Community-Partnered Evaluation of Depression Services for Clients of Community-Based Agencies in Under-Resourced Communities in Los Angeles

BACKGROUND

As medical homes are developing under health reform, little is known regarding depression services need and use by diverse safety-net populations in under-resourced communities. For chronic conditions like depression, primary care services may face new opportunities to partner with diverse community service providers, such as those in social service and substance abuse centers, to support a collaborative care model of treating depression.

OBJECTIVE

To understand the distribution of need and current burden of services for depression in under-resourced, diverse communities in Los Angeles.

DESIGN

Baseline phase of a participatory trial to improve depression services with data from client screening and follow-up surveys.

PARTICIPANTS

Of 4,440 clients screened from 93 programs (primary care, mental health, substance abuse, homeless, social and other community services) in 50 agencies, 1,322 were depressed according to an eight-item Patient Health Questionnaire (PHQ-8) and gave contact information; 1,246 enrolled and 981 completed surveys. Ninety-three programs, including 17 primary care/public health, 18 mental health, 20 substance abuse, ten homeless services, and 28 social/other community services, participated.

MAIN MEASURES

Comparisons by setting in 6-month retrospective recall of depression services use.

KEY RESULTS

Depression prevalence ranged from 51.9 % in mental health to 17.2 % in social-community programs. Depressed clients used two settings on average to receive depression services; 82 % used any setting. More clients preferred counseling over medication for depression treatment.

CONCLUSIONS

Need for depression care was high, and a broad range of agencies provide depression care. Although most participants had contact with primary care, most depression services occurred outside of primary care settings, emphasizing the need to coordinate and support the quality of community-based services across diverse community settings.     

The Effect of Targeted and Tailored Patient Depression Engagement Interventions on Patient–Physician Discussion of Suicidal Thoughts: A Randomized Control Trial

BACKGROUND

Despite improvements in the diagnosis and treatment of depression, primary care provider (PCP) discussion regarding suicidal thoughts among patients with depressive symptoms remains low.

OBJECTIVE

To determine whether a targeted depression public service announcement (PSA) video or an individually tailored interactive multimedia computer program (IMCP) leads to increased primary care provider (PCP) discussion of suicidal thoughts in patients with elevated risk for clinical depression when compared to an attention control.

DESIGN

Randomized control trial at five different healthcare systems in Northern California; two academic, two Veterans Affairs (VA), and one group-model health maintenance organization (HMO).

PARTICIPANTS

Eight-hundred sixty-seven participants, with mean age 51.7; 43.9 % women, 43.4 % from a racial/ethnic minority group.

INTERVENTION

The PSA was targeted to gender and socio-economic status, and designed to encourage patients to seek depression care or request information regarding depression. The IMCP was an individually tailored interactive health message designed to activate patients to discuss possible depressive symptoms. The attention control was a sleep hygiene video.

MAIN MEASURES

Clinician reported discussion of suicidal thoughts. Analyses were stratified by depressive symptom level (Patient Health Questionnaire [PHQ-9] score?<?9 [mild or lower] versus ≥ 10 [at least moderate]).

KEY RESULTS

Among patients with a PHQ-9 score ≥ 10, PCP discussion of suicidal thoughts was significantly higher in the IMCP group than in the control group (adjusted odds ratio?=?2.33, 95 % confidence interval?=?1.5, 5.10, p?=?0.03). There were no significant effects of either intervention on PCP discussion of suicidal thoughts among patients with a PHQ-9 score?<?9.

CONCLUSIONS

Exposure of patients with at least moderate depressive symptoms to an individually tailored intervention designed to increase patient engagement in depression care led to increased PCP discussion of suicidal thoughts.     

How do older patients and their GPs evaluate shared decision-making in healthcare?

Background

Physical activity shows potential in combating the poor outcomes associated with depression in older people. Meta-analyses show gaps in the research with poor trial design compromising certainty in conclusions and few programmes showing sustained effects.

