Search

To inform the potential use of patient-reported depression symptom outcomes as measures of care quality, this study collected and analyzed longitudinal Patient Health Questionnaire (PHQ9) scores among 1,638 patients who screened positive for major depression according to a PHQ9 ≥ 10 across 29 Department of Veterans Affairs facilities. The study found baseline PHQ9, prior mental health visits, physical functioning, and treatment expectancy were consistently associated with subsequent PHQ9 outcomes. No facilities outperformed any others on PHQ9 scores at the 6-month primary endpoint, and the corresponding intra-class coefficient was ≤ .01 for the entire sample (n = 1,214) and 0.03 for the subgroup of patients with new depression episodes (n = 629). Measures of antidepressant receipt, psychotherapy, or treatment intensification were not associated with 6-month PHQ9 scores. PHQ9 outcomes are therefore unlikely to be useful as quality indicators for VA healthcare facilities due to low inter-facility variation, and new care process measures are needed to inform care for patients with chronic depression prevalent in this sample.

Diagnosis and treatment of depression has increased over the past decade in the United States. Whether self-reported depressive symptoms among older adults have concomitantly declined is unknown.To examine trends in depressive symptoms among older adults in the US between 1998 and 2008.Serial cross-sectional analysis of six biennial assessments.Health and Retirement Study (HRS), a nationally-representative survey. PATIENTS OR OTHER PARTICIPANTS Adults aged 55 and older (N = 16,184 in 1998).The eight-item Center for Epidemiologic Studies Depression scale (CES-D8) assessed three levels of depressive symptoms (none = 0, elevated = 4+, severe = 6+), adjusting for demographic and clinical characteristics.Having no depressive symptoms increased over the 10-year period from 40.9 % to 47.4 % (prevalence ratio [PR]: 1.16, 95 % CI: 1.13-1.19), with significant increases in those aged ≥ 60 relative to those aged 55-59. There was a 7 % prevalence reduction of elevated symptoms from 15.5 % to 14.2 % (PR: 0.93, 95 % CI: 0.88-0.98), which was most pronounced among those aged 80-84 in whom the prevalence of elevated symptoms declined from 14.3 % to 9.6 %. Prevalence of having severe depressive symptoms increased from 5.8 % to 6.8 % (PR: 1.17, 95 % CI: 1.06-1.28); however, this increase was limited to those aged 55-59, with the probability of severe symptoms increasing from 8.7 % to 11.8 %. No significant changes in severe symptoms were observed for those aged ≥ 60.Overall late-life depressive symptom burden declined significantly from 1998 to 2008. This decrease appeared to be driven primarily by greater reductions in depressive symptoms in the oldest-old, and by an increase in those with no depressive symptoms. These changes in symptom burden were robust to physical, functional, demographic, and economic factors. Future research should examine whether this decrease in depressive symptoms is associated with improved treatment outcomes, and if there have been changes in the treatment received for the various age cohorts.

In this study we examine the longitudinal effects of psychiatric and substance use disorders on employment, in an employed population. The sample included respondents to the National epidemiologic survey on alcohol related conditions (NESARC) who were employed at Wave 1 (N=22,407). Bivariate and multivariable analyses were conducted examining the associations between 12-month and new onset 12-month psychiatric diagnoses at Wave 1 and employment status at Wave 2. Past year and new onset 12-month depression, 12-month bipolar, new onset 12-month drug abuse, and 12-month and new onset 12-month drug dependence were associated with a decreased odds of being employed at Wave 2. This study suggests that it would be beneficial for employers to support their employees in participating in mental health treatment. Additionally, understanding how psychiatric disorders influence employment over the life course might inform the development of preemptive interventions to treat mental health symptoms.

Depressed patients discharged from psychiatric hospitalizations face increased risks for adverse outcomes including suicide, yet antidepressant adherence rates during this high-risk period are unknown. Using Veterans Affairs (VA) data, we assessed antidepressant adherence and predictors of poor adherence among depressed veterans following psychiatric hospitalization. We identified VA patients nationwide with depressive disorders who had a psychiatric hospitalization between April 1, 1999 and September 30, 2003, received antidepressant medication, and had an outpatient appointment following discharge. We calculated medication possession ratios (MPRs), a measure of medication adherence, within 3 and 6 months following discharge. We assessed patient factors associated with having lower levels of adherence (MPRs < 0.8) after discharge. The criteria for 3- and 6-month MPRs were met by 20,931 and 23,182 patients respectively. The mean 3 month MPR was 0.79 (SD = 0.37). The mean 6 month MPR was 0.66 (SD = 0.40). Patients with poorer adherence were male, younger, non-white, and had a substance abuse disorder, but were less likely to have PTSD or other anxiety disorders. Poor antidepressant adherence is common among depressed patients after psychiatric hospitalization. Efforts to improve adherence at this time may be critical in improving the outcomes of these high-risk patients.

This report evaluates whether consideration of out-of-system use affects Veterans Affairs (VA) health system assessments of depression treatment. We measured effective medication management and optimal practitioner contacts among veterans whose VA data indicated a new episode of depression. Among 3,567 VA patients who were Medicare age-eligible, VA data indicated that 69% received recommended antidepressant coverage and 9% received recommended practitioner contacts. After including Medicare data, 295 patients (8%) no longer met inclusion criteria. Among the remainder, 3% received Medicare depression treatment and 0.5% were re-classified as having recommended contacts. Medicare use does not substantially supplement VA depression treatment.

