Behavioral Health Workforce Development in Washington State: Addition of a Behavioral Health Support Specialist

The mental and behavioral health workforce shortage has hindered access to care in the United States, resulting in long waitlists for persons who need behavioral health care. Global models for task sharing, combined with U.S.-led studies of nonspecialists delivering interventions for depression and anxiety, support the development of this workforce in a stepped care system. This Open Forum highlights an innovative effort in Washington State to initiate a bachelor's-level behavioral health support specialist curriculum leading to credentialing to expand the mental health workforce and improve access to care for people with depression and anxiety.

Metabolic Syndrome, Modifiable Lifestyle Factors, and Sleep-Disordered Breathing: The Hispanic Community Health Study

BACKGROUND

US Hispanics/Latinos are disproportionately susceptible to metabolic syndrome (MetS), attributed in part to systemic inequities related to health and lifestyle factors such as low physical activity (PA) levels, diet quality, alcohol use, tobacco use, and sleep disorder. Gender and heritage group differences are vastly understudied and need to be examined in this heterogeneous population.

PURPOSE

To examine the relationships between select health and lifestyle factors and MetS among Hispanic gender and heritage subgroups (Hypothesis 1) and determine whether gender and heritage moderate those relationships (Hypothesis 2).

METHODS

Participants included 14,155 Hispanic Americans aged 18-76 (59% female, mean age 45.92 ± 13.97) from seven heritage subgroups. This secondary analysis of cross-sectional data from the observational Hispanic Community Health Study/Study of Latinos (HCHS/SOL) dataset used hierarchical multinomial logistic regression to test Hypothesis 1; the dependent variable, MetS, included three categories delineating absence of MetS and presence of MetS with or without related medication use. Hayes' PROCESS macro tested Hypothesis 2.

RESULTS

Low PA and sleep-disordered breathing (SDB) each had significant (p < .001) predictive value of MetS group membership, whereas both low and high alcohol use (p < .001) were associated with decreased MetS risk. Cigarette pack-years were not significantly associated with MetS outcomes. Gender moderated the association between MetS and alcohol use (p < .001), cigarette pack-years (p < .001), and SDB (p < .001) such that the effects on MetS were higher in females than males. The association between MetS and diet quality (p < .001) was stronger among males than in females.

CONCLUSIONS

Gender and heritage differences were prominent among study variables.

A low-intensity behavioral intervention for depression in older adults delivered by lay coaches: proof-of-concept trial

OBJECTIVES

A broader workforce is necessary to expand U.S. geriatric mental health services. We examined (1) feasibility of training undergraduate students to deliver Do More, Feel Better (DMFB), an evidence-informed program for depression; and (2) feasibility, acceptability, and outcomes in a single-arm proof-of-concept trial.

METHOD

In Study 1, we taught DMFB to 18 upper-level undergraduate students and assessed fidelity using role plays. In Study 2, four students delivered six weekly DMFB sessions to 12 community-dwelling older adults (M = 66.83 years old, SD = 10.39) with depression (PHQ ≥ 10). Patient outcomes were change in pre- to post-treatment depressive symptoms, disability, and the target mechanism of increased activity.

RESULTS

Fidelity was high in the course (Study 1; 82.4% of role plays rated as 'passing') and the trial (Study 2; 100% of 24 sessions rated as 'passing'). The majority (83.3%) of patients were retained and evidenced statistically and clinically significant improvement in depressive symptoms (Hamilton Rating Scale for Depression [HAM-D]), disability (World Health Organization's Disability Assessment Schedule 2.0 [WHODAS 2.0], and activity (Behavioral Activation for Depression Scale [BADS]).

CONCLUSION

It is feasible to train bachelor's-level students to deliver a brief, structured intervention for depression. Future research should consider implementation strategies and stakeholder feedback.

Mental health is related to metabolic syndrome: The Hispanic community health study/ study of Latinos

OBJECTIVE

Metabolic syndrome (MetS) is associated with common mental health conditions. Using cross-sectional data from the observational Hispanic Community Health Study / Study of Latinos (HCHS/SOL), this study examined the relationship between MetS and depression and anxiety in addition to testing moderating effects of gender and Hispanic heritage subgroups.

METHODS

Participants included 13,496 Hispanic Americans aged 18-74 (59% women, mean age 46.59 ± 13.65) from seven heritage subgroups. Depression was measured using the Center for Epidemiologic Studies Depression 10-item scale, and anxiety was assessed using the State-Trait Anxiety Inventory 10-item scale. A 3-level categorical variable was developed to assess the combined influence of depression and anxiety. The dependent variable is dichotomous, delineating the presence or absence of MetS as defined by the National Cholesterol Education Program Third Adult Treatment Panel. Logistic regression and Hayes' PROCESS macro assessed these relationships and the moderating effects of gender-heritage subgroups.

RESULTS

Results suggest depression (p < .001) and anxiety (p < .001) were associated with an increased likelihood of MetS. Puerto Ricans had the highest, and South Americans had the lowest, levels of depression and anxiety. Gender moderated the relationship between mental health and MetS, with women having a significant increase in the probability of MetS with depression (p < .001), anxiety (p < .001), or both (p < .001).

CONCLUSION

Elevated symptoms of depression and anxiety are associated with the presence of MetS in US Hispanic subgroups. Gender-heritage differences are present among the study variables. Strategies to manage psychological well-being must be employed to optimize cardiometabolic health in US Hispanics.

Self-objectification: Implications for physical activity in middle-aged women and men

Self-objectification (i.e., valuing the body primarily for its attractiveness to others) is negatively related to physical health, including physical activity (PA) attitudes and behaviors. Given the low levels of PA among middle-aged adults in the US, self-objectification may be a novel correlate of PA in this population. The present study examined self-objectification and PA variables in a cross-sectional Western U.S. community sample of women (n = 215) and men (n = 134), aged 45-64, including gender as a moderator of these relations. Data were collected via survey, including measures of self-objectification, PA enjoyment, PA perceived benefits and barriers, and self-reported levels of PA. Women and men in our sample did not differ in levels of self-objectification. Results of regression analyses indicated that self-objectification predicted less PA enjoyment. In addition, men higher in self-objectification reported higher levels of PA. The findings implicate self-objectification as a potentially novel determinant of PA attitudes and behaviors in middle-aged adults.

Sport and mental health performance optimization in an adolescent gymnast: A case evaluation

The Optimum Performance Program in Sports (TOPPS) is a multi-component, sport-specific Family Behavior Therapy that has demonstrated improved sport performance, relationships, and mental health outcomes in adult and adolescent athletes with, and without, diagnosed mental health disorders in clinical trials. The current case trial demonstrates successful implementation of a novel component of TOPPS (i.e., talk aloud optimal sport performance imagery leading to dream mapping) in a biracial Latina and White adolescent gymnast without a mental health diagnosis. The participant demonstrated significant improvements from baseline to both post-treatment and 3-month follow-up in severity of mental health functioning, factors interfering with sports performance, and her relationships with teammates, coaches, and family. Results suggest it may be possible to optimize mental health through sport performance optimization.

