Comparative Effectiveness of Clinician- Versus Peer-Supported Problem-Solving Therapy for Rural Older Adults With Depression.

OBJECTIVE: Self-guided and peer-supported treatments for depression among rural older adults may address some common barriers to treatment. This pilot study compared the effect on depression of peer-supported, self-guided problem-solving therapy (SG-PST) with case management problem-solving therapy (CM-PST) among older adults in rural California. METHODS: Older adults with depression (N=105) received an introductory PST session with a clinician, followed by 11 sessions of CM-PST with a clinician (N=85) or SG-PST with a peer counselor (N=20). RESULTS: Both interventions resulted in clinically significant improvement in depression by week 12. Depression scores in the CM-PST group dropped by 4.1 points more than in the SG-PST group between baseline and week 12 (95% CI=0.99-7.22, p<0.001, Hedges's g=1.08). CONCLUSIONS: The results suggest that peer-supported SG-PST is a viable, acceptable option for rural older adults with depression as a second-line treatment if access to clinicians is limited.

Effectiveness of Case Management with Problem-Solving Therapy for Rural Older Adults with Depression.

OBJECTIVE: To evaluate the effect of case management with problem solving therapy (CM-PST) on depression and disability among rural older adults and compare its effect with outcomes derived from a previous, but similar study among 84 urban older adults. METHODS: This study examined the comparative effectiveness of a CM-PST intervention for older adults with depression and unmet needs across rural and urban settings. Participants received 12 one-hour sessions of CM-PST with a master's-level clinician. A total of 56 rural and 84 urban adults aged 60 and older experiencing mild to moderate depression received services in their homes. RESULTS: The rural CM-PST intervention resulted in significantly reduced depression (reduction of 13.9 points, 95% CI 12.2 to 15.7, t(422)= 15.35, p<0.0001) and disability by week 12 (reduction of 6.7 points, 95% CI 4.8 to 8.5, t(425)= 7.01, p<0.0001). Reductions in depression and disability were sustained through week 24. The reductions in depression (F=3.98 df=4,388. p=0.0035) and disability (F=2.71, df=4,381, p=0.03) found in the rural sample were comparable to, or better than, those found in the urban sample. Improvements in unmet need and resilience predicted lower depression scores at 12 weeks, while improvements in unmet need and hopelessness predicted improvements in disability. No moderators of depression were identified, but baseline values of self-efficacy, resilience, and hopelessness moderated disability. CONCLUSIONS: CM-PST was as effective at reducing depression and disability among rural older adults as it was for urban older adults. Home-delivered CM-PST can be successfully adapted to meet the specific needs of rural seniors using resources often available in rural communities.

Is computerized cognitive-behavioural therapy a treatment option for depression in late-life? A systematic review.

OBJECTIVE: Computerized cognitive-behavioural therapy (CCBT) may enhance older adults' access to evidence-based depression treatment. Our objective was to determine the extent to which adults aged 65 years and older are represented in existing studies of CCBT for depression and describe available data on recruitment, retention, and outcomes. METHODS: We retrieved all controlled and uncontrolled trials of CCBT for depression published between 2000 and 2010. We obtained data on older adults via the article text or correspondence with authors. RESULTS: Older adults comprised approximately 3% of study participants in reviewed studies. Authors reported that older participants may be less likely than younger adults to drop out, but more likely to experience technical challenges. CONCLUSIONS: Older adults are under-represented in studies of CCBT for depression.

Sustained adoption of an evidence-based treatment: a survey of clinicians certified in problem-solving therapy.

Training models that incorporate case supervision in addition to didactic instruction appear to be effective in maximizing clinicians' proficiency in evidence-based treatments (EBTs). However, it is unknown the extent to which these models promote sustained adoption of EBTs. We describe the results of an online survey on post-training utilization of an EBT, problem-solving therapy (PST), among 40 clinicians highly trained in PST. Seventy-five percent of the survey's 40 respondents reported that they continued to use PST in their clinical practices. Many PST-trained clinicians reported that they had modified the PST protocol in their clinical practices according to patient characteristics or preferences. Considering these results, we recommend emphasizing patient variability and treatment tailoring throughout the training process as a means for promoting clinicians' sustained adoption of EBTs.

Health-related internet use in older primary care patients.

BACKGROUND: Adults aged 65 years and older stand to benefit from the accumulating wealth of Internet-based health resources, including online interventions to assist in the self-management of chronic health conditions. However, concerns have been expressed that lesser Internet use and familiarity among older adults may limit the utility of web-based health interventions in older age groups. As these interventions become more prevalent, it is important to understand older adults' receptivity to using the Internet as a tool in managing healthcare. OBJECTIVE: The purpose of the present study was to gauge the extent to which older primary care patients are receptive to using web-based health resources, and to explore how health-related Internet use may be related to patient characteristics such as age, income, and health and mental health status. METHODS: We surveyed 50 adults aged 65 years and older in a Veterans Administration primary care clinic regarding: (1) Internet use for any purpose, (2) Internet use to obtain health or mental-related information, and (3) interest in using Internet-based interventions to address various health-related needs. A substantial proportion of respondents were in their 70s, 80s, and 90s, and many had multiple medical conditions. RESULTS: Nearly three-quarters of older primary care patients in our sample were regular Internet users and over half had experience in using the Internet to search for health information. The majority of Internet users endorsed an interest in using web-based resources to manage various aspects of their health and mental healthcare. CONCLUSIONS: Our results support the conclusion that older primary care patients, including those among the oldest-old and those with multiple medical conditions, are amenable to using the Internet as a means of enhancing healthcare.

