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Looking back to 1993, the articles published in the American Journal of Geriatric Psychiatry's inaugural issue focused on central questions in geriatric psychiatry-from how age-related changes in brain structure and function affect illness etiology, expression, course, and outcomes(1) to how best to identify and address the unmet mental health needs in different populations of older adult.(2) Today's journal reflects both an enduring commitment to these questions and the growth of the field itself, both in terms of scientific advancement and the breadth of research that is relevant. Thus, questions with pressing clinical and public health significance continue to be addressed but with increasing sophistication in specificity to the questions and the availability of tools to investigate them.

Objectives To determine whether treating depression decreases mortality from various chronic medical conditions. Design Long-term follow-up of multisite-practice randomized controlled trial (Prevention of Suicide in Primary Care Elderly: Collaborative Trial). Setting Twenty primary care practices randomized to intervention or usual care. Participants Individuals aged 60 and older identified through depression screening of random patients (N = 1,226). Intervention For 2 years, a depression care manager worked with primary care physicians in intervention practices to provide algorithm-based care for depression. Measurements Mortality risk based on a median follow-up of 98 months (range 0.8–116.4 months) through 2008; chronic medical conditions ascertained through self-report. Results For heart disease, persons with major depression were at greater risk of death, whether in usual-care or intervention practices. Older adults with major depression and diabetes mellitus in practices randomized to the intervention condition (hazard ratio = 0.47, 95% confidence interval = 0.24–0.91) were less likely to die. For other medical conditions, the point estimates for risk of death in persons with major depression were all in the direction of indicating lower risk in intervention practices but did not reach statistical significance. Conclusion Older adults with depression and medical comorbidity pose a significant clinical and public health challenge. Evidence was found of a statistically significant intervention effect on mortality for diabetes mellitus in persons with major depression.

IMPORTANCE: Collaborative care is an intensive care model involving several health care professionals working together, typically a physician, a case manager, and a mental health professional. Meta-analyses of aggregate data have shown that collaborative care is particularly effective in people with depression and comorbid chronic physical conditions. However, only participant-level analyses can rigorously test whether the treatment effect is influenced by participant characteristics, such as chronic physical conditions.OBJECTIVE: To assess whether the effectiveness of collaborative care for depression is moderated by the presence, type, and number of chronic physical conditions.DATA SOURCES: Data were obtained from MEDLINE, EMBASE, PubMed, PsycINFO, CINAHL Complete, and Cochrane Central Register of Controlled Trials, and references from relevant systematic reviews. The search and collection of eligible studies was ongoing until May 22, 2015.STUDY SELECTION: This was an update to a previous meta-analysis. Two independent reviewers were involved in the study selection process. Randomized clinical trials that compared the effectiveness of collaborative care with usual care in adults with depression and reported measured changes in depression severity symptoms at 4 to 6 months after randomization were included in the analysis. Key search terms included depression, dysthymia, anxiety, panic, phobia, obsession, compulsion, posttraumatic, care management, case management, collaborative care, enhanced care, and managed care.DATA EXTRACTION AND SYNTHESIS: Individual participant data on baseline demographics and chronic physical conditions as well as baseline and follow-up depression severity symptoms were requested from authors of the eligible studies. One-step meta-analysis of individual participant data using appropriate mixed-effects models was performed.MAIN OUTCOMES AND MEASURES: Continuous outcomes of depression severity symptoms measured using self-reported or observer-rated measures.RESULTS: Data sets from 31 randomized clinical trials including 36 independent comparisons (N = 10 962 participants) were analyzed. Individual participant data analyses found no significant interaction effects, indicating that the presence (interaction coefficient, 0.02 [95% CI, -0.10 to 0.13]), numbers (interaction coefficient, 0.01 [95% CI, -0.01 to 0.02]), and types of chronic physical conditions do not influence the treatment effect.CONCLUSIONS AND RELEVANCE: There is evidence that collaborative care is effective for people with depression alone and also for people with depression and chronic physical conditions. Existing guidance that recommends limiting collaborative care to people with depression and physical comorbidities is not supported by this individual participant data meta-analysis.

