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Task sharing improves access to mental health care in many countries, but little formative research has examined uptake in the United States. This Open Forum proposes the development of nonspecialist professional roles to deliver low-intensity behavioral interventions for common mental health conditions in U.S. settings such as primary care. Using data from a multilevel stakeholder assessment, the authors discuss findings and challenges associated with such a role. Key themes from stakeholder surveys concerned scope of practice, competencies, pragmatic concerns, and training needs. Although stakeholders generally found this role to be acceptable and feasible, the themes raised will be critical to developing and implementing such a role.

Little research examined the decision-making preferences of older, racially and ethnically diverse minority patients with untreated depression. The study's aims were to identify decision-making preferences and the characteristics associated with a more active preference in the decision-making process for general medical and depression treatment decisions. We assessed the preferred involvement in making general medical and depression treatment decisions of 201 older primary care patients with untreated depression. Linear regressions examined the association of sociodemographic and clinical characteristics with decision-making preference for both decision types. Majority of patients preferred shared decision-making for general medical and depression treatments. Female gender was associated with a preference for active decision-making for depression treatment. For this sample older depressed patients preferred sharing the decision-making responsibilities with physicians. To improve communication and the initiation and adherence to mental health care, physicians must consider older, minority patients' preferences for involvement in the decision-making process.

A broader workforce is necessary to expand U.S. geriatric mental health services. We examined (1) feasibility of training undergraduate students to deliver Do More, Feel Better (DMFB), an evidence-informed program for depression; and (2) feasibility, acceptability, and outcomes in a single-arm proof-of-concept trial.In Study 1, we taught DMFB to 18 upper-level undergraduate students and assessed fidelity using role plays. In Study 2, four students delivered six weekly DMFB sessions to 12 community-dwelling older adults (Fidelity was high in the course (Study 1; 82.4% of role plays rated as 'passing') and the trial (Study 2; 100% of 24 sessions rated as 'passing'). The majority (83.3%) of patients were retained and evidenced statistically and clinically significant improvement in depressive symptoms (Hamilton Rating Scale for Depression [HAM-D]), disability (World Health Organization's Disability Assessment Schedule 2.0 [WHODAS 2.0], and activity (Behavioral Activation for Depression Scale [BADS]).It is feasible to train bachelor's-level students to deliver a brief, structured intervention for depression. Future research should consider implementation strategies and stakeholder feedback.

ImportanceApproximately half of older adults with depression remain symptomatic at treatment end. Identifying discrete clinical profiles associated with treatment outcomes may guide development of personalized psychosocial interventions.ObjectiveTo identify clinical subtypes of late-life depression and examine their depression trajectory during psychosocial interventions in older adults with depression.Design, Setting, and ParticipantsThis prognostic study included older adults aged 60 years or older who had major depression and participated in 1 of 4 randomized clinical trials of psychosocial interventions for late-life depression. Participants were recruited from the community and outpatient services of Weill Cornell Medicine and the University of California, San Francisco, between March 2002 and April 2013. Data were analyzed from February 2019 to February 2023.InterventionsParticipants received 8 to 14 sessions of (1) personalized intervention for patients with major depression and chronic obstructive pulmonary disease, (2) problem-solving therapy, (3) supportive therapy, or (4) active comparison conditions (treatment as usual or case management).Main Outcomes and MeasuresThe main outcome was the trajectory of depression severity, assessed using the Hamilton Depression Rating Scale (HAM-D). A data-driven, unsupervised, hierarchical clustering of HAM-D items at baseline was conducted to detect clusters of depressive symptoms. A bipartite network analysis was used to identify clinical subtypes at baseline, accounting for both between- and within-patient variability across domains of psychopathology, social support, cognitive impairment, and disability. The trajectories of depression severity in the identified subtypes were compared using mixed-effects models, and time to remission (HAM-D score ≤10) was compared using survival analysis.ResultsThe bipartite network analysis, which included 535 older adults with major depression (mean [SD] age, 72.7 [8.7] years; 70.7% female), identified 3 clinical subtypes: (1) individuals with severe depression and a large social network; (2) older, educated individuals experiencing strong social support and social interactions; and (3) individuals with disability. There was a significant difference in depression trajectories (F2,2976.9 = 9.4; P 22 = 18.2; P Conclusions and RelevanceIn this prognostic study, bipartite network clustering identified 3 subtypes of late-life depression. Knowledge of patients’ clinical characteristics may inform treatment selection. Identification of discrete subtypes of late-life depression may stimulate the development of novel, streamlined interventions targeting the clinical vulnerabilities of each subtype.

Integrated care is a common approach to leverage scarce psychiatric resources to deliver mental health care in primary care settings.Describe a formal clinical fellowship devoted to professional development for the integrated care psychiatrist role.The development of a formal year-long clinical fellowship in integrated care is described. The curriculum consists of an Integrated Care Didactic Series, Integrated Care Clinical Skill Experiences, and Integrated Care System-Based Leadership Experiences. Evaluation of impact was assessed with descriptive statistics.We successfully recruited 3 classes of fellows to the Integrated Care Fellowship, with 5 program graduates in the first 3 years. All 5 graduated fellows were hired into integrated care and/or telepsychiatry positions. Integrated Care fellows had a high participation rate in didactics (mean attendance = 80.6%; n = 5). We received a total of 582 didactic evaluations for the 151 didactic sessions. On a scale of 1 (poor) to 6 (fantastic), the mean quality of the interactive learning experience was rated as 5.33 (n = 581) and the mean quality of the talk was 5.35 (n = 582). Rotations were rated with the mean overall teaching quality of 4.98/5 (n = 76 evaluations from 5 fellows).The Integrated Care clinical fellowship serves as a model for training programs seeking to provide training in clinical and systems-based skills needed for practicing integrated care. Whether such training is undertaken as a standalone fellowship or incorporated into existing consultation-liaison psychiatry programs, such skills are increasingly valuable as integrated care becomes commonplace in practice.

