Deborah B. Wagenaar

Late-life depression and mental health services in primary care

Mental health services in the treatment of late-life depression are critical in the primary care arena. A significant proportion of elderly patients experience depression, a problem causing a far-reaching impact on morbidity, mortality, and quality of life. A number of barriers may prevent effective depression treatment including negative physician and patient attitudes toward the stigma of depression, somatically focused clinical presentations, health care plan constraints, and competing medical demands, as well as gender and geographic isolation. Screening for depression in primary care settings is not always standard fare as physicians may feel confident in their diagnostic abilities. Research addressing effective depression treatment in the primary care setting has been limited to few clinical trials and physician-focused academic detailing. Future research should address real-world scenarios encountered by the primary care physician in their treatment of the “old-old” patient with complex medical comorbidities and functional decline.

Comparing Clinical Practice With Guideline Recommendations for the Treatment of Depression in Geriatric Patients: Findings From the APA Practice Research Network

OBJECTIVE The authors describe treatments provided for depressed geriatric patients (age 65+) treated by psychiatrists in the American Psychiatric Associations (APA) Practice Research Network (PRN) and compare treatments with recommended guidelines for treating late-life depression. METHODS Detailed demographics, diagnoses, service utilization, and treatment information were collected on relevant patients treated by psychiatrists participating in the APAs PRN during 1997, sample-weighted to produce nationally representative estimates. Treatment data were qualitatively compared with existing depression treatment guidelines from the APA and the Expert Consensus Guideline Series on pharmacotherapy of depressive disorders in older patients. RESULTS Of patients treated by psychiatrists in the PRN (N=152), just over 41% had a diagnosable depressive disorder, and, of those with depression, nearly 84% had major depression. Over 90% received a psychotropic medication, and over 75% received an antidepressant. Treatment intensity, as measured by visit frequency and duration of treatment, were more intense than typically found in primary care. Most patients received a combination of medication management and psychotherapy. Selective serotonin reuptake inhibitors were the most frequently prescribed antidepressant, although they were less frequently prescribed than in primary care and other national surveys. Just over 11% received a tertiary amine antidepressant, and nearly 43% received benzodiazepines, this frequency being inconsistent with existing guidelines. CONCLUSION Depressed geriatric patients treated by psychiatrists in APAs PRN receive active treatments largely consistent with existing guidelines, which generally resulted in favorable patient outcomes.

Six Things All Medical Students Need to Know about Geriatric Psychiatry (and How to Teach Them)

Given the demographics of aging and the prevalence of psychiatric disorders, virtually all physicians can expect to care for older adults whose mental health merits professional attention. According to the World Health Organization, by 2050, individuals 65 or older will comprise 20% of the US population, and approximately 15% of this population will have mental health needs [1]. Despite this anticipated “Silver Tsunami,” the pipeline of geriatric specialty-trained physicians, including geriatric psychiatrists, remains woefully inadequate [2]. In 2012, the Institute of Medicine (IOM) issued a report entitled The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? [3]. Emphasizing changing demographics, the prevalence of psychiatric disorders, and the critical shortage of specialty-trained clinicians, the IOM recommended development of core competencies in geriatric mental health and substance use for all healthcare providers. Our responsibility as psychiatric educators is to ensure that physicians in training for any specialty are prepared to assess and manage the mental health concerns of older adult patients. Despite this compelling mandate, many medical students receive little geriatric psychiatry education. After surveying psychiatry clerkship directors from 110 US medical schools, Lehmann, Blazek, and Popeo reported that 21% of responding psychiatric clerkships lacked any specific instruction or clinical experience focused on the mental health needs of older patients [4]. They recommended the development of competence-based learning objectives in geriatric psychiatry, which could be implemented by educators across the medical school curriculum, including those who are not geriatric specialists. In 2012, five medical student educators/geriatric psychiatrists formed a workgroup of the Teaching and Training Committee of the American Association for Geriatric Psychiatry with the purpose of developing geriatric psychiatry learning objectives for all medical students to attain prior to graduation. The workgroup reviewed the literature on geriatric learning objectives and sought input from content experts in psychiatry, neurology, geriatric medicine, and medical education. The iterative development process included solicitation of local and national feedback with ongoing revisions through oral presentations at the annual meeting of the American Association for Geriatric Psychiatry in 2014 [5] and the annual meeting of the Association of American Medical Colleges Medical Education meeting in 2014 [6]. The resulting document identifies six domains of geriatric psychiatry essential in preparing medical students to deliver competent and safe care to their older patients in residency and beyond: normal aging, mental health assessment of the older adult, psychopharmacology, depression, dementia, and delirium (Table 1). The set of learning objectives is endorsed by the American Association for Geriatric Psychiatry’s Teaching and Training Committee and is featured as an educational resource on its website [7]. * Kirsten M. Wilkins kirsten.wilkins@yale.edu