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OBJECTIVE: This pilot study tests the usefulness of the Treatment Initiation Program (TIP) to improve depression in older adults. The TIP is an individualized, early intervention to address older adults’ attitudes (e.g., perceived need for care and stigma) about depression and treatment. METHOD: Older adults with major depression seeking mental health treatment were randomly assigned to either pharmacotherapy alone or with the TIP. Severity was assessed with the Hamilton Depression Rating Scale at admission and at 6, 12, and 24 weeks. Mixed-effects models were calculated to evaluate the effects of the TIP. RESULTS: In mixed-effects models, TIP patients had a greater decrease in depression severity and reported less hopelessness than the patients receiving usual care. TIP patients were more likely to remain in treatment 12 and 24 weeks after seeking care. CONCLUSIONS: These data support the usefulness of the TIP to improve depression outcomes and treatment participation among older adults.

Despite their high rates of depression, homebound older adults have limited access to evidence-based psychotherapy. The purpose of this paper was to report both depression and disability outcomes of telehealth problem-solving therapy (tele-PST via Skype video call) for low-income homebound older adults over 6 months postintervention.A 3-arm randomized controlled trial compared the efficacy of tele-PST to in-person PST and telephone care calls with 158 homebound individuals who were aged 50+ and scored 15+ on the 24-item Hamilton Rating Scale for Depression (HAMD). Treatment effects on depression severity (HAMD score) and disability (score on the WHO Disability Assessment Schedule [WHODAS]) were analyzed using mixed-effects regression with random intercept models. Possible reciprocal relationships between depression and disability were examined with a parallel-process latent growth curve model.Both tele-PST and in-person PST were efficacious treatments for low-income homebound older adults; however the effects of tele-PST on both depression and disability outcomes were sustained significantly longer than those of in-person PST. Effect sizes (dGMA-raw ) for HAMD score changes at 36 weeks were 0.68 for tele-PST and 0.20 for in-person PST. Effect sizes for WHODAS score changes at 36 weeks were 0.47 for tele-PST and 0.25 for in-person PST. The results also supported reciprocal and indirect effects between depression and disability outcomes.The efficacy and potential low cost of tele-delivered psychotherapy show its potential for easy replication and sustainability to reach a large number of underserved older adults and improve their access to mental health services.

Subjects from the Epidemiologic Catchment Area Program, interviewed during 1979–1983, were linked to data in the National Death Index through 2007 to estimate the association of mental and behavioral disorders with death. There were more than 25 years of follow-up for 15,440 individuals, with 6,924 deaths amounting to 307,881 person-years of observation. Data were analyzed by using age as the time scale and parametric approaches to quantify the years of life lost due to disorders. Alcohol, drug use, and antisocial personality disorders were associated with increased risk of death, but there was no strong association with mood and anxiety disorders. Results of high- and low-quality matches with the National Death Index were similar. The 3 behavioral disorders were associated with 5–15 years of life lost, estimated along the life course via the generalized gamma model. Regression tree analyses showed that risk of death was associated with alcohol use disorders in nonblacks and with drug disorders in blacks. Phobia interacted with alcohol use disorders in nonblack women, and obsessive-compulsive disorder interacted with drug use disorders in black men. Both of these anxiety disorders were associated with lower risk of death early in life and higher risk of death later in life.

This study examined the prevalence and associates of anxiety symptoms in older home health care recipients (N = 249) who completed structured interviews assessing sociodemographic, cognitive, medical and disability, and psychosocial variables--including anxiety (assessed by the Clinical Anxiety Scale). Mild or moderate anxiety was reported by 3.6% of the sample. No anxiety symptoms whatsoever were reported by 63.9%, while the remaining endorsed at least one symptom. Binary logistic regression analysis revealed that the odds of having any anxiety were elevated among participants who had had a recent fall, OR = 2.81, 95% CI [1.46, 5.43]; and those with major depression, OR = 4.78, 95% CI [1.46, 15.68]. These findings point to the importance of conducting studies to clarify whether the mild severity of anxiety found in this sample is best accounted for by protective factors inherent to the home health care setting or assessment factors that diminish the reporting of anxiety symptoms.

Major depression is disproportionately common among elderly adults receiving home healthcare and is characterized by greater medical illness, functional impairment and pain. Depression is persistent in this population and is associated with numerous poor outcomes such as increased risk of hospitalization, injury-producing falls and higher healthcare costs. Despite the need for mental healthcare in these patients, significant barriers unique to the home healthcare setting contribute to the underdetection and undertreatment of depression. Intervention models target the home healthcare nurse as liaison between patients and physicians, and instruct in the identification and management of depression for their patients. Successful implementation requires interventions that ‘fit’ how home healthcare is organized and practiced, and long distance implementation strategies are required to increase the reach of these interventions.

The objective of this study is to determine the racial/ethnic effect of depression symptom recognition by home healthcare nurses.This is a secondary analysis of administrative data from a large urban home healthcare agency. Patients' age were 65 years and older with a valid depression screen, identified as Caucasian, African American, or Hispanic and admitted to homecare in 2010 (N = 3711). All demographic and clinical information were obtained from the electronic medical record.Subjects were 29.34% Caucasian, 37.81% African American, and 32.85% Hispanic. About 6.52% had a formal chart diagnosis of depression, and 13.39% received antidepressant therapy. The rates of positive depression screens by nurses were higher in Caucasians than that of in African Americans or Hispanics (13.41% vs. 9.27% vs. 10.99%; χ(2) = 10.70, df [degrees of freedom] = 2; p 0.01). Depression screening rates were then stratified by the number of clinical indicators from the chart (depression diagnosis or antidepressant on medication list). The proportion of positive screen increased for minorities with an increase in the number of indicators. African Americans had significantly greater positive screens with two indicators compared with that of the Caucasians and Hispanics (50.00% vs. 23.81% vs. 35.59%; χ(2) = 6.65, df = 2; p = 0.04).These findings show a wide range of variation in screening for depression among ethnic groups. The rates increase for minorities with the presence of increased clinical indicators, suggesting that nurses may screen higher in minorities when there is higher clinical suspicion. Future research in home healthcare should be aimed at training nurses to conduct culturally tailored depression screening to improve management of depression in older minorities.