Methods/design

The Depression in Late Life: an Intervention Trial of Exercise (DeLLITE) is a 12 month randomised controlled trial of a physical activity intervention to increase functional status in people aged 75 years and older with depressive symptoms. The intervention involves an individualised activity programme based on goal setting and progression of difficulty of activities delivered by a trained nurse during 8 home visits over 6 months. The control group received time matched home visits to discuss social contacts and networks. Baseline, 6 and 12 months measures were assessed in face to face visits with the primary outcome being functional status (SPPB, NEADL). Secondary outcomes include depressive symptoms (Geriatric Depression Scale), quality of life (SF-36), physical activity (AHS Physical Activity Questionnaire) and falls (self report).

Discussion

Due to report in 2008 the DeLLITE study has recruited 70% of those eligible and tests the efficacy of a home based, goal setting physical activity programme in improving function, mood and quality of life in older people with depressive symptomatology. If successful in improving function and mood this trial could prove for the first time that there are long term health benefit of physical activity, independent of social activity, in this high risk group who consume excess health related costs.

Trial registration

Australian and New Zealand Clinical Trials Register ACTRN12605000475640     

Community-Partnered Cluster-Randomized Comparative Effectiveness Trial of Community Engagement and Planning or Resources for Services to Address Depression Disparities

BACKGROUND

Depression contributes to disability and there are ethnic/racial disparities in access and outcomes of care. Quality improvement (QI) programs for depression in primary care improve outcomes relative to usual care, but health, social and other community-based service sectors also support clients in under-resourced communities. Little is known about effects on client outcomes of strategies to implement depression QI across diverse sectors.

OBJECTIVE

To compare the effectiveness of Community Engagement and Planning (CEP) and Resources for Services (RS) to implement depression QI on clients’ mental health-related quality of life (HRQL) and services use.

DESIGN

Matched programs from health, social and other service sectors were randomized to community engagement and planning (promoting inter-agency collaboration) or resources for services (individual program technical assistance plus outreach) to implement depression QI toolkits in Hollywood-Metro and South Los Angeles.

PARTICIPANTS

From 93 randomized programs, 4,440 clients were screened and of 1,322 depressed by the 8-item Patient Health Questionnaire (PHQ-8) and providing contact information, 1,246 enrolled and 1,018 in 90 programs completed baseline or 6-month follow-up.

MEASURES

Self-reported mental HRQL and probable depression (primary), physical activity, employment, homelessness risk factors (secondary) and services use.

RESULTS

CEP was more effective than RS at improving mental HRQL, increasing physical activity and reducing homelessness risk factors, rate of behavioral health hospitalization and medication visits among specialty care users (i.e. psychiatrists, mental health providers) while increasing depression visits among users of primary care/public health for depression and users of faith-based and park programs (each p?<?0.05). Employment, use of antidepressants, and total contacts were not significantly affected (each p?>?0.05).

CONCLUSION

Community engagement to build a collaborative approach to implementing depression QI across diverse programs was more effective than resources for services for individual programs in improving mental HRQL, physical activity and homelessness risk factors, and shifted utilization away from hospitalizations and specialty medication visits toward primary care and other sectors, offering an expanded health-home model to address multiple disparities for depressed safety-net clients.     

A Matched-Pair Cluster-Randomized Trial of Guided Care for High-Risk Older Patients

BACKGROUND

Patients at risk for generating high health care expenditures often receive fragmented, low-quality, inefficient health care. Guided Care is designed to provide proactive, coordinated, comprehensive care for such patients.

OBJECTIVE

We hypothesized that Guided Care, compared to usual care, produces better functional health and quality of care, while reducing the use of expensive health services.

DESIGN

32-month, single-blind, matched-pair, cluster-randomized controlled trial of Guided Care, conducted in eight community-based primary care practices.

PATIENTS

The “Hierarchical Condition Category” (HCC) predictive model was used to identify high-risk older patients who were insured by fee-for-service Medicare, a Medicare Advantage plan or Tricare. Patients with HCC scores in the highest quartile (at risk for generating high health care expenditures during the coming year) were eligible to participate.

