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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.

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.

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.

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 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.

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

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.

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.

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.

Despite the benefits of treatment for late-life depression, we are faced with the challenges of underutilization of mental health services by older adults and non-adherence to offered interventions. This paper describes psychosocial and interactional barriers and facilitators of treatment engagement among depressed older adults served by community health care settings. We describe the need to engage older adults in treatment using interventions that: 1. target psychological barriers such as stigma and other negative beliefs about depression and its treatment; and 2. increase individuals’ involvement in the treatment decision-making process. We then present personalized treatment engagement interventions that our group has designed for a variety of community settings.

Objectives: Depression in older adult home care recipients is frequently undetected and inadequately treated. Failed communication between home healthcare personnel and the patient's physician has been identified as a barrier for depression care. The purpose of this pilot intervention study was to improve nurse competency for communicating depression-related information to the physician. Design: A single group pre-post experimental design. Setting: Two Medicare-certified home healthcare agencies serving an urban and suburban area in New York. Participants: Twenty-eight home care nurses, all female Registered Nurses. Intervention: Two-hour skills training workshop. Measurements: To evaluate the intervention, pre-post changes in effective nurse communication using Objective Structured Clinical Examinations and nurse survey reports. Results: The intervention significantly improved the ability of the home care nurse to perform a case presentation in a complete and standard organized format pre versus postintervention. The intervention also increased nurse-reported certainty to communicate depression-related information to the physician. Conclusions: Our findings provide support for the ability of a brief, depression-focused communication skills training intervention to improve home care nurse competency for effectively communicating depression-related information to the physician.

Objective: Although medical illness and physical disability are strongly associated with depression, the majority of older adults who experience medical illness or disability at any given time are not depressed. The aim of these analyses was to identify risk factors for new onset depression in a sample of medically ill, disabled older adults. Methods: The authors used data from a representative sample of homebound older adults who recently started receiving Medicare home healthcare services for medical or surgical problems (N = 539). The authors report on the rate and baseline predictors of new onset major or minor depression, using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria and assessed by the Structured Clinical Interview for DSM-IV Axis I Disorders, at 1-year follow-up. Our analyses were conducted with a subsample of older adults (N = 268) who did not meet criteria for major or minor depression and were not on an antidepressant medication at our baseline interview. Results: At 1-year follow-up, 10% (28/268) of patients met criteria for either major (3%; 9/268) or minor depression (7%; 19/268). In multivariate analyses, the authors found that worse self-rated health (odds ratio [OR] = 0.53, p=0.042), more somatic depressive symptoms (OR = 1.19, p=0.015), greater number of activities of daily living (ADL) limitations at baseline (OR = 1.63, p=0.014), and greater decline in ADL functioning from baseline to 1 year (OR = 1.59, p=0.022) were all independently associated with onset depression. Conclusion: These findings underscore the significant fluctuations in both depression and disability in high-risk older adults and suggest that both persistent and new onset disability increase the risk of depression. They may also help in designing preventive strategies to promote the ongoing good mental health of these high-risk patients over time.

Objective To empirically evaluate the psychometric properties of the 15-item Geriatric Depression Scale (GDS-15); determine the optimal cutoff points and screening performance for the detection of major depression; and examine differential item functioning (DIF) to determine the variability of item responses across sociodemographics in an elderly home care population. Design A secondary analysis of data collected from a random sample study. Setting Homebound subjects newly admitted over a 2-year-period to a large visiting nurse service agency in Westchester, New York. Participants Five hundred twenty-six subjects over age 65, newly admitted to home care for skilled nursing. Measurements Major depression was diagnosed using both patient, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and best estimate procedures. Self-report measures included the GDS-15, activities of daily living (ADL), instrumental ADL, and pain intensity. Cognitive impairment was assessed using the Mini-Mental State Examination and medical morbidity using the Charlson Comorbidity Index. Results Optimal cutoff (5) yielded sensitivity 71.8% and specificity of 78.2%, however, the accuracy of the GDS-15 was not influenced by severity of medical burden. Persons with a cluster of ailments were twice as likely (Adj odds ratio=2.47; 95% confidence interval=1.49–4.09) to be diagnosed with depression. DIF analyses revealed no variability of item responses across sociodemographics. Conclusion Main findings suggest that the accuracy of the GDS-15 was not influenced by severity of clinical or functional factors, or sociodemographics. This has broad implications suggesting that the very old, ill, and diverse populations can be appropriately screened for depression using the GDS-15.

