The 'research magnificent' in late life: psychiatric epidemiology and the primary health care of older adults

Examining the Efficacy of a Brief Cognitive-Behavioral Therapy for Chronic Pain (Brief CBT-CP) Group Delivered via VA Video Connect (VVC) Among Older Adult Veterans

OBJECTIVES

To evaluate the effectiveness of a Brief CBT-CP Group delivered via VA Video Connect (VVC) among different age groups of Veterans with chronic noncancer pain being seen in primary care. A secondary aim was to evaluate participant characteristics of patients who completed vs. did not complete the group.

METHODS

Single-arm treatment study in which outcomes were evaluated by comparing self-reported symptom levels pre- and post-treatment. Dependent variables included generalized anxiety, quality of life, disability, physical health, and pain outcomes.

RESULTS

Following a 2 × 3 mixed-model ANCOVA, a main effect of time was found for all outcome variables, demonstrating significant improvements in disability rating, physical health, quality of life, generalized anxiety, and pain outcomes from pre- to post-treatment. There were no significant main effects for age group for any outcome variable, suggesting that patients of all ages reported improvements.

CONCLUSIONS

Accommodations and adaptations to telehealth treatment for older adults are proposed and discussed.

CLINICAL IMPLICATIONS

The Brief CBT-CP Group via VVC is an effective and accessible treatment for older adults with chronic noncancer pain who are being managed in the primary care setting. Certain Veterans are less likely to complete the Brief CBT-CP Group via VVC.

Screening Older Adults for Depression: Barriers Across Clinical Discipline Training

Background and Objectives

Depressed older adults are more likely to be seen in primary care than in specialty mental health settings, but research shows that physicians may not routinely screen for depression. Other clinical disciplines are also in a position to screen for depression, but have not been studied. This study examined barriers to screening older adults for depression, and disciplinary differences in clinical trainees’ likelihood of screening.

Research Design and Methods

We used a cross-sectional, online survey with experimental manipulation of vignettes. A four-way mixed analysis of variance explored the effects of clinical discipline (between subjects) and time pressure, patient difficulty, and level of symptoms (within subjects) on trainees’ likelihood of screening.

Results

Participants were 229 trainees in medicine (83), psychology (51), nursing (49), and social work (46). Lower time pressure and greater symptom severity increased likelihood of screening. There was a significant three-way interaction among discipline, patient difficulty, and symptom level that was driven by social work graduate trainees’ greater likelihood of screening for depression when there were more symptoms present, which was diminished if the patient was being difficult. There was a two-way interaction between patient difficulty and level of symptoms: more symptoms resulted in increased likelihood of screening, an effect that diminished with greater patient difficulty.

Discussion and Implications

The study holds implications for identifying and addressing gaps in education on depression screening to minimize the effects of barriers. Interventions could address education about older adults and depression, including practice-based screening, time management, and behavior management skills.

Course of depression and mortality among older primary care patients

CONTEXT

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

OBJECTIVE

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

DESIGN AND SETTING

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

PARTICIPANTS

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

MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

Twelve-month diagnosed prevalence of behavioral health disorders among elderly medicare and medicaid members

OBJECTIVES

We examined the 12-month diagnosed prevalence of behavioral health disorders (BHDs) and dementia among elderly Medicare and Medicaid members in Massachusetts by primary payment source group (dual eligible, Medicare only, and Medicaid only) and age group (65-74 years, 75-84 years, and 85 years and older).

DESIGN

A retrospective cross-sectional study.

SETTING

Medicare and Medicaid programs.

PARTICIPANTS

Massachusetts Medicare or Medicaid enrollees age 65 and older as of January 1, 2005, (N = 679,182).

MEASUREMENTS

International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes recorded on Medicare and Medicaid claims were used to identify the BHDs.

RESULTS

The 12-month diagnosed prevalence was 19.4% for any BHD and 11.2% for dementia. The most common BHDs by disease category were major depression (severe mental illness [SMI]), other depression (other mental illness [OMI]), and alcohol abuse or dependence (subtance use disorder [SUD]). Dual eligibles had a considerably higher diagnosed prevalence of any BHD (38.8%), compared with 16.1% in the Medicare only group. The 12-month diagnosed prevalence of SMI, OMI, and dementia was higher in the older-age groups. Co-occurring SUD was higher for younger dual eligibiles. Dementia and mental illness co-occurred at much higher rates for dual eligibles than for either of the single-insurance groups. This combination increased with age in all three groups.

CONCLUSIONS

The 12-month prevalence of BHDs and dementia among elderly dual eligibles was disproportionately higher than other elderly Medicare or Medicaid members. However, access barriers to behavioral health services for this vulnerable population could be significant because Medicare and Medicaid payment limitations resulted in financial disincentives for providing these services.

