Physician willingness to refer older depressed patients for psychotherapy

Stigma and Intentions to Seek Psychotherapy Among Primary Care Providers During the COVID-19 Pandemic: A Mediational Analysis

Background

Medical personnel have reported increases in psychological distress and depression during the COVID-19 pandemic. Additionally, many providers, including primary care providers (PCPs), face significant stigma related to personal mental healthcare. However, the process by which stigma affects help-seeking among PCPs is unclear.

Method

Between January and May 2020, 112 PCPs completed a survey of perceived public stigma, self-stigma, attitudes, intentions to seek psychotherapy for depression, and a clinical vignette on patient referrals to psychotherapy.

Results

Self-stigma and attitudes toward psychotherapy sequentially mediated the relationship between perceived public stigma and intentions to seek psychotherapy. PCPs were more likely to refer a depressed patient to psychotherapy than seek personal psychotherapy, but lower personal help-seeking intentions were associated with lower referral intentions.

Conclusion

These results clarify processes by which stigma hinders PCPs’ psychotherapy use and highlight interventions to encourage their help-seeking. Addressing cultural and practical barriers in the medical field is needed to reduce stigma.

Spatio-Temporal Gait Parameters in Association with Medications and Risk of Falls in the Elderly

Purpose

The aim of this study was to analyze factors affecting spatio-temporal gait parameters in elderly people of both genders and different ages with different risks of fall, fall history, and medications.

Patients and Methods

A total of 210 community-dwelling older adults (156 females, 54 males; mean age 72.84±6.26 years) participated in this study. To assess the risk of falls, the Downton Fall Risk Index was used. An additional question about medication intake (all prescribed drugs) was asked. To assess the spatio-temporal gait parameters, the Zebris FDM platform was used. Gait parameters and Downton Fall Risk Index, stratified by participants’ history of falls, multiple medication use (0/1/2+), gender, age, and medication categories, were statistically analyzed using the Mann–Whitney U-test and Kruskal–Wallis test.

Results

When comparing different medication categories, a Downton Fall Risk Index score indicating a high risk of falls was observed in the psychotropic medication category (3.56±1.67). A gait velocity suggesting a higher risk of falls (≤3.60 km/h) was observed in the psychotropic (2.85±1.09 km/h) and diabetes (2.80±0.81 km/h) medication categories, in the age groups 70–79 years (3.30±0.89 km/h) and 80+ years (2.67±0.88 km/h), and in participants using two or more medications (3.04±0.93 km/h).

Conclusion

The results of this study confirm previous observations and show that higher age and multiple medication negatively affect the gait, and that the higher risk of falls is associated with psychotropic and diabetes medication use. These results provide important information for future fall preventive programs for the elderly that would be especially beneficial for elderly people taking psychotropic and diabetes medication.

The Prevalence and Characteristics of Psychotropic-Related Hospitalizations in Older People: A Systematic Review and Meta-Analysis

OBJECTIVES

To assess the prevalence and characteristics of psychotropic medication-related hospitalizations in older people.

DESIGN

Systematic review with meta-analysis.

SETTING AND PARTICIPANTS

Older adults (≥65 years of age) with psychotropic-related hospitalizations.

METHODS

A search of published literature was performed in Medline, Embase, CINAHL, and Scopus from 2010 to March 2020. Three authors independently screened titles, abstracts, and full texts of relevant studies for relevance. Two authors independently extracted full text data, including characteristics, measures of causality, prevalence data, and performed quality assessment. A meta-analysis was conducted to estimate pooled prevalence and 95% confidence intervals (CIs) of psychotropic-related hospitalizations using random effects models. Heterogeneity was explored using subgroup analyses.

RESULTS

Of 815 potentially relevant studies, 11 were included in the final analysis. Five studies were cross-sectional studies, 5 were cohort studies, and 1 was a case control study. The majority of studies were rated as good quality. Psychotropic medications contributed to 2.1% (95% CI 1.2%-3.3%) of total hospitalizations and 11.3% (95% CI 8.2%-14.8%) of adverse drug event-related hospitalizations. The main psychotropic medications attributable to hospitalizations were antidepressants, hypnotics, sedatives, and antipsychotics.