A systematic review and meta-analysis of factors influencing ImPACT concussion testing in high school and collegiate athletes with self-reported ADHD and/or LD

OBJECTIVE

Sport concussion is a common injury, and athletes with attention-deficit/hyperactivity disorder (ADHD) and/or learning disorder (LD) are at increased risk and require specialized attention in clinical settings. Although systematic reviews of the relationship between ADHD/LD and concussion are reported in the literature, these reviews do not include quantitative syntheses. Additionally, no reviews have focused on the most commonly utilized concussion assessment, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). The current review provides an update of sport concussion assessment in athletes with ADHD and/or LD from 2000 to 2021 on these topics: baseline and postconcussion performance on ImPACT, baseline and postconcussion symptom reporting using the Postconcussion Symptom Scale, invalid baseline classification on ImPACT, and self-reported history of concussion.

METHOD

Meta-analyses were conducted on baseline ImPACT performance, symptom reporting, invalid baseline classification, and concussion rates. Thirty-four studies were included in systematic review and 19 were included in meta-analyses.

RESULTS

Decreased baseline performance was found for athletes with ADHD (trivial to small effects), LD (small-to-medium effects), and ADHD/LD (small-to-medium effects). Increased baseline symptom reporting was found for athletes with ADHD (small effect). Increased odds of invalid baseline performance (trivial effect) and self-reported concussion history (small effect) were found in ADHD.

CONCLUSIONS

These results provide the first quantitative synthesis of the literature in this area. It is recommended that future research further examines these topics in athletes with LD and co-occurring ADHD/LD (given the focus on ADHD), as well as the effects that all of these conditions may have on concussion recovery and return-to-play decision-making. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Electrocardiogram Abnormalities Associated With Metabolic Syndrome: The Hispanic Community Health Study/Study of Latinos

BACKGROUND

Metabolic syndrome (MetS) is a prognostic cluster of physiologic risk factors that may develop into cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). Electrocardiogram abnormalities (ECGA) can be instrumental in identifying the early stages of disease and may be associated with MetS in Hispanic Americans.

OBJECTIVE

To explore the relationships between MetS and major and minor ECGA in the Hispanic population (Hypothesis 1) and determine whether gender-ethnic subgroups moderate these relationships (Hypothesis 2).

METHODS

This secondary data analysis was conducted using large-scale data from the cohort study Hispanic Community Health Study/Study of Latinos (N = 13,628; 59% women and 41% men). Major ECGA encompassed 9 abnormalities including pathologic Q waves and left ventricular hypertrophy. Minor ECGA were tested independently of major ECGA. MetS was classified into 4 categories delineating metabolic abnormalities and related medication use. Multinomial logistic regression and Hayes' PROCESS macro were used for statistical analysis.

RESULTS

Major ECGA were significantly associated with the presence of MetS and/or related medication use, whereas minor ECGA abnormalities were associated with MetS for participants who also took MetS-related medications only. Gender moderated the association between MetS and minor ECGA such that women with minor ECGA had a higher likelihood of MetS when compared to men.

CONCLUSIONS

Findings suggest that early recognition and associated treatment of major and minor ECGA can be important to prevent MetS and further morbidities in the Hispanic population.

Perspectives of Nonspecialists Delivering a Brief Depression Treatment in the United States: A Qualitative Investigation

BACKGROUND

Task sharing is an implementation strategy which increases access to services by training and supporting treatment delivery by nonspecialists. Such an approach has demonstrated effectiveness for depression and other mental health outcomes; however, few studies in high-income countries have examined nonspecialist providers' (NSPs) perspectives of the acceptability, feasibility, and appropriateness of delivering mental health interventions. We examine qualitative reports of NSPs experiences delivering a brief structured behavioral intervention for depression (called "Do More, Feel Better" [DMFB]) to adults aged 55 and older.

METHODS

All NSPs (N = 4, 100%) who delivered DMFB participated in a focus group to probe their perceptions of the acceptability, feasibility, and appropriateness of both the intervention and their delivery experience as NSPs. Two coders analyzed the qualitative data from focus groups using codebook thematic analysis.

RESULTS

NSPs perceived the intervention and delivery experience to be acceptable, feasible, and appropriate. Qualitative results provided insight into specific barriers and facilitators which may be important to consider when planning to implement task sharing. Themes that emerged from qualitative data included supervision being highly acceptable and feasible, appropriateness of the intervention for NSPs, and the feasibility of tailoring the intervention to patient participants. NSPs also expressed difficulty managing emotional investment in patients' success and providing therapy during a pandemic and racial violence in the US.

CONCLUSIONS

Our results can inform future implementation and sustainment of task sharing interventions to expand access to care.

Psychometric properties of the eating disorder examination questionnaire: Factor analysis and measurement invariance by race/ethnicity and gender

OBJECTIVE

The Eating Disorder Examination Questionnaire (EDE-Q) was originally validated in non-Hispanic White women and has become widely used as an assessment tool for research on eating pathology in college students. However, the original factor structure has generally failed to replicate across various samples, especially among diverse populations. The current study examined the factor structure and measurement invariance of the EDE-Q in a large sample of racially/ethnically diverse college men and women.

METHOD

Participants included a diverse sample of men and women from two universities (N = 1981). Exploratory factory analysis (EFA) was conducted to examine the factor structure of the EDE-Q, followed by confirmatory factor analysis (CFA) to verify the factor structure, and establish the configural model. Furthermore, we explored the measurement invariance of the configural model by gender (i.e., men, women) and race/ethnicity (i.e., White, Black, Asian, Hispanic, and multiracial).

RESULTS

EFA and CFA results suggested a three-factor, 10-item measure best fit the data, reflecting Dietary Restraint, Preoccupation and Eating Concern, and Shape/Weight Overvaluation. This measure achieved strict invariance by gender and race/ethnicity, indicating that mean comparisons across groups are meaningful. Women, relative to men, reported higher scores for all subscales. Significant differences across race/ethnicity emerged for Dietary Restraint and Shape/Weight Overvaluation in which Hispanic individuals endorsed the highest means compared to other racial/ethnic groups.

DISCUSSION

The three-factor, 10-item measure is a brief, valid, and reliable measure of eating disorder psychopathology for U.S. college students.

Task Sharing to Expand Access to Care: Development of a Behavioral Health Support Specialist

Task sharing improves access to mental health care in many countries, but little formative research has examined uptake in the United States. This Open Forum proposes the development of nonspecialist professional roles to deliver low-intensity behavioral interventions for common mental health conditions in U.S. settings such as primary care. Using data from a multilevel stakeholder assessment, the authors discuss findings and challenges associated with such a role. Key themes from stakeholder surveys concerned scope of practice, competencies, pragmatic concerns, and training needs. Although stakeholders generally found this role to be acceptable and feasible, the themes raised will be critical to developing and implementing such a role.

