Effective management of depression in the primary care setting requires a systematic, population-based approach, which entails systematic case finding and diagnosis, patient engagement and education, use of evidence-based treatments, including medications and/or psychotherapy, close follow-up to ensure patients are improving, and a commitment to adjust treatments or consult with mental health specialists until depression is significantly improved. Programs in which primary care providers and mental health specialists collaborate effectively using principles of measurement-based stepped care and treatment to target can substantially improve patients' health and functioning while reducing overall health care costs.

Background

Although collaborative care programs are effective in improving late-life depression, only about half of treated patients achieve clinically meaningful improvement. Thus, we need to examine what characteristics may predict poor late-life depression course. Despite the robust evidence for the negative association between the quality of couple relationships and depression outcomes, few studies have examined these associations in the context of long-term late-life depression course.

Aim

The objective of this study is to examine the relations between the severity of couple conflict, receiving collaborative depression care program, and 24-months depression outcomes.

Methods

Study sample comprised 840 depressed older adults subsample from the improving mood, promoting access to collaborative treatment for late-life depression trial (IMPACT). Depression and couple conflict were assessed at baseline, 12-month, and 24-month follow-up. Descriptive statistics and multivariate regression analyses were performed to examine mean 24-month depression-free days (DFD) and the marginal effects of receiving IMAPCT program over usual care among participants with varying degrees of 24-month couple conflict.

Results

Compared with those who never endorsed frequent couple conflict over the three observation points, those who did twice had 63 fewer DFD (p = 0.01), and those who did three times experienced 148 fewer DFD (p < 0.001). Although the marginal effects of receiving IMPACT program over usual care was greater in overall sample, it was not statistically significant among those who endorsed frequent conflict at two or three times.

Conclusion

Frequent couple conflict is associated with worse long-term late-life depression outcomes among the patients in primary care clinics.

Depression is a common, disabling, and costly condition encountered in older patients. Effective strategies for detection and treatment of late-life depression are summarized based on a case of a 69-year-old woman who struggled with prolonged depression. Clinicians should screen older patients for depression using a standard rating scale, initiate treatment such as antidepressant medications or evidence-based psychotherapy, and monitor depression symptoms. Patients who are not improving should be considered for psychiatric consultation and treatment changes including electroconvulsive therapy. Several changes in treatment approaches are usually needed before patients achieve complete remission. Maintenance treatment and relapse-prevention planning (summarization of early warning signs for depression, maintenance treatments such as medications, and other strategies to reduce the risk of relapse [eg, regular physical activity or pleasant activities]) can reduce the risk of relapse. Collaborative programs, in which primary care clinicians work closely with mental health specialists following a measurement-based treatment-to-target approach, are significantly more effective than typical primary care treatment.

To examine the associations between family conflict, family cohesion and late-life depression in Latino and Asian populations and test if these associations vary by race/ethnicity and gender. We used a subsample of older adults from the National Latino Asian American Study (N = 395). All analyses were weighted and adjusted for individual and clinical characteristics. Greater family cohesion was associated with decrease in risk for depression in Latino and Asian older adult populations (OR: 0.68, 95% CI: 0.54, 0.84). These associations varied by gender, with men being more sensitive to family cohesion and family conflict than women. Asian older adults were more sensitive to family conflict, whereas Latino older adults were more sensitive to family cohesion. The quality of family relationships is strongly associated with late-life depression. Further research is needed to better understand the complex interplay between social support, ethnicity, and gender in latelife depression outcomes.

Considerable progress has been made in the treatment of late-life depression over the past 20 years, yet considerable gaps in care remain. Gaps in care are particularly pronounced for older men, certain racial and ethnic minority groups, and those with comorbid medical or mental disorders. We reviewed the peer-reviewed literature and conducted interviews with experts in late-life depression to identify promising directions for effectiveness research to address these gaps in care. We searched the PubMed, PsychInfo, and CINHAL databases between January 1, 1998, through August 31, 2013, using terms related to late-life depression and any of the following: epidemiology, services organization, economics of care, underserved groups including health disparities, impact on caregivers, and interventions. The results of this selective review supplemented by more current recommendations from national experts highlight three priority research areas to improve health services for late-life depression: focusing on the unique needs of the patient through patient-centered care and culturally sensitive care, involving caregivers outside the traditional clinical care team, and involving alternate settings of care. We build on these results to offer five recommendations for future effectiveness research that hold considerable potential to advance intervention and health services development for late-life depression.

BACKGROUND: Collaborative care is an evidence-based program for treating depression in primary care. We sought to expand this model by recruiting clinics interested in incorporating community partners (i.e., community-based organizations (CBO) and/or family members) in the care team. Seven sites implemented evidence-based collaborative care programs with community partners while collecting information on costs of implementing and sustaining programs. METHODS: Sites retrospectively collected data on planning and implementation costs with technical assistance from study researchers. Sites also prospectively collected cost of care activities over a 1-month period once the program was implemented to determine resources needed to sustain programs. Personnel salary costs were adjusted, adding 30% for benefits and 30% for administrative overhead. RESULTS: The programs implemented varied considerably in staffing, involvement of care partners, and allocation of costs. Total planning and implementation costs varied from $39,280 to $60,575. The largest implementation cost category involved workflow development and ranged from $16,325 to $31,375 with the highest costs in this category attributed to the most successful implementation among clinic-CBO programs. Following implementation, cost per patient over the 1-month period ranged from $154 to $544. Ongoing strategic decision-making and administrative costs, which were included in cost of care, ranged from $284 to $2328 for the month. CONCLUSIONS: Sites implemented collaborative care through differing partnerships, staffing, and related costs. Costs to implement and sustain programs developed in partnership are often not collected but are crucial to understanding financial aspects of developing sustainable partnerships. Assessing such costs is feasible and can inform future partnership efforts.

