Mental health services research: moving from academia to the community

Aging and Mental Health: Collaborating on Research Priorities with Older Adults, Caregivers and Health and Social Care Providers across Canada

Age-related changes can affect mental health, but aging-focused mental health research is limited. The objective was to identify the top 10 unanswered research questions on aging and mental health according to what matters most to aging Canadians. A steering group of experts-by-experience (e.g., older adults, caregivers, health and social care providers) guided three phases of a modified James Lind Alliance priority-setting partnership: (1) a broad national survey (n = 305) and a rapid literature scan; (2) a follow-up national survey (n = 703); and (3) four online workshops (n = 52) with a nominal group technique. Forty-two unique questions on aging and mental health resulted, of which 18 were determined to be answered by existing evidence. Of the 25 partially and unanswered questions, 10 were ranked as top priority. Findings can be used to prioritize future research, knowledge mobilization, and funding decisions, and to promote and support collaboration between longstanding siloed research and care fields.

Design and Development of a Community-Based, Interdisciplinary, Collaborative Dementia Care Program

OBJECTIVE

To describe the design, development, and baseline characteristics of enrollees of a home-based, interdisciplinary, dyadic, pilot dementia care program.

DESIGN

Single-arm, dementia care intervention in partnership with primary care providers delivered by Health Coaches to persons with dementia and caregiver "dyads" and supervised by an interdisciplinary team.

SETTING

Home- and virtual-based dyad support.

PARTICIPANTS

Persons with mild cognitive impairment or dementia diagnosis and/or who were prescribed antidementia medications; had an identified caregiver willing to participate; were under the care of a partner primary care provider; and had health insurance through the affiliated accountable care organization (Banner Health Network).

INTERVENTION

Provision of personalized dementia education and support in the home or virtually by Health Coaches supported by an interdisciplinary team.

MEASUREMENTS

Cognition, function, mood, and behavior of persons with dementia; caregiver stress and program satisfaction; primary care provider satisfaction.

RESULTS

Served dyads from three primary care clinics with a total of 87 dyads enrolled between December 2018 and June 2020.

CONCLUSION

A pilot Dementia Care Partners demonstrated feasibility and suggested acceptability, and high satisfaction among primary care providers and caregivers.

Views on ageing in place from relocated low‑income housing residents in the US

BACKGROUND

Ageing in place (AIP) is the ability to live in one's home and community independently, despite age, ability level or income.

AIM

To elicit knowledge and feelings about AIP from low-income older adults relocated to low-income housing.

METHOD

Nursing students, supervised by nursing faculty trained in research, conducted semi-structured interviews about AIP with volunteer residents living in a low-income apartment complex in the southern US.

FINDINGS

Seven participants discussed common fears and worries as well as needs for AIP in low-income housing. Mental health issues were prominent.

CONCLUSION

Mental health warrants consideration along with physical, social and emotional well-being in beginning to identify and address the needs of older people ageing anywhere, perhaps especially in relocated low-income older adults. This information could inform future interventions to encourage AIP in the US and potentially in other countries.

Delivery Characteristics, Acceptability, and Depression Outcomes of a Home-based Depression Intervention for Older African Americans: The Get Busy Get Better Program

PURPOSE OF THE STUDY

To facilitate replication, we examined delivery characteristics, acceptability, and depression outcomes of a home-based intervention, Get Busy Get Better, Helping Older Adults Beat the Blues (GBGB). GBGB, previously tested in a randomized trial, reduced depressive symptoms and enhanced quality of life in African Americans.

DESIGN AND METHODS

A total of 208 African Americans aged above 55 years with Patient Health Questionnaire (PHQ-9) scores ≥5 on two subsequent screenings were randomized to receive GBGB immediately or 4 months later. GBGB involves up to 10 home sessions consisting of care management, referral/linkage, depression education/symptom recognition, stress reduction, and behavioral activation. Interventionists recorded delivery characteristics (dose, intensity) and perceived acceptability of sessions. Baseline and post-tests were used to characterize participants and examine associations between dose/intensity and depression scores. Participant satisfaction and perceived benefits were examined at 8 months.

RESULTS

Of 208 participants, 181 (87%, mean age = 69.6) had treatment data. Of these, 165 (91.2%) had ≥3 treatment sessions (minimal dose). Participants had on average 8.1 sessions (SD = 2.6) for an average of 65.4min (SD = 18.3) each. Behavioral activation and care management were provided the most (average of six sessions for average duration = 17.9 and 22.2min per session respectively), although all participants received each treatment component. GBGB was perceived as highly acceptable and beneficial by interventionists and participants. More sessions and time in program were associated with greater symptom reduction.

