Jo Anne Sirey

Depressive Symptoms and Suicidal Ideation among Older Adults Receiving Home Delivered Meals

Homebound older adults may be vulnerable to the deleterious impact of untreated depression. Yet because these elders are difficult to reach, there is little data on the rates of depressive symptoms and suicidal ideation among this group. The objective of this study is to document the rates of depression and correlates among a population of homebound elders.

Improving Antidepressant Adherence and Depression Outcomes in Primary Care: The Treatment Initiation and Participation (TIP) Program

OBJECTIVE To test the impact of a novel psychosocial intervention to improve antidepressant adherence and depression outcomes among older adults prescribed pharmacotherapy by their primary care physician (PCP). DESIGN A randomized controlled pilot study was conducted to examine the usefulness of the Treatment Initiation and Participation (TIP) program as an intervention to improve antidepressant adherence and depression outcomes. SETTING The study was conducted at two primary care clinics in New York city: one clinic served geriatric adults and the second clinic served a diverse group of mixed aged adults. PARTICIPANTS The sample consisted of adults aged 60 years and older with major depression who were recommended antidepressant therapy by their PCPs. INTERVENTION All participants were prescribed antidepressant therapy and randomly assigned to either the intervention (TIP) or the treatment as usual (TAU) group. The TIP intervention identifies and targets psychological barriers to depression care, especially stigma, as well as fears and misconceptions of depression and its treatment. TIP participants are encouraged to develop a treatment goal and create an adherence strategy. MEASUREMENT Study participants were assessed at entry, 6, 12, and 24 weeks later. Adherence was measured based on self-report with chart verification. Depression severity was measured using the Hamilton Depression Rating Scale. RESULTS Participants in TIP were significantly more adherent to their antidepressant pharmacotherapy at all assessment time points and had a significantly greater decrease in depressive symptoms than older adults who received TAU. CONCLUSION The results provide support for the usefulness of TIP as a brief intervention to improve adherence to depression medication treatment provided in primary care settings.

Medication Beliefs and Self-Reported Adherence Among Community-Dwelling Older Adults

BACKGROUND Nonadherence to medications among older adults can compromise quality care. Among older adults with chronic diseases, nonadherence rates can reach 50%. Individual-level obstacles to full adherence may come from psychological, illness (and disability due to aging or other impairments), and tangible barriers. In this study, we examine the barriers associated with nonadherence among community-dwelling older persons participating in Aging Service Network nutrition programs. OBJECTIVE The goal of this study was to examine the relation of psychological, illness, and tangible barriers to reported medication adherence among older adults in a community, nonmedical setting. METHODS Older adults (N = 299) receiving congregate meals participated in a study of factors associated with medication-taking behaviors and adherence. Self-reported medication nonadherence was measured by using the Morisky Medication Adherence Scale. Psychological barriers were assessed by using a risk/benefit score (perceived concerns vs necessity of medications). Illness barriers reviewed included overall cognitive functioning, disability, medical burden, and depression. Tangible barriers included number of medications, difficulty handling medication, and perceived cost. RESULTS Most participants took multiple medications (mean, 4.8) each day, and 4 of 10 older adults (41% [122 of 299]) reported at least 1 nonadherent behavior. The psychological barrier of a low risk/benefit score (odds ratio = 0.73 [95% CI, 0.6-0.94]) and the tangible barrier of difficulty opening the medication bottle (odds ratio = 2.16 [95% CI, 1.3-3.6]) were independently associated with nonadherence. CONCLUSIONS In a community-dwelling sample of older adults, nonadherence to medication was associated with both tangible and psychological barriers. Beliefs about medication can be powerful barriers to a successful adherence strategy. Adherence interventions should address the multilevel barriers (psychological, illness, and tangible) to adherence among older adults.

Promoting the transition to independent scientist: a national career development program.

The loss of new investigators from academic science places the future of biomedical science at risk. Failure to obtain independent funding contributes significantly to attrition from the academic career path. In this article, the authors describe the Advanced Research Institute (ARI) in Geriatric Mental Health, a national program based at Weill Cornell Medical College of Cornell University that matches new investigators with mentors to help them make a successful transition to independence. The program is multidisciplinary, and its faculty and participants (the latter known as “scholars”) span the spectrum of translation, interventions, and services research. ARI helps scholars overcome three barriers to independence through the development of grant-preparation and time-management skills and consultation with statistical and other experts. The authors analyze the record of federal grant funding among the first four cohorts of ARI scholars (2004–2007, n = 42). As of January 2010, 45.2% of these scholars had achieved R01 funding and 69.1% had obtained National Institutes of Health grants (not including career development or small grants). The 24 scholars who had National Institute of Mental Health (NIMH) mentored career development (mentored K) awards were 2.36 times (P = .048) more likely than the other 380 recipients of NIMH mentored K awards during the same period (2001–2005) to achieve R01 funding. Based on objective outcomes, ARI offers an effective model for stemming attrition of new investigators from the academic career path that is generalizable to other fields and promotes innovative, translational science.

