Integrated Care for Depression in Older Primary Care Patients

Cost-effectiveness of behavioral activation compared to treatment as usual for depressed older adults in primary care: A cluster randomized controlled trial

INTRODUCTION

Depression in older adults is associated with decreased quality of life and increased utilization of healthcare services. Behavioral activation (BA) is an effective treatment for late-life depression, but the cost-effectiveness compared to treatment as usual (TAU) is unknown.

METHODS

An economic evaluation was performed alongside a cluster randomized controlled multicenter trial including 161 older adults (≥65 years) with moderate to severe depressive symptoms (PHQ-9 ≥ 10). Outcome measures were depression (response on the QIDS-SR), quality-adjusted life-years (QALYs) and societal costs. Missing data were imputed using multiple imputation. Cost and effect differences were estimated using bivariate linear regression models, and statistical uncertainty was estimated with bootstrapping. Cost-effectiveness acceptability curves showed the probability of cost-effectiveness at different ceiling ratios.

RESULTS

Societal costs were statistically non-significantly lower in BA compared to TAU (mean difference (MD) -€485, 95 % CI -3861 to 2792). There were no significant differences in response on the QIDS-SR (MD 0.085, 95 % CI -0.015 to 0.19), and QALYs (MD 0.026, 95 % CI -0.0037 to 0.055). On average, BA was dominant over TAU (i.e., more effective and less expensive), although the probability of dominance was only 0.60 from the societal perspective and 0.85 from the health care perspective for both QIDS-SR response and QALYs.

DISCUSSION

Although the results suggest that BA is dominant over TAU, there was considerable uncertainty surrounding the cost-effectiveness estimates which precludes firm conclusions.

Predictors of depression among the elderly persons with disabilities in Indonesia

BACKGROUND

Depression is a major mental problem in the elderly, particularly those with disability. This study's aim was to identify variables that predict depression in the elderly with disabilities.

MATERIALS AND METHODS

This cross-sectional study was conducted in Gunungkidul Regency and Yogyakarta City from April to June 2021. The study participants were community-dwelling elderly aged 60 years and above with disabilities, who could communicate verbally without any apparent cognitive impairment. Data was collected by interviewing participants using structured questionnaire on following sections: Demographic characteristics, Mini-Mental State Examination (MMSE), Washington Group Short Set (WG-SS), Barthel Index of activities of daily living (ADL), Lawton Instrumental ADL (IADL) Scale, and Geriatric Depression Scale-30 (GDS-30). Multivariate linear regression analysis applied to identify variables significantly correlated with depression. Multinomial logistic regression analysis performed to obtain the odds ratio (OR).

RESULTS

Study included 115 elderly persons with disabilities. Most of them had mobility impairment. Higher independence in ADL and being married were related with lower risk of depression, whereas increased age at disability increased the risk of depression (P = 0.001). The elderly who had greater independence with daily activities were less likely to have depression (OR = 0.639 for mild depression and OR = 0.589 for severe depression). Those who were not married were more likely to have mild depression (OR = 3.203) and severe depression (OR = 29.119). compared to the married elderly. Age at acquiring disability was associated with higher risk for mild depression (OR = 1.025) and severe depression (OR = 1.053). Higher independence in ADL and being married were related with lower risk of depression, whereas increased age at disability increased the risk of depression (P = 0.001).

CONCLUSION

Independence in the ADL, being married, and being disabled as a young adult are negative predictors of depression in the elderly with disability.

Research-Practice Partnership to Develop and Implement Routine Mental Health Symptom Tracking Tool Among Older Adults During COVID-19

OBJECTIVE

Older adults are disproportionally impacted by the COVID-19 pandemic, causing a mental health crisis in late life, due to physical restrictions (e.g., quarantine), limited access to services, and lower literacy and access to technology. Despite established benefits, systematic screening of mental health needs of older adults in community and routine care settings is limited and presents multiple challenges. Cross-disciplinary collaborations are essential for identification and evaluation of mental health needs and service delivery.

