-physician communication about depressive symptoms during routine primary care visits with Chinese and Latino patients with and without language barriers.

METHODS

We examined 17 audio-recorded conversations between primary care physicians and Chinese (N = 7) and Latino (N = 10) patients who discussed mental health during their visit and reported depressive symptoms on a post-visit survey. Conversations (in English, Cantonese, Mandarin, Hoisan-wa, Spanish) were transcribed and translated by bilingual/bicultural research assistants and analyzed using inductive and deductive thematic and discourse analysis.

RESULTS

Patients initiated mental health discussion in eleven visits. Physicians demonstrated care in word choice and sometimes avoided openly mentioning depression; this could contribute to miscommunication around symptoms and treatment goals. Interpreters had difficulty finding single words to convey terms used by either patients or physicians.

CONCLUSION

Patients and doctors appeared willing to discuss mental health; however, variability in terminology presented challenges in mental health discussions in this culturally and linguistically diverse sample.

PRACTICE IMPLICATIONS

Further understanding patient preferred terminology about mental health symptoms and interpreter training in these terms could improve patient-physician communication about depressive symptoms and treatment preferences.

Enhancing supports to children of incarcerated parents: Introducing trauma informed training to church mentors

A child who has a parent incarcerated is likely to experience a number of life challenges including school failure, poverty, substance abuse, and justice system involvement. The negative outcomes associated with having a parent incarcerated disproportionately expose children to adverse childhood events (ACE's) which have been associated with higher morbidity and mortality. However, engagement with caring adults who can provide both practical and spiritual mentorship can increase a child's resilience and buffer the impact of these negative outcomes. Church-based mentors have the capacity to provide support to this population when adequately trained in trauma-informed responses. This study describes Camp Agape California (CAC), a church-based mentoring program for children with an incarcerated parent. Specifically, this study describes the development and implementation of a trauma focused mentorship training purposed to equip church members to better meet the needs of this vulnerable population. Seventy-six volunteer mentors from various churches participated in the training and completed the post-training survey. Results suggest that the trauma informed training was effective at increasing knowledge and self-efficacy and was identified as being relevant to the mentor role. Implications for the utility of church-based mentorship for vulnerable populations are explored.

Older immigrant Latino gay men and childhood sexual abuse: Findings from the Palabras Fuertes project

Childhood Sexual Abuse (CSA) and maltreatment have long-term negative impacts on survivors, including older adults. Yet, limited qualitative examinations of how these experiences impact the lives of older adults exists and even fewer among older Latino gay men. We drew data from life-history narratives the first author conducted with five Spanish speaking older Latino gay men in New York City. Our analyses were guided by an Ecological Model, a Suffering lens, and our clinical social work experience with older adults, sexual minorities and people of color. All participants reported sexual experiences prior to the age of 15 and possible emotional and physical maltreatment. Yet, not all participants perceived these experiences as abuse. Our findings indicate how cultural, linguistic and contextual factors may affect disclosure and coping. Despite the fact that CSA and maltreatment occurred decades ago, these early experiences affected long-term psychosocial functioning. Our findings support a need for future research and clinical practice that considers the subjective perceptions of childhood sexual experiences and maltreatment and how these relate to psychosocial functioning in Latino gay men during older adulthood.

Equitability of Depression Screening After Implementation of General Adult Screening in Primary Care

IMPORTANCE

Depression is a debilitating and costly medical condition that is often undertreated. Men, racial and ethnic minority individuals, older adults, and those with language barriers are at increased risk for undertreatment of depression. Disparities in screening may contribute to undertreatment.

OBJECTIVE

To examine depression screening rates among populations at risk for undertreatment of depression during and after rollout of general screening.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study from September 1, 2017, to December 31, 2019, of electronic health record data from 52 944 adult patients at 6 University of California, San Francisco, primary care facilities assessed depression screening rates after implementation of a general screening policy. Patients were excluded if they had a baseline diagnosis of depression, bipolar disorder, schizophrenia, schizoaffective disorder, or dementia.

EXPOSURES

Screening year, including rollout (September 1, 2017, to December 31, 2017) and each subsequent calendar year (January 1 to December 31, 2018, and January 1 to December 31, 2019).

MAIN OUTCOMES AND MEASURES

Rates of depression screening performed by medical assistants using the Patient Health Questionnaire-2. Data collected included age, sex, race and ethnicity, and language preference (English vs non-English); to compare English and non-English language preference groups and also assess depression screening by race and ethnicity within the English-speaking group, a single language-race-ethnicity variable with non-English language preference and English language preference categories was created. In multivariable analyses, the likelihood of being screened was evaluated using annual logistic regression models for 2018 and 2019, examining sex, age, language-race-ethnicity, and comorbidities, with adjustment for primary care site.

RESULTS

There were 52 944 unique, eligible patients with 1 or more visits in one of the 6 primary care practices during the entire study period (59% female; mean [SD] age, 48.9 [17.6] years; 178 [0.3%] American Indian/Alaska Native, 13 241 [25.0%] English-speaking Asian, 3588 [6.8%] English-speaking Black/African American, 4744 [9.0%] English-speaking Latino/Latina/Latinx, 760 [1.4%] Pacific Islander, 22 689 [42.9%] English-speaking White, 4857 [9.0%] English-speaking other [including individuals who indicated race and ethnicity as other and individuals for whom race and ethnicity data were missing or unknown], and 2887 [5.5%] with language barriers [non-English language preference]). Depression screening increased from 40.5% at rollout (2017) to 88.8% (2019). In 2018, the likelihood of being screened decreased with increasing age (adusted odds ratio [aOR], 0.89 [95% CI, 0.82-0.98] for ages 45-54 and aOR, 0.75 [95% CI, 0.65-0.85] for ages 75 and older compared with ages 18-30); and, except for Spanish-speaking patients, patients with limited English proficiency were less likely to be screened for depression than English-speaking White patients (Chinese language preference: aOR, 0.59 [95% CI, 0.51-0.67]; other non-English language preference: aOR, 0.55 [95% CI, 0.47-0.64]). By 2019, depression screening had increased dramatically for all at-risk groups, and for most, disparities had disappeared; the odds of screening were only still significantly lower for men compared with women (aOR, 0.87 [95% CI, 0.81 to 0.93]).

