Postpartum women's experiences in a randomized controlled trial of a web-based lifestyle intervention following Gestational Diabetes: a qualitative study

INTRODUCTION

Gestational diabetes mellitus (GDM) is associated with an increased maternal risk for the development of type 2 diabetes (T2DM). We previously demonstrated in a randomized trial that a web-based postpartum lifestyle intervention program, Balance After Baby, increased weight loss among postpartum women with recent pregnancies complicated by GDM. The aim of this analysis is to identify the impact of the intervention on study participants as assessed by exit interviews after completion of the 12 month study.

METHODS

We conducted structured exit interviews created with a concurrent-contextual design with subjects randomized to the intervention group at the conclusion of their participation (∼12 months) in the Balance After Baby study, with the objectives of 1) understanding the impact of the intervention on participants and their family members, 2) identifying which program components were most and least helpful, and 3) identifying the perceived best timing for diabetes prevention interventions in postpartum women with recent GDM.

RESULTS

Seventy-nine percent (26/33) of eligible intervention participants participated in interviews. Participants noted changes in diet and physical activity as a result of the intervention. Several components of the intervention, particularly the online modules and support from the lifestyle coach, were perceived by intervention participants to have had a positive effect on personal and familial lifestyle change, while other components were less utilized, including the community forum, YMCA memberships, and pedometers. Nearly all participants felt that the timing in the intervention study, beginning about 6 weeks postpartum, was ideal.

DISCUSSION

Results of this study identify the importance of individualized coaching, impact on family members, and demonstrate that postpartum women feel ready to make changes by 6 weeks postpartum. Findings from this study will help inform the development of future technologically-based lifestyle interventions for postpartum women with recent GDM.

Effectiveness of the National Diabetes Prevention Program After Gestational Diabetes

INTRODUCTION

Women with previous gestational diabetes are at high risk of developing Type 2 diabetes. The National Diabetes Prevention Program (NDPP) is a widely disseminated lifestyle intervention to prevent Type 2 diabetes. Although NDPP programs are open to adults of any age, participants are usually older adults. Effectiveness among younger women with previous gestational diabetes is largely unknown.

METHODS

The NDPP was delivered by lifestyle coaches in a large network of Federally Qualified Health Centers. Reach, retention, physical activity, and weight loss outcomes were compared between women aged <40 years with previous gestational diabetes and all other participants. Data were collected from 2013 to 2019 and analyzed in 2022.

RESULTS

Among 2,865 enrollees who agreed to start the yearlong NDPP, 63.3% were Latinx, 18.8% were non-Latinx Black, and 16.4% were non-Latinx White. Younger women with previous gestational diabetes represented <4% (n=107) of participants. There was no significant difference in the frequency of attending ≥1 NDPP session between these women and all other participants (37.4% vs 44.6%; p=0.146). However, among those attending ≥1 session (n=1,265), younger women with previous gestational diabetes attended more (11.27 ± 1.27 vs 8.50 ± 0.22 sessions, p=0.021) and had greater weight loss (3.04% ± 0.59 vs. 1.49% ± 0.11, p=0.010) in covariate-adjusted models than other participants.

CONCLUSIONS

Diverse younger women with previous gestational diabetes attending the NDPP had one third greater attendance and twice as much weight loss as other NDPP participants but represented a much smaller proportion of enrollees. Thus, the NDPP appears to be a beneficial but underutilized resource for this high-risk population.

Highlighting the value of Alzheimer's disease-focused registries: lessons learned from cancer surveillance

Like cancer, Alzheimer's disease and related dementias (ADRD) comprise a global health burden that can benefit tremendously from the power of disease registry data. With an aging population, the incidence, treatment, and mortality from ADRD is increasing and changing rapidly. In the same way that current cancer registries work toward prevention and control, so do ADRD registries. ADRD registries maintain a comprehensive and accurate registry of ADRD within their state, provide disease prevalence estimates to enable better planning for social and medical services, identify differences in disease prevalence among demographic groups, help those who care for individuals with ADRD, and foster research into risk factors for ADRD. ADRD registries offer a unique opportunity to conduct high-impact, scientifically rigorous research efficiently. As research on and development of ADRD treatments continue to be a priority, such registries can be powerful tools for conducting observational studies of the disease. This perspectives piece examines how established cancer registries can inform ADRD registries' impact on public health surveillance, research, and intervention, and inform and engage policymakers.

Reflections on Mentorship From Scientists and Mentors in an Alzheimer's Disease Focused Research Training Program

This paper presents reflections on mentorship from scientists and mentors of the National Institute on Aging (NIA)-funded Carolina Center on Alzheimer's Disease and Minority Research (CCADMR). Using a network approach to mentoring, this program aims to increase the pipeline of underrepresented minority (URM) scientists studying Alzheimer's disease (AD) disparities. Six mentors and five scientists participated in interviews. Thematic analysis identified recurring themes; transcripts of mentors and scientists were compared. Most common thematic categories identified by mentors included experience interacting with scientists, goals as a mentor, recruitment of underrepresented minorities, scientists' challenges, and programmatic qualities. The most mentioned categories by scientists were challenges, seminars, working with mentors, career development, and project experience. The CCADMR will use findings to enhance the experience and training methods for future grant years. Results can benefit other training programs focused on aging and AD.

Evaluation of the Reliability and Validity of the Alzheimer's Disease-Related Quality of Life Instrument among Older Adults with Cognitive Impairment in Mainland China

The purpose of this study is to examine the reliability and validity of the ADRQL instrument among older adults with cognitive impairment in mainland China. Three hundred older adults with cognitive impairment and their primary family caregivers from Wuhan participated in structured interviews. Cronbach's α and Kuder-Richardson Formula 20 were used to examine internal consistency reliability. Confirmatory factor analysis, Heterotrait-Monotrait ratios, and ordinary least square regression were used to assess the factorial validity, discriminant validity, and criterion validity. The ADRQL had acceptable reliability and validity, which can be used to assess overall quality of life for this population.