CONCLUSIONS AND IMPLICATIONS

Psychotropic medications are a significant contributor to hospitalizations in older adults. The risk of hospitalization was greatest for those taking antidepressants, antipsychotics, hypnotics, and sedatives. Future studies should aim to address specific medication subgroups and implement uniform adverse drug event-related classification systems to improve comparability across studies.

Exploring older adults’ experiences seeking psychological services using the network episode model

Older adults’ mental health problems are a growing public health concern, especially because their rate of mental health service use is particularly low. Decades of mental health service utilisation models have been developed, yet key assumptions from these models focus primarily on factors that facilitate or inhibit access into the treatment system without taking into considering the dynamics of how individuals respond to their mental health problems and engage in service utilisation. More recently, dynamic models like the Network Episode Model (NEM-II) have been developed to challenge the underlying, rational choice assumption of traditional utilisation models. Given the multifaceted and complex nature of older adults’ mental health problems, the objective of this study was to examine whether the NEM-II is a helpful and appropriate model for understanding the dynamic process of how older adults navigate the mental health system, including factors that advanced and delayed help-seeking. Our qualitative analyses from 15 interviews with older adults revealed that their backgrounds, social supports and treatment systems influence, and are influenced by, their illness careers. Factors that delayed help-seeking included: a lack of support, ‘inappropriate’ referrals/advice from treatment professionals and poor mental health literacy. This research suggests the NEM-II is a helpful and appropriate theory for understanding older adults’ pathways to treatment, and has implications to enhance older adults’ access to psychological services.

Psychotropic drugs and the risk of fall injuries, hospitalisations and mortality among older adults

OBJECTIVE

To investigate whether psychotropics are associated with an increased risk of fall injuries, hospitalizations, and mortality in a large general population of older adults.

METHODS

We performed a nationwide matched (age, sex, and case event day) case-control study between 1 January and 31 December 2011 based on several Swedish registers (n = 1,288,875 persons aged ≥65 years). We used multivariate conditional logistic regression adjusted for education, number of inpatient days, Charlson co-morbidity index, dementia and number of other drugs.

RESULTS

Antidepressants were the psychotropic most strongly related to fall injuries (OR_adjusted : 1.42; 95% CI: 1.38-1.45) and antipsychotics to hospitalizations (OR_adjusted : 1.22; 95% CI: 1.19-1.24) and death (OR_adjusted : 2.10; 95% CI: 2.02-2.17). Number of psychotropics was associated with increased the risk of fall injuries, (4 psychotropics vs 0: OR_adjusted : 1.53; 95% CI: 1.39-1.68), hospitalization (4 psychotropics vs 0: OR_adjusted : 1.27; 95% CI: 1.22-1.33) and death (4 psychotropics vs 0: OR_adjusted : 2.50; 95% CI: 2.33-2.69) in a dose-response manner. Among persons with dementia (n = 58,984), a dose-response relationship was found between number of psychotropics and mortality risk (4 psychotropics vs 0: OR_adjusted : 1.99; 95% CI: 1.76-2.25).

CONCLUSIONS

Our findings support a cautious prescribing of multiple psychotropic drugs to older patients. © 2016 The Authors. International Journal of Geriatric Psychiatry Published by John Wiley & Sons, Ltd.

Mental health service use among older Canadians with anxiety and comorbid physical conditions

OBJECTIVES

The objective of this study was to understand the relationship between mental health service use and comorbid any anxiety and commonly occurring physical conditions (i.e., arthritis, cardiovascular disease, and gastrointestinal disease) in a national sample of older Canadians.

METHODS

The sample consisted of older adults aged 55 years and older from the Canadian Community Health Survey 1.2 (N = 12,792). Trained lay interviewers assessed mental disorders based on Diagnostic and Statistical Manual of Mental Disorders - 4th Edition (DSM-IV) criteria. Physical conditions were based on self-reported diagnoses by health professionals. Past-year mental health service use was categorized into whether services were utilized in the general or specialty sectors. Crosstabulations and multiple logistic regressions examined the effects of both anxiety and physical conditions on mental health service use within the general and specialty mental health sectors.

