Cory Bolkan

Implementing collaborative care for depression treatment in primary care: A cluster randomized evaluation of a quality improvement practice redesign

BackgroundMeta-analyses show collaborative care models (CCMs) with nurse care management are effective for improving primary care for depression. This study aimed to develop CCM approaches that could be sustained and spread within Veterans Affairs (VA). Evidence-based quality improvement (EBQI) uses QI approaches within a research/clinical partnership to redesign care. The study used EBQI methods for CCM redesign, tested the effectiveness of the locally adapted model as implemented, and assessed the contextual factors shaping intervention effectiveness.MethodsThe study intervention is EBQI as applied to CCM implementation. The study uses a cluster randomized design as a formative evaluation tool to test and improve the effectiveness of the redesign process, with seven intervention and three non-intervention VA primary care practices in five different states. The primary study outcome is patient antidepressant use. The context evaluation is descriptive and uses subgroup analysis. The primary context evaluation measure is naturalistic primary care clinician (PCC) predilection to adopt CCM.For the randomized evaluation, trained telephone research interviewers enrolled consecutive primary care patients with major depression in the evaluation, referred enrolled patients in intervention practices to the implemented CCM, and re-surveyed at seven months.ResultsInterviewers enrolled 288 CCM site and 258 non-CCM site patients. Enrolled intervention site patients were more likely to receive appropriate antidepressant care (66% versus 43%, p = 0.01), but showed no significant difference in symptom improvement compared to usual care. In terms of context, only 40% of enrolled patients received complete care management per protocol. PCC predilection to adopt CCM had substantial effects on patient participation, with patients belonging to early adopter clinicians completing adequate care manager follow-up significantly more often than patients of clinicians with low predilection to adopt CCM (74% versus 48%%, p = 0.003).ConclusionsDepression CCM designed and implemented by primary care practices using EBQI improved antidepressant initiation. Combining QI methods with a randomized evaluation proved challenging, but enabled new insights into the process of translating research-based CCM into practice. Future research on the effects of PCC attitudes and skills on CCM results, as well as on enhancing the link between improved antidepressant use and symptom outcomes, is needed.Trial RegistrationClinicalTrials.gov: NCT00105820

Stigma Predicts Treatment Preferences and Care Engagement Among Veterans Affairs Primary Care Patients with Depression

BackgroundWhereas stigma regarding mental health concerns exists, the evidence for stigma as a depression treatment barrier among patients in Veterans Affairs (VA) primary care (PC) is mixed.PurposeThis study tests whether stigma, defined as depression label avoidance, predicted patients’ preferences for depression treatment providers, patients’ prospective engagement in depression care, and care quality.MethodsWe conducted cross-sectional and prospective analyses of existing data from 761 VA PC patients with probable major depression.ResultsRelative to low-stigma patients, those with high stigma were less likely to prefer treatment from mental health specialists. In prospective controlled analyses, high stigma predicted lower likelihood of the following: taking medications for mood, treatment by mental health specialists, treatment for emotional concerns in PC, and appropriate depression care.ConclusionsHigh stigma is associated with lower preferences for care from mental health specialists and confers risk for minimal depression treatment engagement.

Relationships between mood and employment over time among depressed VA primary care patients

OBJECTIVE Associations between depression, productivity and work loss have been reported, yet few studies have examined relationships between longitudinal depression status and employment continuity. We assessed these relationships among Veterans of conventional working ages. METHODS We used longitudinal survey data from Veterans receiving primary care in 1 of 10 Veterans Health Administration primary care practices in five states. Our sample included 516 participants with nine-item Patient Health Questionnaire (PHQ-9) scores indicating probable major depression (PHQ-9≥10) at baseline and who completed either the 7-month follow-up survey or follow-up surveys at both 7 and 18 months postbaseline. We examined relationships between depression persistence and employment status using multinomial logistic regression models. RESULTS Although general employment rates remained stable (21%-23%), improved depression status was associated with an increased likelihood of becoming employed over 7 months among those who were both depressed and nonemployed at baseline. Improvements in depression status starting at 7 months and continuing through 18 months were associated with remaining employed over the 18-month period, relative to those who were depressed throughout the same time frame. CONCLUSIONS Given the pressing need to prevent socioeconomic deterioration in the increasing population of conventional working-aged Operation Enduring Freedom and Operation Iraqi Freedom Veterans, further attention to the depression/employment relationship is urgently needed.

