Hongtu Chen

PRISM-E: Comparison of Integrated Care and Enhanced Specialty Referral Models in Depression Outcomes

OBJECTIVE This study, entitled Primary Care Research in Substance Abuse and Mental Health for the Elderly, examined six-month outcomes for older primary care patients with depression who received different models of treatment. METHODS Clinical outcomes were compared for patients who were randomly assigned to integrated care or enhanced specialty referral. Integrated care consisted of mental health services co-located in primary care in collaboration with primary care physicians. Enhanced specialty referral consisted of referral to physically separate, clearly identified mental health or substance abuse clinics. RESULTS A total of 1,531 patients were included; their mean age was 73.9 years. Remission rates and symptom reduction for all depressive disorders were similar for the two models at the three- and six-month follow-ups. For the subgroup with major depression, the enhanced specialty referral model was associated with a greater reduction in depression severity than integrated care, but rates of remission and change in function did not differ across models of care for major depression. CONCLUSIONS Six-month outcomes were comparable for the two models. For the subgroup with major depression, reduction in symptom severity was superior for those randomly assigned to the enhanced specialty referral group.

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.

Design and sample characteristics of the PRISM-E multisite randomized trial to improve behavioral health care for the elderly.

Objective: To describe the design of the Primary Care Research in Substance Abuse and Mental Health for Elderly (PRISM-E) study and baseline characteristics of the randomized primary care patients with mental health problems and at-risk alcohol use. Method: Adults aged 65 and older were screened at primary care clinics from 10 study sites throughout the United States. Those diagnosed for depression, anxiety, and/or at-risk alcohol consumption were randomized to either integrated or enhanced referral care. Results: Of the 23,828 participants, 14% had a positive assessment for depressive and/or anxiety disorders, and 6% had at-risk alcohol consumption diagnoses. Among patients with mental health diagnoses, there was a higher preponderance of younger ages, women, and ethnic minorities. Among patients with at-risk drinking, there was a higher preponderance of younger ages, Whites, and men. Discussion: These findings indicate the need for screening in primary care and for engaging older adults in treatment.

BRIEF REPORT The Emotional Distress in a Community After the Terrorist Attack on the World Trade Center

AbstractObjectives: To examine psychological impact of the September 11th disaster on the immediate neighborhood of the New York World Trade Center. Methods: 555 residents from the local Chinatown community participated in the study. They were surveyed retrospectively on their emotional distress immediately after the tragedy and five months later. Results: Prevalent anxiety was found in general community residents and additional depression in those who lost family members or friends. The mental health condition of the community improved tremendously five months later, with the initial 59% of general residents having 4 or more emotional symptoms dropping to 17%. However, More than half of the community residents had persistently shown one or more symptoms of emotional distress. Those who had lost a family member or friend in the disaster showed significantly higher distress, with 90% of them had four or more major psychiatric symptoms during the first few weeks right after the disaster, and the rate dropped to 35% five months later. Overall, those in their 40s and 50s seemed to have had relatively higher emotional distress than both younger and older groups. Discussion: Methodological limitations were discussed concerning retrospective reporting and sample characteristics.

Integrated specialty mental health care among older minorities improves access but not outcomes: results of the PRISMe study.

In this secondary data analysis of Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRIMSe) study, we hypothesized that older minorities who receive mental health services integrated in primary care settings would have greater service use and better mental health outcomes than older minorities referred to community services.

Engaging Asian Americans for Mental Health Research: Challenges and Solutions

Asian American communities have important and unmet mental health needs, but there is comparatively little research data on process and outcomes that can guide evidence-based approaches to mental health care. This paper describes our experience of building research programs in a community-based health care facility, some of the challenges we faced, and barriers that were overcome. We have learned that a) mental health services research can be carried out in a community health center with minimal intrusion on usual patient flow; b) the effort must be shared between the health center and the community; c) barriers to participation in mental health research programs are multifactorial ranging from conceptual, cultural, and attitudinal biases to practical concerns inherent in the ethnic minority population; and d) resistance can be overcome by working with participants’ cultural and social needs and using their explanatory belief models when developing and pursuing studies.

Self-attention as a mediator of cultural influences on depression.