METHODS

Using a research-practice partnership model, we developed and implemented a routine mental health needs identification and tracking tool at a community-based social services organization. Repeated screenings were conducted remotely over 5 months and included depression, anxiety, perceived loneliness, social support, and related domains such as sleep quality, resilience, and trauma symptoms linked to COVID-19. We examined symptomatic distress levels and associations between different domains of functioning.

RESULTS

Our project describes the process of establishing a research-practice partnership during the COVID-19 pandemic. We collected 292 screenings from 124 individuals; clients were mildly to moderately depressed and anxious, reporting large amounts of time alone and moderate levels of loneliness. Those reporting higher depressive symptoms reported higher anxiety symptoms, poorer sleep quality, lower quality of life, lower capacity to adapt to challenging situations, and greater trauma symptoms due to COVID-19.

CONCLUSION

Our routine screening tool can serve as a blueprint for case management agencies and senior centers nationwide, beyond the pressing mental health crisis due to COVID-19, to continue identifying needs as they emerge in the community.

Comorbidity and Management of Concurrent Psychiatric and Medical Disorders

Aging increases susceptibility to medical and psychiatric comorbidity via interrelated biological, psychological, and social mechanisms. Mental status changes or other psychiatric symptoms occurring in older adults with medical disorders most often result from delirium, depression, or the onset of Alzheimer's disease and related dementias (ADRD). Clinicians can use evidence-based tools to evaluate such symptoms including the 4A's Test for delirium, the Saint Louis University Mental Status Exam, and the Geriatric Depression Scale. Innovative models such as collaborative care can improve the outcome of care of older adults with medical disorders requiring treatment for depression or ADRD..

Mental health training programs for community pharmacists, pharmacy staff and students: A systematic review

BACKGROUND

Primary care is often the first point of contact for people living with mental disorders. Community pharmacists, pharmacy staff and students are increasingly being trained to deliver mental health care. However, there is still a gap in the literature exploring the characteristics of all available mental health training programs and their components and their influence on pharmacists, pharmacy staff and students' outcomes.

OBJECTIVES

To summarize the evidence evaluating mental health training programs completed by community pharmacists, pharmacy staff and students. More specifically, to explore the components of mental health training programs and identify those that facilitate significant improvements in outcomes.

METHODS

A systematic review was conducted following the Cochrane handbook and reported according to PRISMA guidelines. A search for published literature was conducted in three databases (PubMed, Scopus, and Web of Science) in July 2021. Eligible studies were included if they described and evaluated the impact of mental health training programs delivered to community pharmacists, pharmacy staff and pharmacy students regardless of design or comparator. The methodological quality of included studies was appraised using both the NIH quality assessment, to evaluate studies with an uncontrolled pre-post design, and the Cochrane EPOC risk of bias assessment, to evaluate studies with a controlled (randomized and non-randomized) study design.

RESULTS

Thirty-three studies were included. Most of the identified mental health training programs contained knowledge-based components and active learning activities. Changes in participants' attitudes, stigma, knowledge, confidence and skills were frequently assessed. An extensive range of self-assessment and observational instruments used to evaluate the impact of the training programs were identified. Positive improvements in participants' attitudes, knowledge and stigma were frequently identified following participation in training programs.

CONCLUSIONS

This systematic review highlights the importance of mental health training programs in increasing pharmacists', pharmacy staff and pharmacy students' skills and confidence to deliver mental health care in community pharmacy. Future research should build upon this basis and further focus on finding the most efficient measures to evaluate these training programs and assess their long-term effectiveness, allowing comparison between programs.