Controlled Evaluation of a Sport-Specific Performance Optimization Program in a Biracial Black and White Athlete Diagnosed with Social Anxiety Disorder and Agoraphobia

There are a very limited number of sport-specific mental health and sport performance interventions available for athletes of color. This study examined The Optimum Performance Program in Sports (TOPPS) in a biracial adolescent athlete who was diagnosed with Agoraphobia and Social Anxiety Disorder. A multiple-baseline across behaviors case trial design was used to evaluate outcomes. A battery of psychological measures specific to mental health and sport performance was administered at baseline, post-intervention, and a 3-month follow-up. Social skill sets (i.e., positive assertion and negative assertion) were systematically targeted sequentially in a virtual format using HIPAA compliant video-conferencing technology to safeguard against contracting COVID-19. Results demonstrated improvement in negative and positive assertion skills when targeted by the intervention. Severity of concurrent symptoms associated with Social Anxiety Disorder and Agoraphobia Symptoms, general psychiatric functioning, relationships with coaches, teammates and family, and factors interfering with sports performance improved from pre- to post-intervention. These improvements were maintained at the 3-month follow-up. Athlete ratings indicated their satisfaction with TOPPS was high, and intervention components were implemented with high integrity.

A-28 Systematic Review And Meta-Analysis Of Factors Influencing Sport Concussion For Athletes with ADHD and/or LD

Purpose: Purpose: Athletes with Attention-Deficit/Hyperactivity Disorder (ADHD) and/or Learning Disorder (LD) are at increased risk for sport concussion and require specialized attention. Although systematic reviews of ADHD/LD and concussion are reported, no meta-analyses have been conducted. Additionally, no reviews focused on the most common concussion assessment, ImPACT. Methods: Data Selection: The current review used PRISMA guidelines. Searches utilized PubMed, Web of Science, and PsycINFO. Articles selected for this meta-analysis examined ADHD and/or LD (high school and collegiate athletes) using ImPACT from 2000–2021. Topics included: 1) baseline and 2) post-concussion performance on ImPACT, 3) symptom reporting using the Post-Concussion Symptom Scale, 4) invalid baseline classification on ImPACT, 5) concussion rates, and 6) concussion recovery. 10,163 articles were identified. 39 were included in review and 19 were included in random-effects meta-analyses on topics 1, 3, 4, and 5. Results: Data Synthesis: Meta-analysis results found decreased baseline performance on ImPACT for athletes with ADHD (trivial to small effects), LD (small to medium effects), and ADHD/LD (small to medium effects). Increased symptom reporting was found for athletes with ADHD (small effect). Increased odds of invalid ImPACT baseline performance (trivial effect) and concussion (small effect) were found in ADHD. Conclusions: Athletes with ADHD and/or LD demonstrate differences on ImPACT in cognitive performance, symptom reporting, and concussion risk (particularly for ADHD). Most research focused on ADHD. Future work should further examine athletes with LD and co-occurring ADHD/LD as well as the effects that these conditions can have on concussion recovery, given the mixed literature in that regard.

Collaborative care for depression yields similar improvement among older and younger rural adults

BACKGROUND

Depressive disorders are among the most prevalent mental health conditions; however, significant barriers to treatment access persist. This study examined differences in depression outcomes between younger and older adults in a large-scale implementation demonstration of the collaborative care model (CoCM).

METHODS

Secondary data analysis of a longitudinal, observational implementation demonstration at eight primary care clinics across low-resourced rural or frontier areas of the Western United States. Seven of these clinics were federally qualified health centers. The sample consisted of 3722 younger (18-64 years) and older (65+ years) adult primary care patients diagnosed with unipolar depression. All participants received depression treatment via CoCM, which enhances usual primary care and makes efficient use of specialists by using a behavioral healthcare manager and a psychiatric consultant to support primary care providers. Clinics were followed for up to 27 months. Patients were followed until they completed treatment or dropped out. The Patient Health Questionnaire (PHQ-9) assessed depressive symptoms at baseline (enrollment) and at most follow-up contacts. The primary treatment outcome was a change between a patient's first and last recorded PHQ-9 scores.

RESULTS

Across both age groups, there was an average overall reduction of 6.9 points on the PHQ-9. Older adults demonstrated a greater decrease in depression scores of 2.06 points (95% CI -2.98 to -1.14, p < 0.001) on the PHQ-9 compared with younger adults. Estimates were robust when adjusting for gender, race, and clinic.

CONCLUSIONS

CoCM resulted in meaningful improvement in depressive symptoms across age groups.

A Typical Week With Mild Cognitive Impairment

BACKGROUND AND OBJECTIVES

Identifying the experience of people with mild cognitive impairment (MCI) may help develop research agendas, interventions, and other supports to better match individuals' needs. The purpose of this study was to explore the subjective experience of a "typical week" living with MCI to document (a) important activities, (b) barriers to usual activities, and (c) facilitators and supports.

RESEARCH DESIGN AND METHODS

We conducted remote individual photo-elicitation interviews with 11 community-dwelling adults aged 55 years or older with MCI. Participants each provided 5-10 photographs of daily life taken over 1 week to facilitate a semistructured qualitative interview. Interview transcriptions were coded in Dedoose software and analyzed using thematic analysis.

RESULTS

Participants shared photos and narratives highlighting the important activities in a typical week, in which physical activity, social engagement, spiritual and religious practice, hobbies, and cognitive stimulation were central. Many also shared disruptions to former routines and reduction of activities alongside increased use of new strategies and environmental supports (e.g., calendars, smartphones). Finally, emergent themes centered on disclosure of their diagnosis and reflections about the future.

DISCUSSION AND IMPLICATIONS

Participant-generated images aided data collection and facilitated discussion of sensitive topics with individuals with MCI. Such narratives may illustrate the needs and opportunities to promote well-being in individuals with MCI, including engagement in meaningful and health-promoting activities, assessing barriers to important daily activities, and considering supports that match the experience and needs of those with MCI.

Behavior change factors and retention in dietary interventions for older adults: scoping review

BACKGROUND AND OBJECTIVES

Although poor diet is a major driver of morbidity and mortality in people 60 and older, few dietary interventions are widely implemented for this population. We mapped behavior change theories, agents, and techniques in dietary interventions for adults 60+ and explored relationships between these factors and ability to retain at least 80% of the study participants.

RESEARCH DESIGN AND METHODS

We conducted a scoping review using MEDLINE, CINAHL, and Web of Science through April 2021 for dietary interventions in adults 60 and older. We collated, summarized, and calculated frequency distributions of behavior change theories, behavior change agents, and behavior change techniques (BCTs) using BCTv1 taxonomy with regard to participant retention across 43 studies.

RESULTS

Only 49% and 30% of the studies reported behavior theory and change agents respectively. Of the studies reporting on theory and agents, the most common were social cognitive theory and the related mechanism of self-efficacy. The most common BCTv1 were "shaping knowledge" and "goals and planning." Several BCTv1 such as "antecedents" and "reward and threat" and evidence for concordance between BCTs and change agents were more common in interventions with higher retention rates.

DISCUSSION AND IMPLICATIONS

Mechanistically concordant studies with BCTs that involve resource allocation and positive reinforcement through rewards may be advantageous for retention in dietary intervention for older adults. Future studies should continue developing theory and mechanism-oriented research. Furthermore, future studies should consider diversifying the portfolio of currently deployed BCTs and strengthening a concordance between BCTs and mechanisms of change.

Understanding Psychological Distress and Protective Factors Amongst Older Adults During the COVID-19 Pandemic

OBJECTIVES

This study examined the emotional distress and loneliness during COVID-19 and the roles of resiliency and activities.

DESIGN

A cross-sectional national survey.

SETTING

Amazon Mechanical Turk (mTurk) and Prolific Research Platforms.