The research community is placing greater emphasis on understanding geriatric bipolar disorder across a variety of settings, as numerous questions remain unanswered about many aspects of the illness and its impact on patients’ lives (e.g., lifetime course, psychiatric and medical comorbidity, mortality, etc.) (1-3). As the overall population ages in the United States, and as the number of elderly with severe mental illness grows, there is a need to better characterize this population in order to better understand the service needs of this group (4-6). Among the few studies that have been conducted on elderly bipolar disorder patients in community (epidemiological) or clinical outpatient settings, prevalence rates vary between 0.15% and 9%. There have been relatively consistent findings that elderly bipolar disorder patients have significant cognitive and functional impairment. These patients also seem to have less substance abuse than a younger cohort (7, 8). In other health domains, findings have been less consistent. For example, compared to younger patients, elderly bipolar disorder patients appear to use similar inpatient and greater outpatient services in a veterans setting, but less inpatient and outpatient services (except case management) in a community health setting (7, 8). A few studies examining the relationship between symptom severity and age also have had mixed findings: in two separate studies, Young, et al. (9) found no decrease in overall severity with age among a mixed-age sample of manic bipolar disorder patients, but this was in contrast to Broadhead and Jacoby (10), who did find decreased overall severity with age among manic bipolar disorder patients. Given the dearth of information on elderly bipolar disorder patients— and virtually none on those dwelling in Adult Congregate Facilities [(ACFs) described below]— it is important to better characterize the health status and needs of this population. ACF is an umbrella term whose precise definition varies somewhat from state to state, but which generally refers to senior-based housing that is publicly supported, provides apartments, suites and/or rooms for residents receiving some form of state assistance and who may need support in personal care or daily activities (11). Generally, these settings accept residents aged 55 years or older, although younger residents may be accepted if they meet physical or mental disability eligibility requirements. ACFs typically provide unskilled support, such as resident monitoring, congregate meals, and certain personal care services, but do not provide skilled nursing or other medical care. The size and organization of ACFs can vary substantially: while large metropolitan regions and states (e.g., New York, California) may have large ACFs housing up to several hundred residents, ACFs can also consist of small group home settings. For a more detailed description of New York's ACFs, see the New York Department of Health (DOH) website: www.health.ny.gov/facilities/adult_care. In 2002, the state of New York undertook a large evaluation of the state's ACFs due to concerns related to a steady change in the population over the past 30 years: although originally oriented toward supportive care for the elderly, approximately 25–30% of the resident population has a psychiatric disability, with a substantial proportion also having medical comorbidities (11). The state evaluation was initiated in order to better understand the needs of these residents, and to determine if the ACF setting was adequately in meeting those needs (11). Under state contract, New York Presbyterian Hospital conducted evaluations of over 2,600 ACF residents between February 2003 and February 2004, examining a full spectrum of resident health status, preferences, needs, and services. In order to meet the needs of the state contract, a large number of residents had to be assessed within a one-year period of time. A full report of the New York ACF project can be found at: www.health.ny.gov/facilities/adult_care/workgroup_report/10-2002/report.htm. The goal of this analysis was to better characterize the demographic and health-related features of the geriatric bipolar disorder residents of these New York ACFs. Based on chart diagnoses of bipolar disorder, we conducted an estimate of the prevalence of the illness among the full sample of residents. We then analyzed data from a subgroup of 100 residents who were either elderly (age ≥ 60) or young (age 18-49), comparing them across (i) demographic characteristics, (ii) clinical features (cognitive status, chronic disease burden, and medical status), (iii) benefit and service use, and (iv) medication use. Based on other studies of geriatric bipolar disorder and the nature of the adult home population, we expected that the prevalence of bipolar disorder would be 5–9%, with lower education levels than those found in other studies of general or outpatient bipolar populations. We also expected higher rates of cognitive impairment and increased medical burden. Between the two age groups, we expected the elderly sample to have greater cognitive impairment and medical burden; a larger number of services and medications used (and more classes); and greater sensory impairment. Given other studies [e.g., Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)] showing lower lithium use among elderly patients, and the potential for lithium to worsen cognitive status among the elderly, we expected lower rates of lithium use among this group compared to the young cohort (6, 12)

Depression and suicide are major public health concerns, and are often unrecognized among the elderly. This study investigated social inequalities in depressive symptoms and suicidal ideation among older adults.Data come from 1,226 participants in PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial), a large primary care-based intervention trial for late-life depression. Linear and logistic regressions were used to analyze depressive symptoms and suicidal ideation over the 2-year follow-up period.Mean Hamilton Depression Rating Scale (HDRS) scores were significantly higher among participants in financial strain [regression coefficient (b) = 1.78, 95 % confidence interval (CI) = 0.67-2.89] and with annual incomes below $20,000 (b = 1.67, CI = 0.34-3.00). Financial strain was also associated with a higher risk of suicidal ideation (odds ratio = 2.35, CI = 1.38-3.98).There exist marked social inequalities in depressive symptoms and suicidal ideation among older adults attending primary care practices, the setting in which depression is most commonly treated. Our results justify continued efforts to understand the mechanisms generating such inequalities and to recognize and provide effective treatments for depression among high-risk populations.

We sought to examine whether there are patterns of evolving depression symptoms among older primary care patients that are related to prognostic factors and long-term clinical outcomes.Primary care practices were randomly assigned to Usual Care or to an intervention consisting of a depression care manager offering algorithm-based depression care. In all, 599 adults 60 years and older meeting criteria for major depression or clinically significant minor depression were randomly selected. Longitudinal analysis via growth curve mixture modeling was carried out to classify patients according to the patterns of depression symptoms across 12 months. Depression diagnosis determined after a structured interview at 24 months was the long-term clinical outcome.Three patterns of change in depression symptoms over 12 months were identified: high persistent course (19.1% of the sample), high declining course (14.4% of the sample), and low declining course (66.5% of the sample). Being in the intervention condition was more likely to be associated with a course of high and declining depression symptoms than high and persistent depression symptoms (OR = 2.53, 95% CI [1.01, 6.37]). Patients with a course of high and persistent depression symptoms were much more likely to have a diagnosis of major depression at 24 months compared with patients with a course of low and declining depression symptoms (adjusted OR = 16.46, 95% CI [7.75, 34.95]).Identification of patients at particularly high risk of persistent depression symptoms and poor long-term clinical outcomes is important for the development and delivery of interventions.

Little research has been done on the use of antidepressants among homebound older adults, especially low-income homebound older adults, and their perceptions of the effectiveness of their medication. The purposes of this study were to examine self-reported use of antidepressants among depressed homebound older adults, class and type of antidepressants used, individual-level correlates of antidepressant use, and users’ perceptions of the effectiveness of antidepressants. Data on self-reported use of antidepressants were obtained as part of a feasibility study of short-term telehealth problem-solving therapy for depressed low-income homebound adults (n = 162) aged 50 or older. The 24-item Hamilton Rating Scale for Depression (HAMD) was used to assess depression severity. The findings show that about half of the study participants were taking antidepressants, with 26.6% of those on antidepressants rating their medications very effective and 21.5% rating them effective. Female gender was positively, but older age and being Black/African American were negatively associated with the likelihood of antidepressant use. Perceived effectiveness of antidepressants was negatively associated with older age and the HAMD score. The findings suggest that personalized approaches to depression management may be needed in subgroups of depressed older adults, including culturally tailored medication counseling in Black/African-American older adults.