This pilot randomized control trial (RCT) tested “Do More, Feel Better” (DMFB), a lay-delivered Behavioral Activation intervention for depressed senior center clients. The study examined: 1. the feasibility of training older lay volunteers to fidelity; and 2. the acceptability, safety, and impact of the intervention. Twenty-one lay volunteers at four senior centers were trained in DMFB. Fifty-six depressed clients were randomized to receive 9 sessions of DMFB or Behavioral Activation delivered by social workers (MSW BA). Research assessments of overall client activity level (BADS) and depression severity (HAM-D) were conducted at baseline and weeks 3, 6, and 9. Eighty-one percent of lay volunteers who underwent training were formally certified in DMFB. Depressed clients receiving each intervention reported high levels of satisfaction and showed large and clinically significant changes in 9-week activity level (d ≥ 1.35) and depression severity (d ≥ 3.34). Differences between treatment groups were very small for both activity level (dMSW = 0.16; 95% CI, -0.70 to 1.02) and depression (dMSW = 0.14; 95% CI, -0.63 to 0.91). Increases in activity level were associated with decreases in depression (β = -0.42; 95% CI, -0.55 to -0.30). Both interventions appeared to work as intended by increasing activity level and reducing depression severity. “Do More, Feel Better” shows the potential of evidence-based behavioral interventions delivered by supervised lay volunteers, and can help address the insufficient workforce available to meet the mental health needs of community-dwelling older adults.

Introduction Depression is common among community-dwelling older adults who make use of senior centre services yet remains undertreated due to a lack of acceptable and available treatments. Emerging evidence suggests that lay health providers can offer psychosocial interventions for mental health disorders experienced by older adults. We developed a streamlined Behavioural Activation intervention (called ‘Do More, Feel Better’; DMFB) to be delivered by older adult volunteers and propose to compare its effectiveness to that of clinician-delivered behavioural activation (BA). Methods and analysis This study is a type I collaborative randomised effectiveness trial testing the effect of DMFB in comparison to BA among 288 senior centre clients (aged 60+). Participant clients will be recruited from 6 Seattle, 6 New York City and 6 Tampa area senior centres serving economically and ethnically diverse communities. Primary outcomes will be increased activity level (target) and decreased depressive symptoms. Secondary outcomes will be functioning and client satisfaction, and an exploratory outcome will be treatment fidelity. Ethics and dissemination The study received ethics approval from the University of Washington Institutional Review Board (STUDY00011434). Client, volunteer and clinician participants will all provide informed consent for study procedures through in-person or remote contact with investigators. Results of this study will be presented in peer-reviewed journals and at professional conferences. Trial registration number NCT04621877; ClinicalTrials.gov.

Trauma-focused psychotherapies for posttraumatic stress disorder (PTSD) are not widely utilized. Clinicians report concerns that direct discussion of traumatic experiences could undermine the therapeutic alliance, which may negatively impact retention and outcome. Studies among adolescents with PTSD found no difference in alliance between trauma-focused and non-trauma-focused psychotherapies, but this has not been tested among adults. The present study is a secondary analysis of a randomized trial of collaborative care, also known as care management, for PTSD. We examined patient-reported therapeutic alliance among 117 veterans with PTSD who participated in cognitive processing therapy (CPT, now called CPT + A; n = 54) or non-trauma-focused supportive psychotherapy for PTSD (n = 73) at VA community outpatient clinics. We tested the hypothesis that alliance in CPT would be noninferior to (i.e., not significantly worse than) non-trauma-focused psychotherapy using patient ratings on the Revised Helping Alliance Questionnaire. Patients' therapeutic alliance scores were high across both groups (CPT: M = 5.13, SD = 0.71, 95% CI [4.96, 5.30]; non-trauma-focused psychotherapy: M = 4.89, SD = 0.64, 95% CI [4.73, 5.05]). The difference between groups (0.23, 95% CI [0.01, 0.48]) was less than the "noninferiority margin" based on suggested clinical cutoffs (0.58 points on a 1-6 scale). These results held even after adjusting for veterans' demographic and clinical characteristics and change in PTSD symptoms from baseline to follow-up. Although there are concerns that direct discussion of traumatic experiences could worsen therapeutic alliance, patients report similar levels of alliance in CPT and non-trauma-focused supportive psychotherapy. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Purpose: This proof-of-concept study assessed the feasibility, acceptability, and effectiveness of an intelligent tutoring system (ITS) as a classroom adjunct to improve training bachelor of social work (BSW) students in client engagement strategies. Methods: We codeveloped the ITS with 11 undergraduate students and pilot tested it with six BSW students enrolled in a class on telephone-based cognitive behavioral therapy (tCBT). Student competencies in tCBT were assessed by expert review of role-plays. We also examined time spent using ITS and relation with competency. Results: The majority of students (81.8%) in Wave 1 and all of the students who submitted role-plays in Wave 2 passed the clinical skills role-play. Students advancing through the ITS more quickly had better tCBT competency ratings than those progressing more slowly. Discussion: One of the most challenging aspects of training is how to competently deliver evidence-based practices. ITS has the potential to streamline and scale such training.