Background: Despite the widespread recognition of cultural differences in depressive symptoms, it is unclear through what processes culture affects depressive symptoms. Aim: This research aims at examining whether self-attention mediates the influence of acculturation on changes in depressive symptoms in an immigrant group. Method: Adults of Asian cultural backgrounds were surveyed. Depressive symptoms were assessed and divided into three categories: affective, somatic and interpersonal items of depression. Acculturation experiences were measured. Self-attention to three aspects (i.e. affective, somatic and interpersonal) of the self was also assessed. Results: As acculturation proceeds, Asian immigrants tend to pay increasingly more attention to the affective aspect of the self and less to the somatic aspect of the self. The changes in the focus of self-attention seem to explain the changes in the experience of depression that include more affective and less somatic symptoms of depression as the degree of acculturation increases. Conclusion: Self-attention to certain aspects of the self seems to play an important role mediating the influence of acculturation on changes in subcategories of depressive symptoms.

A Classification Scheme for Analyzing Mobile Apps Used to Prevent and Manage Disease in Late Life

Background There are several mobile apps that offer tools for disease prevention and management among older adults, and promote health behaviors that could potentially reduce or delay the onset of disease. A classification scheme that categorizes apps could be useful to both older adult app users and app developers. Objective The objective of our study was to build and evaluate the effectiveness of a classification scheme that classifies mobile apps available for older adults in the “Health & Fitness” category of the iTunes App Store. Methods We constructed a classification scheme for mobile apps according to three dimensions: (1) the Precede-Proceed Model (PPM), which classifies mobile apps in terms of predisposing, enabling, and reinforcing factors for behavior change; (2) health care process, specifically prevention versus management of disease; and (3) health conditions, including physical health and mental health. Content analysis was conducted by the research team on health and fitness apps designed specifically for older adults, as well as those applicable to older adults, released during the months of June and August 2011 and August 2012. Face validity was assessed by a different group of individuals, who were not related to the study. A reliability analysis was conducted to confirm the accuracy of the coding scheme of the sample apps in this study. Results After applying sample inclusion and exclusion criteria, a total of 119 apps were included in the study sample, of which 26/119 (21.8%) were released in June 2011, 45/119 (37.8%) in August 2011, and 48/119 (40.3%) in August 2012. Face validity was determined by interviewing 11 people, who agreed that this scheme accurately reflected the nature of this application. The entire study sample was successfully coded, demonstrating satisfactory inter-rater reliability by two independent coders (95.8% initial concordance and 100% concordance after consensus was reached). The apps included in the study sample were more likely to be used for the management of disease than prevention of disease (109/119, 91.6% vs 15/119, 12.6%). More apps contributed to physical health rather than mental health (81/119, 68.1% vs 47/119, 39.5%). Enabling apps (114/119, 95.8%) were more common than reinforcing (20/119, 16.8%) or predisposing apps (10/119, 8.4%). Conclusions The findings, including face validity and inter-rater reliability, support the integrity of the proposed classification scheme for categorizing mobile apps for older adults in the “Health and Fitness” category available in the iTunes App Store. Using the proposed classification system, older adult app users would be better positioned to identify apps appropriate for their needs, and app developers would be able to obtain the distributions of available mobile apps for health-related concerns of older adults more easily.

Food stamps: A reminiscence therapy tablet game for Chinese seniors

During their aging process, many seniors are likely to develop mild cognitive impairment which could easily lead to Alzheimers disease or dementia. Besides medication treatment, various reminiscence therapy methods have been proven to be effective in terms of enhancing the cognitive capacities of seniors, as well as improving their capabilities to participate in daily activities. This paper describes our design and implementation a reminiscence therapy game on Android tablet for Chinese seniors to help them maintain their memory capacities as well as their calculating abilities. To be more effective as a method of reminiscence therapy, we choose government food stamps that were mandated in China from 1960s to 1980s, as the backdrop of our game. With our experiment and further studies in the future, we aim to prove that this type of reminiscence therapy games can help seniors to maintain their memory capacity and postpone the development of potential Alzheimers disease, and eventually dementia.

Delivering Telemonitoring Care to Digitally Disadvantaged Older Adults: Human-Computer Interaction (HCI) Design Recommendations

Although telemonitoring has promise in improving care delivery and reducing unnecessary health care costs, the recent years have witnessed growing interest in identifying and resolving barriers to engagement, participation, and spreading of telemonitoring service programs among digitally disadvantaged populations. Based on a review of three key conceptual perspectives relevant to the problem of the digital divide, specific issues concerning technological acceptance, human resources development, and collaboration with service systems are described. Major strategies and policy implications are discussed with regard to HCI design considerations for telemonitoring of medical and aging conditions of the target population, integration of the telemonitoring service into the existing clinical and social context, and development of reimbursement policy that supports not only service use but also access to technology services and additional training for effective use of the technology.