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Objectives: In older U.S. nursing home residents with suicidal ideation (SI), limited studies have longitudinally investigated their health changes as related to cognitive function. This study aimed to identify the health profiles and the transitions between profiles at admission and 90-days and examine the associations with cognitive impairment., Methods: Using Minimum Data Set 3.0 (2011-15), we identified 10,079 older residents without severe cognitive impairment who reported SI on Patient Health Questionnaire-9. Health profile indicators included at-admission and 90-day post-admission depressive symptoms, frailty, and pain frequency and intensity. Using latent transition analysis, we identified distinct health profiles, examined the transitions between profiles over time, and estimated their associations with cognitive impairment., Results: One third of residents continued to report SI at 90 days. The five health profiles identified at admission were distinctive with varying levels of frailty, depressive symptoms, and pain, from the most severe Profile 1 characterized by frailty, all depressive symptoms, and horrible or frequent pain, to the least severe Profile 5 characterized by pre-frailty, depressed mood, and no pain. The 90-day profiles were mostly consistent. Most residents remained in a similar profile over time. Relative to residents with intact cognition/mild cognitive impairment, those with moderate impairment were less likely to belong to profiles characterized by more depressive symptoms and pain., Conclusions: Residents with SI had heterogeneous health profiles, which varied by cognitive impairment levels, but showed minimal changes despite being in a medically supervised setting. Findings highlighted the critical need for adequate recognition and management of SI in nursing homes., (© 2024 John Wiley & Sons Ltd.)

Objectives: Identify the health profiles of older nursing home residents with and without at-admission self-reported suicidal ideation (SI) and examine the association between the identified profiles and self-reported SI at 90 days., Methods: Using the Minimum Data Set 3.0 and the ninth Patient Health Questionnaire-9 (PHQ-9) item, we identified 15,277 older residents with and 562,184 without self-reported SI at nursing home admission. Latent class analysis, using frailty, cognitive impairment, palliative care index, pain, and remaining PHQ-9 items as indicators, identified health profiles by at-admission SI and the BCH method estimated their association with SI at 90 days., Results: Profiles identified for residents without at-admission SI were: (1) frail and depressed NoSI (prevalence: 33.9%); (2) frail and severe cognitive impairment NoSI (38.1%); (3) pre-frail NoSI (28.0%). Residents in the frail and depressed NoSI group had greater odds [adjusted OR: 2.80; 95% Confidence Interval: 2.60-3.00] while those in the frail and severe cognitive impairment NoSI group had lower odds [aOR: 0.79; 95% CI: 0.71-0.86] of 90-day SI than those in the pre-frail NoSI group. Profiles identified for residents with at-admission SI were: (1) frail and all depressive symptoms SI (22.8%); (2) frail and some depressive symptoms SI (32.2%); (3) frail and severe cognitive impairment SI (22.9%); (4) pre-frail SI (22.0%). Compared to those in the pre-frail SI group, residents in the frail and all depressive symptoms SI group had greater odds of continuing reporting SI at 90 days [aOR: 1.22; 95% CI:1.09-1.35]., Conclusions: Findings indicated unique health profiles of nursing home residents at higher risk of new onset of or continued SI., (© 2022 John Wiley & Sons Ltd.)

Objective: To estimate overall prevalence of bipolar disorder (BD) and the prevalence and timing of bipolar-spectrum mood episodes in perinatal women., Data Sources: Databases (PubMed, Scopus, PsycINFO, CINAHL, Cochrane, ClincalTrials.gov) were searched from inception to March 2020., Study Selection: Included studies were original research in English that had (1) populations of perinatal participants (pregnant or within 12 months postpartum), aged ≥ 18 years, and (2) a screening/diagnostic tool for BD. Search terms described the population (eg, perinatal ), illness (eg, bipolar disorder ), and detection (eg, screen , identify )., Data Extraction: Study design data, rates, and timing of positive screens/diagnoses and mood episodes were extracted by 3 independent reviewers. Pooled prevalences were estimated using random-effects meta-analyses., Results: Twenty-two articles were included in qualitative review and 12 in the meta-analysis. In women with no known psychiatric illness preceding the perinatal period, pooled prevalence of BD was 2.6% (95% CI, 1.2%-4.5%) and prevalence of bipolar-spectrum mood episodes (including depressed, hypomanic/manic, mixed) during pregnancy and the postpartum period was 20.1% (95% CI, 16.0%-24.5%). In women with a prior BD diagnosis, 54.9% (95% CI, 39.2%-70.2%) were found to have at least one bipolar-spectrum mood episode occurrence in the perinatal period., Conclusions: Our review suggests that the perinatal period is associated with high rates of bipolar-spectrum mood episodes and that pregnant and postpartum women represent a special risk population. This review may help to inform clinical care recommendations, thus helping to identify those who may have., (© Copyright 2022 Physicians Postgraduate Press, Inc.)

Objective: This cross-sectional study examined the association between nursing home quality and admission of working-age persons (ages 22-64 years) with serious mental illness., Methods: The study used 2015 national Minimum Data Set 3.0 and Nursing Home Compare (NHC) data. A logistic mixed-effects model estimated the likelihood (adjusted odds ratios [AORs] and 95% confidence intervals [CIs]) of a working-age nursing home resident having serious mental illness, by NHC health inspection quality rating. The variance partition coefficient (VPC) was calculated to quantify the variation in serious mental illness attributable to nursing home characteristics. Measures included serious mental illness (i.e., schizophrenia, bipolar disorder, and other psychotic disorders), health inspection quality rating (ranging from one star, below average, to five stars, above average), and other sociodemographic and clinical covariates., Results: Of the 343,783 working-age adults newly admitted to a nursing home in 2015 (N=14,307 facilities), 15.5% had active serious mental illness. The odds of a working-age resident having serious mental illness was lowest among nursing homes of above-average quality, compared with nursing homes of below-average quality (five-star vs. one-star facility, AOR=0.78, 95% CI=0.73-0.84). The calculated VPC from the full model was 0.11., Conclusions: These findings indicate an association between below-average nursing homes and admission of working-age persons with serious mental illness, suggesting that persons with serious mental illness may experience inequitable access to nursing homes of above-average quality. Access to alternatives to care, integration of mental health services in the community, and improving mental health care in nursing homes may help address this disparity.

Objectives: Persons aged <65 years account for a considerable proportion of US nursing home residents with schizophrenia. Because they are often excluded from psychiatric and long-term care studies, a contemporary understanding of the characteristics and management of working-age adults (22-64 years old) with schizophrenia living in nursing homes is lacking. This study describes characteristics of working-age adults with schizophrenia admitted to US nursing homes in 2015 and examines variations in these characteristics by age and admission location. Factors associated with length of stay and discharge destination were also explored., Design: This is a cross-sectional study using the Minimum Data Set 3.0 merged to Nursing Home Compare., Setting and Participants: This study examines working-age (22-64 years) adults with schizophrenia at admission to a nursing home., Methods: Descriptive statistics of resident characteristics (sociodemographic, clinical comorbidities, functional status, and treatments) and facility characteristics (ownership, geography, size, and star ratings) were examined overall, stratified by age and by admission location. Generalized estimating equation models were used to explore the associations of age, discharge to the community, and length of stay with relevant resident and facility characteristics. Coefficient estimates, adjusted odds ratios, and 95% CIs are presented., Results: Overall, many of the 28,330 working-age adults with schizophrenia had hypertension, diabetes, and obesity. Those in older age subcategories tended to have physical functional dependencies, cognitive impairments, and clinical comorbidities. Those in younger age subcategories tended to exhibit higher risk of psychiatric symptoms., Conclusions and Implications: Nursing home admission is likely inappropriate for many nursing home residents with schizophrenia aged <65 years, especially those in younger age categories. Future psychiatric and long-term care research should include these residents to better understand the role of nursing homes in their care and should explore facility-level characteristics that may impact quality of care., (Copyright © 2021. Published by Elsevier Inc.)

