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

Importance Among older home health care patients, depression is highly prevalent, is often inadequately treated, and contributes to hospitalization and other poor outcomes. Feasible and effective interventions are needed to reduce this burden of depression. Objective To determine whether, among older Medicare Home Health recipients who screen positive for depression, patients of nurses receiving randomization to an intervention have greater improvement in depressive symptoms during 1 year than patients receiving enhanced usual care. Design, Setting, and Participants This cluster randomized effectiveness trial conducted at 6 home health care agencies nationwide assigned nurse teams to an intervention (12 teams) or to enhanced usual care (9 teams). Between January 13, 2009, and December 6, 2012, Medicare Home Health patients 65 years and older who screened positive for depression on routine nursing assessments were recruited, underwent assessment, and were followed up at 3, 6, and 12 months by research staff blinded to intervention status. Patients were interviewed at home and by telephone. Of 502 eligible patients, 306 enrolled in the study. Interventions The Depression Care for Patients at Home (Depression CAREPATH) trial requires nurses to manage depression at routine home visits by weekly symptom assessment, medication management, care coordination, education, and goal setting. Nurses’ training totaled 7 hours (4 onsite and 3 via the web). Researchers telephoned intervention team supervisors every other week. Main Outcomes and Measures Depression severity, assessed by the 24-item Hamilton Scale for Depression (HAM-D). Results The 306 participants were predominantly female (69.6%), were racially/ethnically diverse (18.0% black and 16.0% Hispanic), and had a mean (SD) age of 76.5 (8.0) years. In the full sample, the intervention had no effect ( P = .13 for intervention × time interaction). Adjusted HAM-D scores (Depression CAREPATH vs control) did not differ at 3 months (10.5 vs 11.4, P = .26) or at 6 months (9.3 vs 10.5, P = .12) but reached significance at 12 months (8.7 vs 10.6, P = .05). In the subsample with mild depression (HAM-D score, P = .90), and HAM-D scores did not differ at any follow-up points. Among 208 participants with a HAM-D score of 10 or higher, the Depression CAREPATH demonstrated effectiveness ( P = .02), with lower HAM-D scores at 3 months (14.1 vs 16.1, P = .04), at 6 months (12.0 vs 14.7, P = .02), and at 12 months (11.8 vs 15.7, P = .005). Conclusion and Relevance Home health care nurses can effectively integrate depression care management into routine practice. However, the clinical benefit seems to be limited to patients with moderate to severe depression. Trial Registration clinicaltrials.gov Identifier:NCT01979302

Integrated models of primary care depression management improve outcomes. Subsequent dissemination efforts and their evaluation need a fidelity measure.We sought to develop and validate a fidelity measure using data gathered during routine clinical application of the clinical model.Longitudinal outcome data on depression severity were obtained from 224 subjects experiencing major depression or dysthymia and assigned to a 3-component model (3CM) intervention. Data on 10 essential 3CM process-of-care components were obtained from telephone logs maintained by care managers administering 3CM care. Stakeholders (n = 23), including researchers, health care administrators, and care managers, independently rated the importance of the 10 elements distributing 100 points among the elements. Mean ratings were used as weights to construct a fidelity score. Predictive validity was assessed using logistic regression for patient response and remission at 3 and 6 months.3CM fidelity was high, with a mean of 74.1 at 3 months and 75.9 at 6 months. Given a large gap in the scores' distribution, subjects were classified into zero, low-, and high-fidelity groups. Logistic regressions adjusting for baseline depression found a distinct continuum. Patients that were provided high fidelity 3CM were significantly more likely to achieve treatment response and remission at 3 months. At 6 months, high-fidelity care was again significantly more likely to produce a response, but remission rate did not differ from patients provided low fidelity.Most patients received a substantially implemented "3CM dose." Even within this high implementation, however, a higher fidelity score was associated with better outcomes. The easily applied measure is a promising tool for monitoring the quality of implementation of integrated care.

This survey of nurses and physicians highlights the need for training initiatives and improved interdisciplinary collaboration and communication to improve treatment for older adult home care patients with depression. EXCERPT Despite its pervasiveness, major depression is largely underrecognized and undertreated in the older adult home health care population (Bruce et al., 2002). Therefore, it is important to recognize that opportunities exist to improve the care of homebound elderly adults with depression. The Outcome and Assessment Information Set (OASIS) requires registered nurses (RNs) working in Medicare-certified agencies to assess patients for symptoms of depression on admission, re-certification, and discharge. Lamentably, however, this ideal opportunity for identifying late-life depression and referring patients for treatment is not fully used (Brown, Bruce, et al., 2004).