Risk and protective factors associated with grandparent kinship caregivers' psychological distress in COVID-19: Kinship license status as a moderator

COVID-19 and its related policy measures have increased the psychological distress of individuals, including grandparent kinship caregivers. Guided by the Resilience Model of Family Stress, Adjustment, and Adaptation, this study examines relationships between material hardship, parenting stress, social support, resilience and psychological distress of grandparent kinship caregivers during the COVID-19 pandemic, as well as the moderating role of kinship license status on these relationships. Kinship care licensing is a prerequisite to receiving financial assistance and other supporting services from the government. We administered a cross-sectional survey of grandparent kinship caregivers (N = 362) in the United States. Logistic regression results indicated that material hardship was associated with higher odds of experiencing psychological distress, whereas resilience and social support were associated with lower odds. Kinship license status moderated the relationships of social support and resilience with psychological distress. Results suggest that additional emergency funds and more tailored financial services should be provided to meet material needs, and interventions with a focus on resilience and social support are particularly needed. The moderating effects of license status indicate that some interventions should be specifically implemented among licensed kinship caregivers, whereas parallel services should be provided to kinship caregivers regardless of their license status.

Understanding the Relationships between Parenting Stress and Mental Health with Grandparent Kinship Caregivers' Risky Parenting Behaviors in the Time of COVID-19

Grandparent kinship caregivers may experience increased parenting stress and mental distress during the COVID-19 pandemic. It may lead to risky parenting behaviors, such as psychological aggression, corporal punishment, and neglectful behaviors towards their grandchildren. This study aims to examine (1) the relationships between parenting stress, mental health, and grandparent kinship caregivers' risky parenting practices, such as psychological aggression, corporal punishment, and neglectful behaviors towards their grandchildren during the COVID-19 pandemic, and (2) whether grandparent kinship caregivers' mental health is a potential mediator between parenting stress and caregivers' psychological aggression, corporal punishment, and neglectful behaviors. A cross-sectional survey among grandparent kinship caregivers (N = 362) was conducted in June 2020 in the United States. Descriptive analyses, negative binomial regression analyses, and mediation analyses were conducted using STATA 15.0. We found that (1) grandparent kinship caregivers' high parenting stress and low mental health were associated with more psychological aggression, corporal punishment, and neglectful parenting behaviors during COVID-19; and (2) grandparent kinship caregivers' mental health partially mediated the relationships between parenting stress and their psychological aggression, corporal punishment, and neglectful behaviors. Results suggest that decreasing grandparent kinship caregivers' parenting stress and improving their mental health are important for reducing child maltreatment risk during COVID-19.

Writing Skills Development for Graduate Studies and Career Readiness in Science and Aging Fields: A Case Study Approach

Increasing the number of racially and ethnically underrepresented students who pursue scientific graduate studies in programs focusing on science and aging offers an opportunity to increase the number of aging specialists while simultaneously promoting diversity in the research labor market and supporting new ideas. This case study aims to better understand how students participating in an academic preparatory program experience a writing class contextualized within (1) students' writing background and (2) students' future ambitions related to science and aging. The individually-tailored writing class was taught as a critical component of a comprehensive educational program that targets underrepresented racial and ethnic minority undergraduate students who are interested in pursuing scientific graduate studies in fields related to aging. The researchers conducted semi-structured qualitative interviews with students (n = 4) enrolled in the 24-month fellowship training program, which included participation in the writing course during the summer prior to their senior year of undergraduate education. All participants were young adult college students who identified as Black or African American and female. Using thematic coding, statements about professional writing skills were divided into four primary themes: (1) prior experiences, (2) class experiences, (3) future goals and ambitions, and (4) structural considerations. These themes suggest potential implications for effective interventions aimed to advance the writing skills and academic and career readiness of racially and ethnically diverse students entering fields of science and aging.

Social Technology: An Interdisciplinary Approach to Improving Care for Older Adults

Population aging is a defining demographic reality of our era. It is associated with an increase in the societal burden of delivering care to older adults with chronic conditions or frailty. How to integrate global population aging and technology development to help address the growing demands for care facing many aging societies is both a challenge and an opportunity for innovation. We propose a social technology approach that promotes use of technologies to assist individuals, families, and communities to cope more effectively with the disabilities of older adults who can no longer live independently due to dementia, serious mental illness, and multiple chronic health problems. The main contributions of the social technology approach include: (1) fostering multidisciplinary collaboration among social scientists, engineers, and healthcare experts; (2) including ethical and humanistic standards in creating and evaluating innovations; (3) improving social systems through working with those who deliver, manage, and design older adult care services; (4) promoting social justice through social policy research and innovation, particularly for disadvantaged groups; (5) fostering social integration by creating age-friendly and intergenerational programs; and (6) seeking global benefit by identifying and generalizing best practices. As an emergent, experimental approach, social technology requires systematic evaluation in an iterative process to refine its relevance and uses in different local settings. By linking technological interventions to the social and cultural systems of older people, we aim to help technological advances become an organic part of the complex social world that supports and sustains care delivery to older adults in need.

Material hardship and child neglect risk amidst COVID-19 in grandparent-headed kinship families: The role of financial assistance

BACKGROUND

COVID-19 has exacerbated material hardship among grandparent-headed kinship families. Grandparent-headed kinship families receive financial assistance, which may mitigate material hardship and reduce child neglect risk.

OBJECTIVE

This study aims to examine (1) the association between material hardship and child neglect risk; and (2) whether financial assistance moderates this association in a sample of kinship grandparent-headed families during COVID-19.

PARTICIPANTS AND SETTING

Cross-sectional survey data were collected from a convenience sample of grandparent-headed kinship families (not necessarily child welfare involved) (N = 362) in the United States via Qualtrics Panels online survey.

METHODS

Descriptive, bivariate, and negative binomial regression were conducted using STATA 15.0.

RESULTS

Experiencing material hardship was found to be associated with an increased risk of child neglect, and receiving financial assistance was associated with a decreased risk of child neglect in the full sample and a subsample with household income > $30,000. Receiving financial assistance buffered the negative effect of material hardship on child neglect risk across analytic samples, and receiving SNAP was a significant moderator in the full sample. Among families with a household income ≤ $30,000, receiving SNAP and foster care payments was associated with a decreased risk of child neglect, while receiving TANF and unemployment insurance was associated with an increased risk of child neglect. Among families with household income > $30,000, only receiving SNAP was associated with a decreased risk of child neglect.

CONCLUSIONS

This study suggests the potential importance of providing concrete financial assistance, particularly SNAP and foster care payments, to grandparent-headed kinship families in efforts to decrease child neglect risk during COVID-19.