Objective Determine the racial/ethnic effect on depression treatment among home healthcare patients. Design Cross-sectional analyses of administrative data. Setting A large home healthcare agency in Bronx, NY. Participants Patients 65 years and older admitted to homecare in 2010 (N = 3,744). Measurements Patient Health Questionnaire (PHQ)-2 depression screen. Other data, such as diagnosis, medications, and demographics, were collected from the patient electronic medical record. Results 6.52% of the sample had a depression diagnosis, 11.11% screened positive for depression (+PHQ-2), and 13.39% were prescribed antidepressants. The odds of receiving an antidepressant among those who screened positive for depression were 0.42 (95% confidence interval [CI]: 0.22–0.79) for African Americans and 0.49 (95% CI: 0.26–0.93) for Hispanics compared with Caucasians. Conclusions These findings suggest that disparities continue to exist in depression treatment for older minority home healthcare patients compared with older Caucasians.

BACKGROUND:: Economic disadvantage is associated with depression and suicide. We sought to determine whether economic disadvantage reduces the effectiveness of depression treatments received in primary care. METHODS:: We conducted differential-effects analyses of the Prevention of Suicide in Primary Care Elderly: Collaborative Trial, a primary-care-based randomized, controlled trial for late-life depression and suicidal ideation conducted between 1999 and 2001, which included 514 patients with major depression or clinically significant minor depression. RESULTS:: The intervention effect, defined as change in depressive symptoms from baseline, was stronger among persons reporting financial strain at baseline (differential effect size = -4.5 Hamilton Depression Rating Scale points across the study period [95% confidence interval = -8.6 to -0.3]). We found similar evidence for effect modification by neighborhood poverty, although the intervention effect weakened after the initial 4 months of the trial for participants residing in poor neighborhoods. There was no evidence of substantial differences in the effectiveness of the intervention on suicidal ideation and depression remission by economic disadvantage. CONCLUSIONS:: Economic conditions moderated the effectiveness of primary-care-based treatment for late-life depression. Financially strained individuals benefited more from the intervention; we speculate this was because of the enhanced treatment management protocol, which led to a greater improvement in the care received by these persons. People living in poor neighborhoods experienced only temporary benefit from the intervention. Thus, multiple aspects of economic disadvantage affect depression treatment outcomes; additional work is needed to understand the underlying mechanisms. Language: en

This paper examines the lifetime prevalence and correlates of major depressive disorder in a cohort of former school-age mothers and compares the prevalence and correlates to those found in women of the same age, ethnicity, and geographical location as the school-age mothers. The sociodemographic characteristics show some striking differences. The former young mothers were less likely to be on public assistance (19% vs. 42%), but were more likely to be working (78% vs. 55%), to have completed high school or college and to meet the DSM-III criteria for depression (10.7% vs. 4.9%) than the sample of community women. The only factor related to depression in the former school-age mothers was a diagnosis of drug/alcohol abuse or dependence.

The relationship between social network structural and support characteristics and onset of new or recurrent activities of daily living (ADL) disability was examined in a cohort of older men and women. No significant protective effects were found for network structural or support characteristics. However, greater frequency of instrumental support was associated with significantly increased risk of ADL disability among men; a similar though nonsignificant pattern was seen among women. These findings indicate that receipt of more instrumental support may not have uniformly beneficial effects on functional status. They serve to underscore the need for more comprehensive research, examining both the positive and negative effects of social interactions on health and functioning. W ITH the ongoing and rapid growth of the oldest seg

The high comorbidity of medical illnesses and late life depression poses both challenges and opportunities. Challenges in assessment techniques, diagnosis, and specific prognosis affect clinical care and research methodology alike. However, investigations that turn this vexing "confound" into research questions may prove fruitful. For clinicians working with older persons, recognizing the prognostic import of comorbid medical illnesses in late-life depression is essential to treatment planning. This comorbidity also poses difficulties in diagnosing depression inasmuch as symptoms of the medical conditions may overlap with those of an affective disorder. Symptom assessments must strike a balance between overly inclusive (e.g., mistakenly treating the psychomotor slowing of Parkinson's disease as depression) and overly exclusive (e.g., erroneously dismissing the patient's mood symptoms as "understandable"). Clinicians also should be sensitive to the broad range of symptomatic presentations with varying severities of both mood and medical disorders, as exemplified by variability across treatment settings. For researchers, similar issues are of relevance in planning investigative strategies. Consideration should be given to the following: 1. Case identification is a crucial first step; the approach to depressive symptoms potentially confounded by medical illnesses must be defined explicitly. Choice of an inclusive approach avoids premature exclusion of relevant phenomena; exploratory analyses can examine the effects of other approaches to the relationships of interest. 2. The use of similar research instruments across sample sites would greatly facilitate comparisons of results. Each subject group offers its own "leverage" for answering particular questions. Psychiatric inpatients will highlight the contributions of severe psychopathology (useful, for example, in identifying biologic markers). Medical inpatients are well suited to studies examining validity of different approaches to case identification, investigating health service utilization, or highlighting the contribution of acute, severe, life-threatening medical disorders to affective illness. Long-term care residents lend themselves to issues that benefit from compression of health processes over time. Medical outpatients have many advantages regarding generalizability and public health significance. Community samples are needed to determine the biases of all the above groups, which are each defined by service utilization. 3. Study of the relationships between depression and medical illness may further understanding of pathogenic mechanisms in late life mood disorders. Research questions might be guided by the biopsychosocial conceptual context described above. On the one hand, this context demands multidimensional study methodology to identify the routes by which medical illness influences depression in particular patient groups. Multivariate models should examine direct and indirect effects of medical illness on depression while, at the same time, considering intervening variables such as functional disability, personality, and social support. Guided multiple regressions or structural equation modeling will allow for determination of strengths of associations. 4. At the same time, and of particular importance if complex multivariate analyses are used, specific theoretic models should help direct focused investigations. The development and testing of such models is a major challenge that should be addressed by current research. Finally, from a societal perspective, the comorbidity of depression and medical illness likely has a tremendous impact on both health and health care delivery for older adults. Further study is needed to identify more specific approaches to treatment. Yet existing data clearly support a policy of routine psychiatric assessment of older people in general medical settings...