CONCLUSIONS AND RELEVANCE

In this cohort study in a large academic health system, full implementation of depression screening was associated with a substantial increase in screening rates among groups at risk for undertreatment of depression. In addition, depression screening disparities narrowed over time for most groups, suggesting that routine depression screening in primary care may reduce screening disparities and improve recognition and appropriate treatment of depression for all patients.

Exploring the Psychosocial Impact of Living With HIV on Minority Older Women

BACKGROUND: Among older adults, minority older women will account for 60% of the new HIV diagnoses. The psychosocial impact of living with HIV among this vulnerable population narrated by their own voices has been understudied. AIMS: The purpose of this study was to explore the psychosocial impact of living with HIV on minority older women. METHODS: In-depth interviews were conducted with 28 minority older women living with HIV at an Ambulatory Care Center HIV Clinic in South Florida. All interviews were audio-recorded and transcribed verbatim. Conventional content analysis was used to identify and define the major themes that emerged from the interviews. Questions included those concerning description of life after the HIV diagnosis, most challenging aspects of life after the diagnosis, and daily activities since the diagnosis. RESULTS: The analysis of the interview data led to five main themes: (I) Social Impact of HIV, (II) Threats to Health and Well-Being, (III) HIV as a Death Sentence, (IV) Spirituality, and (V) HIV Treatment Adherence. In their narratives, women described a myriad of psychosocial issues such as depressed mood, isolation, economic challenges, stigma, anhedonia of interest, fear of death, among others. CONCLUSIONS: There is a compelling empirical need for rapid implementation of a culturally tailored, holistic, low-cost, multistrategy intervention to early screen and reduce the psychosocial impact of HIV among minority older women.

Primary Care Physician Recognition and Documentation of Depressive Symptoms Among Chinese and Latinx Patients During Routine Visits: A Cross-Sectional Study

Purpose: Asian and Latinx individuals have a high burden of untreated depression. Under-recognition of depressive symptoms may contribute to existing disparities in depression treatment. The objective of this cross-sectional study was to determine whether physicians recognize and treat depressive symptoms for Chinese and Latinx patients during routine primary care visits. Methods: We analyzed data from 1171 Chinese and Latinx patients who were interviewed within 1 week after a primary care visit in a large academic practice, which had not yet implemented universal depression screening. We included participants with depressive symptoms (defined as a Patient Health Questionaire-2 score ≥3) and no prior history of depression (N=118). We investigated whether patients perceived having a mental health need in the prior year and conducted chart reviews to assess provider recognition of depressive symptoms, defined as documentation of symptoms, antidepressant initiation, or mental health referral within 30 days of the visit. We further examined differences by race/ethnicity and language preference. Results: Among the 118 patients with depressive symptoms and no prior depression diagnosis (mean age 68), 71 (61%) reported a mental health need in the prior 12 months; however, providers recognized depressive symptoms in only 8/118 patients (7%). The number of patients with recognized symptoms was small across race/ethnicity and language preference groups and we found no significant differences. Conclusion: Physicians recognized and documented depressive symptoms for 1 in 10 Chinese and Latinx patients during routine primary care visits. Targeted efforts are needed to address under-recognition of symptoms and improve depression care for these populations.

The Association Between Social Support and Psychological Distress in Latina Mothers Living in Miami-Dade County, Florida

BACKGROUND

This study analysed the relationship between social support and psychological distress in Latina women in Miami-Dade County. Acculturation was examined as a modifying factor.

METHODS

A 2005 data set from interviews of 155 Latina mothers in Miami-Dade County, from mother-daughter dyads, was analysed. Social support was measured using the Interpersonal Support Evaluation List (ISEL) score. Psychological distress was based on self-reporting symptoms of depression, anxiety, or suicidality. Acculturation was based on English proficiency and length of U.S. residency.

RESULTS

Compared to those with high social support, women with low social support had greater odds of reporting psychological distress (odds ratio = 7.8 [95% CI 2.70-22.10]). Acculturation did not modify the association (p=0.74).

CONCLUSIONS

Social support was inversely associated with psychological distress among Latina women. Acculturation was not an effect modifier, likely due to inadequate power. The study has clinical implications for mental illness prevention in this population.

Mental Health of Asian American Older Adults: Contemporary Issues and Future Directions

Given the increased attention to older Asian Americans due to their increasing numbers in the United States, this article aims to provide a collective appraisal of older Asian American mental health issues by reviewing trends in older Asian American mental health research over the past 2 decades. This review article provides an overview of the current state of mental health and care research on older Asian Americans and vital factors associated with older Asian American mental health and care. We also identify gaps in current research on Asian American mental health issues and propose 5 potential areas for future research into which gerontologists need to put more effort during the next decade. Ways to reduce disparities in mental health and improve the quality of mental health of older Asian Americans are also discussed.

