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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).

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.

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.

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 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.

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.

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 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.

Depression is related to disability and affects rehabilitation participation, outcomes, and compliance with treatment. Improving older adult depression detection and referral requires knowledge, skills, supportive organizational policies, and access to mental health experts. This review provides a selected overview of evidence-based approaches for screening of suspected cases of depression in older adults by physical therapists and other non-mental health professionals and discusses procedures to refer suspected cases to primary care providers and/or mental health specialists for evaluation, including resources and a tool to assist in communicating depression-related information to the primary care provider or mental health specialist. We hope that this review will promote the incorporation of evidence-based screening and referral of suspected cases of depression in older adults into routine practice.

High levels of depressive symptoms are common and contribute to poorer clinical outcomes even in geriatric patients who are already taking antidepressant medication. The Depression CARE for PATients at Home (Depression CAREPATH) intervention was designed to meet the needs of medical and surgical patients who suffer from depression. The intervention’s clinical protocols are designed to guide clinicians in managing depression as part of routine home care.

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.

The authors hypothesized that the depression treatment preferences of elderly home care patients would vary by their experience of depression and that preferences for active treatment would be associated with current depression and with antidepressant treatment.The authors conducted cross-sectional secondary analyses of data from the TRIAD study (Training in the Assessment of Depression) of 256 randomly selected elderly patients newly admitted to home care. The study assessed preference for active treatments (medication or psychotherapy) and nonactive or complementary approaches (such as religious activities or doing nothing). Nondepressed patients were asked to choose as if they had serious depression. Two separate indicators of depression experience were used: a current diagnosis of major or minor depression and current or previous antidepressant treatment.Of the 256 patients, 16% (N=41) met criteria for major or minor depression. Forty-seven percent of the sample (N=121) preferred an active treatment as their first choice, and others preferred nonactive or complementary approaches. Logistic regression indicated that current antidepressant use, previous psychotherapy experience, white or Hispanic race-ethnicity (versus black), greater impairment in instrumental activities of daily living, and less personal stigma about depression were independently associated with preference for an active treatment.Elderly home care patients had a variety of treatment preferences, ranging from active treatments, to religious or spiritual activities, to no treatment. Several factors were associated with a preference for active treatment, including treatment experience, physical impairment, race-ethnicity, and attitudes and beliefs. An understanding of patient preferences may help engage older depressed home care patients in treatment.

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.

Since Medicare first implemented the home care Outcome and Assessment Information Set (OASIS) in 1999, we have learned a great deal about depression among the homebound elderly. First, we know that major depression is a highly prevalent illness in home care. With depression rates at almost 15%, home care—along with nursing homes—has among the highest rates of any healthcare setting (Bruce et al., 2002; Parmelee et al., 1992; Jones et al., 2003).