Approximately 30% of patients with chronic obstructive pulmonary disease (COPD) experience depression. Pulmonary rehabilitation for COPD focuses on physical conditioning, but includes behavioral interventions that may address depressive symptoms. This study tested the hypothesis that brief inpatient pulmonary rehabilitation is followed by improvement in both depressive symptoms and function in patients with COPD with major depression.The subjects, who were recruited from the pulmonary rehabilitation unit of the Burke Rehabilitation Hospital in White Plains, NY, who had COPD and major depression were consecutively admitted patients to a pulmonary rehabilitation unit. Symptoms of depression, disability, medical burden, the experience of support, and satisfaction with treatment were systematically ascertained on admission and before discharge.Three hundred sixty-one patients were screened and 63 met criteria for COPD and major depression. Depressive symptoms improved by discharge (z = -6.785, p0.0001); median length of stay was 16 days. Approximately 51% of subjects met criteria for response (50% or greater reduction in depressive symptoms scores from baseline), and 39% met criteria for remission (final Hamilton Depression scale score equal to or less than 10). History of treatment for depression was associated with limited change in depressive symptoms, whereas social support and satisfaction with treatment were predictors of improvement. All disability domains were lower at discharge compared to baseline (z = -3.928, p0.0001). Subjects with pronounced disability at baseline had the greatest improvement if their depression improved by discharge.Acute inpatient rehabilitation is followed by improvement of depressive symptoms and disability in older patients with COPD and major depression. Improvement of depression may be the result of behavioral interventions rather than the use of antidepressant drugs.

Objective Studies in primary care settings have shown that depression is often chronic and associated with negative outcomes among patients with medical illness. The stability of depression among home care recipients has not been investigated. The authors examined the 1-month stability of major depression in a representative sample of elderly adults shortly after their admission to home care. Methods A group of 539 subjects over age 65, newly admitted to home care for skilled nursing, were interviewed with the Structured Clinical Interview for DSM-IV (SCID-IV). Depression severity, medical comorbidity, pain, functional status, cognitive status, and recent life events were also assessed. Of 84 subjects who met criteria for major depression (MDD) at baseline, 74 were available for 1-month follow-up interview. Results At 1-month follow-up, 31 subjects (42%) continued to meet MDD criteria; 20 (27%) achieved partial remission; and 23 (31%) were in full remission. Fewer instrumental activity limitations at baseline, experiencing "a great deal" of pain, and absence of a recent stressful life event were associated with full remission at 1-month follow-up. Conclusion Nearly one-half of newly admitted elderly home care patients who meet criteria for MDD continue to meet full criteria 1 month later. Functional and psychosocial factors affect the short-term course.

OBJECTIVE The authors compared the efficacy of problem-solving therapy (PST) and supportive therapy (ST) in a group of elderly subjects with impairment in executive functions. This group was targeted because it has been shown to be at the risk for poor response to pharmacotherapy. METHODS A total of 25 elderly subjects with major depression and abnormal scores in initiation/perseveration and response inhibition tasks were randomly assigned to receive weekly sessions of PST or ST for 12 weeks. The subjects were systematically evaluated by raters blind to the study hypotheses. RESULTS PST was more effective than ST in leading to remission of depression, fewer post-treatment depressive symptoms, and less disability. A substantial part of the change in depression and disability was explained by the subjects' improvement of skills in generating alternatives and in decision-making. CONCLUSION This preliminary study suggests that PST is effective in reducing depressive symptoms and disability in elderly patients with major depression and executive dysfunction. If these findings are confirmed, PST may become an important therapeutic alternative for a patient population who may otherwise remain symptomatic and disabled.

This paper reviews the clinical and cost effectiveness of psychotherapy for treating major and minor depression in primary care practice. Conclusions drawn from psychotherapy studies completed prior to 1995 were constrained by methodological deficiencies such as ambiguity regarding patient diagnostic status, use of non-specific psychotherapies, and lack of treatment manuals. More recent studies have addressed these flaws by shifting from efficacy to effectiveness designs, using standard diagnostic assessment procedures and appropriate follow-up time periods, using empirically evaluated treatment manuals, and selecting appropriate comparison conditions. Twelve primary care studies meeting these design criteria were analyzed, and the following conclusions were drawn: When used to treat major depression, a depression-specific psychotherapy produces better clinical outcomes than a primary care physician's usual care and outcomes similar to those produced by pharmacotherapy. When used to treat minor depression or dysthymia, the effectiveness of psychotherapy in comparison to usual care remains more equivocal. A review of the sparse data on cost effectiveness suggests that while psychotherapy has a higher fiscal cost than a physician's usual care, psychotherapy's higher value in treating patients with major depression may justify its use.

