Assessment and treatment of geriatric depression in primary care settings

Screening Older Adults for Depression: Barriers Across Clinical Discipline Training

Background and Objectives

Depressed older adults are more likely to be seen in primary care than in specialty mental health settings, but research shows that physicians may not routinely screen for depression. Other clinical disciplines are also in a position to screen for depression, but have not been studied. This study examined barriers to screening older adults for depression, and disciplinary differences in clinical trainees’ likelihood of screening.

Research Design and Methods

We used a cross-sectional, online survey with experimental manipulation of vignettes. A four-way mixed analysis of variance explored the effects of clinical discipline (between subjects) and time pressure, patient difficulty, and level of symptoms (within subjects) on trainees’ likelihood of screening.

Results

Participants were 229 trainees in medicine (83), psychology (51), nursing (49), and social work (46). Lower time pressure and greater symptom severity increased likelihood of screening. There was a significant three-way interaction among discipline, patient difficulty, and symptom level that was driven by social work graduate trainees’ greater likelihood of screening for depression when there were more symptoms present, which was diminished if the patient was being difficult. There was a two-way interaction between patient difficulty and level of symptoms: more symptoms resulted in increased likelihood of screening, an effect that diminished with greater patient difficulty.

Discussion and Implications

The study holds implications for identifying and addressing gaps in education on depression screening to minimize the effects of barriers. Interventions could address education about older adults and depression, including practice-based screening, time management, and behavior management skills.

Physicians' Knowledge and Attitude towards Mental Health in Saudi Arabia

Background

Physicians working in Saudi Arabia belong to different countries and may have differences in knowledge and attitude towards psychiatry. We evaluated non-psychiatric physician's knowledge and attitude towards psychiatric disorders, such as anxiety and depression, in the Kingdom of Saudi Arabia.

Methods

A descriptive cross-sectional study design was used. The current knowledge and attitude towards anxiety and depression of physicians were determined by using a questionnaire. We distributed 180 study questionnaires at various hospitals to be answered by physicians in the Riyadh Province of Saudi Arabia. One hundred and forty-two completed questionnaires were included in the study. The participants were divided into three groups: (1) 63(44.4%) general practitioners (GPs), (2) 55 (38.7%) specialists and (3) 24 (16.9%) family practitioners. Data were analysed using the chi-square, ANOVA and independent sample t-test.

Results

GPs and specialists showed a negative attitude towards psychiatric patients, but family practitioners showed a positive attitude. There were statistically significant differences (p<0.05) in the knowledge regarding anxiety and depression among the groups. The relationship between specialty and knowledge was statistically significant (p<0.05) and the effect of first language is insignificant (p>0.05).

Conclusion

Expansive enlightenment programmes, continued medical education and inclusion of psychiatric posting in rotating residential internship programme during undergraduate courses are required for physicians not only to fill the gap in knowledge and attitude but also to improve their cognitive, communication and interpersonal skills.

Depression, cardiac mortality and all-cause mortality

Depression is an illness that kills. The links between depression and medical illness are well established and bi-directional, but evidence is mounting that depression increases mortality as well as morbidity in adults, particularly older adults. We examine the evidence that the increase in mortality in depression applies to all-cause mortality as well as cardiac mortality, and describe plausible physiological theories for the association. We conclude that excess mortality arising from depression is a major public health problem that is largely unrecognised and needs to be addressed by a range of clinicians.

Training residents in depression and grief

BACKGROUND

About 20 per cent of Americans will experience depression in their lifetimes, and almost all will experience the death of a loved one. Both depression and grief have been associated with adverse health outcomes, including a decline in quality of life and excess mortality. Primary care physicians (PCPs) are the initial health care contact for most patients with depression and grief, yet often perceive that they lack the skills to adequately address these issues. Previous studies have investigated whether educational efforts improve PCP depression and grief knowledge or perceived skills, but few have focused on medical residents. There is the potential that resident education may impact practice over a longer span of time than later career training, simply because it occurs earlier in one's medical career.

METHODS

The authors examined whether a brief educational curriculum, delivered in two 2-hour sessions to 40 internal medicine residents, was associated with changes in knowledge, attitudes, comfort level and reported behaviours, with regards to grieving or depressed patients. Self-report surveys were administered before and about 5 months after receipt of the new curriculum.

RESULTS

Residents receiving the curriculum reported increases in knowledge, confidence and self-reported behaviours in working with patients suffering depression and grief. Both depression and grief have been associated with adverse health outcomes DISCUSSION: Although more research is needed to determine whether these findings can be replicated in other settings, the results are promising. Further dissemination of such training may ultimately enhance the detection and treatment of depression and grief in primary care, and decrease the associated emotional and functional burdens in patients.

Taking Policy Action to Reduce Benzodiazepine Use and Promote Self-Care Among Seniors

This article reviews current knowledge on the risks and benefits of benzodiazepine use for seniors and addresses potential policies that could be made to reduce use and support sentors' mental health. Although seniors are only 12% to 15% of the population, they consume between 35% and 52% of all benzodiazepines prescribed in Canada and the United States. Despite significant long-term use among seniors, relatively few studies demonstrate the efficacy of more than short-term use for anxiety and insomnia. There is significant data to suggest that use is associated with increased potential for injury, cognitive and memory deficits, and a dependency syndrome. This article argues that the current controversy rests not so much in the scientific data but in the willingness of clinicians to interpret and act on that information. As internationally developed guidelines for practice suggest that benzodiazepine treatment for anxiety and insomnia may not be without risks, other first-line treatments should be developed.

The Psychosocial Challenges and Care of Older Adults with Diabetes: "Can't Do What I Used To Do; Can't Be Who I Once Was"

The prevalence of diabetes is increasing in older populations worldwide. Older adults with diabetes have unique psychosocial and medical challenges that impact self-care and glycemic control. These challenges may include psychological factors such as depression or anxiety, social factors such loss of independence and removal from home environment/placement in a facility, and medical factors such as multiple comorbidities and polypharmacy. Importantly, these challenges interact and complicate the everyday life of the older adult with diabetes. Thus, timely identification and interventions for psychosocial and medical challenges are a necessary component of diabetes care. This review summarizes the current literature, research findings, and clinical recommendations for psychosocial care in older adults with diabetes.

Sound mind vs sound heart

Depressive and anxiety disorders have both have been associated with an increased risk of cardiovascular disease. This article highlights the multifactorial and bidirectional interaction between cardiovascular diseases, depression and anxiety, and the need for early assessment, diagnosis and intervention.

