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Kennedy MA, Stevens CJ, Pepin R, Lyons KD. Behavioral Activation: Values-Aligned Activity Engagement as a Transdiagnostic Intervention for Common Geriatric Conditions. THE GERONTOLOGIST 2024; 64:gnad046. [PMID: 37068017 PMCID: PMC10943502 DOI: 10.1093/geront/gnad046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Indexed: 04/18/2023] Open
Abstract
Scalable, transdiagnostic interventions are needed to meet the needs of a growing population of older adults experiencing multimorbidity and functional decline. Behavioral activation (BA) is a pragmatic, empirically supported treatment for depression that focuses on increasing engagement in values-aligned activities. We propose BA is an ideal transdiagnostic intervention approach for older adults because it (a) specifically targets activity restriction, a shared characteristic of common conditions of aging; and (b) has strong potential for scalability through delivery by a broad range of clinician and nonclinician interventionists and via telehealth. We describe the history of BA and review recent literature demonstrating impacts beyond depression including on cognition, social isolation, and disability. We also describe the feasibility of delivering BA across interventionists, settings, and modalities. Our approach advances scholarship by proposing BA as a scalable, transdiagnostic behavioral intervention to address functional decline in older adults with common geriatric conditions.
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Affiliation(s)
- Meaghan A Kennedy
- New England Geriatric Research, Education, and Clinical Center, VA Bedford Healthcare System, Bedford, Massachusetts, USA
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Courtney J Stevens
- Department of Psychiatry, Dartmouth-Hitchcock Medicine Center, Lebanon, New Hampshire, USA
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Renée Pepin
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Kathleen D Lyons
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Department of Occupational Therapy, MGH Institute of Health Professions, Boston, Massachusetts, USA
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Smith ML, Steinman LE, Montoya CN, Thompson M, Zhong L, Merianos AL. Effectiveness of the Program to Encourage Active, Rewarding Lives (PEARLS) to reduce depression: a multi-state evaluation. Front Public Health 2023; 11:1169257. [PMID: 37361168 PMCID: PMC10289834 DOI: 10.3389/fpubh.2023.1169257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/15/2023] [Indexed: 06/28/2023] Open
Abstract
Introduction An estimated 15% of community-dwelling older adults have depressive symptoms in the U.S. The Program to Encourage Active, Rewarding Lives (PEARLS) is an evidence-based program for managing late-life depression. PEARLS is a home/community-based collaborative care model delivered by community-based organizations to improve access to quality depression care. Trained staff actively screen for depression to improve recognition, teach problem-solving and activity planning skills for self-management, and connect participants to other supports and services as needed. Methods This study examined 2015-2021 data from 1,155 PEARLS participants across four states to assess PEARLS effectiveness to reduce depressive symptoms. The clinical outcomes were measured by the self-reported PHQ-9 instrument to assess changes in depressive symptoms scored as depression-related severity, clinical remission, and clinical response. A generalized estimating equation (GEE) model was fitted to examine changes in composite PHQ-9 scores from baseline to the final session. The model adjusted for participants' age, gender, race/ethnicity, education level, income level, marital status, number of chronic conditions, and number of PEARLS sessions attended. Cox proportional hazards regression models were conducted to estimate the hazard ratio for improvement of depressive symptoms (i.e., remission or response), while adjusting for the covariates. Results PHQ-9 scale scores significantly improved from baseline to their final sessions (mean difference = -5.67, SEM = 0.16, p < 0.001). About 35% of participants achieved remission with PHQ-9 score < 5. Compared to participants with mild depression, patients with moderate depression (HR = 0.43, 95%CI = 0.35-0.55), moderately severe depression (HR = 0.28, 95%CI = 0.21-0.38), and severe depression (HR = 0.22 95%CI = 0.14-0.34) were less likely to experience clinical remission with PHQ-9 score < 5, while adjusting for the covariates. About 73% achieved remission based on no longer having one or both cardinal symptoms. Compared to participants with mild depression, patients with moderate depression (HR = 0.66, 95%CI = 0.56-0.78), moderately severe depression (HR = 0.46, 95%CI = 0.38-0.56), and severe depression (HR = 0.38, 95%CI = 0.29-0.51) were less likely to experience clinical remission, while adjusting for the covariates. Nearly 49% of participants had a clinical response or a ≥ 50% decrease in PHQ-9 scores over time. There were no differences between the severity of depression groups based on the time to clinical response. Discussion Findings confirm that PEARLS is an effective program to improve depressive symptoms among older adults in diverse real-world community settings and can be a more accessible option for depressive older adults who are traditionally underserved by clinical care.
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Affiliation(s)
- Matthew Lee Smith
- Department of Health Behavior, School of Public Health, Texas A&M University, College Station, TX, United States
- Center for Community Health and Aging, Texas A&M University, College Station, TX, United States
- Center for Health Equity and Evaluation Research, Texas A&M University, College Station, TX, United States
| | - Lesley E. Steinman
- Department of Health Systems and Population Health, Health Promotion Research Center, School of Public Health, University of Washington, Seattle, WA, United States
| | | | | | - Lixian Zhong
- School of Pharmacy, Texas A&M University, College Station, TX, United States
| | - Ashley L. Merianos
- School of Human Services, University of Cincinnati, Cincinnati, OH, United States
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Frounfelker RL, Mishra T, Carroll A, Brennan RT, Gautam B, Ali EAA, Betancourt TS. Past trauma, resettlement stress, and mental health of older Bhutanese with a refugee life experience. Aging Ment Health 2022; 26:2149-2158. [PMID: 34396853 PMCID: PMC9386683 DOI: 10.1080/13607863.2021.1963947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/30/2021] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Older displaced persons often receive limited attention from aid organizations, policy-makers and service providers in countries of resettlement. The objective of this study is to identify the relationship between experiencing traumatic events and stressors prior to resettlement, current resettlement stressors, social support, and mental health of older Bhutanese with a refugee life experience. METHOD Study participants were 190 older Bhutanese with a refugee life experience living in a metropolitan area in New England (US) and Ontario (Canada). We used structural equation modeling to determine the association between traumatic and stressful events in Bhutan and Nepal, current resettlement stressors, and symptoms of anxiety and depression, as measured by the GAD-7 and PHQ-9. We assessed the role of social support as an effect modifier in the relationship between these variables. RESULTS Surviving torture was associated with anxiety (p=.006), and experiencing threats to physical wellbeing in Nepal was associated with both anxiety (p=.003) and depression (p=.002). The relationship between physical threats in Nepal and current mental health were partially mediated by resettlement stressors. Social support moderated the relationship between trauma, stress, and mental health. CONCLUSION Both past traumas and current resettlement stressors contribute to the current psychosocial functioning of older Bhutanese with a refugee life experience. Based on our findings, social support is critical in promoting mental health in this population.
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Affiliation(s)
- Rochelle L Frounfelker
- Division of Social and Transcultural Psychiatry, Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Tej Mishra
- Research Program on Children and Adversity, Boston College School of Social Work, Chestnut Hill, MA, USA
| | - Alexa Carroll
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Robert T Brennan
- Research Program on Children and Adversity, Boston College School of Social Work, Chestnut Hill, MA, USA
- Women's Study Research Center, Brandeis University, Waltham, MA, USA
| | - Bhuwan Gautam
- Bhutanese Society of Western Massachusetts, Inc., Springfield, MA, USA
| | - Eman Abdullahi Alas Ali
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Theresa S Betancourt
- Research Program on Children and Adversity, Boston College School of Social Work, Chestnut Hill, MA, USA
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Walsh S, Moseley GL, Gray RJ, Gillam M, Gunn KM, Barker T, Tran K, Eshetie T, Jones M. Use of behavioural activation to manage pain: a systematic scoping review. BMJ Open 2022; 12:e056404. [PMID: 35649614 PMCID: PMC9161098 DOI: 10.1136/bmjopen-2021-056404] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Behavioural activation (BA) is an effective treatment for depression; however, it is unclear if it can be used to manage pain. OBJECTIVES To conduct a scoping review of primary research that reported using BA to support people living with chronic pain to understand how BA had been used in relation to pain. In addition, we wanted to understand whether there were any reported changes in that pain, and how and who delivered BA. ELIGIBILITY CRITERIA Primary research published in English. SOURCES OF EVIDENCE We searched seven databases MEDLINE, Ovid Embase, Ovid Emcare, PsycINFO, CINAHL, Scopus and Web of Science, for primary research. No initial date limit was used with the date the searches were conducted used as the end date limit (1 July 2021). CHARTING METHODS A customised data extraction table was developed, piloted and used. RESULTS 551 papers were screened for inclusion, with 15 papers included in our review. Studies were conducted in North America and in Canada. These included three case studies, nine uncontrolled trials and three randomised controlled trials. Only two studies reported pain as the primary outcome. BA was applied across a range of pain related conditions. The dose of BA ranged from 3 to 16 sessions. Duration of treatment was 3 weeks to 12 months. Most studies reported reductions in pain following exposure to BA. CONCLUSION BA has the potential to reduce pain. Caution needs to be exercised in the interpretation of these findings as a high risk of bias was observed in most studies. High-quality research is required to test if BA is an effective intervention for chronic pain.