Internet-delivered cognitive behavioral therapies for late-life depressive symptoms: a systematic review and meta-analysis

Background: This study aimed to review and synthesize evidence related to the effectiveness of internet-based cognitive behavioral therapy (iCBT) for reducing depressive symptoms in older adults.Method: The authors conducted a systematic review of intervention studies testing iCBT for symptoms of depression in older adults. An initial search of PubMed, PsychINFO, and Web of Science was undertaken, followed by a manual search of reference lists of the relevant articles. The Cochrane Risk of Bias Tool was used to appraise study quality. The mean effect size for included studies was estimated in a random effects model. Meta-regression was used to examine potential moderators of effect sizes.Results: Nine studies met the inclusion criteria, including 1272 participants averaging 66 years of age. The study design included randomized controlled trials (k = 3), controlled trials without randomization (k = 2), uncontrolled trials (k = 2), and naturalistic evaluation (k = 2). Seven studies tested iCBT with some level of therapist involvement and 2 examined self-guided iCBT. Six studies tested interventions specifically adapted for older adults. The mean within-group effect size was 1.27 (95% CI = 1.09, 1.45) and the mean between-group effect size was 1.18 (95% CI = 0.63, 1.73). Participants' age was negatively associated with within-group effect sizes (b = -0.06, p = .016).Conclusions: iCBT is a promising approach for reducing depressive symptoms among older adults with mild to moderate depressive symptoms. However, studies involving older adults in iCBT trials were limited, had considerable heterogeneity, and were of low quality, calling for more studies with rigorous designs to produce a best-practice guideline.

Depression Among Older Adults in the United States by Disaggregated Race and Ethnicity

BACKGROUND AND OBJECTIVES

As the population becomes increasingly diverse, it is important to understand the prevalence of depression across a racially and ethnically diverse older population. The purpose of this study was to compare rates of depression by age and disaggregated racial and ethnic groups to inform practitioners and target resource allocation to high risk groups.

RESEARCH DESIGN AND METHODS

Data were from the Centers for Medicare and Medicaid Services Health Outcomes Survey, Cohorts 15 and 16, a national and annual survey of a racially diverse group of adults aged 65 and older who participate in Medicare Advantage plans (N = 175,956). Depression was operationalized by the Patient Health Questionnaire-2 (PHQ-2); we estimated a logistic regression model and adjusted standard errors to account for 403 Medicare Advantage Organizations.

RESULTS

Overall, 10.2% of the sample (n = 17,957) reported a PHQ-2 score of 3 or higher, indicative of a positive screen for depression. After adjusting for covariates, odds of screening positively for depression were higher among participants self-reporting as Mexican (odds ratio [OR] = 1.19), Puerto Rican (OR = 1.46), Cuban (OR = 1.57), another Hispanic/Latino (OR = 1.29), and multiple Hispanic/Latino (OR = 1.84) ethnicities, compared with non-Hispanic whites. Odds were also higher among participants reporting that their race was black/African American (OR = 1.20), Asian Indian (OR = 1.67), Filipino (OR = 1.30), Native Hawaiian/Pacific Islander (OR = 1.82), or two or more races (OR = 1.50), compared with non-Hispanic whites.

DISCUSSION AND IMPLICATIONS

Prevalence varied greatly across segments of the population, suggesting that certain racial/ethnic groups are at higher risk than others. These disparities should inform distribution of health care resources; efforts to educate and ameliorate depression should be culturally targeted.

The Role of County Characteristics in Mental Health Service Use by Older African Americans

OBJECTIVE

Older African Americans may underutilize mental health services, although they experience mental health problems at rates comparable with those of whites. Untreated mental disorders contribute to increased risk of morbidity and mortality and decreased quality of life, and therefore, understanding the factors that influence racial disparities in service use is critical. This study examined whether county characteristics were associated with mental health service use by older African Americans after the analyses adjusted for individual characteristics.

METHODS

This study combined individual-level data from the 2008-2012 Medical Expenditure Panel Survey with county-level data for 2008-2012 from the 2013-2014 Area Health Resources Files and county-level data from the 2008-2012 Chronic Conditions Report of the Chronic Conditions Data Warehouse for 1,567 community-dwelling African Americans ages 60 and older. Multilevel logistic regressions were used to examine the role of county characteristics on mental health services use with adjustment for individual-level risk factors.

RESULTS

At the county level, individuals living in a county with a higher proportion of African Americans were less likely to use mental health services. At the individual level, higher income and mental health status were associated with mental health service utilization.

CONCLUSIONS

Among older African Americans, the racial composition of one's county of residence played a role in mental health service use, indicating the need for future research focusing on the relationship between an area's racial composition and mental health service use. Programs may be able to ameliorate racial disparities in mental health care by targeting areas with a higher percentage of African Americans.

Depression Treatment Status of Economically Disadvantaged African American Older Adults

Background: It is known that depression remains largely untreated in underserved communities. Hence, it is desirable to gain more knowledge on the prevalence and correlates of untreated depression among African-American (AA) older adults in economically disadvantaged areas. This knowledge may have the public health benefit of improving detection of AA older adults with depression who are at high risk of not receiving treatment, thereby reducing this health disparity. Objective: To study health and social correlates of untreated depression among AA older adults in economically disadvantaged areas. Methods: Between 2015 and 2018, this cross-sectional survey was conducted in South Los Angeles. Overall, 740 AA older adults who were 55+ years old entered this study. Independent variables were age, gender, living arrangement, insurance type, educational attainment, financial strain, chronic medical conditions, and pain intensity. Untreated depression was the dependent variable. Logistic and polynomial regression models were used to analyze these data. Results: According to the polynomial regression model, factors such as number of chronic medical conditions and pain intensity were higher in individuals with depression, regardless of treatment status. As our binary logistic regression showed, age, education, and number of providers were predictive of receiving treatment for depression. Conclusion: Age, educational attainment, number of providers (as a proxy of access to and use of care) may be useful to detect AA older adults with depression who are at high risk of not receiving treatment. Future research may focus on decomposition of the role of individual-level characteristics and health system-level characteristics that operate as barriers and facilitators to AA older adults receiving treatment for depression.