Effective psychotherapies for late-life depression are underutilized, mainly because of their complexity. “Engage” is a novel, streamlined psychotherapy that relies on neurobiology to identify core behavioral pathology of late-life depression and targets it with simple interventions, co-designed with community therapists so that they can be delivered in community settings. Consecutively recruited adults (≥60 years) with major depression (n = 249) were randomly assigned to 9 weekly sessions of “Engage” or to the evidence-based Problem-Solving Therapy (PST) offered by 35 trained community social workers and assessed by blind raters. “Engage” therapists required an average of 30% less training time to achieve fidelity to treatment than PST therapists and had one-third of the PST therapists’ skill drift. Both treatments led to reduction of HAM-D scores over 9 weeks. The mixed effects model-estimated HAM-D ratings were not significantly different between the two treatments at any assessment point of the trial. The one-sided 95% CI for treatment-end difference was (−∞, 0.07) HAM-D points, indicating a non-inferiority margin of 1.3 HAM-D points or greater; this margin is lower than the pre-determined 2.2-point margin. The two treatment arms had similar response (HR = 1.08, 95% CI (0.76, 1.52), p = 0.67) and remission rates (HR = 0.89, 95% CI (0.57, 1.39), p = 0.61). We conclude that “Engage” is non-inferior to PST. If disseminated, “Engage” will increase the number of therapists who can reliably treat late-life depression and make effective psychotherapy available to large numbers of depressed older adults.

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.

Background older people coping with the impacts of living with multimorbidity are at increased risk of developing a depressive disorder. Objective this article reports the 24-month results of a randomised controlled trial of an internet-delivered cognitive behaviour therapy, which aimed to test whether depressive disorders could be prevented in this population. Participants community-based participants aged 65 years and over, who had two or more chronic physical health conditions and were assessed as having no current depressive disorder. Methods in total, 302 participants were randomised to an 8-week, five-lesson, internet-delivered intervention program (n = 150) or treatment as usual (TAU, n = 152). The primary outcomes were cases of depressive disorder, assessed post-intervention and at 3-month intervals throughout the trial, and depressive symptoms, assessed at pre-intervention, post-intervention, 6, 12 and 24 months following the intervention. Results there were significantly fewer cases of depressive disorder in the intervention group (n = 23, 15%) compared with the TAU group (n = 41, 27%) during the 24 months after the intervention (χ2(1, N = 302) = 6.13, P = 0.013, odds ratio = 0.490 [95% confidence interval: 0.277, 0.867]), representing a 44% reduction in cases of depressive disorder. No differences were found on depressive symptoms at 24-month follow-up. Internet-delivered cognitive behaviour therapy had high engagement and acceptability. Conclusions the results provide support that depressive disorders can be prevented in older people with multimorbidity through participation in internet-delivered cognitive behaviour therapy. With access to internet-delivered interventions in clinical care settings increasing, this has implications for older patient care where multimorbidity is extremely common.

This study aimed to identify subgroups of depressed older adults with distinct trajectories of suicidal ideation during brief psychotherapy and to detect modifiable predictors of membership to the trajectories of suicidal ideation. Latent growth mixed models were used to identify trajectories of the presence of suicidal ideation in participants to a randomized controlled trial comparing Problem Solving Therapy with “Engage” therapy in older adults with major depression over 9 weeks. Predictors of membership to trajectories of suicidal ideation were identified by the convergence of four machine learning models, i.e., least absolute shrinkage and selection operator logistic regression, random forest, gradient boosting machine, and classification tree. The course of suicidal ideation was best captured by two trajectories, a favorable and an unfavorable trajectory comprising 173 and 76 participants respectively. Members of the favorable trajectory had no suicidal ideation by week 8. In contrast, members of the unfavorable trajectory had a 60% probability of suicidal ideation by treatment end. Convergent findings of the four machine learning models identified hopelessness, neuroticism, and low general self-efficacy as the strongest predictors of membership to the unfavorable trajectory of suicidal ideation during psychotherapy. Assessment of suicide risk should include hopelessness, neuroticism, and general self-efficacy as they are predictors of an unfavorable course of suicidal ideation in depressed older adults receiving psychotherapy. Psychotherapeutic interventions exist for hopelessness, emotional reactivity related to neuroticism, and low self-efficacy, and if used during therapy, may improve the course of suicidal ideation.

Objective: The authors assessed the impact of a shared decision-making (SDM) intervention among elderly depressed minority primary care patients not currently receiving treatment. Methods: A total of 202 English and Spanish-speaking primary care participants aged 65 and older who scored positive on the Patient Health Questionnaire-9 (≥10) were randomized at the physician level to receive a brief SDM intervention or usual care (UC). Primary analyses focused on patient adherence to either psychotherapy or antidepressant medication, and reduction in depression severity (Hamilton Depression Rating Scale) over 12 weeks. Results: Patients randomized to physicians in the SDM condition were significantly more likely than patients of physicians randomized to UC to receive a mental health evaluation or initiate some form of treatment (39% versus 21%), and to adhere to psychotherapy visits over 12 weeks. There were no differences between groups in adherence to antidepressant medication or in reduction of depressive symptoms. Conclusion: Among untreated elderly depressed minority patients from an inner-city municipal hospital, a brief SDM intervention was associated with greater initiation and adherence to psychotherapy. However, low treatment adherence rates across both groups and the intervention's lack of impact on clinical outcomes highlight the need to provide focused and accessible mental health services to patients choosing active treatments.

