Anxious depression among Puerto Rican and African-American older adults

Objectives: To determine racial/ethnic differences in the prevalence and impact of anxious depression (i.e. major depressive disorder, MDD, occurring concomitant with generalized anxiety symptoms) among older adults.

Method: Interviews were conducted with 218 Puerto Rican and 206 African American older (age ≥60) urban senior housing residents. Data were collected on diagnostic status, depression severity and psychosocial functioning.

Results: Results indicated a higher prevalence of MDD and anxious depression among Puerto Rican participants. Anxious depression was associated with more severe ratings of distress and suicidality compared with MDD alone, and the impact of depression and anxiety was most pronounced for the Puerto Rican participants. Puerto Rican participants also reported poorer subjective health and more substantial disability; however, these effects were independent of depression or anxiety status.

Conclusions: Anxious depression is common among older ethnic minority adults and the impact of these symptoms differs by race/ethnicity. These results highlight the importance of conducting culturally sensitive assessments of depression and anxiety among older adults.     

Depression in later-life Puerto Rican primary care patients: the role of illness, stress, social integration, and religiosity

BACKGROUND: Older Puerto Ricans belong to two rapidly growing demographic groups known to have high rates of depression: the aging and Hispanic populations. Studies of depression in Puerto Ricans have primarily focused on the impact of demographic factors and health. This study expands previous research, examining the relationships between depression and social stressors, social support, and religiosity, for Puerto Rican primary care patients aged 50 and older. PATIENTS: Participants included 303 Puerto Ricans from six primary care clinics in a northeastern city. METHODS: Patients completed in-person interview in Spanish. The Composite International Diagnostic Interview indicated depressive disorders meeting DSM-IV criteria. Bivariate and multivariate relationships between depression and demographics, health, social stress and support, and religiosity were explored. RESULTS: One fifth of participants met DSM-IV criteria for major depression or dysthymia. Participants with the lowest income, more recent migration, and poor subjective health were significantly more likely to be depressed. In addition, rates of depression increased steeply for patients caring for grandchildren and those with personal or family legal problems. Seeing few relatives each month and needing more instrumental, emotional, or financial support were also related to higher rates of depression. Unexpectedly, low objective illness severity correlated with increased depression, whereas religiosity and religious participation had no relationship to depression. CONCLUSIONS: The findings presented here indicate the potential for social stressors and inadequate supports to substantially increase the risk of depression in older Puerto Ricans in primary care settings. Further studies should explore incorporating these social risk factors into improved prevention, clinical detection, and culturally sensitive treatment of older depressed Puerto Ricans.     

Caring for mental illness in the United States: a focus on older adults.

OBJECTIVE: The authors compared rates of common mental disorders and the use of primary care and specialty mental health services among younger and older adults. METHODS: They used data from 9,585 respondents to the HealthCare for Communities (HCC) Household Telephone Survey. Mental disorders during the past year, including depression, dysthymia, and generalized anxiety disorder, were identified with a short questionnaire. The survey also collected information about sociodemographic and insurance status, perceived need for mental health care, and use of health services. RESULTS: Older adults (age 65 and older) were significantly less likely than younger adults (18-29) or middle-aged adults (30-64) to meet diagnostic criteria for a mental disorder (8% versus 15% in each of the younger age-groups). Older adults who met diagnostic criteria for mental disorders were less likely to perceive a need for mental health care, to receive specialty mental health care or counseling, or to receive referrals from primary care to mental health specialty care than young or middle-aged adults. CONCLUSION: Few older adults with mental disorders use mental health services, particularly specialty mental health services. The lack of perceived need for mental health care may contribute to low rates of mental health service use among older adults.     