Objective The objective of this study was to examine the associations between objective and subjective social support and suicidal ideation in older adults receiving home healthcare services. Method Participants were randomly selected from a sample of older adults newly starting skilled nursing care from a certified home health agency in Westchester County, NY. Research interviewers assessed 522 older adults aged 65 years and older who were receiving home care services. Subjective and objective components of social support were assessed using measures of social network, social interaction patterns, instrumental support, and perceptions of social support. Suicidal ideation was assessed using items from the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and the Hamilton Depression Rating Scale. Results In bivariate analyses, neither objectively determined size of social network nor instrumental support was associated with suicidal ideation. However, lower social interaction patterns and lower perceived social support were significantly related to suicidal ideation. After adjusting for potential confounders, only lower perceived support remained significantly associated with suicidal ideation. In post hoc analyses of the perceptions of social support scale items, satisfaction with one's relationships and feeling useful to family and friends were significantly associated with a lower likelihood of suicidal ideation in the final multivariate logistic regression model controlling for possible confounding variables. Conclusions Subjective social support is a potentially modifiable risk factor for suicide in later life. Findings suggest that the perception of social support is an important construct to examine in future longitudinal studies examining risk and protective factors for suicidal ideation and behaviors in older adults.

Assess patients with major depression or substance abuse for suicide ideation, as they are at elevated risk for self-harm. Severity of suicide ideation is associated with suicide risk. Its assessment, therefore, should proceed sequentially from passive to active suicide ideation, to a specific detailed plan, including intention to harm oneself, reasons for living, and impulse control. Primary care patients at mild to moderate risk for suicide can be effectively treated in primary care settings; however, patients at high risk should be referred to mental health specialists given their need for intensive treatments and frequent monitoring.

In some lights, the connection between depression and disability seems almost commonsensical and obvious. But empirical data on the nature of this relationship suggest that the links between the two are surprisingly subtle and complex. This chapter has recommended a number of analytic strategies that could be useful to clarifying these relationships. Given the heterogeneity of both depression and disability, it is likely that simple solutions will be insufficient. In a very real sense, this complexity offers the potential that not one but a variety of strategies may be useful in reducing the burden of depression and disability in the lives of older adults.

This article describes the development, administration, and reliability of the Cornell Services Index (CSI), a new instrument that measures health service use. The CSI was developed to create a standardized measure of the quantity and characteristics (for example, site and provider) of services used by adults. Descriptive data are provided to illustrate the application of the CSI in a community sample of adults who were newly admitted to outpatient mental health clinics. These data provide information about the pathways to care.The interrater and test-retest reliability of the CSI were evaluated by using a sample of 40 adults who were seeking mental health treatment. Descriptive data on service use in a sample of 1,279 adults seeking care in outpatient mental health clinics was provided to demonstrate the application of the CSI.The CSI is a portable, easy to use, and brief assessment of service use. It has good interrater and test-retest reliability among adults without cognitive impairment. In the three months before seeking care, 31 percent of the adults interviewed had made a mental health visit, 36 percent had been hospitalized, and more than half (59 percent) had made a medical visit. Twenty-three percent of adults had sought care from a hospital's emergency department.The CSI is a reliable method to assess health service use for adults. The measure can extend assessment of use beyond the traditional mental health service use questions and provide a snapshot of service use patterns across types, providers, and sites of service among adults who seek mental health care.

Background. This study compares patient and informant reports of depressive disorders in a community sample of elderly medical homecare patients. The associations between specific patterns of agreement/disagreement and other patient and informant characteristics are examined.Method. A random sample of 355 elderly medical homecare patients and their informants were interviewed using the current mood section of the Structured Clinical Interview for DSM-IV (SCID).Results. Thirty-seven patients (10·4%) reported a depressive disorder (major or subsyndromal) that was also identified by their informant while 27 (7·6%) patients self-reported depression that the informant did not identify. There were 250 patients (70·4%) who were not depressed according to both patient and informant report and 41 patients (11·5%) were identified as depressed by informant report alone. Patients identified as depressed by informant report alone were similar to patients who self-reported depression on a number of the sociodemographic and clinical correlates of depression, but had significantly poorer performance on items assessing orientation and short-term recall. These patients also had poorer functioning in a number of domains (social, cognitive, and functional) when compared with patients who were not depressed according to both the patient and informant. Finally, patients with younger informants were more likely to be identified as depressed by their informant.Conclusions. Obtaining informant reports of depression may be a useful method for detecting clinically significant cases of late-life depression that would otherwise be missed when relying only on patient report.

OBJECTIVE: This study determined if actors could portray depressed patients to establish the interrater reliability of raters using the Hamilton Depression Rating Scale (HDRS). METHOD: Actors portrayed depressed patients using scripts derived from HDRS assessments obtained at three points during treatment. Four experienced raters blindly viewed videotapes of two patients and two actors. They guessed if each interviewee was a patient or an actor and rated the certainty of their guesses. For each interview, they also rated the realism of the portrayal and completed the HDRS. RESULTS: Experienced raters could not distinguish actors and patients better than chance and were equally certain of their right and wrong guesses. Actors and patients received high scores on the realism of their portrayals. The HDRS scores of the actor-patient pairs were correlated. CONCLUSIONS: Actors can effectively portray depressed patients. Future studies will determine if actors can accurately portray patients with anxiety and ps...