Understanding diagnosis and management of dementia and guideline implementation in general practice: a qualitative study using the theoretical domains framework

Background

Dementia is a growing problem, causing substantial burden for patients, their families, and society. General practitioners (GPs) play an important role in diagnosing and managing dementia; however, there are gaps between recommended and current practice. The aim of this study was to explore GPs’ reported practice in diagnosing and managing dementia and to describe, in theoretical terms, the proposed explanations for practice that was and was not consistent with evidence-based guidelines.

Methods

Semi-structured interviews were conducted with GPs in Victoria, Australia. The Theoretical Domains Framework (TDF) guided data collection and analysis. Interviews explored the factors hindering and enabling achievement of 13 recommended behaviours. Data were analysed using content and thematic analysis. This paper presents an in-depth description of the factors influencing two behaviours, assessing co-morbid depression using a validated tool, and conducting a formal cognitive assessment using a validated scale.

Results

A total of 30 GPs were interviewed. Most GPs reported that they did not assess for co-morbid depression using a validated tool as per recommended guidance. Barriers included the belief that depression can be adequately assessed using general clinical indicators and that validated tools provide little additional information (theoretical domain of ‘Beliefs about consequences’); discomfort in using validated tools (‘Emotion’), possibly due to limited training and confidence (‘Skills’; ‘Beliefs about capabilities’); limited awareness of the need for, and forgetting to conduct, a depression assessment (‘Knowledge’; ‘Memory, attention and decision processes’). Most reported practising in a manner consistent with the recommendation that a formal cognitive assessment using a validated scale be undertaken. Key factors enabling this were having an awareness of the need to conduct a cognitive assessment (‘Knowledge’); possessing the necessary skills and confidence (‘Skills’; ‘Beliefs about capabilities’); and having adequate time and resources (‘Environmental context and resources’).

Conclusions

This is the first study to our knowledge to use a theoretical approach to investigate the barriers and enablers to guideline-recommended diagnosis and management of dementia in general practice. It has identified key factors likely to explain GPs’ uptake of the guidelines. The results have informed the design of an intervention aimed at supporting practice change in line with dementia guidelines, which is currently being evaluated in a cluster randomised trial.

Outcomes of bereavement care among widowed older adults with complicated grief and depression

Bereavement is common among older adults and may result in major depression or complicated grief (CG). Little is known about the effectiveness of physician care for these conditions. We examined whether, among older adults with CG and/or major depression, using physician support was associated with reductions in grief, depression, or anxiety severity. Outcomes were compared to group and religious support. We analyzed data from the Changing Lives of Older Couples (CLOC) Study, a prospective cohort study of married couples in the Detroit area. Spousal death was tracked over 5 years, and follow-up interviews conducted with widowed participants at 6 months (wave 1) and 18 months (wave 2) post loss. Analyses were limited to those with CG or depression with support-seeking data (weighted n = 89). Yes/no items asked whether participants had seen each provider for help with grief up until wave 1. A 19-item grief severity measure was developed by CLOC researchers. The 20-item Center for Epidemiologic Studies Depression scale measured depression severity. The Symptom Checklist 90-Revised assessed anxiety severity. Regressions indicated that seeking support from a family doctor at wave 1 was not associated with changes in anxiety, depression, or grief severity at wave 2 (P > .05). However, support group use was associated with reductions in grief severity (β = -8.46, P < .05), and religious leader support-seeking associated with reductions in depression severity (β = -10.12, P < .01). Findings imply that physician care for grief may not be effective, and support group referral may be helpful. Physicians may benefit from training in recognizing and appropriate referring for bereavement-related distress.

Depression Treatment Among Rural Older Adults: Preferences and Factors Influencing Future Service Use

The purpose of this study was to investigate depression treatment preferences and anticipated service use in a sample of adults aged 55 years or older who reside in rural Wyoming. Sixteen participants (mean age = 59) completed 30- to 60-minute, semi-structured interviews. Qualitative methods were used to characterize common themes. Social/provider support and community gatekeepers were perceived by participants as important potential facilitators for seeking depression treatment. In contrast, perceived stigma and the value placed on self-sufficiency emerged as key barriers to seeking treatment for depression in this rural, young-old sample. Participants anticipated presenting for treatment in the primary care sector and preferred a combination of medication and psychotherapy for treatment. Participants were, however, more willing to see mental health professionals if they were first referred by a clergy member or primary care physician.

Eyes Wide Open or Not

Depression is significant among older Americans in the United States. A literature review found only five studies on the interrelationship between individual and neighborhood effects in predicting depression among older Americans. This article presents the results of exploring this interrelationship using data from the Brookdale Demonstration Project Initiative on Healthy Urban Aging (BDI). The BDI database is from a sample of 1,870 enrollees in New York City senior centers in 2008. The BDI analysis finds the association with depression is highest with visual impairment ( p = .000); frequent falling ( p = .000); lower income ( p = .000); little leisure-time physical activity ( p = .000); low neighborhood satisfaction ( p = .000); trouble hearing ( p = .000); arthritis/rheumatoid arthritis ( p = .001); and being disabled ( p = .005). Implications for senior center and home care provider collaboration on early preventive interventions relating to sensory impairment, depression, and conditions related to falls and the built environment are discussed.

Identifying depressed older adults in primary care: a secondary analysis of a multisite randomized controlled trial

OBJECTIVE

To determine whether a subset of depressive symptoms could be identified to facilitate diagnosis of depression in older adults in primary care.

METHOD

Secondary analysis was conducted on 898 participants aged 60 years or older with major depressive disorder and/or dysthymic disorder (according to DSM-IV criteria) who participated in the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) study, a multisite, randomized trial of collaborative care for depression (recruitment from July 1999 to August 2001). Linear regression was used to identify a core subset of depressive symptoms associated with decreased social, physical, and mental functioning. The sensitivity and specificity, adjusting for selection bias, were evaluated for these symptoms. The sensitivity and specificity of a second subset of 4 depressive symptoms previously validated in a midlife sample was also evaluated.

RESULTS

Psychomotor changes, fatigue, and suicidal ideation were associated with decreased functioning and served as the core set of symptoms. Adjusting for selection bias, the sensitivity of these 3 symptoms was 0.012 and specificity 0.994. The sensitivity of the 4 symptoms previously validated in a midlife sample was 0.019 and specificity was 0.997.