County Context and Mental Health Service Utilization by Older Hispanics

BACKGROUND AND OBJECTIVES

Although older Hispanics experience high rates of depression, they tend to underuse mental health services. The study examined the association between county characteristics and mental health service use among older Hispanics, controlling for individual characteristics.

RESEARCH DESIGN AND METHODS

The study used the 2008-2012 Medical Expenditure Panel Study and linked county-level data from the 2013-2014 Area Health Resources Files and the 2008-2012 Chronic Conditions Data Warehouse, using the Federal Information Processing Standard county code. The sample includes 1,143 community-dwelling Hispanics ages 60 years or older (Level 1) and 156 counties (Level 2) where the sample resides. The single dichotomous measure of mental health service utilization was based on whether or not the respondent met one or more of three conditions: (1) the respondent received care from a mental health professional, (2) received a service including mental health counseling or psychotherapy, or (3) received a service that was related to the International Classification of Diseases. Multilevel logistic regression analysis was used to examine the role of county context.

RESULTS

The proportion of older adults and the existence of community mental health centers at the county-level were associated with mental health services use among this population. At the individual-level, education and mental health status were also associated with using mental health services.

DISCUSSION AND IMPLICATIONS

The county context plays an important role in understanding mental health services use among older Hispanics, indicating the need for intervention strategies at the county level.

The Imperative for Research to Promote Health Equity in Indigenous Communities

Health disparities exact a devastating toll upon Indigenous people in the USA. However, there has been scant research investment to develop strategies to address these inequities in Indigenous health. We present a case for increased health promotion, prevention, and treatment research with Indigenous populations, providing context to the recent NIH investment in the Intervention Research to Improve Native American Health (IRINAH) network. We discuss the disproportionate costs and consequences of disparities borne by Indigenous groups, the limited evidence base on effective intervention for this population, how population uniqueness often makes transfer of existing intervention models difficult, and additional challenges in creating interventions for Indigenous settings. Given the history of colonial disruption that has included genocide, forced removal from lands, damaging federal, state and local policies and practices, environmental contamination, and most recently, climate change, we conclude research that moves beyond minor transformations of existing majority population focused interventions, but instead truly respects Indigenous wisdom, knowledge, traditions, and aspirations is needed, and that investment in intervention science to address Indigenous health disparities represent a moral imperative.

Taking a Closer Look at Mental Health Treatment Differences: Effectiveness of Mental Health Treatment by Provider Type in Racial and Ethnic Minorities

OBJECTIVES

To estimate racial/ethnic differences in the extent to which mental health treatment is obtained from mental health providers, primary care physicians (PCPs), or both and to examine the effects of provider type on change in mental component scores (MCS) of the SF-12 on different race/ethnic groups.

METHODS

Secondary data analysis of 2008 to 2015 Medical Expenditure Panel Survey (MEPS). Non-institutionalized civilian US population, aged 18 to 64 (N = 62 558). Based on counts of all mental health visits in a calendar year, we identified patients who obtained care from PCPs, mental health provider, PCP and mental health providers and other providers and examined changes in MCS by type of care.

RESULTS

9.9% of Non-Hispanic Whites obtained mental health treatment, compared to 5.0% for Hispanics, 5.3% for Blacks and 5.5% for Other Races (P < .001). Non-Hispanic Blacks and non-Hispanic "Other" were more likely than other groups to obtain care from mental health providers only (P = .017). All obtaining care solely from PCP had better mental health (mean (se)) MCS: 43.2(0.28)) than those obtaining care solely from mental health provider (39.8 (0.48)), which in turn was higher than for those obtaining care from both PC and MH providers (38.5 (0.31), (P < .001).

CONCLUSION

Even when diagnosed with a mental health disorder, Hispanics and Blacks were less likely to seek mental health treatment than Whites, highlighting the continuing disparity. Future research should focus on understanding how and what aspects of integrated care models and other mental health delivery models that reduce disparities and provide greater accessibility.

Disclosing psychiatric diagnosis to close others: a cultural framework based on older Latin@s participating in a depression trial in Los Angeles county

Objectives: The objective of this qualitative study is to explore disclosure of depression diagnosis to close others among older adult Latinas/Latinos (Latin@s) recruited from an urban health care system specializing in low-cost community health services in Los Angeles County. Method: Semi-structured in-depth interviews were conducted with 35 older Latinos who participated in an NIMH-funded randomized depression trial. Results: Psychiatric disclosure is a dynamic, multidimensional, and culturally ladened experience that entails weighing in on interrelated factors. This study presents a cultural framework of depression disclosure that highlights 15 facilitators and barriers which were organized into three intrinsic and relational domains: (a) individual emotional and support needs; (b) personal characteristics of the recipient of the disclosure; and (c) quality of the interpersonal interactions between the patient and recipient. Conclusion: Knowledge of Latin@ older adults' perspectives and experiences with depression disclosure can inform strategies to support older Latin@s facing the dilemma of disclosure.

Variation of Follow-Up Rate After Psychiatric Hospitalization of Medicare Beneficiaries by Hospital Characteristics and Social Determinants of Health

OBJECTIVE

Early follow-up after inpatient psychiatric hospitalization is a key part of the care transition process and has been found to reduce the risk of readmission and emergency department utilization. Our objective was to determine the extent to which hospital performance on measures of 7- and 30-day mental health follow-up after hospitalization for Medicare beneficiaries varies by hospital characteristics and hospital neighborhood socioeconomic characteristics.