INTERVENTION

A registered nurse collaborated with two to five primary care physicians in providing eight services to participants: comprehensive assessment, evidence-based care planning, proactive monitoring, care coordination, transitional care, coaching for self-management, caregiver support, and access to community-based services.

MAIN MEASURES

Functional health was measured using the Short Form–36. Quality of care and health services utilization were measured using the Patient Assessment of Chronic Illness Care and health insurance claims, respectively.

KEY RESULTS

Of the eligible patients, 904 (37.8 %) gave written consent to participate; of these, 477 (52.8 %) completed the final interview, and 848 (93.8 %) provided complete claims data. In intention-to-treat analyses, Guided Care did not significantly improve participants’ functional health, but it was associated with significantly higher participant ratings of the quality of care (difference?=?0.27, 95 % CI?=?0.08–0.45) and 29 % lower use of home care (95 % CI?=?3–48 %).

CONCLUSIONS

Guided Care improves high-risk older patients’ ratings of the quality of their care, and it reduces their use of home care, but it does not appear to improve their functional health.     

The Interconnections Project: Development and Evaluation of a Community-Based Depression Program for African American Violence Survivors

BACKGROUND

Multi-faceted depression care programs based within the healthcare system have been found to be effective, but may not fully address the needs of African American Intimate Partner Violence (IPV) survivors, many of whom are not seeking depression care in healthcare settings.

OBJECTIVES

To develop and evaluate a multifaceted, community-based depression care program (the Interconnections Project) for African American women with a history of IPV.

METHODS

We used a community-based participatory research (CBPR) approach to develop, implement, and evaluate the intervention. Participants were African American women who had current depressive symptoms and a lifetime history of IPV. They participated in a 6-month intervention where a peer advocate provided education, skills training, and case management services, and used Motivational Interviewing to support self-management behaviors. We conducted pre-intervention and post-intervention assessments using quantitative and qualitative data.

RESULTS

Fifty-nine women participated, with 92 % attending any sessions and 51 % attending at least 6 h of intervention activities. Intervention changes made to better accommodate participants’ unpredictable schedules improved participation rates. Participants noted high levels of satisfaction with the program. There were significant improvements in depression severity (PHQ-9 13.9 to 7.9, p?<?0.001), self-efficacy, self-management behaviors, and self-esteem (all p?<?0.001), but no increase in use of antidepressants. Common themes related to why the program was helpful included that the program was by and for African American women, that it fostered trust, and that it taught self-management strategies with practical, lasting value.

CONCLUSION

Culturally specific, community-based interventions led by peer advocates may be a promising way to help African American IPV survivors effectively address depression.     

Efficacy of a multicomponent support programme for the caregivers of disabled persons

Aim

The goal of the present work was to measure the efficacy of a multicomponent programme designed to provide tailored support for the caregivers of disabled persons.

Subjects

A total of 135 caregivers–care receiver dyads were randomly divided into an intervention group (n?=?66) and a control group (n?=?69). One-third of the care receivers were demented, and two-thirds had other diseases.

Setting

Health centres (publicly funded primary health care systems) in 8 rural and urban communities in southeast Finland.

Intervention

The multicomponent support programme for the caregivers consisted of a 2-week rehabilitation period. The control group received standard care.

Outcome measurements

Continuation of the caregiver and care receiver relationship, care receiver mortality at the 2-year follow-up as well as the health-related quality of life (15D scale) and Zung’s depression scale of the caregiver at the 1-year follow-up were evaluated.

Results

At the 2-year follow-up, the caregiver–care receiver relationship was terminated for any reason in 11 cases (17%) in the intervention group, and in 25 cases (36%) in the control group. After adjusting, the primary outcome (i.e., termination of care giving for any reason) indicated statistical significance (p?=?0.04) with a hazard rate of 1.83 (95% confidence interval 1.03–3.29). With a similar adjustment, the difference in mortality and placement to institutional care between the two groups demonstrated a trend towards statistical significance. The caregivers’ health, as related to quality of life and depressive symptoms, remained unchanged in both groups at the 1-year follow-up.