CONCLUSION

We identified 3 depression symptoms that were highly specific for major depressive disorder in older adults. However, these symptoms and a previously identified subset were too insensitive for accurate diagnosis. Therefore, we recommend a full assessment of DSM-IV depression criteria for accurate diagnosis.

Non-psychiatric physicians' knowledge, attitudes and behavior toward depression

BACKGROUND/PURPOSE

Depression is a major health concern, often treated by non-psychiatrists. This study assessed self-reported knowledge, attitudes and treatment practices of non-psychiatric physicians in the recognition and management of depression.

METHODS

Survey questionnaires were given to non-psychiatric physicians who attended a depression training program. We asked physicians about their current clinical practice, knowledge, confidence, attitudes and perceived barriers to care regarding recognition and management of patients with depression.

RESULTS

Of 524 eligible non-psychiatric physicians, 375 (72%) completed surveys. The majority of physicians held a strong sense of responsibility for managing depression, although they provided treatment to only a small proportion of depressed patients. Most of them were not confident treating depressed patients, and they reported that incomplete knowledge and training were major barriers that limited their involvement. The patient and organization barriers were not related to reported management, but the physician barriers (lack of skills and knowledge in managing depression) were related to reported rate of treatment. Age, prior depression training, and education were major contributing factors to domains of knowledge, attitude and behavior, in terms of the number of domains involved. Family physician orientation was associated with higher score on knowledge scale, but not with other variables of attitude and behavior.

CONCLUSION

Our study suggests that non-psychiatrists may also play a role in the care of depression, but identifying and managing depression can be a challenge to them. Attitudinal barriers, confidence, and knowledge of treatment may compromise the physicians ability to manage depression. Future interventions and educational efforts need to address each of these issues.

Harm reduction among at-risk elderly drinkers: a site-specific analysis from the multi-site Primary Care Research in Substance Abuse and Mental Health for Elderly (PRISM-E) study

OBJECTIVES

To assess the efficacy of a harm-reduction based intervention to enhance access to treatment and clinical outcomes among elderly at-risk drinkers.

DESIGN

A site-specific secondary data analysis of Primary Care Research in Substance Abuse and Mental Health for Elders study (PRISM-E).

PARTICIPANTS

Thirty-four at-risk drinkers age 65 or older who were randomized into one of two treatment conditions: an integrated care condition which incorporated a harm-reduction based approach to treatment and an enhanced referral condition.

MEASURES

Access to subsequent services and clinical outcomes were examined 6 months post index-interview date. Clinical outcomes included changes in the number of drinks in the week prior to assessment, changes in the number of binges in the past 3 months prior to assessment, and changes in scores on the Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G).

RESULTS

At-risk drinkers in the integrated care condition were more likely to access treatment than at-risk drinkers assigned to the enhanced referral condition (93% vs 35%; chi(2) = 11.38, df = 1, p = 0.001). Among those who received treatment, there were no differences in the total amount of treatment visits or in the number of brief alcohol interventions received among at-risk drinkers in the two conditions. However, those in integrated care condition received services sooner than those in the referral condition. Those in the integrated care condition showed a significant decrease in the number of drinks in the past week and in the number of binge drinking episodes in the past 3 months while there were no significant changes in these outcomes among the at-risk drinkers in the enhanced referral condition.

CONCLUSIONS

At-risk drinkers in the integrated care condition were more likely to access treatment and decrease harmful drinking behaviors than those in the enhanced referral condition. Implications for future research and treatment are discussed.

Comparison of treatment persistence, hospital utilization and costs among major depressive disorder geriatric patients treated with escitalopram versus other SSRI/SNRI antidepressants

OBJECTIVE

To assess treatment persistence, hospitalization outcomes and mean healthcare costs of geriatric major depressive disorder (MDD) patients treated with escitalopram compared to other selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs).

RESEARCH DESIGN AND METHODS

Patients aged > or = 65 years with at least one inpatient claim or two independent claims associated with MDD diagnosis were identified in the IHCIS National Managed Care Database (2003-2005). Patients were continuously enrolled for at least > or = 12 months, filled at least one prescription for an SSRI/SNRI and did not use any second-generation antidepressant during the 6 months pre-index date. Unadjusted and multivariate analyses adjusting for baseline characteristics were conducted.

MAIN OUTCOME MEASURES

Treatment persistence, hospitalization utilization, and average prescription drug, medical, and total healthcare costs were compared between patients initiated on escitalopram versus other SSRI/SNRIs.

RESULTS

Escitalopram-treated patients (N = 459) were less likely to discontinue treatment (HR = 0.85, p = 0.012) or switch to another second-generation antidepressant (HR = 0.76, p = 0.006) compared to patients treated with other SSRI/SNRIs (N = 1517). Escitalopram-treated patients had 39% fewer hospitalization days (p = 0.004). Both groups had similar mean prescription drug costs ($1659 vs. $1630, p = 0.687). After controlling for baseline characteristics, escitalopram-treated patients had lower mean total medical service costs ($9425 vs. $12,703, p < 0.001) and mean total healthcare costs ($11,043 vs. $14,163, p < 0.001).

LIMITATIONS

This study's limitations include its small sample size, short observational periods and exclusivity of indirect costs.

CONCLUSIONS

Geriatric patients treated with escitalopram had higher treatment persistence, fewer hospitalization days and lower total healthcare costs than patients on other SSRI/SNRIs after controlling for baseline characteristics. Most of the cost savings were due to reductions in hospitalizations.

Comparison of escitalopram versus citalopram for the treatment of major depressive disorder in a geriatric population

OBJECTIVE

To compare escitalopram versus citalopram for the treatment of major depressive disorder (MDD) in geriatric patients.

RESEARCH DESIGN AND METHODS

Administrative claims data (2003-2005) were analyzed for patients aged > or =65 years with at least one inpatient claim or two independent medical claims associated with MDD diagnosis. Patients were continuously enrolled for at least 12 months, filled at least one prescription for citalopram or escitalopram and had no second generation antidepressant use during the 6-month pre-index date. Contingency table analysis and survival analysis were used to compare outcomes between the two treatment groups.

MAIN OUTCOME MEASURES

Treatment persistence, hospitalization utilization, and prescription drug, medical, and total healthcare costs were analyzed. Outcomes were compared between patients initiated on escitalopram and those initiated on citalopram both descriptively and using multivariate analysis adjusting for baseline characteristics.

