Cynthia Zubritsky

Factors Associated With Age of Diagnosis Among Children With Autism Spectrum Disorders

Objective. Early diagnosis of children with autism spectrum disorders (ASD) is critical but often delayed until school age. Few studies have identified factors that may delay diagnosis. This study attempted to identify these factors among a community sample of children with ASD. Methods. Survey data were collected in Pennsylvania from 969 caregivers of children who had ASD and were younger than 21 years regarding their service experiences. Linear regression was used to identify clinical and demographic characteristics associated with age of diagnosis. Results. The average age of diagnosis was 3.1 years for children with autistic disorder, 3.9 years for pervasive developmental disorder not otherwise specified, and 7.2 years for Aspergers disorder. The average age of diagnosis increased 0.2 years for each year of age. Rural children received a diagnosis 0.4 years later than urban children. Near-poor children received a diagnosis 0.9 years later than those with incomes >100% above the poverty level. Children with severe language deficits received a diagnosis an average of 1.2 years earlier than other children. Hand flapping, toe walking, and sustained odd play were associated with a decrease in the age of diagnosis, whereas oversensitivity to pain and hearing impairment were associated with an increase. Children who had 4 or more primary care physicians before diagnosis received a diagnosis 0.5 years later than other children, whereas those whose pediatricians referred them to a specialist received a diagnosis 0.3 years sooner. Conclusion. These findings suggest improvements over time in decreasing the age at which children with ASD, especially higher functioning children, receive a diagnosis. They also suggest a lack of resources in rural areas and for near-poor families and the importance of continuous pediatric care and specialty referrals. That only certain ASD-related behaviors, some of which are not required to satisfy diagnostic criteria, decreased the age of diagnosis suggests the importance of continued physician education.

Suicidal and Death Ideation in Older Primary Care Patients With Depression, Anxiety, and At-Risk Alcohol Use

The authors identified correlates of active suicidal ideation and passive death ideation in older primary care patients with depression, anxiety, and at-risk alcohol use. Participants included 2,240 older primary care patients (age 65+), who were identified in three mutually exclusive groups on the basis of responses to the Paykel suicide questions: No Ideation, Death Ideation, and Suicidal Ideation. Chi-square, ANOVA, and polytomous logistic regression analyses were used to identify characteristics associated with suicidal ideation. The highest amount of suicidal ideation was associated with co-occurring major depression and anxiety disorder (18%), and the lowest proportion occurred in at-risk alcohol use (3%). Asians have the highest (57%) and African Americans have the lowest (27%) proportion of suicidal or death ideation. Fewer social supports and more severe symptoms were associated with greater overall ideation. Death ideation was associated with the greatest medical comorbidity and highest service utilization. Contrary to previous reports, authors failed to find that active suicidal ideation was associated with increased contacts with healthcare providers. Accordingly, targeted assessment and preventive services should be emphasized for geriatric outpatients with co-occurring depression and anxiety, social isolation, younger age, and Asian or Caucasian race.

Primary Care Clinicians Evaluate Integrated and Referral Models of Behavioral Health Care For Older Adults: Results From a Multisite Effectiveness Trial (PRISM-E)

BACKGROUND Recent studies have shown that integrated behavioral health services for older adults in primary care improves health outcomes. No study, however, has asked the opinions of clinicians whose patients actually experienced integrated rather than enhanced referral care for depression and other conditions. METHOD The Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) study was a randomized trial comparing integrated behavioral health care with enhanced referral care in primary care settings across the United States. Primary care clinicians at each participating site were asked whether integrated or enhanced referral care was preferred across a variety of components of care. Managers also completed questionnaires related to the process of care at each site. RESULTS Almost all primary care clinicians (n = 127) stated that integrated care led to better communication between primary care clinicians and mental health specialists (93%), less stigma for patients (93%), and better coordination of mental and physical care (92%). Fewer thought that integrated care led to better management of depression (64%), anxiety (76%), or alcohol problems (66%). At sites in which the clinicians were rated as participating in mental health care, integrated care was highly rated as improving communication between specialists in mental health and primary care. CONCLUSIONS Among primary care clinicians who cared for patients that received integrated care or enhanced referral care, integrated care was preferred for many aspects of mental health care.