Depression in older adults has been detected, diagnosed and treated more frequently in recent years. However, substantial gaps in effective treatment remain. Adherence to depression treatment can be viewed as the 'next frontier' in the treatment of late-life depression. Using the Theory of Reasoned Action, a model of health behaviours, this paper conceptualizes and reviews the current evidence for key patient-level factors associated with depression treatment adherence among older adults. We categorize these factors according to how their impact on adherence might be affected by specialized treatment approaches or interventions as: (i) modifiable; (ii) potentially modifiable; and (iii) non-modifiable. Based on current evidence, modifiable factors associated with depression treatment adherence include patient attitudes, beliefs and social norms. Patient attitudes include perceptions of the effectiveness of depression treatment, preferences for the type of depression treatment and concepts regarding the aetiology of depression (e.g. resistance to viewing depression as a medical illness). There is also evidence from the literature that spiritual and religious beliefs may be important determinants of adherence to depression care. Social norms such as the impact of caregiver agreement with treatment recommendations and stigma may also affect adherence to depression treatment. Other factors may be less modifiable per se, but they may have an impact on adherence that is potentially modifiable by specialized interventions. Based upon a review of the current literature, potentially modifiable factors associated with adherence to depression treatment include co-morbid anxiety, substance use, cognitive status, polypharmacy and medical co-morbidity, social support and the cost of treatment. Finally, non-modifiable factors include patient gender and race. Importantly, non-modifiable factors may interact with modifiable factors to affect health behavioural intent (e.g. race and spiritual beliefs). Thus, adherence to depression treatment in older adults is associated with multiple factors. Strategies to improve patient adherence need to be multidimensional, including consideration of age-related cognitive and co-morbidity factors, environmental and social factors, functional status and belief systems. Evidence-based interventions involving greater patient, caregiver, provider and public health education should be developed to decrease stigma, negative attitudes and other modifiable barriers to detection, diagnosis, treatment and adherence to depression treatment. These interventions should also be tailored to the individual as well as to the treatment setting. While important progress has been made in increasing detection of depression in older adults, greater focus now needs to be placed on treatment engagement and continuation of improvements in quality of life, reducing suffering and achieving better outcomes.

We sought to determine mutuality and specificity in rates of mental disorders between advanced cancer patients and their caregivers.Data from 168 non-genetically related patient-caregiver dyads participating in the multi-site Coping with Cancer (CWC) study were included in this analysis. Multivariate logistic regression analyses were conducted to examine associations between diagnoses of a psychiatric disorder in patients with diagnoses of psychiatric disorders in caregivers, and vice versa, controlling for confounders.When patients met criteria for any psychiatric diagnosis, then caregivers were 7.9 times (P0.0001) more likely to meet criteria for any psychiatric diagnosis, and vice versa. Caregiver Panic Disorder (PD) diagnosis was associated with patient Generalized Anxiety Disorder (GAD). Patient GAD was also associated with caregiver PD. Finally, patient PD was associated with caregiver GAD and caregiver Post-Traumatic Stress Disorder (PTSD).To our knowledge, this is the first study that demonstrates the mutuality of psychiatric disorders in both advanced cancer patients and their informal caregivers. Specifically, the presence of anxiety disorders in one partner (either caregiver or patient) was associated with a greater likelihood of anxiety disorders in the other. Results suggest that psychiatric distress should be assessed in both patients and their caregivers, and that mental illness in one should raise concern about the possibility of a psychiatric disorder in the other. Results also suggest that targeted interventions to address shared fears and concerns of patients and caregivers might reduce anxiety in the end phases of the patient's illness.

Poor mood adjustment to chronic medical illness is often accompanied by decrements in function.To evaluate the effectiveness of a telephone-based intervention for psychologic distress and functional impairment in cardiac illness.Randomized, controlled trial.We recruited survivors of acute coronary syndromes using the Hospital and Anxiety Depression Scale (HADS) with scores indicative of mood disturbances at 1-month postdischarge. Recruited patients were randomized to experimental or control status. Intervention patients received 6 30-minute telephone counseling sessions to identify and address illness-related fears and concerns. Control patients received usual care. Patients' responses to the HADS and the Workplace Social Adjustment Scale (WSAS) were collected at baseline, 2, 3, and 6 months using interactive voice recognition technology. At baseline, the PRIME-MD was used to establish diagnosis of depression. We used mixed effects regression to study changes in outcomes.We enrolled 100 patients. Mean age was 60; 67% of the patients were male. Findings confirmed that the intervention group had a 27% improvement in depression symptoms (P=.05), 27% in anxiety (P=.02), and a 38% improvement in home limitations (P=.04) compared with controls. Symptom improvement tracked those for WSAS measures of home function (P=.04) but not workplace function.The intervention had a moderate effect on patient's emotional and functional outcomes that were observed during a critical period in patients' lives. Patient convenience, ease of delivery, and the effectiveness of the intervention suggest that the counseling can help patients adjust to chronic illness.