RESULTS

Among 691 geriatric patients, escitalopram-treated patients (n=459) were less likely to discontinue treatment (hazard ratio [HR]=0.83, p=0.049) or switch to another second generation antidepressant (HR=0.62, p=0.001) compared to patients treated with citalopram (n=232). Patients treated with escitalopram had a significantly lower hospitalization rate (31.2% vs. 38.8%, p=0.045) and 66% fewer hospitalization days based on negative binomial regression (p<0.001). While escitalopram patients had comparable prescription drug costs, they had lower total medical service costs (regression: $9748 vs. $19,208, p<0.001) and lower total healthcare costs (regression: $11,434 vs. $20,601, p<0.001).

LIMITATIONS

This study's limitations include its small sample size, short observational periods and exclusivity of indirect costs.

CONCLUSIONS

Geriatric patients treated with escitalopram had better treatment persistence, fewer hospitalizations, and lower medical and total healthcare costs than patients treated with citalopram. Most of the cost reduction was attributable to significantly lower hospitalizations and total medical costs.

Detecting depression in the aged: Is there concordance between screening tools and the perceptions of nursing home staff and residents? A pilot study in a rural aged care facility

OBJECTIVE

Recognition of depression in the elderly is exacerbated in rural and remote regions by a lack of mental health specialists. In nursing homes, screening tools have been advocated to circumvent the variable reliability of both nursing staff and residents in recognising depression. Debate concerning the utility of screening tools abounds. Previous research has neglected concordance between screening tools, nursing staff and residents in recognising depression. The present study aimed to determine if there was a significant difference in the proportion of depressed residents identified by recognition sources, and assessed the level of chance corrected agreement between sources.

PARTICIPANTS

One hundred and two residents of aged care facilities in Wagga Wagga, Australia, mean age of 85.19 +/- 7.09 years.

SETTING

Residents were interviewed within their residential aged care facility.

DESIGN

Cross-sectional, between-subjects design.

MAIN OUTCOME MEASURES

Residents, nursing staff, Geriatric Depression Scale (GDS-12R) and Hamilton Depression Rating Scale.

RESULTS

Hamilton Depression Rating Scale and nursing staff professional opinion were not significantly different; however, both measures were significantly different to the resident measures (GDS-12R and resident opinion). Kappa statistic analysis of outcome measures revealed, at best, no more than a moderate level of chance corrected agreement between said sources.

CONCLUSION

It is tentatively argued that the different sources might correspond to qualitatively different 'depression' constructs, and that health professionals who are concerned with depression in the elderly be aware of the disparity between, and subsequently consider, a variety of recognition sources.

The prevalence and recognition of major depression among low-level aged care residents with and without cognitive impairment

Previous research has demonstrated a high level of depression in nursing homes. The current study was designed to determine the prevalence of depression, using a structured diagnostic interview, among older people with and without mild-moderate cognitive impairment residing in low-level care facilities. The results demonstrated that, consistent with previous research in nursing homes, 16.9% of older people were diagnosed with major depressive disorder. Less than half of these cases had been detected or treated. Individuals with moderate cognitive impairment were more likely to be depressed, but cognitive impairment did not appear to act as a strong impediment to the detection of depression by general practitioners. A low awareness of their use of antidepressant medications was demonstrated among older people prescribed this treatment, including those with normal cognitive function. Reasons for the poor recognition of depression among older people are discussed.

Elderly depressed patients: what are their views on treatment options?

The aim of this study was to explore attitudes of elderly patients with depression receiving secondary psychiatric care towards different types of treatment for depression. One hundred patients, recruited from a large teaching hospital in Birmingham, were subjected to structured interviews at which their attitudes towards the effectiveness, likelihood of causing side-effects and acceptability of anti-depressant medication, ECT and psychotherapy were measured on a five-point Likert scale. Psychotherapy was considered both effective and acceptable by our patients although it is not widely available across the UK. Anti-depressants were also considered to be effective and acceptable although likely to cause side-effects. However, our patients did not think highly of ECT, either in its effectiveness or acceptability.

When mental health becomes health: age and the shifting meaning of self-evaluations of general health

Do self-evaluations of general health change as individuals age? Although several perspectives point to age-related shifts, few researchers have compared them. For this article, several competing hypotheses were tested using a large, nationally representative, and longitudinal data set. The results suggest two trends. First, the correspondence between functional limitations and self-rated health declines, especially after age 50. Similarly, the correspondence between various chronic conditions and self-rated health declines with age. These findings are consistent with social comparison theory. Yet, the results also suggest that the correspondence between depressive symptoms and self-rated health increases. Indeed, after age 74, the correspondence between self-rated health and some common symptoms of depression becomes stronger than that between self-rated health and several chronic, and often fatal, somatic conditions. This crossover has important implications for the detection and treatment of depressive symptoms in later life.

Primary care clinicians evaluate integrated and referral models of behavioral health care for older adults: results from a multisite effectiveness trial (PRISM-e)

BACKGROUND

Recent studies have shown that integrated behavioral health services for older adults in primary care improves health outcomes. No study, however, has asked the opinions of clinicians whose patients actually experienced integrated rather than enhanced referral care for depression and other conditions.

METHOD

The Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) study was a randomized trial comparing integrated behavioral health care with enhanced referral care in primary care settings across the United States. Primary care clinicians at each participating site were asked whether integrated or enhanced referral care was preferred across a variety of components of care. Managers also completed questionnaires related to the process of care at each site.

RESULTS

Almost all primary care clinicians (n = 127) stated that integrated care led to better communication between primary care clinicians and mental health specialists (93%), less stigma for patients (93%), and better coordination of mental and physical care (92%). Fewer thought that integrated care led to better management of depression (64%), anxiety (76%), or alcohol problems (66%). At sites in which the clinicians were rated as participating in mental health care, integrated care was highly rated as improving communication between specialists in mental health and primary care.

CONCLUSIONS

Among primary care clinicians who cared for patients that received integrated care or enhanced referral care, integrated care was preferred for many aspects of mental health care.

The role of provider attitudes in prescribing antidepressants to older adults: leverage points for effective provider education

OBJECTIVES

The purpose of this study was to determine if primary care provider knowledge of late-life depression, attitudes about treatment of depression in late life, and experience treating late-life depression affect the likelihood internists would prescribe antidepressants to older patients.

METHODS

This study was a primary care provider survey study. From a pool of 456 eligible mailed surveys, 253 providers completed (55% response rate) a survey assessing provider self-reported knowledge about treating late-life depression with antidepressants, their attitudes about older patients' acceptance and response to antidepressant medications, their professional and personal experience with antidepressant medication, and their comfort with prescribing antidepressants to older patients was created for this study.

