PERSPECTIVE: A Path to Value-Based Insurance Design for Mental Health Services

BACKGROUND

Aligning cost of mental health care with expected clinical and functional benefits of that care would incentivize the delivery of high value treatments and services. In turn, ineffective or untested care could still be offered but at costs high enough to offset the delivery of high value care.

AIMS

The authors comment on Benson and Fendrick's paper on Value-Based Insurance Design (VBID) for mental health in the September 2023 special issue of this journal. The authors also present a preliminary framework of key ingredients needed to consider VBID for mental health treatments and services.

METHODS

The authors briefly review current and past efforts to contain costs and improve quality of mental health care, which include (for example) use of carve-out and carve-in programs, evaluation of cost sharing models, impact of accountable care organizations, and studying other benefit designs and impact of federal and state policies.

RESULTS

Using PTSD as an example, key ingredients of VBID for mental health services were identified and include the following: tools for case identification and monitoring progress over time at the population level; specific treatments and services with evidence of clinical effectiveness, cost-effectiveness, and health equity; and an approach to document the specific treatment or service was delivered (versus another treatment or service that may lack evidence).

DISCUSSION

The inability to afford mental health care is a top barrier to treatment seeking. People who do elect to spend time and money on mental health care are further disadvantaged by accessing care that is not well regulated and the quality at best is questionable. VBID could be an important lever for increasing access to and use of high value mental health care. Partnerships among the research, practice, and policy communities can help ensure research solutions meet needs of these two communities.

IMPLICATIONS FOR HEALTH CARE

VBID holds promise to make high value mental health care more affordable while discouraging low value treatments and services.

IMPLICATIONS FOR HEALTH POLICIES

While evidence gaps remain, these gaps can be filled concurrently with pursuit of VBID for mental health services.

IMPLICATIONS FOR FUTURE RESEARCH

This paper identifies important research opportunities to help make VBID a reality for mental health care.

Participant retention in a fully remote trial of digital psychotherapy: Comparison of incentive types

Numerous studies have found that long term retention is very low in remote clinical studies (>4 weeks) and to date there is limited information on the best methods to ensure retention. The ability to retain participants in the completion of key assessments periods is critical to all clinical research, and to date little is known as to what methods are best to encourage participant retention. To study incentive-based retention methods we randomized 215 US adults (18+ years) who agreed to participate in a sequential, multiple assignment randomized trial to either high monetary incentive (HMI, $125 USD) and combined low monetary incentive ($75 USD) plus alternative incentive (LMAI). Participants were asked to complete daily and weekly surveys for a total of 12 weeks, which included a tailoring assessment around week 5 to determine who should be stepped up and rerandomized to one of two augmentation conditions. Key assessment points were weeks 5 and 12. There was no difference in participant retention at week 5 (tailoring event), with approximately 75% of the sample completing the week-5 survey. By week 10, the HMI condition retained approximately 70% of the sample, compared to 60% of the LMAI group. By week 12, all differences were attenuated. Differences in completed measures were not significant between groups. At the end of the study, participants were asked the impressions of the incentive condition they were assigned and asked for suggestions for improving engagement. There were no significant differences between conditions on ratings of the fairness of compensation, study satisfaction, or study burden, but study burden, intrinsic motivation and incentive fairness did influence participation. Men were also more likely to drop out of the study than women. Qualitative analysis from both groups found the following engagement suggestions: desire for feedback on survey responses and an interest in automated sharing of individual survey responses with study therapists to assist in treatment. Participants in the LMAI arm indicated that the alternative incentives were engaging and motivating. In sum, while we were able to increase engagement above what is typical for such study, more research is needed to truly improve long term retention in remote trials.

Message-based psychotherapy for older adults: A cohort comparison study

OBJECTIVE

Digital Mental Health Interventions (DMHI) can diminish inequities in mental health care provision. As DMHIs increase in popularity, however, older adults may be unintentionally excluded due to barriers such as lack of awareness, internet access, digital tools, technological socialization and education, physiological accessibility, and communication technology infrastructure. The aim of this study was to examine longitudinal treatment engagement patterns and 15-week clinical outcomes of depressed and anxious older adults compared to a matched cohort of younger adults seeking treatment from a large asynchronous telemedicine provider.

METHODS

The 2,470 older adults (55+ years) and a matched cohort of younger adults (26-35 years) diagnosed with depression or anxiety were treated by licensed therapists via messaging 5 days a week. Patterns of treatment engagement on the platform were compared across groups by examining total number of days in treatment, days actively messaging on the platform, and average words and messages per week sent by patients over the entire period they remained in treatment. Symptoms were assessed every 3 weeks using the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Scale (GAD-7), and changes were compared across age groups over 15 weeks.

RESULTS

Older patients attended more days in treatment than younger patients, but there were no differences in number of days actively messaging on the platform, number of messages per week, or word count per week. The two age groups did not differ in their final anxiety or depressive symptoms when controlling for total number of weeks attended. Patients in the younger age group experienced a quicker rate of reduction than older adults in their anxiety, but not depressive symptoms.

CONCLUSIONS

Among individuals willing to initiate care through a DMHI, older adults had overall similar engagement as younger adults and they showed similar improvement in symptoms of depression and anxiety. Given the advantages of message-based care for aiding a mental health workforce in serving larger numbers of individuals in need and the expected growth of the aging population, these findings could help healthcare systems in evaluating a variety of treatment options and delivery media for meeting the healthcare needs of the future.

A-148 Executive Dysfunction in Late-Life Depression: Changes and Relationship to Treatment Response in a Clinical Trial

Objective

Executive dysfunction is the core neurocognitive deficit associated with late-life depression (LLD). This study identified changes in executive functioning during a structured behavioural treatment for depression in older adults and ascertained if pre-treatment executive dysfunction predicted treatment response.

