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Task sharing improves access to mental health care in many countries, but little formative research has examined uptake in the United States. This Open Forum proposes the development of nonspecialist professional roles to deliver low-intensity behavioral interventions for common mental health conditions in U.S. settings such as primary care. Using data from a multilevel stakeholder assessment, the authors discuss findings and challenges associated with such a role. Key themes from stakeholder surveys concerned scope of practice, competencies, pragmatic concerns, and training needs. Although stakeholders generally found this role to be acceptable and feasible, the themes raised will be critical to developing and implementing such a role.

There are a very limited number of sport-specific mental health and sport performance interventions available for athletes of color. This study examined The Optimum Performance Program in Sports (TOPPS) in a biracial adolescent athlete who was diagnosed with Agoraphobia and Social Anxiety Disorder. A multiple-baseline across behaviors case trial design was used to evaluate outcomes. A battery of psychological measures specific to mental health and sport performance was administered at baseline, post-intervention, and a 3-month follow-up. Social skill sets (i.e., positive assertion and negative assertion) were systematically targeted sequentially in a virtual format using HIPAA compliant video-conferencing technology to safeguard against contracting COVID-19. Results demonstrated improvement in negative and positive assertion skills when targeted by the intervention. Severity of concurrent symptoms associated with Social Anxiety Disorder and Agoraphobia Symptoms, general psychiatric functioning, relationships with coaches, teammates and family, and factors interfering with sports performance improved from pre- to post-intervention. These improvements were maintained at the 3-month follow-up. Athlete ratings indicated their satisfaction with TOPPS was high, and intervention components were implemented with high integrity.

A broader workforce is necessary to expand U.S. geriatric mental health services. We examined (1) feasibility of training undergraduate students to deliver Do More, Feel Better (DMFB), an evidence-informed program for depression; and (2) feasibility, acceptability, and outcomes in a single-arm proof-of-concept trial.In Study 1, we taught DMFB to 18 upper-level undergraduate students and assessed fidelity using role plays. In Study 2, four students delivered six weekly DMFB sessions to 12 community-dwelling older adults (Fidelity was high in the course (Study 1; 82.4% of role plays rated as 'passing') and the trial (Study 2; 100% of 24 sessions rated as 'passing'). The majority (83.3%) of patients were retained and evidenced statistically and clinically significant improvement in depressive symptoms (Hamilton Rating Scale for Depression [HAM-D]), disability (World Health Organization's Disability Assessment Schedule 2.0 [WHODAS 2.0], and activity (Behavioral Activation for Depression Scale [BADS]).It is feasible to train bachelor's-level students to deliver a brief, structured intervention for depression. Future research should consider implementation strategies and stakeholder feedback.

Self-objectification (i.e., valuing the body primarily for its attractiveness to others) is negatively related to physical health, including physical activity (PA) attitudes and behaviors. Given the low levels of PA among middle-aged adults in the US, self-objectification may be a novel correlate of PA in this population. The present study examined self-objectification and PA variables in a cross-sectional Western U.S. community sample of women (

Background Depressive disorders are among the most prevalent mental health conditions; however, significant barriers to treatment access persist. This study examined differences in depression outcomes between younger and older adults in a large-scale implementation demonstration of the collaborative care model (CoCM). Methods Secondary data analysis of a longitudinal, observational implementation demonstration at eight primary care clinics across low-resourced rural or frontier areas of the Western United States. Seven of these clinics were federally qualified health centers. The sample consisted of 3722 younger (18-64 years) and older (65+ years) adult primary care patients diagnosed with unipolar depression. All participants received depression treatment via CoCM, which enhances usual primary care and makes efficient use of specialists by using a behavioral healthcare manager and a psychiatric consultant to support primary care providers. Clinics were followed for up to 27 months. Patients were followed until they completed treatment or dropped out. The Patient Health Questionnaire (PHQ-9) assessed depressive symptoms at baseline (enrollment) and at most follow-up contacts. The primary treatment outcome was a change between a patient's first and last recorded PHQ-9 scores. Results Across both age groups, there was an average overall reduction of 6.9 points on the PHQ-9. Older adults demonstrated a greater decrease in depression scores of 2.06 points (95% CI -2.98 to -1.14, p Conclusions CoCM resulted in meaningful improvement in depressive symptoms across age groups.

Background and Objectives Although poor diet is a major driver of morbidity and mortality in people aged 60 and older, few dietary interventions are widely implemented for this population. We mapped behavior change theories, agents, and techniques in dietary interventions for adults aged 60 and older and explored relationships between these factors and ability to retain at least 80% of the study participants. Research Design and Methods We conducted a scoping review using MEDLINE, CINAHL, and Web of Science through April 2021 for dietary interventions in adults aged 60 and older. We collated, summarized, and calculated frequency distributions of behavior change theories, behavior change agents, and behavior change techniques (BCTs) using BCTv1 taxonomy with regard to participant retention across 43 studies. Results Only 49% and 30% of the studies reported behavior theory and change agents, respectively. Of the studies reporting on theory and agents, the most common were social cognitive theory and the related mechanism of self-efficacy. The most common BCTv1 clusters were “shaping knowledge” and “goals and planning.” Several BCTv1 clusters such as “antecedents” and “reward and threat” and evidence for concordance between BCTs and change agents were more common in interventions with higher retention rates. Discussion and Implications Mechanistically concordant studies with BCTs that involve resource allocation and positive reinforcement through rewards may be advantageous for retention in dietary intervention for older adults. Future studies should continue developing theory and mechanism-oriented research. Furthermore, future studies should consider diversifying the portfolio of currently deployed BCTs and strengthening a concordance between BCTs and mechanisms of change.