RESULTS

Univariate analyses indicated that 75% of primary care providers were knowledgeable about the use of antidepressant treatment in older people, and 86% said they felt comfortable treating depression in older patients. Multivariate analyses indicated that the decision to treat older patients with antidepressants was largely influenced by time to treat patients, provider belief that antidepressants could treat late-life depression, their comfort with treating late-life depression, and having had older patients respond to antidepressant treatment in the past (R2 = .52, p < .001).

CONCLUSIONS

This study shows that attitudinal and experiential factors play an important role in the likelihood that a provider will treat an older, depressed patient with an antidepressant, more so than knowledge about how to prescribe an antidepressant to older patients. Residency programs for primary care practitioners should include education about the efficacy of antidepressant treatment in older people and should involve hands-on experience in treating late-life depression.

Design and sample characteristics of the PRISM-E multisite randomized trial to improve behavioral health care for the elderly

OBJECTIVE

To describe the design of the Primary Care Research in Substance Abuse and Mental Health for Elderly (PRISM-E) study and baseline characteristics of the randomized primary care patients with mental health problems and at-risk alcohol use.

METHOD

Adults aged 65 and older were screened at primary care clinics from 10 study sites throughout the United States. Those diagnosed for depression, anxiety, and/or at-risk alcohol consumption were randomized to either integrated or enhanced referral care.

RESULTS

Of the 23,828 participants, 14% had a positive assessment for depressive and/or anxiety disorders, and 6% had at-risk alcohol consumption diagnoses. Among patients with mental health diagnoses, there was a higher preponderance of younger ages, women, and ethnic minorities. Among patients with at-risk drinking, there was a higher preponderance of younger ages, Whites, and men.

DISCUSSION

These findings indicate the need for screening in primary care and for engaging older adults in treatment.

Unipolar late-onset depression: A comprehensive review

Background

The older population increases all over the world and so also does the number of older psychiatric patients, which manifest certain specific and unique characteristics. The aim of this article is to provide a comprehensive review of the international literature on unipolar depression with onset at old age.

Methods

The authors reviewed several pages and books relevent to the subject but did not search the entire literature because of it's overwhelming size. They chose to review those considered most significant.

Results

The prevalence of major depression is estimated to be 2% in the general population over 65 years of age. The clinical picture of geriatric depression differs in many aspects from depression in younger patients. It is not yet clear whether it also varies across cultures and different socio-economic backgrounds. Biological data suggest that it is associated with an increased severity of subcortical vascular disease and greater impairment of cognitive performance. Many authors consider the existence of a somatic disorder to be related to the presence of depression in late life, even constituting a negative prognostic factor for the outcome of depression. Most studies support the opinion that geriatric depression carries a poorer prognosis than depression in younger patients. The therapeutic intervention includes pharmacotherapy, mainly with antidepressants, which is of established value and psychotherapy which is not equally validated.

Conclusion

A significant number of questions regarding the assessment and treatment of geriatric depression remain unanswered, empirical data are limited, and further research is necessary.

Evaluation and management of geriatric depression in primary care

Geriatric depression is a common but frequently unrecognized or inadequately treated condition in the elderly population. Manifestations of major depression in elderly persons may hinder early detection; anxiety, somatic complaints, cognitive impairment, and concurrent medical and neurologic disorders are more frequent. Like major depression, minor depression, which is often ignored, produces morbidity for elderly persons. Both major and minor depression are associated with high mortality rates if left untreated. This article reviews the important aspects of geriatric depression for the nonpsychiatric clinician: the etiology of depressive conditions in the elderly population, the unique clinical features of depression in older people, important evaluation considerations in a population with many medical and neurologic comorbidities, and the nonpharmacological and pharmacological treatment options for managing depression in the geriatric population.

Unrecognized medical disorders in older psychiatric inpatients in a senior behavioral health unit in a university hospital

Medical disorders may cause psychiatric symptoms. This study investigated the frequency and nature of previously unrecognized medical disorders associated with behavioral disturbances in acute geriatric psychiatry inpatients. Data came from a chart review of 79 consecutive admissions to the University of California, San Diego, Senior Behavioral Health Unit from May 1999 to October 1999. The most common Axis I admission diagnoses were depression and psychosis. At admission, 27 of 79 cases (34%) had unrecognized medical disorders. Comparison of these cases with the cases that did not have unrecognized medical disorders found no differences in age, education, gender, or cognitive abilities. The group with unrecognized medical disorders had more medical disorders (mean 5.0 vs 3.6; P = .002). Unrecognized conditions (n) included constipation (7), urinary infection (7), and hypothyroidism (5). Elderly psychiatric patients are more likely to have physical comorbidity. A large number of medical disorders should alert clinicians to look carefully for unrecognized medical disorders.

Reported differences in management strategies by primary care physicians and psychiatrists in older patients who are depressed

OBJECTIVE

To compare reported management suggestions by primary care physicians and psychiatry specialists for case vignette examples of old age depression, and to explore further training needs in geriatric depression for both professional groups.

DESIGN

Qualitative study using case vignettes in focus groups. Single group training sessions were arranged for 25 primary care physicians and 11 psychiatrists. The same two clinical vignettes were presented at all training sessions. Written management suggestions by participants, group discussion field notes and transcripts of group session videotapes were analysed.

RESULTS

Differences emerged in intended depression management. Primary care physicians tended to assess the symptoms as less serious and the situation as less urgent than psychiatrists. Management suggestions given by the psychiatrists included more recommendations of immediate psychiatric treatment and more precise descriptions of medication. Both groups recognized the somatic issues and were willing to assume responsibility for treatment.

CONCLUSIONS

Identifying management differences seems to benefit the professional development of both groups. Exploring and discussing the underlying reasoning leading to management differences may be a productive format for primary care doctors and psychiatric specialists to teach and learn together. It may also promote collaboration in caring for the depressed elderly.

Do family physicians and internists differ in knowledge, attitudes, and self-reported approaches for depression?

OBJECTIVES

The purpose of this investigation was to assess the relationship of primary care specialty training with self-assessed skill, knowledge, attitudes, and behavior toward depression recognition and management.

METHOD

A baseline self-report questionnaire was administered to 184 internists and 138 family physicians participating in a multisite depression intervention study.