Much of the research on geriatric bipolar disorder is from outpatient populations or epidemiological surveys with small samples. In contrast, in this study a descriptive analysis was conducted of geriatric and younger adult residents with bipolar disorder or mania in non-clinical adult congregate facilities (ACFs) in the greater New York City region.A total of 2602 ACF residents were evaluated in 19 facilities, across multiple demographic and health domains. Within this sample, 200 residents had chart diagnoses of bipolar disorder or mania. Among these, 50 geriatric residents (age ≥ 60) were compared to 50 younger adult residents (age50) on a number of demographic and health measures. Based on chart diagnoses, the overall prevalence of bipolar disorder was 7.8%. Compared to other studies of outpatient, epidemiological, and census samples, both older and younger residents with bipolar disorder had higher rates of cognitive impairment, impairment in executive functioning, vision impairment, and proportion of residents who had never been married. The younger group also had higher rates of obesity and the elderly group had a greater proportion of residents without high-school education. Both age groups had rates of lithium or valproate use comparable to those found in outpatient studies. Comparing the two age groups, the elderly sample had lower overall cognitive and executive functioning, and was using a larger number of medication classes than the younger group. The elderly group also had a larger proportion of residents who were separated/divorced or widowed compared to the younger group, which had higher rates of never-married residents.Overall, both age groups had relatively high rates of bipolar disorder, with significant cognitive impairment, medical burden, obesity, mental health service use, and lower education levels, as compared to outpatient, epidemiological, and census samples. Of note was the significant cognitive impairment across age groups.

Objective The objective is to provide information on successful programs providing home-based services to mentally ill elderly in order to assist other communities wishing to establish such programs. Participants The ten programs described in this article were selected by peer review from applications for an award given by the American Association for Geriatric Psychiatry and were participants in an invitational conference. Results Eight of the programs were components of a community agency and two were components of a medical school department of psychiatry. Six of the programs focused primarily on individuals with anxiety and depression and utilized a range of individual psychotherapies. The other four accepted patients with any psychiatric diagnosis including dementia and included medication management as part of their services. The numbers served by the ten programs ranged from about 50 to 300 new cases per year, and the staffing ranged from 2 to 13 often with a combination of full and part time. The annual budget for the ten programs ranged from $30,000 to $1,250,000. Budget sources usually included some combination of public funds, philanthropy, and fee-for-service income. Conclusions Despite the logistic and fiscal challenges of providing home-based services to mentally ill older adults there are many long-standing successful programs that can serve as models for communities wishing to establish similar programs. A great opportunity exists for a unified outcome research endeavor as well as expansion into many more communities.

To the sociologist, perhaps the single most important characteristic of the psychiatric perspective is that psychiatry views mental illness as a real illness, as distinct from being a socially constructed myth. Whereas some social perspectives might argue that “mental illness” is a label applied by society or social groups to subsets of unusual, unappealing, or disruptive behaviors and feelings, the psychiatric perspective would argue that these behaviors and feelings are themselves the signs and symptoms of true underlying disease or disorder states. Psychiatry uses the term mental illness for a spectrum of syndromes that are classified by clusters of symptoms and behaviors considered clinically meaningful in terms of course, outcome, and response to treatment. The purpose of this chapter is to describe how psychiatry defines and organizes these syndromes and to identify the kinds of clinical features associated with the syndromes most relevant to sociological inquiry. The overall goal is to show how the psychiatric perspective of mental illness encompasses more than a single dichotomous category—indeed, even more than a series of dichotomous diagnoses—for use as outcome variables. Rather, psychiatric notions of heterogeneity along a number of clinical axes within and among psychiatric disorders offer considerable richness to a sociological understanding of the risks and outcomes of mental illness.

The Authors Reply: —We are pleased to respond to Dr. Lau and Ms. Dwyer’s letter. Dr. Lau and Ms. Dwyer point out that the validity of using the Beers list to evaluate prescribing quality among patients receiving end-of-life (EOL) care is questionable. They raise concerns about our examination of potentially inappropriate medication (PIM) without distinguishing between patients receiving and not receiving EOL care in the home health setting. We agree with Dr. Lau and Ms. Dwyer that, given the different needs and treatment goals between the two patient populations, medication appropriateness should be examined by EOL status. In response, we conducted the same analysis as reported in our article, but stratified by EOL status. To define EOL status, we used a variable in the survey indicating that the patient had a life expectancy of 6 months or less or was receiving palliative/EOL care. Consistent with Lau and Dwyer, we estimated that a weighted 15.7% of our original study population were EOL patients. Estimated rate of PIM use was similar between EOL patients (36.6%, 95% CI: 29.2–44.8%) and non-EOL patients (39.0%, 95% CI: 36.0–42.1%). Lau and Dwyer mentioned several classes of medications on the Beers list that may be clinically appropriate for EOL patients. Our estimates indicate that prevalence of medication use in these classes were also comparable by EOL status. For example, 6.5% (CI: 3.6–11.4%) of EOL patients vs. 6.5% (CI: 5.1–8.2%) of non-EOL patients used antihistamines included in the Beers list. The rate of long-acting benzodiazepines use was 2.9% (CI: 1.5–5.4%) among the EOL patients vs. 2.2% (CI: 1.5–3.2%) among the non-EOL patients. Use of anticholinergic agents (including gastrointestinal antispasmodics and other anticholinergics on the Beers list) was low (1–2%) for both populations, with confidence intervals overlapping. These results indicate that our original estimate of close to 40% PIM use among older home health care patients was not driven by the potentially greater (and appropriate) use of these medications by patients with limited life expectancy or receiving EOL care. Lau and Dwyer make a legitimate point of the need to take into account EOL status when examining medication appropriateness. The policy and practice implications of our original findings, however, remain highly relevant to the vast majority of home health patients who receive active treatment.