Background: Task sharing is an implementation strategy which increases access to services by training and supporting treatment delivery by nonspecialists. Such an approach has demonstrated effectiveness for depression and other mental health outcomes; however, few studies have examined lay counselors’ perspectives of the acceptability, feasibility, and appropriateness of delivering mental health interventions. We examine quantitative and qualitative reports of lay counselors’ experiences delivering a brief structured behavioral intervention for depression (called “Do More, Feel Better” [DMFB]) to older adults. Methods: All lay counselors (N = 4) who delivered DMFB completed quantitative measures assessing their perceptions of acceptability, feasibility, and appropriateness, and participated in a focus group, which provided insight into the quantitative ratings using an explanatory sequential mixed methods approach. Qualitative data were analyzed using thematic analysis and were double coded.Results: Lay counselors endorsed high acceptability, feasibility, and appropriateness of DMFB, with qualitative results providing some insight into specific barriers and facilitators which may be important to consider when planning to implement task sharing. Themes that emerged from qualitative data included supervision being highly acceptable and feasible, appropriateness of the intervention for lay counselors, and the feasibility of tailoring the intervention to clients. Lay counselors also expressed difficulty managing emotional investment in clients’ success and providing therapy during a pandemic and racial violence in the US.Conclusions: Our results can inform future implementation and sustainment of task sharing interventions to expand access to care.

Background and Objectives Identifying the experience of people with mild cognitive impairment (MCI) may help develop research agendas, interventions, and other supports to better match individuals’ needs. The purpose of this study was to explore the subjective experience of a “typical week” living with MCI to document (a) important activities, (b) barriers to usual activities, and (c) facilitators and supports. Research Design and Methods We conducted remote individual photo-elicitation interviews with 11 community-dwelling adults aged 55 years or older with MCI. Participants each provided 5–10 photographs of daily life taken over 1 week to facilitate a semistructured qualitative interview. Interview transcriptions were coded in Dedoose software and analyzed using thematic analysis. Results Participants shared photos and narratives highlighting the important activities in a typical week, in which physical activity, social engagement, spiritual and religious practice, hobbies, and cognitive stimulation were central. Many also shared disruptions to former routines and reduction of activities alongside increased use of new strategies and environmental supports (e.g., calendars, smartphones). Finally, emergent themes centered on disclosure of their diagnosis and reflections about the future. Discussion and Implications Participant-generated images aided data collection and facilitated discussion of sensitive topics with individuals with MCI. Such narratives may illustrate the needs and opportunities to promote well-being in individuals with MCI, including engagement in meaningful and health-promoting activities, assessing barriers to important daily activities, and considering supports that match the experience and needs of those with MCI.

Purpose: This proof-of-concept study assessed the feasibility, acceptability, and effectiveness of an intelligent tutoring system (ITS) as a classroom adjunct to improve training bachelor of social work (BSW) students in client engagement strategies. Methods: We codeveloped the ITS with 11 undergraduate students and pilot tested it with six BSW students enrolled in a class on telephone-based cognitive behavioral therapy (tCBT). Student competencies in tCBT were assessed by expert review of role-plays. We also examined time spent using ITS and relation with competency. Results: The majority of students (81.8%) in Wave 1 and all of the students who submitted role-plays in Wave 2 passed the clinical skills role-play. Students advancing through the ITS more quickly had better tCBT competency ratings than those progressing more slowly. Discussion: One of the most challenging aspects of training is how to competently deliver evidence-based practices. ITS has the potential to streamline and scale such training.

Effective psychotherapies for late-life depression are underutilized, mainly because of their complexity. “Engage” is a novel, streamlined psychotherapy that relies on neurobiology to identify core behavioral pathology of late-life depression and targets it with simple interventions, co-designed with community therapists so that they can be delivered in community settings. Consecutively recruited adults (≥60 years) with major depression (n = 249) were randomly assigned to 9 weekly sessions of “Engage” or to the evidence-based Problem-Solving Therapy (PST) offered by 35 trained community social workers and assessed by blind raters. “Engage” therapists required an average of 30% less training time to achieve fidelity to treatment than PST therapists and had one-third of the PST therapists’ skill drift. Both treatments led to reduction of HAM-D scores over 9 weeks. The mixed effects model-estimated HAM-D ratings were not significantly different between the two treatments at any assessment point of the trial. The one-sided 95% CI for treatment-end difference was (−∞, 0.07) HAM-D points, indicating a non-inferiority margin of 1.3 HAM-D points or greater; this margin is lower than the pre-determined 2.2-point margin. The two treatment arms had similar response (HR = 1.08, 95% CI (0.76, 1.52), p = 0.67) and remission rates (HR = 0.89, 95% CI (0.57, 1.39), p = 0.61). We conclude that “Engage” is non-inferior to PST. If disseminated, “Engage” will increase the number of therapists who can reliably treat late-life depression and make effective psychotherapy available to large numbers of depressed older adults.

Background Metabolic syndrome (MetS) is a prognostic cluster of physiologic risk factors that may develop into cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). Electrocardiogram abnormalities (ECGA) can be instrumental in identifying the early stages of disease and may be associated with MetS in Hispanic Americans. Objective To explore the relationships between MetS and major and minor ECGA in the Hispanic population (Hypothesis 1) and determine whether gender-ethnic subgroups moderate these relationships (Hypothesis 2). Methods This secondary data analysis was conducted using large-scale data from the cohort study Hispanic Community Health Study/Study of Latinos ( N = 13,628; 59% women and 41% men). Major ECGA encompassed 9 abnormalities including pathologic Q waves and left ventricular hypertrophy. Minor ECGA were tested independently of major ECGA. MetS was classified into 4 categories delineating metabolic abnormalities and related medication use. Multinomial logistic regression and Hayes’ PROCESS macro were used for statistical analysis. Results Major ECGA were significantly associated with the presence of MetS and/or related medication use, whereas minor ECGA abnormalities were associated with MetS for participants who also took MetS-related medications only. Gender moderated the association between MetS and minor ECGA such that women with minor ECGA had a higher likelihood of MetS when compared to men. Conclusions Findings suggest that early recognition and associated treatment of major and minor ECGA can be important to prevent MetS and further morbidities in the Hispanic population.