Folk hero modeling therapy for Puerto Rican adolescents

Puerto Ricans are concentrated in the Northeastern United States in predominantly low socioeconomic status, urban Hispanic communities. Due to a constellation of stressors associated with their minority status, bilingualism and bicultural conflicts, Puerto Rican adolescents are at high risk of mental disorder. Research has shown that factors such as migration experiences, low socioeconomic status, and Hispanic values conflicting with Anglo culture (e.g., familism, spiritualistic and folk beliefs, orientation to time) are associated with higher rates of psychiatric symptomatology in the Hispanic population. Community mental health resources are under utilized, and traditional therapy modalities have had limited success in remedying the emotional and behavioural problems of Hispanics. This paper reviews several approaches to the delivery of culturally sensitive mental health services to Hispanic populations and describes the development of a new modality for Puerto Rican adolescents. The modality presents Puerto Rican folk heroes and heroines in a modelling therapy targeted towards enhancing adolescents' pride in their ethnic heritage, self-esteem, and adaptive coping with stress. The therapy was implemented on a small-group basis with 21 Puerto Rican adolescents, some of whom participated with their mothers. A clinical evaluation of the therapy was conducted by summarizing therapists' progress reports on each participant and by interviewing the participants about their impressions of the therapy experience. Progress reports and participants' self-reports indicated that the adolescents increased in self-disclosure and self-confidence; they gained pride in being Puerto Rican; they learned adaptive mechanisms for coping with stress; and they enjoyed learning about famous Puerto Ricans and their culture.     

Detection of depression and anxiety disorders by home care nurses

Several studies have reported that psychiatric disorders, mainly depression and anxiety disorders, were masked and undiagnosed among older adults, particularly frail elderly. This phenomenon could have a significant impact on elderly quality of life. In this study, we assessed the utility of three measures for detecting mental health disorders among frail elderly receiving home care services: (1) the PRIME-MD; (2) a standard psychological distress measure (PDI-29), and (3) the health care case manager'sa priori judgment on the subject's mental health status. Results obtained by home care nurses were compared to those obtained by clinical psychologists using a structured diagnostic interview (SCID for DSM-IV). The study was conducted in two community health service centres. During the study's period, all patients in the health care workers' caseload without cognitive impairment and not reporting significant stressful life events during the six-week period preceding the interview (n = 315) were asked to participate in the study. Results showed that 42.9% of the volunteers that agreed to meet a psychologist at home (n = 177) had a current SCID-IV diagnosis. The specificity of the PRIME-MD test performed by nurses was 83.8% and its sensitivity was 41.7%. The correct classification rate was 66.7%. Results indicated that the PDI-29 items showed better performance characteristics than the PRIME-MD in identifying current cases. The specificity of the PDI-29 was 59.0% and its sensitivity was 73.6%. These results lead us to the conclusion that the PRIME-MD, previously proposed by Spitzer, R.L., Williams, J.B., Kroenke, K., Linzer, M., DeGruy, F.V. 3rd, Hahn, S.R., et al. (1994, Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. Journal of the American Medical Association, 272 (22), 1749-1756.) to help physicians in primary care clinics, could be less appropriate than the PDI-29 when used by home care nurses in identifying undiagnosed mental health disorders in frail older adults living at home. Moreover, this study showed that the health care case manager'sa priori judgment on the care receiver's mental health status is not sufficient in identifying frail elderly mental health services needs. A two-stage screening procedure is proposed to help home care nurses.     

The plight of extremely poor Puerto Rican and Non-Hispanic White single mothers

Using data from a case-control study of family homelessness in Worcester, Massachusetts, this analysis compares the economic, psychosocial and health characteristics of 159 Puerto Rican and 170 Non-Hispanic White poor, single mothers. When compared to Non-Hispanic Whites, the Puerto Rican mothers had more children, less education, fewer work experiences, fewer social supports, and more English language problems. Although the absolute rates were high in both groups, Puerto Rican mothers had experienced less violence and suffered fewer mental health problems, with the exception of major depression, than Non-Hispanic Whites. In addition, Puerto Rican mothers were less likely to use traditional health services. These findings suggest that to escape poverty, Puerto Rican mothers need a unique combination of educational opportunities (including English as a Second Language), job training, and child care. Accepted: 9 December 1997     

Religious participation as a predictor of mental health status and treatment outcomes in older persons

OBJECTIVES: This study focuses on examining the relations of religious participation and affiliation to mental health status among older primary care patients, and to the use and clinical outcomes of mental health services. METHODS: A sample of older adults participating in a clinical study (PRISM-E) to treat their depression with or without co-morbid anxiety (n = 1610) were queried about their religious affiliation and the frequency of their participation in religious activities. The diagnoses of depressive and anxiety disorders were made based on the MINI-International Neuropsychiatric Interview. Severity of depressive disorders was assessed by emotional distress using the CES-D. RESULTS: Those attending religious activities on a weekly, monthly, or occasional basis were significantly less likely to have suicidal ideation (p < 0.02) and emotional distress (p < 0.0001) than those who never participated or participated on a less frequent basis. Frequency of religious participation was not associated with mental health service utilization (p = 0.16), but it was predictive of a lower CES-D score at the end of the study intervention (p < 0.001). CONCLUSIONS: Religious participation is positively associated with older adults' mental health status and treatment effects, but results regarding mental health service utilization were inconclusive.     