Possible Selves and Depressive Symptoms in Later Life

The pursuit of personal goals has been linked to general psychological well-being; however, less is known about the association with depression in later adulthood when individuals are contending with age-related changes in health and social relationships. We explored the connection between both health- and social related goals (as measured by possible selves) and depressive symptoms in a sample of 85 community-dwelling older adults who ranged in age from 60 to 92 (M = 74, standard deviation = 7.5). Participants took part in face-to-face, semistructured interviews in which they responded to measures of possible selves (future images of oneself), health, and depressive symptoms. We found that the presence of health-related, but not social-related, possible selves was significantly associated with fewer reported depressive symptoms. Additionally, the presence of health-related fears was specifically linked to fewer reported depressive symptoms. These findings suggested that the promotion of and investment in health-related personal goals may be useful in off-setting depressive symptoms in older adults, as well as indicated a potential benefit of a disease prevention focus regarding health in later life. Finally, the results may have implications for potential clinical interventions in addressing late-life depression.

Suicide risk management: development and analysis of a telephone-based approach to patient safety

Research-based queries about patients’ experiences often uncover suicidal thoughts. Human subjects review requires suicide risk management (SRM) protocols to protect patients, yet minimal information exists to guide researchers’ protocol development and implementation efforts. The purpose of this study was to examine the development and implementation of an SRM protocol employed during telephone-based screening and data collection interviews of depressed primary care patients. We describe an SRM protocol development process and employ qualitative analysis of de-identified documentation to characterize protocol-driven interactions between research clinicians and patients. Protocol development required advance planning, training, and team building. Three percent of screened patients evidenced suicidal ideation; 12% of these met protocol standards for study clinician assessment/intervention. Risk reduction activities required teamwork and extensive collaboration. Research-based SRM protocols can facilitate patient safety by (1) identifying and verifying local clinical site approaches and resources and (2) integrating these features into prevention protocols and training for research teams.

The Role of Caregivers in Physical Activity for Older Adults With Alzheimer’s Disease:

This study examined the determinants of physical activity (PA) for older adults with Alzheimer’s disease (AD) to learn more about how to promote PA in this population. Caregivers of older adults with AD (N = 99) provided information related to care recipient’s PA, as well as addressed sociodemographics and perceptions about their care recipient’s PA. Gender of care recipient was a significant predictor of PA (β = .80, P < .05); men with AD participated in more PA than women with AD. Also, caregivers outcome expectation for care recipients PA also predicted more PA (β = .82, P < .05). Caregiver’s perceived benefits of PA (outcome expectation) for their care recipient partially mediated the relationship between self-efficacy for care recipient’s PA and the reported levels of PA for the care recipient. This study demonstrated the importance of caregiver perceptions about care recipient’s PA.

Addressing the needs of Nicaraguan older adults living on the edge: A university–community partnership in international service-learning

ABSTRACT Nicaragua is a very low-income country entering a period of rapid aging with limited geriatric training for health care professionals. To help build capacity and to enhance student learning, a short-term international service-learning program was implemented in 2004 in partnership with the Jessie F. Richardson Foundation and Nicaraguan community stakeholders. Graduate and undergraduate students at Portland State University complete coursework for one term in the United States then travel to Nicaragua for about two weeks to participate in educational, research, and service activities, primarily in group homes for older Nicaraguans. Students learn about global aging, gerontology, community development, service learning, and Nicaraguan history and culture, then apply their gerontology-related knowledge by training direct care staff, older adults and their family members, and students. The authors describe the impetus for and evolution of the program, students’ evaluation of the program, faculty observations on program benefits and challenges, lessons learned, and future plans.

Learning Through Loss: Implementing Lossography Narratives in Death Education

Students may have a greater willingness to discuss issues of death and loss through written assignments; however, there is little guidance for instructors regarding how to manage these sensitive assignments, nor how students benefit from them. The authors implemented and evaluated a “lossography” assignment in an undergraduate thanatology course in which students wrote about their losses and anonymously shared these narratives with their classmates. Although many themes of loss emerged, the most frequently reported significant loss was death of a grandparent. Additionally, most significant losses occurred in childhood/adolescence. Prominent themes related to student learning included gaining self-awareness, knowledge about grief responses, and compassion for others. Students (N = 64) also completed a survey reflecting on their course learning. Of all aspects of course delivery, 44% identified the lossography as the most beneficial, whereas 97% recommended this assignment for future students. The implications of the assignment for death education are also discussed.