Conclusion

These results indicate that a tailored support programme for caregivers may help the caregiver to continue the caregiver–care receiver relationship and delay institutionalization.     

Characteristics, Management, and Depression Outcomes of Primary Care Patients Who Endorse Thoughts of Death or Suicide on the PHQ-9

BACKGROUND

With increasing emphasis on integrating behavioral health services, primary care providers play an important role in managing patients with suicidal thoughts.

OBJECTIVE

To evaluate whether Patient Health Questionnaire-9 (PHQ-9) Item 9 scores are associated with patient characteristics, management, and depression outcomes in a primary care-based mental health program.

DESIGN

Observational analysis of data collected from a patient registry.

PARTICIPANTS

Eleven thousand fifteen adults enrolled in the Mental Health Integration Program (MHIP).

INTERVENTIONS

MHIP provides integrated mental health services for safety-net populations in over 100 community health centers across Washington State. Key elements of the team-based model include: a disease registry; integrated care management; and organized psychiatric case review.

MAIN MEASURES

The independent variable, suicidal ideation (SI), was assessed by PHQ-9 Item 9. Depression severity was assessed with the PHQ-8. Outcomes included four indicators of depression treatment process (care manager contact, psychiatric case review, psychotropic medications, and specialty mental health referral), and two indicators of depression outcomes (50 % reduction in PHQ-9 score and PHQ-9 score?<?10).

KEY RESULTS

SI was common (45.2 %) at baseline, with significantly higher rates among men and patients with greater psychopathology. Few patients with SI (5.4 %) lacked substantial current depressive symptoms. After adjusting for age, gender, and severity of psychopathology, patients with SI received follow-up earlier (care manager contact HR?=?1.05, p?<?0.001; psychiatric review HR?=?1.02, p?<?0.05), and were more likely to receive psychotropic medications (OR?=?1.11, p?=?0.001) and specialty referral (OR?=?1.23, p?<?0.001), yet were less likely to achieve a PHQ-9 score?<?10 (HR?=?0.87, p?<?0.001).

CONCLUSIONS

Suicidal thoughts are common among safety-net patients referred by primary care providers for behavioral health care. Scores on Item 9 of the PHQ-9 are easily obtainable in primary care, may help providers initiate conversations about suicidality, and serve as useful markers of psychiatric complexity and treatment-resistance. Patients with positive scores should receive timely and comprehensive psychiatric evaluation and follow-up.     

Health, wellbeing and nutritional status of older people living in UK care homes: an exploratory evaluation of changes in food and drink provision

Background

Food and drink are important determinants of physical and social health in care home residents. This study explored whether a pragmatic methodology including routinely collected data was feasible in UK care homes, to describe the health, wellbeing and nutritional status of care home residents and assess effects of changed provision of food and drink at three care homes on residents' falls (primary outcome), anaemia, weight, dehydration, cognitive status, depression, lipids and satisfaction with food and drink provision.

Methods

We measured health, wellbeing and nutritional status of 120 of 213 residents of six care homes in Norfolk, UK. An intervention comprising improved dining atmosphere, greater food choice, extended restaurant hours, and readily available snacks and drinks machines was implemented in three care homes. Three control homes maintained their previous system. Outcomes were assessed in the year before and the year after the changes.

Results

Use of routinely collected data was partially successful, but loss to follow up and levels of missing data were high, limiting power to identify trends in the data. This was a frail older population (mean age 87, 71% female) with multiple varied health problems. During the first year 60% of residents had one or more falls, 40% a wound care visit, and 40% a urinary tract infection. 45% were on diuretics, 24% antidepressants, and 43% on psychotropic medication. There was a slight increase in falls from year 1 to year 2 in the intervention homes, and a much bigger increase in control homes, leading to a statistically non-significant 24% relative reduction in residents' rate of falls in intervention homes compared with control homes (adjusted rate ratio 0.76, 95% CI 0.57 to 1.02, p = 0.06).