PARTICIPANTS

Five hundred and one U.S. dwelling English-speaking adults 60 years old and older.

MEASUREMENTS

Participants completed an online survey with the PHQ-9; GAD-7; Short Health Anxiety Inventory; 3-item UCLA Loneliness scale; PROMIS measures of global health, instrumental, and emotional support; 10-item Connor-Davidson Resilience Scale; and COVID-19 needs assessment.

RESULTS

Across the sample 13% reported moderate depressive symptoms, 9% reported moderate anxiety symptoms, and 26% endorsed being "lonely." The emotionally distressed group endorsed more loneliness, lower resiliency, less physical exercise, and worse physical health. The low Socio-Economic Status group endorsed less loneliness, less likely to engage in physical exercise and worse physical health.The lonely group endorsed less resilience, less physical exercise, and worse physical health. A multiple logistic regression found that resilience, socioeconomic status, and physical health were significant predictors of loneliness, whereas global health was the best predictor of emotional distress.

CONCLUSIONS

Even after prolonged social distancing, older adults in this study did not report greater psychological distress compared to earlier studies of older adults during COVID-19. Older adults with lower SES, worse physical health, and less resiliency, were more likely to report more loneliness. It is this group that should be the focus of intervention.

Comparing the streamlined psychotherapy "Engage" with problem-solving therapy in late-life major depression. A randomized clinical trial

Effective psychotherapies for late-life depression are underutilized, mainly because of their complexity. "Engage" is a novel, streamlined psychotherapy that relies on neurobiology to identify core behavioral pathology of late-life depression and targets it with simple interventions, co-designed with community therapists so that they can be delivered in community settings. Consecutively recruited adults (≥60 years) with major depression (n = 249) were randomly assigned to 9 weekly sessions of "Engage" or to the evidence-based Problem-Solving Therapy (PST) offered by 35 trained community social workers and assessed by blind raters. "Engage" therapists required an average of 30% less training time to achieve fidelity to treatment than PST therapists and had one-third of the PST therapists' skill drift. Both treatments led to reduction of HAM-D scores over 9 weeks. The mixed effects model-estimated HAM-D ratings were not significantly different between the two treatments at any assessment point of the trial. The one-sided 95% CI for treatment-end difference was (-∞, 0.07) HAM-D points, indicating a non-inferiority margin of 1.3 HAM-D points or greater; this margin is lower than the pre-determined 2.2-point margin. The two treatment arms had similar response (HR = 1.08, 95% CI (0.76, 1.52), p = 0.67) and remission rates (HR = 0.89, 95% CI (0.57, 1.39), p = 0.61). We conclude that "Engage" is non-inferior to PST. If disseminated, "Engage" will increase the number of therapists who can reliably treat late-life depression and make effective psychotherapy available to large numbers of depressed older adults.

A-148 Executive Dysfunction in Late-Life Depression: Changes and Relationship to Treatment Response in a Clinical Trial

Objective

Executive dysfunction is the core neurocognitive deficit associated with late-life depression (LLD). This study identified changes in executive functioning during a structured behavioural treatment for depression in older adults and ascertained if pre-treatment executive dysfunction predicted treatment response.

Method

We analyzed data from a large multisite randomized controlled trial of structured behavioral psychotherapies (PST and Engage) for unipolar depression in adults ≥60 years. Participants were diagnosed with major depressive disorder and had Mini-Mental State Examination [MMSE] ≥24. Cognitive measures included the Stroop test, digit span, Iowa Gambling Task (IGT), and Wisconsin Card Sorting Test (WCST). Treatment response outcomes included pre- to post-treatment changes on the Hamilton Depression Rating Scale (HAM-D) and World Health Organization Disability Assessment Schedule II (WHODAS-II). One-way analysis of variance (ANOVA) assessed pre- and post-treatment changes in executive functioning measures across 9 weeks of treatment for 95 participants with complete data. Multiple linear regression models tested whether baseline measures of executive functioning predicted treatment response in (a) HAM-D depression and (b) WHODAS disability scores.

Results

A one-way ANOVA revealed improvements on IGT performance (Total Money) between baseline and week 9 post-treatment (F(1,186) = 7.00, p &lt; 0.01). No combination of baseline measures of executive functioning significantly predicted change in HAM-D or WHODAS scores across treatment (ps &gt; 0.05).

Conclusion

Baseline executive functioning did not predict treatment response (change in depressive symptoms or disability ratings). That is, individuals improved on treatment outcomes regardless of baseline executive dysfunction. In addition, results suggest that these approaches may actually improve real-life decision-making.

Patient Digital Technologies to Support Primary Care across Disorders: Survey of Primary Care Providers, Behavioral Health Consultants, and Nurses (Preprint)

Background

Objective

Methods

Results

Conclusions

Making Psychotherapy Available in the United States: Implementation Challenges and Solutions

About 46.6 million Americans have mental illnesses, yet profound treatment gaps exist in this country. Among those receiving treatment, most are treated solely with medication, even though >50% prefer to include psychotherapy in treatment. Other countries have changed policies to enhance access to evidence-based psychotherapy, resulting in availability and utilization reflective of patient preferences. To improve access to these treatments, the U.S. health care system would need to seek agreement among stakeholders regarding what constitutes effective treatment; enhance training, credentialing, and continuing education requirements; implement quality measures; integrate services into nontraditional venues; and incentivize best practices.

Assessing the Usability of Complex Psychosocial Interventions: The Intervention Usability Scale

BACKGROUND

Usability - the extent to which an intervention can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction - may be a key determinant of implementation success. However, few instruments have been developed to measure the design quality of complex health interventions (i.e., those with several interacting components). This study evaluated the structural validity of the Intervention Usability Scale (IUS), an adapted version of the well-established System Usability Scale (SUS) for digital technologies, to measure the usability of a leading complex psychosocial intervention, Motivational Interviewing (MI), for behavioral health service delivery in primary care. Prior SUS studies have found both one- and two-factor solutions, both of which were examined in the current study of the IUS.

METHOD

A survey administered to 136 medical professionals from 11 primary care sites collected demographic information and IUS ratings for MI, the evidence-based psychosocial intervention that primary care providers reported using most often for behavioral health service delivery. Factor analyses replicated procedures used in prior research on the SUS.

RESULTS

Analyses indicated that a two-factor solution (with "usable" and "learnable" subscales) best fit the data, accounting for 54.1% of the variance. Inter-item reliabilities for the total score, usable subscale, and learnable subscale were α = .83, α = .84, and α = .67, respectively.

CONCLUSIONS

This study provides evidence for a two-factor IUS structure consistent with some prior research, as well as acceptable reliability. Implications for implementation research evaluating the usability of complex health interventions are discussed, including the potential for future comparisons across multiple interventions and provider types, as well as the use of the IUS to evaluate the relationship between usability and implementation outcomes such as feasibility.