METHODS

We linked 2015 hospital-level follow-up rates from the Centers for Medicare and Medicaid Services' Hospital Compare website to hospital characteristics obtained from the American Hospital Association Annual Survey and characteristics of the community within a 5-mile radius of the hospital obtained from the American Community Survey. Our population included 1,275 inpatient psychiatric facilities in 2015 in the United States. State fixed effects multivariate linear regression was used.

RESULTS

Hospital 30-day follow-up rates ranged from 16.00% to 95.00%, with an average of 55.80%. After controlling for hospital- and community-level factors, and applying state-level fixed effects, we found that psychiatric specialty hospitals, public hospitals, and minority-serving hospitals were associated with lower rates of mental health follow-up.

CONCLUSION

Hospitals have considerable opportunity to improve the quality of their transitional care processes and increase the percentage of Medicare patients receiving timely mental health follow-up after discharge. Policymakers should consider strengthening the incentives for hospital performance on these quality measures while working to improve the behavioral health infrastructure of minority communities.

Descriptions of depression and depression treatment in older Hispanic immigrants in a geriatric collaborative care program

OBJECTIVES

To explore experiences with depression and depression treatment among older Hispanic immigrants participating in a collaborative care program of psychotherapy and antidepressant medication.

METHOD

Semi-structured, in-depth interviews were conducted with 14 older Spanish-speaking Hispanic immigrants with major depression who participated in a collaborative care program within a public sector specialty geriatric clinic in Los Angeles, CA.

RESULTS

Findings revealed that participants used various idioms to describe their experiences with depression, and that depression had a strong impact on functioning. Other findings indicated that depression was caused by various psychosocial problems, antidepressants were helpful in reducing depression, and that bilingual psychotherapists provided a welcoming and safe environment to express emotions and find solutions to problems.

CONCLUSION

Results revealed participants' experiences with depression and the impact of participating in a collaborative care intervention for depression. Findings from this project should be used to inform future geriatric interventions for older Hispanic immigrants in the USA.

Computerized Cognitive Training to Improve Mood in Senior Living Settings: Design of a Randomized Controlled Trial

Purpose

This two-arm, randomized controlled trial was designed to evaluate a computerized cognitive speed of processing (SOP) training known as Road Tour in the generally older group of adults residing in assisted living (AL) and related senior housing. Study aims focused on depression-related outcomes that were observed in earlier SOP studies using Road Tour with younger, home-dwelling seniors. Study design and baseline outcomes are discussed.

Participants and methods

A community-based design engaged AL and related senior living settings as partners in research. Selected staff served as on-site research assistants who were trained to recruit, consent, and train a target of 300 participants from AL and independent living (IL) programs to use the intervention and attention-control computerized training. Ten hours of initial computerized training was followed by two booster sessions at 5 and 11 months. Outcome measures included Useful Field of View (UFOV), 9-item Patient Health Questionnaire (PHQ-9), 12-item Centers for Epidemiological Studies Depression scale (CESD-12), 7-item Generalized Anxiety Disorders GAD-7), Brief Pain Inventory (BPI) and SF-36 Health Survey. Assessments occurred before randomization (pre-training), post-training, 26 and 52 weeks.

Results

A total of 351 participants were randomized to the intervention (n=173) and attention-control (n=178) groups. There were no significant differences between groups in demographic characteristics with the exception of education and reported osteoporosis. There were no significant differences in study outcomes between groups at baseline. Participants in AL had significantly lower SOP and self-rated health, and significantly higher depression, anxiety and pain when compared to those in IL programs on the same campus.

Conclusions

Compared to earlier SOP training studies using Road Tour, this sample of senior living participants were older, reported more health conditions and poorer overall health, had lower UFOV scores and greater depressive symptoms at baseline. Moreover, participants in AL had greater health challenges than those in IL.

A Community-Based Collaborative Care Model to Improve Functional Health in Underserved Community-Dwelling Older Adults

OBJECTIVE

Examine the effects of a 6-month health multidimensional intervention on physical function, bone density, and mood in a diverse sample of community-dwelling older adults at risk for frailty and excess disability.

METHOD

A quasi-experimental, pre- post-program design was implemented. Adults aged 55 years and older ( n = 337, 60% African American) participated in the intervention and received assessments at baseline, 6 months, and 12 months.

RESULTS

Physical function was maintained during the intervention for both African American and White elders but declined at 12 months for both groups ( p < .0001). Symptoms of depression improved during the intervention ( M = 0.65 ± 0.07, M = 0.15 ± 0.04, M = 0.68 ± 0.07, p < .001, respectively) but worsened at 12 months ( M = 0.68 ± 0.07, p < .001). Bone density scores remained stable from baseline (distal: -1.62 ± 1.17, proximal: -2.73 ± 1.85) to 12 months (distal: -1.72 ± 1.21, proximal: -3.11 ± 1.85, ps > .05) for both groups.

DISCUSSION

Program findings may serve as a basis for the development of a randomized, controlled study to provide empirical evidence of intervention efficacy. Such findings may help inform the development of community-based programs to identify vulnerable older adults and provide vital preventative care to decrease frailty and excess disability.

Role of depression in diabetes management in an ethnic minority population: a case of Korean Americans with type 2 diabetes

BACKGROUND

Comorbid depression and diabetes mellitus (DM) compound challenges to disease management such as low health literacy, insufficient access to care, and social or linguistic isolation. Korean Americans (KAs), predominantly first-generation immigrants, suffer from a high prevalence of type 2 DM and depression. Limited research on KAs has prevented the development of effective interventions.