RESULTS

There were no marked differences in knowledge of internists and family physicians regarding depression, in attitudes about the effectiveness of specific therapies, or in barriers to providing optimum treatment for depression. However, compared to internists, family physicians rated themselves as more skilled in the management of depression. When considering management of patients with moderate to severe depression, family physicians were more likely to report that they prescribed a selective serotonin-reuptake inhibitor (relative odds (RO) = 3.51, 95 percent Confidence interval (CI) [2.19, 5.60] and to personally counsel patients (RO = 1.97, 95 percent CI [1.16, 3.38]) more than half the patients, but were less likely to refer to a specialist in mental health (RO = 0.52, 95 percent CI [0.33, 0.82]) than were internists. Additional potentially influential characteristics did not wholly account for the reported differences in practice according to specialty. Physicians of both specialties expressed considerable uncertainty in their knowledge of psychotherapy and in their evaluation of the effectiveness of other strategies for the prevention of recurrence of depression.

CONCLUSION

Strategies to improve mental health care should account for the orientation of primary care physicians to mental health issues.

Physician willingness to refer older depressed patients for psychotherapy

OBJECTIVE

Psychotherapy for late-life depression is an efficacious treatment option for older primary care patients who do not wish to take or do not respond to antidepressant medication. However, rates of physician referral to psychotherapy to treat late-life depression tend to be low. The purpose of this study was to assess attitudes toward psychotherapy for late-life depression and to identify predictors of physician willingness to refer older patients to psychotherapy.

METHODS

Two hundred and five physicians identified from PPO directories of general internists in California and North Carolina completed a brief mailed survey about how they would treat a hypothetical older depressed patient and specific attitudes and practices regarding their own treatment of late-life depression.

RESULTS

Only 27 percent of physicians said they would refer a depressed older patient to psychotherapy. In a regression analysis, female gender, the belief that psychotherapy is effective for older adults, and physician use of psychosocial techniques were associated with increased willingness to refer to psychotherapy. Practicing in North Carolina, awareness of depression treatment guidelines, and the perception of patient willingness to attend psychoeducational classes on depression and medication management were associated with decreased willingness to refer.

CONCLUSIONS

More efforts are needed to increase the use of referral to psychotherapy as a treatment option for older medical patients. Education about guideline-level treatment alone may not be sufficient. More specific education, including information about the efficacy of psychotherapy for older adults, as well as direct training in psychosocial techniques, may be helpful in promoting referral to psychotherapy.

Early antidepressant therapy for elderly patients

PURPOSE

We studied factors affecting the management of depression in older patients, especially the use of early antidepressant therapy.

METHODS

We recruited 128 primary care physicians to view one version of a 5-minute videotape of an elderly patient with somatic symptoms that were suggestive of depression, and to complete an interview that assessed decision making. Using an experimental factorial design, 16 versions of the videotape were produced, holding constant the clinical features of the case, while varying the patient's age, race, sex, and socioeconomic status. Dependent variables were the physicians' probability assessment of depression and the recommendation of antidepressant medication after the first visit.

RESULTS

Depression was considered a possible diagnosis by 121 physicians (95%) and the most likely diagnosis by 69 (54%). Sixteen physicians (13%) recommended antidepressant therapy after the first visit, and they were less likely than other physicians to order initial laboratory tests to assess the possibility of other conditions. Recommendations for antidepressant therapy was not associated with patient age, sex, race, or socioeconomic status, or with physician sex, race, or experience. Family physicians were more likely than internists to recommend an antidepressant (19% [12/64] vs. 6% [4/64], P = 0.04).

CONCLUSION

Based on a 5-minute vignette, physicians were likely to recognize depression, independent of patient characteristics. Those recommending early antidepressant therapy were more likely to be in family medicine and less likely to investigate other diagnoses initially.

Evaluating the Impact of an Educational Program on Practice Patterns of Canadian Family Physicians Interested in Depression Treatment

BACKGROUND: Depression is frequently unrecognized and undertreated. Therefore, there is a need to increase the knowledge and skills of primary care physicians regarding the diagnosis and treatment of depression. The aim of this study was to provide, and evaluate the impact of, a brief educational program with a number of practice tools and resources in order to improve family physicians' knowledge, diagnosis, and treatment of depression. METHODS: Two educational programs (general and enhanced) were delivered to family physicians interested in depression treatment. The enhanced program focused on more practical clinical issues such as use of diagnostic and symptom assessment tools, recommended dosing of citalopram, how to initiate and discontinue treatment, and relapse prevention. Physicians' knowledge of depression was assessed pretraining and posttraining. Chart audits were conducted for 6 months. Primary endpoints were recognition of depression and pharmacologic management (initial dose, maximum dose, length of treatment, adverse events, and concomitant psychotropic drugs). Secondary endpoints were patient satisfaction with treatment, compliance, withdrawal from the study, treatment outcome, use of adjunctive psychotherapy, and number of office visits. RESULTS: There was a global increase in physicians' knowledge of depression in the short term. Physicians in the enhanced group were more likely to use a symptom-based diagnostic checklist, record the diagnosis of depression, and prescribe the recommended initial dose of citalopram, and they referred less frequently for adjunctive psychotherapy. No difference between educational intervention groups was found in patient satisfaction, compliance, and treatment outcome. CONCLUSIONS: A well-designed brief, simple, and low-cost educational program can increase family physicians' knowledge of depression, improve their diagnostic skills, and optimize their treatment of depression.

Assessment of late life depression

This article focuses on diagnostic and nosologic challenges intrinsic to geriatric depression, including characteristics interfering with symptom and syndrome ascertainment, the impact of medical and cognitive disorders, the usefulness of screening instruments, and barriers imposed by treatment settings. The article also identifies gaps in existing knowledge and outlines a research agenda. Nosologic characterization of depressives syndromes contributed by specific medical disorders may lead to effective strategies for prevention and treatment of depression. Studies need to examine whether treatment of depression can improve the outcome of medical illnesses requiring active patient involvement in treatment. Considering disability a distinct aspect of health status may add an important dimension to the assessment of depression and result in complementary interventions aimed at depression and disability concurrently. The provisional criteria for depression of Alzheimer's disease, if validated, may facilitate treatment research. Studies need to characterize cognitive dysfunctions associated with later development of dementia or poor treatment response in patients with depression. Care managers working together with primary care physicians can improve the recognition and treatment of depressed elderly patients by obtaining the training in using validated instruments and treatment algorithms.