Objective

Depression is associated with poor quality of life, higher healthcare costs, and suicide. Older, especially minority, men suffer high rates of depression under-treatment. Illness attributes may influence depression under-treatment by shaping help-seeking and physician recognition in older and minority men. Improved understanding of depression attributes may help to close gaps in care for older men. The study aims are to describe the range and most frequent attributes of depression in a diverse sample of older men and to describe ethnic similarities and differences in depression attributes between white non-Hispanic and Mexican-origin older men.

Methods

In this qualitative study of white non-Hispanic and Mexican-origin older men who were recruited from outpatient primary care clinics in central California, 77 (47 white non-Hispanic and 30 Mexican-origin) men aged 60 and older who were identified as depressed and/or receiving depression treatment in the past year completed in-depth interviews covering their experiences of depression. Transcribed interviews were analyzed per established descriptive qualitative techniques.

Results

Twenty-one depression attributes were identified and 9 were present in at least 17% of the interviews. Men often attributed their depression to stressors such as grief/loss and spousal conflicts, feelings of moral failure, and poor health. Although there were similarities in depression attributes between the groups, we found several differences in the frequency of certain attributes.

Conclusion

Similarities and differences in depression attributes between Mexican-origin and white non-Hispanic older men suggest the confluence of various sociocultural factors. Awareness of the variety of ways that older men understand depression can help clinicians identify and engage them in depression treatment.

This study examined the relationship between herbal medication and dietary supplement (HMDS) use and mental health characteristics. Data are drawn from a national household survey of the United States’ civilian, non-institutionalized population (N = 9,585). Psychiatric medication and HMDS use, psychiatric diagnoses and treatment needs, utilization and satisfaction were assessed. Compared to non-users, HMDS users were more likely to perceive themselves as having mental health needs, to have received mental health and primary care treatment, and to be dissatisfied with their overall healthcare. Psychiatric medication use was not related to HMDS use, and in multivariate analyses, HMDS use was associated with perceived mental health needs. Differences in use of specific HMDS between those with and without a psychiatric disorder were also examined. The use of HMDS warrants particular attention in persons with perceived mental health problems as these individuals may be turning to HMDS use for treatment of their symptoms.

Background

Family members often play important roles in the lives of depressed older men and frequently attend primary care visits with their loved ones, yet surprisingly little is known about how to most effectively engage and include family members in depression treatment. However, including family in depression treatment may be difficult due to several factors, such as depression stigma and family conflicts. The objective of this study was to describe challenges in engaging family members in older men's depression treatment and potential strategies to overcome those challenges.

Methods

A cross-sectional, qualitative descriptive interview study was conducted in a safety-net, Federally Qualified Health Center in California's Central Valley. A total of 37 stakeholders were recruited, including 15 depressed older (i.e. age ≥ 60) men, 12 family members, and 10 clinic staff. Depressed men were identified through mail outreach, waiting room screening, and referral. Depressed men identified family members who were later approached to participate. We also recruited a purposeful sample of clinic staff. Interviews explored stakeholder perspectives on family involvement in men's depression treatment as part of a primary care intervention. Interviews were conducted using a semi-structured interview guide, tape-recorded, transcribed verbatim, and translated if the interview was conducted in Spanish.

Results

Four themes were identified representing core challenges: engaging men at the right time; preserving men's sense of autonomy; managing privacy concerns; and navigating family tensions. Stakeholders also provided practical suggestions and advice about how each of these challenges might be addressed.

Conclusions

While engaging family is a promising approach to strengthen depression care for older men in primary care settings, several potential challenges exist. Family- centered depression intervention development and clinical practice need to anticipate these challenges and to develop approaches and guidelines to address them.

OBJECTIVE This study examined effectiveness of collaborative care for depression among Asians treated either at a community health center that focuses on Asians (culturally sensitive clinic) or at general community health centers and among a matched population of whites treated at the same general community clinics. METHODS For 345 participants in a statewide collaborative care program, use of psychotropic medications, primary care visits with depression care managers, and depression severity (as measured with the nine-item Patient Health Questionnaire) were tracked at baseline and 16 weeks. RESULTS After adjustment for differences in baseline demographic characteristics, all three groups had similar treatment process and depression outcomes. Asian patients served at the culturally sensitive clinic (N=129) were less likely than Asians (N=72) and whites (N=144) treated in general community health clinics to be prescribed psychotropic medications. CONCLUSIONS Collaborative care for depression showed similar response rates among all three groups.