Conclusions

Care home residents are frail and experience multiple health risks. This intervention to improve food and drink provision was well received by residents, but effects on health indicators (despite the relative reduction in falls rate) were inconclusive, partly due to problems with routine data collection and loss to follow up. Further research with more homes is needed to understand which, if any, components of the intervention may be successful.

Trial registration

Trial registration: ISRCTN86057119.     

Humortherapie bei alten Menschen mit einer Depression

Background

Positive effects of humor on older patients with depressive symptoms have been repeatedly reported. Empirical evidence, however, is rare. We investigated the effects of a standardized humor therapy group in a clinical context especially for older depressed patients.

Patients and methods

For this purpose, an experimental group with treatment (52 patients participating in the humor group) was compared to a control group with no specific treatment (38 patients); all 90 participants had clinical depressive symptoms according to ICD-10 classification. Questionnaires (among them GDS, SF-12, State-Trait Cheerfulness Inventory, Satisfaction with Life Scale) were administered at two time points (pre- and post-treatment).

Results

From pre- to post-measurement, significant improvements could be shown only in the experimental group for resilience and satisfaction with life (p<0.05). Analyses of the subgroups with at least medium to severe depression showed further significant effects for cheerfulness, seriousness, bad mood, and satisfaction with life (p<0.05). These severely affected patients seemed to profit best from humor therapy.

Conclusion

Our results indicate the efficacy of this specific therapeutic intervention for older depressed patients.     

Trends in Depressive Symptom Burden Among Older Adults in the United States from 1998 to 2008

CONTEXT

Diagnosis and treatment of depression has increased over the past decade in the United States. Whether self-reported depressive symptoms among older adults have concomitantly declined is unknown.

OBJECTIVE

To examine trends in depressive symptoms among older adults in the US between 1998 and 2008.

DESIGN

Serial cross-sectional analysis of six biennial assessments.

SETTING

Health and Retirement Study (HRS), a nationally-representative survey. PATIENTS OR OTHER PARTICIPANTS Adults aged 55 and older (N?=?16,184 in 1998).

MAIN OUTCOME MEASURE

The eight-item Center for Epidemiologic Studies Depression scale (CES-D8) assessed three levels of depressive symptoms (none?=?0, elevated?=?4+, severe?=?6+), adjusting for demographic and clinical characteristics.

RESULTS

Having no depressive symptoms increased over the 10-year period from 40.9 % to 47.4 % (prevalence ratio [PR]: 1.16, 95 % CI: 1.13–1.19), with significant increases in those aged ≥ 60 relative to those aged 55–59. There was a 7 % prevalence reduction of elevated symptoms from 15.5 % to 14.2 % (PR: 0.93, 95 % CI: 0.88–0.98), which was most pronounced among those aged 80–84 in whom the prevalence of elevated symptoms declined from 14.3 % to 9.6 %. Prevalence of having severe depressive symptoms increased from 5.8 % to 6.8 % (PR: 1.17, 95 % CI: 1.06–1.28); however, this increase was limited to those aged 55–59, with the probability of severe symptoms increasing from 8.7 % to 11.8 %. No significant changes in severe symptoms were observed for those aged ≥ 60.

CONCLUSIONS

Overall late-life depressive symptom burden declined significantly from 1998 to 2008. This decrease appeared to be driven primarily by greater reductions in depressive symptoms in the oldest-old, and by an increase in those with no depressive symptoms. These changes in symptom burden were robust to physical, functional, demographic, and economic factors. Future research should examine whether this decrease in depressive symptoms is associated with improved treatment outcomes, and if there have been changes in the treatment received for the various age cohorts.     