Youth in Foster Care and the Reasonable and Prudent Parenting Standard

Children in foster care face disproportionate rates of biopsychosocial challenges but social and extracurricular activities (SEAs) may support their healthy development. The Reasonable and Prudent Parenting Standard (RPPS), a 2014 federal policy, aims to increase access to these opportunities for children in foster care. Analyses of statutes from 50 US states and the District of Columbia (n = 51) revealed similarities and differences in state-level RPPS policy implementation. Building on these findings, researchers conducted semi-structured retrospective telephone interviews with foster parents across one southeastern state (n = 20) to identify local retrospective perspectives on RPPS implementation. Using thematic inductive coding two unique themes emerged about SEAs prior to RPPS: 1) negative social impacts and 2) complicated activity approval processes. Three unique themes emerged after RPPS: 1) empowerment, 2) implementation disparities and 3) resource recommendations. Policy implications include the need to support foster parents by increasing resources (funding, transportation, access), clarifying liability and clarifying motivation expectations.

A Web-Based HIV/STD Prevention Intervention for Divorced or Separated Older Women

BACKGROUND AND OBJECTIVE

Sexually transmitted diseases (STDs) are increasing among older adults concomitant with a rise in divorce after the age of 50 years. The objective of this study was to examine the effectiveness of a web-based human immunodeficiency virus (HIV)/STD risk reduction intervention for divorced and separated women aged more than 50 years.

RESEARCH DESIGN AND METHODS

Two hundred nineteen divorced or separated women, aged 50 years and older, participated in 60-day randomized pre-post control group study. Recruitment occurred via health agencies in Boston and Columbia, SC, and Craigslist advertisements placed in Boston, Columbia, Charleston, New York City, Washington DC, Baltimore, Chicago, Atlanta, Orlando, and Miami.

RESULTS

Intervention group reported greater intention to practice safe sex compared to the control group (B = .55, p = .03). Intention to practice safe sex differed by perceived stress (B = .15, p = .005), with no difference between control and intervention groups for those with low levels of stress. For high levels of stress, intervention group reported greater intention to practice safe sex compared to controls. Sexual risk was reduced by 6.10 points (SD: 1.10), and self-efficacy for sexual discussion was increased by 2.65 points (SD: 0.56) in the intervention group.

DISCUSSION AND IMPLICATIONS

A web-based intervention represents a promising tool to reduce HIV/STD risk among older women. Offering HIV/STD education in the context of other topics of interest to at-risk older women, such as divorce, may solve the problem of at-risk older women not seeking out prevention information due to lack of awareness of their heightened risk.

mHealth for pre-exposure prophylaxis adherence by young adult men who have sex with men

BACKGROUND

Young adult men who have sex with men (YMSM) are at increased risk for HIV, especially minority YMSM. Pre-exposure prophylaxis (PrEP) is a breakthrough daily pill to prevent HIV. Consistent adherence is key to PrEP effectiveness, which is why the CDC recommends adherence support be provided to all PrEP patients. Mobile health can overcome barriers to the delivery of adherence support, particularly for YMSM who may be most in need of it due, at least in part, to their young age.

METHODS

We created a culturally- and developmentally-sensitive PrEP adherence mobile app (called "Dot") that was tailored for culturally-diverse young adult MSM. After formative research and usability testing, we conducted a 6-week pre-post study to evaluate the impact of Dot on self-reported PrEP adherence, PrEP treatment self-efficacy, PrEP knowledge, and intention to practice safe sex among culturally-diverse YMSM, age 20-29.

RESULTS

At 6 weeks, there were significant improvements in PrEP adherence, PrEP self-efficacy, and intention to practice safe sex. PrEP knowledge scores did not significantly change.

CONCLUSIONS

The Dot app proved feasible and effective at improving PrEP adherence among culturally-diverse YMSM. Moreover, the app had a high-degree of user appeal, which is foundational to success of an mhealth intervention.

Development and Feasibility of an App to Decrease Risk Factors for Type 2 Diabetes in Hispanic Women With Recent Gestational Diabetes (Hola Bebé, Adiós Diabetes): Pilot Pre-Post Study

Background

Hispanic women have increased risk of gestational diabetes mellitus (GDM), which carries an increased risk for future type 2 diabetes, compared to non-Hispanic women. In addition, Hispanic women are less likely to engage in healthy eating and physical activity, which are both risk factors for type 2 diabetes. Supporting patients to engage in healthy lifestyle behaviors through mobile health (mHealth) interventions is increasingly recognized as a viable, underused tool for disease prevention, as they reduce barriers to access frequently experienced in face-to-face interventions. Despite the high percentage of smartphone ownership among Hispanics, mHealth programs to reduce risk factors for type 2 diabetes in Hispanic women with prior GDM are lacking.

Objective

This study aimed to (1) develop a mobile app (¡Hola Bebé, Adiós Diabetes!) to pilot test a culturally tailored, bilingual (Spanish/English) lifestyle program to reduce risk factors for type 2 diabetes in Hispanic women with GDM in the prior 5 years; (2) examine the acceptability and usability of the app; and (3) assess the short-term effectiveness of the app in increasing self-efficacy for both healthy eating and physical activity, and in decreasing weight.

Methods

Social cognitive theory provided the framework for the study. A prototype app was developed based on prior research and cultural tailoring of content. Features included educational audiovisual modules on healthy eating and physical activity; personal action plans; motivational text messages; weight tracking; user-friendly, easy-to-follow recipes; directions on building a balanced plate; and tiered badges to reward achievements. Perceptions of the app’s acceptability and usability were explored through four focus groups. Short-term effectiveness of the app was tested in an 8-week single group pilot study.

Results

In total, 11 Hispanic women, receiving care at a federally qualified community health center, aged 18-45 years, and with GDM in the last 5 years, participated in four focus groups to evaluate the app’s acceptability and usability. Participants found the following sections most useful: audiovisual modules, badges for completion of activities, weight-tracking graphics, and recipes. Suggested modifications included adjustments in phrasing, graphics, and a tiering system of badges. After app modifications, we conducted usability testing with 4 Hispanic women, with the key result being the suggestion for a “how-to tutorial.” To assess short-term effectiveness, 21 Hispanic women with prior GDM participated in the pilot. There was a statistically significant improvement in both self-efficacy for physical activity (P=.003) and self-efficacy for healthy eating (P=.007). Weight decreased but not significantly. Backend process data revealed a high level of user engagement.

Conclusions

These data support the app’s acceptability, usability, and short-term effectiveness, suggesting that this mHealth program has the potential to fill the gap in care experienced by Hispanic women with prior GDM following pregnancy. Future studies are needed to determine the effectiveness of an enhanced app in a randomized controlled trial.

