Honors and Awards
Suicide rates in older men are higher than in the general population, yet their utilization of mental health services is lower.
This study aimed to describe: (a) what primary care providers (PCPs) can do to prevent late-life suicide, and (b) older men's attitudes toward discussing suicide with a PCP.
Thematic analysis of interviews focused on depression and suicide with 77 depressed, low-socioeconomic status, older men of Mexican origin, or US-born non-Hispanic whites recruited from primary care.
Several themes inhibiting suicide emerged: it is a problematic solution, due to religious prohibition, conflicts with self-image, the impact on others; and, lack of means/capacity. Three approaches to preventing suicide emerged: talking with them about depression, talking about the impact of their suicide on others, and encouraging them to be active. The vast majority, 98%, were open to such conversations. An unexpected theme spontaneously arose: "What prevents men from acting on suicidal thoughts?"
Suicide is rarely discussed in primary care encounters in the context of depression treatment. Our study suggests that older men are likely to be open to discussing suicide with their PCP. We have identified several pragmatic approaches to assist clinicians in reducing older men's distress and preventing suicide.
The purpose of the present study was to examine a new protocol involving the spontaneous correction of the misplaced tip of a peripherally inserted central catheter (PICC). Patients with PICCs misplaced in the jugular or contralateral subclavian veins were recruited. All patients underwent chest X-ray (CXR) after 3 days. In addition, those whose PICC tip still was misplaced and received another CXR after 4 days. The functions of the catheters, the subjective feelings of the patients, and local symptoms of the neck and upper anterior chest wall were recorded. Among 866 patients who had PICCs, we observed 22 PICC tips misplaced in the jugular, 3 tips misplaced in the contralateral subclavian vein, and 7 tips misplaced in other locations, which was confirmed by CXR. A total of 22 PICC tips automatically returned to the superior vena cava, which included all 3 tips in the contralateral subclavian vein and 19 tips in the jugular vein. All catheters functioned normally, and the patients had no complaints. In addition, we observed no local symptoms of the neck and upper anterior chest wall. For patients experiencing a PICC misplaced in the jugular and contralateral subclavian veins, there is no need to manually replace. In addition, the function of the catheter can remain normal.
Siblings of individuals diagnosed with schizophrenia are an important source of family caregiving. Unfortunately, limited information is available about sibling caregivers because existing studies have focused on other family relationships such as parents, spouses, and children. To fill the knowledge gap, the purpose of this study is to describe Korean sibling caregivers' experience with individuals diagnosed with schizophrenia. Guided by Colaizzi's descriptive phenomenological methodology, we conducted in-depth, semi-structured, face-to-face interviews with eight individuals who have a sibling (1) diagnosed with schizophrenia and (2) hospitalized in an inpatient psychiatric unit. We discerned six key themes: sorrow, burnout, shame, different perspectives in life, acceptance, and responsibility. We categorized these themes into three groups: suffering, hope, and responsibility and obligation. Sibling caregivers of individuals with schizophrenia experience a mixture of several emotions. Participants loved their brother or sister with schizophrenia, but at the same time they felt shame and fear. While they were burdened by the responsibilities of caregiving, they remained loyal to their sibling with schizophrenia, continuing to help their siblings reach their full potential. Although participants were confused about the symptoms of schizophrenia, they were committed to learning more about the illness. Because we conducted the current study in Korea, the findings of this study may be unique to Korea culture. Further studies are needed to compare and contrast nuanced differences in sibling caregivers' experience among different cultural groups.
Supportive behaviors (both instrumental and emotional) from spouses and close family members can impact the trajectory of older adults' depressive symptoms. Interventions that target both the patient and support person may be more effective than interventions that target the patient only, in terms of alleviating mood symptoms in the identified patient. The purpose of this paper was to review the characteristics and findings of dyadic and family-oriented interventions for late-life mood disorders to determine if they are effective and beneficial.
Following PRISMA guidelines, we conducted a systematic review of reports in the literature on dyadic or family-oriented interventions for late-life mood disorders. We searched PubMed, OVID PsycINFO, and EMBASE for peer-reviewed journal articles in English through October 2014.
We identified 13 articles, representing a total of 10 independent investigations. Identified studies focused on spouses and close family members as support persons. Effect sizes for dyadic interventions that treated major depressive disorder were, on average, moderately strong, while effect sizes for dyadic interventions that reduced depressive symptoms were generally small. We did not identify any dyadic studies that treated bipolar disorder.