Method

We analyzed data from a large multisite randomized controlled trial of structured behavioral psychotherapies (PST and Engage) for unipolar depression in adults ≥60 years. Participants were diagnosed with major depressive disorder and had Mini-Mental State Examination [MMSE] ≥24. Cognitive measures included the Stroop test, digit span, Iowa Gambling Task (IGT), and Wisconsin Card Sorting Test (WCST). Treatment response outcomes included pre- to post-treatment changes on the Hamilton Depression Rating Scale (HAM-D) and World Health Organization Disability Assessment Schedule II (WHODAS-II). One-way analysis of variance (ANOVA) assessed pre- and post-treatment changes in executive functioning measures across 9 weeks of treatment for 95 participants with complete data. Multiple linear regression models tested whether baseline measures of executive functioning predicted treatment response in (a) HAM-D depression and (b) WHODAS disability scores.

Results

A one-way ANOVA revealed improvements on IGT performance (Total Money) between baseline and week 9 post-treatment (F(1,186) = 7.00, p < 0.01). No combination of baseline measures of executive functioning significantly predicted change in HAM-D or WHODAS scores across treatment (ps > 0.05).

Conclusion

Baseline executive functioning did not predict treatment response (change in depressive symptoms or disability ratings). That is, individuals improved on treatment outcomes regardless of baseline executive dysfunction. In addition, results suggest that these approaches may actually improve real-life decision-making.

Toward a Mobile Platform for Real-world Digital Measurement of Depression: User-Centered Design, Data Quality, and Behavioral and Clinical Modeling

BACKGROUND

Although effective mental health treatments exist, the ability to match individuals to optimal treatments is poor, and timely assessment of response is difficult. One reason for these challenges is the lack of objective measurement of psychiatric symptoms. Sensors and active tasks recorded by smartphones provide a low-burden, low-cost, and scalable way to capture real-world data from patients that could augment clinical decision-making and move the field of mental health closer to measurement-based care.

OBJECTIVE

This study tests the feasibility of a fully remote study on individuals with self-reported depression using an Android-based smartphone app to collect subjective and objective measures associated with depression severity. The goals of this pilot study are to develop an engaging user interface for high task adherence through user-centered design; test the quality of collected data from passive sensors; start building clinically relevant behavioral measures (features) from passive sensors and active inputs; and preliminarily explore connections between these features and depression severity.

METHODS

A total of 600 participants were asked to download the study app to join this fully remote, observational 12-week study. The app passively collected 20 sensor data streams (eg, ambient audio level, location, and inertial measurement units), and participants were asked to complete daily survey tasks, weekly voice diaries, and the clinically validated Patient Health Questionnaire (PHQ-9) self-survey. Pairwise correlations between derived behavioral features (eg, weekly minutes spent at home) and PHQ-9 were computed. Using these behavioral features, we also constructed an elastic net penalized multivariate logistic regression model predicting depressed versus nondepressed PHQ-9 scores (ie, dichotomized PHQ-9).

RESULTS

A total of 415 individuals logged into the app. Over the course of the 12-week study, these participants completed 83.35% (4151/4980) of the PHQ-9s. Applying data sufficiency rules for minimally necessary daily and weekly data resulted in 3779 participant-weeks of data across 384 participants. Using a subset of 34 behavioral features, we found that 11 features showed a significant (P<.001 Benjamini-Hochberg adjusted) Spearman correlation with weekly PHQ-9, including voice diary-derived word sentiment and ambient audio levels. Restricting the data to those cases in which all 34 behavioral features were present, we had available 1013 participant-weeks from 186 participants. The logistic regression model predicting depression status resulted in a 10-fold cross-validated mean area under the curve of 0.656 (SD 0.079).

CONCLUSIONS

This study finds a strong proof of concept for the use of a smartphone-based assessment of depression outcomes. Behavioral features derived from passive sensors and active tasks show promising correlations with a validated clinical measure of depression (PHQ-9). Future work is needed to increase scale that may permit the construction of more complex (eg, nonlinear) predictive models and better handle data missingness.

A randomized controlled trial of internet-delivered cognitive behaviour therapy to prevent the development of depressive disorders in older adults with multimorbidity

BACKGROUND

Multimorbidity, which commonly impacts older adults is associated with higher rates of depression. We aimed to investigate whether internet delivered cognitive-behaviour therapy (iCBT) could prevent depressive disorders in older adults with multimorbidity who were not currently depressed.

METHOD

302 primary care and community participants aged 65 years and over, who had multimorbidity but did not meet criteria for a depressive disorder were randomised to an intervention group who received an eight-week, five session iCBT (n = 150) or to a control group (n = 152) who received treatment as usual. Diagnostic interviews were conducted at baseline, and three and six months after the intervention period, where indicated, and the presence of depressive disorder was the primary outcome.

RESULTS

The intention to treat, chi-square analyses indicated there were significantly fewer cases of depressive disorder in the treatment group compared to the control group by six-month follow-up (χ²(1,302) = 5.21, p = .02).

LIMITATIONS

The main limitations of this RCT are a short follow up period and low proportion of participants who developed depressive disorders. Participants were relatively well educated, with a majority having English as their first language.

CONCLUSIONS

These results indicate that depressive disorder was prevented in the first six months following iCBT with three times the number of cases of depressive disorder in the control group compared to the treatment group. Further research is required to determine whether iCBT can be effective for preventing depressive disorder in this population over a longer time period.

Using Mobile Apps to Assess and Treat Depression in Hispanic and Latino Populations: Fully Remote Randomized Clinical Trial

BACKGROUND

Most people with mental health disorders fail to receive timely access to adequate care. US Hispanic/Latino individuals are particularly underrepresented in mental health care and are historically a very difficult population to recruit into clinical trials; however, they have increasing access to mobile technology, with over 75% owning a smartphone. This technology has the potential to overcome known barriers to accessing and utilizing traditional assessment and treatment approaches.

