Self-rated health, depression, and one-year health outcomes in older primary care patients.

OBJECTIVE: The authors tested the hypothesis that poorer self-rated health is associated with poorer health outcomes. METHOD: They prospectively examined the association of self-rated health to 1-year outcomes in 247 older subjects from primary care settings. RESULTS: Poorer self-rated health was independently associated with 1-year functional disability, after covarying initial clinical and functional measures, but was not independently associated with 1-year depression diagnosis. Results were mixed regarding associations with 1-year medical burden or mortality. CONCLUSIONS: Clinicians should be vigilant for functional decline in patients who perceive their health negatively. Future research should test potential mechanisms that might underlie this association.     

Diagnosis and treatment of older adults with depression in primary care.

This article provides an overview of current challenges in the diagnosis and treatment of depressed older adults in primary care and considers suggestions for clinicians, researchers, and policy makers to improve care for this population. Despite the enormous toll of depression on individuals and society and the availability of effective treatments, depressed older adults remain largely untreated or undertreated. They rarely see mental health professionals, but have relatively frequent contact with primary care providers. In primary care, the chronic and recurrent nature of depression and a number of patient, provider, and policy-related barriers interfere with effective depression treatment. Recent research suggests that improving care for individuals with late life depression will require education and engagement of older adults and their primary care providers as active partners in caring for depression. It will also require additional human resources and systematic models of care dedicated to proactively managing depression as a chronic illness. Finally, it will require training of mental health professionals to effectively collaborate with their colleagues in primary care in treating depressed older adults. Further improvement in depression care would likely result from the implementation of true parity for mental health treatments for older adults.     

Life stress as a correlate of depression among older adults

Although there is some evidence that stressful life events are related to depression in the general population, there has been less research on this relationship with random community samples of older adults. The purpose of this study was to examine whether life stress (both stressful life events and chronic life strains) is correlated with depressive symptoms among a representative sample of noninstitutionalized elderly people. The findings indicate that chronic life strains (strains associated with financial and physical health problems) as well as bereavement are highly significant correlates of depression. Issues in the statistical estimation of these effects are also addressed.     

Posttraumatic stress disorders and depression among male inpatient adults involved in the Lebanese war

Purpose : to evaluate factors associated with posttraumatic stress disorder (PTSD) and depression in a sample of hospitalized Lebanese adult males who directly or indirectly were involved in armed conflicts. Design : Cross-sectional. Methods : Seventy-seven hospitalized males were enrolled between June and December 2016. The Hamilton Anxiety and Depression Scale and the Mini International Neuropsychiatric Interview were used to assess anxiety, depression, and PTSD. Results : Participation in war (adjusted odds ratio [ORa] = 6.35) and depression (ORa = 1.08) were associated with higher PTSD, whereas age (ORa = 0.94) and substance use (ORa = 0.19) were associated with lower PTSD. Anxiety (β = .87), substance use (β = 6.27) and PTSD (β = 8.78; P = .008) were associated with higher depression. Practice Implications : People who experienced war conflicts (directly or indirectly) are more prone to suffer from mental health disorders.     

Social inequalities in depression and suicidal ideation among older primary care patients

Purpose

Depression and suicide are major public health concerns, and are often unrecognized among the elderly. This study investigated social inequalities in depressive symptoms and suicidal ideation among older adults.

Methods

Data come from 1,226 participants in PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial), a large primary care-based intervention trial for late-life depression. Linear and logistic regressions were used to analyze depressive symptoms and suicidal ideation over the 2-year follow-up period.

Results

Mean Hamilton Depression Rating Scale (HDRS) scores were significantly higher among participants in financial strain [regression coefficient (b) = 1.78, 95 % confidence interval (CI) = 0.67–2.89] and with annual incomes below $20,000 (b = 1.67, CI = 0.34–3.00). Financial strain was also associated with a higher risk of suicidal ideation (odds ratio = 2.35, CI = 1.38–3.98).

Conclusions

There exist marked social inequalities in depressive symptoms and suicidal ideation among older adults attending primary care practices, the setting in which depression is most commonly treated. Our results justify continued efforts to understand the mechanisms generating such inequalities and to recognize and provide effective treatments for depression among high-risk populations.     

Recovery from depression, work productivity, and health care costs among primary care patients

We describe a secondary analysis of data from a randomized trial conducted at seven primary care clinics of a Seattle area HMO. Adults with major depression (n=290) beginning antidepressant treatment completed structured interviews at baseline, 1, 3, 6, 9, 12, 18, and 24 months. Interviews examined clinical outcomes (Hamilton Depression Rating Scale and depression module of the Structured Clinical Interview for DSM-IIIR), employment status, and work days missed due to illness. Medical comorbidity was assessed using computerized pharmacy data, and medical costs were assessed using the HMO's computerized accounting data. Using data from the 12-month assessment, patients were classified as remitted (41%), improved but not remitted (47%), and persistently depressed (12%). After adjustment for depression severity and medical comorbidity at baseline, patients with greater clinical improvement were more likely to maintain paid employment (P=.007) and reported fewer days missed from work due to illness (P<.001). Patients with better 12-month clinical outcomes had marginally lower health care costs during the second year of follow-up (P=.06). We conclude that recovery from depression is associated with significant reductions in work disability and possible reductions in health care costs. Although observational data cannot definitively prove any causal relationships, these longitudinal results strengthen previous findings regarding the economic burden of depression on employers and health insurers.     