Age-related patterns in mental health-related complementary and alternative medicine utilization in Canada.

BACKGROUND: The aim of this study was to examine whether age-related differences in rates of use of complementary and alternative medicine (CAM) specifically for mental health problems parallel well-known age-related differences in use of conventional mental health services and medications. METHODS: A sample of middle-aged (45-64 years; n = 10,762), younger-old (65-74; n = 4,113) and older-old adults (75 years and older; n = 3,623) was drawn from the 2001-2002 Canadian Community Health Survey (CCHS), Cycle 1.2, Mental Health and Wellbeing. Age-related utilization rates of conventional and complementary mental health services and medications/products were calculated. Logistic regression analyses were used to examine the strength of association between age group and utilization of services and medications or products in the context of other important sociodemographic and clinical characteristics. RESULTS: When considered in the context of other sociodemographic and clinical characteristics, older age was positively associated with mental health-related utilization of alternative health products. Older age was not significantly associated with mental health-related consultations with CAM providers. CONCLUSIONS: Overall, age-related patterns in mental health-related use of CAM did not directly correspond to age-related patterns in conventional mental health care utilization, suggesting different sets of predictors involved in seeking each type of care.

Cognitive-Behavioral Therapy for Depression in an Older Gay Man: A Clinical Case Study.

Although strong evidence supports cognitive-behavioral therapy for late-life depression and depression in racial and ethnic minorities, there are no empirical studies on the treatment of depression in older sexual minorities. Three distinct literatures were tapped to create a depression treatment protocol for an older gay male. Interventions were deduced from the late-life depression literature, culturally adapted CBT protocols for racial minorities, and the emerging social and developmental psychological theories for lesbian, gay, and bisexual populations. Specific treatment interventions, processes, and outcomes are described to illustrate how these literatures may be used to provide more culturally appropriate and effective health care for the growing, older sexual minority population.

Utilization of mental health care services among older adults with depression.

Despite the availability of effective treatments for late life depression, data indicate that only a small minority of adults over the age of 65 years with depression access any kind of care for emotional or mental health problems. Using data from the Canadian Community Health Survey (Cycle 1.1), we compared patterns of mental health service utilization among middle-aged (45-64 years), younger old (65-74 years), and older old (75 years and older) adults with and without depression and identified predictors associated with accessing different services (n=59,302). Compared to middle-aged adults with depression, individuals aged 65 and older with depression were less likely to report any mental health consultation in the past year and especially unlikely to report consulting with professionals other than a family physician. Age remained a significant predictor of mental health service utilization even after accounting for other relevant variables such as gender, marital status, years of education, depression caseness, and number of chronic medical conditions. Although the prevalence of depression is lower in older age groups, the present study provides compelling evidence that mental health services are particularly underutilized by depressed older adults.

Propagating fronts, chaos and multistability in a cell replication model.

Numerical solutions to a model equation that describes cell population dynamics are presented and analyzed. A distinctive feature of the model equation (a hyperbolic partial differential equation) is the presence of delayed arguments in the time (t) and maturation (x) variables due to the nonzero length of the cell cycle. This transport like equation balances a linear convection with a nonlinear, nonlocal, and delayed reaction term. The linear convection term acts to impress the value of u(t,x=0) on the entire population while the death term acts to drive the population to extinction. The rich phenomenology of solution behaviour presented here arises from the nonlinear, nonlocal birth term. The existence of this kinetic nonlinearity accounts for the existence and propagation of soliton-like or front solutions, while the increasing effect of nonlocality and temporal delays acts to produce a fine periodic structure on the trailing part of the front. This nonlinear, nonlocal, and delayed kinetic term is also shown to be responsible for the existence of a Hopf bifurcation and subsequent period doublings to apparent "chaos" along the characteristics of this hyperbolic partial differential equation. In the time maturation plane, the combined effects of nonlinearity, nonlocality, and delays leads to solution behaviour exhibiting spatial chaos for certain parameter values. Although analytic results are not available for the system we have studied, consistency and validation of the numerical results was achieved by using different numerical methods. A general conclusion of this work, of interest for the understanding of any biological system modeled by a hyperbolic delayed partial differential equation, is that increasing the spatio-temporal delays will often lead to spatial complexity and irregular wave propagation. (c) 1996 American Institute of Physics.