Objective Loneliness and social isolation are associated with depressive symptoms, cognitive and physical disabilities, and increased risk of mortality among older adults. Socially rewarding activities reduce loneliness, and neurobiological evidence suggests that these activities may activate neural reward systems in older adults to a greater extent than other rewarding experiences. The current study was designed to investigate whether engagement in social and interpersonal activities (i.e., exposure to social rewards) predicts subsequent increase in behavioral activation and reduction in depressive symptoms in reward exposure treatment for late-life depression. Methods Forty-eight older adults without cognitive impairment and with major depression received nine sessions of “Engage” psychotherapy. Behavioral activation and depression severity were assessed by trained raters at baseline and weeks 6 and 9. Patients’ weekly behavioral plans were categorized into three groups: 1) solitary activities; 2) social-group activities (attending a social gathering or a social setting such as church or a senior center); and 3) interpersonal-individual activities (engaging in an interpersonal interaction with a specific friend or family member). Results Mixed-effects models showed reduction in depression severity and increase in behavioral activation over time. In linear regression models, a higher percentage of interpersonal-individual activities (but not solitary or social-group activities) predicted subsequent increase in behavioral activation and improvement of depression. Conclusion These findings highlight the importance of understanding the effects of engagement in specific types of rewarding activities in behavioral activation treatments for late-life depression. Exposure to socially rewarding interpersonal interactions could contribute to the efficacy of psychotherapy for late-life depression.

PURPOSE. Shared decision making is an important implementation “pull” strategy for increasing uptake of evidence-based mental health practices. In this qualitative study, we explored provider perspectives on implementing shared decision making at the point of mental health treatment initiation using a publicly available, patient-facing decision support tool for post-traumatic stress disorder (PTSD). METHODS. We conducted semi-structured interviews with 22 mental health providers (psychiatrists, nurses, psychologists, and social workers) working in one of five VA primary care clinics. Interviewed were analyzed using thematic analysis. RESULTS. Provider were enthusiastic about using decision aids as a source of high quality information that could improve patient experience and confidence in treatment. However, providers had concerns about decision aid accessibility, time constraints to conduct shared decision making in-session, and patient motivation to engage in shared decision making. Providers stated they would prefer to use shared decision making with patients that they felt were most likely to follow through with treatment. CONCLUSIONS. While providers believed that shared decision making could improve PTSD treatment planning, they thought it most appropriate for patients with the highest levels of motivation and fewest barriers to care. These beliefs may limit widespread adoption and reflect missed opportunities to reach difficult-to-engage patients.

Objectives This study examined the emotional distress and loneliness during COVID-19 and the roles of resiliency and activities. Design A cross-sectional national survey. Setting Amazon Mechanical Turk (mTurk) and Prolific Research Platforms. Participants Five hundred and one U.S. dwelling English-speaking adults 60 years old and older. Measurements Participants completed an online survey with the PHQ-9; GAD-7; Short Health Anxiety Inventory; 3-item UCLA Loneliness scale; PROMIS measures of global health, instrumental, and emotional support; 10-item Connor-Davidson Resilience Scale; and COVID-19 needs assessment. Results Across the sample 13% reported moderate depressive symptoms, 9% reported moderate anxiety symptoms, and 26% endorsed being “lonely.” The emotionally distressed group endorsed more loneliness, lower resiliency, less physical exercise, and worse physical health. The low Socio-Economic Status group endorsed less loneliness, less likely to engage in physical exercise and worse physical health.The lonely group endorsed less resilience, less physical exercise, and worse physical health. A multiple logistic regression found that resilience, socioeconomic status, and physical health were significant predictors of loneliness, whereas global health was the best predictor of emotional distress. Conclusions Even after prolonged social distancing, older adults in this study did not report greater psychological distress compared to earlier studies of older adults during COVID-19. Older adults with lower SES, worse physical health, and less resiliency, were more likely to report more loneliness. It is this group that should be the focus of intervention.

Older adults frequently under-report depressive symptoms and often fail to access services after a disaster. To address unmet mental health needs, we developed a service delivery program (SMART-MH) that combines outreach, assessment, and therapy and implemented it in New York City after Hurricane Sandy. This study aimed to examine the feasibility, effectiveness, and patients’ engagement of our brief psychotherapy (“Engage”). We predicted that Engage would result in reductions of depression, and that the benefits would be comparable to those of a historical comparison group who received Engage in a controlled experimental setting. A total of 2,831 adults (age ≥ 60) impacted by Hurricane Sandy were screened for depression. Assessments and therapy were conducted in English, Spanish, Cantonese, and Russian. Depressed individuals (PHQ-9 ≥ 10) who were not in treatment were offered Engage therapy in their native language at local senior center/nutrition sites. Twelve percent of the participants reported depression (N = 333). Of these 333 participants, 201 (60%) were not receiving treatment and 143 agreed to receive Engage therapy. Linear mixed-effects model showed that depression severity decreased significantly over time. More than two thirds had a five-point reduction in PHQ-9 scores and post-treatment scores ≤9. Post-hoc comparison of standardized slopes of change found patterns of depression reductions equivalent to Engage provided in a controlled setting. Partnerships to integrate mental health care into community settings can increase detection of mental-health needs and access to services in patients’ native language. Brief reward exposure-based psychotherapy delivered in the community can provide comparable benefits to those achieved in research settings.