OBJECTIVES. The purpose of these analyses was to test the hypothesis that depressive symptomatology affects the risk of onset of physical disability in high-functioning elderly adults. METHODS. The data come from the MacArthur Study of Successful Aging, a community-based cohort of high-functioning adults aged 70 through 79 years who were assessed twice at a 2.5-year interval. Physical and cognitive status was assessed by performance as well as by self-report measures. RESULTS. In gender-stratified logistic regression models, high depressive symptoms as measured by the depression subscale of the Hopkins Symptom Checklist were associated with an increased risk of onset of disability in activities of daily living for both men and women, adjusting for baseline sociodemographic factors, physical health status, and cognitive functioning. CONCLUSIONS. Joined with evidence that physical disability is a potential risk factor for depression, these findings suggest that both depressive symptoms and physical disability can initiate a spiralling decline in physical and psychological health. Given the important impact of activities-of-daily-living functioning on utilization of medical services and quality of life, prevention or reduction of depressive symptoms should be considered an important point of intervention.

Using prospective data on 3,170 respondents aged 18 years and over who were at risk for a first-onset major depression from the New Haven site of the Epidemiologic Catchment Area (ECA) study, these analyses assessed the effects of social status, physical health status, and social isolation on first-onset depression in a 1-year period, controlling for demographic characteristics and baseline psychiatric factors. Among the assessed potential risk factors, poverty status [odds ratio (OR = 2.034, P0.05)] and confinement to a bed or chair (OR = 4.015, P0.05) were independently associated with an increased risk for a first-onset depressive episode when controlling for gender, age, past history of substance abuse, and subclinical depressive symptoms. The effects of poverty, and to a lesser degree homebound status, were substantially reduced when controlling for degree of isolation from friends and family, suggesting that social isolation mediates some of the relationships between social and physical statuses and major depression.

OBJECTIVE This study examined the effects of nine axis I psychiatric disorders, as assessed by the Diagnostic Interview Schedule, on the risk of mortality over a 9-year period among a community sample of 3,560 men and women aged 40 and older. METHOD The study identified the vital status as of Oct. 1, 1989, of respondents who were first interviewed in 1980 by the New Haven Epidemiologic Catchment Area study. Mortality risk by psychiatric status was estimated by using Cox proportional hazards models. RESULTS Nine years after the baseline interview, it was confirmed that 1,194 (33.5%) of the respondents were deceased and 2,344 (65.8%) survived; the vital status of 22 (0.6%) remained unknown. When the relative risk of mortality was adjusted for age, several disorders--major depression, alcohol abuse or dependence, and schizophrenia--increased the likelihood of mortality. CONCLUSIONS These data are further evidence of the negative outcome of some psychiatric problems even when assessed in community samples. The relatively high prevalence of depression and alcohol disorders indicates the far-reaching impact that these problems have on community health in general.

Previous randomized controlled trials (RCTs) showed the efficacy of in-home, short-term problem-solving therapy (PST) for reducing depressive symptoms among medically ill, homebound older adults.1,2 Despite its efficacy with depressed homebound older adults, in-home, in-person PST or other psychotherapy for them is likely to be cost prohibitive. Most mental health and aging-service agencies lack sufficient professional staff to deliver in-person depression interventions at older adults' homes. Travel expenses for in-person delivery are likely to create an undue burden on these providers. Moreover, one study that tested the effectiveness of providing a home delivered, therapeutic psychosocial intervention for rural older adults found that it was not unusual for interventionists to travel an hour to a participant's home for a scheduled appointment only to discover that no one was there, or that the older adult was not feeling well enough to participate in a treatment session.3 Previous studies of telepsychiatry in general, compared to face-to-face modalities, have reported overall favorable findings about reliability of clinical assessment, equivalent clinical outcomes and client satisfaction, and long-term cost effectiveness.4-8 Despite the rapid growth in telepsychiatry over the past decade, however, our literature search yielded only two studies focusing on the practice using videoconferencing link and its effectiveness with frail and disabled older adults: one on psychogeriatric assessment in Hong Kong and the other on dementia assessment in Australia.9,10 In these past practices of telepsychiatry, however, clients had to be at a site where videoconferencing equipment was set up for use by many others. Internet-based, guided self-help PST for depression has been tested with younger age persons with depression.11,12 However, we found no studies that evaluated delivery of psychosocial intervention via an interactive videoconferencing link between a therapist's office and homebound older adults' residences. Telephone-administered psychotherapy for depression or other mental disorders has also been found to be effective and to result in lower attrition rates than in-person psychotherapy.13-16 However, videoconferencing therapy has advantages over telephone delivery of psychotherapy, as it enables therapist and client to maintain visual contact and see nonverbal behavior. Videoconferencing also allows therapist and client to show each other worksheets and other therapy aids. For isolated homebound older adults, the visual contact and interactive nature of videoconferencing are likely to be especially beneficial as they allow most of the benefits of in-person sessions. Considering the resource constraints and high costs of in-person PST delivery and the advantages of videoconferencing over telephone delivery, home-based telehealth PST (tele-PST) may have potential to facilitate homebound older adults' access to depression treatment. With the availability of low-cost videoconferencing tools, real-time, interactive tele-PST, which allows therapists and clients most benefits of in-person sessions, holds promise as the most practical, accessible depression treatment for homebound older adults and disabled persons. The purpose of this study was to evaluate the acceptance and preliminary efficacy of in-home tele-PST (via Skype video call) among low-income homebound older-adults who participated in a pilot RCT designed to test its feasibility and preliminary signal of efficacy, compared to in-person PST and telephone support calls. We examined tele-PST acceptance among these older adults and the changes in depressive symptoms over 24 weeks.

Background With substantial morbidity and functional impairment, older patients receiving home health care are especially susceptible to the adverse effects of unsafe or ineffective medications. Home health agencies’ medication review and reconciliation services, however, provide an added mechanism of medication safety that could offset this risk.