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Affiliation(s)
- Sandra Walsh
- Department of Rural Health, University of South Australian - Whyalla Campus, Whyalla Norrie, Barngarla Country, South Australia, Australia
- IIMPACT in Health, University of South Australia, Adelaide, South Australia, Australia
| | - G Lorimer Moseley
- IIMPACT in Health, University of South Australia, Adelaide, South Australia, Australia
| | - Richard John Gray
- School of Nursing, La Trobe University, Bundoora, Victoria, Australia
- Department of Rural Health, University of South Australia, Mt Barker, South Australia, Australia
| | - Marianne Gillam
- IIMPACT in Health, University of South Australia, Adelaide, South Australia, Australia
- Department of Rural Health, University of South Australia, Mt Barker, South Australia, Australia
| | - Kate M Gunn
- IIMPACT in Health, University of South Australia, Adelaide, South Australia, Australia
- Department of Rural Health, University of South Australia, Adelaide, South Australia, Australia
| | - Trevor Barker
- IIMPACT in Health, University of South Australia, Adelaide, South Australia, Australia
| | - Kham Tran
- IIMPACT in Health, University of South Australia, Adelaide, South Australia, Australia
- Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Tesfahun Eshetie
- Department of Rural Health, University of South Australia, Adelaide, South Australia, Australia
| | - Martin Jones
- IIMPACT in Health, University of South Australia, Adelaide, South Australia, Australia
- Department of Rural Health, University of South Australia, Mt Barker, South Australia, Australia
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Raue PJ, Hawrilenko M, Corey M, Lin J, Chen S, Mosser BA. "Do More, Feel Better": Pilot RCT of Lay-Delivered Behavioral Activation for Depressed Senior Center Clients. Behav Ther 2022; 53:458-468. [PMID: 35473649 PMCID: PMC9046684 DOI: 10.1016/j.beth.2021.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 10/26/2021] [Accepted: 11/18/2021] [Indexed: 11/02/2022]
Abstract
This pilot randomized control trial (RCT) tested "Do More, Feel Better" (DMFB), a lay-delivered Behavioral Activation intervention for depressed senior center clients. The study examined: (1) the feasibility of training older lay volunteers to fidelity; and (2) the acceptability, safety, and impact of the intervention. Twenty-one lay volunteers at four senior centers were trained in DMFB. Fifty-six depressed clients were randomized to receive 9 sessions of DMFB or Behavioral Activation delivered by social workers (MSW BA). Research assessments of overall client activity level (BADS) and depression severity (HAM-D) were conducted at baseline and Weeks 3, 6, and 9. Eighty-one percent of lay volunteers who underwent training were formally certified in DMFB. Depressed clients receiving each intervention reported high levels of satisfaction and showed large and clinically significant changes in 9-week activity level (d ≥ 1.35) and depression severity (d ≥ 3.34). Differences between treatment groups were very small for both activity level (dMSW = 0.16; 95% CI, -0.70 to 1.02) and depression (dMSW = 0.14; 95% CI, -0.63 to 0.91). Increases in activity level were associated with decreases in depression (β = -0.42; 95% CI, -0.55 to -0.30). Both interventions appeared to work as intended by increasing activity level and reducing depression severity. "Do More, Feel Better" shows the potential of evidence-based behavioral interventions delivered by supervised lay volunteers, and can help address the insufficient workforce available to meet the mental health needs of community-dwelling older adults.
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Jang S, Kunde L. A systematic review of music therapy interventions used to address emotional needs of older adults. ARTS IN PSYCHOTHERAPY 2021. [DOI: 10.1016/j.aip.2021.101842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Falgas-Bague I, Ramos Z, del Cueto P, Kim E, Zhen-Duan J, Wong YJ, Chieng CK, Frontera W, Alegría M. Adaptation of an Evidence-Based Intervention for Disability Prevention, Implemented by Community Health Workers Serving Ethnic Minority Elders. Am J Geriatr Psychiatry 2021; 29:260-269. [PMID: 32855041 PMCID: PMC7855421 DOI: 10.1016/j.jagp.2020.07.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Changing demographics have created substantial unmet needs for mental health and physical disability services for immigrant and racial/ethnic minority elders. Workforce shortages can be reduced by task-shifting to community health workers (CHWs) who speak the same language and share the culture of these elders. Yet, implementation of interventions offered by CHWs requires adaptations of content and delivery, ideally under clinical supervision. OBJECTIVE To culturally adapt two evidence-based interventions, offered in community settings, to address mental health and physical disability prevention for diverse minority elders. METHODS We followed the Castro-Barrera stepped model for cultural adaptation of two evidence-based interventions into one combined program of disability management and prevention delivered by CHWs. We used feedback from key stakeholders, including four clinical supervisors, 16 CHWs, 17 exercise trainers, and 153 participants, collected at three time points to further adapt the intervention to a diverse population of elders. RESULTS Adaptations for administration by CHWs/exercise trainers included: systematization of supervision process, increased flexibility in sessions offered per participants' needs, inclusion of self-care content, modification of materials to better reflect elders' daily life experiences, and greater focus on patient engagement in care. Areas for additional adaptation included enhancing examples with culturally relevant metaphors, incorporating visual aids, and training CHWs in the importance of building trust. CONCLUSION This study identifies key aspects of the cultural adaptation process that facilitates broader cultural sensitivity of service delivery by CHWs to diverse elders in community settings.
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Affiliation(s)
- Irene Falgas-Bague
- Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA; Department of Medicine, Harvard Medical School, Boston, MA.
| | - Zorangeli Ramos
- Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Paola del Cueto
- Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Emily Kim
- Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jenny Zhen-Duan
- Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Yankau Josephine Wong
- Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ching-King Chieng
- Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Walter Frontera
- Departments of Physical Medicine, Rehabilitation and Sports Medicine and Physiology and Biophysics, University of Puerto Rico, Río Piedras, Puerto Rico
| | - Margarita Alegría
- Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Department of Medicine, Harvard Medical School, Boston, MA, USA,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Raue PJ, Dawson A, Hoeft T, Russo J, Ferguson D, Green L, Petersky C, Kaplan C. Acceptability of a lay-delivered intervention for depression in senior centers. Aging Ment Health 2021; 25:445-452. [PMID: 31799880 PMCID: PMC7269871 DOI: 10.1080/13607863.2019.1698515] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We examined: 1. depression rates among senior center clients; and 2. the acceptability of a lay-delivered intervention for depression ("Do More, Feel Better") from the perspective of key stakeholders prior to its implementation. METHOD We conducted cross-sectional surveys at four Seattle-area senior centers of 140 clients, 124 volunteers, and 12 administrators and staff. Client measures included the Patient Health Questionnaire-9 (PHQ-9) to determine depression severity, and items assessing depression treatment preferences. Following description of "Do More, Feel Better" as a lay-delivered intervention focused on increasing participation in rewarding activities, we used quantitative and qualitative items to assess acceptability to: 1. clients participating in; 2. volunteers administering; and 3. administrators and staff supporting the intervention. RESULTS 25% of senior center clients (35/140) endorsed elevated depressive symptoms (PHQ-9 ≥ 10). 81% of clients (114/140) reported that they would consider participating in "Do More, Feel Better," and 59% percent of volunteers (73/123) expressed interest in learning how to assist others using the intervention. Administrators and staff reported high comfort levels with proposed volunteer training procedures, and they identified funding and staffing considerations as challenges to sustaining the intervention. CONCLUSION Findings indicate high depression rates among senior center clients and support the acceptability of lay-delivered behavioral interventions for depression from a variety of stakeholders. Further investigation of the feasibility, effectiveness, and implementation of "Do More, Feel Better" is warranted, particularly in the context of a lack of health care professionals available to meet the mental health needs of older adults.
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Affiliation(s)
| | | | | | - Joan Russo
- University of Washington School of Medicine
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Effectiveness of a Disability Preventive Intervention for Minority and Immigrant Elders: The Positive Minds-Strong Bodies Randomized Clinical Trial. Am J Geriatr Psychiatry 2019; 27:1299-1313. [PMID: 31494015 PMCID: PMC6842701 DOI: 10.1016/j.jagp.2019.08.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/08/2019] [Accepted: 08/08/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To test the acceptability and effectiveness of a disability prevention intervention, Positive Minds-Strong Bodies (PMSB), offered by paraprofessionals to mostly immigrant elders in four languages. DESIGN Randomized trial of 307 participants, equally randomized into intervention or enhanced usual care. SETTING Community-based organizations in Massachusetts, New York, Florida, and Puerto Rico serving minority elders. Data collected at baseline, 2, 6, and 12 months, between May 2015 and March 2019. PARTICIPANTS English-, Spanish-, Mandarin-, or Cantonese-speaking adults, age 60+, not seeking disability prevention services, but eligible per elevated mood symptoms and minor to moderate physical dysfunction. INTERVENTIONS Ten individual sessions of cognitive behavioral therapy (PM) concurrently offered with 36 group sessions of strengthening exercise training (SB) over 6 months compared to enhanced usual care. MEASUREMENTS Acceptability defined as satisfaction and attendance to >50% of sessions. Effectiveness determined by changes in mood symptoms (HSCL-25 and GAD-7), functional performance (SPPB), self-reported disability (LLFDI), and disability days (WHODAS 2.0). RESULTS Around 77.6% of intervention participants attended over half of PM Sessions; 53.4% attended over half of SB sessions. Intent-to-treat analyses at 6 months showed significant intervention effects: improved functioning per SPPB and LLFDI, and lowered mood symptoms per HSCL-25. Intent-to-treat analyses at 12 months showed that effects remained significant for LLFDI and HSCL-25, and disability days (per WHODAS 2.0) significantly decreased 6-month after the intervention. CONCLUSIONS PMSB offered by paraprofessionals in community-based organizations demonstrates good acceptability and seems to improve functioning, with a compliance-benefit effect showing compliance as an important determinant of the intervention response.
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Raue PJ, Sirey JA, Dawson A, Berman J, Bruce ML. Lay-delivered behavioral activation for depressed senior center clients: Pilot RCT. Int J Geriatr Psychiatry 2019; 34:1715-1723. [PMID: 31368583 PMCID: PMC6803033 DOI: 10.1002/gps.5186] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 07/28/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We describe the development of a lay-delivered behavioral intervention ("Do More, Feel Better") for depressed senior center clients, and we present preliminary data from a pilot randomized controlled trial (RCT) on (a) the feasibility of training lay volunteers to fidelity and (b) the acceptability, impact, and safety of the intervention. METHODS We trained 11 volunteers at two aging service settings in "Do More, Feel Better" and randomized 18 depressed clients to receive the intervention or referral to mental health services. RESULTS Pilot data indicated that we can successfully train and certify 64% of older volunteers and that depressed clients receiving the intervention reported high levels of session attendance and satisfaction. While there were no significant differences in 12-week reduction in Hamilton Depression Rating Scale scores between groups, intervention clients showed an 8-point reduction in comparison with a 0-point reduction among referral clients. CONCLUSIONS "Do More, Feel Better" has the potential of transferring evidence-based behavioral interventions to the hands of supervised lay volunteers and can address the insufficient workforce providing geriatric mental health services.