Importance of Subsyndromal Symptoms of Depression in Elderly Patients

OBJECTIVE There is a debate about the importance of subsyndromal symptoms of depression (SSD). The current study examined the cross-sectional and longitudinal significance of SSD in geriatric subjects both with and without a past history of major depression. METHODS Elderly primary-care subjects with SSD, both with (SSD+; N=54) and without (SSD-; N=204) a history of major depression, were compared with subjects with major depression (MDD; N=111), minor depression (MinD; N=74), and symptom-free comparison subjects (N=59). Assessment domains included physical and psychological disability, health-care utilization, hopelessness, death and suicidal ideation, and a diagnostic evaluation at a 3-month follow-up. RESULTS Both subjects with SSD+ and SSD- differed from the symptom-free comparison subjects on measures of psychological disability, hopelessness, and death ideation, with SSD+ subjects being more severely psychologically disabled than SSD- subjects. There were few differences between SSD+ and MinD subjects or those with MDD, except on measures of psychological disability. Finally, more than 24% of SSD+ subjects progressed to meet criteria of MDD, MinD, or dysthymia over a 3-month period. Utilization of outpatient services did not differ among any of the depression groups or comparison subjects. CONCLUSIONS SSD (with or without a past history of MDD) is associated with significant disability. Moreover, the risk of developing a diagnosis of MDD, MinD, or dysthymia is substantially elevated in subjects with a past history of MDD.

Older patients’ aversion to antidepressants

BACKGROUND: Depression is common among older patients yet is often inadequately treated. Patient beliefs about antidepressants are known to affect treatment initiation and adherence, but are often not expressed in clinical settings.OBJECTIVE: To explore attitudes toward antidepressants in a sample of depressed, community-dwelling elders who were offered treatment.DESIGN. Cross-sectional, qualitative study utilizing semi-structured interviews.PARTICIPANTS: Primary care patients age 60 years and over with depression, from academic and community primary care practices of the University of Pennsylvania Health System and the Philadelphia Department of Veterans Affairs. Patients participated in either the Prevention of Suicide in Primary Care Elderly: Collaborative Trial or the Primary Care Research in Substance Abuse and Mental Health for the Elderly Trial. Sixty-eight patients were interviewed and responses from 42 participants with negative attitudes toward medication for depression were analyzed.MEASUREMENTS: Interviews were audiotaped, transcribed, and entered into a qualitative software program for coding and analysis. A multidisciplinary team of investigators coded the transcripts and identified key features of narratives expressing aversion to antidepressants.RESULTS: Four themes characterized resistance to antidepressants: (1) fear of dependence; (2) resistance to viewing depressive symptoms as a medical illness; (3) concern that antidepressants will prevent natural sadness; (4) prior negative experiences with medications for depression.CONCLUSIONS: Many elders resisted the use of antidepressants. Patients expressed concerns that seems to reflect their concept of depression as well as their specific concerns regarding antidepressants. These findings may enhance patient-provider communication about depression treatment in elders.

Posttraumatic Stress, Depression, and Health Among Older Adults in Primary Care

OBJECTIVE The authors examined 1) rates of trauma and posttraumatic stress (PTS) in older adults in primary care; 2) factors related to more posttraumatic stress symptoms; and 3) the influence of posttraumatic stress and depression on health perceptions and negative health behaviors (i.e., suicidal ideation, smoking, and at-risk drinking). METHODS As part of participation in a study at the Philadelphia VAMC and the University of Pennsylvania, a random subset (N = 2,718) of older adults (age > or = 65 years) with scheduled primary care visits were screened concerning demographics, the General Health Questionnaire-12, suicidal thoughts, alcohol consumption, cigarette smoking, perceived health status, PTS, and cognitive impairment. RESULTS The rate of trauma in older adult primary care patients was high in both the VA (37%) and university-based clinics (24%). Many older adults reported interference from at least one of the three posttraumatic stress items assessed (VA, 18%; university-based primary care, 8%). In a model including demographic factors, higher PTS and depression were uniquely related to more negative health perceptions. In a model including demographic factors, both higher PTS and depression were uniquely related to higher likelihood of suicidal ideation. In contrast, PTS no longer contributed to a model of smoking once depression was included. Neither PTS nor depression significantly contributed to a model of at-risk drinking. CONCLUSIONS Trauma and posttraumatic stress are frequent and significant problems for older adults in primary care. Both posttraumatic stress and depression are related to more negative health perceptions and higher likelihood of suicidal ideation.