Depression remains a significant public health problem for older adults in all service sectors (hospitals, primary care, long-term care).1,2 The failure to detect and adequately treat depression is associated with higher costs,3 morbidity, risk of suicide, and mortality from other causes,1,2 but depression is a treatable condition.4–6 Guidelines based on evidence from pharmacotherapy, psychotherapy,7 and care models for the primary care setting have been established,8 but there has been little research on practical approaches to operationalizing depression detection or treatment for the homecare setting.9 There is a substantial need for depression research in homecare, with major depression twice as common in older adults receiving homecare services10 as in those receiving primary care.11 A previous study found that 13.5% of subjects newly admitted to homecare suffered from major depression,10 that depression often remained unrecognized,12,13 and that few (12%) received adequate treatment. 10 The aim of the TRaining In the Assessment of Depression (TRIAD) intervention14 is to address inadequacies and improve routine depression case finding in older adult patients by homecare nurses. The U.S. Preventive Task Force15 recommends that all individuals aged 60 and older should be screened for depression periodically, and evidence-based nursing practice guidelines call for nurse depression screening.16,17 A few investigators have focused on the homecare nurse’s ability to implement such screening.14,18–20 The rationale for leveraging the role of homecare nurses includes their frequent and regular contact with patients. In Medicare-certified agencies, homecare nurses provide the vast majority (85%) of skilled care21 and are mandated to perform patient assessments periodically, including assessment for depression symptoms, yet homecare nurses do not feel adequately prepared22 and often fail to identify depression.12,13 Homecare nurses have expressed concerns about “asking direct questions about depression,” “invasion of patient privacy,” “precipitating patient distress (e.g., suicide ideation),” and the added paperwork burden required for screening activities.20 In addition, agencies may lack the supportive infrastructure to improve depression case finding. In a randomized trial,14 TRIAD was found to be a successful intervention. Specifically, it was found that nurses who received the TRIAD were 2.5 times as likely to correctly identify depressed patients and refer them for further evaluation, following agency protocols, and that referrals led to better clinical outcomes. There was no effect on unnecessary referrals for research-confirmed patients without depression (i.e., the intervention did not promote false-positive referrals). To promote dissemination of a proven effective intervention, this article describes in more detail the rationale, development, and use of TRIAD as it was implemented in a randomized controlled trial.14 It describes partnership activities with participating homecare agencies, needs assessment surveys, shadowing activities, and the content of the training curriculum and reports on nurses’ acceptance of the TRIAD intervention to develop their confidence in conducting depression detection, before and after the intervention.

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.

Depression and dementia are the two most frequent psychiatric syndromes in the older adult population. Depression in older adults with and without dementia often goes unrecognized and untreated (Charney et al., 2003; Kales, Chen, Blow, Welsh, Mellow, 2005). Estimates of the prevalence of depression in older adults with dementia vary widely (Alexopoulos, Abrams, 1991; Wragg, Jeste, 1989), which is attributed to differences in sampling, diagnostic criteria used to identify depression, and the way it is assessed (Alexopoulos, Abrams, 1991; McCabe et al., 2006). Depression in older adults is not simply due to aging; medical conditions increase the likelihood of depression (Alexopoulos, 2000). Despite expert recommendations (Alexopoulos et al., 2001) and increased availability of a range of depression treatment options (e.g., medication, psychotherapy, combination therapy, and ECT), depression remains a significant public health problem for older adults (Surgeon General Healthy People 2010). Detection is the first essential step to improving depression care for patients with dementia. Major depression is a syndrome characterized by a number of signs and symptoms. According to the DSM-IV TR (American Psychiatric Association, 2000), at least five symptoms must be present for a diagnosis of major depression to be made (see Definitions of Key terms). In a study conducted in a nursing home, 25% of residents screened positive for major depression (Gruber-Baldini et al., 2005). This is close to the prevalence rate of major depression reported for persons with Alzheimer’s disease (Alexopoulos, Abrams, 1991 [15%–20%]; Lyketsos et al., 1997 [22%]; Wragg, Jeste, 1989 [10%–20%]). In recognition that many demented patients experience clinically significant depression that may not meet full criteria for major depression, Olin et al. (2002b) have proposed new provisional diagnostic criteria for depression of Alzheimer disease. Diagnostic criteria include fewer symptoms of depression (three symptoms versus five symptoms required for major depression). In addition, symptoms need to be present for a shorter period of time due to the fluctuating nature of depression in persons with dementia (Abrams, Alexopoulos, 1994; Jost, Grossberg, 1996). However, research studies are still needed to validate these new depression criteria (Charney et al., 2003). Depression screening in persons with dementia is hindered at times by the patient’s inability to self-report symptoms and tendency to underestimate degree of depression, and discrepant caregiver reports (Teri, Wagner, 1991). The assessment of depression in dementia is complicated by the considerable overlap in its clinical presentation with that of dementia.