Objective To test the effectiveness of an evidence based model for management of depression in primary care with support from quality improvement resources. Design Cluster randomised controlled trial. Setting Five healthcare organisations in the United States and 60 affiliated practices. Patients 405 patients, aged ≥ 18 years, starting or changing treatment for depression. Intervention Care provided by clinicians, with staff providing telephone support under supervision from a psychiatrist. Main outcome measures Severity of depression at three and six months (Hopkins symptom checklist-20): response to treatment (≥ 50% decrease in scores) and remission (score of Results At six months, 60% (106 of 177) of patients in intervention practices had responded to treatment compared with 47% (68 of 146) of patients in usual care practices (P = 0.02). At six months, 37% of intervention patients showed remission compared with 27% for usual care patients (P = 0.014). 90% of intervention patients rated their depression care as good or excellent at six months compared with 75% of usual care patients (P = 0.0003). Conclusion Resources such as quality improvement programmes can be used effectively in primary care to implement evidence based management of depression and improve outcomes for patients with depression.

BACKGROUND Recent trials have shown improved depression outcomes with chronic care models. We report the methods of a project that assesses the sustainability and transportability of a chronic care model for depression and change strategy. METHODS In a randomized controlled trial (RCT), a clinical model for depression was implemented through a strategy supporting practice change. The clinical model is evidence based. The change strategy relies on established quality improvement programs and is informed by diffusion of innovations theory. Evaluation will address patient outcomes, as well as process of care and process of change. RESULTS Five medical groups and health plans are participating in the trial. The RCT involves 180 clinicians in 60 practices. All practices assigned to the clinical model have implemented it. Participating organizations have the potential to disseminate this clinical model of care to 700 practices and 1,700 clinicians. CONCLUSIONS It is feasible to implement the clinical model and change strategy in diverse practices. Follow-up evaluation will determine the impact, sustainability, and potential for dissemination. Materials are available through http://www. depression-primarycare.org; more in-depth descriptions of the clinical model and change strategy are available in the online-only appendixes to this article.

Objective: This article explores the potential of community intervention perspectives for increasing the relevance, reach, and public health impact of mental health services research. Method: The authors reviewed community intervention strategies, including public health and community development and empowerment interventions, and contrast community intervention with practice-based quality improvement and policy research. Results: A model was proposed to integrate health services and community intervention research, building on the evidence-based strength of quality improvement and participatory methods of community intervention to produce complementary functions, such as linking community-based case finding and referral with practice-based quality improvement, enhanced by community-based social support for treatment adherence. Conclusions: The community intervention approach is a major paradigm for affecting public health or addressing health disparities. Despite challenges in implementation and evaluation, it represents a promising approach for extending the reach of mental health services interventions into diverse communities.

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

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

Objective: To examine the relationship between religious practice and depression in a sample of geriatric patients receiving homecare nursing services. Methods: Patients were sampled weekly for six months from all those aged 65 to 102, and newly enrolled in a visiting nurse agency ( N = 130). Depression was assessed by home interviews using the SCID and HRSD. Patients reported their religious service participation prior to receiving homecare and currently. Health status, disability, pain, social support and history of depression were also assessed. Results: The current prevalence of DSM-IV Major Depressive Disorder (MDD) was significantly greater ( p < .05), and depressive symptoms were more severe ( p < .02), among those persons who had not attended religious services prior to receiving homecare. Logistic regression demonstrated that the effect of religious attendance remained significant when controlling for health status, disability, pain, social support and history of depression. A subsequent analysis compared three groups of patients. They were those who had: 1) Not attended religious services; 2) Stopped attending since homecare; 3) Continued attending. Data demonstrated significantly decreasing prevalence of MDD ( p < .03) across the groups. Conclusions: Prevalence of DSM-IV Major Depressive Disorder and the severity of depressive symptoms were significantly lower among homecare patients who attend religious services. Because a large proportion of persons stop attending religious services after initiating homecare, it is suggested that visitation by clergy may improve depressive symptoms for these patients.