Protocol for Project FACT: a randomised controlled trial on the effect of a walking program and vitamin B supplementation on the rate of cognitive decline and psychosocial wellbeing in older adults with mild cognitive impairment [ISRCTN19227688]

Background

The objective of this article is to describe the design of an evaluation of the cost-effectiveness of systematic home visits by nurses to frail elderly primary care patients. Pilot objectives were:

1. To determine the feasibility of postal multidimensional frailty screening instruments;
2. to identify the need for home visits to elderly.

Methods

Main study: The main study concerns a randomized controlled in primary care practices (PCP) with 18 months follow-up and blinded PCPs. Frail persons aged 75 years or older and living at home but neither terminally ill nor demented from 33 PCPs were eligible. Trained community nurses

1. visit patients at home and assess the care needs with the Resident Assessment Instrument-Home Care, a multidimensional computerized geriatric assessment instrument, enabling direct identification of problem areas;
2. determine the care priorities together with the patient;
3. design and execute interventions according to protocols;
4. and visit patients at least five times during a year in order to execute and monitor the care-plan.

Controls receive usual care. Outcome measures are Quality of life, and Quality Adjusted Life Years; time to nursing home admission; mortality; hospital admissions; health care utilization.

1. Three brief postal multidimensional screening measures to identify frail health among elderly persons were tested on percentage complete item response (selected after a literature search):
   1. Vulnerable Elders Screen,
   2. Strawbridge's frailty screen, and
   3. COOP-WONCA charts.
2. Three nurses visited elderly frail patients as identified by PCPs in a health center of 5400 patients and used an assessment protocol to identify psychosocial and medical problems. The needs and experiences of all participants were gathered by semi-structured interviews.

Discussion

The design holds several unique elements such as early identification of frail persons combined with case-management by nurses. From two pilots we learned that of three potential postal frailty measures, the COOP-WONCA charts were completed best by elderly and that preventive home visits by nurses were positively evaluated to have potential for quality of care improvement.     

The LUCAS* consortium

Background

Decline in functional competence is a major determinant of older persons?? needs, the development of dependency, use of care, clinical outcome and mortality. The interactions between rising life expectancy and changes in morbidity and disability warrant interdisciplinary research on functional disability, health promotion and prevention. The LUCAS (Longitudinal Urban Cohort Ageing Study) research consortium was established to study particular aspects of functional competence, its changes with ageing, to detect preclinical signs of functional decline, and to address questions on how to maintain functional competence and to prevent adverse outcome. The questions originate from problems encountered in practical health care provision in different settings, i.e. community, hospital and nursing home.

Methods

The subprojects apply a longitudinal cohort follow-up study, an embedded randomised controlled intervention, cross-sectional comparative, and prospective intervention studies.

Conclusion

The results will provide instruments to screen for preclinical signs of functional decline and concrete recommendations to sustain independence and prevent adverse outcomes in older age in daily practice.     

Older adults who persistently present to the emergency department with severe, non-severe, and indeterminate episode patterns

Background

Rapidly aging populations with an increased desire to remain at home and changes in health policy that promote the transfer of health care from formal places, as hospitals and institutions, to the more informal setting of one's home support the need for further research that is designed specifically to understand the experience of home among older adults. Yet, little is known among health care providers about the older adult's experience of home. The aim of this study was to understand the experience of home as experienced by older adults living in a rural community in Sweden.

Methods

Hermeneutical interpretation, as developed by von Post and Eriksson and based on Gadamer's philosophical hermeneutics, was used to interpret interviews with six older adults. The interpretation included a self examination of the researcher's experiences and prejudices and proceeded through several readings which integrated the text with the reader, allowed new questions to emerge, fused the horizons, summarized main and sub-themes and allowed a new understanding to emerge.

Results

Two main and six sub-themes emerged. Home was experienced as the place the older adult could not imagine living without but also as the place one might be forced to leave. The older adult's thoughts vacillated between the well known present and all its comforts and the unknown future with all its questions and fears, including the underlying threat of loosing one's home.