RESULTS

Adjusted logistic regressions indicated that there was no effect of anxiety among older adults with gastrointestinal disease on mental health service use. Conversely, in adjusted regressions, having a comorbid anxiety disorder with cardiovascular disease or arthritis was associated with increased odds of service use from the general sector in comparison to cardiovascular disease and arthritis, respectively, alone. Additionally, older adults with comorbid any anxiety disorder and gastrointestinal disease in comparison to anxiety alone had lower rates of seeking mental health services; however, these effects were no longer significant in an adjusted model.

CONCLUSION

Comorbidity between gastrointestinal conditions and anxiety was associated with unmet mental health service needs. This may be conceptualized in the context overlapping symptomatology in gastrointestinal conditions and anxiety.

Guided self-help for generalized anxiety disorder in older adults

OBJECTIVE

The main objective of this study was to examine the efficacy of a guided self-help treatment based on cognitive behavioral principles (CBT-GSH) for generalized anxiety disorder (GAD) in older adults.

METHODS

Three older adults aged from 66 to 70 and diagnosed with GAD were included in a single-case experimental multiple-baseline protocol. Data were collected using daily self-monitoring, standardized clinician ratings, and self-report questionnaires at pretest, posttest, and 6-month and 12-month follow-ups. Treatment consisted of awareness training, worry interventions, relaxation training, pleasant activities scheduling, and relapse prevention. Participants used a manual presenting weekly readings and at-home practice exercises. They also received weekly supportive phone calls from a therapist.

RESULTS

At posttest, participants showed improvement on worries and GAD severity, on psychological process variables targeted by treatment (intolerance of uncertainty, negative problem orientation, cognitive avoidance, and perceived usefulness of worry), and on secondary variables associated with GAD (anxiety, depression, sleep difficulties, cognitive functioning, and disability). These results were generally maintained at 12 months after the end of treatment. Participants had favorable opinions toward the treatment.

CONCLUSION

The results of this study suggest that CBT-GSH is both feasible and effective for the treatment of GAD in older adults.

Depressive symptoms in late life in urban and semi-urban areas of South-West Greece: An undetected disorder?

OBJECTIVE

The objective of this study was to estimate the prevalence and probable under-diagnosis of depressive symptoms in elderly of an urban and semi-urban area in Greece.

MATERIALS AND METHODS

A cross-sectional study was conducted among the members of 4 days care centers for older people (KAPI), three in the municipality of Patras, West-Greece, and in one in Tripolis, Peloponnese, Greece. A total of 378 individuals took part in the study, aged >60 years. A questionnaire was developed to collect basic demographic data, including three questions from the European Health Interview Survey, regarding self-reported or by a physician-diagnosed depression. Moreover, to all participants the Greek validated version of the Geriatric Depression Scale-15 (GDS-15) was applied, to screen for depressive symptoms.

RESULTS

According to GDS-15, 48.1% of the studied population screened positive for depressive symptoms (38.6% moderate, 9.5% severe), whereas having ever been affected with chronic depression reported 19.0% by themselves. In 162 members of KAPI of Patras and in 106 of Tripolis, who never reported have been affected by depression and depressive symptoms were observed in 27.7% and 44.7%, respectively. In 28 individuals from Patras, who reported not to know if they have depression and in 10 from Tripolis, depressive symptoms were observed in 60.7% and 90%, respectively, applying the GDS-15.

CONCLUSION

Except the high prevalence, the present study reveals a remarkable under-detection of depressive symptoms in older adults. Various interventions in primary care are necessary so as to increase detection rates of depression among the elderly.