The Eating Disorder Examination Questionnaire (EDE-Q) was originally validated in non-Hispanic White women and has become widely used as an assessment tool for research on eating pathology in college students. However, the original factor structure has generally failed to replicate across various samples, especially among diverse populations. The current study examined the factor structure and measurement invariance of the EDE-Q in a large sample of racially/ethnically diverse college men and women.Participants included a diverse sample of men and women from two universities (N = 1981). Exploratory factory analysis (EFA) was conducted to examine the factor structure of the EDE-Q, followed by confirmatory factor analysis (CFA) to verify the factor structure, and establish the configural model. Furthermore, we explored the measurement invariance of the configural model by gender (i.e., men, women) and race/ethnicity (i.e., White, Black, Asian, Hispanic, and multiracial).EFA and CFA results suggested a three-factor, 10-item measure best fit the data, reflecting Dietary Restraint, Preoccupation and Eating Concern, and Shape/Weight Overvaluation. This measure achieved strict invariance by gender and race/ethnicity, indicating that mean comparisons across groups are meaningful. Women, relative to men, reported higher scores for all subscales. Significant differences across race/ethnicity emerged for Dietary Restraint and Shape/Weight Overvaluation in which Hispanic individuals endorsed the highest means compared to other racial/ethnic groups.The three-factor, 10-item measure is a brief, valid, and reliable measure of eating disorder psychopathology for U.S. college students.

About 46.6 million Americans have mental illnesses, yet profound treatment gaps exist in this country. Among those receiving treatment, most are treated solely with medication, even though >50% prefer to include psychotherapy in treatment. Other countries have changed policies to enhance access to evidence-based psychotherapy, resulting in availability and utilization reflective of patient preferences. To improve access to these treatments, the U.S. health care system would need to seek agreement among stakeholders regarding what constitutes effective treatment; enhance training, credentialing, and continuing education requirements; implement quality measures; integrate services into nontraditional venues; and incentivize best practices.

Background The acceptance of digital health technologies to support patient care for various clinical conditions among primary care providers and staff has not been explored. Objective The purpose of this study was to explore the extent of potential differences between major groups of providers and staff in primary care, including behavioral health consultants (BHCs; eg, psychologists, social workers, and counselors), primary care providers (PCPs; eg, physicians and nurse practitioners), and nurses (registered nurses and licensed practical nurses) in the acceptance of various health technologies (ie, mobile apps, wearables, live video, phone, email, instant chats, text messages, social media, and patient portals) to support patient care across a variety of clinical situations. Methods We surveyed 151 providers (51 BHCs, 52 PCPs, and 48 nurses) embedded in primary care clinics across the United States who volunteered to respond to a web-based survey distributed in December 2020 by a large health care market research company. Respondents indicated the technologies they consider appropriate to support patients’ health care needs across the following clinical contexts: acute and chronic disease, medication management, health-promoting behaviors, sleep, substance use, and common and serious mental health conditions. We used descriptive statistics to summarize the distribution of demographic characteristics by provider type. We used contingency tables to compile summaries of the proportion of provider types endorsing each technology within and across clinical contexts. This study was exploratory in nature, with the intent to inform future research. Results Most of the respondents were from urban and suburban settings (125/151, 82.8%), with 12.6% (n=19) practicing in rural or frontier settings and 4.6% (n=7) practicing in rural-serving clinics. Respondents were dispersed across the United States, including the Northeast (31/151, 20.5%), Midwest (n=32, 21.2%), South (n=49, 32.5%), and West (n=39, 25.8%). The highest acceptance for technologies across clinical contexts was among BHCs (32/51, 63%) and PCPs (30/52, 58%) for live video and among nurses for mobile apps (30/48, 63%). A higher percentage of nurses accepted all other technologies relative to BHCs and PCPs. Similarly, relative to other groups, PCPs indicated lower levels of acceptance. Within clinical contexts, the highest acceptance rates were reported among 80% (41/51) of BHCs and 69% (36/52) of PCPs endorsing live video for common mental health conditions and 75% (36/48) of nurses endorsing mobile apps for health-promoting behaviors. The lowest acceptance across providers was for social media in the context of medication management (9.3% [14/151] endorsement across provider type). Conclusions The survey suggests potential differences in the way primary care clinicians and staff envision using technologies to support patient care. Future work must attend to reasons for differences in the acceptance of various technologies across providers and clinical contexts. Such an understanding will help inform appropriate implementation strategies to increase acceptability and gain greater adoption of appropriate technologies across conditions and patient populations.

Objective Poor sleep is highly prevalent in inpatient medical settings and has been associated with attenuated healing and worsened outcomes following hospitalization. Although nonpharmacological interventions are preferred, little is known about the best way to intervene in hospital settings. Method A systematic review of published literature examining nonpharmacological sleep interventions among inpatients in Embase, PsycINFO and PubMed in accordance with PRISMA guidelines. Results Forty-three of the 1529 originally identified manuscripts met inclusion criteria, encompassing 2713 hospitalized participants from 18 countries comprised of psychiatric and older adult patients living in hospital settings. Main outcomes were subjective and objective measures of sleep duration, quality, and insomnia. Conclusions Overall, the review was unable to recommend any specific intervention due to the current state of the literature. The majority of included research was limited in quality due to lack of controls, lack of blinding, and reliance on self-reported outcomes. However, the literature suggests melatonin and CBT-I likely have the most promise to improve sleep in inpatient medical settings. Additionally, environmental modifications, including designated quiet time and ear plugs/eye masks, could be easily adopted in the care environment and may support sleep improvement. More rigorous research in nonpharmacological sleep interventions for hospitalized individuals is required to inform clinical recommendations.