The loss of new investigators from academic science places the future of biomedical science at risk. Failure to obtain independent funding contributes significantly to attrition from the academic career path. In this article, the authors describe the Advanced Research Institute (ARI) in Geriatric Mental Health, a national program based at Weill Cornell Medical College of Cornell University that matches new investigators with mentors to help them make a successful transition to independence. The program is multidisciplinary, and its faculty and participants (the latter known as "scholars") span the spectrum of translation, interventions, and services research. ARI helps scholars overcome three barriers to independence through the development of grant-preparation and time-management skills and consultation with statistical and other experts. The authors analyze the record of federal grant funding among the first four cohorts of ARI scholars (2004-2007, n = 42). As of January 2010, 45.2% of these scholars had achieved R01 funding and 69.1% had obtained National Institutes of Health grants (not including career development or small grants). The 24 scholars who had National Institute of Mental Health (NIMH) mentored career development (mentored K) awards were 2.36 times (P = .048) more likely than the other 380 recipients of NIMH mentored K awards during the same period (2001-2005) to achieve R01 funding. Based on objective outcomes, ARI offers an effective model for stemming attrition of new investigators from the academic career path that is generalizable to other fields and promotes innovative, translational science.

Collaborative depression care management (DCM), by addressing barriers disproportionately affecting patients of racial/ethnic minority and low education, may reduce disparities in depression treatment and outcomes.To examine the effects of DCM on treatment disparities by education and race/ethnicity in older depressed primary care patients.Analysis of data from the randomized controlled trial Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT).Twenty primary care practices.A total of 396 individuals 60 years or older with major depression. We conducted model-based analysis to estimate potentially differential intervention effects by education, independent of those by race/ethnicity (and vice versa).Algorithm-based recommendations to physicians and care management by care managers.Antidepressant use, depressive symptoms, and intensity of DCM over 2 years.The PROSPECT intervention had a larger and more lasting effect in less-educated patients. At month 12, the intervention increased the rate of adequate antidepressant use by 14.2 percentage points (pps) (95% confidence interval [CI], 1.7 to 26.4 pps) in the no-college group compared with a null effect in the college-educated group (-9.2 pps [95% CI, -25.0 to 2.7 pps]); at month 24, the intervention reduced depressive symptoms by 2.6 pps on the Hamilton Depression Rating Scale (95% CI, -4.6 to -0.4 pps) in no-college patients, 3.8 pps (95% CI, -6.8 to -0.4) more than in the college group. The intervention benefitted non-Hispanic white patients more than minority patients. Intensity of DCM received by minorities was 60% to 70% of that received by white patients after the initial phase but did not differ by education.The PROSPECT intervention substantially reduced disparities by patient education but did not mitigate racial/ethnic disparities in depression treatment and outcomes. Incorporation of culturally tailored strategies in DCM models may be needed to extend their benefits to minorities.clinicaltrials.gov Identifier forNCT00279682.

To design a bundled case rate for Collaborative Care for Depression (CCD) that aligns incentives with evidence-based depression care in primary care.A clinical information system used by all care managers in a randomized controlled trial of CCD for older primary care patients.We conducted an empirical investigation of factors accounting for variation in CCD resource use over time and across patients. CCD resource use at the patient-episode and patient-month levels was measured by number of care manager contacts and direct patient contact time and analyzed with count data (Poisson or negative binomial) models.Episode-level resource use varies substantially with patient's time in the program. Monthly use declines sharply in the first 6 months regardless of treatment response or remission status, but it remains stable afterwards. An adjusted episode or monthly case rate design better matches payment with variation in resource use compared with a fixed design.Our findings lend support to an episode payment adjusted by number of months receiving CCD and a monthly payment adjusted by the ordinal month. Nonpayment tools including program certification and performance evaluation and reward systems are needed to fully align incentives.

This study estimated the prevalence of diagnosed depression among elderly Medicare fee-for-service home health patients and identified demographic, functional, and care utilization characteristics associated with the diagnosis.Data from the 2007 National Home and Hospice Care Survey were analyzed to generate nationally representative estimates. Chi square and Wald tests, corrected for the sampling design, tested for differences in categorical and continuous measures, respectively.Nationally, 6.4% (N=42,192) of the study population received a diagnosis of depression, which was associated with younger age (p=.016), lack of a primary caregiver other than the home care agency (p.001), a lower likelihood of receiving medical social services (p=.010), and a greater likelihood of using antidepressants (p.001).The rate of diagnosed depression was higher than the rate found in a previous study but lower than rates in studies that used diagnostic interviews or screening tools. Diagnosed depression was associated with a limited number of patient characteristics.

Objective: The study examined in home health care (HHC) the demographic, functional and clinical factors by antidepressant (AD) type including selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs) and “Other” ADs such as bupropion and mirtazapine. Method: Cross-sectional sample (N=909) was analyzed from the 2007 National Home Health and Hospice Care Survey that included patients 65 years and older [mean=78.79 years, confidence interval (CI)=77.88–79.69 years] taking one AD. Results: Selective serotonin reuptake inhibitors were the most commonly used (63.89%) AD, followed by “Other” ADs (14.29%), TCAs (11.31%) and SNRIs. In a multinomial regression referencing SSRIs, blacks had increased odds of tricyclic use compared to whites [odds ratio (OR)=5.96, CI=1.85–19.19]. Hispanics had decreased odds of “Other” AD (OR=0.13, CI=0.02–0.73) and SNRI use (OR=0.06, CI=0.008–0.45) compared to non-Hispanics. The HHC elderly taking psychotropic medications besides ADs were less likely to use SNRIs (OR=0.31, CI=0.11– 0.88) and tricyclics (OR=0.27, CI=0.08–0.87). Advancing age was marginally associated with tricyclic use (OR=1.04, CI=0.99–1.09). Conclusion: Race/ethnicity and age differences by AD type — including blacks' increased TCA use, Hispanics' decreased SNRI and “Other” AD use, and older elderly's increased tricyclic use — suggest systematic differences in prescribing practice variations including differences by geography, patient preferences or access to care in the HHC elderly.