Objectives To review progress made during the past decade in late-life mood disorders and to identify areas of unmet need in health care delivery and research. Participants The Consensus Development Panel consisted of experts in late-life mood disorders, geriatrics, primary care, mental health and aging policy research, and advocacy. Evidence (1) Literature reviews addressing risk factors, prevention, diagnosis, treatment, and delivery of services and (2) opinions and experiences of primary care and mental health care providers, policy analysts, and advocates. Consensus Process The Consensus Development Panel listened to presentations and participated in discussions. Workgroups considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed and edited to incorporate input from the entire Consensus Development Panel. Conclusions Despite the availability of safe and efficacious treatments, mood disorders remain a significant health care issue for the elderly and are associated with disability, functional decline, diminished quality of life, mortality from comorbid medical conditions or suicide, demands on caregivers, and increased service utilization. Discriminatory coverage and reimbursement policies for mental health care are a challenge for the elderly, especially those with modest incomes, and for clinicians. Minorities are particularly underserved. Access to mental health care services for most elderly individuals is inadequate, and coordination of services is lacking. There is an immediate need for collaboration among patients, families, researchers, clinicians, governmental agencies, and third-party payers to improve diagnosis, treatment, and delivery of services for elderly persons with mood disorders.

This paper explores the potential of community-based, public health-oriented interventions as a tool for reducing the burden of affective disorders on individuals, their families, and communities. The paper reviews the use of community-based interventions with other health-related problems and describes potential applicability for affective disorders such as changing public attitudes, reducing social stigma, facilitating access, or supporting treatment adherence for populations in their community settings. An agenda for developing this field of intervention research is proposed.

This paper summarizes 3 sets of barriers to reducing burden of affective disorders including factors that contribute to 1) the risk, course, and outcomes of affective disorders; 2) help-seeking and use of health and mental health services for affective and other mental disorders; and 3) the appropriateness of treatments used for affective disorders. On the basis of this review, the authors recommend research needed to identify modifiable barriers to reducing the burden of affective disorders and to identifying opportunities to reduce these barriers. This new research should focus on clarifying societal, family, and consumer, clinician, and system barriers to recognizing disorders, seeking and providing care, and adhering with guideline concordant care, and should include barriers that apply to both treatment and prevention services.

Gender differences in overcoming barriers to mental health care for affective disorders have not been studied. Further, the role of mental health care for parents as it affects child outcomes is important but currently not well studied. In particular, care for disadvantaged young women is an area in need of further research.

Late life depression is common and associated with disability, reduced quality of life, mortality, and high health care costs. Depressed older adults frequently have comorbid medical illnesses and cognitive impairment, but relatively little is known about the diagnosis and treatment of depression in the face of these comorbid conditions. Only a minority of depressed older adults receive specialty mental health care and most depression care is provided in primary care where few receive effective treatment. Very little is known about the epidemiology and quality of care for bipolar disorder in late life. Additional research should focus on the quality and outcomes of care for older adults with affective disorders in diverse settings (including primary care, specialty mental health care, home health care, nursing homes, and assisted living facilities) and on the care of older adults who have affective disorders and comorbid medical disorders, dementia, substance use disorders, or chronic pain.

Depression among older home care patients is prevalent but undertreated. The purpose of this study was to investigate the ability of home health nurses to correctly identify depression among older patients and to describe nurse and patient characteristics associated with more accurate assessment of depression.Forty-two nurses were surveyed about the presence of depressive symptoms among patients who had been evaluated independently for depressive disorders by research staff using the Structured Clinical Interview for Axis I DSM-IV Disorders. A sample of newly admitted home health care patients who were aged 65 years or older was randomly selected for this evaluation on a weekly basis from December 1997 to December 1999.Of 403 patients who were evaluated, 97 (24 percent) were found to have either major depression (64 patients) or minor depression (33 patients). The nurses correctly identified depression among 44 of the 97 patients who were depressed (sensitivity of 45.4) and 230 of the 306 patients who were not depressed (specificity of 75.2). The kappa coefficient measuring overall agreement between the nurses' assessment and the diagnosis of depression was.19. Nurses who had more geriatric nursing experience were more likely to correctly identify depression.Home health nurses have difficulty making accurate assessments of depression among older home care patients. Inaccuracy in assessment of depression by home health nurses is a significant barrier to treatment in this elderly homebound population.

The study assessed the contribution of depressive symptoms and cognitive impairment to the prediction of self-neglect in elderly persons living in the community.Data were drawn from the New Haven Established Populations for Epidemiologic Studies of the Elderly cohort, which included 2,812 community residents age 65 years and older in 1982. The principal outcome examined was the incidence of self-neglect, corroborated by the state's investigation, during 9 years of follow-up (1982-1991).Among the 2,161 subjects included in the analysis, 92 corroborated cases of self-neglect occurred from 1982 to 1991. The prevalence of clinically significant depressive symptoms at baseline (scoreor=16 on the Center for Epidemiologic Studies Depression Scale [CES-D]) was 15.4%, and the prevalence of clinically significant cognitive impairment (four or more errors on the Pfeiffer Short Portable Mental Status Questionnaire) was 7.5%. Subjects with clinically significant depressive symptoms and/or cognitive impairment were more likely than others to experience self-neglect. Clinically significant depressive symptoms and cognitive impairment remained significant predictors of self-neglect in a multivariate model that included age, gender, race, and income. A final model for self-neglect constructed with stepwise selection of risk factors included depressive symptoms and cognitive impairment, as well as male gender, older age, income less than $5,000 per year, living alone, history of hip fracture, and history of stroke.Elderly individuals living in the community who experience clinically significant depressive symptoms and/or cognitive impairment may be at risk for the development of self-neglect and may become candidates for intervention.