Objectives: Although older adults are often accompanied to routine physician visits and commonly receive disability-related task assistance, the overlap and persistence of this help is not well understood. This study investigates whether older adults who are accompanied to routine physician visits (1) also receive task assistance and (2) continue to be accompanied at 12-months by the same family companion. Design: Observational study. Setting: Nationally representative survey. Participants: Community-dwelling adults aged 65 and older who responded to the Medicare Current Beneficiary Survey (MCBS) in 2006 (n = 11,582) and a subset (n = 7,510) who responded in 2005 and 2006. Measurements: Accompaniment to physician visits by a family companion and receipt of task assistance with activities of daily living (ADLs) or instrumental activities of daily living (IADLs). Persistent accompaniment and consistent family companion involvement was ascertained from 2005 and 2006 survey responses. Results: Among community-dwelling older adults, 18.6% were accompanied to physician visits only, and 12.7% were accompanied to physician visits and received task assistance. Accompanied older adults who received task assistance were older, less educated, and had worse self-rated health than their counterparts who were accompanied only. Family companions who provided task assistance (vs those who did not) were more actively engaged in physician visit processes and more often identified as always present. Three-fourths (74.5%) of accompanied older adults were persistently accompanied to physician visits at 12 months, nearly always (87.9%) by the same family companion. Receipt of task assistance was strongly associated with persistent accompaniment (aOR = 2.52; 95% CI: 1.93�3.29). Conclusions: Older adults� accompaniment to physician visits typically persists, most often by consistently involved family companions. Findings have implications for the patient�physician partnership and the patient-centered medical home.

Objectives Determine rates and demographic, clinical, and functional correlates of antidepressants (ADs) in home healthcare patients. Methods Year 2007 cross-sectional National Home Health and Hospice Care Survey (N = 3,226) of patients 65 years or older (mean 80.11, confidence interval [CI] = 79.65–80.57). Results Overall 33.50% used ADs. Among the 6.76% with depression, 70.84% used ADs compared with 29.15% who used ADs without a documented depression diagnosis. In a regression, controlling for depression, blacks used less ADs than whites (odds ratio [OR] = 0.41, CI=0.24–0.70). Younger age (OR = 0.96, CI=0.94–0.98), activities of daily living impairments (OR = 1.15, CI=1.05–1.26), benzodiazepines (OR = 2.63, CI=1.88–3.69), antipsychotics (OR = 2.08, CI=1.29–3.36), and nonpsychotropics (OR = 1.07, CI=1.04–1.10) were related to AD use. Conclusion Among home healthcare patients, more than one-third took ADs including patients without depression. Blacks used fewer ADs than whites. Increased use was associated with younger age, disability, and nonpsychotropics.

The objective of this study was to test the feasibility, acceptability, and preliminary clinical outcomes of a method to leverage existing home healthcare telemonitoring technology to deliver depression care management (DCM) to both Spanish- and English-speaking elderly homebound recipients of homecare services.Three stand-alone, nonprofit community homecare agencies located in New York, Vermont, and Miami participated in this study. Evidence-based DCM was adapted to the telemonitor platform by programming questions and educational information on depression symptoms, antidepressant adherence, and side effects. Recruited patients participated for a minimum of 3 weeks. Telehealth nurses were trained on DCM and received biweekly supervision. On-site trained research assistants conducted in-home research interviews on depression diagnosis and severity and patient satisfaction with the protocol.An ethnically diverse sample of 48 English- and Spanish-only-speaking patients participated, along with seven telehealth nurses. Both patients and telehealth nurses reported high levels of protocol acceptance. Among 19 patients meeting diagnostic criteria for major depression, the mean depression severity was in the "markedly severe" range at baseline and in the "mild" range at follow-up.Results of this pilot support the feasibility of using homecare's existing telemonitoring technology to deliver DCM to their elderly homebound patients. This was true for both English- and Spanish-speaking patients. Preliminary clinical outcomes suggest improvement in depression severity, although these findings require testing in a randomized clinical trial. Implications for the science and service of telehealth-based depression care for elderly patients are discussed.

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.

The increasing prevalence of depression in elderly home health care patients led to a statewide initiative in Connecticut to enhance evidence-based depression treatment for older adults. A training curriculum on depression screening and interventions was developed and disseminated to 25 home care professionals representing 14 agencies in Connecticut using a train-the-trainer model. Home care trainers included nurses and social workers. This article describes Phase I curriculum design and initial evaluation of the impact of the training on the preparation of trainers to provide depression care education at their home care agencies. Several evaluation measures, including an appraisal of the self-reported attitudes and self-efficacy of home care professionals towards depressed older adults, a pre/post-test to assess the trainers’ knowledge, and willingness of trainers to implement the education program at their agencies were used to assess program outcomes. Participants’ self-efficacy levels in screening and caring for depressed older adults was significantly increased following the education program compared to immediately before the education program (t, (24) = -4.204; p < .001).

Objectives The purpose of this study was to examine the relationship between the severity of baseline depressive symptoms and the problems that low-income homebound older adults (n = 66) identified in their problem-solving therapy (PST) sessions.

Collaborative Care for Depression (CCD) in primary care redesigns care processes to incorporate evidence-based depression treatment guidelines and components of the Chronic Care Model (Wagner 2000; Wagner, Austin, and Von Korff 1996). A central element of the model is a care manager in the clinic who serves as a physician extender and conducts patient assessment, education, follow-ups, and care coordination, largely outside a patient’s visits to his/her primary care physician (PCP) (Schulberg et al. 2001). More than 30 randomized controlled trials have shown that CCD improves depression outcomes, patient adherence to treatment, and satisfaction with care (Gilbody et al. 2006; Neumeyer-Gromen et al. 2004; Williams et al. 2007). The prevailing visit-based fee-for-service physician payment system, however, constitutes a serious disincentive for providing this service (Bachman et al. 2006; Berenson, and Horvath 2003; Unutzer et al. 2006; Wolff, and Boult 2005). Recognizing the importance of a payment mechanism, several recent large-scale implementation initiatives adopted case-rate based payment models to cover the cost of delivering evidence-based CCD. The Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) initiative adopted a flat monthly case rate (Institute for Clinical Systems Improvement 2008). This monthly rate was determined based on the average monthly cost of a 12-month CCD intervention tested in a randomized controlled trial (RCT) known as IMPACT (Improving Mood-Promoting Access to Collaborative Treatment) (Unutzer et al. 2002b). A more recent implementation of the IMPACT model to treat a broader set of behavioral health disorders among community health centers in Washington state adopted a lump sum payment to each clinic covering the cost of the yearlong program, with minimum caseload expectations and 25% of the payment retained to reward providers achieving pre-specified depression treatment and outcome targets. The CCD payment in both initiatives is intended to cover CCD program cost to the clinic that is not covered by the visit-based physician payment. The underlying goals of these pioneering efforts to pay for CCD are twofold: 1) to adequately cover the cost of providing CCD, and 2) to align incentives with the delivery of CCD in a way that leads to better outcomes. The design of such a payment should reflect meaningful variation in resource requirement for evidence-based practice of CCD. In addition, it requires a consideration of incentives associated with a given design, and ways to address or ameliorate related issues. In this paper, we used data from a large randomized controlled trial, the IMPACT study (Unutzer et al. 2002b; Unutzer et al. 2001) to investigate salient and feasible properties of a bundled case rate payment design for CCD. In IMPACT, with close monitoring and guidance from the research team, the CCD intervention protocol was implemented with high fidelity. Meanwhile, participating practices came from diverse community and organizational settings (Unutzer et al. 2001). Delivery of CCD as seen in IMPACT thus represents probably the closest to evidence-based practice in “real-world” implementation where provider adoption of financial strategies is likely to be minimal. This unique feature of the data enables us to identify factors accounting for practically significant variation in resource use of CCD, which then guided our recommendation of two case rate based payment models. We further compared implications for health care organizations in the IMPACT study of alternative payment models..