Objective Given the paucity of information available regarding standardized ratings of depression symptoms in bipolar manic states, and in particular those in older adults, we explored depression ratings in symptomatic participants in a multicenter study of treatment of bipolar I disorder in late life. Methods Baseline data was obtained from the first 100 patients enrolled in an NIMH-funded, 9-week, randomized, double-blind RCT comparing treatment with lithium or valproate in patients of age 60 years and older with Type I Bipolar mania or hypomania. This multi-site study was conducted at six academic medical centers in the United States and enrolled inpatients and outpatients with a total Young Mania Rating Scale (YMRS) score of 18 or greater. Depressive symptoms were evaluated with the Hamilton Depression Rating Scale (HAM-D) and the Montgomery-Asberg Depression Rating Scale (MADRS). The criterion for at least moderate bipolar depressive symptoms was the European College of Neuropsychopharmacology (ECNP) Consensus Meeting definition of HAM-D 17 total score >20. Results Eleven percent of patients had mixed symptoms defined by depression scale severity according to ECNP criterion. In the overall sample, total scores on the two depression scales were highly correlated. Total YMRS scores of this mixed symptom group were similar to the remainder of the sample. Conclusions These preliminary findings suggest that moderate to severe depressive symptoms occur in about one in ten bipolar manic elders. Future studies are needed to further evaluate symptom profiles, clinical correlates, and treatments for bipolar older adults with combined manic and depressive symptoms. Copyright © 2011 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.

OBJECTIVES: The objectives of the pilot study were to modify existing psychological first aid (PFA) materials so they would be appropriate for use with institutionalized elders, evaluate the feasibility of using nursing home staff to deliver the intervention to residents, and solicit feedback from residents about the intervention. The STORM Study, an acronym for "services for treating older residents' mental health", is the first step in the development of an evidence-based disaster mental health intervention for this vulnerable and underserved population. METHOD: Demographic characteristics were collected on participating residents and staff. Program evaluation forms were completed by staff participants during the pilot test and nurse training session. Staff and resident discussion groups were conducted during the pilot test to collect qualitative data on the use of PFA in nursing homes. RESULTS: Results demonstrate the feasibility of the PFA program to train staff to provide residents with PFA during disasters. CONCLUSIONS: Future research should focus on whether PFA improves coping and reduces stress in disaster exposed nursing home residents.

The articles in this month’s journal provide empirical evidence of the clinical relevance of subsyndromal and nondiagnostic measures of depression.1–5 The authors’ thoughtful discussion sections led me to consider the implications of their findings for services delivery, and I wondered whether this important body of research is on a collision course with other research aimed at improving depression assessment and care in nonmental health settings. One way to think about this question is through the lens of history, and because this year is the 30th anniversary of the first wave of data collection for the Epidemiologic Catchment Area (ECA) Study,6,7 the ECA offers as useful starting point.

This study evaluated the association between depression and hospitalization among geriatric home care patients.A sample of 477 patients newly admitted to home care over two years was assessed for depression. Bivariate and logistic regression analyses examined the likelihood of hospitalization during a 60-day home care episode.The hospitalization rate was similar for the 77 depressed patients and 400 nondepressed patients (about 7%). However, mean time to hospitalization was 8.4 versus 19.5 days after start of care, respectively. Hospitalization risk was significantly higher for depressed patients during the first few weeks. A main effect for depression and a depression-by-time interaction was found when analyses controlled for medical comorbidity, cognitive status, age, gender, race, activities of daily living and instrumental activities of daily living, and referral to home care after hospitalization.Depression appears to increase short-term risk of hospitalization for geriatric home care patients immediately after starting home care.

Objective To compare the prevalence of specific psychiatric disorders in the homebound elderly to other elders, controlling for demographic, physical health, and socio-economic factors. Design Survey. Setting Epidemiologic Catchment Area (ECA) project in New Haven, CT. Participants 2,553 non-institutionalized elders representing the total elderly population of the greater New Haven area. Intervention None Main Measures Homebound status determined by self-report; psychiatric status according to DSM III by the Diagnostic Interview Schedule (DIS); cognitive status by Mini-Mental Status Examination. Results Cognitive impairment (21.8% vs 11.0%, P < 0.001), depression (2.3% vs 0.7%, P < 0.01), dysthymia (3.9% vs 1.7%, P < 0.01), and anxiety disorders (2.2% vs 0.4%, P < 0.001) were each at least twice as prevalent among elders confined to a bed or chair as among non-homebound elders. Most of this increase was consistent with the poorer physical health status of the homebound; after controlling for health status, only dysthymia (Odds ratio = 2.1, P < 0.01) was significantly more prevalent among elders confined to a bed or chair. Conclusions The higher prevalence of disorders among the homebound support recommendations that psychiatric assessments become routine in primary care examinations of homebound elders and that the availability of preventive and therapeutic psychiatric services to the homebound increase.

Findings are reported evaluating the effects of aging and alcoholism histories on the 6-month prevalence rates of panic disorder. The data were collected in 5 communities as part of the Epidemiologic Catchment Area (ECA) study: New Haven, CT; Baltimore, MD; St. Louis, MO; Durham, NC; and Los Angeles, CA. Reanalysis of ECA data provided additional support for a decline in the prevalence of panic disorder among elderly people. In addition, the presence of a history of alcohol abuse or dependence was associated with significantly elevated panic disorder rates in younger individuals, but an earlier decline in panic disorder prevalence with age, regardless of gender. These findings offer preliminary support for neurodevelopmental hypotheses for the onset and outgrowing of panic disorder. They also highlight the impact of alcoholism on the course of panic disorder.

Objective We suggest that clinicians consider models of shared decision-making (SDM) for their potential ability to improve the treatment of major depression in the primary care setting and overcome limitations of collaborative care and other interventions. Methods We explore the characteristics and techniques of patient–clinician SDM, with particular emphasis on this model's relevance to the unique treatment concerns of depressed older adults. Results We describe a SDM intervention to engage older adults in depression treatment in the primary care sector. Conclusions It is timely to examine SDM models for elderly depressed primary care patients given their potential ability to improve treatment adherence and clinical outcomes. Copyright © 2009 John Wiley & Sons, Ltd.

