Katy Ruckdeschel

Affect and quality of life: objective and subjective.

Objectives:The objective of this article is to determine direct and indirect contributions of objective and subjective quality of life (QOL) to positive and negative indicators of mental health. Specifically, the dual-channel hypothesis predicted that objective and subjective social engagement would enhance positive affect (PA) but be unrelated to depression. Methods:Older people from senior centers and several housing environments volunteered to complete a questionnaire or interview about a number of aspects of their everyday lives (N= 602). Objective and subjective were related to one another. Results:Objective activity participation and subjective time use and friend quality were associated with PA. Only time use was related to depression. Discussion:The importance of assessing both amount of behavior (objective) and its quality (subjective) when measuring QOL was demonstrated. Although external engagement bears a closer relationship to PA than to negative, the dual-channel model relating locus of stimulation differentially to PA and depression requires modification.

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.

Valuation of Life A Concept and a Scale

Objectives: The objectivewas to derive and test the psychometric characteristics of a scale to measure Valuation of Life (VOL). Methods: Four samples were used in successive phases of exploratory factor analysis, confirmatory factor analysis, reliability and validity testing, and exploration of response-error effects. Estimates of Years of Desired Life were obtained under a variety of hypothetical quality-of-life (QOL)-compromising conditions of poor health. Results: Confirmed 13-item (Positive VOL) and 6-item (Negative VOL) factors were obtained. A significant relationship betweenVOLand mostYears of Desired Life estimates remained when demographic, health, quality of life, and mental health measures were controlled. Analysis of Negative VOL revealed that some respondents misunderstand the meaning of an agree response to negatively phrased items. Discussion: VOL is a cognitive-affective schema whose function as a mediator and moderator between health and end-of-life decisions deserves further research.

R-E-M psychotherapy: A manualized approach for long-term care residents with depression and dementia

ABSTRACT Although depression and dementia are common comorbid illnesses among long-term care residents, psychotherapeutic services for these individuals have not been tailored for their particular needs and circumstances. In this article we present a new model for brief individual psychotherapy-Restore, Empower, Mobilize, or R-E-M-to treat depression in long-term care residents who have mild to moderate dementia. R-E-M treatment has three goals: (1) restore self-esteem and support a positive self-concept, (2) empower residents to make use of their existing abilities, and (3) mobilize residents and the environment to achieve and maintain long-term mental health. We describe the interventions of R-E-M treatment, the construction of a treatment manual, and a pilot evaluation of the treatment with three nursing home residents. Positive outcomes in the pilot have encouraged us to pursue additional treatment development and evaluation. Standardized treatments, such as R-E-M, that yield measurable gains are needed to ensure that long-term care residents with depression and dementia receive the mental health services they require and deserve.

Care of dementia and other mental disorders in assisted living facilities: new research and borrowed knowledge.

Research on assisted living facilities (ALFs) has demonstrated that their residents overlap considerably with those receiving long-term care in nursing homes (NHs) in terms of their ages, cognitive status, chronic medical illnesses, disability, and care needs. Based on these findings, studies conducted specifically in these facilities and lessons learned from research and experience in NHs should inform policies and practice in ALFs. Two articles in this issue of the Journal demonstrate high levels of dementia, other psychiatric disorders, and behavioral disturbance in ALFs, similar to the rates reported for NHs. Together, the articles provide compelling evidence that mental health (MH) care is an important component of the services that should be provided in these facilities, but interpreting and applying their findings requires integrating them with knowledge about the care of NH residents with these conditions. The article by Rosenblatt et al. reports findings from the Maryland Assisted Living Study, a National Institute of Mental Health–supported study based on structured clinical interviews of a representative sample of residents, families, and staff from a stratified sample of small and large ALFs in central Maryland. It reports that approximately two-thirds of the residents had a diagnosable dementia, and 70% of these had clinically significant psychiatric symptoms. Furthermore, more than one-quarter of the residents had another diagnosable psychiatric disorder. Approximately 70% of the residents had depression; 13% had an anxiety disorder, and 12% had a psychosis. Altogether, 80% of the residents had dementia or an active psychiatric disorder. The article proposes a broad view of what constitutes appropriate treatment for dementia, stating, ‘‘Treatment did not necessarily imply pharmacological or medical treatment. For example a participant with Alzheimer’s disease, whose condition was recognized by the facility staff, who was receiving appropriate supervision, and who had a behavioral plan in place to prevent falls or other accidents, might have been regarded as fully treated for dementia.’’ They do not discuss activities or sensitivity to cognitive impairment in the manner in which moment-to-moment or day-to-day care is provided as components of treatment. Nevertheless, using this approach, they judged that approximately 50% of residents with dementia were receiving complete treatment. The article by Gruber-Baldini et al. reports on the Collaborative Studies of Long-term Care, a National Institute on Aging–supported study that obtained caregiver reports of behavioral symptoms in a random sample of residents from ALFs in Florida, Maryland, New Jersey, and North Carolina. It reported that approximately 50% of residents had dementia or cognitive impairment, 14% had depression, and 13% had a psychosis. Altogether, two-thirds had dementia, depression, psychosis, or another psychiatric disorder. The major findings were that approximately onethird of the residents exhibited a behavioral symptom at least once during the 2 weeks before the assessment. Twelve percent of the sample exhibited aggression, with the most common symptoms in this category being cursing and verbal aggression; 22% exhibited verbal behavioral symptoms, with the most common symptoms being constant requests for attention or help; 21% exhibited physical nonaggressive behavioral symptoms, with the most common being pacing, aimless wandering, and trying to get to a different place; and 12% of residents were reported to exhibit resistance to care. They found that behavioral symptoms were more frequent in residents with cognitive impairment, depression, psychosis, and other psychiatric disorders; those taking psychotropic medications; and those with functional impairment. Fifty-three percent of residents were taking a psychotropic medication, 21% were taking neuroleptics, 33% were taking antidepressants, and 24% were taking anxiolytics or hypnotics. Fifty-nine percent of residents taking psychotropic medications did not have current behavioral symptoms; according to the authors, this could represent either appropriate care or inappropriately high medication use. Thirty-six percent of those with behavioral symptoms were not receiving medication; again, according to the authors, this might represent insufficient assessment and treatment. In their discussion, the authors borrow from the recent consensus recommendations from the American Geriatrics Society and the American Association of Geriatric Psychiatry on Improving the Quality of Mental Health in U.S. NHs to recommend interdisciplinary assessment and treatment of behavioral symptoms and greater use of nonpharmacological interventions. The recommendation for nonpharmacological approaches includes the parenthetical qualification ‘‘especially if medications are not effective.’’ The two articles together provide compelling evidence that MH care is a necessary part of assisted living. In this, they extend previous findings on the similarity of ALF and NH residents. The implication must be that dementia and other psychiatric disorders are common causes, components, complications, or comorbidities of the disabilities that make long-term care necessary, regardless of whether services are delivered in ALFs, NHs, or other settings. The