Sabine M. Oishi

Improving primary care for depression in late life: the design of a multicenter randomized trial.

Background.Late life depression can be successfully treated with antidepressant medications or psychotherapy, but few depressed older adults receive effective treatment. Research Design. A randomized controlled trial of a disease management program for late life depression. Subjects.Approximately 1,750 older adults with major depression or dysthymia are recruited from seven national study sites. Intervention.Half of the subjects are randomly assigned to a collaborative care program where a depression clinical specialist supervised by a psychiatrist and a primary care expert supports the patient’s regular primary care provider to treat depression. Intervention services are provided for 12 months using antidepressant medications and Problem Solving Treatment in Primary Care according to a stepped care protocol that varies intervention intensity according to clinical needs. The other half of the subjects are assigned to care as usual. Evaluation.Subjects are independently assessed at baseline, 3 months, 6 months, 12 months, 18 months, and 24 months. The evaluation assesses the incremental cost-effectiveness of the intervention compared with care as usual. Specific outcomes examined include care for depression, depressive symptoms, health-related quality of life, satisfaction with depression care, health care costs, patient time costs, market and nonmarket productivity, and household income. Conclusions.The study blends methods from health services and clinical research in an effort to protect internal validity while maximizing the generalizability of results to diverse health care systems. We hope that this study will show the cost-effectiveness of a new model of care for late life depression that can be applied in a range of primary care settings.

Depression Treatment in a Sample of 1,801 Depressed Older Adults in Primary Care

OBJECTIVES: To examine rates and predictors of lifetime and recent depression treatment in a sample of 1,801 depressed older primary care patients

Reducing Suicidal Ideation in Depressed Older Primary Care Patients

OBJECTIVES: To determine the effect of a primary care–based collaborative care program for depression on suicidal ideation in older adults.

The Alcohol‐Related Problems Survey: Identifying Hazardous and Harmful Drinking in Older Primary Care Patients

OBJECTIVES: Older adults can incur problems at low levels of alcohol consumption because of age‐related physiological changes, declining health and functional status, and medication use. We have developed and tested a screening measure specifically for older people, the Alcohol‐Related Problems Survey (ARPS), to identify older adults with these risks.

Impacting late life depression: integrating a depression intervention into primary care.

Care for depression in late life is often less successful in primary care than in carefully controlled clinical trials. Collaborative care models attempt to integrate mental health services into primary care. The authors conducted two focus groups and semi-structured individual interviews with all Depression Clinical Specialists (DCSs) working with Project IMPACT (Improving Mood: Promoting Access to Collaborative Treatment), a study testing a collaborative care intervention for late life depression, to examine integration of the intervention model into primary care. DCSs described key intervention components, including supervision from a psychiatrist and a liaison primary care provider, weekly team meetings, computerized patient tracking, and outcomes assessment tools as effective in supporting patient care. DCSs discussed details of protocols, training, environmental set-up, and interpersonal factors that seemed to facilitate integration. DCSs also identified research-related factors that may need to be preserved in the real world. Basic elements of the IMPACT model seem to support integration of late life depression care into primary care. Research-related components may need modification for dissemination.

Using data to enhance the expert panel process. Rating indications of alcohol-related problems in older adults.

OBJECTIVE To enhance the validity of a well-known expert panel process, we used data from patient surveys to identify and correct rating errors. METHODS We used the two-round RAND/UCLA panel method to rate indications of harmful (presence of problems), hazardous (at risk for problems), and nonhazardous (no known risks) drinking in older adults. Results from the panel provided guidelines for classifying older individuals as harmful, hazardous, or nonhazardous drinkers, using a survey. The classifications yielded unexpectedly high numbers of harmful and hazardous drinkers. We hypothesized possible misclassifications of drinking risks and used the survey data to identify indications that may have led to invalid ratings. We modified problematic indications and asked three clinician panelists to evaluate the clinical usefulness of the modifications in a third panel round. We revised the indications based on panelist response and reexamined drinking classifications. RESULTS Using the original indications, 48% of drinkers in the sample were classified as harmful, 31% as hazardous, and 21% as nonhazardous. A review of the indications revealed framing bias in the original rating task and vague definitions of certain symptoms and conditions. The modified indications resulted in classifications of 22% harmful, 47% hazardous, and 31% nonhazardous drinkers. CONCLUSIONS Analysis of survey data led to identification and correction of specific errors occurring during the panel-rating process. The validity of the RAND/UCLA method can be enhanced using data-driven modifications.