The study aimed to: a) Identify distinct trajectories of change in depressive symptoms by mid-treatment during psychotherapy for late-life depression with executive dysfunction; b) examine if non-response by mid-treatment predicted poor response at treatment end; c) identify baseline characteristics predicting an early non-response trajectory by mid-treatment. A sample of 221 adults 60 years and older with major depression and executive dysfunction were randomized to 12 weeks of either Problem-Solving Therapy or Supportive Therapy. We used Latent Growth Mixture Models (LGMM) to detect subgroups with distinct trajectories of change in depression by mid-treatment (6th week). We conducted regression analyses with LGMM subgroups as predictors of response at treatment end. We used random forest machine learning algorithms to identify baseline predictors of LGMM trajectories. We found that approximately 77.5% of participants had a declining trajectory of depression in weeks 0–6, while the remaining 22.5% had a persisting depression trajectory, with no treatment differences. The LGMM trajectories predicted remission and response at treatment end. A random forests model with high prediction accuracy (80%) showed that the strongest modifiable predictors of the persisting depression trajectory were low perceived social support, followed by high neuroticism, low treatment expectancy, and low perception of the therapist as accepting. Our results suggest that modifiable risk factors of early non-response to psychotherapy can be identified at the outset of treatment and addressed with targeted personalized interventions. Therapists may focus on increasing meaningful social interactions, addressing concerns related to treatment benefits, and creating a positive working relationship.

OBJECTIVE: We examined: 1. depression rates among senior center clients; and 2. the acceptability of a lay-delivered intervention for depression (“Do More, Feel Better”) from the perspective of key stakeholders prior to its implementation. METHOD: We conducted cross-sectional surveys at four Seattle-area senior centers of 140 clients, 124 volunteers, and 12 administrators and staff. Client measures included the Patient Health Questionnaire-9 (PHQ-9) to determine depression severity, and items assessing depression treatment preferences. Following description of “Do More, Feel Better” as a lay-delivered intervention focused on increasing participation in rewarding activities, we used quantitative and qualitative items to assess acceptability to: 1. clients participating in; 2. volunteers administering; and 3. administrators and staff supporting the intervention. RESULTS: 25% of senior center clients (35/140) endorsed elevated depressive symptoms (PHQ-9≥10). 81% of clients (114/140) reported that they would consider participating in “Do More, Feel Better,” and 59% percent of volunteers (73/123) expressed interest in learning how to assist others using the intervention. Administrators and staff reported high comfort levels with proposed volunteer training procedures, and they identified funding and staffing considerations as challenges to sustaining the intervention. CONCLUSION: Findings indicate high depression rates among senior center clients and support the acceptability of lay-delivered behavioral interventions for depression from a variety of stakeholders. Further investigation of the feasibility, effectiveness, and implementation of “Do More, Feel Better” is warranted, particularly in the context of a lack of health care professionals available to meet the mental health needs of older adults.

Objective The Personalized Intervention for Depressed Patients with Chronic Obstructive Pulmonary Disease (PID-C) is an intervention aiming to help patients adhere to their rehabilitation and care. This study tested the hypothesis that the Problem-Solving Adherence (PSA) intervention, which integrates problem-solving into adherence enhancement procedures, reduces dyspnea-related disability more than PID-C. Exploratory analyses sought to identify patients with distinct dyspnea-related disability trajectories and to compare their clinical profiles. Methods In this randomized controlled trial in an acute inpatient rehabilitation and community, 101 participants diagnosed with chronic obstructive pulmonary disease (COPD) and major depression were included after screening 633 consecutive admissions for acute inpatient rehabilitation. Participants underwent 14 sessions of PID-C versus PSA over 26 weeks using the Pulmonary Functional Status and Dyspnea Questionnaire. Results The study hypothesis was not supported. Exploratory latent class growth modeling identified two distinct disability trajectories. Dyspnea-related disability improved in 39% of patients and remained unchanged in the rest. Patients whose dyspnea-related disability improved had more severe disability and less sense of control over their condition at baseline. Conclusion Improvement or no worsening of disability was noted in both treatment groups. This is a favorable course for depressed patients with a severe, deteriorating medical illness. PID-C is compatible with the expertise of clinicians working in community-based rehabilitation programs, and after further testing in the community, it can be integrated in the care of depressed COPD patients.

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 0.05). 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.

Background Multi-morbidity in older adults is commonly associated with depressed mood. Similarly, subjective reports of pain are also associated with both physical illness and increased depressive symptoms. However, whether pain independently contributes to the experience of depression in older people with multi-morbidity has not been studied. Methods In this study, participants were 1281 consecutive older adults presenting to one of 19 primary care services in Australia (recruitment rate = 75%). Participants were asked to indicate the presence of a number of common chronic illnesses, to rate their current pain severity and to complete the Geriatric Depression Scale. Results Results confirmed that the number of medical illnesses reported was strongly associated with depressive symptoms. Twenty-six percent of participants with multi-morbidity scored in the clinical range for depressive symptoms in comparison to 15% of participants with no illnesses or a single illness. In regression analyses, the presence of chronic pain (t = 5.969, p