Spotlight on the Challenges of Depression following Retirement and Opportunities for Interventions

As a major life transition characterized by changes in social, behavioral, and psychological domains, retirement is associated with numerous risk factors that can contribute to the development of depression in later life. Understanding how these risk factors intersect with overall health and functioning can inform opportunities for mental health promotion during this transition. The objective of this review is to summarize the literature on risk and protective factors for depression during retirement transitions, discuss challenges related to appropriate management of depression in later life, and describe opportunities for prevention and intervention for depression relating to retirement transitions, both within and beyond the health care system. Key implications from this review are that 1) the relationship between depression and retirement is multifaceted; 2) while depression is a common health condition among older adults, this syndrome should not be considered a normative part of aging or of retirement specifically; 3) the existing mental health specialty workforce is insufficient to meet the depression management needs of the aging population, and 4) therefore, there is a need for interprofessional and multidisciplinary intervention efforts for preventing and managing depression among older adults. In sum, both healthcare providers, public health practitioners, and community organizations have meaningful opportunities for promoting the mental health of older adults during such major life transitions.

A qualitative exploration of mental health services provided in community pharmacies

The burden of mental health problems continues to grow worldwide. Community pharmacists’, as part of the primary care team, optimise care for people living with mental illness. This study aims to examine the factors that support or hinder the delivery of mental health services delivered in Australian community pharmacies and proposes ideas for improvement. A qualitative study was conducted comprising focus groups with community pharmacists and pharmacy staff across metropolitan, regional, and rural areas of New South Wales, Australia. Data were collected in eight focus groups between December 2020 and June 2021. Qualitative data were analysed using thematic analysis. Thirty-three community pharmacists and pharmacy staff participated in an initial round of focus groups. Eleven community pharmacists and pharmacy staff participated in a second round of focus groups. Twenty-four factors that enable or hinder the delivery of mental health services in community pharmacy were identified. Participant’s perception of a lack of recognition and integration of community pharmacy within primary care were identified as major barriers, in addition to consumers’ stigma and lack of awareness regarding service offering. Suggestions for improvement to mental health care delivery in community pharmacy included standardised practice through the use of protocols, remuneration and public awareness. A framework detailing the factors moderating pharmacists, pharmacy staff and consumers’ empowerment in mental health care delivery in community pharmacy is proposed. This study has highlighted that policy and funding support for mental health services is needed that complement and expand integrated models, promote access to services led by or are conducted in collaboration with pharmacists and recognise the professional contribution and competencies of community pharmacists in mental health care. The framework proposed may be a step to strengthening mental health support delivered in community pharmacies.

Depression and Exercise in Older Adults: Exercise Looks after You Program, User Profile

INTRODUCTION

Depression is a challenge for public health policies, as it is the number one leading cause of disability in the world. In order to combat and prevent it, different social and health interventions are being developed to promote health through physical activity.

OBJECTIVE

Analyze and describe the user profile of the patients with depression from the Exercise Looks After You program, which is a physical activity program that works on improving public health and has an essential role preventing chronic diseases and improving the quality of life of the elderly in Extremadura.

DESIGN

Cross-sectional study.

PARTICIPANTS

total sample of 1972 users (96.4% women, 3.6% men), of whom 724 (94.6% women, 5.4% men) suffer from depression.

RESULTS

It was observed that the dominant user profile of the patients with depression within the program is female, 71 years old, physically active, overweight, married, with low educational level, non-smoker, no alcohol consumption and below average physical fitness and health-related quality of life, which translates into a high incidence of primary care, nursing and prescription visits.

CONCLUSIONS

This study presents the user profile of depressive versus non-depressive participants of the Exercise Looks After You physical activity program. This data could be meaningful in order to improve and optimize public health programs and resources.

Alcohol use disorder and treatment receipt among individuals aged 50 years and older: Other substance use and psychiatric correlates

OBJECTIVE

Alcohol use disorder (AUD) is increasing among U.S. individuals aged 50+. We examined associations of past-year AUD with other substance use and any mental illness (AMI) and associations of past-year AUD treatment receipt with other substance use, AMI, and mental health treatment receipt among those with AUD.

METHODS

Data came from the 2015-2018 National Survey on Drug Use and Health (N = 35,229). We used multivariable logistic regression analysis to examine the research questions.