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.

The growing population of elders is increasing the attention to bipolar disorder (BD) in late life (1, 2). The scant relevant literature highlights the challenges of treating BD in older adults, including greater medical comorbidity and lower tolerance to standard pharmacotherapies than in younger patients (3-6). Evidence specific to geriatric BD is urgently needed (7, 8). While depressive symptoms contribute to reduced quality of life among BD elders (4), there are no published prospective studies of the treatment of geriatric bipolar depression. The challenge of managing bipolar depression in mixed-age populations has been highlighted by previous reports (9-12), and a limited number of medications have been shown to be efficacious for bipolar depression. In addition to the possible precipitation of mania or rapid cycling (13, 14), the addition of multiple psychotropic agents to stabilize mood and treat depression is of concern in older adults due to the risks associated with polypharmacy (15, 16). Lamotrigine was approved by the U.S. Food and Drug Administration for the treatment of epilepsy in 1994, and for the maintenance treatment of BD in 2003. Meta-analysis and meta-regression of monotherapy randomized controlled trials (RCTs) suggest minimal to modest efficacy for lamotrigine in acute bipolar depression (17, 18). However, lamotrigine is widely used in clinical settings for the treatment of bipolar depression, typically in combination with other agents. A recent study of combined lamotrigine and lithium in bipolar depression demonstrated significant improvement and good tolerability in mixed-age adults (19). A literature review and a secondary data-analysis of lamotrigine in older adults with BD (20, 21) suggest that lamotrigine is well tolerated and efficacious, with particular benefit against depressive relapse. The secondary analysis (20) focused on older adults (≥ 55 years) from two placebo-controlled, RCTs evaluating lamotrigine, lithium, and placebo in BD maintenance. There were 638 patients in the double-blind treatment phase including 98 older adults (mean age 61 years, SD = 6.0; range: 55–82 years). Lamotrigine significantly delayed time-to-intervention for depression compared with lithium, while lithium performed better than lamotrigine for time-to-intervention for mania. Side effects for both lamotrigine and lithium were generally time-limited and mild to moderate in intensity, including similar rates of skin rash (3% for lamotrigine, 5% for lithium). Given the positive prospective findings in mixed-age patients and encouraging results in the secondary analysis with older BD patients, we conducted a 12-week, open label trial of lamotrigine in adults age 60 and older with type I or II bipolar depression, assessing its dosing, tolerability, and efficacy. We hypothesized that lamotrigine would be associated with improvement in depressive symptoms and would be well tolerated by these older adults with bipolar depression.

Objective To review the literature on depression in cancer patients with a particular focus on depression assessment and barriers to mental health treatment in older cancer patients. Design We conducted a review of the literature on depression and barriers to mental health treatment in older cancer patients. Results Depression is prevalent in cancer patients. However, little is known about prevalence rates of depression in older adults with cancer, assessing depression in older cancer patients and barriers that impede proper mental health treatment in this sample. Conclusion Improved diagnostic clarity and a better understanding of barriers to mental health treatment can help clarify and facilitate mental health referrals and ultimately improve access to care among older cancer patients in need. Continuing to consider the complexities associated with diagnosing depression in older cancer patients is necessary. Further work may be needed to develop new diagnostic measures for such detection, determine the prevalence of depression among older cancer and ways in which to overcome barriers to mental health care. Copyright © 2010 John Wiley & Sons, Ltd.

There are currently more than 38.9 million people aged 65 an older in the United States. Up to 3.6 million of these people are considered housebound and in need of home-based care. Although homebound status is not defined specifically, with a broad range of disability levels, it is evident that people who are homebound suffer from a multitude of medical and psychiatric illnesses. This review examines the current literature to identify the specific physical and psychiatric factors most responsible for older adults becoming and remaining housebound. Homebound older adults suffer from metabolic, cardiovascular, cerebrovascular, and musculoskeletal diseases, as well as from cognitive impairment, dementia, and depression, at higher rates than the general elderly population. The information in this review will explain the specific types of care the homebound population needs and discuss the care that could help ease their suffering and delay their entry into a nursing home or hospital.

Rates of suicide among veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) rose significantly from 2005 to 2007, adding to existing concerns about veteran suicide risk by the Department of Veterans Affairs. This paper summarizes the available data about risk and rates of suicide in veterans, including the choice of appropriate comparison groups and the identification of risk factors. The data suggest that taking into account the selection bias of who enters the military (known as the healthy soldier effect), rates of suicide in veterans are higher than expected, especially among activity duty OEF/OIF veterans and even more so among those who experienced injuries and trauma. Thus, the experiences of war and the downstream sequelae, in particular the individuals' psychological reactions and societal responses, lead to suicide risk. This paper describes the VA's response to these data in developing and implementing suicide prevention interventions.