This review showed that dyadic interventions are feasible and that these interventions can decrease symptomatology in individuals who have major depressive disorder. Research is needed to understand the relative efficacy of a dyadic approach over a single-target approach in treating depression. Copyright © 2016 John Wiley & Sons, Ltd.
Variations Among Medicare Beneficiaries Living in Different Settings: Demographics, Health Status, and Service Use.
Older people with complex health issues and needs for functional support are increasingly living in different types of residential care environments as alternatives to nursing homes. This study aims to compare the demographics and health-care expenditures of Medicare beneficiaries by the setting in which they live: nursing homes, residential care settings, and at home using data from the 2002 to 2010 Medicare Current Beneficiary Study (MCBS), a nationally representative survey of the Medicare population. All Medicare beneficiaries aged 65 years or older who participated in the fall MCBS interview (years 2002-2010) and were alive for the full year (N = 83,507) were included in the sample. We found that there is a gradient in health status, physical and cognitive functioning, and health-care use and spending across settings. Minority elderly are overrepresented in facilities and underrepresented in alternative living settings.
Where You Live May Make You Old: The Association between Perceived Poor Neighborhood Quality and Leukocyte Telomere Length.
Strong evidence supports that living in disadvantaged neighborhoods has direct unfavorable impact on mental and physical health. However, whether it also has direct impact on cellular health is largely unknown. Thus we examined whether neighborhood quality was associated with leukocyte telomere length, an indicator of cellular aging.
In May 2014, we extracted and analyzed baseline data from the Netherlands Study of Depression and Anxiety (NESDA), a large epidemiological study of individuals age between 18-65 years (n=2902). Telomere length was determined using quantitative polymerase chain reaction. Neighborhood quality was assessed using modified measures of perceived neighborhood disorder, fear of crime, and noise. We used multivariable linear regression models to examine association between perceived neighborhood quality and telomere length with comprehensive adjustment for individual and community characteristics related to socioeconomic and demographic status, urbanization level, mental and physical health, and lifestyle.
Compared to individuals who reported good neighborhood quality, the mean telomere length of those who reported moderate neighborhood quality was approximately 69 base pair shorter (β =-69.33, 95% CI: -119.49, -19.17, p= 0.007), and that of those who reported poor neighborhood quality were 174 base pair shorter (β =-173.80, 95% CI: -298.80, -49.01, p=0.006). For illustrative purposes, one could extrapolate these outcomes to 8.7 and 11.9 years in chronological age, respectively.
We have established an association between perceived neighborhood quality and cellular aging over and above a range of individual attributes. Biological aging processes may be impacted by socioeconomic milieu.
Ethnic and gender variations in the associations between family cohesion, family conflict, and depression in older Asian and Latino adults.
To examine the associations between family conflict, family cohesion and late-life depression in Latino and Asian populations and test if these associations vary by race/ethnicity and gender. We used a subsample of older adults from the National Latino Asian American Study (N = 395). All analyses were weighted and adjusted for individual and clinical characteristics. Greater family cohesion was associated with decrease in risk for depression in Latino and Asian older adult populations (OR: 0.68, 95% CI: 0.54, 0.84). These associations varied by gender, with men being more sensitive to family cohesion and family conflict than women. Asian older adults were more sensitive to family conflict, whereas Latino older adults were more sensitive to family cohesion. The quality of family relationships is strongly associated with late-life depression. Further research is needed to better understand the complex interplay between social support, ethnicity, and gender in latelife depression outcomes.
Social support is an important extra-therapeutic context of depression treatment, yet no overall estimate is available on how depression treatment affects social support or the size of such an effect. We conducted a meta-analysis of clinical trials of psychotherapy for depression that reported results for social support at post-treatment. A total of 1,579 adults with depression from 11 trials comparing psychotherapy to care-as-usual or waiting list were included. The majority of these studies assessed the participants' perceptions of social support. Specifically, three studies targeted women with postpartum depression, and four studies targeted individuals with chronic disease. In all these studies, psychotherapy had a small to moderate, yet consistent effect on social support compared to care-as-usual or waiting list at post-treatment (g = 0.38; 95% CI: 0.29~0.48) and at 3-6 month follow-up (g= 0.38; 95% CI: 0.14~0.63). Little evidence of heterogeneity was found across studies, and the results were consistent in several sensitivity analyses. No significant publication bias was detected (Egger's test p > 0.1). The result of meta-regression showed that improvement in depression symptoms was associated with improvement in social support, but this was not statistically significant.