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Zuverink A, Xiang X. Anxiety and Unmet Needs for Assistance With Daily Activities Among Older Adults. J Aging Health 2019; 32:491-500. [DOI: 10.1177/0898264319830805] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To examine the potentially bidirectional relationship between anxiety symptoms and unmet needs for assistance with daily activities among older adults. Method: Data came from the National Health and Aging Trends Study, 2011 through 2016 surveys. The study sample consisted of 3,936 Medicare beneficiaries with activity limitations at baseline, aged 65 or older. Cox proportional hazards regression was used to test the proposed relationship between anxiety symptoms and unmet needs for assistance with daily activities. Result: Having unmet needs increased the risk of the onset of anxiety symptoms, and elevated anxiety symptoms increased the risk of incident unmet needs for assistance with daily activities. Conclusion: Anxiety symptoms and unmet needs form a bidirectional relationship. Integrated mental health and community-based long-term care services may help reduce the burden of late-life anxiety disorders and stressful life incidents contributing to disability.
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Affiliation(s)
- Ashley Zuverink
- University of Michigan School of Social Work, Ann Arbor, USA
| | - Xiaoling Xiang
- University of Michigan School of Social Work, Ann Arbor, USA
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Major Depression and Subthreshold Depression among Older Adults Receiving Home Care. Am J Geriatr Psychiatry 2018; 26:939-949. [PMID: 29884541 PMCID: PMC6108943 DOI: 10.1016/j.jagp.2018.05.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 05/02/2018] [Accepted: 05/03/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aims to estimate the prevalence and correlates of major and subthreshold depression and the extent of treatment utilization in older adults receiving home care. METHODS The study sample included 811 community-dwelling adults aged 60 and over who received paid home care during the 2008-2014 waves of the Health and Retirement Study. Depression was assessed using short forms of the Composite International Diagnostic Interview and the Center for Epidemiologic Studies Depression Scale. Logistic regression was used to examine correlates of depression type and treatment utilization. RESULTS One in two older home care recipients suffered from probable depression; 13.4% of the sample suffered from major depression and an additional 38.7% met study criteria for subthreshold depression. The majority (72.7%) of participants with major depression and almost half (44.5%) of participants with subthreshold depression reported taking medication for anxiety or depression. One-third (33.2%) of older home care recipients with major depression and 14.2% of those with subthreshold depression reported receiving formal psychiatric or psychological treatment. Males as compared with females and persons with pain problems as compared with no pain complaints had a higher risk of subthreshold and major depression. The receipt of medication or psychiatric treatment declined with age. African Americans were less likely to receive medication for anxiety or depression compared with non-Hispanic whites. CONCLUSION Depression affects a substantial proportion of older adults receiving home care and may be inappropriately treated. Future research is needed to develop optimal strategies for integrating depression assessment and treatment into home care.
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Smith ML, Bergeron CD, Ahn S, Towne SD, Mingo CA, Robinson KT, Mathis J, Meng L, Ory MG. Engaging the Underrepresented Sex: Male Participation in Chronic Disease Self-Management Education (CDSME) Programs. Am J Mens Health 2018; 12:935-943. [PMID: 29355070 PMCID: PMC6131430 DOI: 10.1177/1557988317750943] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 08/30/2017] [Accepted: 10/31/2017] [Indexed: 12/13/2022] Open
Abstract
Females are more likely than males to participate in evidence-based health promotion and disease prevention programs targeted for middle-aged and older adults. Despite the availability and benefits of Stanford's Chronic Disease Self-Management Education (CDSME) programs, male participation remains low. This study identifies personal characteristics of males who attended CDSME program workshops and identifies factors associated with successful intervention completion. Data were analyzed from 45,375 male CDSME program participants nationwide. Logistic regression was performed to examine factors associated with workshop attendance. Males who were aged 65-79 (OR = 1.27, p < .001), Hispanic (OR = 1.22, p < .001), African American (OR = 1.13, p < .001), Asian/Pacific Islander (OR = 1.26, p < .001), Native Hawaiian (OR = 3.14, p < .001), and residing in nonmetro areas (OR = 1.26, p < .001) were more likely to complete the intervention. Participants with 3+ chronic conditions were less likely to complete the intervention (OR = 0.87, p < .001). Compared to health-care organization participants, participants who attended workshops at senior centers (OR = 1.38, p < .001), community/multipurpose facilities (OR = 1.21, p < .001), and faith-based organizations (OR = 1.37, p < .001) were more likely to complete the intervention. Men who participated in workshops with more men were more likely to complete the intervention (OR = 2.14, p < .001). Once enrolled, a large proportion of males obtained an adequate intervention dose. Findings highlight potential strategies to retain men in CDSME programs, which include diversifying workshop locations, incorporating Session Zero before CDSME workshops, and using alternative delivery modalities (e.g., online).
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Affiliation(s)
- Matthew Lee Smith
- Center for Population Health and Aging,
Texas A&M University, College Station, TX, USA
- Department of Environmental and
Occupational Health, School of Public Health, Texas A&M University, College
Station, TX, USA
- Department of Health Promotion and
Behavior, College of Public Health, The University of Georgia, Athens, GA, USA
| | | | - SangNam Ahn
- Center for Population Health and Aging,
Texas A&M University, College Station, TX, USA
- Division of Health Systems Management
and Policy, School of Public Health, The University of Memphis, Memphis, TN,
USA
| | - Samuel D. Towne
- Center for Population Health and Aging,
Texas A&M University, College Station, TX, USA
- Department of Health Promotion and
Community Health Sciences, School of Public Health, Texas A&M University,
College Station, TX, USA
| | - Chivon A. Mingo
- Gerontology Institute, College of Arts
& Sciences, Georgia State University, Atlanta, GA, USA
| | - Kayin T. Robinson
- Department of Health Promotion and
Behavior, College of Public Health, The University of Georgia, Athens, GA, USA
| | - Jamarcus Mathis
- Department of Health Promotion and
Behavior, College of Public Health, The University of Georgia, Athens, GA, USA
| | - Lu Meng
- Department of Environmental and
Occupational Health, School of Public Health, Texas A&M University, College
Station, TX, USA
| | - Marcia G. Ory
- Center for Population Health and Aging,
Texas A&M University, College Station, TX, USA
- Department of Environmental and
Occupational Health, School of Public Health, Texas A&M University, College
Station, TX, USA
- Department of Health Promotion and
Community Health Sciences, School of Public Health, Texas A&M University,
College Station, TX, USA
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14
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Xiang X, Danilovich MK, Tomasino KN, Jordan N. Depression prevalence and treatment among older home health services users in the United States. Arch Gerontol Geriatr 2018; 75:151-157. [DOI: 10.1016/j.archger.2017.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 02/19/2017] [Accepted: 12/10/2017] [Indexed: 01/20/2023]
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15
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Maslow K, Fortinsky RH. Nonphysician Care Providers Can Help to Increase Detection of Cognitive Impairment and Encourage Diagnostic Evaluation for Dementia in Community and Residential Care Settings. THE GERONTOLOGIST 2018; 58:S20-S31. [DOI: 10.1093/geront/gnx171] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Indexed: 11/13/2022] Open
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16
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Kunik ME, Mills WL, Amspoker AB, Cully JA, Kraus-Schuman C, Stanley M, Wilson NL. Expanding the geriatric mental health workforce through utilization of non-licensed providers. Aging Ment Health 2017; 21:954-960. [PMID: 27243369 PMCID: PMC5568805 DOI: 10.1080/13607863.2016.1186150] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES We evaluate policy and practice strategies for bolstering the geriatric mental healthcare workforce and describe costs and considerations of implementing one approach. METHOD Narrative overview of the literature and policy retrieved from searches of databases, hand searches, and authoritative texts. We identified three proposed strategies to increase the geriatric mental healthcare workforce: (1) production of more geriatric mental health providers; (2) team-based care; and (3) non-licensed providers. We evaluate each in terms of challenges and potential and provide estimates of costs, policy, and practice considerations for training, employing, and supervising non-licensed mental health providers. RESULTS Use of non-licensed providers is key to reforms needed to allow a more older adults to access necessary mental healthcare. Licensed and non-licensed providers have achieved similar improvements for generalized anxiety disorder among patients, although non-licensed providers did so at a lower cost. CONCLUSION Supervised non-licensed providers can extend the reach of licensed providers for specific mental health conditions, resulting in lower costs and increased number of patients treated. Although several barriers to implementation exist, policy and infrastructure changes that may support this type of care delivery model are emerging from reforms in financing and associated delivery initiatives created by the Affordable Care Act.
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Affiliation(s)
- Mark E. Kunik
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe, Houston, TX 77030, 713-791-1414,Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, 713-798-4951,South Central Mental Illness Research, Education and Clinical Center, 2002 Holcombe, Houston, TX 77030, 713-791-1414
| | - Whitney L. Mills
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe, Houston, TX 77030, 713-791-1414,Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, 713-798-4951
| | - Amber B. Amspoker
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe, Houston, TX 77030, 713-791-1414,Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, 713-798-4951
| | - Jeffrey A. Cully
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe, Houston, TX 77030, 713-791-1414,Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, 713-798-4951,South Central Mental Illness Research, Education and Clinical Center, 2002 Holcombe, Houston, TX 77030, 713-791-1414
| | - Cynthia Kraus-Schuman
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, 713-798-4951,Michael E. DeBakey VA Medical Center, 2002 Holcombe, Houston, TX 77030, 713-791-1414
| | - Melinda Stanley
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe, Houston, TX 77030, 713-791-1414,Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, 713-798-4951,South Central Mental Illness Research, Education and Clinical Center, 2002 Holcombe, Houston, TX 77030, 713-791-1414
| | - Nancy L. Wilson
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe, Houston, TX 77030, 713-791-1414,Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, 713-798-4951
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17
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Calmer Life: A Hybrid Effectiveness-implementation Trial for Late-life Anxiety Conducted in Low-income, Mental Health-Underserved Communities. J Psychiatr Pract 2017; 23:180-190. [PMID: 28492456 PMCID: PMC5448556 DOI: 10.1097/pra.0000000000000234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Anxiety is common among older adults and is associated with multiple negative outcomes. Late-life anxiety is usually unrecognized by providers and undertreated, although evidence supports the effectiveness of psychosocial treatment. Access to mental health care is especially poor among African American seniors. New treatment models are needed to expand the reach of mental health care to minority elders. METHODS Our article outlines a study designed to test the effectiveness and implementation potential of Calmer Life (CL), a community-based, person-centered, flexible and culturally tailored intervention for late-life anxiety and worry, offered in low-income, mental health-underserved and predominantly African American communities. CL is skills-based, but also includes resource counseling and an option to integrate religion/spirituality. The study population includes individuals 50 years of age and older who are experiencing high levels of worry. The program was developed in the context of a community-academic partnership with organizations that provide services for seniors in underserved communities, and it trains nontraditional community providers to deliver the intervention. RESULTS Study progress to date, challenges, and lessons learned are discussed. Data collection is ongoing, and study findings will be available in late 2017. CONCLUSIONS CL will offer valuable information to help expand the reach of anxiety treatment among minority seniors living in underserved neighborhoods.