Background: U.S. nursing homes provide long-term care to over 1.2 million older adults, 60% of whom were physically frail and 68% had moderate or severe cognitive impairment. Limited research has examined the longitudinal experience of these two conditions in older nursing home residents., Methods: This national longitudinal study included newly-admitted non-skilled nursing care older residents who had Minimum Data Set (MDS) 3.0 (2014-16) assessments at admission, 3 months, and 6 months (n = 266,001). Physical frailty was measured by FRAIL-NH and cognitive impairment by the Brief Interview for Mental Status. Separate sets of group-based trajectory models were fitted to identify the trajectories of physical frailty and trajectories of cognitive impairment, and to estimate the association between older residents' characteristics at admission with each set of trajectories. A dual trajectory model was used to quantify the association between the physical frailty trajectories and cognitive impairment trajectories., Results: Over the course of the first six months post-admission, five physical frailty trajectories ["Consistently Frail" (prevalence: 53.0%), "Consistently Pre-frail" (29.0%), "Worsening Frailty" (7.6%), "Improving Frailty" (5.5%), and "Consistently Robust" (4.8%)] and three cognitive impairment trajectories ["Consistently Severe Cognitive Impairment" (35.5%), "Consistently Moderate Cognitive Impairment" (31.8%), "Consistently Intact/Mild Cognitive Impairment" (32.7%)] were identified. One in five older residents simultaneously followed the trajectories of "Consistently Frail" and "Consistently Severe Cognitive Impairment". Characteristics associated with higher odds of the "Improving Frailty", "Worsening Frailty", "Consistently Pre-frail" and "Consistently Frail" trajectories included greater at-admission cognitive impairment, age ≥ 85 years, admitted from acute hospitals, cardiovascular/metabolic diagnoses, neurological diagnoses, hip or other fractures, and presence of pain. Characteristics associated with higher odds of the "Consistently Moderate Cognitive Impairment" and "Consistently Severe Cognitive Impairment" included worse at-admission physical frailty, neurological diagnoses, hip fracture, and receipt of antipsychotics., Conclusions: Findings provided information regarding the trajectories of physical frailty, the trajectories of cognitive impairment, the association between the two sets of trajectories, and their association with residents' characteristics in older adults' first six months post-admission to U.S. nursing homes. Understanding the trajectory that the residents would most likely follow may provide information to develop a comprehensive care approach tailored to their specific healthcare goals., (© 2022. The Author(s).)

Introduction: Suicide is a leading cause of mortality in the United States and recent initiatives have sought to increase monitoring of suicide risk within healthcare systems. Working-age adults (22-64 years) admitted to nursing homes may be at risk for suicidal ideation, yet little is known about this population., Methods: The national nursing home database, Minimum Dataset 3.0, was used to identify 323,436 working-age adults newly admitted to a nursing home in 2015. This cross-sectional study sought to describe sociodemographic and clinical characteristics, examine behavioral health treatment received, and determine resident characteristics associated with suicidal ideation at nursing home admission using logistic regression and reports adjusted odds ratios (aOR)., Results: Suicidal ideation was present among 1.27% of newly admitted working-age residents. Almost 25% of those with suicidal ideation had no psychiatric diagnosis. Factors associated with increased odds of suicidal ideation included younger age (aOR 1.90), admission from the community (aOR 1.92) or a psychiatric hospital (aOR 2.38), cognitive impairments (aOR 1.46), pain (aOR 1.40), rejection of care (aOR 1.91), and psychiatric comorbidity (aOR depression: 1.91, anxiety disorder: 1.11, bipolar disorder: 1.62, schizophrenia: 1.32, post-traumatic stress disorder: 1.17)., Limitations: Due to the cross-sectional nature of this study, no causal inferences about suicidal ideation and the explored covariates can be made. The Minimum Dataset 3.0 has only one measure of suicidal ideation the Patient Health Questionnaire., Conclusion: Factors other than psychiatric diagnosis may be important in identifying newly admitted working-age nursing home residents who require on-going suicide screening and specialized psychiatric care., (Copyright © 2021. Published by Elsevier B.V.)

Objective: To elicit the perspectives of individuals with a traumatic birth experience on barriers and facilitators to receiving mental health support in the postpartum period., Methods: Individuals who experienced a traumatic birth within the last three years (n = 32) completed semi-structured phone interviews about their birth and postpartum experience. The Post-traumatic Stress Disorder Checklist for DSM-V (PCL-5), Patient Health Questionnaire (PHQ-8), and Generalized Anxiety Disorder scale (GAD-7) were administered. Qualitative data was analyzed using a modified grounded theory by three independent coders., Results: Among participants, 34.4% screened positive for PTSD, 18.8% for depression, and 34.4% for anxiety. Participants described multi-level barriers that prevented clinicians from recognizing and supporting patients' postpartum mental health needs; those involved lack of communication, education, and resources. Recommendations from participants included that 1) obstetric professionals should acknowledge birth-related trauma experienced by any individual, 2) providers of multiple disciplines need to be integrated into postpartum care, and 3) mental health support may be needed before the ambulatory postpartum visit., Conclusions: There are multi-level barriers towards detecting and responding to individuals' mental health needs after a traumatic birth. Obstetric professionals need to use a trauma-informed approach and proactively assess mental health throughout the postpartum period., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To longitudinally examine the latent statuses of depressive symptoms and their association with cognitive impairment in older U.S. nursing home (NH) residents., Method: Using Minimum Data Set 3.0, newly-admitted, long-stay, older NH residents with depression in 2014 were identified ( n  = 88,532). Depressive symptoms (Patient Health Questionnaire-9) and cognitive impairment (Brief Interview of Mental Status) were measured at admission and 90 days. Latent transition analysis was used to examine the prevalence of and the transition between latent statuses of depressive symptoms from admission to 90 days, and the association of cognitive impairment with the statuses at admission., Results: Four latent statuses of depressive symptoms were identified: ' Multiple Symptoms ' (prevalence at admission: 17.3%; 90 days: 13.6%), ' Depressed mood ' (20.0%; 19.5%), ' Fatigue ' (27.4%; 25.7%), and ' Minimal Symptoms ' (35.3%; 41.2%). Most residents remained in the same status from admission to 90 days. Compared to residents who were cognitively intact, those with moderate impairment were more likely to be in ' Multiple Symptoms ' and ' Fatigue ' statuses; those with severe impairment had lower odds of belonging to ' Multiple Symptoms ', ' Depressed Mood ', and ' Fatigue ' statuses., Conclusion: By addressing the longitudinal changes in the heterogeneous depressive symptoms and the role of cognitive impairment, findings have implications for depression management in older NH residents.

Background: Little is known about the heterogeneous clinical profile of physical frailty and its association with cognitive impairment in older U.S. nursing home (NH) residents., Methods: Minimum Data Set 3.0 at admission was used to identify older adults newly-admitted to nursing homes with life expectancy ≥6 months and length of stay ≥100 days (n = 871,801). Latent class analysis was used to identify physical frailty subgroups, using FRAIL-NH items as indicators. The association between the identified physical frailty subgroups and cognitive impairment (measured by Brief Interview for Mental Status/Cognitive Performance Scale: none/mild; moderate; severe), adjusting for demographic and clinical characteristics, was estimated by multinomial logistic regression and presented in adjusted odds ratios (aOR) and 95% confidence intervals (CIs)., Results: In older nursing home residents at admission, three physical frailty subgroups were identified: "mild physical frailty" (prevalence: 7.6%), "moderate physical frailty" (44.5%) and "severe physical frailty" (47.9%). Those in "moderate physical frailty" or "severe physical frailty" had high probabilities of needing assistance in transferring between locations and inability to walk in a room. Residents in "severe physical frailty" also had greater probability of bowel incontinence. Compared to those with none/mild cognitive impairment, older residents with moderate or severe impairment had slightly higher odds of belonging to "moderate physical frailty" [aOR (95%CI) moderate cognitive impairment : 1.01 (0.99-1.03); aOR (95%CI) severe cognitive impairment : 1.03 (1.01-1.05)] and much higher odds to the "severe physical frailty" subgroup [aOR (95%CI) moderate cognitive impairment : 2.41 (2.35-2.47); aOR (95%CI) severe cognitive impairment : 5.74 (5.58-5.90)]., Conclusions: Findings indicate the heterogeneous presentations of physical frailty in older nursing home residents and additional evidence on the interrelationship between physical frailty and cognitive impairment., (© 2021. The Author(s).)