Trial Registration

ClinicalTrials.gov NCT04149054; https://clinicaltrials.gov/ct2/show/NCT04149054

Material hardship and parenting stress among grandparent kinship providers during the COVID-19 pandemic: The mediating role of grandparents' mental health

BACKGROUND

The COVID-19 pandemic has exposed the vulnerability of many families, including grandparent kinship families, to deal with a health/economic crisis. The fear of COVID-19 plus stay-at-home orders have increased individuals' psychological distress. Moreover, school closures and homeschooling further increased parenting stress among caregivers.

OBJECTIVES

This study examined the relationship between material hardship and parenting stress among grandparent kinship providers, and assessed grandparents' mental health as a potential mediator to this relationship during the COVID-19 pandemic in the United States.

PARTICIPANTS AND SETTING

Grandparent kinship providers (N = 362) that took primary care of their grandchildren participated in a cross-sectional survey via Qualtrics Panels in June 2020 in the United States.

METHODS

Descriptive and bivariate analyses, binary logistic regression, and mediation analyses were conducted using STATA 15.0.

RESULTS

Suffering material hardship was significantly associated with higher odds of experiencing parenting stress among grandparent kinship providers, and grandparents' mental health partially mediated this association.

CONCLUSIONS

Addressing material and mental health needs among grandparent kinship providers is critical to decreasing their parenting stress.

Army Warrior Care Project (AWCP): Rationale and methods for a longitudinal study of behavioral health care in Army Warrior Transition Units using Military Health System data, FY2008-2015

OBJECTIVES

Warrior Transition Units (WTUs) are specialized military units co-located with major military treatment facilities providing a Triad of Care involving primary care physicians, case managers, and military leadership to soldiers needing comprehensive medical care. We describe the rationale and methods for studying behavioral health care in WTUs and characterize soldiers assigned to WTUs.

METHODS

The Army Warrior Care Project (AWCP) analyzes U.S. Department of Defense Military Health System data to examine behavioral health problems and service utilization among Army soldiers who were assigned to WTUs after returning from Afghanistan and Iraq deployments, FY2008-2015.

RESULTS

WTU members (N = 31,094) comprised 3.5% of the AWCP cohort (N = 883,091). Almost all (96.5%) had one WTU assignment for a median of 327 days; 77.3% were assigned before deployment ended, ≤30 or >365 days post-deployment; 59.4% had deployment-related behavioral health diagnoses.

CONCLUSIONS

An overwhelming majority of soldiers had one WTU assignment for almost a year. A substantial proportion of WTU soldiers had psychological impairment, which limited performance of their military duties. The AWCP is the first longitudinal study of redeployed soldiers assigned to WTUs and provides a unique opportunity to advance our understanding of behavioral health among soldiers needing comprehensive medical care after combat deployments.

Feasibility of a Texting Intervention to Improve Medication Adherence Among Older HIV+ African Americans: A Mixed-Method Pilot Study

Antiretroviral therapy (ART) is the primary treatment for HIV, and adherence to it is crucial to addressing health disparities. Approximately half of individuals in the United States living with HIV are African Americans, and those over 45 years of age are more likely to die early from HIV/AIDS than their White counterparts. This mixed-method pilot study evaluated the feasibility of a text-based mobile phone intervention designed to improve ART adherence among older African Americans with HIV. Feasibility was assessed via implementation, participant adherence, acceptability, and satisfaction, as well as short-term impact on medication adherence, adherence-related self-efficacy, and positive affect. The intervention utilized pill reminder, motivational, and health educational texts. Participants (N = 21) ranged in age from 50 to 68 years. Outcomes were evaluated via quantitative results from self-report measures and qualitative data from four focus groups. Attrition to the study was 100%. After 8 weeks, participants reported statistically significant improvements in medication adherence, but not in self-efficacy or affect scores. Qualitative findings highlight the psychologically supportive potential of the intervention, challenges to adherence, as well as suggestions for improvement. The study demonstrates that a text messaging intervention may be feasible for older African Americans with HIV, and helpful in supporting ART adherence.

Experiences of caregivers by care recipient's health condition: A study of caregivers for Alzheimer's disease and related dementias versus other chronic conditions

This study described experiences of caregivers of persons with Alzheimer's disease and other dementias (ADRD) and caregivers of persons with other chronic conditions on self-reported health, type of assistance they provide, perceptions of how caregiving interferes with their lives, and perceived level of support. A secondary analysis was conducted of the 2013 Porter Novelli SummerStyles survey data. Of the 4033 respondents, 650 adults self-identified as caregivers with 11.6% caring for people with ADRD. Over half of all caregivers reported that caregiving interfered with their lives to some extent. The greater the perceived support caregivers reported, the less they thought that caregiving interfered with their lives (p < .001). No significant differences were found between ADRD and non-ADRD caregivers regarding general health, types of assistance they provided, and perceived level of support. These findings have the potential to inform future research and practice in the development of supportive services for caregivers.

Comparing behavioral health models for reducing risky drinking among older male veterans

BACKGROUND

Screening older veterans in Veterans Affairs Medical Center (VAMC) primary care clinics for risky drinking facilitates early identification and referral to treatment.

OBJECTIVE

This study compared two behavioral health models, integrated care (a standardized brief alcohol intervention co-located in primary care clinics) and enhanced referral care (referral to specialty mental health or substance abuse clinics), for reducing risky drinking among older male VAMC primary care patients. VAMC variation was also examined.

METHOD

A secondary analysis of longitudinal data from the Primary Care Research in Substance Abuse and Mental Health for Elderly (PRISM-E) study, a multisite randomized controlled trial, was conducted with a sample of older male veterans (n = 438) who screened positive for risky drinking and were randomly assigned to integrated or enhanced referral care at five VAMCs.

RESULTS

Generalized estimating equations revealed no differences in either behavioral health model for reducing risky drinking at a 6-month follow-up (AOR: 1.46; 95% CI: 0.42-5.07). Older veterans seen at a VAMC providing geriatric primary care and geriatric evaluation and management teams had lower odds of risky drinking (AOR: 0.24; 95% CI: 0.07-0.81) than those seen at a VAMC without geriatric primary care services.

CONCLUSIONS

Both integrated and enhanced referral care reduced risky drinking among older male veterans. However, VAMCs providing integrated behavioral health and geriatric specialty care may be more effective in reducing risky drinking than those without these services. Integrating behavioral health into geriatric primary care may be an effective public health approach for reducing risky drinking among older veterans.