Older adults with Diabetes Mellitus (DM) experience greater risk for comorbid depression compared to those who do not have DM. Undetected, untreated or under-treated depression impinges an individual's ability to manage their DM successfully, hinders their adherence to treatment regime, and undermines provider-patient relationships. Thus, in the context of caring for older adults with DM, comorbid depression presents special challenges and opportunities for clinicians. In this article, we summarize the clinical presentation of late-life depression, potential mechanisms of comorbidity of depression and DM, importance of depression in the successful management of DM, and available best practice models for depression treatment.
Socioeconomic and racial/ethnic oral health disparities among US older adults: oral health quality of life and dentition.
This study aims to examine if older adults living in poverty and from minority racial/ethnic groups experienced disproportionately high rates of poor oral health outcomes measured by oral health quality of life (OHQOL) and number of permanent teeth.
Cross-sectional analysis of 2,745 community-dwelling adults aged ≥65 years from the National Health and Nutrition Examination Survey (NHANES) 2005-2008. Oral health outcomes were assessed by questionnaire using the NHANES-Oral Health Impact Profile for OHQOL and standardized examination for dentition. Logistic and linear regression analyses were used to determine the association between oral health outcomes and predictors of interest. All analyses were weighted to account for complex survey sampling methods.
Both poverty and minority race/ethnicity were significantly associated with poor oral health outcomes in OHQOL and number of permanent teeth. Distribution of scores for each OHQOL domain varied by minority racial/ethnic group.
Oral health disparities persist in older adults living in poverty and among those from minority racial/ethnic groups. The racial/ethnic variation in OHQOL domains should be further examined to develop interventions to improve the oral health of these groups.
A descriptive qualitative study of the roles of family members in older men's depression treatment from the perspectives of older men and primary care providers.
The aim of this study is to describe the roles of family members in older men's depression treatment from the perspectives of older men and primary care physicians (PCPs).
Cross-sectional, descriptive qualitative study conducted from 2008-2011 in primary care clinics in an academic medical center and a safety-net county teaching hospital in California's Central Valley. Participants in this study were the following: (1) 77 age ≥ 60, noninstitutionalized men with a 1-year history of clinical depression and/or depression treatment who were identified through screening in primary care clinics and (2) a convenience sample of 15 PCPs from the same recruitment sites. Semi-structured and in-depth qualitative interviews were conducted and audiotaped then transcribed and analyzed thematically.
Treatment-promoting roles of family included providing an emotionally supportive home environment, promoting depression self-management and facilitating communication about depression during primary care visits. Treatment-impeding roles of family included triggering or worsening men's depression, hindering depression care during primary care visits, discouraging depression treatment and being unavailable to assist men with their depression care. Overall, more than 90% of the men and the PCPs described one or more treatment-promoting roles of family and over 75% of men and PCPs described one or more treatment-impeding roles of family.
Families play important roles in older men's depression treatment with the potential to promote as well as impede care. Interventions and services need to carefully assess the ongoing roles and attitudes of family members and to tailor treatment approaches to build on the positive aspects and mitigate the negative aspects of family support.
The number of studies on psychological treatments of depression in older adults has increased considerably in the past years. Therefore, we conducted an updated meta-analysis of these studies. A total of 44 studies comparing psychotherapies to control groups, other therapies or pharmacotherapy could be included. The overall effect size indicating the difference between psychotherapy and control groups was g=0.64 (95% CI: 0.47-0.80), which corresponds with a NNT of 3. These effects were maintained at 6 months or longer post randomization (g=0.27; 95%CI: 0.16-0.37). Specific types of psychotherapies that were found to be effective included cognitive behavior therapy (g=0.45; 95% CI: 0.29-0.60), life review therapy (g=0.59; 95% CI: 0.36-0.82) and problem-solving therapy (g=0.46; 95% CI: 0.18-0.74). Treatment compared to waiting list control groups resulted in larger effect sizes than treatments compared to care-as-usual and other control groups (p
Hundred forty eight more days with depression: the association between marital conflict and depression-free days.