Monoclonal gammopathy of undetermined significance (MGUS), precursor of multiple myeloma, is an asymptomatic plasma cell disorder that overproduces serum monoclonal protein. Older age, male sex, black race, and family history of MGUS increase the risk of MGUS, yet other risk factors are known. We systematically reviewed observational epidemiological studies that examined sociodemographic, clinical, and behavioral risk factors for the development of MGUS. The protocol for this study was registered on the PROSPERO registry for systematic reviews. We identified epidemiological studies from PubMed and Scopus. Articles were limited to those written in English and published before February 2019. Five case-control and three cohort studies were eligible for data extraction. Studies evaluating factors associated with MGUS risk are limited, with conflicting conclusions regarding risk associated with obesity. Despite the limited research, a significant elevated risk for being diagnosed with MGUS was associated with several specific prior infections, inflammatory disorders, and smoking. The sparse existing literature suggests an increased risk of MGUS associated with several risk factors related to immune function. Further research is needed to explore the potential mechanisms underlying the development of MGUS and to confirm risk factors, both modifiable and non-modifiable.

Introduction: In older US nursing home (NH) residents, there is limited research on the prevalence of physical frailty, its potential dynamic changes, and its association with cognitive impairment in older adults' first 6 months of NH stay., Methods: Minimum Data Set (MDS) 3.0 is the national database on residents in US Medicare-/Medicaid-certified NHs. MDS 3.0 was used to identify older adults aged ≥65 years, newly admitted to NHs during January 1, 2014, and June 30, 2016, with life expectancy ≥6 months at admission and NH length of stay ≥6 months (N = 571,139). MDS 3.0 assessments at admission, 3 months, and 6 months were used. In each assessment, physical frailty was measured by FRAIL-NH (robust, prefrail, and frail) and cognitive impairment by Brief Interview for Mental Status and Cognitive Performance Scale (none/mild, moderate, and severe). Demographic characteristics and diagnosed conditions were measured at admission, while presence of pain and receipt of psychotropic medications were at each assessment. Distribution of physical frailty and its change over time by cognitive impairment were described. A nonproportional odds model was fitted with a generalized estimation equation to longitudinally examine the association between physical frailty and cognitive impairment, adjusting for demographic and clinical characteristics., Results: Around 60% of older residents were physically frail in the first 6 months. Improvement and worsening across physical frailty levels were observed. Particularly, in those who were prefrail at admission, 23% improved to robust by 3 months. At admission, 3 months, and 6 months, over 37% of older residents had severe cognitive impairment and about 70% of those with cognitive impairment were physically frail. At admission, older residents with moderate cognitive impairment were 35% more likely (adjusted odds ratio [aOR]: 1.35, 95% confidence interval [CI]: 1.33-1.37) and those with severe impairment were 74% more likely (aOR: 1.74, 95% CI: 1.72-1.77) to be frail than prefrail/robust, compared to those with none/mild impairment. The association between the 2 conditions remained positive and consistently increased over time., Discussion/conclusion: Physical frailty was prevalent in NHs with potential to improve and was strongly associated with cognitive impairment. Physical frailty could be a modifiable target, and interventions may include efforts to address cognitive impairment., (© 2021 S. Karger AG, Basel.)

Objectives: To identify subgroups of nursing home (NH) residents in the USA experiencing homogenous depression symptoms and evaluate if subgroups vary by cognitive impairment., Methods: We identified 104 465 newly admitted, long-stay residents with depression diagnosis at NH admission in 2014 using the Minimum Data Set 3.0. The Patient Health Questionnaire-9 was used to measure depression symptoms and the Brief Interview of Mental Status for cognitive impairment (intact; moderately impaired; severely impaired). Latent class analysis (LCA) with logistic regression was used to: (a) construct the depression subgroups and (b) estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) of the associations between the subgroups and cognitive impairment level, adjusting for demographic and clinical characteristics., Results: The best-fitted LCA model suggested four subgroups of depression: minimal symptoms (latent class prevalence: 42.4%), fatigue (32.0%), depressed mood (14.5%), and multiple symptoms (11.2%). Odds of subgroup membership varied by cognitive impairment. Compared to residents with intact cognition, those with moderate or severe cognitive impairment were less likely to belong to the fatigue subgroup [aOR(95% CI): moderate: 0.75 (0.71-0.80); severe: 0.26 (0.23-0.29)] and more likely to belong to the depressed mood subgroup [aOR (95% CI): moderate: 4.54 (3.55-5.81); severe: 6.41 (4.86-8.44)]. Residents with moderate cognitive impairment had increased odds [aOR (95% CI): 1.19 (1.12-1.27)] while those with severe impairment had reduced odds of being in the multiple symptoms subgroup [aOR (95% CI): 0.63 (0.58-0.68)]., Conclusions: Findings provide a basis for improving depression management with consideration of both subgroups of depression symptoms and levels of cognitive function., (© 2020 John Wiley & Sons Ltd.)

Background and Objectives: Nursing homes remain subjected to institutional racial segregation in the United States. However, a standardized approach to measure segregation in nursing homes does not appear to be established. A systematic review was conducted to identify all formal measurement approaches to evaluate racial segregation among nursing home facilities, and to then identify the association between segregation and quality of care in this context., Research Design and Methods: PubMed, Scopus, and Web of Science databases were searched (January 2018) for publications relating to nursing home segregation. Following the PRISMA guidelines, studies were included that formally measured racial segregation of nursing homes residents across facilities with regional-level data., Results: Eight studies met the inclusion criteria. Formal segregation measures included the Dissimilarity Index, Disparities Quality Index, Modified Thiel's Entropy Index, Gini coefficient, and adapted models. The most common data sources were the Minimum Data Set (MDS; resident-level), the Certification and Survey Provider Enhanced Reporting data (CASPER; facility-level), and the Area Resource File/ U.S. Census Data (regional-level). Most studies showed evidence of racial segregation among U.S. nursing home facilities and documented a negative impact of segregation on racial minorities and facility-level quality outcomes., Discussion and Implications: The measurement of racial segregation among nursing homes is heterogeneous. While there are limitations to each methodology, this review can be used as a reference when trying to determine the best approach to measure racial segregation in future studies. Moreover, racial segregation among nursing homes remains a problem and should be further evaluated., (© The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Prior studies of healthy populations have found religious practices to be associated with survival. However, no contemporary studies have examined whether religiosity influences survival among patients discharged from the hospital after an acute coronary syndrome (ACS). The present study examined the relationship between religious practices and 2-year all-cause mortality among hospital survivors of an ACS., Methods: Patients hospitalized for an ACS were recruited from 6 medical centers in Massachusetts and Georgia between 2011 and 2013. Study participants self-reported three items assessing religiosity: strength/comfort from religion, petition prayers for health, and awareness of intercessory prayers by others. All cause-mortality within 2-years of hospital discharge was ascertained by review of medical records at participating study hospitals and from death certificates. Cox proportional hazards models were used to estimate the multivariable adjusted risk of 2-year all-cause mortality., Results: Participants (n = 2,068) were on average 61 years old, 34% were women, and 81% were non-Hispanic White. Approximately 85% derived strength/comfort from religion, 61% prayed for their health, and 89% were aware of intercessions. Overall, 6% died within 2 years post-discharge. After adjusting for sociodemographic variables (age, sex, and race/ethnicity), petition prayers were associated with an increased risk of 2-year all-cause mortality (HR: 1.64; 95% CI: 1.01-2.66). With further adjustment for several clinical and psychosocial measures, this association was no longer statistically significant. Strength and comfort from religion and intercessory prayers were not significantly associated with mortality., Conclusions: Most ACS survivors acknowledge deriving strength and comfort from religion, praying for their health, and intercessions made by others for their health. Although the reported religious practices were not associated with post-discharge survival after multivariable adjustment, acknowledging that patients utilize their religious beliefs and practices as strategies to improve their health would ensure a more holistic approach to patient management and promote cultural competence in healthcare., Competing Interests: Dr. David McManus receives sponsored research support from Bristol Myers Squibb, Pfizer, Biotronik, Boehringer Ingelheim, and has consulted for Bristol Myers Squibb, Pfizer, Samsung Electronics, and FlexCon. This does not alter our adherence to PLOS ONE policies on sharing data and materials. The other authors declare no potential conflict of interest.