Efficacy of Psychosocial Interventions in Men Over 55

Whether psychosocial treatments work equally well for late middle-aged and older men and women is unknown. For this critical review, sixteen studies were identified that examined psychosocial treatments for psychopathology in men age 55 and older. The preponderance of evidence showed that treatments worked at least as well in men as in women. Six studies reported statistically significant treatment effects in exclusively male participants. Methodological problems include weak research designs, small sample size, and absence of indication of clinical significance. There continues to be a paucity of research addressing the efficacy of psychosocial interventions for late middle-aged and older men. Researchers are encouraged to include racially and ethnically diverse older men in carefully controlled studies that examine clinically significant change.

National evaluation of the effectiveness of cognitive behavioral therapy for insomnia among older versus younger veterans

OBJECTIVES

Limited research has examined the effects of cognitive behavioral therapy for insomnia (CBT-I) among older adults (age >65 years) receiving treatment in real-world clinical settings and even less has examined effects on outcomes beyond reducing insomnia, such as improved quality of life. The current article examines and compares outcomes of older versus younger (age 18-64 years) veterans receiving CBT-I nationally in nonsleep specialty settings.

METHOD

Patient outcomes were assessed using the Insomnia Severity Index, Beck Depression Inventory-II, and the World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed using the Working Alliance Inventory-Short Revised.

RESULTS

A total of 536 younger veterans and 121 older veterans received CBT-I; 77% of older and 64% of younger patients completed all sessions or finished early due to symptom relief. Mean insomnia scores declined from 19.5 to 9.7 in the older group and from 20.9 to 11.1 in the younger group. Within-group effect sizes were d = 2.3 and 2.2 for older and younger groups, respectively. CBT-I also yielded significant improvements in depression and quality of life for both age groups. High and increasing levels of therapeutic alliance were observed for both age groups.

CONCLUSIONS

Older (and younger) patients receiving CBT-I from nonsleep specialists experienced large reductions in insomnia and improvements in depression and quality of life. Effects were similar for both age groups, and the rate of dropout was lower among older adults. The results provide strong support for the effectiveness and acceptability of CBT-I for older adults receiving care in routine treatment settings.

The association between race and gender, treatment attitudes, and antidepressant treatment adherence

OBJECTIVES

We examined the associations between treatment attitudes and beliefs with race-gender differences in antidepressant adherence.

METHODS

Subjects (n = 186) were African-American and White subjects aged ≥60 years, diagnosed with clinically significant depression, and had a new outpatient primary care recommendation for antidepressant treatment. Antidepressant adherence was assessed using the Brief Medication Questionnaire. Attitudes and beliefs were assessed using the Patients Attitudes Toward and Ratings of Care for Depression, two items rating perceived medication importance, and a modified version of the Stigma Scale for Receiving Psychological Help.

RESULTS

African-American men and women had significantly greater concerns about antidepressants and significantly less understanding about treatment than White women. African-American men had significantly more negative attitudes toward healthcare providers than African-American and White women. African-American women were more likely than White men and women to endorse a medication other than their antidepressant as most important. Whereas some race-gender differences were found in personal spirituality, no group differences were found in perceived stigma. In a logistic regression model adjusted for key baseline variables, White women were significantly more adherent to antidepressants than African-American women (OR = 3.05, 95% CI = 1.06-8.81). Fewer concerns about antidepressants and indicating the antidepressant as the most important medication were both significantly associated with adherence. After including either of these two variables, the adherence difference between White women and African-American women was no longer significant (OR = 2.56, 95% CI = 0.84-7.80).

CONCLUSIONS

Concerns about antidepressants and the importance of antidepressant medication are associated with adherence and are potentially modifiable through improved patient-provider communication, psycho-education, and therapeutic interventions.

Psychotherapy for depression in primary care: a panel survey of general practitioners' opinion and prescribing practice

PURPOSE

Psychotherapy is recommended as first-line treatment in patients presenting with mild-to-moderate depression. Although this disorder is mostly managed in primary care, little is known about General Practitioners' (GPs) practice of prescribing psychotherapy. The objectives were to explore GPs' opinion on psychotherapy for depression, and the personal and professional characteristics associated with reported strategies for prescribing psychological therapy and/or an antidepressant in mild-to-moderate depression.