This article summarizes research findings on psychosocial risk factors for late life depressive disorders. The article draws heavily on longitudinal cohort studies of well-defined, population-based samples with diagnostic measures that assess the risk of incident or new-onset depressive episodes. These studies have identified a number of significant psychosocial risk factors for late life depressive disorders, including life events and ongoing difficulties; death of a spouse or other loved one; medical illness and injuries; disability and functional decline; and lack of social contact. Additional evidence suggests that the impact of these psychosocial risk factors on depression can be enhanced or buffered by personal or environmental factors. Although many of these psychosocial risk factors are more prevalent among older than younger adults, it is not clear that their impact on the risk of depression differs by age. Methodological challenges to advancing research on psychosocial risk factors for late life depression are reviewed, including problems related to study designs, sample selection, and measurement.

Background Twenty years have elapsed since the National Institute of Mental Health Collaborative Depression Study reported on the early course and treatment of major depression within the mental health sector. Using similar methods, an observational study was conducted to assess relationships between initial depression severity, personality dysfunction and other baseline characteristics, subsequent treatment, and 3-month outcomes among persons admitted to public and voluntary sector outpatient clinics, including 1 academic program. Methods A 2-stage sampling technique was used to recruit subjects (N = 165) diagnosed by the Structured Clinical Interview for DSM-IV, Patient Version, as having a major depression episode. Sociodemographic and clinical characteristics were assessed at admission. Data on treatment and outcome were obtained at 3 months using structured instruments from the Longitudinal Interview Follow-up Evaluation. Logistic regression was used to assess hypothesized predictors of early recovery. Analyses were carried out in the total sample and after dichotomizing subjects by baseline depression severity. Results Fifty (30.3%) of the 165 subjects met recovery criteria. Less than half of the subjects (45%) met criteria for adequate pharmacotherapy. Less severe depression, having received adequate antidepressant treatment, female sex, and being married independently predicted early recovery. In the more depressed subgroup, early recovery was associated with female sex. Among less severely depressed subjects, high personality dysfunction scores and being married were significant predictors. Conclusions Initial depression severity and receiving adequate pharmacotherapy predict early recovery in individuals with major depression seeking outpatient treatment. A minority of persons receive intensive antidepressant treatment. Less severe personality dysfunction and being married predicts early recovery among persons with less severe depression.

The current work evaluated the interaction of life stressors with cognitive/personality styles in predicting late-onset depression in 42 elderly outpatients with DSM-IV unipolar Major Depression and 42 nondepressed controls. Control subjects were matched to cases on age, sex, race, and years of education. As suggested by Beck's cognitive theory of depression, a multivariate model indicated that specific stressful-event types interacted with specific cognitive/personality styles in strongly predicting depression onset, adjusting for the positive associations of medical illness and reduced physical functioning with depression.

This article is the second of a two-part series on assessing behavioral health in adult and elderly home care patients using OASIS. Part 1 presented an assessment approach for depressive symptoms and suicidality. This article presents the assessment of cognitive impairment, problematic behaviors, and anxiety using OASIS as a framework and stresses the importance of direct questioning. Case scenarios and guidelines for referral for further evaluation and possible treatment are provided.

This article is the first of a two-part series on assessing behavioral health in adult and elderly patients using OASIS. Direct questioning about emotional and behavioral symptoms in addition to observation, reports from family members, and input from other team members are used. This approach improves assessment information and increases nurse confidence and accuracy when making referrals for further psychiatric evaluation and treatment.

The authors, a group of investigators with extensive research and clinical experience related to both late-life depression and Alzheimer disease (AD), propose provisional affective and behavioral inclusion and exclusion diagnostic criteria for Depression of AD.

It has been proposed that a "depression-executive dysfunction (DED) syndrome" occurs in late life. This assertion was based on clinical, neuropathological, and neuroimaging findings suggesting that frontostriatal dysfunctions contribute to the development of both depression and executive dysfunction and influence the course of depression. The authors describe the clinical presentation of DED and its relationship to disability, studying 126 elderly subjects with major depression and evaluating depressive symptoms, cognitive functioning, disability, and personality dimensions. Patients with the DED syndrome had reduced fluency, impaired visual naming, paranoia, loss of interest in activities, and psychomotor retardation, but showed a rather mild vegetative syndrome. Depressive symptomatology, and especially psychomotor retardation and loss of interest in activities, contributed to disability in DED patients, whereas paranoia was associated with disability independently of executive dysfunction. These findings may aid clinicians in identifying patients needing vigilant follow-up, because depression with executive dysfunction was found to be associated with disability, poor treatment response, relapse, and recurrence.