Patricia Marino, Jo Anne Sirey, Patrick J Raue, George S AlexopoulosDepartment of Psychiatry, Weill Medical College of Cornell University, White Plains, NY, USAObjective: The objective of this study was to examine the association between social support, self-efficacy, and functioning among a sample of depressed older adults with chronic obstructive pulmonary disease (COPD).Methods: Participants were recruited immediately following admission to an acute pulmonary rehabilitation unit of a rehabilitation hospital. One hundred and fifty-six subjects completed assessments of depression, functioning, social support, and self-efficacy at admission to the rehabilitation unit. Regression analyses were conducted to evaluate the impact of different aspects of social support and self-efficacy on overall functioning at admission.Results: Controlling for depression, COPD severity, and age, subjective social support (p = 0.05) and self-efficacy (p

Background Geriatric depression preferentially afflicts individuals with chronic medical illnesses. Disability, hopelessness, lack of acceptance of antidepressant treatment, and limited problem-solving skills contribute to poor treatment adherence, compromised outcomes, and chronically experienced adversity. Methods This paper uses depression comorbid with chronic obstructive pulmonary disease (COPD) as a model entity to develop an approach for integrating treatment components essential for improving treatment adherence and outcomes. Results The behavioral inertia of depression and its coexisting cognitive problems reduce adherence to the sustained and complex demands of the COPD rehabilitation regimen and antidepressant treatment. An intervention identifying reasons for poor treatment adherence and offering direct instructions for addressing them can be combined with problem-solving therapy to target treatment adherence, depressive symptoms, and disability. Conclusions An intervention focusing on treatment adherence and problem-solving skills development may serve as the platform for administering specific treatments to address the interacting problems of depressed medically ill patients. Copyright © 2007 John Wiley & Sons, Ltd.

OBJECTIVES: To determine whether an educational intervention would improve depression assessment and appropriate referral. Secondary analyses tested whether referral led to depression improvement. DESIGN: Training in the Assessment of Depression (TRIAD) was a three-group, nurse-randomized trial. Researchers interviewed randomly selected patients at baseline and 8 weeks. SETTING: Three certified home healthcare agencies in Westchester County, New York. PARTICIPANTS: Fifty-three medical/surgical nurses were randomized within agency to three intervention groups: full, minimal, or control. Research contact with nurses' patients (aged >65; N=477) yielded 256 (53.7%) enrolled subjects, 84 (17.6%) ineligibles, and 120 (25.2%) refusals; 233 of the 256 (87.1%) enrolled patients completed follow-up interviews. INTERVENTION: Nurse training in clinically meaningful use of depression sections of Medicare's mandatory Outcome and Assessment Information Set (OASIS). MEASUREMENTS: Nurse-assessed mood or anhedonia (OASIS) versus research assessments using the Structured Clinical Interview for Axis I Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Disorders (SCID); referrals for mental health evaluation (agency records), and depression severity (24-item Hamilton Depression Rating Scale; HDRS). RESULTS: Referral rates for patients with (SCID) depressed mood or anhedonia (n=75) varied according to nurse group: 50.0% full intervention, 18.5% minimal, 21.4% control (P=.047). Rates for nondepressed patients (n=180) did not differ (4.9%, 2.0%, 5.8%, respectively; P=.60). In patients with major or minor depression (n=37), referral was associated with symptom improvement. Change in HDRS was 5 points greater in referred patients than others (P=.04). Concordance between OASIS and SCID did not differ between intervention groups. CONCLUSION: TRIAD showed that training nurses to assess for depression using an approach developed in partnership with home healthcare agencies led to appropriate referral and care for depressed patients.

Background Interpersonal psychotherapy (IPT) is an empirically-validated intervention for treating late-life depression. Objective To determine the manner in which IPT is utilized by primary care physicians in relation to antidepressant medications. Methods The authors reviewed treatment logs prepared by care managers during the first 12 months of a patient's participation in the PROSPECT clinical trial to determine initial and longitudinal treatment patterns utilized by physicians, and clinical outcomes associated with initial treatment assignment. Results Primary care physicians in practices randomized to PROSPECT's intervention arm initially prescribed an antidepressant medication for 58% of eligible patients and referred only 11% of them to IPT. Over time, however, 27% of patients participated in IPT as monotherapy or augmentation therapy. Initial treatment assignment was not associated with depressive status at 4 and 12 months nor with suicidal ideation at 4, 8, and 12 months. Conclusion IPT is an effective treatment for late-life depression whose greater use by primary care physicians should be encouraged. Copyright © 2006 John Wiley & Sons, Ltd.