We present a case study using a multilevel modeling approach to determine whether depressive symptoms are affected by genetic factors. Existing studies examining this question have focused on twins. The present study built on the literature by conducting a preliminary study of the heritability of depressive symptoms within extended families. At the same time, this study assessed the need for adjustment of a heritability measure in a family study using a multigenerational sample. The sample consisted of 230 community‐dwelling extended families that included 431 adult offspring, comprising full siblings, half siblings and cousins that participated in the University of Southern California Longitudinal Study of Generations. All participants filled out the Center for Epidemiologic Studies Depression (CES‐D) scale. The multilevel analysis allowed us to model the natural hierarchy of the extended family. Results indicate that the proportion of the phenotypic variance for CES‐D that occurs due to genetic differences is not significantly larger than zero among these participants [h 2 = 8.6%, 95% confidence interval (CI) = 0–57%, p = 0.71]. Our findings suggest that future studies examining depressive symptoms in this sample can focus on non‐genetic explanatory factors without the necessity to control for genetic variation. However, our study may be limited by measurement of prevalent depressive symptoms, which may not generalize to lifetime depressive symptoms. Copyright © 2009 John Wiley & Sons, Ltd.

Objective To serve as a conceptual map of the role of new interventions designed to reduce the burden of late-life depression. Methods We identified three needs to be addressed by intervention research: (1) the need for novel interventions given that the existing treatments leave many older adults depressed and disabled; (2) the need for procedures enabling community-based agencies to offer interventions of known efficacy with fidelity; and (3) the need to increase access of depressed older adults to care. Results Our model orders novel interventions according to their role in serving depressed older adults and according to their position in the efficacy, effectiveness, implementation, and dissemination testing continuum. We describe three interventions designed by our institute to exemplify intervention research at different level of the model. A common element is that each intervention personalizes care both at the level of the individuals served and the level of community agencies providing care. To this end, each intervention is designed to accommodate the strengths and limitations of both patients and agencies and introduces changes in the patients' environment and community agencies needed in order to assimilate the new intervention. Conclusions We suggest that this model provides conceptual guidance on how to shorten the testing cycle and bring urgently needed novel treatments and implementation approaches to the community. While replication studies are important, propose that most of the support should be directed to those projects that take rational risks, and after adequate preliminary evidence, make the next step along the testing continuum. Copyright © 2009 John Wiley & Sons, Ltd.

Objectives The authors examined the impact of the wish to die on mortality over a 5-year period, stratified by baseline depressive status (i.e., major, minor, and no depression diagnosis). The authors also examined whether a depression care management intervention would minimize these relationships. Design Longitudinal analyses of the practice-randomized Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT). Setting Twenty primary care practices from New York City, Philadelphia, and Pittsburgh. Participants One thousand two hundred two participants were identified through two-stage, age-stratified (60–74 years; 75 years and older) depression screening of randomly sampled participants. Intervention Practices randomized to Care Management Intervention or Usual Care conditions. Measurements Vital status at 5 years using the National Death Index. Results Rates of the wish to die were 29% (major depression), 11% (minor depression), and 7% (no depression). In Usual Care, the wish to die was associated with an increased risk of 5-year mortality across depressive status (adjusted hazard ratios ranging from 1.62 to 1.71). In intervention practices, this association was greater among the no depression (adjusted hazard ratio 1.64) compared with major depression group (adjusted hazard ratio 0.68). Conclusions The wish to die was associated with mortality in the usual care of elderly primary care patients, suggesting that the wish to die has clinical significance and may be worth assessing even in patients without other evidence of depression. This association was not observed among depressed patients located in primary care practices that implemented the PROSPECT intervention, suggesting potential long-term benefits of treatment and management of depression.

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.Secondary analysis of data from a randomized trial.Community, primary care.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.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 was first 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.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)=5.63, P.001) and continuation of antidepressant medication for at least 4 months (OR=6.57, P=.04) for patients who were depressed at baseline.Evidence-based DCM models are highly effective at improving antidepressant treatment in older primary care patients.

Objective—Homebound older adults may be vulnerable to the deleterious impact of untreated depression. Yet because these elders are difficult to reach, there is little data on the rates of depressive symptoms and suicidal ideation among this group. The objective of this study is to document the rates of depression and correlates among a population of homebound elders. Methods—Using a community based participatory research partnership, we implemented a routine screening for depressive symptoms and suicidal ideation among older recipients of Westchester County’s home meal program. Older adults enrolled in the home delivered meal program were administered the Physician Health Questionnaire–9 item (PHQ-9), and questions to assess pain, recent falls, alcohol abuse and perceived emotional distress. Results—In our sample of 403 meal recipients, 12.2% of older adults reported clinically significant depression (PHQ-9>9) and 13.4% reported passive or active suicidal thoughts. One third of recipients with significant depressive symptoms were currently taking an antidepressant. Almost a third of older adults who endorsed suicide ideation did not report clinically significant depressive symptoms. Among men, suicidal thoughts were associated with chronic pain and greater depression severity, whereas pain was not a predictor of suicidal thoughts among women. Conclusion—More than 1 in 9 elders suffer from depression; most are untreated with one third on antidepressants but still symptomatic. Through partnerships between public agencies that provide age related services and academic investigators there is an opportunity for improved detection of unmet mental health needs. Future research should explore innovative models to improve access to mental health services once unmet need is detected.

The purpose of this pilot study was to explore the approaches to depression care preferred by older home-care patients and examine characteristics associated with those preferences. Twenty-eight long-term home-care patients, ages 62 to 95, were interviewed. Patients ranked their depression care preferences and provided rationale for their responses. Results indicated prayer was preferred by the highest percentage of patients (50%). Comparing patients with and without depression experience, prayer was preferred by the latter group. The results highlight the importance of addressing patient preferences during care planning to improve participation in geriatric depression care management.