Older adults, especially older white men, are more likely to commit suicide than other age-groups. The assessment and management of suicide ideation and behavior for the elderly is especially relevant for primary care physicians because many patients visit their physician shortly before committing suicide. In 1993, the Agency for Health Care Policy and Research (AHCPR) released clinical practice guidelines for the treatment of depression in primary care settings. The AHCPR guidelines offered some assistance with respect to detecting and treating patients who are suicidal. However, these guidelines lacked detailed and specific instructions for managing high-risk patients within the context of intervention research. The current set of guidelines builds upon this previous work by describing (1) a general approach for interacting with suicidal patients; (2) structured assessments for determining the degree of risk for suicide; (3) crisis intervention strategies; and (4) ongoing management procedures for working with suicidal patients in primary care settings.

OBJECTIVE: The authors’ goal was to examine the extent to which perceived stigma affected treatment discontinuation in young and older adults with major depression. METHOD: A two-stage sampling design identified 92 new admissions of outpatients with major depression. Perceived stigma was assessed at admission. Discontinuation of treatment was recorded at 3-month follow-up. RESULTS: Although younger patients reported perceiving more stigma than older patients, stigma predicted treatment discontinuation only among the older patients. CONCLUSIONS: Patients’ perceptions of stigma at the start of treatment influence their subsequent treatment behavior. Stigma is an appropriate target for intervention aimed at improving treatment adherence and outcomes.

This study measured distinctions made by a sample of clergy and mental health professionals in response to three categories of presenting problems with religious content: mental disorder, religious or spiritual problem, and "pure" religious problem. A national, random sample of rabbis (N = 111) and clinical psychologists (N = 90) provided evaluations of three vignettes: schizophrenia, mystical experience, and mourning. The participants evaluated the religious etiology, helpfulness of psychiatric medication, and seriousness of the presenting problems. The rabbis and psychologists distinguished between the three diverse categories of presenting problems and concurred in their distinctions. The results provide empirical evidence for the construct validity of the new DSM-IV category religious or spiritual problem (V62.89). Use of the V code allows for more subtle distinctions among the variety of problems that persons bring to clergy and mental health professionals. These distinctions may also provide a foundation for the initiation of co-professional consultation.

Stressful life events are known to precipitate major depression. However, it remains unclear why some individuals who experience adverse events develop depression whereas others do not, and how the occurrence of life events affects treatment outcome. Emerging models posit that the effect of adverse life events varies by cognitive-personality style. This study examines the direct and interactive effects of stressful life events and cognitive-personality style in predicting 1) episode onset in patients with DSM-IV unipolar depression versus community comparison subjects and 2) depressive symptom severity at the completion of a 6-week standard antidepressant regimen.Multivariate models were used to test the effects of adverse life events, cognitive-personality style, and the congruence of event type (interpersonal versus achievement) with cognitive-personality style on depressive onset and treatment outcome in 43 patients with major depression and 43 healthy comparison subjects. Cognitive-personality characteristics were assessed by using Beck's measures of sociotropy (interpersonal dependency) and autonomy (need for independence and control).Adverse life events, sociotropy, and an autonomy factor need for control were each significantly related to depressive onset and predicted group status for 88% of the subjects. Event types affected outcome differently, and specific life event types interacted with cognitive-personality styles in predicting response to treatment. A multivariate model accounted for 65% of the variance in predicting outcome.Adverse life events are a potent factor in predicting depression. However, cognitive-personality characteristics also confer susceptibility to depression. Better outcome is associated with occurrence of adverse interpersonal events (e.g., death of a loved one) rather than adverse achievement events (e.g., loss of job) and occurs when the event type is congruent with cognitive-personality style.

Background The aim of this study was to find clinical characteristics that can identify elderly patients with depression at risk for suicidal ideation and to determine their prognosis. Method Suicidal ideation, past suicidal behavior, severity of depression, cognitive impairment, medical burden, disability, and social support were studied in 354 patients with depression aged 61 to 93 years. The patients had in-person evaluations every 6 months and telephone evaluations for a mean of 1.8 years (SD, 2.2). Results During the index episode, suicidal ideation was predicted by previous suicide attempts with serious intent (odds ratio [OR], 2.82; 95% confidence interval [CI], 1.37-5.80), severity of depression (OR, 1.09; 95% CI, 1.03-1.16), and poor social support (OR, 1.77; 95% CI, 1.18-2.65). Suicide attempts during the year prior to entry were reported by patients with a severe index episode (OR, 1.05; 95% CI, 1.00-1.11), impaired instrumental activities of daily living (OR, 0.78; 95% CI, 0.67-0.93), and limited impairment in activities of daily living (OR, 1.53; 95% CI, 1.10-2.14). At the initial evaluation, severity of depression, previous attempts, and seriousness of suicidal intent during previous attempts predicted the course of suicidal ideation (concordance correlation, 0.78). During follow-up, contemporaneous severity of depression was the most important determinant of suicidal ideation over time (concordance correlation, 0.88). Conclusions Elderly individuals with severe depression, history of suicide attempts with serious intent, and poor social support are most likely to have suicidal ideation and should be targeted for appropriate interventions. Severity of depression is the strongest predictor of the course of suicidal ideation.