Although collaborative care programs are effective in improving late-life depression, only about half of treated patients achieve clinically meaningful improvement. Thus, we need to examine what characteristics may predict poor late-life depression course. Despite the robust evidence for the negative association between the quality of couple relationships and depression outcomes, few studies have examined these associations in the context of long-term late-life depression course.
The objective of this study is to examine the relations between the severity of couple conflict, receiving collaborative depression care program, and 24-months depression outcomes.
Study sample comprised 840 depressed older adults subsample from the improving mood, promoting access to collaborative treatment for late-life depression trial (IMPACT). Depression and couple conflict were assessed at baseline, 12-month, and 24-month follow-up. Descriptive statistics and multivariate regression analyses were performed to examine mean 24-month depression-free days (DFD) and the marginal effects of receiving IMAPCT program over usual care among participants with varying degrees of 24-month couple conflict.
Compared with those who never endorsed frequent couple conflict over the three observation points, those who did twice had 63 fewer DFD (p = 0.01), and those who did three times experienced 148 fewer DFD (p
Frequent couple conflict is associated with worse long-term late-life depression outcomes among the patients in primary care clinics.
Although bereavement and depression are both common in older primary care patients, the effect of bereavement on depression intervention outcomes is unknown. We examined whether standard interventions for depression in primary care were as effective for bereaved as for non-bereaved depressed patients.
Randomized controlled trial.
Twenty community-based primary care practices in New York City, greater Philadelphia, and Pittsburgh. Randomization to either intervention or usual care occurred by practice.
Patients aged 60 years or older who met criteria for major depression or clinically significant minor depression (N = 599). Patients who did not complete the bereavement measure or who were missing 4-month data were excluded (final N = 417).
Study-trained depression care managers offered guideline-concordant recommendations to primary care physicians at intervention sites and assisted patients with treatment adherence. Patients who did not wish to take antidepressants could receive interpersonal psychotherapy.
Bereavement was captured using the Louisville Older Persons Events Schedule. Depression severity was assessed using the 24-item Hamilton Depression Rating Scale (HDRS). Outcomes at 4 months were remission (HDRS ≤7) and response (HDRS reduction ≥50% from baseline).
Logistic regressions indicated that, for non-bereaved participants, response and remission were higher in intervention than usual care. However, recently bereaved older adults were less likely to achieve response or remission at 4 months if treated in the intervention condition.
Standard depression care management appears to be ineffective among recently bereaved older primary care patients. Greater attention should be paid in primary care to emotional distress in the context of bereavement.
OBJECTIVE This study examined effectiveness of collaborative care for depression among Asians treated either at a community health center that focuses on Asians (culturally sensitive clinic) or at general community health centers and among a matched population of whites treated at the same general community clinics. METHODS For 345 participants in a statewide collaborative care program, use of psychotropic medications, primary care visits with depression care managers, and depression severity (as measured with the nine-item Patient Health Questionnaire) were tracked at baseline and 16 weeks. RESULTS After adjustment for differences in baseline demographic characteristics, all three groups had similar treatment process and depression outcomes. Asian patients served at the culturally sensitive clinic (N=129) were less likely than Asians (N=72) and whites (N=144) treated in general community health clinics to be prescribed psychotropic medications. CONCLUSIONS Collaborative care for depression showed similar response rates among all three groups.
Depression and risk of mortality in individuals with diabetes: a meta-analysis and systematic review.
To estimate risk of comorbid depression on all-cause mortality over time among individuals with diabetes.
The Medline, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Embase and Science Direct databases were searched through September 30, 2012. We limited our search to longitudinal or prospective studies reporting all-cause mortality among those having depression and diabetes, compared with those having diabetes alone that used hazard ratios (HRs) as the main outcome. Two reviewers independently extracted primary data and evaluated the quality of studies using predetermined criteria. The pooled random effects adjusted HRs were estimated using meta-analysis. The impact of moderator variables on study effect size was examined with meta-regression.
A total of 42,363 respondents from 10 studies were included in the analysis. Depression was significantly associated with risk of mortality (pooled HR=1.50, 95% confidence interval=1.35-1.66). Little evidence for heterogeneity was found across the studies (Cochran Q=13.52, P=.20, I(2)=26.03). No significant possibility of publication bias was detected (Egger's regression intercept=0.98, P=.23).