OBJECTIVES

To compare the prevalence of depression in KAs with DM and all Americans with/without DM, and to explore correlates of comorbid DM and depression and strategies to address KAs' DM and depression.

METHODS

KAs' data were from a clinical trial of a community-based self-help intervention to improve KAs' DM and mental health outcomes. National Health and Nutrition Examination Survey data sets enabled comparison. Clinical indicators included hemoglobin A1C, lipid panel, and body mass index. Psychobehavioral indicators included self-efficacy for DM management, quality of life, and depression (Patient Health Questionnaire-9 (PHQ-9)).

RESULTS

More KAs with DM had depression (44.2%) than did all Americans with DM (28.7%) or without DM (20.1%). Significantly more KAs with DM had mild (29.3%) or clinical (14.9%) depression than did Americans with DM (mild, 17.2%; clinical, 11.5%) or without (mild, 13.8%; clinical, 6.3%). One of six KAs with DM (16.9%) thought of suicide or self-harm (Americans with/without =5.0%, 2.8%). The self-help intervention reduced the mean PHQ-9 from 5.4 at baseline to 4.1 at 12 months.

LIMITATIONS

External validity might be limited; KAs' data were from one study site.

CONCLUSIONS

The prevalence of depression and DM among KAs warrants the development of efficacious interventions.

TRIAL REGISTRATION NUMBER

NCT01264796.

Correlates of depression in self-neglecting older adults: A cross-sectional study examining the role of alcohol abuse and pain in increasing vulnerability

Self-neglect among older adults results in increased morbidity and mortality rates. Depression is strongly linked to self-neglect and when untreated, severely complicates management of health and functional outcomes. The study aims to identify factors correlated with depression to inform approaches to service recruitment and retention that improve long-term outcomes. The sample included urban community-dwelling older adults (n = 96) 65 years of age and older with Adult Protective Services-substantiated self-neglect. All participants completed a range of validated cognitive, functional, and self-report demographic and clinical measures around health and mental health functioning. A secondary data analysis using multivariable logistic regression revealed that a positive screen for alcohol abuse, low self-rated health, and higher self-reported pain were associated with significantly higher odds of self-reported depression. Further research is needed to understand the temporality between these correlates and depression and to inform prevention and intervention practices for self-neglecting older adults.

Use of Decision Aids with Minority Patients: a Systematic Review

BACKGROUND

One potential approach to reducing health disparities among minorities is through the promotion of shared decision making (SDM). The most commonly studied SDM intervention is the decision aid (DA). While DAs have been extensively studied, we know relatively little about their use in minority populations. We conducted a systematic review to characterize the application and effectiveness of DAs in racial, ethnic, sexual, and gender minorities.

METHODS

We searched PubMed for randomized controlled trials (RCTs) evaluating DAs between 2004 and 2013. We included trials that enrolled adults (> 18 years of age) with > 50 % representation by minority patients. Four reviewers independently assessed 597 initially identified articles, and those with inconclusive results were discussed to consensus. We abstracted decision quality, patient-doctor communication, and clinical treatment decision outcomes. Results were considered significantly modified by the DA if the study reported p < 0.05.

RESULTS

We reviewed 18 RCTs of DA interventions in minority populations. The majority of interventions (78 %) addressed cancer screening. The most common mode of delivery for the DAs was personal counseling (46 %), followed by multi-media (29 %), and print materials (25 %). Most of the trials studied racial (78 %) or ethnic (17 %) minorities with only one trial focused on sexual minorities and none on gender minorities. Ten studies tailored their interventions for their minority populations. Comparing intervention vs. control, decision quality outcomes improved in six out of eight studies and patient-doctor communication improved in six out of seven studies. Of the 15 studies that reported on clinical decisions, eight demonstrated significant changes in decisions with DAs.

DISCUSSION

DAs have been effective in improving patient-doctor communication and decision quality outcomes in minority populations and could help address health disparities. However, the existing literature is almost non-existent for sexual and gender minorities and has not included the full breadth of clinical decisions that affect minority populations.

Directions for Effectiveness Research to Improve Health Services for Late-Life Depression in the United States

Considerable progress has been made in the treatment of late-life depression over the past 20 years, yet considerable gaps in care remain. Gaps in care are particularly pronounced for older men, certain racial and ethnic minority groups, and those with comorbid medical or mental disorders. We reviewed the peer-reviewed literature and conducted interviews with experts in late-life depression to identify promising directions for effectiveness research to address these gaps in care. We searched the PubMed, PsychInfo, and CINHAL databases between January 1, 1998, through August 31, 2013, using terms related to late-life depression and any of the following: epidemiology, services organization, economics of care, underserved groups including health disparities, impact on caregivers, and interventions. The results of this selective review supplemented by more current recommendations from national experts highlight three priority research areas to improve health services for late-life depression: focusing on the unique needs of the patient through patient-centered care and culturally sensitive care, involving caregivers outside the traditional clinical care team, and involving alternate settings of care. We build on these results to offer five recommendations for future effectiveness research that hold considerable potential to advance intervention and health services development for late-life depression.

Delivery Characteristics, Acceptability, and Depression Outcomes of a Home-based Depression Intervention for Older African Americans: The Get Busy Get Better Program

PURPOSE OF THE STUDY

To facilitate replication, we examined delivery characteristics, acceptability, and depression outcomes of a home-based intervention, Get Busy Get Better, Helping Older Adults Beat the Blues (GBGB). GBGB, previously tested in a randomized trial, reduced depressive symptoms and enhanced quality of life in African Americans.