OBJECTIVE

This study aimed to compare recruitment and engagement in a fully remote trial of individuals with depression who either self-identify as Hispanic/Latino or not. A secondary aim was to assess treatment outcomes in these individuals using three different self-guided mobile apps: iPST (based on evidence-based therapeutic principles from problem-solving therapy, PST), Project Evolution (EVO; a cognitive training app based on cognitive neuroscience principles), and health tips (a health information app that served as an information control).

METHODS

We recruited Spanish and English speaking participants through social media platforms, internet-based advertisements, and traditional fliers in select locations in each state across the United States. Assessment and self-guided treatment was conducted on each participant's smartphone or tablet. We enrolled 389 Hispanic/Latino and 637 non-Hispanic/Latino adults with mild to moderate depression as determined by Patient Health Questionnaire-9 (PHQ-9) score≥5 or related functional impairment. Participants were first asked about their preferences among the three apps and then randomized to their top two choices. Outcomes were depressive symptom severity (measured using PHQ-9) and functional impairment (assessed with Sheehan Disability Scale), collected over 3 months. Engagement in the study was assessed based on the number of times participants completed active surveys.

RESULTS

We screened 4502 participants and enrolled 1040 participants from throughout the United States over 6 months, yielding a sample of 348 active users. Long-term engagement surfaced as a key issue among Hispanic/Latino participants, who dropped from the study 2 weeks earlier than their non-Hispanic/Latino counterparts (P<.02). No significant differences were observed for treatment outcomes between those identifying as Hispanic/Latino or not. Although depressive symptoms improved (beta=-2.66, P=.006) over the treatment course, outcomes did not vary by treatment app.

CONCLUSIONS

Fully remote mobile-based studies can attract a diverse participant pool including people from traditionally underserved communities in mental health care and research (here, Hispanic/Latino individuals). However, keeping participants engaged in this type of "low-touch" research study remains challenging. Hispanic/Latino populations may be less willing to use mobile apps for assessing and managing depression. Future research endeavors should use a user-centered design to determine the role of mobile apps in the assessment and treatment of depression for this population, app features they would be interested in using, and strategies for long-term engagement.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01808976; https://clinicaltrials.gov/ct2/show/NCT01808976 (Archived by WebCite at http://www.webcitation.org/70xI3ILkz).

"Engage" therapy: Prediction of change of late-life major depression

OBJECTIVE

Engage grew out of the need for streamlined psychotherapies that can be accurately used by community therapists in late-life depression. Engage was based on the view that dysfunction of reward networks is the principal mechanism mediating depressive symptoms. Accordingly, Engage uses "reward exposure" (exposure to meaningful activities) and assumes that repeated activation of reward networks will normalize these systems. This study examined whether change in a behavioral activation scale, an index of reward system function, predicts change in depressive symptomatology.

METHODS

The participants (N = 48) were older adults with major depression treated with 9 weekly sessions of Engage and assessed 27 weeks after treatment. Depression was assessed with the 24-item Hamilton Depression Rating Scale (HAM-D) and behavioral activation with the four subscales of Behavioral Activation for Depression Scale (activation, avoidance/rumination, work impairment, social impairment) at baseline, 6 weeks (mid-treatment), 9 weeks (end of treatment), and 36 weeks.

RESULTS

Change only in the Activation subscale during successive periods of assessment predicted depression severity (HAM-D) at the end of each period (F_{1, 47} = 21.05, p<0.0001). An increase of one standard deviation in the Activation score resulted in a 2.04 (95% CI: 1.17-2.92) point decrease in HAM-D. For every one point increase in the Activation score, HAM-D was decreased by 0.22 points (95% CI: 0.12-0.31).

LIMITATIONS

No comparison group. Partial overlap of Activation Subscale with HAM-D, lack of detailed neurocognitive assessment and social support.

CONCLUSION

Change in behavioral activation predicts improvement of depressive symptoms and signs in depressed older adults treated with Engage.

The Use and Effectiveness of Mobile Apps for Depression: Results From a Fully Remote Clinical Trial

Background

Mobile apps for mental health have the potential to overcome access barriers to mental health care, but there is little information on whether patients use the interventions as intended and the impact they have on mental health outcomes.

Objective

The objective of our study was to document and compare use patterns and clinical outcomes across the United States between 3 different self-guided mobile apps for depression.

Methods

Participants were recruited through Web-based advertisements and social media and were randomly assigned to 1 of 3 mood apps. Treatment and assessment were conducted remotely on each participant’s smartphone or tablet with minimal contact with study staff. We enrolled 626 English-speaking adults (≥18 years old) with mild to moderate depression as determined by a 9-item Patient Health Questionnaire (PHQ-9) score ≥5, or if their score on item 10 was ≥2. The apps were (1) Project: EVO, a cognitive training app theorized to mitigate depressive symptoms by improving cognitive control, (2) iPST, an app based on an evidence-based psychotherapy for depression, and (3) Health Tips, a treatment control. Outcomes were scores on the PHQ-9 and the Sheehan Disability Scale. Adherence to treatment was measured as number of times participants opened and used the apps as instructed.

Results

We randomly assigned 211 participants to iPST, 209 to Project: EVO, and 206 to Health Tips. Among the participants, 77.0% (482/626) had a PHQ-9 score >10 (moderately depressed). Among the participants using the 2 active apps, 57.9% (243/420) did not download their assigned intervention app but did not differ demographically from those who did. Differential treatment effects were present in participants with baseline PHQ-9 score >10, with the cognitive training and problem-solving apps resulting in greater effects on mood than the information control app (χ22=6.46, P=.04).

Conclusions

Mobile apps for depression appear to have their greatest impact on people with more moderate levels of depression. In particular, an app that is designed to engage cognitive correlates of depression had the strongest effect on depressed mood in this sample. This study suggests that mobile apps reach many people and are useful for more moderate levels of depression.