ObjectiveResearch on the impact of natural disasters on the mental health of older adults finds both vulnerabilities and resilience. We report on the rates of clinically significant depression among older adults (aged ≥60 years) living in areas affected by Hurricane Sandy in 2012 and the factors associated with mental health need.MethodsThe Sandy Mobilization, Assessment, Referral and Treatment for Mental Health (SMART-MH) program integrates community outreach and needs assessments to identify older adults with mental health and aging service needs. Older adults with significant anxiety or depressive symptoms were offered short-term psychotherapy. Social service referrals were made directly to community agencies. All SMART-MH activities were offered in Spanish, Russian, Mandarin/Cantonese, and English.ResultsAcross the full sample, 14% of participants screened positive for depression. Hurricane Sandy stressors predicted increased odds of depression, including storm injury, post-storm crime, and the total count of stressors. Outcomes varied significantly by age group, such that all Sandy-related variables remained significant for younger-old adults (aged 60–74 years), whereas only the loss of access to medical care was significant for older-old adults (aged ≥75 years).ConclusionsStorm-affected communities show higher rates of depressive symptoms than seen in the general population, with storm stressors affecting mental health needs differentially by age group. (Disaster Med Public Health Preparedness. 2017;11:97–109)

Objective We describe the development of a lay-delivered behavioral intervention ("Do More, Feel Better") for depressed senior center clients, and we present preliminary data from a pilot randomized controlled trial (RCT) on (a) the feasibility of training lay volunteers to fidelity and (b) the acceptability, impact, and safety of the intervention. Methods We trained 11 volunteers at two aging service settings in "Do More, Feel Better" and randomized 18 depressed clients to receive the intervention or referral to mental health services. Results Pilot data indicated that we can successfully train and certify 64% of older volunteers and that depressed clients receiving the intervention reported high levels of session attendance and satisfaction. While there were no significant differences in 12-week reduction in Hamilton Depression Rating Scale scores between groups, intervention clients showed an 8-point reduction in comparison with a 0-point reduction among referral clients. Conclusions "Do More, Feel Better" has the potential of transferring evidence-based behavioral interventions to the hands of supervised lay volunteers and can address the insufficient workforce providing geriatric mental health services.

Objective Personalized Intervention for Depressed Patients with COPD (PID-C), a treatment mobilizing patients to participate in their care, was found more effective than usual care. To further improve its efficacy, we developed a Problem Solving-Adherence (PSA) intervention integrating problem solving into adherence enhancement procedures. We tested the hypothesis that PSA is more effective than PID-C in reducing depressive symptoms. Exploratory analyses sought to identify patients with distinct depressive symptom trajectories and compare their clinical profiles. Design Randomized controlled trial. Setting Acute inpatient rehabilitation and community. Participants A total of 101 diagnosed with chronic obstructive pulmonary disease (COPD) and major depression after screening 633 consecutive admissions for acute inpatient rehabilitation. Intervention Fourteen sessions of PID-C versus PSA over 26 weeks. Measurements 24-item Hamilton Depression Rating Scale. Results PSA was not more efficacious than PID-C in reducing depressive symptoms. Exploratory latent class growth modeling identified two distinct depressive symptoms trajectories. Unlike patients with unfavorable course (28%) who remained symptomatic, patients with favorable course (72%) had a decline of symptoms during the hospitalization followed by a milder decline after discharge. Patients with unfavorable course were younger and had greater scores in disability, anxiety, neuroticism, and dyspnea related limitation in activities and lower self-efficacy scores. Conclusions Both interventions led to sustained improvement depressive symptoms. PID-C matches the skills of clinicians employed by community rehabilitation programs and can be integrated in the care of depressed COPD patients. Patients with severe disability, anxiety, neuroticism, and low self-efficacy are at risk for poor outcomes and in need of close follow-up and targeted interventions.

Objectives To determine whether a depression care management intervention in Medicare home health recipients decreases risk of hospitalization. Design Cluster-randomized trial. Nurse teams were randomized to intervention (12 teams) or enhanced usual care (EUC; 9 teams). Setting Six home health agencies from distinct geographic regions. Home health recipients were interviewed at home and over the telephone. Participants Individuals aged 65 and older who screened positive for depression on nurse assessments (N = 755) and a subset who consented to interviews (n = 306). Intervention The Depression CARE for PATients at Home (CAREPATH) guides nurses in managing depression during routine home visits. Clinical functions include weekly symptom assessment, medication management, care coordination, patient education, and goal setting. Researchers conducted telephone conferences with team supervisors every 2 weeks. Measurements Hospitalization while receiving home health services was assessed using data from the home health record. Hospitalization within 30 days of starting home health, regardless of how long recipients received home health services, was assessed using data from the home care record and research assessments. Results The relative hazard of being admitted to the hospital directly from home health was 35% lower within 30 days of starting home health care (hazard ratio (HR) = 0.65, P = .01) and 28% lower within 60 days (HR = 0.72, P = .03) for CAREPATH participants than for participants receiving EUC. In participants referred to home health directly from the hospital, the relative hazard of being rehospitalized was approximately 55% lower (HR = 0.45, P = .001) for CAREPATH participants. Conclusion Integrating CAREPATH depression care management into routine nursing practice reduces hospitalization and rehospitalization risk in older adults receiving Medicare home health nursing services.