METHODS

A cross-sectional survey was carried out among participants in a panel of randomly selected GPs (2,114/2,496 participated: 84.7%). GPs were interviewed using a standardized questionnaire covering their professional and personal characteristics, their practices and opinions in the area of depression management. A multi-model averaging approach was used to explore the characteristics associated with practice of prescribing psychological therapy in mild-to-moderate depression.

RESULTS

Most GPs had a favourable opinion regarding the efficacy of psychotherapy in depression. Slightly more than one out of four reported prescribing psychological therapy alone often/very often in mild-to-moderate depression. These GPs were more likely to be female (OR = 1.56, 95% CI 1.24; 1.97), to have a personal history of psychotherapy (OR = 1.76, 95% CI 1.31; 2.38), no history of depression in someone close (OR = 0.80, 95% CI 0.65; 0.99), and to consider that antidepressants are over-prescribed (OR = 2.02, 95% CI 1.63; 2.49). No association was found with professional characteristics.

CONCLUSIONS

GPs' personal experience has a greater impact on psychological therapy prescription than professional characteristics. This finding suggests that educational efforts are required for providing GPs decision-making skills regarding psychological therapy prescription, based upon evidence-based medicine rather than subjective factors.

Comparison of the effectiveness of cognitive behavioral therapy for depression among older versus younger veterans: results of a national evaluation

OBJECTIVES

The effectiveness of cognitive behavioral therapy for depression (CBT-D) among older adults in routine clinical settings has received limited attention. The current article examines and compares outcomes of older versus younger veterans receiving CBT-D nationally.

METHOD

Patient outcomes were assessed using the Beck Depression Inventory-II and World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed using the Working Alliance Inventory-Short Revised.

RESULTS

A total of 764 veterans aged 18-64 and 100 veterans aged 65+ received CBT-D; 68.0% of older and 68.3% of younger patients completed all sessions or finished early due to symptom relief, and mean depression scores declined from 27.0 (standard deviation [SD] = 10.7) to 16.2 (SD = 12.4) in the older group and from 29.1 (SD = 11.2) to 17.8 (SD = 13.5) in the younger group. Within-group effect sizes were d = 1.01 for both groups. Significant increases in quality of life and therapeutic alliance were observed for both groups.

DISCUSSION

CBT-D resulted in significant improvements in depression and quality of life among older patients. Outcomes and rate of attrition were equivalent to younger patients. Findings indicate that CBT-D is an effective and acceptable treatment for older veterans in real-world settings with often high levels of depression.

Racial differences in adherence to antidepressant treatment in later life

OBJECTIVE

Although antidepressants are an effective treatment for later-life depression, older patients often choose not to initiate or to discontinue medication treatment prematurely. Although racial differences in depression treatment preferences have been reported, little is known about racial differences in antidepressant medication adherence among older patients.

DESIGN

Prospective, observational study comparing antidepressant adherence for older African American and white primary care patients.

PARTICIPANTS

A total of 188 subjects age 60 and older, diagnosed with clinically significant depression with a new recommendation for antidepressant treatment by their primary care physician.

MEASUREMENT

Study participants were assessed at study entry and at the 4-month follow-up (encompassing the acute treatment phase). Depression medication adherence was based on a well-validated self-report measure.

RESULTS

At the 4-month follow-up, 61.2% of subjects reported that they were adherent to their antidepressant medication. In unadjusted and two of the three adjusted analyses, African American subjects (n = 82) had significantly lower rates of 4-month antidepressant adherence than white subjects (n = 106). African American women had the lowest adherence rates (44.4%) followed by African American men (56.8%), white men (65.3%), and white women (73.7%). In logistic regression models controlling for demographic, illness, and functional status variables, significant differences persisted between African American women and white women in reported 4-month antidepressant adherence (OR: 3.58, 95% CI: 1.27-10.07, Wald χ(2) = 2.42, df = 1, p <0.02).

CONCLUSIONS

The results demonstrate racial and gender differences in antidepressant adherence in older adults. Depression treatment interventions for older adults should take into account the potential impact of race and gender on adherence to prescribed medications.