Gambling Among Older, Primary-Care Patients: An Important Public Health Concern

OBJECTIVES Authors assessed the prevalence rate of gambling in a sample of elderly patients (over age 65) and evaluated the sociodemographic characteristics, health, cognitive status, and psychiatric comorbidities of elderly gamblers. METHODS This study is a cross-sectional survey of gambling habits. A random sample of older adults with a scheduled primary-care clinic appointment was selected and screened with the General Health Questionnaire and questions about suicidality and alcohol use. Also, participants were asked about their gambling habits. RESULTS Of 843 screened patients completing the gambling questionnaire, 69.6% reported that they had participated in at least one gambling activity in the last year. At-risk gamblers were defined as those who reported having bet more than

Managing suicide risk in late life: access to firearms as a public health risk.

100 on a single bet and/or having bet more than they could afford to lose in the last year. Of those responding, 10.9% were identified as at-risk gamblers. The strongest predictors of at-risk gambling behavior were being a binge drinker, presence of current posttraumatic stress disorder symptoms, minority race/ethnicity, and being a VA clinic patient. Subjects with mild-to-moderate cognitive impairment were just as likely as those without impairment to gamble and to report at-risk gambling behavior. At-risk gambling behavior was not significantly associated with gender, current or past depressive symptoms, or cigarette smoking. CONCLUSIONS These data raise a significant public health concern that gambling behaviors are prevalent in older adults. Additional research is needed to further define the determinants of gambling behavior in older adults and evaluate the social, health, and economic costs and benefits of gambling by older adults, especially among those groups determined to be at risk.

Health-related Quality of Life: Expanding a Conceptual Framework to Include Older Adults Who Receive Long-term Services and Supports

OBJECTIVE The authors assessed the prevalence of gun availability for elderly patients to determine whether gun availability is related to the presence of suicidal or depressive symptoms. METHODS This is a cross-sectional epidemiologic survey of firearm availability and safety practices. A random sample of older adults with a scheduled primary-care clinic appointment was selected and screened with the General Health Questionnaire and questions about suicidality and alcohol use. Participants were also asked about the availability of firearms in their home and about safe gun practices. RESULTS Of 1,023 patients screened, 285 (27.9%) reported having some type of firearm in the home, and 202 (19.7%) reported having a handgun in the home. Patients with suicidal ideation or high levels of depression or psychological distress were not significantly more or less likely to have a gun in the home than those without these emotional stressors. The strongest predictors of firearm availability were being male and being married. CONCLUSIONS These preliminary data suggest that a significant proportion of elderly people have firearms available to them in their homes. Those patients with emotional distress did not differ from those without distress with respect to having firearms available to them. These data strongly suggest the need for screening for firearm availability and education about the safe storage of firearms as a potential means of prevention of suicide among elderly patients suffering from emotional distress or suicidal ideation.

A Daily Diary Study of Late-Life Depression

For older adults receiving long-term services and supports (LTSS), health-related quality of life (HRQoL) has emerged as a critical construct to examine because of its focus on components of well-being, which are affected by progressive changes in health status, health care, and social support. HRQoL is a health-focused quality of life (QOL) concept that encompasses aspects of QOL that affect health such as function, physical, and emotional health. Examining existing theoretical constructs and indicators of HRQoL among LTSS recipients led us to posit a revised conceptual framework for studying HRQoL among LTSS recipients. We adapted the Wilson and Cleary HRQoL model by expanding function to specifically include cognition, adding behavior and LTSS environmental characteristics in order to create a more robust HRQoL conceptual framework for older adults receiving LTSS. This refined conceptual model allows for the measurement of a mix of structural, process, and outcome measures. Continued development of a multidimensional conceptual framework with specific HRQoL measures that account for the unique characteristics of older adults receiving LTSS will contribute significantly to LTSS research, policy, and planning efforts.