Background: Randomized trial evaluated problem-solving therapy in home care (PST-HC) for homebound older adults with cardiovascular disease receiving acute home care services. This study hypothesized that compared with usual care plus education intervention, home-based PST-HC would significantly reduce depression and anxiety scores, lead to improved quality of life, and greater satisfaction with treatment among elderly with cardiovascular disease. Methods: Thirty-eight participants were recruited from a university-affiliated home healthcare agency for the trial. Six 1-hour PST-HC sessions included depression education, problem-solving skills, pleasurable activity scheduling, homework, and weekly telephone calls over a 6-week period. The control comparison group received usual care plus two sessions of education and a depression brochure. Outcome measures included the Beck Depression Inventory, Hamilton Rating Scale for Depression, Beck Anxiety Inventory, and the short form (SF)-36 health status measure. After the intervention, both groups completed the Patient Satisfaction Questionnaire. Results: Compared with the control group, the PST-HC group showed a significant decrease in depression but not anxiety scores. The PST-HC group generally reported more favorable satisfaction with treatment than the control group. The PST-HC group improved significantly, when compared with the control group in only two of eight SF-36 subscales: mental health and emotional role function. Conclusions: The brief PST-HC intervention demonstrated that depression improved among home care elderly. However, there was no change in six of eight health status measures or anxiety level. Authors discuss integrating interdisciplinary depression care in the home care setting.

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: To test the impact of a novel psychosocial intervention to improve antidepressant adherence and depression outcomes among older adults prescribed pharmacotherapy by their primary care physician (PCP). Design: A randomized controlled pilot study was conducted to examine the usefulness of the Treatment Initiation and Participation (TIP) program as an intervention to improve antidepressant adherence and depression outcomes. Setting: The study was conducted at two primary care clinics in New York city: one clinic served geriatric adults and the second clinic served a diverse group of mixed aged adults. Participants: The sample consisted of adults aged 60 years and older with major depression who were recommended antidepressant therapy by their PCPs. Intervention: All participants were prescribed antidepressant therapy and randomly assigned to either the intervention (TIP) or the treatment as usual (TAU) group. The TIP intervention identifies and targets psychological barriers to depression care, especially stigma, as well as fears and misconceptions of depression and its treatment. TIP participants are encouraged to develop a treatment goal and create an adherence strategy. Measurement: Study participants were assessed at entry, 6, 12, and 24 weeks later. Adherence was measured based on self-report with chart verification. Depression severity was measured using the Hamilton Depression Rating Scale. Results: Participants in TIP were significantly more adherent to their antidepressant pharmacotherapy at all assessment time points and had a significantly greater decrease in depressive symptoms than older adults who received TAU. Conclusion: The results provide support for the usefulness of TIP as a brief intervention to improve adherence to depression medication treatment provided in primary care settings.

This report considers the conceptual and methodological concerns confronting clinical investigators seeking to generate knowledge regarding the tolerability and benefits of pharmacotherapy in geriatric bipolar disorder (BD) patients.There is continuing need for evidence-based guidelines derived from randomized controlled trials that will enhance drug treatment of geriatric BD patients. Therefore, we present the complex conceptual and methodological choices encountered in designing a multisite clinical trial and the decisions reached by the investigators with the intention that study findings be pertinent to, and can facilitate, routine treatment decisions.Guided by a literature review and input from peers, the tolerability and antimanic effects of lithium and valproate were judged to be the key mood stabilizers to investigate with regard to treating bipolar I disorder manic, mixed, and hypomanic states. The patient selection criteria are intended to generate a sample that not only experiences common treatment needs but also represents the variety of older patients seen in university-based clinical settings. The clinical protocol guides titration of lithium and valproate to target serum concentrations, with lower levels allowed when necessitated by limited tolerability. The protocol emphasizes initial monotherapy. However, augmentation with risperidone is permitted after three weeks when indicated by operational criteria.A randomized, controlled trial that both investigates commonly prescribed mood stabilizers and maximizes patient participation can meaningfully address high-priority clinical concerns directly relevant to the routine pharmacologic treatment of geriatric BD patients.

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).

OBJECTIVE. In this pilot study of a home-based occupational therapy intervention intended to reduce disability and improve quality of life, our objective was to identify rates of goal attainment and patterns of goal adjustment of participants. METHOD. Thirty older adults with cancer were randomized to the intervention arm, and 24 participants identified goals and completed the six-session intervention. An exploratory content analysis of qualitative and quantitative session data was performed. RESULTS. Participants set 63 6-wk goals and attained 62% of them. Most of the goals addressed walking (28%), sedentary leisure (24%), exercising (16%), or instrumental activities of daily living (14%). When 6-wk goals were not attained (n = 24), there were 10 instances of goal disengagement and 14 instances of goal reengagement. CONCLUSION. Although most participants were able to meet their goals, many also changed their goals and priorities after reflection and attempts to resume or initiate meaningful activities.

This report summarizes the findings and recommendations of an expert consensus workgroup that addressed the endangered pipeline of geriatric mental health (GMH) researchers. The workgroup was convened at the Summit on Challenges in Recruitment, Retention, and Career Development in Geriatric Mental Health Research in late 2007. Major identified challenges included attracting and developing early-career investigators into the field of GMH research; a shortfall of geriatric clinical providers and researchers; a disproportionate lack of minority researchers; inadequate mentoring and career development resources; and the loss of promising researchers during the vulnerable period of transition from research training to independent research funding. The field of GMH research has been at the forefront of developing successful programs that address these issues while spanning the spectrum of research career development. These programs serve as a model for other fields and disciplines. Core elements of these multicomponent programs include summer internships to foster early interest in GMH research (Summer Training on Aging Research Topics-Mental Health Program), research sponsorships aimed at recruitment into the field of geriatric psychiatry (Stepping Stones), research training institutes for early career development (Summer Research Institute in Geriatric Psychiatry), mentored intensive programs on developing and obtaining a first research grant (Advanced Research Institute in Geriatric Psychiatry), targeted development of minority researchers (Institute for Research Minority Training on Mental Health and Aging), and a Web-based clearinghouse of mentoring seminars and resources (MedEdMentoring.org). This report discusses implications of and principles for disseminating these programs, including examples of replications in fields besides GMH research.

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.