Objectives This study examined the emotional distress and loneliness during COVID-19 and the roles of resiliency and activities. Design A cross-sectional national survey. Setting Amazon Mechanical Turk (mTurk) and Prolific Research Platforms. Participants Five hundred and one U.S. dwelling English-speaking adults 60 years old and older. Measurements Participants completed an online survey with the PHQ-9; GAD-7; Short Health Anxiety Inventory; 3-item UCLA Loneliness scale; PROMIS measures of global health, instrumental, and emotional support; 10-item Connor-Davidson Resilience Scale; and COVID-19 needs assessment. Results Across the sample 13% reported moderate depressive symptoms, 9% reported moderate anxiety symptoms, and 26% endorsed being “lonely.” The emotionally distressed group endorsed more loneliness, lower resiliency, less physical exercise, and worse physical health. The low Socio-Economic Status group endorsed less loneliness, less likely to engage in physical exercise and worse physical health.The lonely group endorsed less resilience, less physical exercise, and worse physical health. A multiple logistic regression found that resilience, socioeconomic status, and physical health were significant predictors of loneliness, whereas global health was the best predictor of emotional distress. Conclusions Even after prolonged social distancing, older adults in this study did not report greater psychological distress compared to earlier studies of older adults during COVID-19. Older adults with lower SES, worse physical health, and less resiliency, were more likely to report more loneliness. It is this group that should be the focus of intervention.

Objectives: Pain assessment and treatment is challenging among persons with dementia (PWDs). To better understand reports of pain interference, we examined ratings made by PWDs, as well as corresponding ratings about PWDs, as reported by the caregiver. We aimed to assess alignment between and predictors of caregiver and PWD report of pain interference. Methods: The sample consisted of 203 veterans with pain and mild to moderately severe dementia and an informal caregiver. Results: Most PWDs and their caregivers reported at least some pain interference and similar levels of pain interference. PWDs with greater cognitive impairment reported less pain interference, whereas caregivers who perceived the PWD to have greater depression reported more pain interference. Conclusions: PWD and caregiver characteristics were differentially associated with PWD versus caregiver report of pain interference. Results suggest the importance of caregiver reports to inform assessment, as well as factors complicating assessment. Pain in Dementia As one ages, the risk of developing both dementia and pain increases substantially (Scherder et al., 2009). It is estimated that 30% to 50% of persons with dementia (PWDs) experience persistent pain, a complex multifactor problem (Corbett et al., 2014). Despite the high prevalence of pain among older adults with dementia, and major advances in pain management, pain often remains unrecognized or undertreated (Hodgson et al., 2014).

Mental health and substance use disorders have traditionally held a lower priority than communicable and noncommunicable diseases such as cardiovascular disease and cancer. As global health began to shift from a focus on mortality alone to morbidity and associated burden in the 1990s, efforts to document and improve mental health became increasingly important. Mental health and substance use disorders comprise a substantial component of burden and disability. The chronicity of these disorders is particularly notable. This chapter presents the epidemiology of selected mental disorders in later life, which typically refers to ages 65 years and older. The focus is on both the prevalence of the most common mental disorders as well as a review of the evidence for associated risk factors for these conditions. We survey the epidemiology of disorders we deem most relevant to aging and mental health, with particular emphasis on depressive and neurocognitive disorders, given the prevalence and associated adverse outcomes in this age group.

Advances in technology have ushered in exciting potential for smartphone sensors to inform mental health care. This commentary addresses the practical challenges of collecting smartphone-based physical activity data. Using data (N = 353) from a large scale, fully remote randomized clinical trial for depression, we discuss findings and limitations associated with using passively collected mobility data to make inferences about depressive symptom severity. We highlight a range of issues in associating mobility data with mental health symptoms, including a high degree of variability, data featurization, granularity, and sparsity. Given the considerable efforts toward leveraging technology in mental health care, it is important to consider these challenges to optimize assessment and guide best practices. Clinical Trials.gov identifier: NCT01808976.

Depression is frequently comorbid with diabetes; however, less is known about this comorbidity in socially disadvantaged populations. This cross-sectional study examined depressive symptomatology among 424 patients with prediabetes or type 2 diabetes mellitus at a federally qualified health center. Prevalence of clinically significant depressive symptoms was assessed using the World Health Organization Five-Item Well-Being Index. The majority (67.7%) endorsed depressive symptoms, with greater prevalence among middle-aged adults (45–64 years) than younger or older counterparts. More women than men endorsed depressive symptoms. Findings suggest the need for routine depression screening in both prediabetes and type 2 diabetes mellitus, particularly among middle-aged and low-income individuals.

Cholinesterase inhibitors (ChEIs) are the primary pharmacological treatment for symptom management of Alzheimer disease (AD), but they carry known risks during long-term use, and do not guarantee clinical effects over time. The balance of risks and benefits may warrant discontinuation at different points during the disease course. Indeed, although there is limited scientific study of deprescribing ChEIs, clinicians routinely face practical decisions about whether to continue or stop medications. This review examined published practice recommendations for discontinuation of ChEIs in AD. To characterize the scientific basis for recommendations, we first summarized randomized controlled trials of ChEI discontinuation. We then identified practice guidelines by professional societies and in textbooks and classified them according to 1) whether they made a recommendation about discontinuation, 2) what the recommendation was, and 3) the proposed grounds for discontinuation. There was no consensus in guidelines and textbooks about discontinuation. Most recommended individualized discontinuation decisions, but there was essentially no agreement about what findings or situations would warrant discontinuation, or even about what domains to consider in this process. The only relevant domain identified by most guidelines and textbooks was a lack of response or a loss of effectiveness, both of which can be difficult to ascertain in the course of a progressive condition. Well-designed, long-term studies of discontinuation have not been conducted; such evidence is needed to provide a scientific basis for practice guidelines. It seems reasonable to apply an individualized approach to discontinuation while engaging patients and families in treatment decisions. .