Objectives. Social support and social networks have been shown to exert significant effects on health and functioning among elderly persons. Although theorists have speculated that the strength of these effects may differ as a function of sociodemographic characteristics and prior health status, few studies have directly tested the moderating effects of these variables. Methods. Longitudinal data from the MacArthur Study of Successful Aging were used to examine the effects of structural and functional social support on changes in physical functioning over a 7-year period, measured by the Nagi scale, in a sample of initially high-functioning men and women aged 70 to 79 years. Multiple regression analyses were used to test the main effects of social support and social network variables, as well as their interactions with gender, income, and baseline physical performance. Results. After controlling for potential confounding effects, respondents with more social ties showed less functional decline. The beneficial effects of social ties were stronger for respondents who were male or had lower levels of baseline physical performance. Discussion. The effects of social support and social networks may vary according to the individual's gender and baseline physical capabilities. Studies of functional decline among elderly persons should not ignore this population variation in the effects of social networks.

BackgroundAlthough subjective ratings of health have been shown to be accurate predictors of physical health outcomes, there is little research on the association between subjective emotional health (SEH) and psychiatric outcomes.MethodThis paper utilises data from the Epidemiologic Catchment Area study to explore the relationship between baseline SEH and the risk for major depression in the next year. Both recurrent and incident episodes of depression are outcomes of interest.ResultsThe age- and gender-adjusted relationship between SEH and depression is quite significant, and remains so after adjusting for other factors associated with major depression. The more positive the SEH rating, the lower the risk of an episode of depression in the next year.ConclusionsSome possible explanations for this association are explored, including possible confounders that were not accounted for and the possibility that SEH ratings pose an independent risk for major depression.

Jo Anne Sirey, Alexandra Greenfield, Alyssa DePasquale, Nathalie Weiss, Patricia Marino, George S Alexopoulos, Martha L Bruce Department of Psychiatry, Weill Cornell Medical College, White Plains, NY, USA Background: Staff who provide support services to older adults are in a unique position to detect depression and offer a referral for mental health treatment. Yet integrating mental health screening and recommendations into aging services requires staff learn new skills to integrate mental health and overcome client barriers to accepting mental health referrals. This paper describes client rates of depression and a novel engagement intervention (Open Door) for homebound older adults who are eligible for home delivered meals and screened for depression by in-home aging service programs. Methods: Homebound older adults receiving meal service who endorsed depressive symptoms were interviewed to assess depression severity and rates of suicidal ideation. Open Door is a brief psychosocial intervention to improve engagement in mental health treatment by collaboratively addressing the individual level barriers to care. The intervention targets stigma, misconceptions about depression, and fears about treatment, and is designed to fit within the roles and responsibilities of aging service staff. Results: Among 137 meal recipients who had symptoms when screened for depression as part of routine home meal service assessments, half (51%) had Major Depressive Disorder and 13% met criteria for minor depression on the SCID. Suicidal ideation was reported by 29% of the sample, with the highest rates of suicidal ideation (47%) among the subgroup of individuals with Major Depressive Disorder. Conclusion: Individuals who endorse depressive symptoms during screening are likely to have clinically significant depression and need mental health treatment. The Open Door intervention offers a strategy to overcome barriers to mental health treatment engagement and to improve the odds of quality care for depression. Keywords: depression, access to care, mental health intervention, engagement

Objective To investigate whether an intervention to improve treatment of depression in older adults in primary care modified the increased risk of death associated with depression. Design Long term follow-up of multi-site practice randomized controlled trial (PROSPECT—Prevention of Suicide in Primary Care Elderly: Collaborative Trial). Setting 20 primary care practices in New York City, Philadelphia, and Pittsburgh, USA, randomized to intervention or usual care. Participants 1226 participants identified between May 1999 and August 2001 through a two stage, age stratified (60-74; ≥75 years) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of patients who screened negative. Intervention For two years, a depression care manager worked with primary care physicians in intervention practices to provide algorithm based care for depression, offering psychotherapy, increasing antidepressant dose if indicated, and monitoring symptoms, adverse effects of drugs, and adherence to treatment. This paper reports the long term follow-up. Main outcome measure Mortality risk based on a median follow-up of 98 (range 0.8-116.4) months through 2008. Results In baseline clinical interviews, 396 people were classified as having major depression, 203 had clinically significant minor depression, and 627 did not meet criteria for depression. At follow-up, 405 patients had died. Patients with major depression in usual care were more likely to die than were those without depression (hazard ratio 1.90, 95% confidence interval 1.57 to 2.31). In contrast, patients with major depression in intervention practices were at no greater risk than were people without depression (hazard ratio 1.09, 0.83 to 1.44). Patients with major depression in intervention practices, relative to usual care, were 24% less likely to have died (hazard ratio 0.76, 0.57 to 1.00; P=0.05). Preliminary data on cause of death are provided. No significant effect on mortality was found for minor depression. Conclusions Older adults with major depression in practices provided with additional resources to intensively manage depression had a mortality risk lower than that observed in usual care and similar to older adults without depression. Trial registration Clinical trials NCT00000367.

