Developing a Pipeline for the Community-Based Primary Care Workforce and Its Leadership: The Kraft Center for Community Health Leadership's Fellowship and Practitioner Programs.

PROBLEM: Community health centers (CHCs) face challenges recruiting and retaining primary care clinicians. Providing advanced training that enhances clinical skills within a public health framework, teaches leadership, protects time for scholarly activities, and focuses on the social mission may be a successful career development strategy. APPROACH: In July 2012, the Kraft Center for Community Health Leadership developed and implemented two 2-year programs to develop physician and nursing leaders with blended academic-community career paths and identities. The fellowship program for physicians and the practitioner program for early-career physicians and advanced practice nurses include mentored practice in a CHC; monthly learning days; completion of a community-based research project; and, for fellows, matriculation in an MPH program and engagement in a bimonthly leadership seminar. OUTCOMES: The first classes of 5 fellows and 14 practitioners graduated in June 2014. All 5 fellowship graduates were offered full-time positions at the CHCs where they practiced, and 2 have accepted leadership positions at their CHCs. All 14 practitioner graduates remain in community health, 5 have accepted leadership positions, and 2 have obtained grants to support ongoing projects. NEXT STEPS: The authors are tracking graduates' career paths and the programs' impact on CHCs while modifying the programs on the basis of feedback; identifying elements of the programs that may be amenable to more cost-effective delivery; and exploring the potential for federal funding to support expansion of the practitioner program, and for the practitioner program to increase the return on investment provided by the National Health Service Corps.

Greater depression severity in elderly patients with memory complaints is associated with decreased left temporal-parietal dominance indicated by dynamic susceptibility contrast magnetic resonance imaging cerebral blood volume measures.

OBJECTIVE: To assess the relationships among depressive signs and symptoms and left versus right temporal-parietal cerebral blood volumes (CBVs) in elderly patients with a primary complaint of memory loss. METHODS: Total Geriatric Depression Scale Short Form (GDS-SF) scores, left and right temporal-parietal cerebral blood volume values, and other prospectively recorded data were obtained via chart review of 24 patients aged >/=65 years, evaluated between 1995 and 2000 at McLean Hospital for a primary complaint of memory loss. Multivariate regression analyses were carried out with GDS-SF total scores as outcome variables, with CBV values as explanatory factors and with several patient characteristics as covariates. RESULTS: Depressive symptoms, as measured by the GDS-SF, were significantly associated with decreased left/right temporal-parietal CBV ratios (beta regression coefficient = -20.7; t [df = 22] = -2.96, p = 0.007). These findings remained statistically significant after controlling for age, sex, Mini-Mental State Exam (MMSE) score, years of education, years of memory loss, and handedness (beta regression coefficient = -16.7; t [df = 16] = -2.67, p = 0.017). CONCLUSION: In this study, severity of depressive symptoms as measured by the GDS-SF in patients >/=65 years old who presented with a primary complaint of memory loss was associated with decreased left/right temporal-parietal CBV ratios, independently of age, sex, MMSE score, years of education, years of memory loss, and handedness. These findings suggest that in the presence of cognitive decline, increased depressive signs and symptoms may be associated with decreased left/right temporal-parietal CBV ratios.

Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life.

OBJECTIVES: To review progress made during the past decade in late-life mood disorders and to identify areas of unmet need in health care delivery and research. PARTICIPANTS: The Consensus Development Panel consisted of experts in late-life mood disorders, geriatrics, primary care, mental health and aging policy research, and advocacy. EVIDENCE: (1) Literature reviews addressing risk factors, prevention, diagnosis, treatment, and delivery of services and (2) opinions and experiences of primary care and mental health care providers, policy analysts, and advocates. CONSENSUS PROCESS: The Consensus Development Panel listened to presentations and participated in discussions. Workgroups considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed and edited to incorporate input from the entire Consensus Development Panel. CONCLUSIONS: Despite the availability of safe and efficacious treatments, mood disorders remain a significant health care issue for the elderly and are associated with disability, functional decline, diminished quality of life, mortality from comorbid medical conditions or suicide, demands on caregivers, and increased service utilization. Discriminatory coverage and reimbursement policies for mental health care are a challenge for the elderly, especially those with modest incomes, and for clinicians. Minorities are particularly underserved. Access to mental health care services for most elderly individuals is inadequate, and coordination of services is lacking. There is an immediate need for collaboration among patients, families, researchers, clinicians, governmental agencies, and third-party payers to improve diagnosis, treatment, and delivery of services for elderly persons with mood disorders.

Estrogen therapy and noncognitive psychiatric signs and symptoms in elderly patients with dementia.

OBJECTIVE: This study investigated the efficacy and safety of short-term estrogen therapy in decreasing noncognitive signs and symptoms of dementia in demented elderly patients. METHOD: Sixteen moderately to severely demented elderly patients with aggressive behavioral disturbances were randomly assigned to receive conjugated equine estrogens or placebo in a 4-week clinical trial. Frequency and severity of noncognitive signs and symptoms of dementia, as assessed with the Dementia Signs and Symptoms Scale, were compared between estrogen and placebo groups. Data were analyzed with intent-to-treat and regression modeling methods. RESULTS: Estrogen therapy was associated with a significantly greater improvement on the Dementia Signs and Symptoms Scale total score than placebo. All five Dementia Signs and Symptoms Scale subscale comparisons favored estrogen therapy. No adverse effects were observed. CONCLUSIONS: These preliminary data suggest that short-term estrogen therapy may safely decrease the frequency and severity of noncognitive signs and symptoms of dementia in elderly patients.

Clinical Research in the Managed Care Environment.

The authors present the conclusions of a workshop devoted to the challenges to clinical research in the changing environment of managed care and health care reform. They identify problems and concerns with current conditions and discuss promising opportunities for new approaches to research.

MRI High-Intensity Signals in Late-Life Depression and Alzheimer's Disease: A Comparison of Subjects Without Major Vascular Risk Factors.

The authors examined periventricular white matter, deep white matter, and subcortical magnetic resonance imaging (MRI) high-intensity signals in subjects with late-life depression, probable Alzheimer's disease (DAT), and healthy, age-matched controls. All subjects were healthy and free of major vascular risk factors, including hypertension. MRIs were performed using a 1.5-tesla GE Signa scanner. T2 and proton-density-weighted images were analyzed by a neuroradiologist blind to the clinical status of all subjects. There were no statistically significant differences on any of the MRI indices between the groups studied. These data demonstrate that late-life depression, like DAT, in the absence of major vascular risk factors, is not associated with a significant increase in MRI high-intensity signals when compared to healthy, control subjects.