Personality disorders and coping among anxious older adults

This study examined the interrelationships among anxiety, personality disorders, and coping strategies in anxious older adults (n = 28; age range = 55-89; mean = 66.0), nonanxious older adults (n = 100, age range = 55-79, mean = 64.6 ), and anxious younger adults (n = 132; age range = 17-30; mean = 20.2). Younger participants were college students and older participants were community-based family members of the students or recruits from local senior centers. Participants completed the Coolidge Axis II Inventory, the Coping Orientations to Problems Experienced scale, and the Brief Symptom Inventory. Results indicated that the prevalence of generalized anxiety states was relatively low and similar in both older and younger groups and dependent on measurement scale and criterion. At least one personality disorder was found in 61% of the older persons group; obsessive-compulsive, schizoid, and avoidant were the most frequently assigned personality disorders. Anxious older adults had elevated rates of dependent and avoidant personality disorder compared with nonanxious older adults. Younger anxious persons were found to have significantly greater personality dysfunction compared with older anxious persons. Finally, coping differences existed between older anxious and older nonanxious adults and between older anxious and younger anxious adults. Implications for diagnosis and treatment of anxiety in older adults were discussed.     

Impact of comorbid panic and posttraumatic stress disorder on outcomes of collaborative care for late-life depression in primary care.

OBJECTIVE: Comorbid anxiety disorders may result in worse depression treatment outcomes. The authors evaluated the effect of comorbid panic disorder and posttraumatic stress disorder (PTSD) on response to a collaborative-care intervention for late-life depression in primary care. METHODS: A total of 1,801 older adults with depression were randomized to a collaborative-care depression treatment model versus usual care and assessed at baseline, 3, 6, and 12 months, comparing differences among participants with comorbid panic disorder (N=262) and PTSD (N=191) and those without such comorbid anxiety disorders. RESULTS: At baseline, patients with comorbid anxiety reported higher levels of psychiatric and medical illness, greater functional impairment, and lower quality of life. Participants without comorbid anxiety who received collaborative care had early and lasting improvements in depression compared with those in usual care. Participants with comorbid panic disorder showed similar outcomes, whereas those with comorbid PTSD showed a more delayed response, requiring 12 months of intervention to show a significant effect. At 12 months, however, outcomes were comparable. Interactions of intervention status by comorbid PTSD or panic disorder were not statistically significant, suggesting that the collaborative-care model performed significantly better than usual care in depressed older adults both with and without comorbid anxiety. CONCLUSIONS: Collaborative care is more effective than usual care for depressed older adults with and without comorbid panic disorder and PTSD, although a sustained treatment response was slower to emerge for participants with PTSD. Intensive and prolonged follow-up may be needed for depressed older adults with comorbid PTSD.     

The outcome of anxiety disorders in older people at 6-year follow-up: results from the Longitudinal Aging Study Amsterdam

OBJECTIVE: To examine long-term outcome of late-life anxiety disorders and utilization of mental health care services. METHOD: A cohort of subjects (aged > or = 55 years) with an anxiety disorder (n = 112) was identified in the Longitudinal Aging Study Amsterdam (n = 3107). At 6 year follow-up, the rate of persistence and prognostic factors for persistence of anxiety were established. RESULTS: Six years after baseline 23% of our sample met the criteria for an anxiety disorder. Another 47% suffered from subclinical anxiety symptoms. Persistence of anxiety was associated with a high score on neuroticism at baseline. Use of benzodiazepines was high (43%), while use of mental health care facilities (14%) and anti-depressants (7%) remained low in those with persistent anxiety. CONCLUSION: Results indicate that those high in neuroticism are at greater risk for persistence of anxiety. Efforts to enhance appropriate referral of anxious older adults do not seem to have had the desired effect.     