RESULTS

In the 50+ age group, 58.7% of women and 66.9% of men reported past-year alcohol use and 2.0% of women and 4.9% of men had AUD. Those with any alcohol use problem (binge drinking, heavy drinking, or AUD) had higher odds of other substance use or use disorders; however, AMI was associated with higher odds of AUD only (AOR = 2.54, 95% CI = 2.15-3.00, AOR = 2.63, 95% CI = 1.98-3.50, and AOR = 3.13, 95% CI = 2.19-4.48, respectively, for mild, moderate, and serious mental illness). Only 7.9% of those with AUD received any alcohol treatment. AMI and mental health treatment were associated with higher odds of alcohol treatment receipt (AOR = 5.18, 95% CI = 2.13-12.55, AOR = 4.14, 95% CI = 1.51-11.30, and AOR = 2.91, 95% CI = 1.41-6.00, respectively, for moderate mental illness, serious mental illness, and mental health treatment receipt).

CONCLUSION

The findings show that fewer than one in 10 older adults with AUD received any alcohol treatment and suggest that individuals need education on alcohol harms and assistance in accessing alcohol treatment. Combined mental health and alcohol treatment at a single location may improve access and use.

Guided Internet-Based Cognitive Behavioral Therapy for Depression: Implementation Cost-Effectiveness Study

Background

Major depressive disorder is a chronic condition; its prevalence is expected to grow with the aging trend of high-income countries. Internet-based cognitive-behavioral therapy has proven efficacy in treating major depressive disorder.

Objective

The objective of this study was to assess the cost-effectiveness of implementing a community internet-based cognitive behavioral therapy intervention (Super@, the Spanish program for the MasterMind project) for treating major depressive disorder.

Methods

The cost-effectiveness of the Super@ program was assessed with the Monitoring and Assessment Framework for the European Innovation Partnership on Active and Healthy Ageing tool, using a 3-state Markov model. Data from the cost and effectiveness of the intervention were prospectively collected from the implementation of the program by a health care provider in Badalona, Spain; the corresponding data for usual care were gathered from the literature. The health states, transition probabilities, and utilities were computed using Patient Health Questionnaire–9 scores.

Results

The analysis was performed using data from 229 participants using the Super@ program. Results showed that the intervention was more costly than usual care; the discounted (3%) and nondiscounted incremental cost-effectiveness ratios were €29,367 and €26,484 per quality-adjusted life-year, respectively (approximately US $35,299 and $31,833, respectively). The intervention was cost-effective based on the €30,000 willingness-to-pay threshold typically applied in Spain (equivalent to approximately $36,060). According to the deterministic sensitivity analyses, the potential reduction of costs associated with intervention scale-up would reduce the incremental cost-effectiveness ratio of the intervention, although it remained more costly than usual care. A discount in the incremental effects up to 5% exceeded the willingness-to-pay threshold of €30,000.

Conclusions

The Super@ program, an internet-based cognitive behavioral therapy intervention for treating major depressive disorder, cost more than treatment as usual. Nevertheless, its implementation in Spain would be cost-effective from health care and societal perspectives, given the willingness-to-pay threshold of €30,000 compared with treatment as usual.