DESIGN AND METHODS

A total of 208 African Americans aged above 55 years with Patient Health Questionnaire (PHQ-9) scores ≥5 on two subsequent screenings were randomized to receive GBGB immediately or 4 months later. GBGB involves up to 10 home sessions consisting of care management, referral/linkage, depression education/symptom recognition, stress reduction, and behavioral activation. Interventionists recorded delivery characteristics (dose, intensity) and perceived acceptability of sessions. Baseline and post-tests were used to characterize participants and examine associations between dose/intensity and depression scores. Participant satisfaction and perceived benefits were examined at 8 months.

RESULTS

Of 208 participants, 181 (87%, mean age = 69.6) had treatment data. Of these, 165 (91.2%) had ≥3 treatment sessions (minimal dose). Participants had on average 8.1 sessions (SD = 2.6) for an average of 65.4min (SD = 18.3) each. Behavioral activation and care management were provided the most (average of six sessions for average duration = 17.9 and 22.2min per session respectively), although all participants received each treatment component. GBGB was perceived as highly acceptable and beneficial by interventionists and participants. More sessions and time in program were associated with greater symptom reduction.

IMPLICATIONS

GBGB treatment components were highly acceptable to participants. Future implementation and sustainability challenges include staffing, training requirements, reimbursement limitations, competing agency programmatic priorities, and generalizability to other groups.

Prevalence and Predictors of Depression in Korean American Elderly: Findings from the Memory and Aging Study of Koreans (MASK)

OBJECTIVES

To estimate the prevalence and identify the predictors of depression among community-dwelling Korean American elderly (KAE).

DESIGN

A cross-sectional descriptive epidemiological survey using a two-step sampling strategy to obtain a representative community sample.

SETTING

The authors recruited study participants at religious, service, and business establishments in the KA community (26 churches, 6 senior centers, 2 medical daycare centers, 1 supermarket).

PARTICIPANTS

Community-dwelling first-generation KAE (N = 1,118; mean age ± SD: 70.5 ± 7.0 years; female: 67.2%).

MEASUREMENTS

Trained bilingual nurses and community health workers interviewed participants face-to-face for demographic information, chronic conditions, and depression using the Korean versions of the Patient Health Questionnaire (PHQ-9K).

RESULTS

30.3% of KAEs were classified as having either mild (PHQ-9K score 5-9; N = 218, 19.5%) or clinical depression (PHQ-9K score ≥10; N = 120, 10.8%), respectively. One of seven KAE (N = 164, 14.7%) endorsed thoughts of death or self-injury, but only 63 (5.7%) reported utilizing mental health services. The authors also identified several predictors of depression, including living arrangement (living alone versus living with family/spouse); having chronic conditions such as diabetes, arthritis, digestive disorders, or chronic bronchitis; years of education; and cognitive impairment.

CONCLUSIONS

The authors' findings reveal a high prevalence of depression among KAE and a low level of mental health service utilization. Because there are urgent needs for culturally and contextually relevant interventions, the authors also discuss the feasibility of community-based interventions to reduce the burden of depression, which should be incorporated into a management system for multiple chronic conditions.

Association of depressive symptomatology with receipt of informal caregiving among older American Indians: the native elder care study

OBJECTIVE

Our study objectives were to identify the primary sources of informal caregiving and to examine the association of depressive symptomatology with receipt of informal caregiving among a sample of community-dwelling older American Indians.

DESIGN

We conducted a cross-sectional study of older American Indians.

PARTICIPANTS

Community-dwelling adults aged 55 years and older who are members of a federally recognized American Indian tribe in the Southeast United States.

MEASUREMENTS

We collected information on the participant's primary caregiver, number of informal care hours received in the past week, depressive symptomatology, demographic characteristics, physical health status, and assistance need.

RESULTS

Daughters, spouses, and sons were the most common informal primary caregivers with distinct differences by sex of those receiving care. Compared with participants with lower levels, those with a high level of depressive symptomatology received substantially greater hours of informal care (33.4 versus 11.5 hours per week).

CONCLUSION

Older American Indians with higher levels of depressive symptomatology received more informal caregiving than those with lower depressive symptomatology. The burden of caregiving of older adults is primarily shouldered by spouses and children with those who care for older adults with depressive symptomatology likely experiencing an even greater burden of care.

Factors mediating the effects of a depression intervention on functional disability in older African Americans

OBJECTIVES

To determine factors mediating the effects of a depression intervention for older African Americans on functional disability and, secondarily, whether functional improvements mediate intervention effects on depressive symptoms.

DESIGN

Structural equation modeling to examine mediators in a secondary analysis of a randomized trial with 4-month follow-up.

SETTING

Philadelphia region.

PARTICIPANTS

Community-dwelling African Americans (≥55) with depressive symptoms living in an urban area (N = 208).

INTERVENTION

Up to 10 one-hour sessions over 4 months conducted by licensed social workers who provided care management, referrals and linkages, stress reduction techniques, depression knowledge and symptom recognition, and behavioral activation techniques.

MEASUREMENTS

Main outcome was self-reported functional difficulty level for 18 basic activities. Mediators included depression severity (Patient Health Questionnaire), depression knowledge and symptom recognition, behavioral activation, and anxiety.

RESULTS

At 4 months, the intervention had positive effects on functional difficulty and all mediators (P < .001). Separate structural equation models indicated that two factors (reduced depressive symptoms (23.5% mediated) and improved depression knowledge and symptom recognition (52.9% mediated)) significantly mediated the intervention's effect on functional disability. Enhancing behavioral activation and decreasing anxiety were not found to mediate improvements in functional disability. The two significant mediators jointly explained 62.5% of the intervention's total effect on functional disability. Functional improvement was not found to mediate the intervention's effect on depressive symptoms.