General practitioners’ assessment of, and treatment decisions regarding, common mental disorder in older adults: thematic analysis of interview data

Primary and secondary care services are charged with failing to adequately detect and treat mental disorder in older adults due to the ‘understandability phenomenon’; the belief that mental disorder in old age is inevitable and therefore not worthy of intervention. Quantitative data appear to support this hypothesis but lack the explanatory power of detailed accounts. Nine general practitioners (GPs) participated in group interviews about their assessment and treatment of older patients, and their expectations and experience of referral to secondary care. Resulting transcripts were subject to Thematic Analysis. Respondents recognised the unique features of these clients, and their impact on the detailed, recursive processes of assessment, clinical decision-making and intervention. GPs described confidence in managing most cases of mental disorder, describing the role of secondary care as one of consultancy in extreme or unusual cases. GPs did view mental disorder as commonly originating in adverse circumstances, and queried the validity of pharmacological or psychological interventions in these cases. They did not, however, equate understandability with acceptability, and called for social interventions to be integrated with health-care interventions to tackle the cause of mental disorder in older adults. At a wider level, findings highlight the discrepancy between assumptions about GP attitudes and actions, and their own accounts. At a local level, findings will assist in focusing secondary care service development where need is perceived, into consultancy and training.

Age differences in satisfaction with and perceived benefit from mental health services: results from the collaborative psychiatric epidemiology surveys

OBJECTIVE

This study examined variation by age in satisfaction with and perceived benefit from mental health services (MHS).

METHODS

Drawn from the nationally representative Collaborative Psychiatric Epidemiology Surveys (2001-2003), the current sample included 1286 adults from age 18 to 87 years who had at least one DSM-IV diagnosis and had used MHS during the past year. Multiple linear regression analyses were used to predict satisfaction with and perceived benefit from past year MHS use. Independent variables were sociodemographic factors and objective and perceived needs.

RESULTS

Results from multiple linear regression analyses showed that older age was positively associated with both MHS satisfaction (p < 0.05, β = 0.105) and perceived amount of benefit (p < 0.05, β = 0.106), as was better self-rated mental health (p < 0.001, β = 0.186; p < 0.001, β = 0.177). A greater number of comorbid psychiatric diagnoses was negatively associated with satisfaction (p < 0.05, β = -0.089). Marital status was found to be a moderator of the effect of age: for married respondents, age had a significant effect on both outcome variables (p < 0.05, β = 0.102; p < 0.05, β = 0.105), but for unmarried respondents, it did not.

CONCLUSIONS

Our findings show clear evidence of age differences in satisfaction with and perceived benefit from MHS. The findings provide important implications for future interventions targeted to improve MHS satisfaction. Age-specific strategies should be developed to prevent delay in mental health treatment.

Treatment preferences in patients with first episode depression

BACKGROUND

Treatment preferences of patients suffering from depression may affect adherence and clinical outcomes. This study examines associations between patients' treatment preferences, their characteristics and illness representations of depression.

METHODS

Illness representations of depression (IPQ-R), treatment acceptability and preferences were assessed in 88 newly diagnosed patients with first episode depression. Other measures recorded: gender, age, education level, income, psychiatric comorbidity, depressive symptomatology (PHQ-9), a family history of depression, and current treatment of depression. Multiple logistic regression was used to identify factors associated with a preference for psychotherapy.

RESULTS

Psychotherapy was preferred by 41% of participants, while 31% favored antidepressants. Acceptability was strongly associated with preference. Patients preferring psychotherapy perceived that their depression has more serious consequences than those preferring medication and were more likely to attribute their depression to social causes than psychological or physical causes. Participants who preferred psychotherapy were more likely to be female, have a university degree and have a family history of depression.

LIMITATIONS

The cross-sectional design precludes causal interpretations.

CONCLUSIONS

Preferences vary according to gender, level of education, family history and illness representations. It may be important to provide accurate information on both treatments and discuss patients' preferences before prescribing treatment.