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18
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Barrera TL, Cummings JP, Armento M, Cully JA, Bush Amspoker A, Wilson NL, Mallen MJ, Shrestha S, Kunik ME, Stanley MA. Telephone-Delivered Cognitive-Behavioral Therapy for Older, Rural Veterans with Depression and Anxiety in Home-Based Primary Care. Clin Gerontol 2017; 40:114-123. [PMID: 28452676 DOI: 10.1080/07317115.2016.1254133] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Rural, homebound older adults are at increased risk for anxiety and depression and have limited access to mental health services. These individuals face many barriers to receiving evidence-based mental health treatment and would benefit from interventions that increase access to and efficiency of care. The aim of this study was to evaluate use of a telephone-delivered, modular, cognitive behavioral therapy (CBT) intervention for both late-life depression and anxiety delivered to rural, homebound Veterans. METHODS Three cases are presented to illustrate the flexible adaptation of the intervention for use among older Veterans enrolled in home-based primary care, with varying symptom presentations and functional limitations. The Veterans received 7 to 9 sessions of the CBT intervention, with ordering of skill modules based on symptom presentation and determined collaboratively between patient and therapist. RESULTS The three Veterans showed improvement in depression and/or anxiety symptoms following treatment and provided positive feedback regarding their experiences in this program. CONCLUSIONS These results suggest that telephone-delivered CBT is acceptable to older adults and can be tailored to individual patient needs. CLINICAL IMPLICATIONS Clinicians should consider telephone-delivered CBT as an alternate mode of therapy to increase access to mental health care for rural, homebound individuals with depression and anxiety.
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Affiliation(s)
- Terri L Barrera
- a Houston VA HSR&D Center for Innovations in Quality , Effectiveness and Safety, Michael E. DeBakey VAMC , Houston , Texas , USA.,b Baylor College of Medicine , Houston , Texas , USA.,c VA South Central Mental Illness Research, Education and Clinical Center , Houston , Texas , USA
| | | | - Maria Armento
- b Baylor College of Medicine , Houston , Texas , USA
| | - Jeffrey A Cully
- a Houston VA HSR&D Center for Innovations in Quality , Effectiveness and Safety, Michael E. DeBakey VAMC , Houston , Texas , USA.,b Baylor College of Medicine , Houston , Texas , USA.,c VA South Central Mental Illness Research, Education and Clinical Center , Houston , Texas , USA
| | - Amber Bush Amspoker
- a Houston VA HSR&D Center for Innovations in Quality , Effectiveness and Safety, Michael E. DeBakey VAMC , Houston , Texas , USA.,b Baylor College of Medicine , Houston , Texas , USA
| | - Nancy L Wilson
- a Houston VA HSR&D Center for Innovations in Quality , Effectiveness and Safety, Michael E. DeBakey VAMC , Houston , Texas , USA.,b Baylor College of Medicine , Houston , Texas , USA
| | - Michael J Mallen
- e Minneapolis Veterans Affairs Health Care System , Minneapolis , Minnesota , USA
| | - Srijana Shrestha
- b Baylor College of Medicine , Houston , Texas , USA.,f University of St. Thomas , Houston , Texas , USA
| | - Mark E Kunik
- a Houston VA HSR&D Center for Innovations in Quality , Effectiveness and Safety, Michael E. DeBakey VAMC , Houston , Texas , USA.,b Baylor College of Medicine , Houston , Texas , USA.,c VA South Central Mental Illness Research, Education and Clinical Center , Houston , Texas , USA
| | - Melinda A Stanley
- a Houston VA HSR&D Center for Innovations in Quality , Effectiveness and Safety, Michael E. DeBakey VAMC , Houston , Texas , USA.,b Baylor College of Medicine , Houston , Texas , USA.,c VA South Central Mental Illness Research, Education and Clinical Center , Houston , Texas , USA
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19
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García-Alberca JM. Cognitive-behavioral treatment for depressed patients with Alzheimer's disease. An open trial. Arch Gerontol Geriatr 2017; 71:1-8. [PMID: 28237746 DOI: 10.1016/j.archger.2017.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 02/05/2017] [Accepted: 02/07/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Depression has a high prevalence among patients with Alzheimer's disease, and it has a significant negative impact on their functioning. However, despite its significant impact and challenge, few treatment outcomes data are available to guide clinical care of depression among this population. We developed a cognitive-behavioral intervention to persons with AD. In this paper, we describe the intervention and results of an open trial evaluating its feasibility and utility. SETTING Dementia Unit. SUBJECT Alzheimer's disease patients. METHODS The treatment was administered over a period of three months with the implication of a caregiver. Dyads were followed for an additional three months in-person sessions. A selection of skills is offered, including education and self-awareness, coping self-statements, behavioral activation, problem-solving therapy, exercise, and caregiver education. RESULTS Nine participants were enrolled. Overall, patients and caregivers were satisfied with the treatment and reported that they benefited-in terms of depression, anxiety, and caregiver distress. CONCLUSIONS These findings are preliminaries and attention now needs to be turned to futher evaluation in a randomized clinical trial.
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20
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Yang F, Lou VWQ. Community Restructuring and Depressive Symptoms of Rural Mature and Elderly Adults: A Multilevel Analysis Based on a National Dataset in China. Community Ment Health J 2017; 53:34-38. [PMID: 27245229 DOI: 10.1007/s10597-016-0020-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 05/26/2016] [Indexed: 11/25/2022]
Abstract
Community restructuring is an important predictor for residents' mental health. However, few studies have investigated how it affects the depressive symptoms of rural ageing population. Using cross-sectional data from China Health and Retirement Longitudinal Study (CHARLS), this study examined how community restructuring was associated with depressive symptoms of Chinese rural mature and older adults and what community-level factors mediated the association. We found that people in restructuring communities reported .75 unit lower depression score (p < .01); community restructuring is associated with more infrastructure, recreational amenities, and grassroots organization (p < .001) in the community; and the availability of infrastructure (p < .01) and grassroots organization (p < .05) had significant indirect effect on the association between community restructuring and depressive symptoms. World countries' urbanization policy shall not only focus on community physical environment, but also on the development of grassroots organizations that involve and connect local people.
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Affiliation(s)
- Fan Yang
- School of International and Public Affairs, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, China.
| | - Vivian W Q Lou
- Department of Social Work and Social Administration, Sau Po Center on Aging, The University of Hong Kong, Hong Kong, China
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21
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Delaney C, Barrere C, Grimes R, Apostolidis B. Testing of a Statewide Initiative to Enhance Depression Care in Older Home Care Patients. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2016. [DOI: 10.1177/1084822316642752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Late-life depression is becoming increasingly prevalent among older adults in the United States and is predictive of a wide range of negative health-related outcomes. Fourteen home care agencies participated in a quasi-experimental, pre-test, post-test design of a depression screening training program nested within a two-cycle, phased introduction of the intervention. The primary aim of this study was to evaluate the effects of the program at three levels of outcomes: the trainers, the trainees, and the agencies. There was a significant increase in the knowledge and self-efficacy of the trainers and trainees and a trend toward decreased hospitalization.
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22
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Gum AM, Dautovich ND, Greene J, Hirsch A, Schonfeld L. Improving home-based providers' communication to primary care providers to enhance care coordination. Aging Ment Health 2015; 19:921-31. [PMID: 25401276 DOI: 10.1080/13607863.2014.977772] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Health care system fragmentation is a pervasive problem. Research has not delineated concrete behavioral strategies to guide providers to communicate with personnel in other organizations to coordinate care. We addressed this gap within a particular context: home-based providers delivering depression care management (DCM) to older adults requiring coordination with primary care personnel. Our objective was to pilot test a communication protocol ('BRIDGE - BRinging Inter-Disciplinary Guidelines to Elders') in conjunction with DCM. METHOD In an open pilot trial (N = 7), home-based providers delivered DCM to participants. Following the BRIDGE protocol, home-based providers made scripted telephone calls and sent structured progress reports to personnel in participants' primary care practices with concise information and requests for assistance. Home-based providers documented visits with participants, contacts to and responses from primary care personnel. A research interviewer assessed participant outcomes [Symptom Checklist-20 (depressive symptoms), World Health Organization Disability Assessment Schedule-12, satisfaction] at baseline, three months, and six months. RESULTS Over 12 months, home-based providers made 2.4 telephone calls and sent 6.3 faxes to other personnel, on average per participant. Primary care personnel responded to 18 of 22 requests (81.8%; 2 requests dropped, 2 ongoing), with at least one response per participant. Participants' depressive symptoms and disability improved significantly at both post-tests with large effect sizes (d ranged 0.73-2.3). Participants were satisfied. CONCLUSION Using BRIDGE, home-based providers expended a small amount of effort to communicate with primary care personnel, who responded to almost all requests. Larger scale research is needed to confirm findings and potentially extend BRIDGE to other client problems, professions, and service sectors.