Negotiating depression treatment with older adults: primary care providers' perspectives

BACKGROUND

Primary care occupies a strategic position in the evaluation and treatment of depression in late life, yet many older patients do not initiate or adhere to treatments available in primary care.

AIM

To explore how primary care providers describe the process of discussing depression care with older adults.

METHOD

 Semi-structured interviews conducted with 15 providers involved with intervention studies of depression management for older adults. We used the constant comparative method to identify themes related to negotiating the treatment of depression with older adults.

RESULTS

Providers felt that older patients often attribute depression to non-medical causes. They talked about the challenges and described the need to 'convince' them of the medical model of depression.

CONCLUSION

How primary care physicians surmise patients' views of depression may influence the discussion of depression in practice. As medication is most often provided for depression treatment, some may feel compelled to convince their patients of biomedical explanations while others may avoid treating depression altogether.

The Short Anxiety Screening Test in Greek: translation and validation

BACKGROUND

The aim of the current study was to assess the reliability and validity of the Greek translation of the Short Anxiety Screening Test (SAST), for use in primary care settings. The scale consists of 10 items and is a brief clinician rating scale for the detection of anxiety disorder in older people, particularly, in the presence of depression.

METHODS

The study was performed in two rural primary care settings in Crete. The sample consisted of 99 older (76 +/- 6.3 years old) people, who fulfilled the participating criteria. The translation and cultural adaptation of the questionnaire was performed according to international standards. Internal consistency using the Cronbach alpha coefficient and test-retest reliability using the intraclass correlation coefficient (ICC) was used to assess the reliability of the tool. An exploratory factor analysis using Varimax with Kaiser normalisation (rotation method) was used to examine the structure of the instrument, and for the correlation of the items interitem correlation matrix was applied and assessed with Cronbach alpha.

RESULTS

Translation and backtranslation did not reveal any specific problems. The psychometric properties of the Greek version of the SAST scale in primary care were good. Internal consistency of the instrument was good, the Cronbach alpha was found to be 0.763 (P <0.001) and ICC (95% CI) for reproducibility was found to be 0.763 (0.686 to 0.827). Factor analysis revealed three factors with eigenvalues >1.0 accounting for 60% of variance, while the Cronbach alpha was >0.7 for every item.

CONCLUSIONS

The Greek translation of the SAST questionnaire is comparable with that of the original version in terms of reliability, and can be used in primary healthcare research. Its use in clinical practice should be primarily as a screening tool only at this stage, with a follow-up consisting of a detailed interview with the patient, in order to confirm the diagnosis.

Patterns of early adherence to the antidepressant citalopram among older primary care patients: the prospect study

OBJECTIVE

Our purpose was to determine the personal characteristics associated with different patterns of adherence to the antidepressant citalopram in a primary care trial of depression management.

METHOD

The study sample consisted of 228 adults aged 60 years and older recruited from primary care settings and who participated in a depression intervention. The intervention consisted of services of trained care managers, who offered recommendations to physicians following a clinical algorithm and helped patients with treatment adherence. Adherence to the antidepressant citalopram was measured using pill counts. We employed the latent class model to classify patients according to the pattern of adherence to citalopram over time. We examined the association of sociodemographic characteristics, depression status, cognitive status, and medical comorbidity with the resulting classes of adherence.

RESULTS

The latent class model generated three classes of adherence: known to be adherent, unknown adherence, and known to be nonadherent. Participants who were white were more likely to be in the known to be adherent class than in the known to be nonadherent class (odds ratio (OR) = 10.38, 95% confidence interval (CI) [3.47, 31.12]). Married participants were less likely to be in the unknown adherence class than the known to be nonadherent class (OR = 0.28, 95% CI [0.09, 0.85]). No associations between age, gender, education level, depression status, cognitive status, or medical comorbidity and classes of adherence were found.

CONCLUSIONS

We found stronger relationships between ethnicity and marital status with patterns of adherence to citalopram than we did other personal characteristics. Identification of a subgroup of patients at particularly high risk of nonadherence is important for the development of adherence interventions.

Depression, cardiovascular disease, diabetes, and two-year mortality among older, primary-care patients

OBJECTIVE

Depression is a major contributor to death and disability, but few follow-up studies of depression have been carried out in the primary-care setting. The authors sought to assess whether depression in older patients is associated with increased mortality after a 2-year follow-up interval and to estimate the population-attributable fraction (PAF) of depression on mortality in older primary-care patients.

METHODS

Longitudinal cohort analysis was carried out in 20 primary-care practices. Participants were identified though a two-stage, age-stratified (60-74 or 75+) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of screened-negative patients. In all, 1,226 persons were assessed at baseline. Vital status at 2 years was the outcome of interest.

RESULTS

Of 1,226 persons in the sample, 598 were classified as depressed. After 2 years, 64 persons had died. Persons with depression at baseline were more likely to die at the end of the 2-year follow-up interval than were persons without depression, even after accounting for potentially influential covariates such as whether the participant reported a history of myocardial infarction (MI) or diabetes.