Objectives: To examine the association between nursing home (NH) quality and new onset of depression and severity of depressive symptoms in a national cohort of long-stay NH residents in the United States., Design: Cohort study., Setting and Participants: 129,837 long-stay residents without indicators of depression admitted to 13,921 NHs., Methods: NH quality was measured by Nursing Home Compare star ratings (overall, health inspection, staffing, quality measures) closest to admission. Study outcomes at 90 days from the Minimum Data Set 3.0 included depression diagnosis and severity of depressive symptoms (minimal; mild; moderate; moderately severe/severe). Symptoms were measured by resident self-report Patient Health Questionnaire (PHQ-9) or a staff-report observational version (PHQ-9-OV). Logistic and multinomial logistic models with generalized estimating equations were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs)., Results: At 90 days postadmission, 14.1% of residents had a new diagnosis of depression, and odds did not differ across star ratings. Nearly 90% of these residents had minimal depressive symptoms, with only 8.5% reporting mild symptoms and 2.6% with moderate to severe symptoms. Using minimal depressive symptoms as the reference, residents in NHs with 5-star overall ratings were 12% less likely than those in 3-star NHs to experience mild (95% CI: 0.81-0.96) and 31% less likely to experience moderate symptoms (95% CI: 0.58-0.82). In NHs with 1-star staffing compared to 3-star, residents had 37% higher odds of moderate symptoms (95% CI: 1.14-1.64) and 57% higher odds of moderately severe to severe depressive symptoms (95% CI: 1.17-2.12). The odds of any above-minimal depressive symptoms decreased as quality measure ratings increased., Conclusions/implications: Lower NH quality ratings were associated with more severe depressive symptoms. Further investigation is warranted to identify potential mechanisms for a targeted intervention to improve quality and provide more equitable care., (Copyright © 2019 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Our objective was to describe the prevalence of adjuvants to opioid therapy and changes in these agents for pharmacologic management in nursing home residents with cancer., Methods: We included Medicare beneficiaries with cancer and documented opioid use at nursing home admission in 2011-2013 (N = 3268). The Minimum Data Set 3.0 provided information on sociodemographic and clinical characteristics. Part D claims provided information on opioid and adjuvant use during the 7 days after admission and 90 days later. Proportions of changes in these agents were estimated. Separate logistic models estimated associations between resident characteristics and (1) use of adjuvants at admission and (2) intensification of pharmacologic management at 90 days., Results: Nearly 20% of patients received adjuvants to opioids at admission, with gabapentin the most common adjuvant (34.4%). After 90 days, approximately 25% had maintained or intensified pharmacologic management. While advanced age (≥ 85 vs. 65-74 years, adjusted odds ratio [aOR] 0.80; 95% confidence interval [CI] 0.63-1.02) and comorbidities, including dementia (aOR 0.65; 95% CI 0.53-0.82) and depression (aOR 1.55; 95% CI 1.29-1.87), were associated with adjuvant use at admission, worse cognitive impairment (severe vs. no/mild, aOR 0.80; 95% CI 0.64-0.99) and presence of more severe pain (moderate/severe vs. no pain, aOR 1.60; 95% CI 1.26-2.03) were associated with intensification of drug regimen., Conclusion: Given aging-related changes and the presence of comorbid conditions in older adults, safety studies of these practices are warranted.

Context: Despite many nursing home residents experiencing pain, research about the multidimensional nature of nonmalignant pain in these residents is scant., Objectives: To identify and describe pain symptom subgroups and to evaluate whether subgroups differed by sex., Methods: Using Minimum Data Set 3.0 data (2011-2012), we identified newly admitted nursing home residents reporting pain (n = 119,379). A latent class analysis included 13 indicators: markers for pain (i.e., severity, frequency, impacts sleep, and function) and depressive symptoms. Sex was evaluated as a grouping variable. Multinomial logistic models identified the association between latent class membership and covariates, including age and cognitive impairment., Results: Four latent subgroups were identified: severe (15.2%), moderate frequent (26.4%), moderate occasional with depressive symptoms (26.4%), and moderate occasional without depressive symptoms (32.0%). Measurement invariance by sex was ruled out. Depressed mood, sleep disturbances, and fatigue distinguished subgroups. Age ≥75 years was inversely associated with belonging to the severe, moderate frequent, or moderate occasional with depressive symptoms subgroups. Residents with severe cognitive impairment had reduced odds of membership in the severe pain subgroup (adjusted odds ratio [aOR]: 0.84; 95% confidence interval [CI]: 0.78-0.90) and moderate frequent pain subgroup (aOR: 0.60; 95% CI: 0.56-0.64) but increased odds in the moderate occasional pain with depressive symptoms subgroup (aOR: 1.12; 95% CI: 1.06-1.18)., Conclusion: Identifying subgroups of residents with different patterns of pain and depressive symptoms highlights the need to consider physical and psychological components of pain. Expanding knowledge about pain symptom subgroups may provide a promising avenue to improve pain management in nursing home residents., (Copyright © 2018 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Sociodemographic group-specific strategies for stress management may contribute to racial and gender disparities in health outcomes in the USA. We aimed to systematically review theoretical and empirical investigations of factors influencing variation in response to and management of identity-related stress among black and white Americans. OvidPsychInfo and PubMed databases were searched to identify eligible studies. Criteria were participant age of ≥ 18 years, conducted in the US sampling black or white participants, and published in English in a peer-reviewed journal. The final sample included 167 articles. Theories suggesting social status inequities as the primary contributor to disparate strategies employed by black and white women and men to manage social identity-related stress were most frequently tested and supported. Studies disproportionally focused on how women and black persons cope as targets of prejudice and discrimination rather than on how management strategies of men or white persons are affected as perpetrators. Finally, there was theoretical support for an interactive effect of race and gender on stress management, but empirical evidence was lacking, particularly among black men, white women, and white men. The literature could be strengthened through the use of prospective cohorts and nationally representative samples, as well as study designs accounting for potential within-race and within-gender variation in the effects of social identity-related stressors on coping. With greater consistency in methodology, future empirical studies may yield additional information regarding group differences in stress management pertinent to clarifying mechanisms for the health consequences of exposure to social inequity among black and white women and men.