Background Previous research found a high prevalence of depression, along with chronic illnesses and disabilities, among older ED patients. This study examined the relationship between depressive symptom severity and the number of ED visits among low-income homebound older adults who participated in a randomized controlled trial of telehealth problem-solving therapy (PST). Methods The number of and reasons for ED visits were collected from the study participants (n=121 at baseline) at all assessment points—baseline and 12- and 24-week follow-ups. Depressive symptoms were measured with the 24-item Hamilton Rating Scale for Depression (HAMD). All multivariable analyses examining the relationships between ED visits and depressive symptoms were conducted using zero-inflated Poisson regression models. Results Of the participants, 67.7% used the ED at least once and 61% of the visitors made at least one return visit during the approximately 12-month period. Body pain (not from fall injury and not including chest pain) was the most common reason. The ED visit frequency at baseline and at follow-up was significantly positively associated with the HAMD scores at the assessment points. The ED visit frequency at follow-up, controlling for the ED visits at baseline, was also significantly associated with the HAMD score change since baseline. Conclusions The ED visit rate was much higher than those reported in other studies. Better education on self-management of chronic conditions, depression screening by primary care physicians and ED, and depression treatment that includes symptom management and problem-solving skills may be important to reduce ED visits among medically ill, low-income homebound adults. Trial registration ClinicalTrials.gov Identifier: NCT00903019

Using 9-year mortality data on a community sample of 3,560 adults aged 40 and over, this study assessed the effects of cognitive functioning and one-year declines in cognitive functioning on mortality controlling for comorbid chronic medical illness, physical disability, and psychiatric illness. The study determined the 9-year vital status and, among the decreased, date of death of respondents who were first interviewed in 1980 by the New Haven Epidemiologic Catchment Area Study. Mortality risk by cognitive functioning, as assessed by the Mini-Mental State Examination (MMSE), was estimated using Cox Proportional Hazards Models controlling for baseline assessments of physical and mental health. For both men and women, lower scores on the MMSE decreased the risk of survival, although the effect was stronger for younger respondents than older respondents. Decline in MMSE scores over the course of one year had no additional effect on mortality beyond the resulting MMSE score. Cause-specific mortality was also examined.

Data on cognitive impairment in the oldest old is reported comparing two different samples, one in Munich, Germany, and the other in the United States (Epidemiologic Catchment Area [ECA] study). In both studies the Mini Mental State Examination (MMSE) was used for assessing cognitive impairment. The Munich sample consisted of 402 and the ECA sample of 827 very old people aged 85 years and above. The results indicate that approximately 40% of each sample scored below 24 points in the MMSE indicating at least mild cognitive impairment. Severe cognitive impairment was found in 13.4% of the Munich and in 14.6% of the American sample. The prevalence of major depression was 1.4% in Munich and 2.0% in the ECA study, and dysthymia was found in 5.1% in the Munich and in 2.0% in the ECA sample aged 85 years and above. Persons living in institutions in both studies more frequently showed signs of cognitive impairment than those living in private households. The ECA sample, but not the Munich sample, showed a significantly higher prevalence of cognitive impairment for females and for the oldest age cohort above 90 years of age. Major depression was more frequent in Munich in persons living in institutions and in the ECA study among the oldest age cohort above 90 years of age. Dysthymia in both studies did not show any association with sociodemographic factors. Most of the excess comorbidity (cognitive impairment and depression) was observed among subjects with mild (and not with severe) cognitive impairment. Very similar prevalence rates were generally found not only for MMSE-based cognitive impairment, but contrary to our expectations, also for major depressive disorder. Out data partially confirm a further increase in the prevalence of cognitive impairment in very old age.

Populations should be prioritzed for research on reducing the burden of affective disorders based on expected or known burden or current level of unmet need for care. We recommend a focus on ethnic minorities, impoverished women, children, adolescents, and individuals with bipolar illness. Studying effectiveness of interventions and the efficiency of delivery systems are priorities for special popultions.