Posttraumatic stress symptoms in older adults hospitalized for fall injury

ObjectiveAlthough unintentional falls may pose a threat of death or injury, few studies have investigated their psychological impact on older adults. This study sought to gather data on early posttraumatic stress symptoms in older adults in the hospital setting after a fall.MethodParticipants in this study were 100 adults age 65 years or older admitted to a large urban hospital in New York City because of a fall. Men and women were represented approximately equally in the sample; most were interviewed within days of the fall event. The study's bedside interview included the Posttraumatic Stress Symptom Scale, which inquires about the presence and severity of 17 trauma-related symptoms.ResultsTwenty-seven participants reported substantial posttraumatic stress symptoms (moderate or higher severity). Exploratory bivariate analyses suggested an association between posttraumatic stress symptom severity and female gender, lower level of education, unemployment, number of medical conditions, and back/chest injury.ConclusionsA significant percentage of older patients hospitalized after a fall suffer substantial posttraumatic stress. Future investigations are needed to assess the association between the psychiatric impact of a fall and short-term inpatient outcomes as well as longer-term functional outcomes.     

Posttraumatic stress disorder in older adults: a conceptual review

Issues that are salient in understanding posttraumatic stress disorder (PTSD) in older adults are examined in this review. Although this issue has received scattered attention in the literature since introduction of the diagnosis of PTSD to the Diagnostic and Statistical Manual (DSM) in 1980, it is clear that numerous conceptual and defining questions exist in our understanding of the aftermath of trauma exposure in older adults. In approaching this issue, studies pertaining to diagnostic status as well as broader dimensions of psychosocial functioning are examined. Concerns that are unique to older adults are highlighted throughout, with particular attention to areas where additional research is warranted.     

Posttraumatic stress and aggression among veterans in long-term care

Because stresses associated with long-term care settings may exacerbate distress and aggression related to past trauma, we investigated self-report and staff reports of posttraumatic stress disorder symptoms and staff observations of verbal and physical aggression in 32 elderly males who were patients in a long-term care unit for veterans. Feelings of anger and irritability were reported by 47% of patients; levels of anger and irritability were significantly correlated with observed aggressive behaviors (r = 0.43, P < .02); and observed aggressive behaviors were significantly more frequent among those reporting past traumatic stressors (t = 2.84, P < .008). Patient-reported posttraumatic stress disorder symptoms were significantly correlated with the frequency of past traumatic stressors (r = 0.48, P < .006). Observer-reported posttraumatic stress disorder symptoms and patient reports of anger were strongly correlated (r = 0.73, P < .001). No patient or staff reports were related to level of cognitive function. These findings are consistent with the hypothesis that posttraumatic symptoms can contribute to aggressive behaviors in elderly, medically ill, and cognitively impaired patients.     

Posttraumatic stress disorder in the primary care medical setting

Posttraumatic stress disorder (PTSD) is a prevalent disorder that adversely affects 2-5% of the general population. Little is known about PTSD in the primary care setting. The purpose of the present study was to evaluate the utility of a screening instrument for PTSD (the PCL-C) in primary care and to examine comorbidity, disability, and patterns of healthcare utilization among persons with PTSD in this setting. Adult, English-speaking patients attending for routine medical care (N=368) participated in a two-stage screening consisting of the administration of a self-report measure for posttraumatic stress disorder (the PCL-C) followed by a structured diagnostic interview. Current (1-month) prevalence of PTSD was determined, as were current comorbid disorders. Brief functional impairment and disability indices were administered, and healthcare utilization in the prior 6 months was ascertained. 11.8% (standard error 1.7%) of primary care attendees met diagnostic criteria for either full or partial PTSD. Comorbidity with major depression (61% of cases of PTSD) and generalized anxiety disorder (39%) was common, but less so with social phobia (17%) and panic disorder (6%). Substance use disorder comorbidity (22%) was also fairly common. Patients with PTSD reported significantly more functional impairment than patients without mental disorders. Patients with PTSD also made greater use of healthcare resources than not mentally ill patients. PTSD frequently is encountered in primary care, and is associated with considerable functional impairment and healthcare utilization. Comorbidity with other mood and anxiety disorders is extensive. It remains to be seen if greater awareness and more aggressive treatment of PTSD in primary care will lead to improved functioning and reduced (or more appropriate) healthcare utilization. These are topics for further study.     

Cerebrovascular risk factors, executive dysfunction, and depression in older primary care patients.