Utilization of emergency center services by older adults with a psychiatric diagnosis

Information regarding older adult emergency center (EC) patient characteristics remains limited, despite its increasing importance in health care delivery systems. This retrospective study encompasses all EC visits over an eight-year period (n = 825,682) to a large urban county hospital. Only participants with a primary psychiatric diagnosis were examined, and included a total of 53,894 adults, 18-64 years old and 1,478 adults, > or =65 years old. Despite an increasing aging population, EC visits for older adults with psychiatric disorders did not increase over time. Within the older adult sample, cognitive, psychotic, and bipolar disorders were associated with higher rates of admission to the hospital, while substance use, depressive, and anxiety disorders were associated with lower numbers of inpatient admissions. African-Americans were over-represented in the EC and admitted to the hospital at higher rates, compared to other ethnic groups. Caucasian patients were the group most frequently diagnosed with a substance use disorder. In conclusion, differences in race, and diagnosis support the idea that such variables directly relate to utilization rates, presentation, and disposition within the EC.     

Anxiety disorders in older Puerto Rican primary care patients.

OBJECTIVE: Authors examined the frequency and comorbidity of anxiety disorders among aging Puerto Ricans seen in primary care. METHODS: A group of 303 middle-aged and older low-socioeconomic-status Puerto Ricans attending primary-care clinics were surveyed, using a Spanish-language diagnostic interview. RESULTS: Twenty-four percent of participants met probable DSM criteria for at least one anxiety disorder in the previous year, especially generalized anxiety disorder, specific phobia, and panic attacks. Psychiatric comorbidity was common; the occurrence of most anxiety disorders increased the conditional risk of a comorbid disorder from 5- to 30-fold. CONCLUSIONS: The present results suggest a need to screen at-risk patients in primary care settings serving this population.     

Mental health service use among Canadian older adults with anxiety disorders and clinically significant anxiety symptoms

Objectives: Despite evidence of disproportionate underutilization of mental health services by older adults and by individuals with anxiety disorders, little is known specifically about service use by older adults with anxiety. This study examines the prevalence of mental health service use among older adults with anxiety disorders and clinically significant anxiety symptoms, as well as factors associated with service use.

Method: The authors used data from the Canadian Community Health Survey–Mental Health and Well-Being, a nationally representative survey of community-dwelling Canadians. This study examined past-year use of mental health services in both the specialty mental health and general medical sectors by adults aged 55+ (N = 12,792). Logistic regression analyses examined predictors of service use among those with anxiety disorders (N = 279) and clinically significant anxiety symptoms (N = 880).

Results: Only 20.8% of older adults with an anxiety disorder and no mood disorder used services in the past year, compared to 43.1% of those with a mood disorder and 72.7% of those with comorbid disorders. In the final logistic regression models, only need variables were significant predictors of service use among older adults with anxiety disorders and among those with significant anxiety symptoms.

Conclusion: Findings indicate that anxious older adults are less likely to use mental health services than those who are depressed. While predisposing and enabling factors do not appear to impede service use, the need for help does. Anxious older adults and those they interact with may not be interpreting their anxiety symptoms as warranting services.     

Perceived stigma and mental health care seeking

OBJECTIVE: There is limited empirical evidence on the extent to which perceived public stigma prevents individuals from using mental health services, despite substantial recent policy interest in this issue. This study investigated associations between perceived public stigma and mental health care seeking. METHODS: This study used cross-sectional survey data from a representative sample of undergraduate and graduate students (N=2,782) at one university. A five-item scale was used to assess perceived public stigma toward mental health service use. Perceived need for help in the past 12 months and current presence of depressive and anxiety disorders were also assessed. RESULTS: Perceived stigma was higher among males, older students, Asian and Pacific Islanders, international students, students with lower socioeconomic status backgrounds, and students with current mental health problems. Perceived stigma was also higher among those without any family members or friends who had used mental health services and among those who believed that therapy or medication is not very helpful. Perceived stigma was negatively associated with the likelihood of perceiving a need for mental health services, but only among younger students. Among those with probable depressive or anxiety disorders, there was no evidence that perceived stigma was associated with service use. CONCLUSIONS: These results suggest that, at least in this population, perceived stigma may not be as important a barrier to mental health care as the mental health policy discourse currently assumes.     