Conclusions

Home has become so integral to life itself and such an intimate part of the older adult's being that when older adults lose their home, they also loose the place closest to their heart, the place where they are at home and can maintain their identity, integrity and way of living. Additional effort needs to be made to understand the older adult's experience of home within home health care in order to minimize intrusion and maximize care. There is a need to more fully explore the older adult's experience with health care providers in the home and its impact on the older adult's sense of "being at home" and their health and overall well-being.     

Electronic Medical Record Availability and Primary Care Depression Treatment

Background

Electronic medical records (EMR) are commonly believed to improve quality of care. Primary care patients with multiple chronic conditions have potentially greater opportunity to benefit from receiving care at practices with EMRs if these systems help coordinate complex care.

Objective

To examine how chronic conditions impact the odds that depressed patients receive depression treatment in primary care practices with EMRs compared to practices without EMRs.

Design

The study uses logistic regression to analyze cross-sectional data of primary care physician office visits in freestanding, office-based practices from the 2006?C2008 National Ambulatory Medical Care Surveys.

Patients

All visits to primary care providers made by patients ages 18 and older with physician-identified depression (N?=?3,467).

Main Measures

Outcomes include depression treatment which is defined as receipt or ordering of antidepressant medication and/or mental health counseling.

Key Results

EMRs were associated with significantly lowered odds that depressed patients received depression treatment (OR?=?0.75, p?=?0.009, 95% CI: 0.61-0.93); however when stratified by the number of chronic conditions, this association was observed only in patients with three or more chronic conditions (OR?=?0.50, p?>?0.001, 95% CI: 0.36-0.70). EMRs did not have a significant association with depression treatment for patients with two or fewer chronic conditions.

Conclusions

EMRs appear to have an unintended negative association with depression care provided during visits made by primary care patients with multiple chronic conditions.     

Validation of Doloplus-2 among nonverbal nursing home patients - an evaluation of Doloplus-2 in a clinical setting

Background

The global prevalence of diabetes among adults will be 6.4% in 2010 and will increase to 7.7% by 2030. Diabetes doubles the odds of depression, and 9% of patients with diabetes are affected by depressive disorders. When subclinical depression is included, the proportion of patients who have clinically relevant depressive symptoms increases to 26%. In patients aged over 65 years, the interaction of diabetes and depression has predicted increased mortality, complications, disability, and earlier occurrence of all of these adverse outcomes. These deleterious effects were observed even in minor depression, where the risk of mortality within 7 years was 4.9 times higher compared with diabetes patients who did not have depressive symptoms. In this paper we describe the design and methods of the Minor Depression and Diabetes trial, a clinical trial within the 'Competence Network for Diabetes mellitus', which is funded by the German Federal Ministry of Education and Research.

Methods/Design

Patients' inclusion criteria are: Type 2 diabetes mellitus, 65 to 85 years of age, 3 to 6 depressive symptoms (minor depression or mild major depression). Our aim is to compare the efficacy of diabetes-specific cognitive behavioural therapy adapted for the elderly vs. intensified treatment as usual vs. a guided self-help intervention regarding improvement of health related quality of life as the primary outcome. The trial will be conducted as a multicentre, open, observer-blinded, parallel group (3 groups) randomized controlled trial. Patients will be randomized to one of the three treatment conditions. After 12 weeks of open-label therapy in all treatment conditions, both group interventions will be reduced to one session per month during the one-year long-term phase of the trial. At the one-year follow-up, all groups will be re-examined regarding the primary and secondary parameters, for example reduction of depressive symptoms, prevention of moderate/severe major depression, improvement of glycaemic control, mortality, and cost effectiveness. Depending on additional funding, the sample will be continuously observed as a prospective cohort; the primary outcome will be changed to mortality for all subsequent follow-up measurements.

Trial registration

Current Controlled Trials Register (ISRCTN58007098).     