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Affiliation(s)
- Amber M Gum
- a Department of Mental Health Law and Policy, Louis de la Parte Florida Mental Health Institute , University of South Florida , Tampa , FL , USA
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23
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Gitlin LN, Harris LF, McCoy MC, Hess E, Hauck WW. Delivery Characteristics, Acceptability, and Depression Outcomes of a Home-based Depression Intervention for Older African Americans: The Get Busy Get Better Program. THE GERONTOLOGIST 2015; 56:956-65. [PMID: 26608333 DOI: 10.1093/geront/gnv117] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 06/18/2015] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Laura N Gitlin
- Johns Hopkins University School of Nursing Center for Innovative Care in Aging, Johns Hopkins University, Baltimore, Maryland.
| | | | | | - Edward Hess
- University of Colorado, Denver, Aurora, Colorado
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24
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Nguyen D, Bornheimer LA. Mental health service use types among Asian Americans with a psychiatric disorder: considerations of culture and need. J Behav Health Serv Res 2015; 41:520-8. [PMID: 24402440 DOI: 10.1007/s11414-013-9383-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Despite levels of need that are comparable with other groups, relatively few Asian Americans receive mental health care. While studies have described the tendency for Asian Americans to delay care until mental health symptoms are severe, relatively little research has examined how the severity of symptoms impact mental health service use. This study uses publicly available data from the National Latino and Asian American Study (NLAAS) and focuses solely on Asian American respondents with a psychiatric disorder (n = 230). Unexpectedly, few Asian Americans with a psychiatric disorder received care in a medical setting. The perception of mental health needs increased the likelihood of using mental health specialist care. Social and systemic barriers together hinder mental health service use. Implications for addressing Asian American mental health service use within a changing health care environment are discussed.
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Affiliation(s)
- Duy Nguyen
- Silver School of Social Work, New York University, 1 Washington Square North, New York, NY, 10003-6654, USA,
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25
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Enabling lay providers to conduct CBT for older adults: key steps for expanding treatment capacity. Transl Behav Med 2015; 5:247-53. [PMID: 26327929 DOI: 10.1007/s13142-015-0306-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The Institute of Medicine advocates the examination of innovative models of care to expand mental health services available for older adults. This article describes training and supervision procedures in a recent clinical trial of cognitive behavioral therapy (CBT) for older adults with generalized anxiety disorder (GAD) delivered by bachelor-level lay providers (BLPs) and to Ph.D.-level expert providers (PLPs). Supervision and training differences, ratings by treatment integrity raters (TIRs), treatment characteristics, and patient perceptions between BLPs and PLPs are examined. The training and supervision procedures for BLPs led to comparable integrity ratings, patient perceptions, and treatment characteristics compared with PLPs. These results support this training protocol as a model for future implementation and effectiveness trials of CBT for late-life GAD, with treatment delivered by lay providers supervised by a licensed provider in other practice settings.
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26
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Examining functional and social determinants of depression in community-dwelling older adults: implications for practice. Geriatr Nurs 2015; 35:236-40. [PMID: 24942525 DOI: 10.1016/j.gerinurse.2014.04.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Coping with declining health, physical illnesses and complex medical regimens, which are all too common among many older adults, requires significant lifestyle changes and causes increasing self-management demands. Depression occurs in community-dwelling older adults as both demands and losses increase, but this problem is drastically underestimated and under-recognized. Depressive symptoms are often attributed to physical illnesses and thus overlooked, resulting in lack of appropriate treatment and diminished quality of life. The purpose of this study is to assess prevalence of depressive symptoms in community-dwelling older adults with high levels of co-morbidity and to identify correlates of depression. In this sample of 533 homebound older adults screened (76.1% female, 71.8% white, mean age 78.5 years) who were screened using the Geriatric Depression Scale (SF), 35.9% scored greater than 5. Decreased satisfaction with family support (p << 0.001) and functional status (p ≤ 0.001) and increased loneliness (p < 0.001) were significant independent predictors of depression status in this sample; thus, these factors should be considered when planning care.
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27
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Choi S, Hasche L, Nguyen D. Effects of depression on the subsequent year's healthcare expenditures among older adults: two-year panel study. Psychiatr Q 2015; 86:225-41. [PMID: 25262007 DOI: 10.1007/s11126-014-9324-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This study investigated changes in depression status over 2 years and examined whether having depression in Year 1 is associated with greater healthcare expenditures in Year 2 among community-dwelling older adults. This study analyzed the Medical Expenditure Panel Survey (Panel 13, 2008-2009) for a nationally representative sample of 1,740 older adults (65+). The two self-reported depression measures used were the ICD-9-CM (depression) and Patient Health Questionnaire-2 (potential depression, scores 3 or higher). Using the combined two-part models, additional healthcare costs at Year 2 associated with the Year 1 depression status were calculated by the service type after adjusting for predisposing, enabling, and need covariates assessed at Year 2. Over 7.9% of older adults reported depression and an additional 6.5% presented with potential depression. The ICD-9 depression status was relatively stable; 84% continued reporting depression during Year 2. Those with depression at Year 1 spent $3,855 more on total healthcare, $1,053 more on office-based visits, and $929 more on prescription drugs during Year 2 compared with non-depressed people after controlling for other covariates, including healthcare needs (p < .05). While potential depression was less persistent (31.1% remained potentially depressed at Year 2), potential depression was associated with lower socio-economic status and greater healthcare expenditures from home health services and emergency department visits during Year 2. These results indicate the importance of monitoring depression in older adults, considering its impacts on the increases in healthcare expenditures in the following year even after controlling for co-occurring health conditions.
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Affiliation(s)
- Sunha Choi
- College of Social Work, The University of Tennessee, 322 Henson Hall, 1618 Cumberland Ave., Knoxville, TN, 37996-3333, USA,
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Kolb P, Conway F. Roles for education in development and implementation of evidence-based practices for community programs for older adults. GERONTOLOGY & GERIATRICS EDUCATION 2015; 36:226-241. [PMID: 25950811 DOI: 10.1080/02701960.2015.1031895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
It is essential for key stakeholders in evidence-based practice (EBP) to be informed about barriers and achievements in EBP and collaborate in developing and implementing EBP. This article provides information to assist educators, students, practitioners, clients, and researchers who are stakeholders in use of EBP in community-based aging programs to understand barriers to EBP and approaches for developing and implementing EBP. Highlighting roles of education in EBP, the authors describe barriers to EBP; use of education to address gaps among research, education, and practice for EBP; cultural competence; and educational approaches for community-based implementation. EBP has been central to development of quality health and social services for older adults, but challenges remain in translation of research findings into EBP. Examples of programs in which research, education, and practice are linked for provision of EBP, as well as educational resources and tools for developing and implementing EBP, are identified.
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Affiliation(s)
- Patricia Kolb
- a Department of Social Work , Lehman College, CUNY , Bronx , New York , USA
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29
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Polenick CA, Flora SR. Behavioral activation for depression in older adults: theoretical and practical considerations. THE BEHAVIOR ANALYST 2015; 36:35-55. [PMID: 25729131 DOI: 10.1007/bf03392291] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Late-life depression (LLD) is a major public health concern that can have devastating effects on older individuals and their families. Behavioral theories predict that decreases in response-contingent positive reinforcement and increases in negatively reinforced avoidance behaviors, often accompanied by aversive life events, result in the selection and maintenance of depression. Based on these theories, behavioral activation treatments for depression are designed to facilitate structured increases in enjoyable activities that increase opportunities for contact with positive reinforcement. We discuss the applicability of behavioral models for LLD, and we briefly review current behavioral activation interventions for LLD with an emphasis on implications for future behavior-analytic research. Behavioral activation has been demonstrated to be effective in reducing depression and increasing healthy behavior in older adults. Potential challenges and considerations for future research are discussed. We suggest that applied behavior analysts and clinical behavior analysts are particularly well suited to improve and expand on the knowledge base and practical application of behavioral activation interventions with this population.
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30
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Hasche LK, Lavery A. "As needed" case management across aging services in response to depression. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2015; 58:272-288. [PMID: 25587880 DOI: 10.1080/01634372.2014.1001931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 12/19/2014] [Indexed: 06/04/2023]
Abstract
A lack of clarity on how and where case management for older adults is delivered persists, even as evidence supports its use to respond to depression. We used in-depth interviews with managers (n = 20) and staff surveys (n = 142) from 17 service agencies to explore the provision of case management services in adult day services, homecare, senior centers, and supportive housing. Limited case management services were found. Barriers included limited time and resources, especially for senior centers and supportive housing. Results revealed a concern about the role, feasibility, and availability of case management for older adults within these settings.
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Affiliation(s)
- Leslie K Hasche
- a Graduate School of Social Work , University of Denver , Denver , Colorado , USA
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Lee HJ, Dugan E. How large is the gap between self-report and assessed mental health and does it impact older adult mental health service utilization? JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2014; 58:3-19. [PMID: 24971776 DOI: 10.1080/01634372.2014.919978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
We examined the relationship between self-reported and assessed mental health status and service use, using data from the Health and Retirement Study (N = 9,547). Twelve percent and thirty percent had inaccurate perceptions of their mood and memory status, respectively. No significant difference was found in the likelihood of service use between older adults who were unaware of current depressive symptoms and those who self-reported problems but had no assessed symptoms. Older adults who scored low in cognitive test were more likely to use services, regardless of self-reported memory status. Discrepancies between self-reported and assessed status may contribute to service utilization.
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Affiliation(s)
- Hyo Jung Lee
- a Department of Gerontology , University of Massachusetts Boston , Boston , USA
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Adapting manualized Behavioural Activation treatment for older adults with depression. COGNITIVE BEHAVIOUR THERAPIST 2014. [DOI: 10.1017/s1754470x14000038] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractThere is growing evidence that Behavioural Activation is an effective treatment for older adults with depression. However, there is a lack of detail given in studies about any adaptations made to interventions or efforts made to remove treatment barriers. Factors such as co-morbid physical health problems, cognitive impairment and problems with social support suggest there may be specific treatment considerations when developing interventions for this group. This article aims to describe adaptations made to a general adult Behavioural Activation manual using literature on treatment factors for older adults as an organizational framework. This information may be of use to mental health workers delivering behavioural interventions to older adults with depression and documents the initial phase of developing a complex intervention.