Evaluating Community-Academic Partnerships of the South Carolina Healthy Brain Research Network

Community-academic partnerships have a long history of support from public health researchers and practitioners as an effective way to advance research and solutions to issues that are of concern to communities and their citizens. Data on the development and evaluation of partnerships focused on healthy aging and cognitive health were limited. The purpose of this article is to examine how community partners view the benefits and barriers of a community-academic partner group established to support activities of the South Carolina Healthy Brain Research Network (SC-HBRN). The SC-HBRN is part of the national Healthy Brain Research Network, a thematic research network funded by the Centers for Disease Control and Prevention (CDC). It is focused on improving the scientific and research translation agenda on cognitive health and healthy aging. Semistructured interviews, conducted at end of Year 2 of the 5-year partnership, were used to collect data from partners of the SC-HBRN. Reported benefits of the partnership were information sharing and networking, reaching a broader audience, and humanizing research. When asked to describe what they perceived as barriers to the collaborative, partners described some lack of clarity regarding goals of the network and opportunities to contribute to the partnership. Study results can guide and strengthen other public health-focused partnerships.

Concern about developing Alzheimer's disease or dementia and intention to be screened: An analysis of national survey data

OBJECTIVE

Early diagnosis of Alzheimer's disease (AD) or dementia is important so that patients can express treatment preferences, subsequently allowing caregivers to make decisions consistent with their wishes. This study explored the relationship between people's concern about developing AD/dementia, likelihood to be screened/tested, if experiencing changes in cognitive status or functioning, and concerns about sharing the diagnostic information with others.

METHOD

A descriptive study was conducted using Porter Novelli's SummerStyles 2013 online survey data. Of the 6105 panelists aged 18+ who received the survey, 4033 adults responded (response rate: 66%). Chi squares were used with case-level weighting applied.

RESULTS

Almost 13% of respondents reported being very worried or worried about getting AD/dementia, with women more worried than men (p<.001), and AD/dementia caregivers more worried than other types of caregivers (p=.04). Women were also more likely than men to agree to be screened/tested if experiencing changes in memory and/or thinking (p<.001). The greater the worry, the more likely respondents would agree to be screened/tested (p<.001). Nearly 66% of respondents were concerned that sharing a diagnosis would change the way others think/feel about them, with women reporting greater concern than men (p=.003).

CONCLUSION

Findings demonstrate that level of worry about AD/dementia is associated with the reported likelihood that individuals agree to be screened/tested. This information will be useful in developing communication strategies to address public concern about AD/dementia that may increase the likelihood of screening and early detection.

Employing a Multi-level Approach to Recruit a Representative Sample of Women with Recent Gestational Diabetes Mellitus into a Randomized Lifestyle Intervention Trial

OBJECTIVE

The postpartum period is a window of opportunity for diabetes prevention in women with recent gestational diabetes (GDM), but recruitment for clinical trials during this period of life is a major challenge.

METHODS

We adapted a social-ecologic model to develop a multi-level recruitment strategy at the macro (high or institutional level), meso (mid or provider level), and micro (individual) levels. Our goal was to recruit 100 women with recent GDM into the Balance after Baby randomized controlled trial over a 17-month period. Participants were asked to attend three in-person study visits at 6 weeks, 6, and 12 months postpartum. They were randomized into a control arm or a web-based intervention arm at the end of the baseline visit at six weeks postpartum. At the end of the recruitment period, we compared population characteristics of our enrolled subjects to the entire population of women with GDM delivering at Brigham and Women's Hospital (BWH).

RESULTS

We successfully recruited 107 of 156 (69 %) women assessed for eligibility, with the majority (92) recruited during pregnancy at a mean 30 (SD ± 5) weeks of gestation, and 15 recruited postpartum, at a mean 2 (SD ± 3) weeks postpartum. 78 subjects attended the initial baseline visit, and 75 subjects were randomized into the trial at a mean 7 (SD ± 2) weeks postpartum. The recruited subjects were similar in age and race/ethnicity to the total population of 538 GDM deliveries at BWH over the 17-month recruitment period.

CONCLUSIONS

Our multilevel approach allowed us to successfully meet our recruitment goal and recruit a representative sample of women with recent GDM. We believe that our most successful strategies included using a dedicated in-person recruiter, integrating recruitment into clinical flow, allowing for flexibility in recruitment, minimizing barriers to participation, and using an opt-out strategy with providers. Although the majority of women were recruited while pregnant, women recruited in the early postpartum period were more likely to present for the first study visit. Given the increased challenges of recruiting postpartum women with GDM into research studies, we believe our findings will be useful to other investigators seeking to study this population.

A social cognitive examination of responses to family conflicts by Arfican-American and Chinese-American carrgivers

Conflict between caregivers and their family members has been examined in relation to caregiver burden. However, specific theoretical models have not been applied to analyses of caregiver family conflicts. Nor has there been much research on the family conflicts of ethnic minority caregivers. Using Selman's1 interpersonal conflict strategies and their related levels of social perspective coordination as our framework, we content analyzed conflict reports of African-American and Chinese-American caregivers. Overall, there were more similarities in the strategies and social perspective coordination levels of the two groups than differences. In narratives where conflict was present (78 percent), about half of caregivers in both groups reported higherlevel conflict strategies, and half reported lower-level strategies. More advanced social perspective coordination seemed associated with greater satisfaction with family sharing of responsibilities in both groups. If these data patterns bear up under further testing, training in conflict resolution and social perspective coordination skills may prove an effective means of fostering better social relationships and sharing arrangements between caregivers and family members, and be a worthwhile complement to existing stress reduction interventions for caregivers.

Improving the postpartum care of women with a recent history of preeclampsia: a focus group study

OBJECTIVE

Women with prior preeclampsia are at increased risk of cardiovascular disease (CVD). This study investigated barriers and facilitators toward learning about this link and engaging in lifestyle modifications to reduce this risk.

METHODS

Four focus groups were held with 14 women within 6 months of a preeclamptic pregnancy.

RESULTS

Participants were unaware of the link between preeclampsia and CVD, suggested improvements to provider-patient communication, and discussed the benefits of social support and online tracking (weight, blood pressure) in making lifestyle modifications.

CONCLUSIONS

Solutions offered may improve efforts to modify lifestyle and communication between providers and women about this link.