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.

Availability of tolerated and relatively safe antidepressants increased the use of antidepressants in late-life depression. However, only one third of depressed older adults achieve remission with any single agent.1 Treatment resistance to antidepressants prompted the development and investigation of effective psychotherapies for cognitively unimpaired, depressed older adults. Since late-life major depression is often accompanied by cognitive impairment, disability, and medical illnesses1,2, novel psychotherapies for depressed patients with cognitive impairment, disability, chronic medical illnesses or acute medical events have also been developed. Thus, the selection and planning of psychotherapy depends on the patient’s clinical state and requires a thorough assessment. Areas of assessment include not only the patient’s depressive symptoms, acute and chronic stressors, interpersonal context, skills and behavioral deficits, but also the presence and degree of the patient’s cognitive deficits, medical burden and disability. This article describes assessment procedures pertinent to psychosocial interventions and outlines psychosocial interventions for depressed older adults.

Objective To test the following hypotheses: (1) Clinical case management integrated with problem-solving therapy (CM-PST) is more effective than clinical case management alone (CM) in improving functional outcomes in disabled, impoverished patients and (2) improvement in depression, self-efficacy, and problem-solving skills mediates improvement of disability. Methods Using a randomized controlled trial with a parallel design, 271 individuals were screened and 171 were randomized to 12 weekly sessions of either CM or CM-PST at 1:1 ratio. Raters were blind to patients' assignments. Participants were at least age 60 years with major depression, had at least one disability, were eligible for home-based meals services, and had income no more than 30% of their counties' median. The WHO Disability Assessment Scale was used. Results Both interventions resulted in improved functioning by 12 weeks (t = 4.28, df = 554, p = 0.001), which was maintained until 24 weeks. Contrary to hypothesis, CM was noninferior to CM-PST (one-sided p = 0.0003, t = −3.5, df = 558). Change in disability was not affected by baseline depression severity, cognitive function, or number of unmet social service needs. Improvements in self efficacy (t = −2.45, df = 672, p = 0.021), problem-solving skill (t = −2.44, df = 546, p = 0.015), and depression symptoms (t = 2.25, df = 672, p = .025) by week 9 predicted improvement in function across groups by week 12. Conclusion CM is noninferior to CM-PST for late-life depression in low-income populations. The effect of these interventions occur early, with benefits in functional status maintained as long as 24 weeks after treatment initiation (clinicaltrials.gov; NCT00540865).

ObjectiveTo test the hypotheses that (1) clinical case management integrated with problem-solving therapy (CM-PST) is more effective than clinical case management alone (CM) in reducing depressive symptoms of depressed, disabled, impoverished patients and that (2) development of problem-solving skills mediates improvement of depression.MethodsThis randomized clinical trial with a parallel design allocated participants to CM or CM-PST at 1:1 ratio. Raters were blind to patients' assignments. Two hundred seventy-one individuals were screened and 171 were randomized to 12 weekly sessions of either CM or CM-PST. Participants were at least 60 years old with major depression measured with the 24-item Hamilton Depression Rating Scale (HAM-D), had at least one disability, were eligible for home-based meals services, and had income no more than 30% of their counties' median.ResultsCM and CM-PST led to similar declines in HAM-D over 12 weeks (t = 0.37, df = 547, p = 0.71); CM was noninferior to CM-PST. The entire study group (CM plus CM-PST) had a 9.6-point decline in HAM-D (t = 18.7, df = 547, p

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.