OBJECTIVE: "Executive" cognitive functions may be of particular clinical importance in geriatric depression and may reflect underlying cerebrovascular disease. This study examined the associations of selected components of executive function with cerebrovascular risk factors, depression, and overall functional status. METHOD: Study measures were completed on 448 primary care patients aged>or=65 years based on patient interviews and medical chart review. Multiple regression techniques determined the presence of specified independent associations. RESULTS: Some but not all study hypotheses were confirmed. Cerebrovascular risk factors were associated with major depression and with some cognitive measures, but their associations with depression and with the most specific measures of executive function were limited and not independent of overall medical burden. Measures of initiation-perseveration and mental set shifting were associated with overall functional disability; these cognitive measures were not associated with depression diagnosis, or with depressive symptoms when also covarying medical burden or excluding patients with dementia. CONCLUSIONS: Clinicians should be aware of the potential functional significance of these components of cognition. Longitudinal risk factor studies and complementary techniques such as neuroimaging may help identify pathogenetically distinct subgroups of later-life depression that might respond preferentially to specific interventions.     

Knowledge, attitudes and practice pertaining to depression among primary health care workers in Tanzania

Background  

Examination of consultation data in a variety of primary care settings in Tanzania shows that, while psychoses are routinely diagnosed and treated at primary care level, depression is rarely recorded as a reason for consultation. Since, epidemiological studies elswhere show that depression is a much more common disorder than psychosis, a series of studies were undertaken to elucidate this apparent paradox in Tanzania and inform mental health policy; firstly, a household prevalence study to ascertain the prevalence of common mental disorders at community level in Tanzania; secondly, a study to ascertain the prevalence of common mental disorders in primary care attenders; and thirdly, a study to ascertain the current status of the knowledge, attitude and practice pertaining to depression among primary health care workers. This paper reports the findings of the latter study.     

Comparison of major depressive disorder and subthreshold depression among older adults in community long-term care

Objectives: This study extends existing knowledge regarding the continuum between major depression (MD) and subthreshold depression (SD) by examining differences in symptomology and associative factors for a subpopulation of older adults with functional disability.

Method: Our sample consisted of clients age 60 and above entering public community long term care derived from the baseline survey of a longitudinal study (315 non-depressed, 74 MD, and 221 SD). We used the Diagnostic Interview Schedule to establish diagnoses of MD, the Center for Epidemiological Studies Depression Scale (CES-D) to assess SD, and other self-report measures to explore potential associative factors of demographics, comorbidity, social support, and stressors.

Results: No differences in CES-D identified symptoms occurred between the two groups. MD and SD were both associated with lower education, poorer social support, more severe medical conditions, and higher stress when compared to non-depressed older adults. Younger age and being female were associated solely with MD; whereas, worse perceived health and more trouble affording food were associated solely with SD. The only associative factor significantly different between MD and SD was age. Those with MD were more likely to be younger than those with SD.

Conclusion: Our findings of symptom profiles and associative factors lend support to the continuum notion of depression. Identification of only older adults within the community long-term care service system who meet criteria for MD would leave many older adults, who also face multiple comorbidities, high levels of stress and social isolation, and substantial depressive symptoms undiagnosed and untreated.     

Relationships among pain, anxiety, and depression in primary care

Pain, anxiety, and depression are commonly seen in primary care patients and there is considerable evidence that these experiences are related. This study examined associations between symptoms of pain and symptoms and diagnoses of anxiety and depression in primary care patients. Results indicate that primary care patients who endorse symptoms of muscle pain, headache, or stomach pain are approximately 2.5-10 times more likely to screen positively for panic disorder, generalized anxiety disorder, or major depressive disorder. Endorsement of pain symptoms was also significantly associated with confirmed diagnoses of several of the anxiety disorders and/or major depression, with odds ratios ranging from approximately 3 to 9 for the diagnoses. Patients with an anxiety or depressive disorder also reported greater interference from pain. Similarly, patients endorsing pain symptoms reported lower mental health functioning and higher scores on severity measures of depression, social anxiety, and posttraumatic stress disorder. Mediation analyses indicated that depression mediated some, but not all of the relationships between anxiety and pain. Overall, these results reveal an association between reports of pain symptoms and not only depression, but also anxiety. An awareness of these relationships may be particularly important in primary care settings where a patient who presents with reports of pain may have an undiagnosed anxiety or depressive disorder.     

Social functioning, polypharmacy and depression in older Chinese primary care patients

Objective: This study aims to identify the relationship among social functioning, polypharmacy and depression among older patients in Hong Kong.

Method: Three out of 18 elderly health centres were selected using the cluster sampling method. 457 elders were randomly selected from all the patients aged 65 and over attending the centres, and were interviewed using the Chinese Minimum Data Set-Home Care in 1999. Of them 318 were re-assessed in 2000.

Results: At follow-up, their mean age was 73.6 (SD?=?5.5), of whom 51.6% were females. Besides negative emotions, respondents’ increased depressive symptoms were associated with using more than four medications and decline in social functioning over time, and behavioural agitation at baseline. If there was no medication review at baseline, the impact of polypharmacy on depression was subsided.

Conclusion: Medication review is important in the prediction and treatment process of depression as it can moderate the impact of social functioning and polypharmacy. Therefore, medical professionals should prescribe fewer medications to eliminate adverse drug reactions and reduce depressive symptoms. However, the study reflects that older adults might feel depressed by not being able to control the result of their reviews. Thus, if the review could involve older patients, it might be more assuring and helps to restore their hope for gaining control in their treatment process.     

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.