This research was funded by: The project was supported by the University of Rochester CTSA award number UL1 RR024160 from the National Center for Research Resources and the National Center for Advancing Translational Sciences of the National Institutes of Health and was partially supported by the National Institutes of Health, Grant R25 MH071544/MH/ NIMH (PI: Dilip V. Jeste, M.D.) and the University of California, San Diego, Stein Institute for Research on Aging. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Change (PGI-C), Quality of Life-Alzheimer’s disease (QOL-AD), ADCS-Activities of Daily Living (ADL), Caregiver Strain Index (CSI), MMSE, and Cornell Scale for Depression in Dementia (CSDD). Standard safety and tolerability outcomes were assessed. Stage 1 and stage 2 results were also analyzed separately. Results: 220 patients were enrolled and 194 (88%) completed the study. In stage 1, 218 patients were included in the modified intent-to-treat (mITT) efficacy population [AVP-923 (n1⁄493); placebo (n1⁄4125)]. In stage 2, 202 patients comprised the mITT: 83 patients from the stage 1 AVP-923 group continued on AVP-923; 89 placebo nonresponders were re-randomized [AVP-923 (n1⁄444); placebo (n1⁄445)], and 30 placebo responders were re-randomized [AVP-923 (n1⁄415); placebo (n1⁄415)]. The primary endpoint was significant for AVP-923 vs placebo (P 0.001). The mean (SD) baseline NPI agitation/aggression domain scores were 7.1 (2.6) for AVP-923 vs. 7.0 (2.4) for placebo, and showed significant improvement for AVP-923 vs placebo both at week 5 (stage 1, mean [SD] change from baseline -3.3 [2.98] vs -1.7 [3.10]; (P 0.001) and at week 10 (stage 2, mean [SD] change from baseline -2.0 [3.19] vs -0.8 [3.59]; P1⁄40.02). ADCS-CGIC agitation improved significantly with AVP-923 vs placebo on the primary analysis (P 0.001), as did PGI-C. Significant improvement for AVP-923 vs. placebo was also seen for secondary endpoints including: NPI total score, NPI-4D, NPI-4A, NPI Caregiver Distress Score, CSDD, and CSI. Treatment-emergent adverse events (TEAEs) occurred in 61.2% of patients taking AVP-923 and 43.3% of patients taking placebo and were considered to be at least possibly related to treatment in 16.4% and 10.2%, respectively. Adverse events led to discontinuation in 5.3% on AVP-923 and 3.1% on placebo. Serious AEs (SAEs) occurred in 7.9% and 4.7% of patients, respectively; no SAEs were considered treatment-related. No deaths occurred during the study. Falls were reported as an AE in 8.6% of patients on AVP-923 and 3.9% on placebo; however, history of falls was more common in the AVP-923 group at baseline (20.4% vs. 12.8%). Other AEs occurring in 5% of patients were diarrhea 5.9% vs. 3.1%, and urinary tract infection 5.3% vs. 3.9%. Conclusions: AVP-923 (dextromethorphan/quinidine) was associated with significant improvement in agitation in patients with AD as seen on the primary, and on the majority of secondary endpoints. These improvements were deemed clinically meaningful by patients/caregivers and physicians (as assessed by PGI-C and ADCS-CGIC ratings), and were associated with reduction in caregiver burden. AVP-923 was generally well tolerated over this 10 week trial.

The problem of managing elders with cogntive impairment can be complex as co-morbid medical and psychiatric symptoms complicate the clinical picture. Family and caregivers are often confused, angry, frustrated or overwhelmed and need to be evaluated for their competence as caregviers. Outside help and the potential need for placement and advanced directives also need to be addresed. After the work up for depression and/or cogntive impairment is complete and appropriate meds are prescribed, the focus of managment shifts to coping strategies for the identified patient and caregivers. Those with accumulated experience working with elders accrue the necessary skills and knowledge to meet these needs but the presenters argue that manual-based approaches can be taught efficiently to sytematically train a new cohort of healthcare personnel to help meet the needs of managing these patients in an aging society.