COPD is a major cause of all-cause mortality. We examined predictors of 1-year mortality in patients with severe COPD and major depression after inpatient treatment in a rehabilitation hospital.We screened 898 consecutively admitted patients. Of these, 138 patients received the diagnoses of COPD according to American Thoracic Society Guidelines and major depression by Diagnostic and Statistical Manual of Mental Disorders, 4th edition and signed consent; 67 were randomized to a treatment adherence enhancement intervention and 71 to usual care. We assessed history of falls, dyspnea-related disability, severity of depression, medical burden, and cognitive functioning. Following discharge from inpatient rehabilitation, participants were prospectively followed, and mortality was ascertained over 52 weeks from hospital notes and reports of primary care physicians and relatives.One-year, all-cause mortality was 22% (31 of 138). Multivariate Cox regression analysis showed that history of falls in the 6 months preceding hospital admission was the strongest predictor of mortality (OR, 3.05; 95% CI, 1.40-6.66; P.005). Dyspnea during activities (Pulmonary Functional Status and Dyspnea Questionnaire-Modified domain) was also associated with mortality (OR, 1.05; 95% CI, 1.02-1.08; P.002). Depression severity, medical burden, and cognitive impairment were not predictors of mortality.Recent falls and dyspnea during activities identify subgroups of depressed patients with COPD at increased risk for all-cause mortality. These subgroups are in need of clinical attention and follow-up and can serve as targets for prevention research aiming to inform clinical strategies and public health planning.

Introduction Late life depression has detrimental effects on older adults’ functioning and well-being. Depressed older adults often experience loneliness and social isolation, which are risk factors for incident depression, increased depression severity, and medical illness. Neurobiological studies suggest that depressed individuals of all ages exhibit impairments in the reward systems and recent studies suggest that socially rewarding experiences may be especially important for depressed older adults. Results of a pilot study conducted by our group has shown that “Engage”, a neurobiologically informed, streamlined brief behavioral activation for depression, led to significant reduction in depressive symptoms. “Engage” targets impairments in positive valence system function through “reward exposure” (i.e. engagement in rewarding and meaningful activities). However, it is unknown whether engagement in certain types of rewarding activities is more beneficial than others. We predicted that given the centrality of social isolation in late life depression, social (versus non-social) rewarding activities would predict greater improvement in depression severity. Methods Forty-eight older adults with unipolar depression without cognitive impairment received 9 sessions of “Engage” psychotherapy. Depression severity was assessed using the Montgomery–Asberg Depression Rating Scale (MADRS) and behavioral activation was measured using the Behavioral Activation for Depression Scale (BADS) at baseline, weeks 6 and 9. We also assessed depression severity on a weekly basis using the Patient Health Questionnaire (PHQ-9). Patients’ weekly behavioral plans were categorized into three groups: a) solitary activities; b) social-group activities (attending a social gathering or going to a social setting such as church or a senior center); c) social-individual activities (engaging in an interpersonal interaction with a specific friend and/or family member). Results Logistic regression analyses showed that higher percentage of social-individual activities (compared to solitary and social-group activities) predicted subsequent improvement in depressive symptoms and increase in behavioral activation, when controlling for baseline scores on MADRS and BADS respectively. Preliminary analysis suggests that patients who selected social individual activities, in addition to solitary and social group activities, had a steeper reduction of depression by the third session compared to patients lacking social individual activities in their reward exposure plans. This observation suggests that engagement in social individual activities is associated with early response of depression to Engage. Conclusions Our preliminary results suggest that exposure to socially rewarding experiences could contribute to the efficacy of psychotherapy for late-life depression. Additionally, these findings highlight the importance of studying the effects of engagement in specific types of rewarding activities in behavioral activation treatment for late-life depression. This research was funded by P50 MH113838 R01 MH102252 T32 MH019132

Objectives The study evaluated the effectiveness of a depression care management intervention in reducing suicidal ideation (SI) among home health patients.

Depression and dementia are the two most common psychiatric syndromes in the older adult population. Depression in older adults with and without dementia often goes unrecognized and untreated. The current guideline recommends a three-step procedure that can be used across health care settings to screen for the presence of depressive symptoms. Implementation of the evidence-based guideline requires administration of the Mini-Mental State Examination and either the Geriatric Depression Scale Short Form or Cornell Scale for Depression in Dementia, depending on level of cognitive functioning. The algorithm provided is designed to be used by nurses, physicians, and social workers for the purpose of depression screening in older adults with dementia. Detection of depression in individuals with dementia is hindered by a lack of a validated, brief screening tool. More research is needed on the use of such screenings among older adults with cognitive impairment. [ Journal of Gerontological Nursing, 41 (11), 15–21.]

Objective To identify patient characteristics associated with concordance of Medicare claims with clinically identified depression. Methods The authors studied a cohort of 742 older primary care patients linked to Medicare claims data using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition major depressive disorder and clinically significant minor depression. Results Among 474 patients with depression, 198 patients had a Medicare claim for depression (sensitivity: 42%; 95% confidence interval [CI]: 37%–46%). Among 268 patients who did not meet criteria for depression, 235 patients did not have a Medicare claim for depression (specificity: 88%; 95% CI: 83%–91%). After adjustment for demographic and clinical characteristics, non-white participants were nearly twice as likely not to have Medicare claims for depression among patients who met criteria for depression ("false negatives"). Smoking status, depression severity (Hamilton Depression Rating Scale), cardiovascular disease, and more primary care physician office visits were also significantly associated with decreased odds to be false negatives. In contrast, after covariate adjustment, white race and chronic pulmonary disease were associated with increased odds of a Medicare claim for depression among patients who did not meet criteria for depression ("false positives"). Using weights based on the screened sample, the positive predictive value of a Medicare claim for depression was 66% (95% CI [63%, 69%]), whereas the negative predictive value was 77% (95% CI [76%, 78%]). Conclusion Investigators using Medicare data to study depression must recognize that diagnoses of depression from Medicare data may be biased by patient ethnicity and the presence of medical comorbidity.