OBJECTIVE Depressive symptoms in middle and later life are associated with an increased risk of greater medical morbidity (i.e., number of chronic health conditions). Yet little is known about mutual influences that may occur within married couples. This study examined the effects of wives' and husbands' depressive symptoms on their own and their partner's number of chronic health conditions over an 8-year period. It was also determined whether these effects varied by gender. METHOD The U.S. sample included 992 heterosexual couples (M = 63.58 years at baseline) drawn from 5 waves of the Health and Retirement Study (2006-2014). Dyadic growth curve models were estimated to evaluate the effects of own and partner baseline depressive symptoms on medical morbidity across time. Models controlled for baseline marital duration and negative marital quality along with age, education, minority status, health-related self-efficacy, body mass index, disability status, alcohol use, smoking, and moderate and vigorous physical activity. RESULTS Husbands' higher baseline depressive symptoms were significantly linked to their own higher number of chronic conditions. When wives had higher depressive symptoms at baseline, husbands showed significantly greater increases in their number of chronic conditions over time. Own and partner depressive symptoms were not significantly associated with baseline levels or changes in wives' number of chronic conditions. CONCLUSIONS This study demonstrates that depressive symptoms within middle-aged and older couples may have long-term associations with medical morbidity. Findings underscore the value of considering the implications of depressive symptoms for chronic health conditions among individuals and couples. (PsycINFO Database Record

Objective Executive dysfunction is the core neurocognitive deficit associated with late-life depression (LLD). This study identified changes in executive functioning during a structured behavioural treatment for depression in older adults and ascertained if pre-treatment executive dysfunction predicted treatment response. Method We analyzed data from a large multisite randomized controlled trial of structured behavioral psychotherapies (PST and Engage) for unipolar depression in adults ≥60 years. Participants were diagnosed with major depressive disorder and had Mini-Mental State Examination [MMSE] ≥24. Cognitive measures included the Stroop test, digit span, Iowa Gambling Task (IGT), and Wisconsin Card Sorting Test (WCST). Treatment response outcomes included pre- to post-treatment changes on the Hamilton Depression Rating Scale (HAM-D) and World Health Organization Disability Assessment Schedule II (WHODAS-II). One-way analysis of variance (ANOVA) assessed pre- and post-treatment changes in executive functioning measures across 9 weeks of treatment for 95 participants with complete data. Multiple linear regression models tested whether baseline measures of executive functioning predicted treatment response in (a) HAM-D depression and (b) WHODAS disability scores. Results A one-way ANOVA revealed improvements on IGT performance (Total Money) between baseline and week 9 post-treatment (F(1,186) = 7.00, p 0.05). Conclusion Baseline executive functioning did not predict treatment response (change in depressive symptoms or disability ratings). That is, individuals improved on treatment outcomes regardless of baseline executive dysfunction. In addition, results suggest that these approaches may actually improve real-life decision-making.

Late-life depression (LLD) is a public health concern with deleterious effects on overall health, cognition, quality of life, and mortality. Although LLD is relatively common, it is not a normal part of aging and is often under-recognized in older adults. However, psychotherapy is an effective treatment for LLD that aligns with many patients’ preferences and can improve health and functioning. This review synthesized the current literature on evidence-based psychotherapies for the treatment of depression in older adults. Findings suggest that active, skills-based psychotherapies (cognitive behavioral therapy [CBT] and problem-solving therapy [PST]) may be more effective for LLD than non-directive, supportive counseling. PST may be particularly relevant for offsetting skill deficit associated with LLD, such as in instances of cognitive impairment (especially executive dysfunction) and disability. Emerging treatments also consider contextual factors to improve treatment delivery, such as personalized care, access, and poverty. Tele-mental health represents one such exciting new way of improving access and uptake of treatment by older adults. Although these strategies hold promise, further investigation via randomized controlled trials and comparative effectiveness are necessary to advance our treatment of LLD. Priority should be given to recruiting and training the geriatric mental health workforce to deliver evidence-based psychosocial interventions for LLD.

BackgroundThis paper presents the protocol for the National Institute of Mental Health (NIMH)–funded University of Washington’s ALACRITY (Advanced Laboratories for Accelerating the Reach and Impact of Treatments for Youth and Adults with Mental Illness) Center (UWAC), which uses human-centered design (HCD) methods to improve the implementation of evidence-based psychosocial interventions (EBPIs). We propose that usability—the degree to which interventions and implementation strategies can be used with ease, efficiency, effectiveness, and satisfaction—is a fundamental, yet poorly understood determinant of implementation.ObjectiveWe present a novel Discover, Design/Build, and Test (DDBT) framework to study usability as an implementation determinant. DDBT will be applied across Center projects to develop scalable and efficient implementation strategies (eg, training tools), modify existing EBPIs to enhance usability, and create usable and nonburdensome decision support tools for quality delivery of EBPIs.MethodsStakeholder participants will be implementation practitioners/intermediaries, mental health clinicians, and patients with mental illness in nonspecialty mental health settings in underresourced communities. Three preplanned projects and 12 pilot studies will employ the DDBT model to (1) identify usability challenges in implementing EBPIs in underresourced settings; (2) iteratively design solutions to overcome these challenges; and (3) compare the solution to the original version of the EPBI or implementation strategy on usability, quality of care, and patient-reported outcomes. The final products from the center will be a streamlined modification and redesign model that will improve the usability of EBPIs and implementation strategies (eg, tools to support EBPI education and decision making); a matrix of modification targets (ie, usability issues) that are both common and unique to EBPIs, strategies, settings, and patient populations; and a compilation of redesign strategies and the relative effectiveness of the redesigned solution compared to the original EBPI or strategy.ResultsThe UWAC received institutional review board approval for the three separate studies in March 2018 and was funded in May 2018.ConclusionsThe outcomes from this center will inform the implementation of EBPIs by identifying cross-cutting features of EBPIs and implementation strategies that influence the use and acceptability of these interventions, actively involving stakeholder clinicians and implementation practitioners in the design of the EBPI modification or implementation strategy solution and identifying the impact of HCD-informed modifications and solutions on intervention effectiveness and quality.Trial RegistrationClinicalTrials.gov NCT03515226 (https://clinicaltrials.gov/ct2/show/NCT03515226), NCT03514394 (https://clinicaltrials.gov/ct2/show/NCT03514394), and NCT03516513 (https://clinicaltrials.gov/ct2/show/NCT03516513).International Registered Report Identifier (IRRID)DERR1-10.2196/14990