IMPLICATIONS

GBGB treatment components were highly acceptable to participants. Future implementation and sustainability challenges include staffing, training requirements, reimbursement limitations, competing agency programmatic priorities, and generalizability to other groups.

Mediators of the impact of a home-based intervention (beat the blues) on depressive symptoms among older African Americans

Older African Americans (N = 208) with depressive symptoms were randomly assigned to a home-based nonpharmacologic intervention (Beat the Blues, or BTB) or wait-list control group. BTB was delivered by licensed social workers and involved up to 10 home visits focused on care management, referral and linkage, depression knowledge and efficacy in symptom recognition, instruction in stress reduction techniques, and behavioral activation through identification of personal goals and action plans for achieving them. Structured interviews by assessors masked to study assignment were used to assess changes in depressive symptoms (main trial endpoint), behavioral activation, depression knowledge, formal care service utilization, and anxiety (mediators) at baseline and 4 months. At 4 months, the intervention had a positive effect on depressive symptoms and all mediators except formal care service utilization. Structural equation models indicated that increased activation, enhanced depression knowledge, and decreased anxiety each independently mediated a significant proportion of the intervention's impact on depressive symptoms as assessed with 2 different measures (PHQ-9 and CES-D). These 3 factors also jointly explained over 60% of the intervention's total effect on both indicators of depressive symptoms. Our findings suggest that most of the impact of BTB on depressive symptoms is driven by enhancing activation or becoming active, reducing anxiety, and improving depression knowledge/efficacy. The intervention components appear to work in concert and may be mutually necessary for maximal benefits from treatment to occur. Implications for designing tailored interventions to address depressive symptoms among older African Americans are discussed.

A home-based intervention to reduce depressive symptoms and improve quality of life in older African Americans: a randomized trial

BACKGROUND

Effective care models for treating older African Americans with depressive symptoms are needed.

OBJECTIVE

To determine whether a home-based intervention alleviates depressive symptoms and improves quality of life in older African Americans.

DESIGN

Parallel, randomized trial stratified by recruitment site. Interviewers assessing outcomes were blinded to treatment assignment. (ClinicalTrials.gov: NCT00511680).

SETTING

A senior center and participants' homes from 2008 to 2010.

PATIENTS

African Americans aged 55 years or older with depressive symptoms.

INTERVENTION

A multicomponent, home-based intervention delivered by social workers or a wait-list control group that received the intervention at 4 months.

MEASUREMENTS

Self-reported depression severity at 4 months (primary outcome) and depression knowledge, quality of life, behavioral activation, anxiety, function, and remission at 4 and 8 months.

RESULTS

Of 208 participants (106 and 102 in the intervention and wait-list groups, respectively), 182 (89 and 93, respectively) completed 4 months and 160 (79 and 81, respectively) completed 8 months. At 4 months, participants in the intervention group showed reduced depression severity (difference in mean change in Patient Health Questionnaire-9 score from baseline, -2.9 [95% CI, -4.6 to -1.2]; difference in mean change in Center for Epidemiologic Studies Depression Scale score from baseline, -3.7 [CI, -5.4 to -2.1]); improved depression knowledge, quality of life, behavioral activation, and anxiety (P < 0.001); and improved function (P = 0.014) compared with wait-list participants. More intervention than wait-list participants entered remission at 4 months (43.8% vs. 26.9%). After treatment, control participants showed benefits similar in magnitude to those of participants in the initial intervention group. Those in the initial intervention group maintained benefits at 8 months.

LIMITATION

The study had a small sample, short duration, and differential withdrawal rate.

CONCLUSION

A home-based intervention delivered by social workers could reduce depressive symptoms and enhance quality of life in most older African Americans.

PRIMARY FUNDING SOURCE

National Institute of Mental Health.

Identification of and beliefs about depressive symptoms and preferred treatment approaches among community-living older African Americans

OBJECTIVE

To examine older African American's recognition of and beliefs about depressive symptoms, preferred symptom management strategies, and factors associated with willingness to use mental health treatments. Differences between the depressed and nondepressed and men and women were examined.

DESIGN

Cross-sectional survey.

SETTING

Home, senior center.

PARTICIPANTS

A total of 153 senior center members (56 male, 97 female) 55 years and older.

MEASUREMENTS

Using a depression vignette, participants indicated if the person was depressed and their endorsement of items reflecting beliefs, stigma, symptom management, and willingness to use treatments (yes/no). A 9-item Patient Health Questionnaire assessed current symptomatology.