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Delaney C, Apostolidis B, Bartos S, Robbins R, Young AK. Pilot Testing of the Home Care Education, Assessment, Remote-Monitoring, and Therapeutic Activities Intervention. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2014. [DOI: 10.1177/1084822314530991] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The primary aim of this pilot study was to develop, implement, and test the feasibility and efficacy of the Home Care Education, Assessment, Remote-Monitoring, and Therapeutic Activities (HEART) trial, a nurse-directed multicomponent home care intervention. A total of 50 patients with a primary diagnosis of heart failure (HF) were assigned to the intervention ( n = 26) or control group ( n = 24) according to geographical location in a large multibranch Medicare-certified home health agency. Forty-six patients completed the study. Patients participating in the HEART intervention demonstrated significantly improved HF knowledge ( F = 1.31, p < .001) in comparison with control group patients’ at the study endpoint. There was a non-significant trend toward improved quality of life (QOL) and lower hospital readmission rates (6 patients vs. 9 patients) in the intervention group.
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Burnett J, Dyer CB, Halphen JM, Achenbaum WA, Green CE, Booker JG, Diamond PM. Four subtypes of self-neglect in older adults: results of a latent class analysis. J Am Geriatr Soc 2014; 62:1127-32. [PMID: 24802542 DOI: 10.1111/jgs.12832] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine whether there are subtypes of elder self-neglect (SN) with different risk factors that can be targeted using medical and social interventions. DESIGN Cohort study using archived data of Adult Protective Services (APS) substantiated cases of elder SN between January 1, 2004, and December 31, 2008. SETTING Houston, Harris County, Texas. PARTICIPANTS Adults aged 65 and older with APS region VI substantiated SN between January 1, 2004, and December 31, 2008 (N = 5,686). MEASUREMENTS Adult Protective Services caseworkers used the Client Assessment and Risk Evaluation (CARE) tool during home investigations, assessing risk of harm in the domains of living conditions, financial status, physical and medical status, mental health, and social connectedness. Latent class analysis was used to identify unique subtypes of elder SN. RESULTS Four unique subtypes of elder SN were identified, with approximately 50% of individuals manifesting physical and medical neglect problems. Other subtypes included environmental neglect (22%), global neglect (21%), and financial neglect (9%). Older age, Caucasian descent, and mental status problems were more strongly associated with global neglect behaviors. African Americans were more likely to experience financial and environmental neglect than Caucasians and non-white Hispanics. CONCLUSION Elder SN consists of unique subtypes that may be amenable to customized multidisciplinary interventions. Future studies are needed to determine whether these subtypes impose differential mortality risks and whether multidisciplinary tailored interventions can reduce SN and prevent early mortality.
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Affiliation(s)
- Jason Burnett
- Division of Geriatric and Palliative Medicine, School of Medicine, University of Texas Health Science Center, Houston, Texas; Texas Elder Abuse and Mistreatment Institute, Houston, Texas; Harris Health System, Houston, Texas
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Stanley MA, Wilson NL, Amspoker AB, Kraus-Schuman C, Wagener PD, Calleo JS, Cully JA, Teng E, Rhoades HM, Williams S, Masozera N, Horsfield M, Kunik ME. Lay providers can deliver effective cognitive behavior therapy for older adults with generalized anxiety disorder: a randomized trial. Depress Anxiety 2014; 31:391-401. [PMID: 24577847 DOI: 10.1002/da.22239] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 12/27/2013] [Accepted: 01/07/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The Institute of Medicine recommends developing a broader workforce of mental health providers, including nontraditional providers, to expand services for older adults. Cognitive behavior therapy (CBT) is effective for late-life generalized anxiety disorder (GAD), but no study has examined outcomes with delivery by lay providers working under the supervision of licensed providers. The current study examined the effects of CBT delivered by lay, bachelor-level providers (BLP) relative to Ph.D.-level expert providers (PLP), and usual care (UC) in older adults with GAD. METHODS Participants were 223 older adults (mean age, 66.9 years) with GAD recruited from primary care clinics at two sites and assigned randomly to BLP (n = 76), PLP (n = 74), or UC (n = 73). Assessments occurred at baseline and 6 months. CBT in BLP and PLP included core and elective modules (3 months: skills training; 3 months: skills review) delivered in person and by telephone, according to patient choice. RESULTS CBT in both BLP and PLP groups significantly improved GAD severity (GAD Severity Scale), anxiety (Spielberger State-Trait Anxiety Inventory; Structured Interview Guide for the Hamilton Anxiety Scale), depression (Patient Health Questionnaire), insomnia (Insomnia Severity Index), and mental health quality of life (Short-Form-12), relative to UC. Response rates defined by 20% reduction from pre- to posttreatment in at least three of four primary outcomes were higher for study completers in BLP and PLP relative to UC (BLP: 38.5%; PLP: 40.0%; UC: 19.1%). CONCLUSION Lay providers, working under the supervision of licensed providers, can deliver effective CBT.
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Affiliation(s)
- Melinda A Stanley
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Houston, Texas; Baylor College of Medicine, Houston, Texas; South Central Mental Illness Research, Education and Clinical Center (A Virtual Center), Houston, Texas
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Gallant MP, Pettinger TM, Coyle CL, Spokane LS. Results of a community translation of the "Women Take PRIDE" heart disease self-management program. J Appl Gerontol 2014; 34:244-62. [PMID: 24652881 DOI: 10.1177/0733464813483552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This article reports the results of a community demonstration of an evidence-based heart disease self-management program for older women. Women Take PRIDE (WTP) is a group-based education and behavior modification program, based on social cognitive theory, designed to enhance heart disease self-management among older women. We implemented the program in community settings with 129 participants. Evaluation data was collected at baseline and at 4- and 12-month follow-ups. Outcomes included general health status, functional health status, and knowledge. Results showed significant improvements in self-rated health, energy, social functioning, knowledge of community resources, and number, frequency, and bother of cardiac symptoms. These results demonstrate that an evidence-based heart disease self-management program can be effective at improving health and quality of life among older women with heart disease when implemented in community settings.
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Affiliation(s)
- Mary P Gallant
- Department of Health Policy, Management, & Behavior, School of Public Health, University at Albany, SUNY, Rensselaer, NY, USA
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Casten RJ, Brawer R, Haller JA, Hark LA, Henderer J, Leiby B, Murchison AP, Plumb J, Rovner BW, Weiss DM. Trial of a behavioral intervention to increase dilated fundus examinations in African–Americans aged over 65 years with diabetes. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.11.69] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Dowrick C, Chew-Graham C, Lovell K, Lamb J, Aseem S, Beatty S, Bower P, Burroughs H, Clarke P, Edwards S, Gabbay M, Gravenhorst K, Hammond J, Hibbert D, Kovandžić M, Lloyd-Williams M, Waheed W, Gask L. Increasing equity of access to high-quality mental health services in primary care: a mixed-methods study. PROGRAMME GRANTS FOR APPLIED RESEARCH 2013. [DOI: 10.3310/pgfar01020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BackgroundEvidence-based interventions exist for common mental health problems. However, many people are unable to access effective care because it is not available to them or because interactions with caregivers do not address their needs. Current policy initiatives focus on supply-side factors, with less consideration of demand.Aim and objectivesOur aim was to increase equity of access to high-quality primary mental health care for underserved groups. Our objectives were to clarify the mental health needs of people from underserved groups; identify relevant evidence-based services and barriers to, and facilitators of, access to such services; develop and evaluate interventions that are acceptable to underserved groups; establish effective dissemination strategies; and begin to integrate effective and acceptable interventions into primary care.Methods and resultsExamination of evidence from seven sources brought forward a better understanding of dimensions of access, including how people from underserved groups formulate (mental) health problems and the factors limiting access to existing psychosocial interventions. This informed a multifaceted model with three elements to improve access: community engagement, primary care quality and tailored psychosocial interventions. Using a quasi-experimental design with a no-intervention comparator for each element, we tested the model in four disadvantaged localities, focusing on older people and minority ethnic populations. Community engagement involved information gathering, community champions and focus groups, and a community working group. There was strong engagement with third-sector organisations and variable engagement with health practitioners and commissioners. Outputs included innovative ways to improve health literacy. With regard to primary care, we offered an interactive training package to 8 of 16 practices, including knowledge transfer, systems review and active linking, and seven agreed to participate. Ethnographic observation identified complexity in the role of receptionists in negotiating access. Engagement was facilitated by prior knowledge, the presence of a practice champion and a sense of coproduction of the training. We developed a culturally sensitive well-being intervention with individual, group and signposting elements and tested its feasibility and acceptability for ethnic minority and older people in an exploratory randomised trial. We recruited 57 patients (57% of target) with high levels of unmet need, mainly through general practitioners (GPs). Although recruitment was problematic, qualitative data suggested that patients found the content and delivery of the intervention acceptable. Quantitative analysis suggested that patients in groups receiving the well-being intervention improved compared with the group receiving usual care. The combined effects of the model included enhanced awareness of the psychosocial intervention among community organisations and increased referral by GPs. Primary care practitioners valued community information gathering and access to the Improving Access to Mental Health in Primary Care (AMP) psychosocial intervention. We consequently initiated educational, policy and service developments, including a dedicated website.ConclusionsFurther research is needed to test the generalisability of our model. Mental health expertise exists in communities but needs to be nurtured. Primary care is one point of access to high-quality mental health care. Psychosocial interventions can be adapted to meet the needs of underserved groups. A multilevel intervention to increase access to high-quality mental health care in primary care can be greater than the sum of its parts.Study registrationCurrent Controlled Trials ISRCTN68572159.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- C Dowrick
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - C Chew-Graham
- Institute of Population Health, University of Manchester, Manchester, UK
- Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - K Lovell
- Institute of Population Health, University of Manchester, Manchester, UK
| | - J Lamb
- Institute of Population Health, University of Manchester, Manchester, UK
| | - S Aseem
- Institute of Population Health, University of Manchester, Manchester, UK
| | - S Beatty
- Institute of Population Health, University of Manchester, Manchester, UK
| | - P Bower
- Institute of Population Health, University of Manchester, Manchester, UK
| | - H Burroughs
- Institute of Population Health, University of Manchester, Manchester, UK
- Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - P Clarke
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - S Edwards
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
- College of Medicine, Swansea University, Swansea, UK
| | - M Gabbay
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - K Gravenhorst
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - J Hammond
- Institute of Population Health, University of Manchester, Manchester, UK
| | - D Hibbert
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - M Kovandžić
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - M Lloyd-Williams
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - W Waheed
- Institute of Population Health, University of Manchester, Manchester, UK
| | - L Gask
- Institute of Population Health, University of Manchester, Manchester, UK
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Lysack C, Leach C, Russo T, Paulson D, Lichtenberg PA. DVD Training for Depression Identification and Treatment in Older Adults: A Two-Group, Randomized, Wait-List Control Study. Am J Occup Ther 2013; 67:584-93. [DOI: 10.5014/ajot.2013.008060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Abstract
OBJECTIVE. To test the effectiveness of an educational intervention aimed at improving mental health knowledge and skills in occupational therapists working with older rehabilitation patients.