Artificial Intelligence: An Interprofessional Perspective on Implications for Geriatric Mental Health Research and Care

Artificial intelligence (AI) in healthcare aims to learn patterns in large multimodal datasets within and across individuals. These patterns may either improve understanding of current clinical status or predict a future outcome. AI holds the potential to revolutionize geriatric mental health care and research by supporting diagnosis, treatment, and clinical decision-making. However, much of this momentum is driven by data and computer scientists and engineers and runs the risk of being disconnected from pragmatic issues in clinical practice. This interprofessional perspective bridges the experiences of clinical scientists and data science. We provide a brief overview of AI with the main focus on possible applications and challenges of using AI-based approaches for research and clinical care in geriatric mental health. We suggest future AI applications in geriatric mental health consider pragmatic considerations of clinical practice, methodological differences between data and clinical science, and address issues of ethics, privacy, and trust.

Modernizing Training in Psychotherapy Competencies With Adaptive Learning Systems: Proof of Concept

PURPOSE

This proof-of-concept study assessed the feasibility, acceptability, and effectiveness of an intelligent tutoring system (ITS) as a classroom adjunct to improve training bachelor of social work (BSW) students in client engagement strategies.

METHODS

We codeveloped the ITS with 11 undergraduate students and pilot tested it with six BSW students enrolled in a class on telephone-based cognitive behavioral therapy (tCBT). Student competencies in tCBT were assessed by expert review of role-plays. We also examined time spent using ITS and relation with competency.

RESULTS

The majority of students (81.8%) in Wave 1 and all of the students who submitted role-plays in Wave 2 passed the clinical skills role-play. Students advancing through the ITS more quickly had better tCBT competency ratings than those progressing more slowly.

DISCUSSION

One of the most challenging aspects of training is how to competently deliver evidence-based practices. ITS has the potential to streamline and scale such training.

Assessment of Real-World Use of Behavioral Health Mobile Applications by a Novel Stickiness Metric

This cross-sectional study uses a novel “stickiness” measure to evaluate which mobile applications for smoking cessation, meditation, and other behavioral health areas are associated with long-term engagement.

Patient Versus Informal Caregiver Proxy Reports of Pain Interference in Persons With Dementia

Objectives: Pain assessment and treatment is challenging among persons with dementia (PWDs). To better understand reports of pain interference, we examined ratings made by PWDs, as well as corresponding ratings about PWDs, as reported by the caregiver. We aimed to assess alignment between and predictors of caregiver and PWD report of pain interference. Methods: The sample consisted of 203 veterans with pain and mild to moderately severe dementia and an informal caregiver. Results: Most PWDs and their caregivers reported at least some pain interference and similar levels of pain interference. PWDs with greater cognitive impairment reported less pain interference, whereas caregivers who perceived the PWD to have greater depression reported more pain interference. Conclusions: PWD and caregiver characteristics were differentially associated with PWD versus caregiver report of pain interference. Results suggest the importance of caregiver reports to inform assessment, as well as factors complicating assessment. Pain in Dementia As one ages, the risk of developing both dementia and pain increases substantially (Scherder et al., 2009). It is estimated that 30% to 50% of persons with dementia (PWDs) experience persistent pain, a complex multifactor problem (Corbett et al., 2014). Despite the high prevalence of pain among older adults with dementia, and major advances in pain management, pain often remains unrecognized or undertreated (Hodgson et al., 2014).

Integrated Brief Cognitive Behavioral Therapy Improves Illness Intrusiveness in Veterans With Chronic Obstructive Pulmonary Disease

Background

Progressive illnesses such as chronic obstructive pulmonary disease (COPD) impart a high level of physical and psychological burden. Evidence-based psychotherapies hold the potential to improve perceptions of physical health impairment, yet few studies have documented these effects.

Purpose

To evaluate the effect of brief cognitive behavioral therapy (bCBT) on disease-related illness intrusiveness.

Methods

Participants were 175 Veterans with COPD and clinically elevated symptoms of depression and/or anxiety enrolled in a larger randomized trial (n = 99 randomized to bCBT, n = 76 to enhanced usual care; EUC). bCBT included up to six treatment sessions and optional booster sessions over a 4-month period. EUC entailed an assessment with documentation in the medical record. Primary outcomes focused on posttreatment changes on the Illness Intrusiveness Rating Scale (IIRS), an established measure of perceived impairment from a chronic health condition.

Results

Illness intrusiveness improved for bCBT participants relative to EUC, after controlling for baseline IIRS scores, depression, and anxiety (p = .03, partial η2 = .03). Specific improvement was observed in the Instrumental subscale (p = .02), encompassing improved intrusiveness of COPD on daily activities and daily functioning. IIRS scores improved in the absence of changes in physical functioning.

Conclusions

Illness intrusiveness was high among Veterans with COPD but improved over the course of bCBT. Integrated behavioral health interventions hold the potential to reduce disease intrusiveness. The IIRS may be a valuable tool to augment traditional assessment and measurement-based care approaches of behavioral health interventions for medically ill patients.

A TYPICAL WEEK WITH MILD COGNITIVE IMPAIRMENT: A PHOTO-ELICITATION STUDY

Mild cognitive impairment (MCI) is an important precursor to dementia syndromes and carries with it both public and personal health significance, yet affected individuals may experience stigma, fear, and reluctance to participate in research or access services. Identifying the experience of people with MCI may help develop research agendas, interventions, and other supports to better match patients’ needs. To this end, we conducted photo-elicitation interviews with 11 community-dwelling adults aged 57-79 years with diagnosed MCI. Interviews took place remotely using teleconferencing software to reduce access barriers. Each semi-structured interview used 5-10 participant-generated photographs to elicit the experience of living with MCI, barriers to daily activities, and facilitators and supports. Interviews were transcribed, coded, and analyzed using Dedoose software. Qualitative analysis revealed themes of important activities, including physical activity, social engagement, and cognitive stimulation. Barriers presented by MCI included difficulty with former routines (e.g., cooking, finances), reduction of activities, and perceived stigma or fear of disclosure. Facilitators of daily activities included increased use of new strategies and environmental supports (e.g., calendars, smartphones), in addition to social and familial support. Multiple participants noted that the diagnosis of MCI led to opportunities for inner reflection and seeking a sense of inner calmness. Incorporating participant-generated images aided in data collection and facilitated discussion of sensitive topics with a cognitively impaired sample. Clinicians and researchers should support engagement in meaningful activities, assess barriers to important daily activities, and consider support to match the experience and needs of those with MCI.

YOU DON’T KNOW WHAT YOU DON’T KNOW: A SURVEY OF CAREER MENTORING NEEDS IN CLINICAL GEROPSYCHOLOGY

Mentorship carries the potential to improve the placement, persistence, and success of those working in geriatric mental health. We sought to explore the career preferences and perceived barriers to obtaining desired jobs in the field of clinical geropsychology using an online survey of trainees and etablished professional geropsychologists. This cross-sectional observational cohort study recruited 96 respondents .Both trainees (n = 42) and professional geropsychologists (n = 54) completed an online survey. Trainees endorsed a variety of characteristics to describe their ideal jobs in geropsychology; particularly interdisciplinary teamwork and jobs in medical settings, palliative/hospice care facilities, long-term care, and geriatric outpatient care. The most commonly endorsed perceived barrier to trainees’ ideal jobs was the location of the position. Responses from professional geropsychologists elucidated factors that influenced their first job and resources that were helpful, or would have been helpful, during their job search process. The majority of respondents described the role of mentoring in career development, specifically with skill development, decision-making assistance, and personal support. Mentorship is instrumental throughout one’s training and career and offers instrumental and emotional support in job-searching and defining one’s career. Results should be considered with respect to training and retention of clinical geropsychologists given the workforce shortage, particularly in academia.