CONCLUSIONS

Among older, primary-care patients over the course of a 2-year follow-up interval, depression contributed as much to mortality as did MI or diabetes.

Relationship between Health Status and Psychological Distress among the Inhabitants in a Methylmercury-Polluted Area in Japan

This study examined the relationship between health parameters and psychological distress among inhabitants of methylmercury-polluted areas in Japan. The subjects were 133 inhabitants over the age of 40 yr living in two methylmercury-polluted villages. Information on demographic factors, health status, and mental health was obtained using questionnaires, including the General Health Questionnaire (GHQ). The proportional odds model was used to estimate the adjusted odds ratios of factors associated with a higher GHQ score after adjustment for age, gender, and district. Very poor self-rated health status, a high number (5+) of subjective symptoms, having monthly outpatient visits and medical house calls, and receiving compensation for methylmercury poisoning were significantly associated with psychological distress. Poor physical condition may lead to the development of psychological distress.

Quality of life in geriatric patients with mood and anxiety disorders

This article reviews the impact of depressive and anxiety disorders on quality of life (QOL), disability, and economic burden in the lives of older individuals. Distinctions between the terms QOL, disability, and burden are important in understanding the extent of improvement needed in treatment for elderly patients with depression or anxiety. Treatment efforts should be extended to remediate not only signs and symptoms of psychiatric syndromes but QOL and disability as well; increased understanding toward this end is evolving, yet it is clear that these issues need to be the focus of more investigation.

Complexity in late-life depression: impact of confounding factors on diagnosis, treatment, and outcomes

Late-life depression is a heterogeneous syndrome. Although depression in elderly patients is highly treatable, a number of factors or confounds create complexity in its overall management. Patient factors, such as medical illness, neuropsychiatric comorbidity, and race, may interact with provider factors to make management more complex. Outcomes and services research indicate that these factors, particularly medical illness, affect whether late-life depression is appropriately detected, diagnosed, and treated. Attention to such factors must be included in an agenda for mental health services research, with emphasis on the delivery of effective treatment to elderly patients with depression and improved outcomes in clinical settings.

The "time and change" test: an appropriate method to detect cognitive decline in the elderly

The Time and Change (T&C) test is an easy and time-saving test validated for the detection of dementia. Our aim was to determine how geriatric features like depression, disability, and comorbidity are able to influence the result of the T&C and, consequently, to decide whether it could be a reliable screening test for cognitive impairment in the elderly. A total of 220 participants (mean age = 75.8+/-9.6 years, 63.7% females) underwent the T&C, Mini-Mental State Examination, and the Clock Drawing Test; Activities of Daily Living, Instrumental Activities of Daily Living, comorbidity, and depression were also evaluated. Time and Change-positive participants were older, had poorer cognitive tests, and had higher levels of disability and comorbidity than participants testing negative. Multivariate analysis showed that cognitive impairment and comorbidity were the only features that influenced the T&C, regardless of age, education, disability, and depression. We conclude that the T&C should be implemented in primary care because it quickly identifies elderly patients with cognitive impairment who need a more accurate evaluation.

Anxiety disorders in the elderly

Although the epidemiology, neurobiology, and treatment of anxiety disorders have received considerable attention in the child and adult literature, they have not received the same consideration in the geriatric population. This disparity is remarkable given the prevalence and associated costs of these disorders that can persist into late life. Further, although a considerable amount is known about these disorders in younger age groups, it is unclear whether the phenomenology of anxiety evolves over the course of the aging process. Thus, conclusions drawn based on younger populations of anxious adults may not hold true for older cohorts. This article reviews issues of epidemiology, phenomenology, neurobiology, and medical comorbidity, as well as pharmacologic and psychotherapeutic treatments in older adults.

Late-onset minor and major depression: early evidence for common neuroanatomical substrates detected by using MRI

The purpose of our study was to examine the neuroanatomical correlates of late-onset minor and major depression and to compare them with similar measures obtained from nondepressed controls. Our study groups were comprised of 18 patients with late-onset minor depression, 35 patients diagnosed with late-onset major depression, and 30 nondepressed controls. All subjects were scanned by using a 1. 5-tesla MRI scanner. Absolute whole brain volume and normalized measures of prefrontal and temporal lobe volumes were obtained and used for comparison among groups. Our findings indicate that patients with minor depression present with specific neuroanatomical abnormalities that are comparable with the major depression group but significantly different from the controls. Normalized prefrontal lobe volumes show a significant linear trend with severity of depression, with volumes decreasing with illness severity. Whole brain volumes did not differ significantly among groups. These findings have broad implications for the biology of late-life depression and suggest that there may be common neurobiological substrates that underlie all clinically significant forms of late-onset mood disturbances.