Identifying postpartum intervention approaches to reduce cardiometabolic risk among American Indian women with prior gestational diabetes, Oklahoma, 2012-2013

Introduction

Innovative approaches are needed to reduce cardiometabolic risk among American Indian women with a history of gestational diabetes. We assessed beliefs of Oklahoma American Indian women about preventing type 2 diabetes and cardiovascular disease after having gestational diabetes. We also assessed barriers and facilitators to healthy lifestyle changes postpartum and intervention approaches that facilitate participation in a postpartum lifestyle program.

Methods

In partnership with a tribal health system, we conducted a mixed-method study with American Indian women aged 19 to 45 years who had prior gestational diabetes, using questionnaires, focus groups, and individual interviews. Questionnaires were used to identify women’s cardiometabolic risk perceptions and feasibility and acceptability of Internet or mobile phone technology for delivery of a postpartum lifestyle modification program. Focus groups and individual interviews were conducted to identify key perspectives and preferences related to a potential program.

Results

Participants were 26 women, all of whom completed surveys; 11 women participated in focus group sessions, and 15 participated in individual interviews. Most women believed they would inevitably develop diabetes, cardiovascular disease, or both; however, they were optimistic that they could delay onset with lifestyle change. Most women expressed enthusiasm for a family focused, technology-based intervention that emphasizes the importance of delaying disease onset, provides motivation, and promotes accountability while accommodating women’s competing priorities.

Conclusions

Our findings suggest that an intervention that uses the Internet, text messaging, or both and that emphasizes the benefits of delaying disease onset should be tested as a novel, culturally relevant approach to reducing rates of diabetes and cardiovascular disease in this high-risk population.

Risk of future cardiovascular disease in women with prior preeclampsia: a focus group study

BACKGROUND

A history of preeclampsia is a risk factor for the future development of hypertension and cardiovascular disease (CVD). The objective of this study was to assess, in women with prior preeclampsia, the level of knowledge regarding the link between preeclampsia and CVD, motivators for and barriers to lifestyle change and interest in a lifestyle modification program to decrease CVD risk following a pregnancy complicated by preeclampsia.

METHODS

Twenty women with a history of preeclampsia participated in 5 phone-based focus groups. Focus groups were recorded, transcribed, and analyzed. Qualitative content analysis was used to identify common themes across focus groups. Consensus was reached on a representative set of themes describing the data.

RESULTS

Women with prior preeclampsia were in general unaware of the link between preeclampsia and future CVD but eager to learn about this link and motivated to achieve a healthy lifestyle. Major perceived barriers to lifestyle change were lack of time, cost of healthy foods and family responsibilities. Perceived facilitators included knowledge of the link between preeclampsia and CVD, a desire to stay healthy, and creating a healthy home for their children. Women with prior preeclampsia were interested in the idea of a web-based program focused on lifestyle strategies to decrease CVD risk in women.

CONCLUSIONS

Women with prior preeclampsia were eager to learn about the link between preeclampsia and CVD and to take steps to reduce CVD risk. A web-based program to help women with prior preeclampsia adopt a healthy lifestyle may be an appropriate strategy for this population.

Bodily Aesthetic Ideals Among Latinas With Type 2 Diabetes

Purpose

The purpose of this study was to examine how attitudes and practices related to bodily aesthetic ideals and self-care might inform the engagement of Latinas with type 2 diabetes (T2DM).

Methods

Focus groups were used to collect qualitative data concerning bodily aesthetic ideals and diabetes management, including help-seeking experiences, from Latina women with T2DM (n = 29) receiving care through Latino Diabetes Initiative at the Joslin Diabetes Center. Focus groups were conducted in Spanish, audiotaped, transcribed, and content analyzed.

Results

Four main themes emerged: (1) a preference among participants for a larger than average body size, although perceptions of attractiveness were more closely linked to grooming than body size; bodily dissatisfaction centered on diabetes-induced skin changes, virilization, and fatigue rather than weight; (2) diabetic complications, especially foot pain, as a major obstacle to exercise; (3) fatalistic attitudes regarding the inevitability of diabetes and reversal of its complications; and (4) social burdens, isolation, and financial stressors as contributing to disease exacerbation.

Conclusions

Interventions that emphasize reduced body size may be less effective with Latinas who have T2DM than those that emphasize the benefits of exercise and weight loss for skin health, energy levels, and reduced virilization.

Diabetes risk perception in women with recent gestational diabetes: delivery to the postpartum visit

OBJECTIVE

Low perceived risk for type 2 diabetes (T2DM) may be a barrier to lifestyle change in women with recent gestational diabetes (GDM). We assessed perceived risk for T2DM at delivery and postpartum.

METHODS

We used a validated diabetes risk perception instrument to survey women with GDM at delivery and postpartum. We compared women with low perceived risk for T2DM at delivery to those with high perceived risk.

RESULTS

The majority (N = 43 of 70, 61%) perceived high risk at delivery. Women who perceived low risk were younger (30.7 ± 6.3 versus 35.0 ± 4.5 years, p = 0.003) than women who perceived high risk. Although knowledge of risk factors for T2DM was poor (mean 6.0 ± 1.9, of 11 points), 95% correctly identified GDM as a risk factor. Perceived risk was maintained in most (N = 51 of 58, 88%) who returned for their postpartum visit. Low perceived risk was not associated with loss to follow up, however correct identification of GDM as a risk factor was protective (OR 0.05, 95% CI 0.005, 0.56).

CONCLUSIONS

Risk perception is accurate in most women with GDM at delivery and postpartum. Further study is needed to translate perceived risk into preventive behaviors in women with recent GDM.

Exposure to trauma and posttraumatic stress disorder symptoms in older veterans attending primary care: comorbid conditions and self-rated health status

OBJECTIVES

Assess the prevalence of posttraumatic stress disorder (PTSD) symptomatology and its association with health characteristics in a geriatric primary care population.

DESIGN

Cross-sectional screening assessments during a multisite trial for the treatment of depression, anxiety, and at-risk drinking.

SETTING

Department of Veterans Affairs (VA)-based primary care clinics across the United States.

PARTICIPANTS

Seventeen thousand two hundred five veterans aged 65 and older.

MEASUREMENTS

Sociodemographic information, the General Health Questionnaire (GHQ-12), questions about death wishes and suicidal ideation, quantity and frequency of alcohol use, smoking, exposure to traumatic events, and PTSD symptom clusters.