RESULTS

Overall, 24.2% reported depressive symptoms (≥5); 88.2% correctly identified the person in the vignette as depressed. Most (≥75%) endorsed active symptom management strategies, preference for treatment in physician and therapist offices, and willingness to take medications, seek therapy, see doctor, and attend support groups; less than 33% viewed depression as stigmatizing, whereas 48% viewed depression as normal aging. Logistic regressions revealed lower education, higher physical function, and feeling okay if community knew of depression diagnosis were associated with willingness to see physician if feeling depressed; being married and believing antidepressant medications are beneficial were related to willingness to use medications. Different associations emerged for depressed/nondepressed and men and women.

CONCLUSIONS

Overall, this older African American sample had positive attitudes and beliefs and endorsed traditional treatment modalities suggesting that beliefs alone are unlikely barriers to underutilization of mental health services. Because different factors were associated with willingness to seek physician help and use medications and factors differed for depressed/nondepressed and by sex, interventions should be tailored.

A community-integrated home based depression intervention for older African Americans: [corrected] description of the Beat the Blues randomized trial and intervention costs

BACKGROUND

Primary care is the principle setting for depression treatment; yet many older African Americans in the United States fail to report depressive symptoms or receive the recommended standard of care. Older African Americans are at high risk for depression due to elevated rates of chronic illness, disability and socioeconomic distress. There is an urgent need to develop and test new depression treatments that resonate with minority populations that are hard-to-reach and underserved and to evaluate their cost and cost-effectiveness.

METHODS/DESIGN

Beat the Blues (BTB) is a single-blind parallel randomized trial to assess efficacy of a non-pharmacological intervention to reduce depressive symptoms and improve quality of life in 208 African Americans 55+ years old. It involves a collaboration with a senior center whose care management staff screen for depressive symptoms (telephone or in-person) using the Patient Health Questionnaire (PHQ-9). Individuals screened positive (PHQ-9 ≥ 5) on two separate occasions over 2 weeks are referred to local mental health resources and BTB. Interested and eligible participants who consent receive a baseline home interview and then are randomly assigned to receive BTB immediately or 4 months later (wait-list control). All participants are interviewed at 4 (main study endpoint) and 8 months at home by assessors masked to study assignment. Licensed senior center social workers trained in BTB meet with participants at home for up to 10 sessions over 4 months to assess care needs, make referrals/linkages, provide depression education, instruct in stress reduction techniques, and use behavioral activation to identify goals and steps to achieve them. Key outcomes include reduced depressive symptoms (primary), reduced anxiety and functional disability, improved quality of life, and enhanced depression knowledge and behavioral activation (secondary). Fidelity is enhanced through procedure manuals and staff training and monitored by face-to-face supervision and review of taped sessions. Cost and cost effectiveness is being evaluated.

DISCUSSION

BTB is designed to bridge gaps in mental health service access and treatments for older African Americans. Treatment components are tailored to specific care needs, depression knowledge, preference for stress reduction techniques, and personal activity goals. Total costs are $584.64/4 months; or $146.16 per participant/per month.

TRIAL REGISTRATION

ClinicalTrials.gov #NCT00511680.

National survey of geriatric psychiatry fellowship programs: comparing findings in 2006/07 and 2001/02 from the American Geriatrics Society and Association of Directors of Geriatric Academic Programs' Geriatrics Workforce Policy Studies Center

OBJECTIVE

: To document the development of geriatric psychiatry (GP) fellowship training in the United States through 2008.

METHODS

: A cross-sectional survey of the 56 U.S. GP fellowship programs was conducted in summer 2007. Longitudinal data from the American Medical Association and the Association of American Medical Colleges' National Graduate Medical Education Census and data from the Accreditation Council for Graduate Medical Education were also analyzed.

RESULTS

: Thirty-seven (66%) of 56 program directors responded. The number of fellowship programs has decreased over the past 7 years. During 2006/07, 72 fellows were in training, as compared with 94 fellows in 2001/02. Application rates declined significantly with a mean of 4.3 applications per program in 2006/07 as compared with the mean of 10 applications per program in 2001/02. The fill rate for first-year GP fellowship positions dropped from 61% in 2001/02 to 48% in 2006/07. During 2006/07, 67% of programs reported having two or fewer first-year fellows and 16% had no first-year fellows. Seventeen programs reported having no United States medical school graduates as first-year fellows.

CONCLUSION

: The number of GP fellows in training has declined by 23% from 2001/02 to 2006/07. This decline has occurred at the same time when the number of older adults continues to expand rapidly. It is critical that an adequate number of geriatric psychiatrists be trained to support and educate general psychiatrists in the care of the elderly. Specific strategies need to be developed urgently to stimulate interest in careers in clinical and academic GP.