Psychotherapy by Primary-Care Providers: Results of a National Sample

The authors used the National Ambulatory Medical Care Survey to examine visit characteristics associated with psychotherapy by primary-care physicians, as compared with psychiatrists. Chi-square tests and hierarchical logistic-regression models were developed to examine visit characteristics associated with receiving psychotherapy by primary-care physicians versus psychiatrists. Over 19% of all psychotherapy visits were reported by primary-care physicians. Visits to primary-care physicians, versus visits to psychiatrists, were significantly greater among those over age 65, in Hispanic patients, and those in rural areas. Primary-care physicians are reporting that they provide psychotherapy and may be filling a void for underserved populations.

Public mental health care utilization by older adults

The present study examined the extent to which older adults began public mental health treatment throughout Texas in 1999, the types of services they used, and how they compared on demographic and clinical variables to younger consumers. Notwithstanding recent policy and related developments, older adults were found to use public mental health services at substantially low rates, as in past decades. Significantly, older consumers tended to be relatively healthy and independent. Among younger and, even more so, older consumers, there were relatively high proportions of rural residents and minorities, groups previously found to be unlikely to utilize private mental health services. Overall, the findings urge that greater attention be devoted to public mental health outreach and service delivery with the elderly, and raise the question of what role the public mental health system should have in nursing homes and other long-term care settings.

Treating late-life depression with interpersonal psychotherapy in the primary care sector

BACKGROUND

Interpersonal psychotherapy (IPT) is an empirically-validated intervention for treating late-life depression.

OBJECTIVE

To determine the manner in which IPT is utilized by primary care physicians in relation to antidepressant medications.

METHODS

The authors reviewed treatment logs prepared by care managers during the first 12 months of a patient's participation in the PROSPECT clinical trial to determine initial and longitudinal treatment patterns utilized by physicians, and clinical outcomes associated with initial treatment assignment.

RESULTS

Primary care physicians in practices randomized to PROSPECT's intervention arm initially prescribed an antidepressant medication for 58% of eligible patients and referred only 11% of them to IPT. Over time, however, 27% of patients participated in IPT as monotherapy or augmentation therapy. Initial treatment assignment was not associated with depressive status at 4 and 12 months nor with suicidal ideation at 4, 8, and 12 months.

CONCLUSION

IPT is an effective treatment for late-life depression whose greater use by primary care physicians should be encouraged.

Depression care for the elderly: reducing barriers to evidence-based practice

This paper provides an overview of five key bodies of evidence identifying: (1) Characteristics of depression among older adults -- its prevalence, risk factors and illness course, and impact on functional status, mortality, use of health services, and health care costs; (2) Effective Interventions, including pharmacologic, psychotherapies, care management, and combined intervention models; (3) Known Barriers to depression care including patient, provider and service system barriers; (4) Effective Organizational and Educational Strategies to reduce barriers to depression care; and (5) Key Factors in Translating Research into Practice. There is strong empirical support for implementing strategies to improve depression care for older adults.

What drives referral from primary care physicians to mental health specialists? A randomized trial using actors portraying depressive symptoms

BACKGROUND

Referral from primary care to the mental health specialty sector is important but poorly understood.

OBJECTIVE

Identify physician characteristics influencing mental health referral.

DESIGN

Randomized controlled trial using Standardized Patients (SPs).

SETTING

Offices of primary care physicians in 3 cities.

PARTICIPANTS

One hundred fifty-two family physicians and general internists recruited from 4 broad practice settings; 18 middle aged Caucasian female actors.

INTERVENTION

Two hundred and ninety-eight unannounced SP visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder.

MEASUREMENTS

Mental health referrals via SP written reports; physician and system characteristics through a self-administered physician questionnaire.