Personalised intervention for people with depression and severe COPD

Chronic obstructive pulmonary disease (COPD) is often complicated by depression and exemplifies the challenge in managing chronic illnesses that require active patient participation in care. In a clinical trial (NCT00151372), we compared a novel personalised intervention for depression and COPD (PID-C) targeting treatment adherence with treatment as usual (TAU). In 138 patients with major depression and severe COPD, PID-C led to a higher remission rate and a greater reduction in depressive symptoms and in dyspnoea-related disability than TAU over 28 weeks and 6 months after the last session. If replicated, PID-C may serve as a care model for patients with both depression and medical illnesses with a deteriorating course.

Ecosystem focused therapy in poststroke depression: a preliminary study

Poststroke depression (PSD) occurs in the context of abrupt, often catastrophic disability that finds the patient and his or her family unprepared. We developed the Ecosystem Focused Therapy (EFT), a systematic intervention aimed to increase the PSD patients and his or her ecosystems abilities to address the “psychosocial storm” of PSD and utilize available treatments effectively and efficiently. This is a preliminary study of its efficacy.

Caregiving Tasks and Training Interest of Family Caregivers of Medically Ill Homebound Older Adults

Objectives: This study assessed the caregiving activities and training interests of family caregivers of medically ill older adults without dementia who receive home health care. Methods: Participants were 101 family caregivers of patients from the Training in the Assessment of Depression (TRIAD) study. Caregivers were assessed using a sociodemographic questionnaire and measures of caregiver tasks and training interest. Results: Family caregivers provided a variety of caregiving tasks and their interest in training was independent of current provision of tasks. Black caregivers expressed greater overall interest in receiving training than did White caregivers, as did younger caregivers compared to same-generation caregivers. Discussion: Family caregivers in this study evidenced both a range of care provision and clear interest in improving caregiving skills through training. Research efforts should focus on meeting the specific training needs of family caregivers and determining the impact training can have on patient health outcomes.

Preferences for Depression Treatment Among Elderly Home Health Care Patients

OBJECTIVE The authors hypothesized that the depression treatment preferences of elderly home care patients would vary by their experience of depression and that preferences for active treatment would be associated with current depression and with antidepressant treatment. METHODS The authors conducted cross-sectional secondary analyses of data from the TRIAD study (Training in the Assessment of Depression) of 256 randomly selected elderly patients newly admitted to home care. The study assessed preference for active treatments (medication or psychotherapy) and nonactive or complementary approaches (such as religious activities or doing nothing). Nondepressed patients were asked to choose as if they had serious depression. Two separate indicators of depression experience were used: a current diagnosis of major or minor depression and current or previous antidepressant treatment. RESULTS Of the 256 patients, 16% (N=41) met criteria for major or minor depression. Forty-seven percent of the sample (N=121) preferred an active treatment as their first choice, and others preferred nonactive or complementary approaches. Logistic regression indicated that current antidepressant use, previous psychotherapy experience, white or Hispanic race-ethnicity (versus black), greater impairment in instrumental activities of daily living, and less personal stigma about depression were independently associated with preference for an active treatment. CONCLUSIONS Elderly home care patients had a variety of treatment preferences, ranging from active treatments, to religious or spiritual activities, to no treatment. Several factors were associated with a preference for active treatment, including treatment experience, physical impairment, race-ethnicity, and attitudes and beliefs. An understanding of patient preferences may help engage older depressed home care patients in treatment.

Untangling therapeutic ingredients of a personalized intervention for patients with depression and severe COPD.

OBJECTIVE We developed a personalized intervention for depressed patients with COPD (PID-C) aimed to mobilize patients to participate in the care of both conditions. We showed that PID-C reduced depressive symptoms and dyspnea-related disability more than usual care over 28 weeks. This study focused on untangling key therapeutic ingredients of PID-C. DESIGN Randomized controlled trial. SETTING Community. PARTICIPANTS 138 patients who received the diagnoses of COPD and major depression after screening 898 consecutive admissions for acute inpatient pulmonary rehabilitation. INTERVENTION Nine sessions of PID-C compared with usual care over 28 weeks. MEASUREMENTS Primary outcome measures were the 17-item Hamilton Depression Rating Scale and the Pulmonary Functional Status and Dyspnea Questionnaire-Modified. Other measures were adherence to rehabilitation exercise (≥2 hours per week) and adherence to adequate antidepressant prescriptions. RESULTS Low severity of dyspnea-related disability and adherence to antidepressants predicted subsequent improvement of depression. Exercise and low depression severity predicted improvement of dyspnea-related disability. CONCLUSIONS PID-C led to an interacting spiral of improvement in both depression and disability in a gravely medically ill population with a 17% mortality rate over 28 weeks and an expected deterioration in disability. The interrelationship of the course of depression and dyspnea-related disability underscores the need to target adherence to both antidepressants and chronic obstructive pulmonary disease rehabilitation. PID-C may serve as a care management model for depressed persons suffering from medical illnesses with a deteriorating course.

Implementing Evidence-Based Psychotherapies in Settings Serving Older Adults: Challenges and Solutions

This Open Forum addresses challenges--insurance limitations, staff and setting limitations, and training and sustainability issues--in the implementation of psychotherapy interventions in settings serving older adults and provides solutions for ensuring that they have access to effective mental health services. There is considerable movement toward developing the geriatric mental health workforce, and it is important that these efforts include a discussion of implementation issues with regard to evidence-based psychotherapies as they are provided in services for aging populations.