Depression significantly increases the risk of mortality among individuals with diabetes. Early detection and treatment of depression may improve health outcomes in this population.
Filial piety and parental responsibility: an interpretive phenomenological study of family caregiving for a person with mental illness among Korean immigrants.
Despite the strong influence of culture on family involvement in disease management, few studies have examined how immigrant families care for persons with mental illness. The purpose of this study was to examine how immigrant families organize their world to care for a mentally ill person in the United States. The current analysis focused on how Confucian notions of filial piety and parental obligation shape caregiving in Korean immigrant families.
Participants in this interpretive phenomenological study were comprised of six Korean immigrant women caring for a family member with mental illness. Participants provided narratives that illustrate challenges and opportunities in caring for their mentally ill family member.
Three family caregiving patterns were discerned. Insulating from the outside world describes a family's effort to accept a member's illness and to manage it within the family. Prioritizing education over well-being concerns parental commitment to the Confucian priority of educating one's children. Reciprocating the sacrifice describes how a family adapts and enacts filial piety.
The findings of this study warrant further study to examine the influence of Confucianism among Korean American families. The three patterns of caregiving are strongly aligned with Confucian notion of family and family engagement. These patterns may help health providers to anticipate the needs of and provide individualized, culturally appropriate mental health care for patients with mental illness and their families of Korean origin.
Depression is a common, disabling, and costly condition encountered in older patients. Effective strategies for detection and treatment of late-life depression are summarized based on a case of a 69-year-old woman who struggled with prolonged depression. Clinicians should screen older patients for depression using a standard rating scale, initiate treatment such as antidepressant medications or evidence-based psychotherapy, and monitor depression symptoms. Patients who are not improving should be considered for psychiatric consultation and treatment changes including electroconvulsive therapy. Several changes in treatment approaches are usually needed before patients achieve complete remission. Maintenance treatment and relapse-prevention planning (summarization of early warning signs for depression, maintenance treatments such as medications, and other strategies to reduce the risk of relapse [eg, regular physical activity or pleasant activities]) can reduce the risk of relapse. Collaborative programs, in which primary care clinicians work closely with mental health specialists following a measurement-based treatment-to-target approach, are significantly more effective than typical primary care treatment.
Effective management of depression in the primary care setting requires a systematic, population-based approach, which entails systematic case finding and diagnosis, patient engagement and education, use of evidence-based treatments, including medications and/or psychotherapy, close follow-up to ensure patients are improving, and a commitment to adjust treatments or consult with mental health specialists until depression is significantly improved. Programs in which primary care providers and mental health specialists collaborate effectively using principles of measurement-based stepped care and treatment to target can substantially improve patients' health and functioning while reducing overall health care costs.
Primary care settings present important opportunities for the detection and management of depression in older adults. In this article, the authors review the common barriers to effective treatment of geriatric depression, identify treatment strategies that can substantially improve the effectiveness of treatment in this setting, and highlight the opportunities for addressing health disparities in geriatric depression care. The importance of engaging and supporting family caregivers of depressed older adults and the 3 strategic areas to improve the treatment of geriatric depression in primary care are also discussed.
This article describes, from mental health providers' perspectives, strengths and challenges in Asian American (AA) family management of mental illness in a member. AA family strengths included loyal engagement in care and creating productive roles for patients. Challenges included transitions to professional care, intense family involvement, care that overlooked needs of non-family members, and revision of expectations for patients.
Confucianism is the central philosophic background for much of the culture in East Asia (EA), particularly for understanding family and social context. The purpose of this article is to examine more fully Confucianism as a conceptual framework for understanding EA family processes and health practices. Confucianism stresses the traditional boundaries of ethical responsibility and the ideal of good human life as a whole. Embedded within Confucian values are five principal relationships, through which each person defines a sense of identity, duty, and responsibility. Current studies of EA families that consider Confucianism as a theoretical base focus almost exclusively on filial piety and collectivism. Focusing only on these two aspects prevents scholars from exploring more complex interpretations of EA family life. A broader inclusion of multiple concepts from Confucianism can provide guidance in exploring the complex and multidimensional aspects of EA family life and allow for broader articulation of family processes.