RESULTS

Among 298 SP visits, 107 (36%) resulted in mental health referral. Referrals were less likely among physicians with greater self-confidence in their ability to manage antidepressant therapy (adjusted odds ratio [AOR] 0.39, 95% confidence interval [CI] 0.17 to 0.86) and were more likely if physicians typically spent > or =10% of professional time on nonclinical activities (AOR 3.42, 95% CI 1.45 to 8.07), had personal life experience with psychotherapy for depression (AOR 2.74, 95% CI 1.15 to 6.52), or usually had access to mental health consultation within 2 weeks (AOR 2.94, 95% CI 1.26 to 6.92).

LIMITATION

The roles portrayed by SPs may not reflect the experience of a typical panel of primary care patients.

CONCLUSIONS

Controlling for patient and health system factors, physicians' therapeutic confidence and personal experience were important influences on mental health referral. Research is needed to determine if addressing these factors can facilitate more appropriate care.

Suicide and its prevention among older adults

OBJECTIVE

To review the research on the epidemiology, risk and resiliency, assessment, treatment, and prevention of late-life suicide.

METHOD

I reviewed mortality statistics. I searched MEDLINE and PsycINFO databases for research on suicide risk and resiliency and for randomized controlled trials with suicidal outcomes. I also reviewed mental health outreach and suicide prevention initiatives.

RESULTS

Approximately 12/100,000 individuals aged 65 years or over die by suicide in Canada annually. Suicide is most prevalent among older white men; risk is associated with suicidal ideation or behaviour, mental illness, personality vulnerability, medical illness, losses and poor social supports, functional impairment, and low resiliency. Novel measures to assess late-life suicide features are under development. Few randomized treatment trials exist with at-risk older adults.

CONCLUSIONS

Research is needed on risk and resiliency and clinical assessment and interventions for at-risk older adults. Collaborative outreach strategies might aid suicide prevention.

Use of psychotherapy for depression in older adults

OBJECTIVE

The authors examine national patterns in psychotherapy for older adults with a diagnosis of depression and analyze correlates of psychotherapy use that is consistent with Agency for Health Care Policy and Research guidelines for duration of treatment.

METHOD

Linked Medicare claims and survey data from the 1992-1999 Medicare Current Beneficiary Survey were used. The data were merged with the Area Resource File to assess the effect of provider-supply influences on psychotherapy treatment. An episode-of-care framework approach was used to analyze psychotherapy use and treatment duration. Multiple logistic regression analysis was used to predict psychotherapy use and its consistency.

RESULTS

The authors identified 2,025 episodes of depression treatment between 1992 and 1999. Overall, psychotherapy was used in 25% (N=474) of the episodes, with 68% of episodes with psychotherapy involving services received only from psychiatrists. (Percentages were weighted for the complex design of the Medicare Current Beneficiary Survey.) Use of psychotherapy was correlated with younger patient age, higher patient educational attainment, and availability of local psychotherapy providers. Among episodes in which psychotherapy was used, only a minority (33%, N=141) involved patients who remained in consistent treatment, defined as extending for at least two-thirds of the episode of depression. Availability of local providers was positively correlated with consistent psychotherapy use. In analyses with adjustment for provider-related factors, patients' socioeconomic and demographic characteristics did not affect the odds of receiving consistent psychotherapy.

CONCLUSIONS

Use of psychotherapy remains uncommon among depressed older adults despite its widely acknowledged efficacy. Some of the disparities in psychotherapy utilization suggest supply-side barriers. Increasing the geographic availability of mental health care providers may be one way of increasing access to psychotherapy for depressed older adults.

Depression in late life: review and commentary

Depression is perhaps the most frequent cause of emotional suffering in later life and significantly decreases quality of life in older adults. In recent years, the literature on late-life depression has exploded. Many gaps in our understanding of the outcome of late-life depression have been filled. Intriguing findings have emerged regarding the etiology of late-onset depression. The number of studies documenting the evidence base for therapy has increased dramatically. Here, I first address case definition, and then I review the current community- and clinic-based epidemiological studies. Next I address the outcome of late-life depression, including morbidity and mortality studies. Then I present the extant evidence regarding the etiology of depression in late life from a biopsychosocial perspective. Finally, I present evidence for the current therapies prescribed for depressed elders, ranging from medications to group therapy.