Although depressive symptoms in older persons are common, their association with disability burden is not well understood. The authors evaluated the association between level of depressive symptoms and severity of subsequent disability over time and determined whether this relationship differed by sex.Participants included 754 community-living persons aged 70 years or older who underwent monthly assessments of disability in four essential activities of daily living for up to 117 months. Disability was categorized each month as none, mild, and severe. Depressive symptoms, assessed every 18 months, were categorized as low (referent group), moderate, and high. Multinomial logit models invoking Generalized Estimating Equation were used to calculate odds ratios and 95% confidence intervals.Moderate (odds ratio = 1.30; 95% confidence interval: 1.18-1.43) and high (odds ratio = 1.68; 95% confidence interval: 1.50-1.88) depressive symptoms were associated with mild disability, whereas only high depressive symptoms were associated with severe disability (odds ratio = 2.05; 95% confidence interval: 1.76-2.39). Depressive symptoms were associated with disability burden in both men and women, with modest differences by sex; men had an increased likelihood of experiencing severe disability at both moderate and high levels of depressive symptoms, whereas only high depressive symptoms were associated with severe disability in women.Levels of depressive symptoms below the threshold for subsyndromal depression are associated with increased disability burden in older persons. Identifying and treating varying levels of depressive symptoms in older persons may ultimately help to reduce the burden of disability in this population.

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.

OBJECTIVES: To estimate the effect of an evidence-based depression care management (DCM) intervention on the initiation and appropriate use of antidepressant in primary care patients with late-life depression. DESIGN: Secondary analysis of data from a randomized trial. SETTING: Community, primary care. PARTICIPANTS: Randomly selected individuals aged 60 and older with routine appointments at 20 primary care clinics randomized to provide a systematic DCM intervention or care as usual. METHODS: Rates of antidepressant use and dose adequacy of patients in the two study arms were compared at each patient assessment (baseline, 4, 8, and 12 months). For patients without any antidepressant treatment at baseline, a longitudinal analysis was conducted using multilevel logistic models to compare the rate of antidepressant treatment initiation, dose adequacy when initiation wasfirst recorded, and continued therapy for at least 4 months after initiation between study arms. All analyses were conducted for the entire sample and then repeated for the subsample with major or clinically significant minor depression at baseline. RESULTS: Rates of antidepressant use and dose adequacy increased over the first year in patients assigned to the DCM intervention, whereas the same rates held constant in usual care patients. In longitudinal analyses, the DCM intervention had a significant effect on initiation of antidepressant treatment (adjusted odds ratio (OR) 55.63, Po.001) and continuation of antidepressant medication for at least 4 months (OR 56.57, P 5.04) for patients who were depressed at baseline. CONCLUSIONS: Evidence-based DCM models are highly effective at improving antidepressant treatment in older primary care patients. J Am Geriatr Soc 57:895–900, 2009.

OBJECTIVES: To examine the associations between major and minor depression and categories of Medicare home healthcare use. DESIGN: Observational prospective study (1997–1999). SETTING: Visiting nurse agency in suburban New York State. PARTCIPANTS: Five hundred thirty-nine new Medicare admissions aged 65 and older (mean age 78.4), 65.1% female, and 15.0% nonwhite. Approximately 13.5% were diagnosed with major depression and another 10.8% with minor depression. MEASUREMENTS: Consensus “best estimate”Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses for major and minor depression assessed using Structured Clinical Interviews for DSM-IV (SCID) plus medical charts. RESULTS: Major and minor depression appear to have little association with probability and amount of use of the types of Medicare home health care (skilled nurse, home health aide, therapist (physical, occupational, and speech), and medical social services). Overall, patients with minor depression appear to have utilization similar to that of patients with major depression. CONCLUSION: It seems likely that any potential incremental depression effect on utilization is being offset by the transitional medical state of the patients that entered Medicare home healthcare directly from a hospital, nursing home, or rehabilitation facility, and the overall severity of disability and chronic illness present in long-term home healthcare patients. Further research is required to determine whether similar findings occur in other home healthcare agencies and whether these are present under the current Medicare Prospective Payment System reimbursement mechanism.

The authors examined the association of treatment preferences with treatment initiation, adherence, and clinical outcome among nonsenior adult and senior primary care patients with depression.Sixty primary care participants meeting DSM-IV criteria for major depression were randomly assigned to receive treatment congruent or incongruent with their primary stated preference. Participants received either 20 weeks of escitalopram, with monitoring by a care manager, or 12 weekly sessions of interpersonal psychotherapy followed by two monthly booster sessions. Adherence to treatment and depression severity were reassessed at weeks 4, 8, 12, and 24.Participants expressed stronger preferences for psychotherapy than for antidepressant medication. Preference strength was a more sensitive measure of outcome than was congruence versus incongruence of preference with the assigned treatment. Across age groups, preference strength was significantly associated with treatment initiation and 12-week adherence rate but not with depression severity or remission.A continuous measure of preference strength may be a more useful measure in clinical practice than preferences per se. Future research should focus on whether and how greater facilitation of the treatment decision-making process between patient and clinician influences clinical outcome.

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.

Because falls are highly prevalent, harmful events for older adults, identification of patients at risk is a high priority for home health care agencies. Using routine administrative data, we demonstrated that patients with depressive symptoms on the Outcome and Assessment Information Set are at risk for falls. A prospective case-control study that matched 54 patients who experienced an adverse fall with 854 controls showed that patients who fell had twice the odds of being depressed (odds ratio = 1.90, 95% confidence interval = 1.01 to 3.59). Bowel incontinence, high medical comorbidity, stair use, injury and poisoning, memory deficit, and antipsychotic medication use were also predictors, but no association was found for antidepressant medications. These data suggest the potential benefit of including depression screening for multifactorial fall prevention interventions.

This study examined the rate and predictors of major depression six months after outpatient mental health admission.Assessments were conducted at admission and three and six months later among 166 participants. Antidepressant treatment adequacy and depression outcomes were assessed at follow-ups.Predictors of major depression at six months included nonremission status at three months (odds ratio [OR]=3.56, p=.003), inadequacy of early pharmacotherapy (OR=2.73, p=.009), worse physical functioning measured by the 36-Item Short-Form Health Survey (OR=.975, p.001), and being unmarried (OR=2.54, p=.031).The findings support the effects of baseline physical disability, marital status, early treatment adequacy, and early remission on the course of major depression. The identification of individuals who do not receive intensive pharmacotherapy or who have not recovered by three months may provide opportunities for interventions to optimize six-month outcomes and to prevent the development of a persistent depression.