Contemporary Views of Research Participant Willingness to Participate and Share Digital Data in Biomedical Research

IMPORTANCE

Using social media to recruit participants is a common and cost-effective practice. Willingness to participate (WTP) in biomedical research is a function of trust in the scientific team, which is closely tied to the source of funding and institutional connections.

OBJECTIVE

To determine whether WTP and willingness to share social media data are associated with the type of research team and online recruitment platform.

DESIGN, SETTING, AND PARTICIPANTS

This mixed-methods longitudinal survey and qualitative study was conducted over 2 points (T1 and T2) using Amazon's Mechanical Turk (MTurk) platform. Participants were US adults aged 18 years or older who use at least 1 social media platform. Recruitment was stratified to match race/ethnicity proportions of the 2010 US Census. The volunteer sample consisted of 914 participants at T1, and 655 participants completed the follow-up survey 5 months later (T2).

MAIN OUTCOMES AND MEASURES

Outcomes were (1) past experience with online research and sharing social media data for research; (2) WTP in research advertised online; (3) WTP in a study sponsored by a pharmaceutical company, a university, or a federal agency; and (4) willingness to share social media data. Opinions were solicited regarding the European Union's General Data Protection Regulation statute, which came into effect between T1 and T2.

RESULTS

Of 914 participants completing the first survey (T1), 604 (66.1%) were aged 18 to 39 years and 494 (54.0%) were female. Of these, 655 participants (71.7%) responded at T2. While 680 participants (74.4%) indicated WTP in biomedical research, only 454 (49.3%) were willing to share their social media data. Participants were significantly less likely to participate in federally sponsored (odds ratio [OR], 0.58; 95% CI, 0.51-0.64; P < .001) or pharmaceutical company (OR, 0.59; 95% CI, 0.53-0.66; P < .001) research than university-led studies. They were also less likely to share their social medial data for federal (OR, 0.65; 95% CI, 0.58-0.72; P < .001) or pharmaceutical company (OR, 0.50; 95% CI, 0.44-0.56; P < .001) research compared with academic studies. Willingness to participate in pharmaceutical company-led research decreased 11.89% from T1 to T2 (OR for T2, 0.62; 95% CI, 0.54-0.77; P < .001). Reasons for WTP were interest in furthering science, financial incentives, trust in the organization, and data security. While 63.0% of respondents reported seeing new privacy policy emails related to the General Data Protection Regulation law, only 27.1% indicated this positively influenced their WTP. Thematic analysis of responses indicated that WTP may improve with stronger data security measures.

CONCLUSIONS AND RELEVANCE

This study suggests that researchers may see reduced online research participation and data sharing, particularly for research conducted outside academia.

Use of Human-Centered Design to Improve Implementation of Evidence-Based Psychotherapies in Low-Resource Communities: Protocol for Studies Applying a Framework to Assess Usability

BACKGROUND

This paper presents the protocol for the National Institute of Mental Health (NIMH)-funded University of Washington's ALACRITY (Advanced Laboratories for Accelerating the Reach and Impact of Treatments for Youth and Adults with Mental Illness) Center (UWAC), which uses human-centered design (HCD) methods to improve the implementation of evidence-based psychosocial interventions (EBPIs). We propose that usability-the degree to which interventions and implementation strategies can be used with ease, efficiency, effectiveness, and satisfaction-is a fundamental, yet poorly understood determinant of implementation.

OBJECTIVE

We present a novel Discover, Design/Build, and Test (DDBT) framework to study usability as an implementation determinant. DDBT will be applied across Center projects to develop scalable and efficient implementation strategies (eg, training tools), modify existing EBPIs to enhance usability, and create usable and nonburdensome decision support tools for quality delivery of EBPIs.

METHODS

Stakeholder participants will be implementation practitioners/intermediaries, mental health clinicians, and patients with mental illness in nonspecialty mental health settings in underresourced communities. Three preplanned projects and 12 pilot studies will employ the DDBT model to (1) identify usability challenges in implementing EBPIs in underresourced settings; (2) iteratively design solutions to overcome these challenges; and (3) compare the solution to the original version of the EPBI or implementation strategy on usability, quality of care, and patient-reported outcomes. The final products from the center will be a streamlined modification and redesign model that will improve the usability of EBPIs and implementation strategies (eg, tools to support EBPI education and decision making); a matrix of modification targets (ie, usability issues) that are both common and unique to EBPIs, strategies, settings, and patient populations; and a compilation of redesign strategies and the relative effectiveness of the redesigned solution compared to the original EBPI or strategy.

RESULTS

The UWAC received institutional review board approval for the three separate studies in March 2018 and was funded in May 2018.

CONCLUSIONS

The outcomes from this center will inform the implementation of EBPIs by identifying cross-cutting features of EBPIs and implementation strategies that influence the use and acceptability of these interventions, actively involving stakeholder clinicians and implementation practitioners in the design of the EBPI modification or implementation strategy solution and identifying the impact of HCD-informed modifications and solutions on intervention effectiveness and quality.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03515226 (https://clinicaltrials.gov/ct2/show/NCT03515226), NCT03514394 (https://clinicaltrials.gov/ct2/show/NCT03514394), and NCT03516513 (https://clinicaltrials.gov/ct2/show/NCT03516513).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14990.

By the numbers: ratings and utilization of behavioral health mobile applications

Although >10,000 behavioral health applications ("apps") are currently available on the Apple and Google Play marketplaces, they have been minimally evaluated or regulated and little is known about "real world" usage patterns. This investigation combined data from online behavioral health app rating frameworks and a mobile health market research firm to identify the most downloaded apps as well as determine rating and ranking concordance between frameworks. Findings demonstrated that the most commonly downloaded apps focus on relaxation, mindfulness, and meditation skills and that they often have notably discordant reviews across rating frameworks. Our results suggest that there is a growing need for: (1) standardized behavioral health app quality and effectiveness measures, (2) up-to-date behavioral health app guidance for clinicians and consumers, and (3) evidence-based apps that incorporate revealed consumer preferences.

Pain intensity, depressive symptoms, and functional limitations among older adults with serious mental illness

OBJECTIVE

To examine pain-related activity interference as a mediator for the relationship between pain intensity and depressive symptoms among older adults with serious mental illness (SMI).

METHOD

Ordinary least-squares regressions were used to investigate the mediation analysis among older adults with SMI (n = 183) from community mental health centers. Analyses used secondary data from the HOPES intervention study.

RESULTS

Higher pain intensity was associated with greater pain-related activity interference. Higher pain intensity and pain-related activity interference were also associated with elevated depressive symptoms. Finally, greater pain-related activity interference significantly mediated the association between higher pain intensity and elevated depressive symptoms.

CONCLUSIONS

These findings demonstrate that pain and depressive symptoms may be linked to functional limitations. Clinicians and researchers in the mental health field should better address pain-related activity interference among older adults with SMI, especially among those with higher pain intensity and elevated depressive symptoms.