Improving Geropsychology Competencies of Veterans Affairs Psychologists

Older adults are more likely to seek mental health care through integrated care settings such as primary care. Currently, there exists a significant shortage of mental health providers trained in geropsychology and integrated care competencies. To address this need within the Veterans Health Administration, a national workforce development program was extended to include psychologists, which is called the Geriatric Scholars Program-Psychology Track (GSP-P). The GSP-P has two overarching educational program aims: (1) to improve geropsychology competencies of practicing VA psychologists, particularly those working within integrated settings (e.g., primary care) and (2) enrich psychologists' abilities to enact change in their clinical settings. Ninety-eight VA clinicians participated in the GSP-P, which includes a multi-day in-person course, from 2014 to 2018. Participants completed measures assessing confidence and self-reported knowledge in geropsychology and integrated care competencies pre-course and 3-months post-completion. Two-weeks post-course participants responded to open-ended survey questions regarding their perceptions of the course and potential applications of learning. Significant improvements in confidence in and knowledge of geropsychology and integrated care competencies emerged from pre-course to 3-months post-completion. Qualitative findings demonstrated that participants valued the face-to-face, integrated multimodal educational program. Findings provided insights regarding clinicians' planned application of the knowledge acquired, such as modifying treatments for older patients. Specialized workforce programs such as the GSP-P have a significant, positive impact on the care of older Veterans.

Treatment Adequacy and Adherence as Predictors of Depression Response in Primary Care

OBJECTIVE

Primary care is the de facto mental health system in the United States where physicians treat large numbers of depressed older adults with antidepressant medication. This study aimed to examine whether antidepressant dosage adequacy and patient adherence are associated with depression response among middle-aged and older adults prescribed with antidepressants by their primary care provider.

DESIGN

A secondary analysis was conducted on a sample drawn from a randomized controlled trial comparing Treatment as Usual to Treatment Initiation Program, an adherence intervention. Treatment Initiation Program improved adherence but not depression compared to Treatment as Usual (Sirey et al., 2017). For this analysis, we examined dosing adequacy and adherence at 6 and 12 weeks as predictors of depression response in both groups at 12 and 24 weeks.

SETTING

Primary care practices.

PARTICIPANTS

One hundred eighty-seven older adults with depression prescribed an antidepressant for depression by their primary care provider.

MEASUREMENTS

Depression response was defined as 50% reduction on the Hamilton Rating Scale for Depression. Adherence was defined as taking 80% of doses at follow-up interviews (6 and 12 weeks). Patient-reported dosage and duration of antidepressant therapy was collected using the Composite Antidepressant Score (adequacy score of >3) at follow-up.

RESULTS

Greater adherence, but not receipt of adequate dosage, was associated with higher likelihood of treatment response at both 12 (Odds ratio (OR) = 2.63; 95% Confidence Interval (CI), 1.19-5.84) and 24 weeks (OR = 3.09; 95% CI, 1.46-6.55).

CONCLUSION

As physicians prescribe antidepressants to the diverse group of adults seen in primary care, special attention to patients' views and approach to adherence may improve depression outcomes.

Correlates of depression outcomes in collaborative care for HIV

BACKGROUND

Collaborative care can treat depression in HIV but existing studies have been limited by excluding patients with acute or severe depression. The purpose of this analysis is to determine if real-world implementation of collaborative care in HIV is associated with improvement in depression, and to identify correlates of depression outcomes.

METHODS

Collaborative care was implemented as part of a large practice transformation initiative. Change in depression, measured by PHQ-9 score, at baseline compared to 12 months post-enrollment was the outcome, which was operationalized as remission, response, and neither response nor remission. Bivariate and multivariate associations were assessed between several variables at baseline and the outcome.

RESULTS

Out of 416, 99 (23.79%) patients remitted and 89 (21.39%) responded (without remission). In the bivariate analysis having a documented psychiatric comorbidity was associated with low remission [31 (16.58%)]; p = 0.008. Having generalized anxiety disorder was associated with low remission [18 (15.00%)] and response rates [26 (21.67%)]; p = 0.022. Having a substance use disorder (alcohol, cocaine, or amphetamine) - was associated with poor remission [29 (16.67%)] and response [33 (18.97%)]; p = 0.004. Social isolation was correlated with lower response and remission rates (p = 0.0022). In the multivariate analysis older age was associated with higher remission rates (OR: 1.10; 95% CI: 1.005-1.194) whereas being a Medicaid beneficiary (OR: 0.652; 95% CI: 1.123-2.797), having comorbid generalized anxiety disorder (OR: 0.267; 95% CI: 0.122-0.584) or a stimulant use disorder (cocaine [OR: 0.413; 95% CI: 0.222-0.926] or amphetamines [OR: 0.185; 95% CI: 0.037-0.766]), was associated with lower remission rates.