Although >10,000 behavioral health applications (“apps”) are currently available on the Apple and Google Play marketplaces, they have been minimally evaluated or regulated and little is known about “real world” usage patterns. This investigation combined data from online behavioral health app rating frameworks and a mobile health market research firm to identify the most downloaded apps as well as determine rating and ranking concordance between frameworks. Findings demonstrated that the most commonly downloaded apps focus on relaxation, mindfulness, and meditation skills and that they often have notably discordant reviews across rating frameworks. Our results suggest that there is a growing need for: (1) standardized behavioral health app quality and effectiveness measures, (2) up-to-date behavioral health app guidance for clinicians and consumers, and (3) evidence-based apps that incorporate revealed consumer preferences.

Several barriers complicate access to psychotherapy for depression, including time commitment, location of services, and stigma. Digital treatment has the potential to address these barriers, yet long term use of digital psychotherapy is poor. This paper presents data from a mixed-methods, online survey to document concerns patients with depression face when given the choice of in-person psychotherapy and digital psychotherapy. Participants were 164 adults living in the United States who had previously used or considered psychotherapy for depression. Rural-dwelling and racial/ethnic minority (Native American, African American, and Spanish-speaking) respondents were purposively sampled. Participants were asked their preferences for and opinions about four treatment modalities: self-guided digital, peer-supported digital, expert-guided digital, or in-person psychotherapy. Less than half (44.5%) of participants preferred in-person psychotherapy, 25.6% preferred self-guided digital treatment, 19.7% preferred expert-guided digital treatment, and 8.5% peer-supported digital treatment. Principal themes extracted from qualitative analysis centered on the efficacy of digital treatment, access to digital treatment, concerns about peer-supported care, confidentiality and privacy concerns, preference for in-person treatment, skepticism about self-guided therapy, and the impact of social anxiety on the use of video-chat based care. Future development of digital psychotherapy will need to address concerns regarding efficacy, privacy, data security, and methods to enhance motivation to use these treatments.

BackgroundSmartphones provide a low-cost and efficient means to collect population level data. Several small studies have shown promise in predicting mood variability from smartphone-based sensor and usage data, but have not been generalized to nationally recruited samples. This study used passive smartphone data, demographic characteristics, and baseline depressive symptoms to predict prospective daily mood.MethodDaily phone usage data were collected passively from 271 Android phone users participating in a fully remote randomized controlled trial of depression treatment (BRIGHTEN). Participants completed daily Patient Health Questionnaire-2. A machine learning approach was used to predict daily mood for the entire sample and individual participants.ResultsSample-wide estimates showed a marginally significant association between physical mobility and self-reported daily mood (B=-0.04, P0.50) for 80.6% of participants and very strong prediction in a subset (median AUC>0.80) for 11.8% of participants.ConclusionsPassive smartphone data with current features may not be suited for predicting daily mood at a population level because of the high degree of intra- and interindividual variation in phone usage patterns and daily mood ratings. Personalized models show encouraging early signs for predicting an individual's mood state changes, with GPS-derived mobility being the top most important feature in the present sample.

The mental status examination (MSE) is a structured assessment of the clinically relevant areas of a client’s behavioral, emotional, and cognitive functioning. It includes descriptions of the client’s overall appearance, comportment, and behavior; it also describes a client’s thought and perceptual processes and content, emotional state, and cognitive abilities, including level of consciousness, orientation and attention, and insight. By coalescing these important domains, the MSE paints a picture of the client at a given point in time.

BackgroundUsability – the extent to which an intervention can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction – is a key determinant of implementation success. However, usability is rarely assessed in implementation research and no instruments have been developed to measure the design quality of complex health interventions, such as the evidence-based psychosocial interventions that characterize the majority of effective practices in mental and behavioral health services. This study evaluated the structural validity of the Intervention Usability Scale (IUS), an adapted version of the well-established System Usability Scale for digital technologies, when measuring the usability of complex health interventions. Prior studies of the original System Usability Scale have found both one- and two-factor solutions, both of which were examined in the current study of the IUS.MethodsA survey was administered to 205 healthcare professionals working at 11 primary care sites. Surveys collected demographic information, including each participant’s professional role (i.e., medical provider, mental/behavioral health provider, pharmacist), and IUS ratings for one of six common evidence-based psychosocial interventions (e.g., cognitive behavioral therapy, motivational interviewing) that they reported using most regularly. Factor analyses replicated the procedures used in prior research on the System Usability Scale, and a sensitivity analysis using analyses of variance compared IUS scores across different groups of respondents and interventions assessed.ResultsAnalyses indicated that a two-factor solution (with “usable” and “learnable” subscales) in which one item was removed best fit the data. This solution accounted for 52.6% of the variance observed. Inter-item reliabilities for the total score, usable subscale, and learnable subscale were α = .83, α = .82, and α = .63, respectively. Resulting scores indicated that usability ranged from below acceptable standards to good, depending on the intervention. On average, behavioral health providers found the interventions to be more usable that other types of healthcare providers.ConclusionsThe current study provides evidence for a two-factor IUS structure consistent with some prior research, as well as acceptable reliability and sensitivity to role and intervention. Future directions for implementation research evaluating the usability of complex health interventions are discussed.Contributions to the Literature• The ease with which interventions can be readily adopted by service providers is a key predictor of implementation success, but very little implementation research has attended to intervention usability.• No instruments exist to evaluate the usability of complex health interventions, such as the evidence-based practices that are commonly used to integrate mental and behavioral health services into primary care.• The current study evaluated the first instrument for assessing the usability of complex health interventions and found that its factor structure replicated some research with the original version of the instrument, a scale developed to assess the usability of digital systems.