Comparing the Functional Independence Measure and the interRAI/MDS for use in the functional assessment of older adults: a review of the literature

Background

The rehabilitation of older persons is often complicated by increased frailty and medical complexity - these in turn present challenges for the development of health information systems. Objective investigation and comparison of the effectiveness of geriatric rehabilitation services requires information systems that are comprehensive, reliable, valid, and sensitive to clinically relevant changes in older persons. The Functional Independence Measure is widely used in rehabilitation settings - in Canada this is used as the central component of the National Rehabilitation Reporting System of the Canadian Institute of Health Information. An alternative system has been developed by the interRAI consortium. We conducted a literature review to compare the development and measurement properties of these two systems.

Methods

English language literature published between 1983 (initial development of the FIM) and 2008 was searched using Medline and CINAHL databases, and the reference lists of retrieved articles. Relevant articles were summarized and charted using the criteria proposed by Streiner. Additionally, attention was paid to the ability of the two systems to address issues particularly relevant to older rehabilitation clients, such as medical complexity, comorbidity, and responsiveness to small but clinically meaningful improvements.

Results

In total, 66 articles were found that met the inclusion criteria. The majority of FIM articles studied inpatient rehabilitation settings; while the majority of interRAI/MDS articles focused on nursing home settings. There is evidence supporting the reliability of both instruments. There were few articles that investigated the construct validity of the interRAI/MDS.

Conclusion

Additional psychometric research is needed on both the FIM and MDS, especially with regard to their use in different settings and with different client groups.     

Potentially inappropriate prescriptions for older patients in long-term care

Background

Regular physical activity may improve different aspects of wellbeing in older people, such as quality of life, vitality and depression. However, there is little experimental evidence to support this assumption. Therefore, we examined the effect of different training protocols on quality of life, vitality and depression of older adults living in long-term care facilities.

Methods

Subjects (n = 173, aged 64 to 94 years, living in long-term care facilities), were randomized to six months of three different moderate-intensity group exercise training protocols, or to an 'educational' control condition. Exercise consisted of two 45–60-minute training sessions per week of 1) resistance training; 2) all-round, functional training; or 3) a combination of both. Perceived health, the Geriatric Depression Scale (GDS), the Vitality Plus Scale (VPS) and the Dementia Quality of Life questionnaire (DQoL) were administered at baseline and after six months.

Results

In the combined training group a small but significant decline was seen in perceived health, DQoL and VPS score compared to the control group.

Conclusions

We conclude that neither strength training nor all-round, functional training of moderate intensity is effective in improving quality of life, vitality or depression of older people living in long-term care facilities.     

Integrated Care: Treatment Initiation Following Positive Depression Screens

BACKGROUND

Primary Care-Mental Health Integration (PC-MHI) may improve mental health services access and continuity of care.

OBJECTIVE

To assess whether receipt of integrated PC-MHI services on the date of an initial positive depression screen influences receipt of depression treatment among primary care (PC) patients in the Veterans Health Administration.

DESIGN

Retrospective cohort study.

SUBJECTS

Thirty-six thousand, two hundred and sixty-three PC patients with positive depression screens between October 1, 2009 and September 30, 2010.

MAIN MEASURES

Subjects were assessed for depression diagnosis and initiation of antidepressants or psychotherapy on the screening day, within 12 weeks, and within 6 months. Among individuals with PC encounters on the screening day, setting of services received that day was categorized as PC only, PC-MHI, or Specialty Mental Health (SMH). Using multivariable generalized estimating equations (GEE) logistic regression, we assessed likelihood of treatment initiation, adjusting for demographic and clinical measures, including depression screening score.

KEY RESULTS

Patients who received same-day PC-MHI services were more likely to initiate psychotherapy (OR: 8.16; 95 % CI: 6.54–10.17) and antidepressant medications (OR: 2.33, 95 % CI: 2.10–2.58) within 12 weeks than were those who received only PC services on the screening day.

CONCLUSIONS

Receipt of same-day PC-MHI may facilitate timely receipt of depression treatment.