METHOD. The DVD-format educational intervention was evaluated using a two-group randomized wait-list control design. Occupational therapists (n = 75) completed a 32-item knowledge questionnaire at three time points. Patient charts were reviewed (n = 960) at 3 months before and 3 and 6 months after DVD training to evaluate clinical practice change.
RESULTS. A two-way analysis of variance showed knowledge scores increased significantly for both groups after DVD training. A significant Group × Time interaction and significant main effects for time and group were found. Chart review data also showed significant increases in desired clinical behaviors in both groups after training. The greatest single item of clinical practice change was use of a standardized depression screen.
CONCLUSION. DVD-based training can significantly improve mental health practice.
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Affiliation(s)
- Cathy Lysack
- Cathy Lysack, PhD, OT(C), is Deputy Director and Professor of Occupational Therapy, Institute of Gerontology, Wayne State University, Room 231, Knapp Building, 87 East Ferry Street, Detroit, MI 48202;
| | - Carrie Leach
- Carrie Leach, MPA, is Manager, Community Based Research and Engagement, Institute of Gerontology, Wayne State University, Detroit
| | - Theresa Russo
- Theresa Russo is Education Program Coordinator, Alzheimer’s Association–Greater Michigan Chapter, Southfield
| | - Daniel Paulson
- Daniel Paulson, MA, is Doctoral Candidate, Department of Psychology, Wayne State University, Detroit, and Clinical Psychology Intern, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC
| | - Peter A. Lichtenberg
- Peter A. Lichtenberg, PhD, ABPP, is Director, Institute of Gerontology, and Professor of Psychology, Department of Psychiatry and Behavioral Neuroscience, Wayne State University, Detroit
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Stanley MA, Calleo J, Bush AL, Wilson N, Snow AL, Kraus-Schuman C, Paukert AL, Petersen NJ, Brenes GA, Schulz PE, Williams SP, Kunik ME. The peaceful mind program: a pilot test of a cognitive-behavioral therapy-based intervention for anxious patients with dementia. Am J Geriatr Psychiatry 2013; 21:696-708. [PMID: 23567399 PMCID: PMC3411894 DOI: 10.1016/j.jagp.2013.01.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 12/05/2011] [Accepted: 12/27/2011] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To assess feasibility and to conduct a preliminary evaluation of outcomes following Peaceful Mind, a cognitive-behavioral therapy-based intervention for anxiety in dementia, relative to usual care. DESIGN Pilot randomized controlled trial including assessments at baseline and 3 and 6 months. SETTING Houston, TX. PARTICIPANTS Thirty-two outpatients diagnosed with mild (47%) or moderate (53%) dementia receiving care through outpatient clinics at the Veterans Affairs medical center, Baylor College of Medicine, Harris County Hospital District, and community day centers for dementia, and their collaterals, who spent at least 8 hours a week with them. INTERVENTION Peaceful Mind included up to 12 weekly in-home sessions (mean: 8.7, SD: 2.27) during the initial 3 months and up to eight brief telephone sessions (mean: 5.4, SD: 3.17) during months 3-6, involving self-monitoring for anxiety, deep breathing, and optional skills (coping self-statements, behavioral activation, and sleep management). Patients learned skills, and collaterals served as coaches. In usual care, patients received diagnostic feedback, and providers were informed of inclusion status. MEASUREMENTS Neuropsychiatric Inventory-Anxiety subscale, Rating Anxiety in Dementia scale, Penn State Worry Questionnaire-Abbreviated, Geriatric Anxiety Inventory, Geriatric Depression Scale, Quality of Life in Alzheimer disease, Patient Health Questionnaire, and Client Satisfaction Questionnaire. RESULTS Feasibility was demonstrated with regard to recruitment, attrition, and treatment characteristics. At 3 months, clinicians rated patients receiving Peaceful Mind as less anxious, and patients rated themselves as having higher quality of life; collaterals reported less distress related to loved ones' anxiety. Although significant positive effects were not noted in other outcomes or at 6-month follow-up, the pilot nature of the trial prohibits conclusions about efficacy. CONCLUSIONS Results support that Peaceful Mind is ready for future comparative clinical trials.
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Affiliation(s)
- Melinda A. Stanley
- VA HSR&D Houston Center of Excellence, Houston, TX
,Michael E. DeBakey VA Medical Center, Houston, TX
,Baylor College of Medicine, Houston, TX
,VA South Central Mental Illness Research, Education and Clinical Center
| | - Jessica Calleo
- VA HSR&D Houston Center of Excellence, Houston, TX
,Baylor College of Medicine, Houston, TX
| | - Amber L. Bush
- VA HSR&D Houston Center of Excellence, Houston, TX
,Baylor College of Medicine, Houston, TX
| | - Nancy Wilson
- VA HSR&D Houston Center of Excellence, Houston, TX
,Baylor College of Medicine, Houston, TX
| | - A. Lynn Snow
- VA South Central Mental Illness Research, Education and Clinical Center
,Center for Mental Health and Aging, The University of Alabama, Tuscaloosa, AL
,Research and Development Service, Tuscaloosa VA Medical Center, Tuscaloosa, AL
| | | | | | - Nancy J. Petersen
- VA HSR&D Houston Center of Excellence, Houston, TX
,Michael E. DeBakey VA Medical Center, Houston, TX
| | | | - Paul E. Schulz
- The University of Texas Health Science Center at Houston, The Mischer Neuroscience Institute and Memorial Hermann Hospital, Houston, TX
| | | | - Mark E. Kunik
- VA HSR&D Houston Center of Excellence, Houston, TX
,Michael E. DeBakey VA Medical Center, Houston, TX
,Baylor College of Medicine, Houston, TX
,VA South Central Mental Illness Research, Education and Clinical Center
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Gum AM, Greene J, DeMuth A, Dautovich ND. Primary Care Physicians’ Attitudes Regarding Collaborating With Home-Based Depression Care Managers. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2013. [DOI: 10.1177/1084822313480178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Home-based case managers face many challenges to collaborating with primary care physicians, including for management of depression. To obtain physicians’ perspectives regarding optimal collaboration strategies, we conducted a mail survey of randomly selected primary care physicians ( N = 74). The survey described a home-based depression care management program to be delivered by case managers and assessed physicians’ preferred collaboration strategies. Most respondents perceived the services described as useful, including having the case manager send a list of medications and send psychotropic medication recommendations per consulting psychiatrist. Most physicians reported being likely to read a written summary sent by the case manager, reply, and send it back to the case manager. Preferred communication procedures varied widely. By considering physicians’ preferences, case managers may enhance collaboration.
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Paukert AL, Kraus-Schuman C, Wilson N, Snow AL, Calleo J, Kunik ME, Stanley MA. The Peaceful Mind manual: a protocol for treating anxiety in persons with dementia. Behav Modif 2013; 37:631-64. [PMID: 23447103 DOI: 10.1177/0145445513477420] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Anxiety disorders are highly prevalent among individuals with dementia and have a significant negative impact on their lives. Peaceful Mind is a form of cognitive-behavioral therapy for anxiety in persons with dementia. The Peaceful Mind manual was developed, piloted, and modified over 2 years. In an open trial and a small randomized, controlled trial, it decreased anxiety and caregiver distress. The treatment meets the unique needs of individuals with dementia by emphasizing behavioral rather than cognitive interventions, slowing the pace, limiting the material to be learned, increasing repetition and practice, using cues to stimulate memory, including a friend or family member in treatment as a coach, and providing sessions in the home. The manual presented here includes modules that teach specific skills, including awareness, breathing, calming self-statements, increasing activity, and sleep management, as well as general suggestions for treatment delivery.
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Affiliation(s)
- Amber L Paukert
- Puget Sound VA Medical Center, 1660 S. Columbian Way, Seattle, WA 98108, USA.
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Choi NG, Sirey JA, Bruce ML. Depression in Homebound Older Adults: Recent Advances in Screening and Psychosocial Interventions. CURRENT TRANSLATIONAL GERIATRICS AND EXPERIMENTAL GERONTOLOGY REPORTS 2013; 2:16-23. [PMID: 23459163 PMCID: PMC3582679 DOI: 10.1007/s13670-012-0032-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Homebound older adults are more likely than their ambulatory peers to suffer from depression. Unfortunately, the effectiveness of antidepressant medications alone in such cases is limited. Greater benefits might be realized if patients received both pharmacotherapy and psychotherapy to enhance their skills to cope with their multiple chronic medical conditions, isolation, and mobility impairment; however, referrals to specialty mental health services seldom succeed due to inaccessibility, shortage of geriatric mental health providers, and cost. Since a large proportion of homebound older adults receive case management and other services from aging services network agencies, the integration of mental health services into these agencies is likely to be cost-efficient and effective. This review summarizes recent advances in home-based assessment and psychosocial treatment of depression in homebound recipients of aging services.
