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| |  Researchers Outline New Strategies to Improve Initiation and Treatment of Depression Among the Elderly: Presented at AAGP By Carole VanSickle Ellis SAVANNAH, Ga -- March 7, 2010 -- Mental health issues have long been under-recognised and undertreated in older adults, largely because of problems initiating and engaging these patients in the treatment process. A series of studies presented here on March 5 at the 2010 Annual Meeting of the American Association for Geriatric Psychiatry (AAGP) were designed to increase providers’ detection of mental health issues and their ability to guide older adults to select an appropriate treatment and use available programmes. The first of the studies, led by Jo Anne Sirey, PhD, Weill Cornell Medical College, White Plains, New York, outlines the feasibility and outcomes of a neighbourhood-centred programme in which 12 aging service community agencies implemented screening and referral processes for mental health concerns. The programme, labelled “Strengthening Neighborhood-Based Programs for the Elderly Initiative,” was evaluated for 2 years, and focused on local community centres in the New York City area. The group partnered with United Neighborhood House (UNH). The team developed a RE-AIM (reach, effectiveness, adoption, implementation, maintenance) model to help document the process and the outcomes of the study. Participants were screened with a 3-month follow-up to determine the level of their depression and the level of their use of services. Depression was rated using the Patient Health Questionnaire 2 (PHQ 2) to establish levels of depression; 775 clients were screened across all agencies. Results at the 3-month follow-up indicated that depression levels were not linked to age, race, or level of education. However, patients with lower physical and mental function were more depressed. Thirty-eight percent of the patients in follow-up did show an improvement in their depression, based on an improved PHQ-2 score, but ambiguous data prevented the researchers from firmly stating that the neighbourhood services and assessment were the source of the improvement. However, Dr. Sirey noted that the data from the study would be beneficial in advocacy efforts. “The data were not surprising, but the achievement lies in establishment of a point of comparison,” she said. The team also conducted a 6-month longitudinal study of service use patterns among older adults. In a study designed to establish a Network Episode Model to determine the impact of both advice and the sources of advice when it comes to using mental health services (MHS), the team determined that there are 4 components of service use: the patient’s illness career, individual social context and episode base (demographic), treatment, and the social support system. This portion of the study worked with a group of patients recruited from community agencies and providers via the Florida Brief Intervention and Treatment for Elders (BRITE) Project, which is funded by the Substance Abuse and Mental Health Services Administration of the US Department of Health and Human Services. These patients had a short-term Geriatric Depression Score of 5, were aged >=60 years, were not receiving specialty MHS, and passed a cognitive screening test. The group (n = 145) was required to attend at least 1 follow-up service and encouraged to attend 6 at 1-month intervals. The team determined that while advice to use MHS was not directly associated with the patients’ decision to take advantage of MHS offerings, it was associated with patients’ expression of an intention to use MHS. Patients who expressed an intention to use MHS did use them in higher numbers and were more likely to be on antidepressant medicines by the 6-month follow-up. “If advice is having an influence on MHS use, then it may be through intention rather than action,” said Amber Gum, PhD, University of South Florida, Tampa, Florida. Lastly, the team conducted a pilot trial in which primary care patients were randomised to receive either a nonstandard treatment for depression, such as bibliotherapy, spiritual counselling, or exercise, or they were encouraged and educated about standard methods of treatment, then followed throughout the experience. The research efforts have resulted in a variety of new strategies for giving choices “relevant to the patient experience,” said Marsha Wittink, MD, MBE, University of Pennsylvania, Philadelphia, Pennsylvania. The team determined that treatment strategies for older adults need to be presented in a way that relates to the patients’ primary care physicians; they also developed a shared decision-making model for older primary-care patients with depression. This model incorporates elements from all of the research in the various studies and includes depression screening, detection by primary-care personnel, education about depression and treatment options, eliciting patient preferences and values when it comes to decision making, and identifying and addressing barriers to treatment. Called the Shared Decision Making (SDM) model, this model directly addresses the symptoms of depression and encourages active involvement of the patient and their support group and caregivers to help them make decisions, said Patrick Raue, PhD, Weill Cornell Medical College, White Plains, New York. “Since a more traditional medical role is preferred and accepted among elderly patients, having nursing staff within the primary-care practice helps with a patient-centred approach and can help keep patients involved in the process and improve adherence,” he said. The SDM is comprised of a 30- to 40-minute interaction in the office between the patient and the nurse in which symptoms are reviewed, education is provided, and ultimately a mutually agreed upon decision is reached for treatment. The primary interaction is followed by 2 follow-ups at 1-week intervals via telephone to help encourage adherence to the treatment, address any barriers, and readdress the SDM as needed. [Presentation title: Advances in Detection, Initiation and Engagement of Older Adults in Mental Health Services. Abstract S10]
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