CONCLUSION

We found that depression improved in our study subjects. We identified several modifiable correlates of depression outcomes.

Prevalence of Depressive Symptoms in the Elderly Population Diagnosed with Type 2 Diabetes Mellitus

Introduction: A sharp rise in the population of elderly people, who are more prone to somatic and mental diseases, combined with the high prevalence of type 2 diabetes mellitus and diabetes-associated complications in this age group, have an impact on the prevalence of depressive symptoms. Aim of the work: The work of the study was the evaluation of the prevalence of depressive symptoms in the elderly population diagnosed with type 2 diabetes mellitus. Materials and methods: The pilot study was conducted in 2019 among 200 people diagnosed with type 2 diabetes mellitus, aged 65 years and above, receiving treatment in a specialist diabetes outpatient clinic. The study was based on a questionnaire aimed at collecting basic sociodemographic and clinical data and the complete geriatric depression scale (GDS, by Yesavage) consisting of 30 questions. Results: The study involved 200 patients receiving treatment in a diabetes outpatient clinic. The mean age of the study subjects was 71.4 ± 5.0 years. The vast majority of the subjects (122; 61%) were women, with men accounting for 39% of the study population (78 subjects). A statistically significant difference in the GDS (p < 0.01) was shown for marital status, body mass index (BMI), duration of diabetes, and the number of comorbidities. Patients with results indicative of symptoms of mild and severe depression were found to have higher BMI, longer disease duration, and a greater number of comorbidities. There were no statistically significant differences in the level of HbA1c. Conclusions: In order to verify the presence of depressive symptoms in the group of geriatric patients with diabetes mellitus, an appropriate screening programme must be introduced to identify those at risk and refer them to specialists, so that treatment can be promptly initiated. Screening tests conducted by nurses might help with patient identification.

Bridging the Behavioral Health Gap in Serious Illness Care: Challenges and Strategies for Workforce Development

Comorbidity with behavioral health conditions is highly prevalent among those experiencing serious medical illnesses and is associated with poor outcomes. Siloed provision of behavioral and physical healthcare has contributed to a workforce ill-equipped to address the often complex needs of these clinical populations. Trained specialist behavioral health providers are scarce and there are gaps in core behavioral health competencies among serious illness care providers. Core competency frameworks to close behavioral health training gaps in primary care exist, but these have not extended to some of the distinct skills and roles required in serious illness care settings. This paper seeks to address this issue by describing a common framework of training competencies across the full spectrum of clinical responsibility and behavioral health expertise for those working at the interface of behavioral health and serious illness care. The authors used a mixed-method approach to develop a model of behavioral health and serious illness care and to delineate seven core skill domains necessary for practitioners working at this interface. Existing opportunities for scaling-up the workforce as well as priority policy recommendation to address barriers to implementation are discussed.

The Role of the Patient-Centered Medical Home in Treating Depression

PURPOSE OF REVIEW

This review discusses the role of the patient-centered medical home (PCMH) in treating depression, focusing on findings from primary care-based studies and their implications for the PCMH.

RECENT FINDINGS

Pharmacotherapy, psychotherapy, and collaborative care are evidence-based treatments for depression that can be delivered in primary care and extended to diverse populations. Recent research aligns with the core components of the PCMH model. The core components of the PCMH are critical elements of depression treatment. Comprehensive care within the PCMH addresses medical and behavioral health concerns, including depression. Psychiatric and psychological care must be flexibly delivered so services remain accessible yet patient-centered. To ensure the quality and safety of treatment, depression symptoms must be consistently monitored. Coordination within and occasionally outside of the PCMH is needed to ensure patients receive the appropriate level of care. More research is needed to empirically evaluate depression treatment within the PCMH.