Background: Depression, anxiety, and pain are commonly experienced by older adults living in nursing homes., Objectives: To describe the prevalence of depression, anxiety disorders, and pain among newly admitted nursing home residents in the United States and to describe the treatment of these disorders., Design: Cross-sectional study of newly admitted residents., Setting: Residents able to complete a pain assessment (n=783,826) living in Medicare- and Medicaid-certified nursing homes in the United States in 2011-2012., Measures: Measures of sociodemographic, mood and behavior, pain, diagnoses, and functioning items from the Minimum Data Set (MDS) version 3.0., Results: Approximately 36% of residents had a diagnosis of depression (other than bipolar disorder) and/or an anxiety disorder (n = 272,311). Of these residents, 25.2% had both depression and an anxiety disorder (95% CI = 25.0-25.4%), 54.3% (95% CI = 54.1-54.5%) had depression without an anxiety disorder, and 20.5% had an anxiety disorder without depression (95% CI = 20.3-20.6%). Fifteen percent had the triad of depression, anxiety, and pain at admission (95% CI = 9.3-23.3%). Depressive symptoms were more commonly reported by residents with pain than by those without pain. Receipt of psychological therapy (range: 0.9%-2.0%) or any psychiatric medication was lacking (range: 35.3%-48.5%), regardless of pain status. Participants reporting pain received a combination of scheduled, pro re nata ( PRN)/as-needed, and non-medication pain interventions (range: 59.8% depression without anxiety to 62.9% depression and anxiety disorder)., Conclusion: Residents often suffer from combinations of depression, anxiety and pain at admission to nursing home. While treatment of pain is more common than treatment of psychiatric treatments, both psychiatric treatment and pain management may be suboptimal in nursing homes.

Purpose: To estimate the proportion of residents newly initiating long-acting opioids in comparison to residents initiating short-acting opioids and examine variation in long-acting opioid initiation by region and resident characteristics., Methods: This cross-sectional study included 182 735 long-stay nursing home residents in 13 881 US nursing homes who were Medicare beneficiaries during 2011 to 2013 and initiated a short-acting or long-acting opioid (excluding residents <50 years old, those with cancer, or receiving hospice care). Medicare Part D prescription claims were used to identify residents as newly initiating short-acting or long-acting opioids, defined as having a prescription claim for an opioid with no prior opioid prescriptions in the preceding 60 days. We estimated the overall proportion of initiators prescribed long-acting opioids. Regional variation was examined by mapping results by state and hospital referral regions. Logistic models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs)., Results: Two percent of opioid initiators were prescribed long-acting opioids. State variation in long-acting opioid initiation ranged from 0.6% to 7.5% (5th-95th percentiles: 0.6-6.4%). Resident characteristics associated with increased long-acting opioid initiation included severe physical limitations (vs none/mild limitations; aOR: 2.13, 95% CI: 1.92-2.37) and pain (staff-assessed vs no pain; aOR: 1.59 95% CI: 1.40-1.80), whereas being non-White was inversely associated (non-Hispanic black vs non-Hispanic white; aOR: 0.70, 95% CI: 0.62-0.79)., Conclusion: United States nursing home residents predominantly initiate short-acting opioids in accordance with Center for Disease Control and Prevention guidelines. Documented variation by geographic and resident characteristics suggests that improvements are possible., (© 2018 John Wiley & Sons, Ltd.)

Aims: To identify factors associated with the receipt of specialty substance use treatment among adults with opioid use disorders (OUD)., Design: Cross-sectional study based on 2010-2014 National Surveys on Drug Use and Health (NSDUH)., Setting and Participants: Adults with a past-year OUD (n = 2488). The sample is representative of non-institutionalized US adults., Measurements: Past-year OUD was determined using DSM-IV criteria. Past-year specialty substance use treatment was defined as receiving treatment for drug use at any of the following locations: rehabilitation facilities, hospitals (inpatient only), outpatient mental health centers, private doctors' offices, or methadone clinics. Multivariable logistic regression models were used to measure the independent association between potential correlates and specialty substance use treatment receipt., Findings: Of adults with an OUD, 8.3% received past-year specialty substance use treatment. In a fully adjusted logistic regression model, the following factors were associated with increased odds of receiving specialty substance use treatment: ≥ 35 years old (adjusted Odds Ratio (aOR) = 2.55, 95% Confidence Interval (CI) = 1.04-6.26); unemployment (aOR = 1.92, 95% CI = 1.02-3.61); not in the labor force (aOR = 2.16, 95% CI = 1.15-4.06); never been married (aOR = 2.14, 95% CI = 1.04-4.39); arrested in past 12 months (aOR = 4.43, 95% CI = 2.45-7.99); opioid dependence (aOR = 3.82, 95% CI = 2.06-7.10); alcohol use disorder (aOR = 2.44, 95% CI = 1.44-4.11); and another drug use disorder (aOR = 3.22, 95% CI = 1.95-5.32). Living in a non-metropolitan county (aOR = 0.29, 95% CI = 0.12-0.68) and fair/poor health (aOR = 0.38, 95% CI = 0.17-0.86) were associated with decreased odds of receiving specialty substance use treatment., Conclusions: These findings suggest a need for the following efforts: strategies to increase individuals' recognition of their need for OUD treatment, expansion of insurance coverage for substance use treatment, expansion of earlier intervention services, adoption of a chronic care approach to substance use treatment, and an expansion of treatment capacity for rural communities., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: To examine and quantify geographic variation in the initiation of commonly used opioids and prescribed dosage strength among older US nursing home residents., Methods: We merged 2011 Minimum Data Set 3.0 to Medicare claims and facility characteristics data to conduct a cross-sectional study among long-stay nursing home residents who initiated short-acting opioids commonly used in nursing homes (oxycodone, hydrocodone, or tramadol). We examined geographic variation in specific opioids initiated and potentially inappropriate doses (≥50 mg oral morphine equivalent/d) across hospital referral regions (HRRs). Multilevel logistic models quantified the proportional change in between-HRR variation and associations between commonly initiated opioids and inappropriate doses after adjusting for resident characteristics, facility characteristics, and state., Results: Oxycodone (9.4%) was initiated less frequently than hydrocodone (56.2%) or tramadol (34.5%) but varied dramatically between HRRs (range, 0%-74.5%). In total, resident/facility characteristics and state of residence, respectively explained 84.1%, 58.2%, 59.1%, and 46.6% of the between-HRR variation for initiating oxycodone, hydrocodone, tramadol, and inappropriate doses. In all cases, state explained the largest proportion of between-HRR variation. Relative to hydrocodone, residents initiating oxycodone were more likely (adjusted odds ratio, 5.00; 95% confidence interval, 4.57-5.47) and those initiating tramadol were less likely (adjusted odds ratio, 0.28; 95% confidence interval, 0.25-0.31) to be prescribed potentially inappropriately high doses., Conclusions: We documented extensive geographic variation in the opioid and dose initiated for nursing home residents, with state explaining the largest proportion of the observed variation. Further work is needed to understand potential drivers of opioid prescribing patterns at the state level.

Objectives: The aim of this study was to estimate the comparative safety of initiating commonly used opioids among older, long-stay United States nursing home residents with fracture hospitalizations., Methods: We conducted a new-user retrospective cohort study of nursing home residents initiating short-acting oxycodone, hydrocodone, or tramadol by merging the 2011-2013 Minimum Data Set 3.0 to Medicare hospitalization and pharmacy claims. Residents (≥ 65 years, no cancer or hospice use) contributed treatment episodes (> 120 days with no prior opioid claims) and were followed for 180 days until incident fracture hospitalization (hip, femur, humerus, pelvis, radius/ulna), death (competing risk), treatment changes (e.g., discontinuation), or administrative censoring. Competing risks models with inverse probability of treatment weighting were used to estimate subdistribution hazard ratios (HR SD ) and 95% confidence intervals (CI)., Results: Overall, 110,862 residents contributed 134,432 treatment episodes: 14,373 oxycodone; 69,182 hydrocodone; and 50,877 tramadol initiators. The incidences of fracture hospitalizations per 100 person-years were 9.4 (95% CI 7.5-11.7) for oxycodone, 7.9 (95% CI 7.1-8.8) for hydrocodone, and 5.0 (95% CI 4.3-5.7) for tramadol initiators. In weighted models, oxycodone initiators had a similar rate of fractures to hydrocodone initiators (HR SD 1.08, 95% CI 0.79-1.48). Tramadol initiators had lower fracture rates than hydrocodone initiators (HR SD 0.67, 95% CI 0.56-0.80)., Conclusions: The lower rate of fractures that we documented among tramadol initiators compared with hydrocodone initiators is consistent, albeit attenuated compared with prior studies among community-dwelling older adults. However, overall fracture rates were lower than in community settings, potentially due to the limited risk of falling in this population with limited mobility.