Although the majority of Veterans are overweight or obese, and many have comorbid mental health disorders, little is known about the most effective way to intervene in this complex population. This case describes a telephone-based cognitive-behavioral treatment for depression and weight management with an obese Veteran with bipolar disorder. His wife joined sessions to leverage spousal support. The Veteran evidenced variable levels of physical activity and mood fluctuations during treatment; although he reported some degree of positive behavior change and improved social support, he did not lose weight. He continued to endorse moderate levels of depressive symptomatology at the end of the nine-session intervention. This case illustrates the complexity of treating those with chronic serious mental illness and multimorbidities. Further research is needed to inform interventions that concurrently improve mental health symptomatology and weight-related outcomes in chronic, complex cases.

This cross-sectional study uses a novel “stickiness” measure to evaluate which mobile applications for smoking cessation, meditation, and other behavioral health areas are associated with long-term engagement.

Pain is highly prevalent in persons with dementia (PWDs), yet under detected and poorly treated. Pain interference, the degree to which pain interferes with a person’s ability to function, is a key measure of pain treatment outcomes. However, there has been little examination of pain interference in PWDs. Our study sought to identify factors that differentiate PWDs experiencing high versus low pain interference. The sample consisted of 92 community-dwelling PWDs and their caregivers that were randomized to receive a home-based 8-week psychosocial intervention to reduce aggression in PWDs with pain (versus enhanced primary care). Pain interference was assessed at the beginning of the first intervention session. The interventionist obtained caregiver/proxy report as to whether the PWD’s pain interfered with 6 activities (e.g., sleeping, daily chores). Pain interfering with 0 to 1 activities was classified as “low pain interference” (n=24) and pain interfering with 4 to 6 activities was classified as “high pain interference” (n=31); this selection resulted in a final sample of 55. Analyses compared the high and low pain interference groups (as defined by caregiver reports) on the following factors: PWD depression, caregiver burden, PWD-caregiver mutuality, and PWD demographics. Among the higher pain interference group, caregiver burden and PWD depression were significantly higher (t (53) = -2.14, p = .037 and t (52) = -3.41, p = .0013, respectively). Accurate assessment of pain in PWDs is challenging due to dementia’s effects on self-report; these findings may highlight the importance of obtaining caregiver-reported pain interference ratings.

Objective This study examined predictors of treatment outcome in a randomized controlled trial of brief cognitive-behavioral therapy (bCBT) for patients with a cardiopulmonary condition and comorbid, clinically significant symptoms of depression and/or anxiety. Method Only those who completed outcome assessments in the bCBT arm were studied (n = 132), to provide information about predictors of change in psychological symptoms. Multivariable linear regressions were conducted with baseline depression and anxiety symptoms, functional limitations, coping, self-efficacy, number of treatment sessions attended, and working alliance as potential predictors of change from pre- to postintervention on the dependent variables, depression [Patient Health Questionniare-9] and anxiety [Beck Anxiety Inventory]). Results Significant predictors of improvement in depression and anxiety included baseline mental health symptoms, physical health functional impairment, and self-efficacy. Coping, working alliance, and number of sessions attended were not associated with change in depression or anxiety. Conclusion Patients with greater physical functioning limitations and lower self-efficacy may experience less change in depression and anxiety during brief CBT. Future research should examine how to boost treatment effectiveness for patients with these characteristics. (PsycINFO Database Record

Background Progressive illnesses such as chronic obstructive pulmonary disease (COPD) impart a high level of physical and psychological burden. Evidence-based psychotherapies hold the potential to improve perceptions of physical health impairment, yet few studies have documented these effects. Purpose To evaluate the effect of brief cognitive behavioral therapy (bCBT) on disease-related illness intrusiveness. Methods Participants were 175 Veterans with COPD and clinically elevated symptoms of depression and/or anxiety enrolled in a larger randomized trial (n = 99 randomized to bCBT, n = 76 to enhanced usual care; EUC). bCBT included up to six treatment sessions and optional booster sessions over a 4-month period. EUC entailed an assessment with documentation in the medical record. Primary outcomes focused on posttreatment changes on the Illness Intrusiveness Rating Scale (IIRS), an established measure of perceived impairment from a chronic health condition. Results Illness intrusiveness improved for bCBT participants relative to EUC, after controlling for baseline IIRS scores, depression, and anxiety (p = .03, partial η2 = .03). Specific improvement was observed in the Instrumental subscale (p = .02), encompassing improved intrusiveness of COPD on daily activities and daily functioning. IIRS scores improved in the absence of changes in physical functioning. Conclusions Illness intrusiveness was high among Veterans with COPD but improved over the course of bCBT. Integrated behavioral health interventions hold the potential to reduce disease intrusiveness. The IIRS may be a valuable tool to augment traditional assessment and measurement-based care approaches of behavioral health interventions for medically ill patients.