RESULTS

Twelve percent (2,041/17,205) of participants screened endorsed PTSD symptoms. Veterans with PTSD symptoms from some (partial PTSD) or each (PTSD all clusters) of the symptom clusters were significantly more likely to report poor general health, currently smoke, be divorced, report little or no social support, and have a higher prevalence of mental distress, death wishes, and suicidal ideation than those with no trauma history or those with trauma but no symptoms. Group differences were most pronounced for mental distress and least for at-risk drinking. Presence of PTSD all clusters was associated with poorer outcomes on all of the above-mentioned health characteristics than partial PTSD.

CONCLUSION

PTSD symptoms are common in a substantial minority of older veterans in primary care, and careful inquiry about these symptoms is important for comprehensive assessment in geriatric populations.

Delirium: an independent predictor of functional decline after cardiac surgery

OBJECTIVES

To determine whether patients who developed delirium after cardiac surgery were at risk of functional decline.

DESIGN

Prospective cohort study.

SETTING

Two academic hospitals and a Veterans Affairs Medical Center.

PARTICIPANTS

One hundred ninety patients aged 60 and older undergoing elective or urgent cardiac surgery.

MEASUREMENTS

Delirium was assessed daily and was diagnosed according to the Confusion Assessment Method. Before surgery and 1 and 12 months postoperatively, patients were assessed for function using the instrumental activities of daily living (IADL) scale. Functional decline was defined as a decrease in ability to perform one IADL at follow-up.

RESULTS

Delirium occurred in 43.1% (n=82) of the patients (mean age 73.7+/-6.7). Functional decline occurred in 36.3% (n=65/179) at 1 month and in 14.6% (n=26/178) at 12 months. Delirium was associated with greater risk of functional decline at 1 month (relative risk (RR)=1.9, 95% confidence interval (CI)=1.3-2.8) and tended toward greater risk at 12 months (RR=1.9, 95% CI=0.9-3.8). After adjustment for age, cognition, comorbidity, and baseline function, delirium remained significantly associated with functional decline at 1 month (adjusted RR=1.8, 95% CI=1.2-2.6) but not at 12 months (adjusted RR=1.5, 95% CI=0.6-3.3).

CONCLUSION

Delirium was independently associated with functional decline at 1 month and had a trend toward association at 12 months. These findings provide justification for intervention trials to evaluate whether delirium prevention or treatment strategies might improve postoperative functional recovery.

Derivation and validation of a preoperative prediction rule for delirium after cardiac surgery

BACKGROUND

Delirium is a common outcome after cardiac surgery. Delirium prediction rules identify patients at risk for delirium who may benefit from targeted prevention strategies, early identification, and treatment of underlying causes. The purpose of the present prospective study was to develop a prediction rule for delirium in a cardiac surgery cohort and to validate it in an independent cohort.

METHODS AND RESULTS

Prospectively, cardiac surgery patients > or =60 years of age were enrolled in a derivation sample (n=122) and then a validation sample (n=109). Beginning on the second postoperative day, patients underwent a standardized daily delirium assessment, and delirium was diagnosed according to the confusion assessment method. Delirium occurred in 63 (52%) of the derivation cohort patients. Multivariable analysis identified 4 variables independently associated with delirium: prior stroke or transient ischemic attack, Mini Mental State Examination score, abnormal serum albumin, and the Geriatric Depression Scale. Points were assigned to each variable: Mini Mental State Examination < or =23 received 2 points, and Mini Mental State Examination score of 24 to 27 received 1 point; Geriatric Depression Scale >4, prior stroke/transient ischemic attack, and abnormal albumin received 1 point each. In the derivation sample, the cumulative incidence of delirium for point levels of 0, 1, 2, and > or =3 was 19%, 47%, 63%, and 86%, respectively (C statistic, 0.74). The corresponding incidence of delirium in the validation sample was 18%, 43%, 60%, and 87%, respectively (C statistic, 0.75).

CONCLUSIONS

Delirium occurs frequently after cardiac surgery. Using 4 preoperative characteristics, clinicians can determine cardiac surgery patients' risk for delirium. Patients at higher delirium risk could be candidates for close postoperative monitoring and interventions to prevent delirium.

Chemokines are associated with delirium after cardiac surgery

BACKGROUND

Delirium has been hypothesized to be a central nervous system response to systemic inflammation during a state of blood-brain barrier compromise. The purpose of this study was to compare postoperative changes in groups of inflammatory markers in persons who developed delirium following cardiac surgery and matched controls without delirium.

METHODS

Serum samples were drawn from 42 patients undergoing cardiac surgery preoperatively and postoperatively at 6 hours and postoperative day 4. The serum concentrations of 28 inflammatory markers were determined with a microsphere flow cytometer. A priori, inflammatory markers were assigned to five classes of cytokines. A class z score was calculated by averaging the standardized, normalized levels of the markers in each class. Beginning on postoperative day 2, patients underwent a daily delirium assessment.

RESULTS

Twelve patients with delirium were matched by surgical duration, age, and baseline cognition to 12 patients without delirium. At the 6-hour time point, patients who went on to develop delirium had higher increases of chemokines compared to matched controls (class z score 0.3 +/- 1.0, p <.05). Among the five classes of cytokines, there were no other significant differences between patients with or without delirium at either the 6 hour or postoperative day 4 assessments.

CONCLUSION

After cardiac surgery, chemokine levels were elevated in patients who developed delirium in the early postoperative period. Because chemokines are capable of disrupting blood-brain barrier integrity in vitro, future studies are needed to define the relationship of these inflammatory mediators to delirium pathogenesis.

Religious participation as a predictor of mental health status and treatment outcomes in older persons

OBJECTIVES

This study focuses on examining the relations of religious participation and affiliation to mental health status among older primary care patients, and to the use and clinical outcomes of mental health services.

METHODS

A sample of older adults participating in a clinical study (PRISM-E) to treat their depression with or without co-morbid anxiety (n = 1610) were queried about their religious affiliation and the frequency of their participation in religious activities. The diagnoses of depressive and anxiety disorders were made based on the MINI-International Neuropsychiatric Interview. Severity of depressive disorders was assessed by emotional distress using the CES-D.

RESULTS

Those attending religious activities on a weekly, monthly, or occasional basis were significantly less likely to have suicidal ideation (p < 0.02) and emotional distress (p < 0.0001) than those who never participated or participated on a less frequent basis. Frequency of religious participation was not associated with mental health service utilization (p = 0.16), but it was predictive of a lower CES-D score at the end of the study intervention (p < 0.001).

CONCLUSIONS

Religious participation is positively associated with older adults' mental health status and treatment effects, but results regarding mental health service utilization were inconclusive.