The prevalence and severity of depression differ in women and men and across racial groups. Psychosocial factors such as chronic stress have been proposed as contributors, but causes of this variation are not fully understood. Allostatic load, a measure of the physiological burden of chronic stress, is known to be associated with depression. Using data from the National Health and Nutrition Examination Survey 2005⁻2010, we examined the associations of nine allostatic load biomarkers with depression among US black and white adults aged 18⁻64 years ( n = 6431). Depressive symptoms were assessed using the Patient Health Questionaire-9; logistic models estimated adjusted odds of depression based on allostatic load biomarkers. High-risk levels of c-reactive protein were significantly associated with increased odds of depression among white women (adjusted odds ratio (aOR) = 1.7, 95% CI: 1.1⁻2.5) and men (aOR = 1.8, 95% CI: 1.1⁻2.8) but not black women (aOR = 0.8, 95% CI: 0.6⁻1.1) or men (aOR = 0.9, 95% CI: 0.5⁻1.5). Among black men, hypertension (aOR = 1.7, 95% CI: 1.1⁻2.7) and adverse serum albumin levels (aOR = 1.7, 95% CI: 1.0⁻2.9) predicted depression, while high total cholesterol was associated with depression among black women (aOR = 1.6, 95% CI: 1.0⁻2.7). The associations between allostatic load biomarkers and depression varies with gendered race, suggesting that, despite consistent symptomatology, underlying disease mechanisms may differ between these groups.

Depression is a significant public health problem but symptom remission is difficult to predict. This may be due to substantial heterogeneity underlying the disorder. Latent class analysis (LCA) is often used to elucidate clinically relevant depression subtypes but whether or not consistent subtypes emerge is unclear. We sought to critically examine the implementation and reporting of LCA in this context by performing a systematic review to identify articles detailing the use of LCA to explore subtypes of depression among samples of adults endorsing depression symptoms. PubMed, PsycINFO, CINAHL, Scopus, and Google Scholar were searched to identify eligible articles indexed prior to January 2016. Twenty-four articles reporting 28 LCA models were eligible for inclusion. Sample characteristics varied widely. The majority of articles used depression symptoms as the observed indicators of the latent depression subtypes. Details regarding model fit and selection were often lacking. No consistent set of depression subtypes was identified across studies. Differences in how models were constructed might partially explain the conflicting results. Standards for using, interpreting, and reporting LCA models could improve our understanding of the LCA results. Incorporating dimensions of depression other than symptoms, such as functioning, may be helpful in determining depression subtypes., (Copyright © 2018. Published by Elsevier B.V.)

Objectives: To synthesize research comparing poststroke health outcomes between patients rehabilitated in skilled nursing facilities (SNFs) and those in inpatient rehabilitation facilities (IRFs) as well as to evaluate relations between facility characteristics and outcomes., Data Sources: PubMed and CINAHL searches spanned January 1, 1998, to October 6, 2016, and encompassed MeSH and free-text keywords for stroke, IRF/SNF, and study outcomes. Searches were restricted to peer-reviewed research in humans published in English., Study Selection: Observational and experimental studies examining outcomes of adult patients with stroke rehabilitated in an IRF or SNF were eligible. Studies had to provide site of care comparisons and/or analyses incorporating facility-level characteristics and had to report ≥1 primary outcome (discharge setting, functional status, readmission, quality of life, all-cause mortality). Unpublished, single-center, descriptive, and non-US studies were excluded. Articles were reviewed by 1 author, and when uncertain, discussion with study coauthors achieved consensus. Fourteen titles (0.3%) were included., Data Extraction: The types of data, time period, size, design, and primary outcomes were extracted. We also extracted 2 secondary outcomes (length of IRF/SNF stay, cost) when reported by included studies. Effect measures, modeling approaches, methods for confounding adjustment, and potential confounders were extracted. Data were abstracted by 1 author, and the accuracy was verified by a second reviewer., Data Synthesis: Two studies evaluating community discharge, 1 study evaluating the predicted probability of readmission, and 3 studies evaluating all-cause mortality favored IRFs over SNFs. Functional status comparisons were inconsistent. No studies evaluated quality of life. Two studies confirmed increased costs in the IRF versus SNF setting. Although substantial facility variation was described, few studies characterized sources of variation., Conclusions: The few studies comparing poststroke outcomes indicated better outcomes (with higher costs) for patients in IRFs versus those in SNFs. Contemporary research on the role of the postacute care setting and its attributes in determining health outcomes should be prioritized to inform reimbursement system reform., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

The burden of depression in men is high. Current diagnostic criteria may not fully capture men's experience with depression. Descriptions of the heterogeneity in depression among men are lacking. The purpose of the study was to characterize latent subtypes of major depression and changes in these subtypes among men receiving citalopram in Level 1 of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. Latent transition analysis was applied to data from 387 men who completed baseline and Week 12 study visits in Level 1 of STAR*D. Items from the self-report version of the Quick Inventory of Depressive Symptomatology were used as indicators of latent depression subtypes. Four statuses were identified at baseline and Week 12. Baseline statuses were Mild (10% of men), Moderate (53%), Severe with Psychomotor Slowing (20%), and Severe with Psychomotor Agitation (17%). At Week 12, the statuses were Symptom Resolution (41%), Mild (36%), Moderate (18%), and Severe with Psychomotor Slowing (5%). Men in the Mild status were most likely to transition to Symptom Resolution (probability = 69%). Men in the Severe with Agitation status were least likely to transition to Symptom Resolution (probability = 0%). This work highlights the need to not focus solely on summary rating scores but to also consider patterns of symptoms when treating depression.