Objective To estimate the projected population of US adults aged 18 years or older with lifetime experience of doctor-diagnosed depressive disorder from 2005–2050. Methods Based on nationally representative survey data from the year 2006 Behavioral Risk Factor Surveillance Survey (BRFSS), prevalence estimates of doctor-diagnosed depression (minor or major, and dysthymia) were weighted to incorporate the complex sampling design and increase generalizability of the findings. The weighted prevalence data by age and sex in 2006 were then used to estimate the projected adult population with lifetime experience of depressive disorder based on the sex-specific US Census national population projections from year 2005–2050. Results In year 2006 the (weighted) prevalence of lifetime experience of depressive disorder was 15.7% among 188,292 respondents aged 18 years or older. Female prevalence was 20.6%, which was about twice as high as the prevalence among males (11%). From year 2005–2050, the total number of US adults with depressive disorder will increase from 33.9 million to 45.8 million, a 35% increase. The increase is projected to be greater in the elderly population aged ≥65 years (3.8–8.2, a 117% increase) than in the young population aged

Secular changes in the rates of mania have been reported in the relatives of affectively ill patients, and the present study is an independent replication of these findings in a large probability sample of a community. Data from the five U.S. sites of the National Institute of Mental Health's Epidemiologic Catchment Area study (ECA), a community survey of adults, are presented. A total of 17,827 respondents were divided into eight birth cohorts, each spanning a 10-year interval. Actuarial life-table analyses showed a greater cumulative risk of mania for white men and women from the three most recently born cohorts (i.e., those born after 1935). The Wilcoxon test for homogeneity indicated an overall significant difference by birth cohort. These findings in a community sample are consistent with those previously reported in relatives of affectively ill patients. The results support the hypothesis that birth cohort changes have occurred in the risk of mania and that the risk was greatest in the post-1935 cohorts.

Using three waves of interviews from the New Haven Epidemiologic Catchment Area Program, the authors contrast the extent and nature of depressive episodes and dysphoria between newly bereaved (N = 39) and married (N = 1,047) respondents age 45 and older. Bereavement greatly increased the risk of both conditions. This observation did not appear to be an artifact because psychosocial risk factors were similar for the bereaved and married groups. Bereavement increased the risk for a depressive episode more among respondents who reported no prior dysphoria than among those who did. Among those meeting criteria for depression, the bereaved reported symptoms similar to those of the married group except for significantly fewer reports of guilt.

To determine whether an educational intervention would improve depression assessment and appropriate referral. Secondary analyses tested whether referral led to depression improvement.Training in the Assessment of Depression (TRIAD) was a three-group, nurse-randomized trial. Researchers interviewed randomly selected patients at baseline and 8 weeks.Three certified home healthcare agencies in Westchester County, New York.Fifty-three medical/surgical nurses were randomized within agency to three intervention groups: full, minimal, or control. Research contact with nurses' patients (aged65; 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.Nurse training in clinically meaningful use of depression sections of Medicare's mandatory Outcome and Assessment Information Set (OASIS).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).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.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.

Few studies have tested the effects of a depression intervention on the risk for death associated with depression.To test whether an intervention to improve depression care can modify the risk for death.Practice-based, randomized, controlled trial.20 primary care practices in New York, New York, and Philadelphia and Pittsburgh, Pennsylvania.1226 randomly sampled patients identified through a 2-stage, age-stratified (60 to 74 years andor =75 years) depression screening.Depression care manager working with primary care physicians to provide algorithm-based care.Depression status based on clinical interview and vital status at 5 years by using the National Death Index.At baseline, 396 patients met criteria for major depression and 203 patients met criteria for clinically significant minor depression. After a median follow-up of 52.8 months, 223 patients died. Patients with depression in intervention practices were less likely to have died than those in usual care practices (adjusted hazard ratio, 0.67 [95% CI, 0.44 to 1.00]). Risk for death was reduced in patients with major depression (adjusted hazard ratio, 0.55 [CI, 0.36 to 0.84]) but not in patients with clinically significant minor depression (adjusted hazard ratio, 0.97 [CI, 0.49 to 1.92]). The benefit seemed to be almost entirely attributable to a reduction in deaths due to cancer.The mechanism for an effect on deaths due to cancer is unclear. Depression status, cause of death, and vital status might have been misclassified.Older primary care patients with major depression in practices that implemented depression care management were less likely to die over a 5-year period than were patients with major depression in usual care practices. The effect seemed to be limited to deaths due to cancer. The mechanism for such an effect is unclear and warrants further investigation. ClinicalTrials.gov registration number: NCT00000367.

To describe the influence of domains of cognition on remission and response of depression in an intervention trial among older primary care patients.Twenty primary care practices were randomly assigned to Usual Care or to an Intervention consisting of a depression care manager offering algorithm-based care for depression. In all, 599 adults 60 years and older with a depression diagnosis were included in these analyses. Depression severity and remission of depression were assessed by the 24-item Hamilton Depression Rating Scale. The Mini-Mental State Examination (MMSE) was our global measure of cognitive function. Verbal memory was assessed with the memory subscale of the Dementia Rating Scale. Attention was measured with the digit span from the Weschler Adult Intelligence Test. Response inhibition, one of the executive functions, was assessed with the Stroop Color-Word test.The intervention was associated with improved remission and response rates regardless of cognitive impairment. Response inhibition as measured by the Stroop Color-Word test appeared to significantly modify the intervention versus usual care difference in remission and response at 4 months. Patients in the poorest performance quartile at baseline on the Stroop Color-Word test in the Intervention Condition were more likely to achieve remission of depression at 4 months than comparable patients in Usual Care [odds ratio (OR) = 17.76, 95% Confidence Interval (CI), 3.06, 103.1].Depressed older adults in primary care with executive dysfunction have low remission and response rates when receiving usual care but benefit from depression care management.

Objective: To assess the completeness and accuracy of clinical information provided by referral sources to visiting nurses for patients admitted to receive home health care. Methods: Clinical referral information for a representative sample of 243 older adults admitted to receive skilled home-health nursing was compared to medical record information from home-health charts and in-home research interviews to determine their concordance. Measures used included referral information, home-care chart documentation, in-home nurse review of medications, medication allergies, caregiver contact information, cognitive status, depression status, and follow-up plan. Results: There were medication discrepancies between in-home nurse review and admission information in 215 cases (88.4%). Clinical information on medication allergies was lacking from referrers in 85 cases (34.9%). No information was provided by the referrers about cognitive status in 38 (73%) cases classified as cognitively impaired and in only 2 of 35 cases with major depression identified with the Structured Clinical Interview for Axis I Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID), was depression related information provided by referrers. Conclusions: The primary finding of this study is that during a transfer of an older adult to the home care service sector, essential clinical information is often missing, and there are significant discrepancies between medication regimens. These findings support the need for both educational initiatives and technology to address the complex care needs of older adults across settings to reduce the risk for medication errors and poor outcomes.