Objectives: The objectives of this pilot study were to determine the incidence of Posttraumatic Stress Disorder (PTSD) one to two months after Myocardial Infarction (MI), and to evaluate potential predictors of PTSD symptoms post-MI. Methods: A convenience sample of 31 patients hospitalized for treatment of acute MI was interviewed during hospitalization and one to two months later. The assessments included socio-demographic questions, questions related to clinical history and hospitalization, assessment of depressive symptoms using the Center for Epidemiologic Studies— Depression (CES-D) scale, medical comorbidity using the Charlson Comorbidity Index (CCI), and perceived social support using the Medical Outcomes Study (MOS) scale. Medical records were reviewed for collection of clinical data. Symptoms of PTSD were evaluated using the Structured Clinical Interview for DSM-IV (SCID) and the Impact of Events Scale-Revised (IES-R). Results: While one patient (4.0%) met DSM IV criteria for PTSD; additional 16% of the patients had significant symptoms of PTSD as measured by the IES-R (scoring above 24). Higher scores of PTSD symptoms were significantly associated ( p < 0.05) with younger age, black race, depressive symptoms in baseline, and self-reported anxiety during the MI. Conclusions: The incidence of PTSD following MI was low, but 16% of MI patients developed subsyndromal PTSD. The emotional status of the patients at the time of the MI and their subjective reaction to the event were important factors in the development of PTSD symptoms. Black and younger patients were in increased risk of developing PTSD symptoms post-MI.

There are over 260,000 religious congregations in the United States. They and their clergy are de facto providers of mental health care. Recent models promoting collaboration between clergy and psychologists advocate that shared religious values underlie effective working relationships. This view may impede collaboration with the majority of psychologists, who are not religious, excluding congregants from needed expertise. The Clergy Outreach and Professional Engagement (C.O.P.E.) model was developed and implemented to facilitate continuity of care across a diversity of caregivers. Handouts based on National Institute of Mental Health prevention science categories and case examples illustrate when and how clergy and clinicians would collaborate. The authors introduce and define the term burden reduction to describe a C.O.P.E. outcome. They consider this clinical work religion inclusive rather than faith based.

OBJECTIVE—We sought to test our a priori hypothesis that depressed patients with diabetes in practices implementing a depression management program would have a decreased risk of mortality compared with depressed patients with diabetes in usual-care practices. RESEARCH DESIGN AND METHODS—We used data from the multisite, practice-randomized, controlled Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), with patient recruitment from May 1999 to August 2001, supplemented with a search of the National Death Index. Twenty primary care practices participated from the greater metropolitan areas of New York City, New York; Philadelphia, Pennsylvania; and Pittsburgh, Pennsylvania. In all, 584 participants identified though a two-stage, age-stratified (aged 60–74 or ≥75 years) depression screening of randomly sampled patients and classified as depressed with complete information on diabetes status are included in these analyses. Of the 584 participants, 123 (21.2%) reported a history of diabetes. A depression care manager worked with primary care physicians to provide algorithm-based care. Vital status was assessed at 5 years. RESULTS—After a median follow-up of 52.0 months, 110 depressed patients had died. Depressed patients with diabetes in the intervention category were less likely to have died during the 5-year follow-up interval than depressed diabetic patients in usual care after accounting for baseline differences among patients (adjusted hazard ratio 0.49 [95% CI 0.24–0.98]). CONCLUSIONS—Older depressed primary care patients with diabetes in practices implementing depression care management were less likely to die over the course of a 5-year interval than depressed patients with diabetes in usual-care practices.

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.

Objective The authors present data from a pilot research program initiated to develop, refine, and test the outcomes of Brief Problem-Solving Therapy in Home Care (PST-HC) that targets the needs of older adults identified with severe depressive symptoms in an acute home care setting. Methods A pilot randomized clinical trial compared the impact of PST-HC to usual care (UC) in a sample of older medically ill home care patients identified with severe depressive symptoms. Forty patients were randomly assigned to either six weekly sessions of PST-HC in their home or standard home care services. Depression, quality of life, and problem-solving ability were measured at baseline, posttreatment, three-month follow-up, and six-month follow-up by blinded evaluators. Results All 40 patients provided follow-up data. No differences between the two groups were found on any demographic variables. Outcome data suggested significant improvements in depression scores over time after PST-HC, relative to UC. PST-HC patients reported higher quality of life and problem-solving ability scores relative to UC. Conclusion Results suggest that PST-HC is well tolerated and holds promise for reducing persistent depressive symptoms. The authors discuss limitations in terms of the "real-world" applicability of this psychosocial treatment for late-life depression.

Objectives To present findings from an expert panel–informed literature review on community-based treatment of late-life depression. Methods A systematic literature review was conducted to appraise publications on community-based interventions for depression in older adults. The search was conducted between March and October 2005. An expert panel of mental health, aging, health services, and epidemiology researchers guided the review and voted on quality and effectiveness of these interventions. Results A total of 3543 articles were found with publication dates from 1967 to October 2005; of these, 116 were eligible for inclusion. Adequate data existed to determine effectiveness for the following interventions: depression care management, group and individual psychotherapy for depression, psychotherapy targeting mental health, psychotherapy for caregivers, education and skills training (to manage health problems besides depression; and for caregivers), geriatric health evaluation and management, exercise, and physical rehabilitation and occupational therapy. After reviewing the data, panelists rated the depression care management interventions as effective. Education and skills training, geriatric health evaluation and management, and physical rehabilitation and occupational therapy received ineffective ratings. Other interventions received mixed effectiveness ratings. Insufficient data availability and poor study quality prevented the panelists from rating several reviewed interventions. Conclusions While several well-described interventions were found to treat depression effectively in community-dwelling older adults, significant gaps still exist. Interventions that did not target depression specifically may be of benefit to older adults, but they should not be presumed to treat depression by themselves. Treating depressed elders may require a multifaceted approach to ensure effectiveness. More research in this area is needed.