PURPOSE We investigated the prevalence, severity, and course of passive and active suicidal ideation occurring in primary care patients with an uncomplicated depressive disorder. METHODS We studied suicidal ideation experienced by patients recruited in 60 primary care practices participating in a randomized controlled trial of depression management. Risk levels associated with suicidal ideation and plans were determined by a 2-stage procedure using pertinent items of the Patient Health Questionnaire-9, the Hopkins Symptom Checklist-20, and the Cornell structured assessment interview and management algorithm. RESULTS Of the 761 patients whom physicians judged in need of treatment for a clinical depression, 405 (53%) were experiencing uncomplicated dysthymia, major depression, or both. Among these depressed patients, about 90% had no risk or a low risk of self-harm based on the presence and nature of suicidal ideation; the rest had an intermediate risk. Almost all patients who were initially classified at the no or low risk levels remained at these levels during the subsequent 6 months. The incidence of suicidal ideation at a risk level requiring the physician’s immediate attention in this no- or low-risk subgroup was 1.1% at 3 months and 2.6% at 6 months. CONCLUSIONS Almost all patients with uncomplicated dysthymia, major depression, or both acknowledging suicidal ideation of the minimal risk type when initially assessed maintained this minimal risk status during the subsequent 6 months.

This study compared time to first remission for elderly depressed patients in primary care for practices that implemented a care management model versus those providing usual care. In addition, it sought to identify risk factors for nonremission that could guide treatment planning and referral to care managers or specialists.Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) data were analyzed. Participants were older patients (or =60 years) selected following screening of 9,072 randomly identified primary care patients. The present analysis examined patients with major depression and a 24-item Hamilton Depression Rating Scale score of 18 or greater who were followed for at least 4 months (N=215). Primary care practices were randomly assigned to offer the PROSPECT intervention or usual care. The intervention consisted of services of trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 18 months.First remission occurred earlier and was more common among patients receiving the intervention than among those receiving usual care. For all patients, limitations in physical and emotional functions predicted poor remission rate. Patients experiencing hopelessness were more likely to achieve remission if treated in intervention practices. Similarly, the intervention was more effective in patients with low baseline anxiety.Longitudinal assessment of depression, hopelessness, anxiety, and physical and emotional functional limitations in depressed older primary care patients is critical. Patients with prominent symptoms or impairment in these areas may be candidates for care management or mental health care, since they are at risk for remaining depressed and disabled.

This study evaluated the accuracy of home care nurses' ratings of the Outcome and Assessment Information Set (OASIS) depression items. The accuracy of home care nurses' depression assessments was studied by comparing nurse ratings of OASIS depression items with a research diagnostic assessment based on the Structured Clinical Interview for Axis I Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). The setting for this study was a nonprofit, Medicare-certified, voluntary home healthcare agency. Sixty-four home care nurses assessed 220 patients aged 65 and older with the OASIS upon admission. Of the 220 patients, using standard SCID criteria, 35 cases of major or minor depression were identified. The home care nurses accurately documented the presence of depression in 13 of 35 cases (sensitivity=37.1%; positive predictive value=0.56). Of the 220 patients, 185 had no SCID-identified major or minor depression. The nurses agreed on the absence of depression in 175 of 185 cases (specificity=94.6%; negative predictive value=88.8%). This study indicates that home care nurses often do not accurately rate OASIS depression items for older adult patients.

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.

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.

The National Strategy for Suicide Prevention (2012) has set a goal to reduce suicides by 20% within 5 years. Suicide rates are higher in older adults compared to most other age groups, and the majority of suicide completers have visited their primary care physician in the year before suicide. Primary care is an ideal setting to identify suicide risk and initiate mental health care. We review risk factors for late-life suicide; methods to assess for different levels of suicidality; and recent research developments regarding both effective assessment and management of suicide risk among older primary care patients. We highlight that broader scale screening of suicide risk may be considered in light of findings that suicidality can occur even in the absence of major risk factors like depression. We also highlight collaborative care models targeting suicide risk, and recent innovative interventions that aim to prevent the development of suicidal ideation and suicidal behavior.