ClinicalTrial

Clinicaltrials.gov NCT00540865; https://www.clinicaltrials.gov/ct2/show/NCT00540865 (Archived by WebCite at http://www.webcitation.org/6mj8IPqQr)

"Engage" Therapy: Behavioral Activation and Improvement of Late-Life Major Depression

OBJECTIVE

Engage is a treatment for late-life depression developed to match the skills of community clinicians based on the theory that dysfunction in the Research Domain Criteria Project positive valence systems is a critical mechanism of late-life depression. Accordingly, it uses "reward exposure" (engagement in meaningful, rewarding activities) as its principal intervention. This study tests the hypothesis that change in behavioral activation, an index of positive valence systems function, during successive treatment periods with Engage and during follow-up predicts depression at the end of each period.

METHODS

Forty-eight nondemented, older adults with unipolar major depression were treated openly with 9 weekly sessions of Engage and assessed 36 weeks after entry. Depression severity was assessed with the 24-item Hamilton Depression Rating Scale (HAM-D) and behavioral activation with the Behavioral Activation for Depression Scale (BADS) at baseline, 6 weeks (mid-treatment), 9 weeks (end of treatment), and 36 weeks.

RESULTS

A mixed-effects model examined whether change in BADS in successive periods occurring during Engage treatment and during follow-up predicts depression at the end of each period. Both BADS change (F1,52 = 18.63, p < 0.0001) and time (F2,52 = 7.68, p = 0.0012) predicted HAM-D scores at the end of each observation period. Every point of increase in BADS change reduced the HAM-D by 0.105 points. HAM-D at each point did not predict subsequent change in BADS (F1,52 = 2.17, p = 0.146).

CONCLUSION

During Engage treatment and follow-up, change in behavioral activation is followed by improvement of depressive symptoms and signs.

Problem-Solving Therapy Reduces Suicidal Ideation In Depressed Older Adults with Executive Dysfunction

OBJECTIVE

To test the hypothesis that Problem Solving Therapy (PST) is more effective than Supportive Therapy (ST) in reducing suicidal ideation in older adults with major depression and executive dysfunction. We further explored whether patient characteristics, such as age, sex, and additional cognitive impairment load (e.g., memory impairments) were related to changes in suicidal ideation over time.

DESIGN

Secondary data analysis using data from a randomized clinical trial allocating participants to PST or ST at 1:1 ratio. Raters were blind to patients' assignments.

SETTING

University medical centers.

PARTICIPANTS

221 people aged 65 years old and older with major depression determined by Structured Clinical Interview for DSM-III-R diagnosis and executive dysfunction as defined by a score of 33 or less on the Initiation-Perseveration Score of the Mattis Dementia Rating Scale or a Stroop Interference Task score of 25 or less.

INTERVENTIONS

12 weekly sessions of PST or ST.

MAIN OUTCOME MEASURES

The suicide item of the Hamilton Depression Rating Scale.

RESULTS

Of the 221 participants, 61% reported suicidal ideation (SI). The ST group had a lower rate of improvement in SI after 12 weeks (44.6%) than did the PST group (60.4%, Fisher's exact test p = 0.031). Logistic regression showed significantly greater reductions in SI in elders who received PST at both 12 weeks (OR: .50, Z = -2.16, p = 0.031) and 36 weeks (OR: 0.5, Z = -1.96, p = 0.05) after treatment.

CONCLUSIONS

PST is a promising intervention for older adults who are at risk for suicide. ClinicalTrials.gov Identifier: NCT00052091.

Depression Treatment Uptake in Integrated Primary Care: How a "Warm Handoff" and Other Factors Affect Decision Making by Latinos

OBJECTIVE

Integrated behavioral health care has the potential to reduce barriers to mental health treatment among low-income and minority populations. This study aimed to identify predictors of Latino patients' decision to follow through with referrals to depression treatment in an integrated primary care setting, including type of referral (a "warm handoff" from a primary care provider [PCP] to a behavioral health care provider or a prescribed referral).

METHODS

The authors conducted a sequential medical record review of 431 patients referred for depression treatment in integrated behavioral health services followed by qualitative semistructured interviews with a subsample of 16 patients.

RESULTS

English-speaking Latinos were four times less likely to attend an initial visit within two months of a referral if they received a warm handoff rather than a prescribed referral. The strength of the patient-provider relationship and the quality of the referral experience, including whether the PCP addressed patients' health literacy and expectations for depression care, affected patients' decision to engage in depression treatment.

CONCLUSIONS

Engaging Latinos in needed mental health treatment is a challenge, even when treatment is provided in primary care settings. Warm handoffs are considered effective components of engagement, but this study suggests that the effectiveness of warm handoffs may vary depending on the patient's primary language. The following factors seem important to engaging Latinos into care: patient-provider relationship, quality of the referral process, addressing expectations about depression care, and reducing communication barriers, including health literacy and linguistic barriers. Future studies of engagement strategies should explore these factors.

Comparing engage with PST in late-life major depression: a preliminary report

OBJECTIVE

The complexity of psychotherapies has been a barrier to community implementation. We used the Research Domain Criteria consensus as a guide to develop Engage, a streamlined, neurobiology-based psychotherapy for late-life depression that may match the skill set of practicing clinicians. This proof of concept study tested the hypotheses that Engage is bioequivalent to Problem Solving Therapy (PST) in reducing depressive symptoms, inducing remission, and ameliorating disability.

METHODS

Engage assumes that abnormal function of the positive valence systems fuels depression and uses "reward exposure" (engagement in meaningful, rewarding activities) as its principal intervention. Negativity bias, apathy, and emotional dysregulation are expressions of abnormalities in the negative valence, arousal and regulatory, and cognitive control systems, respectively. Engage targets each of them with simple interventions only if they interfere with reward exposure. We treated openly, with 9 weekly sessions of Engage, 39 older adults with unipolar major depression. We compared their course of depression (HAM-D), remission rate (HAM-D<10), and disability (WHODAS) with those of a historical comparison group (N = 97) treated with 9 weekly sessions of PST.