The accuracy of passive phone sensors in predicting daily mood

BACKGROUND

Smartphones provide a low-cost and efficient means to collect population level data. Several small studies have shown promise in predicting mood variability from smartphone-based sensor and usage data, but have not been generalized to nationally recruited samples. This study used passive smartphone data, demographic characteristics, and baseline depressive symptoms to predict prospective daily mood.

METHOD

Daily phone usage data were collected passively from 271 Android phone users participating in a fully remote randomized controlled trial of depression treatment (BRIGHTEN). Participants completed daily Patient Health Questionnaire-2. A machine learning approach was used to predict daily mood for the entire sample and individual participants.

RESULTS

Sample-wide estimates showed a marginally significant association between physical mobility and self-reported daily mood (B = -0.04, P < 0.05), but the predictive models performed poorly for the sample as a whole (median R² ∼ 0). Focusing on individuals, 13.9% of participants showed significant association (FDR < 0.10) between a passive feature and daily mood. Personalized models combining features provided better prediction performance (median area under the curve [AUC] > 0.50) for 80.6% of participants and very strong prediction in a subset (median AUC > 0.80) for 11.8% of participants.

CONCLUSIONS

Passive smartphone data with current features may not be suited for predicting daily mood at a population level because of the high degree of intra- and interindividual variation in phone usage patterns and daily mood ratings. Personalized models show encouraging early signs for predicting an individual's mood state changes, with GPS-derived mobility being the top most important feature in the present sample.

Predictors of response to brief CBT in patients with cardiopulmonary conditions

OBJECTIVE

This study examined predictors of treatment outcome in a randomized controlled trial of brief cognitive-behavioral therapy (bCBT) for patients with a cardiopulmonary condition and comorbid, clinically significant symptoms of depression and/or anxiety.

METHOD

Only those who completed outcome assessments in the bCBT arm were studied (n = 132), to provide information about predictors of change in psychological symptoms. Multivariable linear regressions were conducted with baseline depression and anxiety symptoms, functional limitations, coping, self-efficacy, number of treatment sessions attended, and working alliance as potential predictors of change from pre- to postintervention on the dependent variables, depression [Patient Health Questionniare-9] and anxiety [Beck Anxiety Inventory]).

RESULTS

Significant predictors of improvement in depression and anxiety included baseline mental health symptoms, physical health functional impairment, and self-efficacy. Coping, working alliance, and number of sessions attended were not associated with change in depression or anxiety.

CONCLUSION

Patients with greater physical functioning limitations and lower self-efficacy may experience less change in depression and anxiety during brief CBT. Future research should examine how to boost treatment effectiveness for patients with these characteristics. (PsycINFO Database Record

Using Mobile Apps to Assess and Treat Depression in Hispanic and Latino Populations: Fully Remote Randomized Clinical Trial

BACKGROUND

Most people with mental health disorders fail to receive timely access to adequate care. US Hispanic/Latino individuals are particularly underrepresented in mental health care and are historically a very difficult population to recruit into clinical trials; however, they have increasing access to mobile technology, with over 75% owning a smartphone. This technology has the potential to overcome known barriers to accessing and utilizing traditional assessment and treatment approaches.

OBJECTIVE

This study aimed to compare recruitment and engagement in a fully remote trial of individuals with depression who either self-identify as Hispanic/Latino or not. A secondary aim was to assess treatment outcomes in these individuals using three different self-guided mobile apps: iPST (based on evidence-based therapeutic principles from problem-solving therapy, PST), Project Evolution (EVO; a cognitive training app based on cognitive neuroscience principles), and health tips (a health information app that served as an information control).

METHODS

We recruited Spanish and English speaking participants through social media platforms, internet-based advertisements, and traditional fliers in select locations in each state across the United States. Assessment and self-guided treatment was conducted on each participant's smartphone or tablet. We enrolled 389 Hispanic/Latino and 637 non-Hispanic/Latino adults with mild to moderate depression as determined by Patient Health Questionnaire-9 (PHQ-9) score≥5 or related functional impairment. Participants were first asked about their preferences among the three apps and then randomized to their top two choices. Outcomes were depressive symptom severity (measured using PHQ-9) and functional impairment (assessed with Sheehan Disability Scale), collected over 3 months. Engagement in the study was assessed based on the number of times participants completed active surveys.

RESULTS

We screened 4502 participants and enrolled 1040 participants from throughout the United States over 6 months, yielding a sample of 348 active users. Long-term engagement surfaced as a key issue among Hispanic/Latino participants, who dropped from the study 2 weeks earlier than their non-Hispanic/Latino counterparts (P<.02). No significant differences were observed for treatment outcomes between those identifying as Hispanic/Latino or not. Although depressive symptoms improved (beta=-2.66, P=.006) over the treatment course, outcomes did not vary by treatment app.

CONCLUSIONS

Fully remote mobile-based studies can attract a diverse participant pool including people from traditionally underserved communities in mental health care and research (here, Hispanic/Latino individuals). However, keeping participants engaged in this type of "low-touch" research study remains challenging. Hispanic/Latino populations may be less willing to use mobile apps for assessing and managing depression. Future research endeavors should use a user-centered design to determine the role of mobile apps in the assessment and treatment of depression for this population, app features they would be interested in using, and strategies for long-term engagement.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01808976; https://clinicaltrials.gov/ct2/show/NCT01808976 (Archived by WebCite at http://www.webcitation.org/70xI3ILkz).

Smartphone-Based Passive Assessment of Mobility in Depression: Challenges and Opportunities

Advances in technology have ushered in exciting potential for smartphone sensors to inform mental health care. This commentary addresses the practical challenges of collecting smartphone-based physical activity data. Using data (N = 353) from a large scale, fully remote randomized clinical trial for depression, we discuss findings and limitations associated with using passively collected mobility data to make inferences about depressive symptom severity. We highlight a range of issues in associating mobility data with mental health symptoms, including a high degree of variability, data featurization, granularity, and sparsity. Given the considerable efforts toward leveraging technology in mental health care, it is important to consider these challenges to optimize assessment and guide best practices. Clinical Trials.gov identifier: NCT01808976.

Comorbidity of depressive symptoms among primary care patients with diabetes in a federally qualified health center

Depression is frequently comorbid with diabetes; however, less is known about this comorbidity in socially disadvantaged populations. This cross-sectional study examined depressive symptomatology among 424 patients with prediabetes or type 2 diabetes mellitus at a federally qualified health center. Prevalence of clinically significant depressive symptoms was assessed using the World Health Organization Five-Item Well-Being Index. The majority (67.7%) endorsed depressive symptoms, with greater prevalence among middle-aged adults (45–64 years) than younger or older counterparts. More women than men endorsed depressive symptoms. Findings suggest the need for routine depression screening in both prediabetes and type 2 diabetes mellitus, particularly among middle-aged and low-income individuals.