Background/objectives: Overall and long-term opioid use among older adults have increased since 1999. Less is known about opioid use in older adults in nursing homes (NHs)., Design: Cross-sectional., Setting: U.S. NHs (N = 13,522)., Participants: Long-stay NH resident Medicare beneficiaries with a Minimum Data Set 3.0 (MDS) assessment between April 1, 2012, and June 30, 2012, and 120 days of follow-up (N = 315,949)., Measurements: We used Medicare Part D claims to measure length of opioid use in the 120 days from the index assessment (short-term: ≤30 days, medium-term: >30-89 days, long-term: ≥90 days), adjuvants (e.g., anticonvulsants), and other pain medications (e.g., corticosteroids). MDS assessments in the follow-up period were used to measure nonpharmacological pain management use. Modified Poisson models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for age, gender, race and ethnicity, cognitive and physical impairment, and long-term opioid use., Results: Of all long-stay residents, 32.4% were prescribed any opioid, and 15.5% were prescribed opioids long-term. Opioid users (versus nonusers) were more commonly prescribed pain adjuvants (32.9% vs 14.9%), other pain medications (25.5% vs 11.0%), and nonpharmacological pain management (24.5% vs 9.3%). Long-term opioid use was higher in women (aPR = 1.21, 95% CI = 1.18-1.23) and lower in racial and ethnic minorities (non-Hispanic blacks vs whites: APR = 0.93, 95% CI = 0.90-0.94) and those with severe cognitive impairment (vs no or mild impairment, aPR = 0.82, 95% CI = 0.79-0.83)., Conclusion: One in seven NH residents was prescribed opioids long-term. Recent guidelines on opioid prescribing for pain recommend reducing long-term opioid use, but this is challenging in NHs because residents may not benefit from nonpharmacological and nonopioid interventions. Studies to address concerns about opioid safety and effectiveness (e.g., on pain and functional status) in NHs are needed., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Objective: The objective of this study is to describe the prevalence of depression and cognitive impairment among newly admitted nursing home residents in the USA and to describe the treatment of depression by level of cognitive impairment., Methods: We identified 1,088,619 newly admitted older residents between 2011 and 2013 with an active diagnosis of depression documented on the Minimum Data Set 3.0. The prevalence of receiving psychiatric treatment was estimated by cognitive impairment status and depression symptoms. Binary logistic regression using generalized estimating equations provided adjusted odds ratios and 95% confidence intervals for the association between level of cognitive impairment and receipt of psychiatric treatment, adjusted for clustering of residents within nursing homes and resident characteristics., Results: Twenty-six percent of newly admitted residents had depression; 47% of these residents also had cognitive impairment. Of those who had staff assessments of depression, anhedonia, impaired concentration, psychomotor disturbances, and irritability were more commonly experienced by residents with cognitive impairment than residents without cognitive impairment. Forty-eight percent of all residents with depression did not receive any psychiatric treatment. Approximately one-fifth of residents received a combination of treatment. Residents with severe cognitive impairment were less likely than those with intact cognition to receive psychiatric treatment (adjusted odds ratio = 0.95; 95% confidence interval: 0.93-0.98)., Conclusions: Many newly admitted residents with an active diagnosis of depression are untreated, potentially missing an important window to improve symptoms. The extent of comorbid cognitive impairment and depression and lack of treatment suggest opportunities for improved quality of care in this increasingly important healthcare setting. Copyright © 2017 John Wiley & Sons, Ltd., (Copyright © 2017 John Wiley & Sons, Ltd.)

Previous studies estimate that >40% of long-stay nursing home (NH) residents experience persistent pain, with 20% of residents in pain receiving no analgesics. Strengthened NH surveyor guidance and improved pain measures on the Minimum Data Set 3.0 were introduced in March 2009 and October 2010, respectively. This study aimed to provide estimates after the important initiatives of (1) prevalence and correlates of persistent pain; and (2) prevalence and correlates of untreated or undertreated persistent pain. We identified 1,387,405 long-stay residents in U.S. NHs between 2011 and 2012 with 2 Minimum Data Set assessments 90 days apart. Pain was categorized as persistent (pain on both assessments), intermittent (pain on either assessment), or none. Pharmacologic pain management was classified as untreated pain (no scheduled or as needed medications received) or potentially undertreated (no scheduled received). Modified Poisson models adjusting for resident clustering within NHs provided adjusted prevalence ratios (APRs) estimates and 95% confidence intervals (CIs). The prevalence of persistent and intermittent pain was 19.5% and 19.2%, respectively, but varied substantially by age, sex, race and ethnicity, cognitive impairment, and cancer. Of residents in persistent pain, 6.4% and 32.0% were untreated and undertreated, respectively. Racial and ethnic minorities (non-Hispanic blacks vs whites, APR = 1.19, 95% CI: 1.13-1.25) and severely cognitively impaired residents (severe vs no/mild APR = 1.51, 95% CI: 1.44-1.57) had an increased prevalence of untreated and undertreated pain. One in 5 NH residents has persistent pain. Although this estimate is greatly improved, many residents may be undertreated. The disturbing disparities in untreated and undertreated pain need to be addressed.

Purpose: We systematically reviewed pharmacoepidemiologic and comparative effectiveness studies that use probabilistic bias analysis to quantify the effects of systematic error including confounding, misclassification, and selection bias on study results., Methods: We found articles published between 2010 and October 2015 through a citation search using Web of Science and Google Scholar and a keyword search using PubMed and Scopus. Eligibility of studies was assessed by one reviewer. Three reviewers independently abstracted data from eligible studies., Results: Fifteen studies used probabilistic bias analysis and were eligible for data abstraction-nine simulated an unmeasured confounder and six simulated misclassification. The majority of studies simulating an unmeasured confounder did not specify the range of plausible estimates for the bias parameters. Studies simulating misclassification were in general clearer when reporting the plausible distribution of bias parameters. Regardless of the bias simulated, the probability distributions assigned to bias parameters, number of simulated iterations, sensitivity analyses, and diagnostics were not discussed in the majority of studies., Conclusion: Despite the prevalence and concern of bias in pharmacoepidemiologic and comparative effectiveness studies, probabilistic bias analysis to quantitatively model the effect of bias was not widely used. The quality of reporting and use of this technique varied and was often unclear. Further discussion and dissemination of the technique are warranted. Copyright © 2016 John Wiley & Sons, Ltd., Competing Interests: All of the authors have no conflicts of interest to report., (Copyright © 2016 John Wiley & Sons, Ltd.)

Unlabelled: The aim of this study was to characterize latent subtypes of major depression and changes in these subtypes among women receiving citalopram in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. Latent transition analysis was applied to data from 755 women who completed baseline and week 12 study visits in level 1 of STAR*D. Items from the self-report version of the Quick Inventory of Depressive Symptomatology were used as indicators of latent depression subtype. Four subtypes were identified at baseline and week 12. The baseline subtypes were Mild (21 %), Moderate (30 %), Severe with Increased Appetite (16 %), and Severe with Decreased Appetite (34 %). The subtypes at week 12 were Symptom Resolution (65 %), Mild (23 %), Moderate (9 %), and Severe with Psychomotor Disturbances (3 %). Women in the Moderate subtype at baseline had the greatest chance of moving to Symptom Resolution (87 %). Women in the Severe with Decreased Appetite subtype had the lowest chance of transitioning to Symptom Resolution (46 %). Depression severity and appetite distinguished depression subtypes for women before treatment with citalopram. Depression severity and psychomotor disturbances characterized the subtypes after treatment. This work highlights the need to consider how depression treatment changes different symptoms instead of relying exclusively on summary rating scores., Clinical Trial Registration: www.clinicaltrials.gov , NCT00021528.

Background: Causal mediation analysis is often used to understand the impact of variables along the causal pathway of an occurrence relation. How well studies apply and report the elements of causal mediation analysis remains unknown., Methods: We systematically reviewed epidemiological studies published in 2015 that employed causal mediation analysis to estimate direct and indirect effects of observed associations between an exposure on an outcome. We identified potential epidemiological studies through conducting a citation search within Web of Science and a keyword search within PubMed. Two reviewers independently screened studies for eligibility. For eligible studies, one reviewer performed data extraction, and a senior epidemiologist confirmed the extracted information. Empirical application and methodological details of the technique were extracted and summarized., Results: Thirteen studies were eligible for data extraction. While the majority of studies reported and identified the effects of measures, most studies lacked sufficient details on the extent to which identifiability assumptions were satisfied. Although most studies addressed issues of unmeasured confounders either from empirical approaches or sensitivity analyses, the majority did not examine the potential bias arising from the measurement error of the mediator. Some studies allowed for exposure-mediator interaction and only a few presented results from models both with and without interactions. Power calculations were scarce., Conclusions: Reporting of causal mediation analysis is varied and suboptimal. Given that the application of causal mediation analysis will likely continue to increase, developing standards of reporting of causal mediation analysis in epidemiological research would be prudent.