BACKGROUND Most people with mental health disorders fail to receive timely access to adequate care. In the U.S., Hispanic/Latino individuals are particularly underrepresented in mental health care and are historically a very difficult population to recruit into clinical trials. However, U.S. Hispanic/Latinos have increasing access to mobile technology, with over 75% owning a smartphone. This technology has the potential to overcome known barriers to accessing and utilizing traditional assessment and treatment approaches. OBJECTIVE This is a feasibility clinical trial comparing three different types of mental health apps for the treatment of mild to moderate depression in Hispanic/Latino adults in the U.S. The primary aim of this study was to to compare recruitment and engagement in a fully remote trial of individuals with depression who either self-identify as Hispanic/Latino or not. A secondary aim was to assess treatment outcomes from three different self-guided mobile apps (iPST (based on evidence-based therapeutic principles from problem-solving therapy [PST])); Project: Evolution™ (EVO; a cognitive training app based on cognitive neuroscience principles); and Health Tips (health information app that served as an information control). METHODS Spanish- and English-speaking participants were recruited through social media platforms, internet-based advertisements, and traditional fliers in select locations in each state across the United States. Assessment and self-guided treatment was conducted on each participant's smartphone or tablet. We enrolled 389 Hispanic/Latino and 637 non-Hispanic/Latino adults (≥18 years old) with mild to moderate depression as determined by a 9-item Patient Health Questionnaire (PHQ-9) score ≥5 or an endorsement of impaired functioning. Participants were first asked their preferences among the three apps available to them, and then randomized to their top two choices. Outcomes were depressive symptom severity (measured using PHQ-9) and functional impairment (assessed with Sheehan Disability Scale) and collected over 3 months. Engagement in the study was assessed based on the number of times participants completed active surveys RESULTS We screened 4,502 participants and enrolled 1,040 participants from throughout the U.S. over 6 months, yielding a sample of 348 active users. The majority of the participants were recruited via posts on craigslist.org, with significant acquisition costs for recruiting Spanish-speaking Hispanic/Latinos participants ($31/ participant) compared to their English-speaking non-Hispanic/Latino counterparts ($1.49/participant). Long-term engagement surfaced as a key issue among Hispanic/Latino participants, who dropped from the study two weeks earlier than their non-Hispanic/Latino counterparts ( p CONCLUSIONS The findings from this study suggest that fully remote mobile-based studies can attract a diverse participant pool including people from traditionally underserved communities in mental health care and research (in this case, Hispanic/Latino individuals). However, keeping participants engaged in this type of ‘low-touch’ research study remains challenging. Hispanic/Latino populations may be less willing to use mobile apps for assessing and managing depression. We recommend that future research endeavors include the use of user-centered design to determine the role of mobile apps in assessment and treatment of depression for this population, app features they would be interested in using, and strategies for long-term engagement. CLINICALTRIAL Clinicaltrials.gov Identifier: NCT01808976

OBJECTIVE: To examine pain-related activity interference as a mediator for the relationship between pain intensity and depressive symptoms among older adults with serious mental illness (SMI). METHOD: Ordinary least-squares regressions were used to investigate the mediation analysis among older adults with SMI (n = 183) from community mental health centers. Analyses used secondary data from the HOPES intervention study. RESULTS: Higher pain intensity was associated with greater pain-related activity interference. Higher pain intensity and pain-related activity interference were also associated with elevated depressive symptoms. Finally, greater pain-related activity interference significantly mediated the association between higher pain intensity and elevated depressive symptoms. CONCLUSIONS: These findings demonstrate that pain and depressive symptoms may be linked to functional limitations. Clinicians and researchers in the mental health field should better address pain- related activity interference among older adults with SMI, especially among those with higher pain intensity and elevated depressive symptoms.

Mental Health conditions are now amongst the top five burdensome diseases in the US. Disparities in access to services and health outcomes vary due to several factors including socioeconomic status, shortage of mental health professionals, stigma and the linguistic gap between providers and non-English speaking minority population. This study explores the utility of providing Spanish (mono and bilingual) speaking Latino/Hispanics an option to access low-cost yet modern depression assessment and interventions available through smartphones. This is a fully remotely run study in order to investigate access, engagement, costs, and impact in an ecologically valid manner in a "real life" setting. The main purpose is to directly address issues of culture and language often overlooked in the digital health space, beginning with a thorough characterization of how these modern tools are perceived, utilized, and digested in the largest minority population in the US.

Multimorbidity (i.e., multiple chronic conditions) among middle-aged and older adults is an increasingly prevalent public health concern. Depressive symptoms are linked to a heightened risk of multimorbidity, yet little is known about mutual influences between depressive symptoms and chronic health conditions that may occur within aging couples. Utilizing a U.S. sample of 1,038 consistently married heterosexual couples (M = 63.51 years at baseline) drawn from five waves (1996 – 2014) of the nationally representative Health and Retirement Study (HRS), we examined the effects of wives’ and husbands’ baseline depressive symptoms (as assessed by the 8-item CES-D) on their own and their partner’s number of chronic conditions across an 8-year period. We also considered whether these links varied by gender. Dyadic growth curve models controlled for baseline length of marriage and marital quality along with age, education, minority status, body mass index, disability status, alcohol use, smoking status, and physical activity. For wives and husbands, elevated depressive symptoms at baseline were significantly linked to an overall higher number of chronic conditions. Beyond these associations, when wives had elevated depressive symptoms at baseline, husbands reported significant increases in their number of chronic conditions over time. This study demonstrates that depressive symptoms are linked to multimorbidity within aging couples, and that wives’ depressive symptoms may have long-term negative health consequences for husbands. Findings highlight the value of considering the health effects of depressive symptoms in middle and later life from both individual and couple perspectives.

Identify factors that predict improvement versus persistence of insomnia symptoms following treatment of obstructive sleep apnea (OSA) with positive airway pressure (PAP) therapy.Archival data from 68 PAP-treated sleep apnea patients aged 25-83 were analyzed using nonparametric tests and stepwise regression to assess the relationships between insomnia symptoms, multiple OSA variables, and PAP use over time.Pretreatment insomnia symptom severity (ISS; b = -0.72, p0.001), PAP average use (b = -0.01, p = 0.01) and respiratory disturbance index (RDI; b = -0.02, p = 0.03) predict change in insomnia following PAP therapy. Forty-five percent (24/53) of the subjects with moderate to severe insomnia at pretreatment reported no/mild symptoms after PAP therapy and were considered improved. Improved subjects had lower pretreatment ISS (p0.001), higher RDI (p = 0.01), and higher average PAP use (p0.035) than subjects with persistent insomnia. Number of medications and comorbidities were similar between improved and persistent groups. New onset of insomnia symptoms occurred in 13% (2/15) of the patients with no/mild pretreatment insomnia.Although ISS declines following PAP treatment, 55% of OSA patients have persistent moderate to severe symptoms despite treatment. More severe OSA is linked to higher likelihood of insomnia improvement and the effect of PAP therapy on insomnia may be mediated by OSA severity. Persistent insomnia is unrelated to medication use or comorbidities and may represent an independent, self-sustaining disorder requiring targeted intervention.