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Affiliation(s)
- Namkee G. Choi
- The University of Texas at Austin School of Social Work, 1925 San Jacinto Blvd, Austin, TX 78712; ; 512-232-9590; 512-471-9600 (fax)
| | - Jo Anne Sirey
- Department of Psychiatry, Westchester Division, Weill Cornell Medical College, 21 Bloomingdale Road, White Plains, NY 10605; ; 914-997-4333; 914-682-6979 (fax)
| | - Martha L. Bruce
- Department of Psychiatry, Westchester Division, Weill Cornell Medical College, 21 Bloomingdale Road, White Plains, NY 10605; ; 914-997-5977
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Delaney C, Fortinsky R, Mills D, Doonan L, Grimes R, Rosenberg S, Pearson TL, Bruce ML. Pilot Study of a Statewide Initiative to Enhance Depression Care Among Older Home Care Patients. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2012. [DOI: 10.1177/1084822312465747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Late-life depression is prevalent in home care. This pilot study, part of a statewide initiative to enhance depression care, evaluated the influence of a 2-hour depression screening and intervention workshop on home care professionals’ knowledge, self-efficacy, and attitudes related to depression in older home care patients. A pretest, posttest design was used to evaluate the effects of the workshop with 280 home care professionals from 7 home care agencies. Following the depression workshop, participants’ knowledge levels in evidence-based screening and care for depressed older adults was significantly increased, t(280) = 16.49, p<.001. A significant increase in confidence and attitude ratings were found (p<.001). Findings from this pilot study support broader dissemination throughout Connecticut home care agencies.
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Affiliation(s)
- Colleen Delaney
- University of Connecticut School of Nursing, Storrs, CT, USA
| | | | - Dana Mills
- University of Connecticut Health Center, Farmington, CT, USA
| | | | - Rita Grimes
- Visiting Nurse and Health Services of Connecticut, Vernon, CT, USA
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Depression interventions among racial and ethnic minority older adults: a systematic review across 20 years. Am J Geriatr Psychiatry 2012; 20:915-31. [PMID: 22828202 PMCID: PMC3479358 DOI: 10.1097/jgp.0b013e31825d091a] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
While there is strong evidence in support of geriatric depression treatments, much less is available with regard to older U.S. racial and ethnic minorities. The objectives of this review are to identify and appraise depression treatment studies tested with samples of U.S. racial and ethnic minority older adults. We include an appraisal of sociocultural adaptations made to the depression treatments in studies meeting our final criteria. Systematic search methods were utilized to identify research published between 1990 and 2010 that describe depression treatment outcomes for older adults by racial/ethnic group, or for samples of older adults who are primarily (i.e., >50%) racial/ethnic minorities. Twenty-three unduplicated articles included older adults and seven met all inclusion criteria. Favorable depression treatment effects were observed for older minorities across five studies that took place in different types of settings and with varying levels of sociocultural adaptations. The effectiveness of depression care remains mixed, although collaborative or integrated care shows promise for African Americans and Latinos. The degree to which the findings generalize to non-English-speaking, low acculturated, and low-income older persons, and to other older minority groups (i.e., Asian and Pacific Islanders, and American Indian and Alaska Natives), remains unclear. Given the high disease burden among older minorities with depression, it is imperative to provide timely, accessible, and effective depression treatments. Increasing their participation in behavioral health research should be a national priority.
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Delaney C, Barrere C. Advanced practice nursing students' knowledge, self-efficacy, and attitudes related to depression in older adults: teaching holistic depression care. Holist Nurs Pract 2012; 26:210-20. [PMID: 22694866 DOI: 10.1097/hnp.0b013e31825852aa] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of this study was to examine the knowledge, attitudes, and self-efficacy of advanced practice nursing students toward depression in older adults. Findings suggest that advanced practice nursing students are interested in caring for the whole person and desired more information on the physical and emotional-spiritual needs of older patients with depression. Suggestions for holistic nursing depression care education are presented.
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Affiliation(s)
- Colleen Delaney
- University of Connecticut School of Nursing, Storrs, Connecticut 06269, USA.
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Cromley EK, Wilson-Genderson M, Pruchno RA. Neighborhood characteristics and depressive symptoms of older people: local spatial analyses. Soc Sci Med 2012; 75:2307-16. [PMID: 22999228 DOI: 10.1016/j.socscimed.2012.08.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 06/11/2012] [Accepted: 08/29/2012] [Indexed: 11/27/2022]
Abstract
Depressive symptoms in community-dwelling older people significantly increase the risk of developing clinically diagnosable depressive disorders. Knowledge of the spatial distribution of depressive symptoms in the older population can add important information to studies of neighborhood contextual factors and mental health outcomes, but analysis of spatial patterns is rarely undertaken. This study uses spatial statistics to explore patterns of clustering in depressive symptoms using data from a statewide survey of community-dwelling older people in New Jersey from 2006 to 2008. A significant overall pattern of clustering in depressive symptoms was observed at the state level. In a subsequent local clustering analysis, places with high levels of depressive symptoms near to other places with high levels of depressive symptoms were identified. The relationships between the level of depressive symptoms in a place and poverty, residential stability and crime were analyzed using geographically weighted regression. Significant local parameter estimates for the three independent variables were observed. Local parameters for the poverty variable were positive and significant almost everywhere in the state. The significant local parameters for residential stability and crime varied in their association with depressive symptoms in different regions of the state. This study is among the first to examine spatial patterns in depressive symptoms among community-dwelling older people, and it demonstrates the importance of exploring spatial variations in the relationships between neighborhood contextual factors and health outcomes.
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Affiliation(s)
- Ellen K Cromley
- Department of Community Medicine and Health Care, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT 06030-6325, USA.
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Ruggiano N, Shtompel N, Hristidis V, Roberts L, Grochowski J, Brown EL. Need and Potential Use of Information Technology for Case Manager–Physician Communication in Home Care. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2012. [DOI: 10.1177/1084822312459615] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Case management has become a popular model for providing home care services to nursing home-eligible older adults. To maximize collaborative decision making and patient outcomes, members of the case management team must engage in ongoing, open communication. However, little is known about the quality of communication between home care case managers and their clients’ physicians. This study examined geriatric home care case managers’ perceptions of their communication with their clients’ physicians. Participating case managers were employed at two large home care agencies located in the South Florida region. The findings suggest that communication between home care case managers and physicians is limited and inefficient. Implication for policy and practice are provided. Finally, we propose ways to leverage Information Technology to bridge this communication gap.
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Affiliation(s)
| | | | | | - Lisa Roberts
- Florida International University, Miami, FL, USA
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Diefenbach GJ, Tolin DF, Gilliam CM. Impairments in life quality among clients in geriatric home care: associations with depressive and anxiety symptoms. Int J Geriatr Psychiatry 2012; 27:828-35. [PMID: 21960438 PMCID: PMC3391339 DOI: 10.1002/gps.2791] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 08/04/2011] [Accepted: 08/05/2011] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The aim of this study was to determine the independent contributions of depressive and anxiety symptoms to quality of life among older adults who were receiving services through a home care program. METHODS The study sample consisted of 66 community-dwelling older adults (ages 65 years and older), who were experiencing chronic medical illness and concomitant functional disability necessitating home care. Participants completed self-report measures of depression, anxiety, and health-related quality of life. Additional data on cognitive, health, and functional status were collected to be used as covariates. RESULTS The associations of depressive symptoms with quality of life impairments in home care were substantial and pervasive. Depressive symptoms were significantly associated with quality of life impairments in nearly all domains. After controlling for depressive symptoms, anxiety symptoms accounted for additional and statistically significant variance in impaired life quality in the domains of mental health, role emotional functioning, and bodily pain. CONCLUSIONS These results indicate that depressive and anxiety symptoms demonstrate negative associations with life quality among older adults in home care and highlight the importance of developing community-based programs to assess and treat depressive and anxiety symptoms among home care clients.
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Affiliation(s)
- Gretchen J. Diefenbach
- Corresponding Author: Gretchen J. Diefenbach, Ph.D., Anxiety Disorders Center, The Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, Phone: (860) 545-7685, Fax: (860) 545-7156,
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Rovner BW, Casten RJ, Hegel MT, Leiby BE. Preventing cognitive decline in older African Americans with mild cognitive impairment: design and methods of a randomized clinical trial. Contemp Clin Trials 2012; 33:712-20. [PMID: 22406101 PMCID: PMC3361551 DOI: 10.1016/j.cct.2012.02.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 01/30/2012] [Accepted: 02/22/2012] [Indexed: 10/28/2022]
Abstract
Mild Cognitive Impairment (MCI) affects 25% of older African Americans and predicts progression to Alzheimer's disease. An extensive epidemiologic literature suggests that cognitive, physical, and/or social activities may prevent cognitive decline. We describe the methods of a randomized clinical trial to test the efficacy of Behavior Activation to prevent cognitive decline in older African Americans with the amnestic multiple domain subtype of MCI. Community Health Workers deliver 6 initial in-home treatment sessions over 2-3 months and then 6 subsequent in-home booster sessions using language, materials, and concepts that are culturally relevant to older African Americans during this 24 month clinical trial. We are randomizing 200 subjects who are recruited from churches, senior centers, and medical clinics to Behavior Activation or Supportive Therapy, which controls for attention. The primary outcome is episodic memory as measured by the Hopkins Verbal Learning Test-Revised at baseline and at months 3, 12, 18, and 24. The secondary outcomes are general and domain-specific neuropsychological function, activities of daily living, depression, and quality-of-life. The negative results of recent clinical trials of drug treatments for MCI and Alzheimer's disease suggest that behavioral interventions may provide an alternative treatment approach to preserve cognition in an aging society.
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Affiliation(s)
- Barry W. Rovner
- Departments of Psychiatry and Neurology, Jefferson Medical College Jefferson Hospital for Neuroscience 900 Walnut Street Philadelphia, Pa 19107
| | - Robin J. Casten
- Department of Psychiatry and Human Behavior, Jefferson Medical College Jefferson Hospital for Neuroscience 900 Walnut Street Philadelphia, Pa 19107
| | - Mark T. Hegel
- Departments Psychiatry and Community & Family Medicine Dartmouth Medical School Dartmouth Hitchcock Medical Center One Medical Center Drive Lebanon, NH 03756
| | - Benjamin E. Leiby
- Division of Biostatistics Department of Pharmacology and Experimental Therapeutics, Jefferson Medical College 1015 Chestnut St., Suite M100, Philadelphia, PA 19107
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