Objective: To characterize the association between functional impairment and major depression subtypes at baseline and to characterize changes in subtypes by functional impairment level in women receiving citalopram in level 1 of the Sequenced Treatment Alternatives to Relieve Depression trial., Method: Women who completed baseline and week 12 study visits were included. Items from the self-reported Quick Inventory of Depressive Symptomatology were used to define the latent depression subtypes. The Work and Social Adjustment Scale was used to classify baseline functional impairment. A latent transition analysis model provided estimates of the prevalence of subtype membership and transition probabilities by functional impairment level., Results: Of the 755 women included, 69% had major functional impairment at baseline. Regardless of functional impairment level, the subtypes were differentiated by depression severity, appetite changes, psychomotor disturbances, and insomnia. Sixty-seven percent of women with normal/significant functional impairment and 60% of women with major impairment were likely to transition to a symptom resolution subtype at week 12. Women with baseline major impairment who were in the severe with psychomotor agitation subtype at the beginning of the study were least likely to transition to the symptom resolution subtype (4% chance)., Conclusions: Functional impairment level was related to both the baseline depression subtype and the likelihood of moving to a different subtype. These results underscore the need to incorporate not only depression symptoms but also functioning in the assessment and treatment of depression.

Background: The objectives were to characterize latent depression subtypes by symptoms, evaluate sex differences in and examine correlates of these subtypes, and examine the association between subtype and symptom remission after citalopram treatment., Methods: Latent class analysis was applied to baseline data from 2772 participants in the Sequenced Treatment Alternatives to Relieve Depression trial. Indicators were from the Quick Inventory of Depressive Symptomatology. Separate multinomial logistic models identified correlates of subtypes and the association between subtype and the distal outcome of remission., Results: Four latent subtypes were identified: Mild (men: 37%, women: 27%), Moderate (men: 24%, women: 21%), Severe with Increased Appetite (men: 13%, women: 22%), and Severe with Insomnia (men: 26%, women: 31%). Generalized anxiety disorder, bulimia, and social phobia were correlated with Severe with Increased Appetite and generalized anxiety disorder, post-traumatic stress disorder, and social phobia with Severe with Insomnia. Relative to those with the Mild subtype, those with Severe with Increased Appetite (odds ratiomen (OR): 0.48; 95% confidence interval (CI): 0.25-0.92; OR women: 0.59; 95% CI: 0.41-0.86) and those with Severe Depression with Insomnia (ORmen: 0.65; 95% CI: 0.41-1.02; ORwomen: 0.45; 95% CI: 0.32-0.64) were less likely to achieve remission., Limitations: The sample size limited exploration of higher order interactions., Conclusions: Insomnia and increased appetite distinguished latent subtypes. Sex and psychiatric comorbidities differed between the subtypes. Remission was less likely for those with the severe depression subtypes. Sleep disturbances, appetite changes, and other mental disorders may play a role in the etiology and treatment of depression., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background: There is no established psychometric instrument dedicated to the measurement of severity in psychotic depression (PD). The aim of this study was to investigate whether a new composite rating scale, the Psychotic Depression Assessment Scale (PDAS), covering both the psychotic and the depressive domains of PD, could detect differences in effect between two psychopharmacological treatment regimens., Methods: We reanalyzed the data from the Study of Pharmacotherapy of Psychotic Depression (STOP-PD), which compared the effect of Olanzapine+Sertraline (n=129) versus Olanzapine+Placebo (n=130). The response to the two regimens was compared using both a mixed effects model and effect size statistics on the total scores of three rating scales: the 17-item Hamilton Depression Rating Scale (HAM-D17), its 6-item melancholia subscale (HAM-D6), and the 11-item PDAS consisting of the HAM-D6 plus five items from the Brief Psychiatric Rating Scale covering psychotic symptoms., Results: According to both statistical approaches, the PDAS, the HAM-D17 and the HAM-D6 were all able to detect significant differences in treatment effect between Olanzapine+Sertraline and Olanzapine+Placebo (Olanzapine+Sertraline being superior). Notably, 45% of the trial participants were at least "probable psychotic" at their last assessment in the trial., Limitations: The STOP-PD was not designed specifically to answer the research questions of the present study., Conclusions: The Psychotic Depression Assessment Scale (PDAS) is a sensitive measure of treatment response in PD. The fact that 45% of the patients still experienced psychotic symptoms at their last trial assessment emphasizes the need to include items pertaining to psychotic symptoms in rating scales for PD., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Objective: Psychotic depression (PD) is a highly debilitating condition, which needs intensive monitoring. However, there is no established rating scale for evaluating the severity of PD. The aim of this analysis was to assess the psychometric properties of established depression rating scales and a number of new composite rating scales, covering both depressive and psychotic symptoms, in relation to PD., Method: The psychometric properties of the rating scales were evaluated based on data from the Study of Pharmacotherapy of Psychotic Depression., Results: A rating scale consisting of the 6-item Hamilton melancholia subscale (HAM-D6 ) plus five items from the Brief Psychiatric Rating Scale (BPRS), named the HAMD-BPRS11 , displayed clinical validity (Spearman's correlation coefficient between HAMD-BPRS11 and Clinical Global Impression - Severity (CGI-S) scores = 0.79-0.84), responsiveness (Spearman's correlation coefficient between change in HAMD-BPRS11 and Clinical Global Impression - Improvement (CGI-I) scores = -0.74--0.78) and unidimensionality (Loevinger's coefficient of homogeneity = 0.41) in the evaluation of PD. The HAM-D6 fulfilled the same criteria, whereas the full 17-item Hamilton Depression Scale failed to meet criteria for unidimensionality., Conclusion: Our results suggest that the HAMD-BPRS11 is a more valid measure than pure depression scales for evaluating the severity of PD., (© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objective: Intravenous N-methyl-d-aspartate (NMDA) antagonists have shown promising results in rapidly ameliorating depression symptoms, but placebo-controlled trials of oral NMDA antagonists as monotherapy have not observed efficacy. We conducted a randomized, double-blind, placebo-controlled trial of the NMDA antagonist memantine as an augmentation treatment for patients with DSM-IV major depressive disorder., Method: Adult outpatients with major depressive disorder and partial response or nonresponse to their current antidepressant (as indicated by a 17-item Hamilton Depression Rating Scale score of ≥ 16 at baseline) were randomized (from July 2006-December 2011) to add memantine (flexible dose 5-20 mg/d, with all memantine group participants reaching the dose of 20 mg/d) (n = 15) or placebo (n = 16) to their existing treatment for 8 weeks. The primary outcome, change in Montgomery-Asberg Depression Rating Score (MADRS), was evaluated with repeated-measures mixed effects models using last-observation-carried-forward methods. Secondary outcomes included other depression and anxiety rating scales, suicidal and delusional ideation, and other adverse effects., Results: 84% of participants completed the trial, including 93% of participants receiving memantine. Participants receiving memantine did not show a statistically or clinically significant change in MADRS scores compared to placebo, either over the entire study (β = 0.133, favoring placebo, P = .74) or at study completion (week 8 mean [SD] MADRS score change = -7.13 [6.61] [memantine]; -7.25 [11.14] [placebo]; P = .97). A minimal to small effect size (comparing change to baseline variability) favoring placebo was observed (Cohen d = 0.19). Similarly, no substantial effect sizes favoring memantine nor statistically significant between-group differences were observed on secondary efficacy outcomes., Conclusions: This trial did not detect significant statistical or effect size differences between memantine and placebo augmentation among nonresponders or poor responders to conventional antidepressants. While the small number of participants is a limitation, this study suggests memantine lacks substantial efficacy as an augmentation treatment for major depressive disorder., Trial Registration: ClinicalTrials.gov identifier: NCT00344682., (© Copyright 2013 Physicians Postgraduate Press, Inc.)

There is a pressing need for comparative effectiveness research to improve mental health treatments. Although U.S. mental health spending has increased dramatically, mainly because of the rapid adoption of newer psychotropic medications, fewer than a quarter of people with serious mental illnesses receive appropriate care. Because of a general lack of information on the relative effectiveness of different treatments, payers are uncertain about the value of current spending, which in turn may deter new investments to reduce unmet need. We use several recent comparative effectiveness trials to illustrate the potential value of such research for improving practice and policy.