RESULTS

Community social workers and research therapists required one third as much training time in Engage as in PST. Engage was non-inferior to PST in reducing HAM-D and WHODAS. Remission rates for Engage at 6 and 9 weeks were 18.2% and 41.1%, respectively. The corresponding figures for PST were 13.7% and 35.0%, respectively.

CONCLUSION

These initial observations suggest that Engage has comparable efficacy with PST in reducing depressive symptoms and disability and warrants a randomized controlled trial.

Causal and bidirectional linkages over time between depression and diabetes regimen distress in adults with type 2 diabetes

AIMS

Diabetes regimen distress (RD) and depression are related constructs, however the nature of their relationship has not been explored over time, leading to difficulties differentiating between RD and depression and for selection of programs of care. We examined longitudinal associations between RD and depression to explicate the direction and mechanism of operation between these two constructs.

METHODS

392 adults with type 2 diabetes participated in a randomized control trial (RCT) to reduce diabetes distress. Participants were assessed for RD and depression symptoms, using the PHQ-8, at baseline, and at 4 and 12 months. Latent growth curve models tested both predictive unidirectional and bidirectional longitudinal associations between changes in RD and depression.

RESULTS

Changes in RD did not significantly predict changes in PHQ-8, nor did changes in PHQ-8 predict changes in RD. A significant bidirectional association was found (Coefficient Estimate=.081, p=.001), where decreases in RD were associated with decreases in PHQ-8. The association was strongest among those with high baseline RD or PHQ-8 scores.

CONCLUSIONS

In the context of an RCT to reduce distress, support was found for a covarying association, in which changes in RD and depression symptoms occurred in tandem over time. No support was found for a causative association. Findings point to RD and depression containing properties that may be related to a shared underlying dimension of emotional distress. Results suggest consideration of both RD and depression in clinical decision making, with interventions selected based on source of distress.

Association of age at depression onset with cognitive functioning in individuals with late-life depression and executive dysfunction

OBJECTIVE

To compare patterns of cognitive performance in older adults with late-onset depression (LOD; ≥65 years of age) with that of older adults with early-onset depression (EOD; <65 years).

METHODS

Participants were 171 adults aged 60 years or older with major depression and executive dysfunction who were participating in a randomized psychotherapy trial. Participants included 72 LOD and 99 EOD individuals. Cognitive performance on measures of verbal learning, memory, and executive functioning were evaluated. Demographic and clinical characteristics, severity of cerebrovascular risk factors, and disability ratings were also compared between groups.

RESULTS

The LOD group was older and had fewer previous episodes of depression and lower severity of depression compared with EOD participants. The LOD group demonstrated poorer performance on measures of verbal learning (F(1,161) = 4.28, p = 0.04) and memory (F(1,160) = 4.65, p = 0.03) than the EOD group. Linear regression analysis demonstrated that LOD and fewer years of education were significant predictors of poorer verbal learning (F(7,114) = 6.25, p <0.001) and memory (F(7,113)=7.24, p <0.001). Performance on measures of executive functioning, severity of vascular risk factors, and disability ratings did not differ between the two groups.

CONCLUSION

In older adults with depression and executive dysfunction, LOD was associated with poorer performance on measures of verbal learning and memory. Aging-related brain changes associated with LOD may play a more important role, leading to dysfunction in these cognitive domains than a history of recurrent depressive episodes in older adults with a dysexecutive syndrome.

Cognitive outcomes after psychotherapeutic interventions for major depression in older adults with executive dysfunction

OBJECTIVE

The purpose of this study was to determine the impact of psychotherapy on cognitive functioning in older adults with late-life depression (LLD) and executive dysfunction.

METHODS

Two hundred twenty-one adults aged 60 years and older participated in a randomized clinical trial comparing the efficacy of Problem Solving Therapy (PST) and Supportive Therapy (ST) for LLD. Cognitive performance on seven tests of executive functioning, verbal learning, and memory was evaluated at baseline, after 12 weeks of treatment, and at 24 weeks after the completion of treatment.

RESULTS

Performance on a measure of executive functioning with a significant information processing speed component (Stroop Color and Word Test) improved after treatment, F (1, 312) = 8.50, p = 0.002, and improved performance was associated with a reduction in depressive symptoms but not treatment type. Performance on other measures of executive functioning, verbal learning, and memory did not change significantly after 12 weeks of psychotherapy treatment.

CONCLUSION

Our results suggest that improvements in cognitive functioning after psychotherapy treatment for depression in older adults with executive dysfunction are likely focal and not distributed across all cognitive domains. Although previous analyses reported that PST was superior to ST in the treatment of depression, this analysis indicated no difference between the two treatments with regard to improvements in cognitive functioning.

Choosing treatment for depression in older adults and evaluating response

An update is provided on the current information regarding late life depression with regard to assessment, clinical implications, and treatment recommendations. Several treatments are considered evidence-based, but when deployed into field trials, the efficacy of these treatments falls short. It is thought that the lower impact in community trials is due in large part to patient, clinical, environmental, socio-economic, and cognitive correlates that influence treatment response. The aim is to assist providers in making decisions about what type of treatment to recommend based on a sound assessment of these clinical correlates.

Do manualized treatments for depression reduce insomnia symptoms?

OBJECTIVE

Researchers evaluated the effect of manualized treatments for depression on comorbid symptoms of insomnia.

METHOD

Hierarchical linear modeling was used to analyze archival data collected from 14 studies (N = 910) examining the efficacy of psychological treatments for depression in adults.

RESULTS

Participants receiving a psychological treatment for depression experienced significantly more relief from symptoms of insomnia with overall, early-, middle-, and late-night sleep than those not receiving such treatment.

CONCLUSION

Symptoms of insomnia in those with an average (or lower) level of depression can be reduced through psychological treatment for depression. However, more severe depressive symptoms do not receive great relief from sleep disturbance and may require an additional treatment component targeting symptoms of insomnia.