A Systematic Review of Practice Guidelines and Recommendations for Discontinuation of Cholinesterase Inhibitors in Dementia

Cholinesterase inhibitors (ChEIs) are the primary pharmacological treatment for symptom management of Alzheimer disease (AD), but they carry known risks during long-term use, and do not guarantee clinical effects over time. The balance of risks and benefits may warrant discontinuation at different points during the disease course. Indeed, although there is limited scientific study of deprescribing ChEIs, clinicians routinely face practical decisions about whether to continue or stop medications. This review examined published practice recommendations for discontinuation of ChEIs in AD. To characterize the scientific basis for recommendations, we first summarized randomized controlled trials of ChEI discontinuation. We then identified practice guidelines by professional societies and in textbooks and classified them according to 1) whether they made a recommendation about discontinuation, 2) what the recommendation was, and 3) the proposed grounds for discontinuation. There was no consensus in guidelines and textbooks about discontinuation. Most recommended individualized discontinuation decisions, but there was essentially no agreement about what findings or situations would warrant discontinuation, or even about what domains to consider in this process. The only relevant domain identified by most guidelines and textbooks was a lack of response or a loss of effectiveness, both of which can be difficult to ascertain in the course of a progressive condition. Well-designed, long-term studies of discontinuation have not been conducted; such evidence is needed to provide a scientific basis for practice guidelines. It seems reasonable to apply an individualized approach to discontinuation while engaging patients and families in treatment decisions. .

Dyadic effects of depressive symptoms on medical morbidity in middle-aged and older couples

OBJECTIVE

Depressive symptoms in middle and later life are associated with an increased risk of greater medical morbidity (i.e., number of chronic health conditions). Yet little is known about mutual influences that may occur within married couples. This study examined the effects of wives' and husbands' depressive symptoms on their own and their partner's number of chronic health conditions over an 8-year period. It was also determined whether these effects varied by gender.

METHOD

The U.S. sample included 992 heterosexual couples (M = 63.58 years at baseline) drawn from 5 waves of the Health and Retirement Study (2006-2014). Dyadic growth curve models were estimated to evaluate the effects of own and partner baseline depressive symptoms on medical morbidity across time. Models controlled for baseline marital duration and negative marital quality along with age, education, minority status, health-related self-efficacy, body mass index, disability status, alcohol use, smoking, and moderate and vigorous physical activity.

RESULTS

Husbands' higher baseline depressive symptoms were significantly linked to their own higher number of chronic conditions. When wives had higher depressive symptoms at baseline, husbands showed significantly greater increases in their number of chronic conditions over time. Own and partner depressive symptoms were not significantly associated with baseline levels or changes in wives' number of chronic conditions.

CONCLUSIONS

This study demonstrates that depressive symptoms within middle-aged and older couples may have long-term associations with medical morbidity. Findings underscore the value of considering the implications of depressive symptoms for chronic health conditions among individuals and couples. (PsycINFO Database Record

Psychosocial Treatment Options for Major Depressive Disorder in Older Adults

Late-life depression (LLD) is a public health concern with deleterious effects on overall health, cognition, quality of life, and mortality. Although LLD is relatively common, it is not a normal part of aging and is often under-recognized in older adults. However, psychotherapy is an effective treatment for LLD that aligns with many patients' preferences and can improve health and functioning. This review synthesized the current literature on evidence-based psychotherapies for the treatment of depression in older adults. Findings suggest that active, skills-based psychotherapies (cognitive behavioral therapy [CBT] and problem-solving therapy [PST]) may be more effective for LLD than non-directive, supportive counseling. PST may be particularly relevant for offsetting skill deficit associated with LLD, such as in instances of cognitive impairment (especially executive dysfunction) and disability. Emerging treatments also consider contextual factors to improve treatment delivery, such as personalized care, access, and poverty. Tele-mental health represents one such exciting new way of improving access and uptake of treatment by older adults. Although these strategies hold promise, further investigation via randomized controlled trials and comparative effectiveness are necessary to advance our treatment of LLD. Priority should be given to recruiting and training the geriatric mental health workforce to deliver evidence-based psychosocial interventions for LLD.

Classifying diabetes-burden: A factor analysis of the Problem Areas in Diabetes Scale

This study sought to identify salient factors associated with the Problem Areas in Diabetes Scale to facilitate improved assessment and treatment of diabetes-related burden. Exploratory factor analysis assessed the factor structure of the Problem Areas in Diabetes Scale among 224 Veterans with uncontrolled type 2 diabetes and depressive symptoms. A four-factor solution of emotional, diabetes management, treatment, and social support burden subscales was extracted. These factors represent clinically relevant components of diabetes burden that include but go beyond symptoms of depression. The Problem Areas in Diabetes subscales may expand assessments for depression and improve medical and behavioral health interventions for patients with diabetes.

Leveraging Spousal Support to Improve Health Promotion in Serious Mental Illness

Although the majority of Veterans are overweight or obese, and many have comorbid mental health disorders, little is known about the most effective way to intervene in this complex population. This case describes a telephone-based cognitive-behavioral treatment for depression and weight management with an obese Veteran with bipolar disorder. His wife joined sessions to leverage spousal support. The Veteran evidenced variable levels of physical activity and mood fluctuations during treatment; although he reported some degree of positive behavior change and improved social support, he did not lose weight. He continued to endorse moderate levels of depressive symptomatology at the end of the nine-session intervention. This case illustrates the complexity of treating those with chronic serious mental illness and multimorbidities. Further research is needed to inform interventions that concurrently improve mental health symptomatology and weight-related outcomes in chronic, complex cases.

Medical provider attitudes about behavioral health consultants in integrated primary care: a preliminary study

Integrated behavioral health increases service utilization and treatment success, particularly with high-risk populations. This study assessed medical personnel's attitudes and perceptions of behavioral health clinicians (BHCs) in primary care using a brief self-report measure. A 6-item survey was given to medical providers (n = 45) from a health care system that includes integrated behavioral health services. Survey items assessed providers' attitudes and perceptions about BHCs. Attitudes about behavioral health were largely favorable. For all items, 73.3% to 100% of participants endorsed strongly agree or agree. Chi-square analyses revealed that those who interacted more frequently with BHCs were more comfortable discussing behavioral health issues with their patients, χ²(6, n = 45) = 13.43, p < .05, and that physicians believe that BHCs help patients effectively address their behavioral health problems, χ²(2, n = 45) = 6.36, p < .05. Age, gender, and health center in which the providers worked were not significantly related to any survey items. Medical providers surveyed believe that BHCs are valuable members of integrated health care, improving their abilities to provide care and to address their patients' physical and behavioral health problems. Although these preliminary results are promising, the setting surveyed has well-integrated behavioral health care services and thus might not be representative of other settings without such integration. Future studies should address medical providers' opinions of BHCs in a variety of settings with larger samples.

Increasing Nutritional Adherence in an African American Woman With Type 2 Diabetes

Chronic diseases such as type 2 diabetes mellitus (T2DM) are increasingly common and costly, imparting debilitating economic and health effects. This case presents the use of an individualized behavioral intervention for diabetes management in a 61-year-old African American woman with T2DM. The intervention was delivered over five home-based treatment sessions and two follow-up probes that focused on nutrition. At the end of treatment, the participant exhibited improved nutrition and dietary habits (i.e., increased intake of fruits and vegetables; eating more, smaller meals throughout the day), which maintained through follow-up. In addition, she demonstrated generalization of treatment effects, as evidenced by the application of treatment strategies to other areas of her health (i.e., exercise and blood glucose testing). This case study highlights how psychological treatment emphasizing behavioral techniques can be effectively applied to manage medical conditions and mitigate future complications and comorbidities.