This study explored tensions between biomedical and psychosocial illness models and between the public health goal of stigma reduction and patients' perceptions of helplessness. Patients' etiological beliefs and use of language are considered as possible pathways to improved care.Qualitative and quantitative data were obtained from 18 adults attending a mood disorders support group in Dublin, Ireland.Respondents reported feelings of helplessness concerning the occurrence of depressive episodes. When describing episodes of wellness and depression, respondents used a "light switch" metaphor to indicate this lack of control. For several respondents, acceptance of biomedical causality was linked to helplessness. In contrast, spiritual beliefs offered hope.Alleviating patients' sense of responsibility may reduce their guilt, but patients' perceptions of illness uncontrollability may diminish their sense of agency, reinforce depressive attributional styles, and undermine overall treatment outcomes. Communication and the patients' involvement in decisions are vital to treatment.

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.

Depression is common in older home health patients and increases their risk of adverse outcomes. Depression screening is required by Medicare's Outcome and Assessment Information Set. The Depression Care for Patients at Home (CAREPATH) was developed as a feasible strategy for home health nurses to manage depression in their patients. The protocol builds on nurses' existing clinical skills and is designed to fit within routine home visits. Major components include ongoing clinical assessment, care coordination, medication management, education, and goal setting. In a randomized trial, Depression CAREPATH patients had greater improvement in depressive symptoms compared to usual care. The difference between groups was significant at 3 months, growing larger and more clinically meaningful over 1 year. The intervention had no impact on patient length of stay, number of home visits, or duration of visits. Thus, nurses can play a pivotal role in the long-term course and outcomes of patients with depression. [ Journal of Psychosocial Nursing and Mental Health Services, 53 (11), 25–30.]

The study assessed gaps between published best practices and real-world practices of treating depression in home health care (HHC) and barriers to closing gaps.The qualitative study used semistructured interviews with nurses and administrators (N=20) from five HHC agencies in five states. Audio-recorded interviews were transcribed and analyzed by a multidisciplinary team using grounded theory method to identify themes.Routine HHC nursing overlapped with all functional areas of depression care. However, gaps were noted between best and real-world practices. Gaps were associated with perceived scope of practice by HHC nurses, knowledge gaps and low self-efficacy in depression treatment, stigma attached to depression, poor quality of antidepressant management in primary care, and poor communication between HHC and primary care clinicians.Strategies to close gaps between typical and best practices include enhancing HHC clinicians' knowledge and self-efficacy with depression treatment and improving the quality of antidepressant management and communication with primary care.

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.

OBJECTIVE: Depression screening has been widely implemented in community settings to increase detection of late-life depression. However, the rates of treatment initiation are low without additional structured follow-up. The current study evaluates the effectiveness of a brief psychosocial intervention, Open Door, designed to improve initiation of mental health treatment among clients of aging service meals programs. DESIGN: Older adult social service clients with depressive symptoms were randomized to either the Open Door intervention or a Service Referral control condition. In Open Door, the counselor collaborates with the client to identify and address both attitudinal and structural barriers to seeking mental health treatment. Independent research assessments were conducted 12 and 24 weeks after baseline to document treatment initiation (at least one session). RESULTS: At follow up, 64.6% (104/161) of participants had initiated a provider visit. Participants in Open Door participants were more likely to initiate treatment compared to those adults in the control condition (χ(2)=5.83, df=2, p=.016). Among participants with at least mild depressive symptoms, Open Door remained significantly more effective than the control condition (p

Two-thirds of older adults have two or more medical conditions that often take precedence over depression in primary care. We evaluated whether evidence-based depression care management would improve the long-term mortality risk among older adults with increasing levels of medical comorbidity. Longitudinal analyses of the practice-randomized Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT). Twenty primary care practices randomized to intervention or usual care. The sample included 1204 older primary care patients completing the Charlson Comorbidity Index (CCI) and other interview questions at baseline. For 2 years, a depression care manager worked with primary care physicians to provide algorithm-based care for depression, offering psychotherapy, increasing the antidepressant dose if indicated, and monitoring symptoms, medication adverse effects, and treatment adherence. Depression status based on clinical interview, CCI to evaluate medical comorbidity, and vital status at 8 years (National Death Index). In the usual care condition, patients with the highest levels of medical comorbidity and depression were at increased risk of mortality over the course of the follow-up compared to depressed patients with minimal medical comorbidity [hazard ratio 3.02 (95 % CI, 1.32 to 8.72)]. In contrast, in intervention practices, patients with the highest level of medical comorbidity and depression compared to depressed patients with minimal medical comorbidity were not at significantly increased risk [hazard ratio 1.73 (95 % CI, 0.86 to 3.96)]. Nondepressed patients in intervention and usual care practices had similar mortality risk. Depression management mitigated the combined effect of multimorbidity and depression on mortality. Depression management should be integral to optimal patient care, not a secondary focus.

OBJECTIVES: To identify the prevalence, correlates, and one-year naturalistic course of suicidal ideation in a representative sample of elderly adults newly admitted to visiting nurse homecare. METHOD: Five hundred and thirty-nine participants (aged >/= 65), newly initiating homecare for skilled nursing services, were interviewed with the Structured Clinical Interview for DSM-IV (SCID-IV) and measures of depression severity, medical comorbidity, functional status, and social support. Participants were classified as having no suicidal ideation in the past month, passive ideation, active ideation, or active ideation with poor impulse control or suicide plan. RESULTS: Fifty-seven participants (10.6%) reported passive and six (1.2%) reported active suicidal ideation. Higher depression severity, greater medical comorbidity, and lower subjective social support were independently associated with the presence of any level of suicidal ideation. At one year, suicidal ideation persisted for 36.7% of those with ideation at baseline, and the incidence of suicide ideation was 5.4% CONCLUSIONS: The high prevalence, persistence, and incidence of suicidal ideation in medically ill home healthcare patients underscore the relevance of this population for suicide prevention efforts. The clinical and psychosocial factors associated with suicidal ideation in this underserved, high-risk population are potentially modifiable, and thus useful targets for suicide prevention interventions. Language: en