Reductions in regimen distress are associated with improved management and glycemic control over time

OBJECTIVE Cross-sectional and longitudinal associations among regimen distress (RD), self-management, and glycemic control were undertaken to explore mechanisms of operation among these variables. RESEARCH DESIGN AND METHODS In a behavioral randomized control trial (RCT) to reduce RD, 392 adults with type 2 diabetes were assessed for RD, diet, exercise, medication adherence, and HbA1c at baseline and at 4 and 12 months. Associations among RD, self-management, and HbA1c were examined in cross-sectional analyses at baseline, in prospective analyses using baseline values to predict change over time, and in time-varying analyses. RESULTS At baseline, greater RD and poorer medication adherence were independently associated with higher HbA1c (P = 0.05 and P < 0.001, respectively), and greater RD was associated with poorer medication adherence (P = 0.03). No consistent pattern of significant prospective associations was found. Significant time-varying findings showed that decreases in RD were associated with improvements in medication adherence (P < 0.01), physical activity (P < 0.001), and HbA1c (P = 0.02) over time following intervention. Changes in self-management were not associated with changes in HbA1c over time. CONCLUSIONS In the context of an RCT to reduce distress, RD, self-management, and HbA1c were interrelated in cross-sectional and time-varying analyses. Decreases in RD were associated with improvements in both self-management and HbA1c over 12 months. Findings point to the complex and likely multifaceted pathways of association among these key constructs, with results indicating significant linkages between RD and both self-management and glycemic control over time.

REDEEM: a pragmatic trial to reduce diabetes distress

OBJECTIVE

To compare three interventions to reduce diabetes distress (DD) and improve self-management among non-clinically depressed adults with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

In REDEEM, 392 adults with T2DM and DD were randomized to computer-assisted self-management (CASM), CASM plus DD-specific problem solving (CAPS), or a computer-administered minimal supportive intervention. Primary outcomes were Diabetes Distress Scale (DDS) total, the Emotional Burden (EB) and Regimen Distress (RD) DDS subscales, and diet, exercise, and medication adherence.

RESULTS

Significant and clinically meaningful reductions in DD (DDS, EB, and RD) and self-management behaviors occurred in all three conditions (P < 0.001), with no significant between-group differences. There was, however, a significant group × baseline distress interaction (P < 0.02), in which patients with high baseline RD in the CAPS condition displayed significantly larger RD reductions than those in the other two conditions. RD generated the most distress and displayed the greatest distress reduction as a result of intervention. The pace of DD reduction varied by patient age: older patients demonstrated significant reductions in DD early in the intervention, whereas younger adults displayed similar reductions later. Reductions in DD were accompanied by significant improvements in healthy eating, physical activity, and medication adherence, although not by change in HbA1c.

CONCLUSIONS

DD is malleable and highly responsive to intervention. Interventions that enhance self-management also reduce DD significantly, but DD-specific interventions may be necessary for patients with high initial levels of DD. Future research should identify the minimal, most cost-effective interventions to reduce DD and improve self-management.

Personalizing behavioral interventions: the case of late-life depression

This article reviews the potential utility of behavioral interventions in personalized depression treatment. The paper begins with a definition of personalized treatment, moves to current thinking regarding the various causes of depression, and proposes how those causes can be used to inform the selection of behavioral interventions. Two examples from the late-life depression field will illustrate how a team of researchers at Cornell University (NY, USA) and University of California, San Francisco (CA, USA) created a research partnership to select and study behavioral interventions for older adults with risk factors associated with poor response to selective serotonin reuptake inhibitor medications. The paper ends with a discussion of how the process used by the Cornell University-University of California, San Francisco team can be applied to the selection and development of behavioral interventions for other psychiatric disorders.

Depression is a common and chronic comorbidity in patients with interstitial lung disease

BACKGROUND AND OBJECTIVE

Little is known about depression in interstitial lung disease (ILD). The aim of this study was to determine the prevalence of depression, characterize the association of depression with clinical variables and describe the natural history of depression in patients with ILD.

METHODS

In this prospective cohort study, clinical variables were recorded at baseline and 6 months. Depression was measured with the Centre for Epidemiologic Studies Depression scale. Depression prevalence was determined using the established threshold of >15 points. Multivariate linear regression was used to determine the baseline features that independently correlated with baseline depression score and that predicted depression severity at follow-up.

RESULTS

Fifty-two subjects were enrolled, and 45 returned for follow-up (three deaths, one lung transplant). Prevalence of depression was 21% at baseline. Independent predictors of depressive symptoms at baseline included dyspnoea severity, pain severity, sleep quality and forced vital capacity (R(2) 0.67). The odds of clinically meaningful depression at follow-up were 34-fold higher for subjects who had clinically meaningful depression at baseline compared with those who were not (95% confidence interval 3.5-422, P < 0.0005). Baseline depression score was the strongest predictor of depression score at follow-up (r 0.59, P < 0.00005).

CONCLUSIONS

Depressive symptoms in ILD are common, persistent, and strongly and independently correlated with dyspnoea, pain, sleep quality and forced vital capacity. Clinically meaningful depression at baseline is the most important predictor of depressive symptoms at follow-up. Patients with ILD should routinely be screened for depression.

Implementing evidence-based psychotherapies in settings serving older adults: challenges and solutions

This Open Forum addresses challenges--insurance limitations, staff and setting limitations, and training and sustainability issues--in the implementation of psychotherapy interventions in settings serving older adults and provides solutions for ensuring that they have access to effective mental health services. There is considerable movement toward developing the geriatric mental health workforce, and it is important that these efforts include a discussion of implementation issues with regard to evidence-based psychotherapies as they are provided in services for aging populations.

Low use of mental health services among older Americans with mood and anxiety disorders

OBJECTIVE

It is unclear why late-life mood and anxiety disorders are highly undertreated, despite being common among older adults. Thus this study examined prevalence of and key factors associated with nonuse of mental health services among older community-dwelling adults with these disorders.