Diagnosis of late life depression: the view from primary care

In the typical primary care practice, in which patients with a wide range of diseases and symptoms present with numerous needs, concerns, and requests, a chronic disease that lacks quantitative, biologically based diagnostic testing, such as depression, can present a daunting diagnostic challenge to even the best and most dedicated primary care physician. Depression does not compete well for patient and physician time and energy with other medical problems and medical co-morbidity in patients who seek care from their primary care physician. Primary care patients may be more comfortable with and accepting of depression being framed as a "normal" chronic disease rather than a psychiatric "brain" disease subject to cultural and generational stigmas, nihilism, and prejudice. Insurance parity in mental health care would make depression and other mental illness more legitimate in the eyes of patients, family members, employers, and physicians. Of particular value would be new and creative approaches to collaborative care, including telephone monitoring, nurse clinician outreach, and improved availability of psychiatric consultation in primary care, because elderly depressed patients often see the care of their depression as part of the integrated care of multiple chronic medical diseases, rather than a separate psychiatric problem to be referred for specialty care.

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.

Barriers to initiating depression treatment in primary care practice

OBJECTIVE AND DESIGN

This study used qualitative and quantitative methods to examine the reasons primary care physicians and nurses offered for their inability to initiate guideline-concordant acute-phase care for patients with current major depression.

PARTICIPANTS AND SETTING

Two hundred thirty-nine patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices were randomized to the intervention arm of a trial of the effectiveness of depression treatment. Sixty-six (27.6%) patients identified as failing to meet criteria for guideline-concordant treatment 8 weeks following the index visit were the focus of this analysis.

METHODS

The research team interviewed the 12 physicians and 6 nurse care managers to explore the major reasons depressed patients fail to receive guideline-concordant acute-phase care. This information was used to develop a checklist of barriers to depression care. The 12 physicians then completed the checklist for each of the 64 patients for whom he or she was the primary care provider. Physicians chose which barriers they felt applied to each patient and weighted the importance of the barrier by assigning a total of 100 points for each patient. Cluster analysis of barrier scores identified naturally occurring groups of patients with common barrier profiles.

RESULTS

The cluster analysis produced a 5-cluster solution with profiles characterized by patient resistance (19 patients, 30.6%), patient noncompliance with visits (15 patients, 24.2%), physician judgment overruled the guideline (12 patients, 19.3%), patient psychosocial burden (8 patients, 12.9%), and health care system problems (8 patients, 12.9%). The physicians assigned 4,707 (75.9%) of the 6,200 weighting points to patient-centered barriers. Physician-centered barriers accounted for 927 (15.0%) and system barriers accounted for 566 (9.1%) of weighting points. Twenty-eight percent of the patients not initiating guideline-concordant acute-stage care went on to receive additional care and met criteria for remission at 6 months, with no statistical difference across the 5 patient clusters.

CONCLUSIONS

Current interventions fail to address barriers to initiating guideline-concordant acute-stage care faced by more than a quarter of depressed primary care patients. Physicians feel that barriers arise most frequently from factors centered with the patients, their psychosocial circumstances, and their attitudes and beliefs about depression and its care. Physicians less frequently make judgments that overrule the guidelines, but do so when patients have complex illness patterns. Further descriptive and experimental studies are needed to confirm and further examine barriers to depression care. Because few untreated patients improve without acute-stage care, additional work is also needed to develop new intervention components that address these barriers.

Quality improvement research on late life depression in primary care

BACKGROUND

Two million older Americans suffer from depression annually. Depression causes more functional impairment than many other common medical conditions and older adults have the highest rate of suicide in the United States. Although many of these patients fail to seek or fail to receive care for depression, the majority will be seen in primary care for the treatment of other conditions.

OBJECTIVE

To review the health services research on quality improvement for late life depression.

METHODS

Qualitative literature review.

RESULTS

During the past 30 years, multiple educational and quality improvement interventions have been designed and tested to improve the recognition and treatment of depression in primary care settings. The findings from this large body of health services research suggest that: (1) the outcome of major depression in the usual care of primary care is typically poor; this is particularly true of late life depression; (2) informational support provided to primary care physicians is necessary but insufficient to improve the outcomes of late life depression in primary care; achieving guideline-level therapy requires the substantial participation of an informed and motivated patient working in concert with a health care team and health care system designed to care for chronic conditions; (3) up to 30% of older primary care patients will fail to respond to excellent guideline-level therapy provided in primary care; and (4) the latest quality improvement efforts focus not only on the clinical skills of primary care physicians, but also on patient's self-care and on innovative strategies to improve the system of care.

CONCLUSIONS

Late life depression is often a chronic disease and outcomes research demonstrates that quality improvement efforts that focus resources on improving systems of care and the active participation of patients offer the best evidence of improved patient outcomes.

Improving primary care for depression in late life: the design of a multicenter randomized trial

BACKGROUND

Late life depression can be successfully treated with antidepressant medications or psychotherapy, but few depressed older adults receive effective treatment.

RESEARCH DESIGN

A randomized controlled trial of a disease management program for late life depression.

SUBJECTS

Approximately 1,750 older adults with major depression or dysthymia are recruited from seven national study sites.

INTERVENTION

Half of the subjects are randomly assigned to a collaborative care program where a depression clinical specialist supervised by a psychiatrist and a primary care expert supports the patient's regular primary care provider to treat depression. Intervention services are provided for 12 months using antidepressant medications and Problem Solving Treatment in Primary Care according to a stepped care protocol that varies intervention intensity according to clinical needs. The other half of the subjects are assigned to care as usual.

EVALUATION

Subjects are independently assessed at baseline, 3 months, 6 months, 12 months, 18 months, and 24 months. The evaluation assesses the incremental cost-effectiveness of the intervention compared with care as usual. Specific outcomes examined include care for depression, depressive symptoms, health-related quality of life, satisfaction with depression care, health care costs, patient time costs, market and nonmarket productivity, and household income.

CONCLUSIONS

The study blends methods from health services and clinical research in an effort to protect internal validity while maximizing the generalizability of results to diverse health care systems. We hope that this study will show the cost-effectiveness of a new model of care for late life depression that can be applied in a range of primary care settings.

Meeting the needs of primary care physicians: a guide to content for programs on depression

OBJECTIVE

The purpose of this article is to identify literature-based content for the design of educational programs on depression for practicing primary care physicians.

METHODS

A MEDLINE search was conducted of English-language medical literature published from 1982 through July 1997 for studies describing primary care physicians' knowledge, skills, practice patterns, and perceived barriers related to care of depressed patients. Studies focusing exclusively on residency training and those describing physician practices outside North America were excluded. Of 377 articles identified, forty met inclusion and exclusion criteria.