Serologic markers of brain injury and cognitive function after cardiopulmonary bypass

OBJECTIVE

To examine the association between biochemical markers of brain injury (MBI) and the inflammatory response in relation to neurocognitive deficiency (NCD) after cardiopulmonary bypass (CPB).

SUMMARY BACKGROUND DATA

In cardiac surgery, NCD is a common but underdiagnosed complication with an unclear pathophysiology leading to significant morbidity. Despite extensive investigation, identification of a MBI for clinical use and clarifying the pathophysiology of NCD have not been achieved.

METHODS

Forty patients undergoing CABG and/or valve procedures using CPB were administered a validated neurocognitive battery preoperatively and postoperatively at day 4 and 3 months. S-100b, neuron specific enolase (NSE), and tau protein were assayed as MBIs preoperatively and postoperatively at 6 hours and day 4. C-reactive protein (CRP), interleukin (IL)-6, C3a, and total peroxide levels were also quantified from serum. Impact of cardiotomy suction and antifibrinolytics on markers of brain injury was assessed.

RESULTS

The incidence of early NCD was 40% (16 of 40). NSE and tau protein at the 6-hour time point were both significantly elevated in the presence of NCD (NCD group) compared with those without NCD (NORM group) (8.69 +/- 0.82 vs. 5.98 +/- 0.61; P = 0.018 and 68.8 vs. 29.2%; P = 0.015; respectively). S-100b increase was not different between the NCD and NORM groups. Cardiotomy suction significantly elevated S-100b levels, whereas NSE and tau were not significantly influenced. Aprotinin did not have an effect on NCD or levels of MBIs. Also, the NCD group had significantly elevated CRP and peroxide levels compared with the NORM group at postoperative day 4 while C3a was significantly elevated at 6 hours.

CONCLUSION

NSE and tau are better associated with NCD and less influenced by cardiotomy suction compared with S-100beta. Inflammatory and oxidative stress is associated with NCD post-CPB.

C-Reactive protein and inflammatory response associated to neurocognitive decline following cardiac surgery

BACKGROUND

It has been recognized that neurocognitive decline (NCD) often occurs as a complication in cardiac surgery. The early inflammatory response and C-reactive protein (CRP) was examined in relation to NCD and to a marker of axonal central nervous system (CNS) injury after cardiopulmonary bypass.

METHODS

A cohort of patients undergoing coronary artery bypass grafting and/or valve procedures using cardiopulmonary bypass were administered a neurocognitive battery preoperatively and postoperatively at 6 hours and day 4. CRP, interleukin 1 beta, and interleukin 10 were quantified from serum. Increase of serum tau protein after surgery was used as a marker of axonal CNS damage.

RESULTS

The rate of NCD was found to be 40.5% in this group. Surprisingly, known predictors of NCD did not differ significantly between patients with/without NCD. Patients with NCD had an early increase of CRP of a significantly higher magnitude than those without NCD (38.01 +/- 11.4 vs 16.49 +/- 3.5 mg/L, P = .042), interleukin 1ss (2.35 +/- 0.3 vs 1.20 +/- 0.2 pg/mL, P = .002), and interleukin 10 (29.77 +/- 4.7 vs 12.94 +/- 2.2 pg/mL, P < .001). Increase in serum Tau protein was significantly correlated to NCD (r = 0.50, P = .02).

CONCLUSION

Perioperative increases in CRP and inflammatory cytokines are associated with NCD in patients after cardiopulmonary bypass. Thus, it appears that inflammation plays a key role in NCD pathophysiology, likely via axonal CNS injury, and could become a target for prevention.

Impaired executive function is associated with delirium after coronary artery bypass graft surgery

OBJECTIVES

To determine the extent to which preoperative performance on tests of executive function and memory was associated with delirium after coronary artery bypass graft (CABG) surgery.

DESIGN

Prospective observational cohort study.

SETTING

Two academic medical centers and one Department of Veterans Affairs medical center in Massachusetts.

PARTICIPANTS

Eighty subjects without preoperative delirium undergoing CABG or CABG-valve surgery completed baseline neuropsychological assessments with validated measures of memory and executive function.

MEASUREMENTS

Beginning on postoperative Day 2, a battery to diagnose delirium was administered daily. Confirmatory factor analysis (CFA) was used to define two cognitive domain composites (memory and executive function). The loading pattern of neuropsychological measures onto the latent cognitive domains was determined a priori. Poisson regression was used to model the association between neuropsychological performance and cognitive domain composite scores and risk of postoperative delirium. The association was expressed as the difference between impaired (0.5 standard deviations (SDs) below mean) and nonimpaired (0.5 SDs above mean) performers.

RESULTS

Forty subjects (50%) developed delirium. Measures of memory function were not significantly related to delirium. Of the executive function measures, verbal fluency, category fluency, Hopkins Verbal Learning Test learning, and backward recounting of days and months were significantly related to delirium. Preoperative mental status was a strong predictor of postoperative delirium. After controlling for age, sex, education, medical comorbidity, mental status, and the other cognitive domain, CFA cognitive domain composites suggest that risk for delirium is specific for executive functioning impairment (relative risk (RR) = 2.77, 95% confidence interval (CI) = 1.12-6.87) but not for memory impairment (RR = 0.49, 95% CI = 0.19-1.25).

CONCLUSION

Worse preoperative performance in executive function was independently associated with greater risk of developing delirium after CABG.

PRISM-E: comparison of integrated care and enhanced specialty referral models in depression outcomes

OBJECTIVE

This study, entitled Primary Care Research in Substance Abuse and Mental Health for the Elderly, examined six-month outcomes for older primary care patients with depression who received different models of treatment.

METHODS

Clinical outcomes were compared for patients who were randomly assigned to integrated care or enhanced specialty referral. Integrated care consisted of mental health services co-located in primary care in collaboration with primary care physicians. Enhanced specialty referral consisted of referral to physically separate, clearly identified mental health or substance abuse clinics.

RESULTS

A total of 1,531 patients were included; their mean age was 73.9 years. Remission rates and symptom reduction for all depressive disorders were similar for the two models at the three- and six-month follow-ups. For the subgroup with major depression, the enhanced specialty referral model was associated with a greater reduction in depression severity than integrated care, but rates of remission and change in function did not differ across models of care for major depression.

CONCLUSIONS

Six-month outcomes were comparable for the two models. For the subgroup with major depression, reduction in symptom severity was superior for those randomly assigned to the enhanced specialty referral group.