METHODS

The sample included 348 participants aged 55 years or older who met 12-month criteria for DSM-IV mood and anxiety disorders and responded to the National Comorbidity Survey Replication (NCS-R), a population-based probability sample. Analyses included frequency measures and logistic regression with weights and complex design-corrected statistical tests. Key factors associated with not using mental health services were determined in a final multivariable model based on a systematic approach that accounted for a comprehensive list of potential predictors.

RESULTS

Approximately 70% of older adults with mood and anxiety disorders did not use services. Those who were from racial-ethnic minority groups, were not comfortable with discussing personal problems, were married or cohabitating, and had middle- versus high-income status had increased odds of not using mental health services. In addition, respondents with mild versus serious disorders, no chronic pain complaints, and low versus high perceived cognitive impairment had greater odds of nonuse.

CONCLUSIONS

Results indicate that improvements are needed in the following areas to combat the very high number of mood and anxiety disorders that go untreated in older Americans: awareness of need, comfort in discussing personal problems with a health care professional, and screening and other prevention efforts.

Does mentoring matter: results from a survey of faculty mentees at a large health sciences university

BACKGROUND

To determine the characteristics associated with having a mentor, the association of mentoring with self-efficacy, and the content of mentor-mentee interactions at the University of California, San Francisco (UCSF), we conducted a baseline assessment prior to implementing a comprehensive faculty mentoring program.

METHOD

We surveyed all prospective junior faculty mentees at UCSF. Mentees completed a web-based, 38-item survey including an assessment of self-efficacy and a needs assessment. We used descriptive and inferential statistics to determine the association between having a mentor and gender, ethnicity, faculty series, and self-efficacy.

RESULTS

Our respondents (n=464, 56%) were 53% female, 62% white, and 7% from underrepresented minority groups. More than half of respondents (n=319) reported having a mentor. There were no differences in having a mentor based on gender or ethnicity (p>or=0.05). Clinician educator faculty with more teaching and patient care responsibilities were statistically significantly less likely to have a mentor compared with faculty in research intensive series (p<0.001). Having a mentor was associated with greater satisfaction with time allocation at work (p<0.05) and with higher academic self-efficacy scores, 6.07 (sd = 1.36) compared with those without a mentor, 5.33 (sd = 1.35, p<0.001). Mentees reported that they most often discussed funding with the mentors, but rated highest requiring mentoring assistance with issues of promotion and tenure.

CONCLUSION

Findings from the UCSF faculty mentoring program may assist other health science institutions plan similar programs. Mentoring needs for junior faculty with greater teaching and patient care responsibilities must be addressed.

Problem solving therapy for the depression-executive dysfunction syndrome of late life

BACKGROUND

The 'depression executive dysfunction syndrome' afflicts a considerable number of depressed elderly patients and may be resistant to conventional pharmacotherapy. Non-pharmacological approaches addressing their behavioral deficits may reduce disability and experienced stress and improve depression.

METHODS

This paper focuses on problem solving therapy (PST) because it targets concrete problems that can be understood by patients with executive dysfunction and trains patients to address them using an easy to comprehend structured approach.

RESULTS

We suggest that PST is a suitable treatment for patients with the depression-executive dysfunction syndrome because it has been found effective in uncomplicated geriatric major depression and in other psychiatric disorders accompanied by severe executive dysfunction. Furthermore, PST can address specific clinical features of depressed patients with executive dysfunction, especially when modified to address difficulties with affect regulation, initiation and perseveration.

CONCLUSIONS

A preliminary study suggests that appropriately modified PST improves problem solving skills, depression and disability in elderly patients with the depression-executive dysfunction syndrome of late life. If these findings are confirmed, PST may become a therapeutic option for a large group of depressed elderly patients likely to be drug resistant.

Developing an intervention for depressed, chronically medically ill elders: a model from COPD

BACKGROUND

Geriatric depression preferentially afflicts individuals with chronic medical illnesses. Disability, hopelessness, lack of acceptance of antidepressant treatment, and limited problem-solving skills contribute to poor treatment adherence, compromised outcomes, and chronically experienced adversity.

METHODS

This paper uses depression comorbid with chronic obstructive pulmonary disease (COPD) as a model entity to develop an approach for integrating treatment components essential for improving treatment adherence and outcomes.

RESULTS

The behavioral inertia of depression and its coexisting cognitive problems reduce adherence to the sustained and complex demands of the COPD rehabilitation regimen and antidepressant treatment. An intervention identifying reasons for poor treatment adherence and offering direct instructions for addressing them can be combined with problem-solving therapy to target treatment adherence, depressive symptoms, and disability.

CONCLUSIONS

An intervention focusing on treatment adherence and problem-solving skills development may serve as the platform for administering specific treatments to address the interacting problems of depressed medically ill patients.

The Role of Cognitive Functioning and Distress in Suicidal Ideation in Older Adults

OBJECTIVES

To evaluate the role of cognitive functioning and other clinical and demographic characteristics as potential predictors of suicidal ideation in older primary care patients.

DESIGN

Cross-sectional.

SETTING

Primary care clinics at three Department of Veterans Affairs Medical Centers, three community health centers, and two hospital networks.

PARTICIPANTS

Fifteen thousand five hundred ninety older adults without dementia who were receiving primary care (mean age+/-standard deviation 74.0+/-6.4; 62.8% men).

MEASUREMENTS

Hierarchical logistic regressions were conducted with passive (e.g., thoughts of being better off dead) and active (e.g., thoughts of hurting one self) suicidal ideation as outcome variables. All demographic variables (age, sex, marital status, and ethnicity) were entered in the first block. All clinical variables (distress, cognitive functioning, alcohol consumption, and perceived health) were entered in the second block.

RESULTS

In addition to the typical demographic predictors of late-life suicide (age, martial status, and ethnicity), having poorer cognitive functioning, poorer health, and greater mental distress were associated with passive suicidal ideation (chi-square (chi2) (14, n=14,618)=1,192.12, P<.001). Younger age, female sex, poorer cognitive functioning, and greater mental distress were associated with active suicidal ideation (chi2(14, n=14,605)=205.35, P<.001).