CONCLUSION

This multicomponent depression intervention for African Americans has an effect on functional disability that is driven primarily by enhancing symptom recognition and decreasing depressive symptoms. Reduction of functional difficulties did not account for improvements in depressive symptoms. Nonpharmacological treatments for depressive symptoms that enhance symptom recognition in older African Americans can also reduce their functional difficulties with daily living activities.

Mediators of the impact of a home-based intervention (beat the blues) on depressive symptoms among older African Americans

Older African Americans (N = 208) with depressive symptoms were randomly assigned to a home-based nonpharmacologic intervention (Beat the Blues, or BTB) or wait-list control group. BTB was delivered by licensed social workers and involved up to 10 home visits focused on care management, referral and linkage, depression knowledge and efficacy in symptom recognition, instruction in stress reduction techniques, and behavioral activation through identification of personal goals and action plans for achieving them. Structured interviews by assessors masked to study assignment were used to assess changes in depressive symptoms (main trial endpoint), behavioral activation, depression knowledge, formal care service utilization, and anxiety (mediators) at baseline and 4 months. At 4 months, the intervention had a positive effect on depressive symptoms and all mediators except formal care service utilization. Structural equation models indicated that increased activation, enhanced depression knowledge, and decreased anxiety each independently mediated a significant proportion of the intervention's impact on depressive symptoms as assessed with 2 different measures (PHQ-9 and CES-D). These 3 factors also jointly explained over 60% of the intervention's total effect on both indicators of depressive symptoms. Our findings suggest that most of the impact of BTB on depressive symptoms is driven by enhancing activation or becoming active, reducing anxiety, and improving depression knowledge/efficacy. The intervention components appear to work in concert and may be mutually necessary for maximal benefits from treatment to occur. Implications for designing tailored interventions to address depressive symptoms among older African Americans are discussed.

Chronic disease self-management interventions for adults with serious mental illness: a systematic review of the literature

OBJECTIVE

While there is strong evidence in support of chronic disease self-management programs, much less is available with regard to individuals living with serious mental illness (SMI). The objectives of this review are to identify and appraise chronic disease self-management studies tested with samples of US adults living with SMI. We include an appraisal of methodological quality of the chronic disease self-management (CDSM) studies that met our final criteria.

METHODS

Systematic search methods were utilized to identify intervention studies published before 2012 that describe CDSM outcomes for adults with SMI.

RESULTS

Eighteen unduplicated articles were identified that included outcomes of CDSM studies, while 10 met all inclusion criteria. Favorable treatment effects were observed for adults with SMI across 10 studies that took place in different types of clinical settings. CDSM studies that met all search criteria had a wide range of methodological quality, indicating that this is a nascent field of study.

CONCLUSIONS

Given the high chronic disease burden experienced by individuals with SMI combined with our nations health care reform, emphasis on self-management to improve population health, coupled with advancing the quality of research to evaluate CDSM programs for adults with SMI, is critically needed.

Ethics and Community Involvement in Syntheses Concerning American Indian, Alaska Native, or Native Hawaiian Health: A Systematic Review

BACKGROUND

The objective of the research was to review reporting of ethical concerns and community involvement in peer-reviewed systematic reviews or meta-analyses concerning American Indian, Alaska Native, or Native Hawaiian (AI/AN/NH) health.

METHODS

Text words and indexed vocabulary terms were used to query PubMed, Embase, Cochrane Library, and the Native Health Database for systematic reviews or meta-analyses concerning AI/AN/NH health published in peer-reviewed journals, followed by a search through reference lists. Each article was abstracted by two independent reviewers; results were discussed until consensus was reached.

RESULTS

We identified 107 papers published from 1986-2012 that were primarily about AI/AN/NH health or presented findings separately for AI/AN/NH communities. Two reported seeking indigenous reviewer feedback; none reported seeking input from tribes and communities. Approximately 7% reported on institutional review board (IRB) approval of included studies, 5% reported on tribal approval, and 4% referenced the sovereignty of AI/AN tribes. Approximately 63% used evidence from more than one AI/AN/NH population study, and 28% discussed potential benefits to communities from the synthesis research.

CONCLUSIONS

Reporting of ethics and community involvement are not prominent. Systematic reviews and meta-analyses making community-level inferences may pose risks to communities. Future systematic reviews and meta-analyses should consider ethical and participatory dimensions of research.

Sociocultural influences on mental health service use by Latino older adults for emotional distress: exploring the mediating and moderating role of informal social support

This study investigated the determinants of mental health services for emotional distress by low-income older Latinos living in Los Angeles County (United States). The functional effects of informal support on service use were tested while accounting for dimensions of support and sociocultural factors. Using data from a cross-sectional survey of older Latinos (n = 235), we preformed a secondary data analysis using path analysis with Poisson regression to assess mediation and moderation models by type of perceived support, emotional and instrumental. Data was originally collected between 1998 and 2005. Results indicated that no mediation effects were present however significant moderation effects emerged. Respondents with low levels of linguistic acculturation and informal support used fewer services. Variations by type of informal support emerged, with emotional support presenting the best model fit compared to instrumental support in the moderation model analysis. The direct effects of linguistic acculturation and age remained significant after controlling for need. Findings reveal limited informal support is a risk factor for the underutilization of mental health services by older Latinos with low levels of linguistic acculturation as they age. Integrating support resources that assist in navigating service systems and address language barriers can enhance service use by older Latino adults. Implications for service delivery and program development are discussed.