RESULTS

Recommendations for educational content were identified from the literature review. For recognition, educators should prioritize communication skills and strategies for the use of depression questionnaires. For diagnosis, practice interpreting symptoms in the medically ill, strategies for efficient diagnosis, and systematic approaches to assessing suicide risk should be emphasized. For treatment, greater attention to the therapeutic alliance, staged therapy, and strategies for improving medication adherence are indicated.

CONCLUSIONS

There is a moderately well developed literature describing self-perceived and observed gaps in the current care for depression in primary care. Addressing the entire list of needs would take more time than practicing physicians are likely to have. An important challenge for educators is to design flexible programs based on individualized needs assessment or, when not possible, to prioritize the most generalizable needs.

Caring for depressed and suicidal older patients: a survey of physicians and nurse practitioners

OBJECTIVE

This study sought to describe patterns of mental health care for depressed and suicidal geriatric patients by primary care physicians (MDs) and nurse practitioners (NPs).

METHODS

A probability sample of 300 Illinois MDs from the AMA Physician Masterfile and a national sample of 595 NPs from the American Academy of Nurse Practitioners were surveyed. Sixty-three percent of MDs and 61 percent of NPs responded regarding their approaches to assessing, treating, and referring older adult patients who were depressed or suicidal. Respondents rated their confidence in assessing and treating depression and suicidality and identified barriers to mental health treatment in a primary care setting.

RESULTS

Both similarities and differences were found among MDs and NPs in their patterns of managing depressed and suicidal older adults. NPs used more varied approaches in assessing, treating, and referring their geriatric patients with mental health problems. MDs relied more heavily on psychotropic medications for the treatment of depression and on psychiatrists when referring suicidal older patients. NPs were more likely than MDs to note lack of training and referral resources as barriers to treating depression of older patients. NPs rated their training in geriatric mental health more favorably than MDs.

CONCLUSIONS

In terms of assessment of depression, preferred treatment approaches, the use of referral resources, and perceived barriers to mental health care, there appears to be a greater orientation towards a psychosocial approach among NPs. Primary care MDs and NPs often have different perspectives that in combination could enhance the mental health care of geriatric patients.

What factors influence the prescribing of antidepressant pharmacotherapy? An assessment of national office-based encounters

OBJECTIVE

This study was designed to identify: 1) predictors of antidepressant pharmacotherapy among patients diagnosed with depression; and 2) predictors of prescription for either a selective-serotonin reuptake inhibitor (SSRI), or a serotonin-norepinephrine reuptake inhibitor (SNRI).

METHOD

Data from the 1995 National Ambulatory Medical Care Survey (NAMCS) were used to discern the number of office-based encounters documenting a diagnosis of depression (ICD-9-CM codes 296.2-296.36; 300.4; or 311) among patients eighteen years of age or older. Logistic regression-derived odds ratios (OR) and 95 percent confidence intervals (CI) were used to elucidate factors predictive of receipt of antidepressant pharmacotherapy, and, more specifically, factors predictive of receipt of an SSRI or an SNRI. Model variables included age (18-49 years as compared to > or = 50 years); race (white as compared to nonwhite, inclusive of Hispanics); gender; self-report of depression as a reason for the office-based encounter; and payer type (private insurance program as compared to public).

RESULTS

Among the estimated 18,046,293 office-based visits resulting in a diagnosis of depression, 56.2 percent of patients self-reported depression as a reason for the office-based encounter; 67.5 percent were prescribed or continued a regimen of antidepressant pharmacotherapy; and 48.3 percent were prescribed an SSRI or an SNRI. Factors predictive of receipt of antidepressant pharmacotherapy included age less than fifty years (OR = 1.30, CI = 1.01-1.67); female gender (OR = 1.45, CI = 1.13-1.85); and self-report of depression as a reason for the office-based encounter (OR = 1.98, CI = 1.57-2.51). Factors predictive of receipt of an SSRI or an SNRI included age less than fifty years (OR = 1.31, CI = 1.03-1.65); female gender (OR = 1.55, CI = 1.23-1.95); and self-report of depression as a reason for the office-based encounter (OR = 1.56, CI = 1.25-1.95). In addition, having private insurance increased the likelihood of having been prescribed an SSRI or SNRI by 46 percent (OR = 1.46, CI = 1.13-1.89).

CONCLUSIONS

Among patients with a diagnosis of depression, the pattern of prescribing antidepressant pharmacotherapy is influenced by a patient's age, gender, self-report of depression, and type of insurance coverage. Further research is required to discern the reasons for these observed effects and to advance clinically rational and equitable access to pharmacotherapeutic innovation.

Psychiatric diagnosis and intervention in older and younger patients in a primary care clinic: effect of a screening and diagnostic instrument

OBJECTIVES

To determine whether patient age is associated with psychiatric diagnosis or provider intervention in a busy primary care clinic, and, if so, whether a screening and diagnostic tool, the PRIME-MD, modifies age-related differences.

DESIGN, SETTING, AND PARTICIPANTS

PRIME-MD use, psychiatric diagnosis, and provider interventions for psychiatric conditions were recorded for eligible patients attending a Veterans Affairs Medical Center primary care clinic. Data from 952 younger (<65 years) and 1135 older patients (> or =65 years) were analyzed to determine whether there were age-related differences in diagnosis/intervention and if use of the PRIME-MD modified these differences.

INTERVENTION

Implementation of the PRIME-MD, a two-step instrument consisting of a self-administered patient questionnaire and a provider-administered structured diagnostic interview.

MEASUREMENTS

Outcome measures were rates of (1) PRIME-MD use, (2) overall psychiatric diagnosis, (3) new psychiatric diagnosis, and (4) provider intervention for psychiatric conditions.

RESULTS

There was no association between patient age and PRIME-MD use. Older patients were less likely to receive a psychiatric diagnosis in analyses that adjusted for "highly positive" screening questionnaires (OR = .45; P<.001). Older patients were also less likely to receive an intervention for a psychiatric condition in analyses that adjusted for whether a psychiatric diagnosis (OR = .62, P = .015) or a new psychiatric diagnosis (OR = .36, P<.001) was made during the study visit. The PRIME-MD increased rates of diagnosis and intervention but did not alter age-related disparities.

CONCLUSIONS

Decreased rates of psychiatric diagnosis and intervention in older primary care patients are of concern. Implementing the PRIME-MD will likely increase rates of diagnosis and intervention but will need to be accompanied by additional measures to eliminate age-related disparities.