Attitudes toward mental health services: Age-group differences in Korean American adults

The present study examined the attitudes toward mental health services held by younger (aged 20–45, n = 209) and older (aged 60 and older, n = 462) groups of Korean Americans. Following Andersen's (1968; A behavioral model of families’ use of health service, Center for Health Administration Studies) behavioral health model, predisposing (age, gender, marital status and education), need (anxiety and depressive symptoms) and enabling (acculturation, health insurance coverage and personal experience and beliefs) variables were considered. In the mean-level assessment, younger and older adults were found to hold a similar level of positive attitudes toward mental health services. In the multivariate analysis, culture-influenced beliefs were shown to have a substantial contribution to the model of attitudes toward mental health services in both age groups. The belief that depression is a medical condition was found to be a common predictor of positive attitudes across the groups. In the older adult sample, more negative attitudes were observed among those who believed that depression is a sign of personal weakness and that having a mentally ill family member brings shame to the whole family. Our findings show that older adults are not only more subject to cultural misconceptions and stigma related to mental disorders, but also their attitudes toward service use are negatively influenced by the cultural stigma. The findings provide important implications for interventions targeted to improve access to mental health care among minority populations. Based on the similarities and differences found between young and old, both general and age-specific strategies need to be developed in order to increase effectiveness of these programs.     

Associations between anxiety disorders,suicide ideation,and age in nationally representative samples of Canadian and American adults

Suicidal behaviors are of significant concern for the individuals displaying such behavior and for service providers who encounter them. Using nationally representative samples of Canadian and American adults, we aimed to examine: whether age moderates the relationship between having any anxiety disorder and suicide ideation (SI), the prevalence of SI among younger and older adults, and whether age and individual anxiety disorders were differentially associated with SI. Age moderated the relationship between any anxiety disorder and SI among Americans only. Past-year SI was less prevalent among older, compared to younger, adults; though, nearly every anxiety disorder was associated with increased odds of SI among younger and older Canadian and American adults after controlling for covariates. Effect sizes were particularly large for older American adults, but were coupled with large confidence intervals. Findings contribute to a growing literature suggesting that SI in the context of anxiety is a highly prevalent and complex mental health problem across the adult lifespan.     

Anxiety-related constructs mediate the relation between age and health anxiety

Objective: Few studies have examined health anxiety in older adults, and it is unknown which factors account for age-related differences in health anxiety. Given similarities between health anxiety and the anxiety disorders, anxiety-related constructs, including anxiety sensitivity, intolerance of uncertainty, emotion regulation, and anxiety control, were examined as mediators of the relation between age (older vs. young adults) and health anxiety. Methods: Eighty-six older adults aged 60 and older and 117 young adults aged 18 to 30 completed several self-report measures of health anxiety and anxiety-related constructs. Results: Young adults reported higher levels of health anxiety than older adults. Anxiety sensitivity and intolerance of uncertainty partially mediated the relation between age and health anxiety. Perceived anxiety control, reappraisal, and suppression did not mediate the relation between age and health anxiety. Conclusions: Anxiety sensitivity and intolerance of uncertainty are predisposing characteristics that appear to partially explain age-related differences in health anxiety. These constructs may be necessary targets for assessment and interventions among older and young adults.     

Incremental Health Care Expenditures of the Spouses of Older Adults With Alzheimer's Diseases and Related Dementias (ADRD)

ObjectivePrevious research has found that having a spouse with Alzheimer's disease and related dementias (ADRD) is associated with higher health care expenditures, however it is unclear if this difference remains after accounting for the demographics and health status of the non-ADRD spouse. This paper aims to estimate the adjusted incremental health care expenditures of having a spouse with ADRD.DesignCross-sectional study of publicly available survey data (2003–2017 Medical Expenditure Panel Survey).SettingRepresentative sample of U.S. households.ParticipantsCommunity-dwelling and married older adults (n = 28,356).MeasurementTwo-part models and recycled prediction techniques to estimate the incremental effects of having a spouse with ADRD on annual health care expenditures, while adjusting for demographics, socioeconomic characteristics, and health conditions.ResultsSpouses of older adults with ADRD were older, had worse perceived mental health, and had greater difficulties with activities of daily living, compared to older adults with cognitively normal spouses. Spouses of ADRD patients had significantly higher unadjusted total health care expenditures, however their adjusted incremental expenditure was not significantly greater. After controlling for demographics and health status, ADRD spouses had significantly higher home health care expenditures, but significantly lower outpatient expenditures.ConclusionResults suggested that the higher health care expenditures in older adults with ADRD spouses can be attributed to the higher rate of comorbidities, rate of functional limitations, and mean age in this group. The increased use of home health and decreased use of outpatient in this population suggests the importance of tailoring preventative health care and social services to meet the needs of this group.