CONCLUSION

Distress and cognitive impairment are the only two variables that consistently predicted passive and active suicidal ideation. Primary care providers who work with older adults need to take both into consideration when evaluating suicidal ideation.

Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life

OBJECTIVES

To review progress made during the past decade in late-life mood disorders and to identify areas of unmet need in health care delivery and research.

PARTICIPANTS

The Consensus Development Panel consisted of experts in late-life mood disorders, geriatrics, primary care, mental health and aging policy research, and advocacy.

EVIDENCE

(1) Literature reviews addressing risk factors, prevention, diagnosis, treatment, and delivery of services and (2) opinions and experiences of primary care and mental health care providers, policy analysts, and advocates.

CONSENSUS PROCESS

The Consensus Development Panel listened to presentations and participated in discussions. Workgroups considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed and edited to incorporate input from the entire Consensus Development Panel.

CONCLUSIONS

Despite the availability of safe and efficacious treatments, mood disorders remain a significant health care issue for the elderly and are associated with disability, functional decline, diminished quality of life, mortality from comorbid medical conditions or suicide, demands on caregivers, and increased service utilization. Discriminatory coverage and reimbursement policies for mental health care are a challenge for the elderly, especially those with modest incomes, and for clinicians. Minorities are particularly underserved. Access to mental health care services for most elderly individuals is inadequate, and coordination of services is lacking. There is an immediate need for collaboration among patients, families, researchers, clinicians, governmental agencies, and third-party payers to improve diagnosis, treatment, and delivery of services for elderly persons with mood disorders.

Psychosocial treatment research with ethnic minority populations: ethical considerations in conducting clinical trials

Because of historical mistreatment of ethnic minorities by research and medical institutions, it is particularly important for researchers to be mindful of ethical issues that arise when conducting research with ethnic minority populations. In this article, we focus on the ethical issues related to the inclusion of ethnic minorities in clinical trials of psychosocial treatments. We highlight 2 factors, skepticism and mistrust by ethnic minorities about research and current inequities in the mental health care system, that researchers should consider when developing psychosocial interventions studies that include ethnic minorities.

Ethical considerations in psychotherapy effectiveness research: choosing the comparison group

The primary purpose behind effectiveness research is to determine whether a treatment with demonstrated efficacy has utility when administered to the general population. The main questions these studies are meant to answer are these: Can the typical patient respond to treatment? Is the treatment acceptable to the typical patient? Can the treatment be administered safely and in its entirety in the typical treatment setting? Is the treatment under study significantly better than the community standard of care both from and a cost and outcome perspective? Answering these questions is meant to provide sufficient information to providers and policymakers so that effective interventions can be adopted and become the new community standard. For this research to make a meaningful impact on a provider and policymaker's decision to change the status quo, study interventions should be compared to the existing community standard of treatment, often referred to as treatment as usual (TAU). From an ethical perspective, this decision may not always be the safest choice. In some populations, TAU may mean no treatment at all, and in others TAU may be worse than withholding treatment. The effectiveness researcher is then caught between the pull to do no harm and the need for research to have an impact on change. The purpose of this article is to highlight certain conditions when TAU is ethically acceptable and to discuss alternatives when TAU may be an unethical treatment condition. For purposes of precision, we focus exclusively on psychotherapy effectiveness research rather than system-intervention research or medication-intervention research.

Do primary care patients accept psychological treatments?

Most individuals seeking care for psychological distress go to primary care physicians rather than to mental health professionals. Many have symptoms of distress that do not meet criteria for psychiatric disorders; pharmacotherapies are generally not available for these subsyndromal problems. Preliminary studies suggest that psychosocial therapies may be useful. The aim of this paper was to learn whether medical patients would accept psychological treatments for 1) depression, an explicit psychopathology; 2) stress, a nonpathological, but psychological, problem; and 3) medical problems, a nonpsychological issue. Respondents were 131 primary care patients at San Francisco General Hospital, a public sector hospital. The results show that most of the patients (107 of 131) found psychological interventions acceptable. In addition, the vast majority were willing to have the treatments focus on psychological issues such as depression and stress. This study demonstrates that primary care patients find psychological interventions acceptable.

Comparative effectiveness of social problem-solving therapy and reminiscence therapy as treatments for depression in older adults

Compared the effects of 2 psychotherapies based on divergent conceptualizations of depression in later life. Seventy-five older adults diagnosed with major depressive disorder were assigned randomly to problem-solving therapy (PST), reminiscence therapy (RT), or a waiting-list control (WLC) condition. Participants in PST and RT were provided with 12 weekly sessions of group treatment. Dependent measures, taken at baseline, posttreatment, and 3-month follow-up, included self-report and observer-based assessments of depressive symptomatology. At posttreatment, both the PST and the RT conditions produced significant reductions in depressive symptoms, compared with the WLC group, and PST participants experienced significantly less depression than RT subjects. Moreover, a significantly greater proportion of participants in PST versus RT demonstrated sufficient positive change to warrant classification of their depression as improved or in remission at the posttreatment and follow-up evaluations.

Comparative effectiveness of social problem-solving therapy and reminiscence therapy as treatments for depression in older adults

Compared the effects of 2 psychotherapies based on divergent conceptualizations of depression in later life. Seventy-five older adults diagnosed with major depressive disorder were assigned randomly to problem-solving therapy (PST), reminiscence therapy (RT), or a waiting-list control (WLC) condition. Participants in PST and RT were provided with 12 weekly sessions of group treatment. Dependent measures, taken at baseline, posttreatment, and 3-month follow-up, included self-report and observer-based assessments of depressive symptomatology. At posttreatment, both the PST and the RT conditions produced significant reductions in depressive symptoms, compared with the WLC group, and PST participants experienced significantly less depression than RT subjects. Moreover, a significantly greater proportion of participants in PST versus RT demonstrated sufficient positive change to warrant classification of their depression as improved or in remission at the posttreatment and follow-up evaluations.