The goal of this pilot program was to test the feasibility of mental health screening among elder abuse victims and of offering those victims a brief psychotherapy for depression and anxiety. Elder abuse victims who sought assistance from a large, urban elder abuse service were screened for depression and anxiety using standardized measures. Clients with clinically significant depression (PHQ-9) or anxiety (GAD-7) were randomized to receive one of three different interventions concurrent with abuse resolution services. Staff were able to screen 315 individuals, with 34% of clients scoring positive for depression or anxiety. Of those with mental health needs, only 15% refused all services. The mental health intervention (PROTECT) was successfully implemented in two different formats with collaboration between staff workers. These findings support both the need for mental health care among elder abuse victims and the feasibility of integrating mental health screening and treatment into routine elder abuse practice.

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.

We review recent advances in psychotherapies for depressed older adults, in particular those developed for special populations characterized by chronic medical illness, acute medical illness, cognitive impairment, and suicide risk factors. We review adaptations for psychotherapy to overcome barriers to its accessibility in non-specialty settings such as primary care, homebound or hard-to-reach older adults, and social service settings. Recent evidence supports the effectiveness of psychotherapies that target late-life depression in the context of specific comorbid conditions including COPD, heart failure, Parkinson’s disease, stroke and other acute conditions, cognitive impairment, and suicide risk. Growing evidence supports the feasibility, acceptability, and effectiveness of psychotherapy modified for a variety of health care and social service settings. Research supports the benefits of selecting the type of psychotherapy based on a comprehensive assessment of the older adult’s psychiatric, medical, functional, and cognitive status, and tailoring psychotherapy to the settings in which older depressed adults are most likely to present.

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 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.

Objective We developed a personalized intervention for depressed patients with COPD (PID-C) aimed to mobilize patients to participate in the care of both conditions. We showed that PID-C reduced depressive symptoms and dyspnea-related disability more than usual care over 28 weeks. This study focused on untangling key therapeutic ingredients of PID-C. Design Randomized controlled trial. Setting Community. Participants 138 patients who received the diagnoses of COPD and major depression after screening 898 consecutive admissions for acute inpatient pulmonary rehabilitation. Intervention Nine sessions of PID-C compared with usual care over 28 weeks. Measurements Primary outcome measures were the 17-item Hamilton Depression Rating Scale and the Pulmonary Functional Status and Dyspnea Questionnaire–Modified. Other measures were adherence to rehabilitation exercise (≥2 hours per week) and adherence to adequate antidepressant prescriptions. Results Low severity of dyspnea-related disability and adherence to antidepressants predicted subsequent improvement of depression. Exercise and low depression severity predicted improvement of dyspnea-related disability. Conclusions PID-C led to an interacting spiral of improvement in both depression and disability in a gravely medically ill population with a 17% mortality rate over 28 weeks and an expected deterioration in disability. The interrelationship of the course of depression and dyspnea-related disability underscores the need to target adherence to both antidepressants and chronic obstructive pulmonary disease rehabilitation. PID-C may serve as a care management model for depressed persons suffering from medical illnesses with a deteriorating course.

Background The effects of therapeutic relationship (TR) in elder mental health are understudied. A greater understanding of TR in geriatric psychotherapy is particularly needed for treating late-life depression with executive dysfunction, which predicts poor response to antidepressant medication and presents unique clinical challenges. Methods Participants were older patients (N = 220) with major depression and executive dysfunction who received 12 weeks of problem-solving therapy or supportive therapy in a randomized control trial. Multilevel growth curve modeling and latent change scores were used to analyze TR dimensions of Understanding and Accepting at the patient level (individual patient ratings, N = 194) and therapist level (ratings of each therapist averaged across participants, N = 10). Results TR predicted reduction of depression in both treatment groups, while treatment×TR interactions were not significant. Patients treated by therapists with higher average Understanding (patient and therapist level) and Accepting (therapist level) ratings had greater decreases in depression. The patient level×therapist level interaction for Understanding approached statistical significance (p=.065), suggesting a synergistic effect on treatment outcome. Together, Understanding and Accepting predicted 21% of variance in depression level changes. Limitations TR was not assessed throughout the course of treatment (only after the first therapy session and at post-treatment) and did not include ratings from an objective evaluator. Conclusions Assessment of patient's experience of the TR and of therapist ability to foster Understanding and Accepting can play a significant role in the delivery of geriatric psychosocial interventions.

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 (F 1,52 = 18.63, p 2,52 = 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 (F 1,52 = 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.

The goal of this pilot program was to test the usefulness of adapted Problem-Solving Therapy (PST) and anxiety management, called PROTECT, integrated into elder abuse services to reduce depression and improve self-efficacy. Depressed women victims were randomized to receive elder abuse resolution services combined with either PROTECT or a mental health referral. At follow-up, the PROTECT group showed greater reduction in depressive symptoms and endorsed greater improved self-efficacy in problem-solving when compared to those in the Referral condition. These preliminary findings support the potential usefulness of PROTECT to alleviate depressive symptoms and enhance personal resources among abused older women.