Negotiating depression treatment with older adults: primary care providers' perspectives.

BACKGROUND: Primary care occupies a strategic position in the evaluation and treatment of depression in late life, yet many older patients do not initiate or adhere to treatments available in primary care. AIM: To explore how primary care providers describe the process of discussing depression care with older adults. METHOD: Semi-structured interviews conducted with 15 providers involved with intervention studies of depression management for older adults. We used the constant comparative method to identify themes related to negotiating the treatment of depression with older adults. RESULTS: Providers felt that older patients often attribute depression to non-medical causes. They talked about the challenges and described the need to 'convince' them of the medical model of depression. CONCLUSION: How primary care physicians surmise patients' views of depression may influence the discussion of depression in practice. As medication is most often provided for depression treatment, some may feel compelled to convince their patients of biomedical explanations while others may avoid treating depression altogether.

When late-life depression improves: what do older patients say about their treatment?

INTRODUCTION: Experts speculate about the mechanisms through which depression interventions operate. However, little is known about what patients think are the "active ingredients" in depression treatment. Given the importance of patient-centered care,understanding this dimension of the provider-intervention-patient interaction provides a missing piece to designing interventions that are congruent with patients' beliefs and preferences about treatment initiation, treatment adherence, and treatment maintenance. METHODS: The authors used a parallel mixed methods design to identify a purposive sample of 24 older adults with depression who participated in either an integrated care or an enhanced referral model of depression treatment. Open-ended semistructured interviews were used to identify patient perceptions about the benefits of depression treatment during the study. Quantitative assessments of depression status were made at the completion of participation in the treatment study and 6 months postparticipation. RESULTS: Twelve of 24 participants achieved remission of their depression symptoms, with the remainder showing no improvement or a partial response to treatment. Participants who achieved and sustained a remission of their depression symptoms (N=7) attributed their improvement to clear psychoeducational support with their depression care providers and described an ability to affect the outcome of their treatment. Participants who improved but then relapsed described their treatment in vague terms, referring to social aspects of participation. Participants who did not achieve remission ascribed recognition and treatment of their depression to forces outside themselves and described few details about their treatment. CONCLUSION: Clinicians should consider patient perceptions of the benefits of depression treatment as they discuss and implement therapeutic interventions with depressed older adults.

Cancer survivors with unmet needs were more likely to use complementary and alternative medicine.

PURPOSE: Despite advancements in cancer care, cancer survivors continue to experience a substantial level of physical and emotional unmet needs (UMN). This study aims to determine the relationship between patients' perceived UMN and their use of complementary and alternative medicine (CAM) to help with cancer problems during and after treatment. METHODS: A mailed, cross-sectional survey was completed by 614 cancer survivors identified through the Pennsylvania Cancer Registry 3.5 to 4 years from initial diagnosis. Relationships among UMN and CAM use along with clinical and socio-demographic factors were examined. RESULTS: Respondents who identified any UMN were 63% more likely to report CAM use than those without UMN (58% vs. 36%), p < 0.001. UMN remained the only independent predictor (adjusted odds ratio = 2.30, 95% confidence interval = 1.57-3.36, p < 0.001) of CAM use in a multivariate logistic regression model that included age, sex, marital status, education, previous chemotherapy and radiotherapy. Adjusted for covariates, UMN in domains of emotional, physical, nutritional, financial, informational, treatment-related, employment-related, and daily living activities were all related to CAM use, whereas UMN in transportation, home care, medical staff, family and spirituality were not related to CAM use. Patients who experienced multiple types of unmet needs were also more likely to use multiple types of CAM (p < 0.001 for model). CONCLUSIONS: Cancer survivors who experienced unmet needs within the existing cancer treatment and support system were more likely to use CAM to help with cancer problems. Research is needed to determine if appropriate CAM use decreases unmet needs among cancer survivors.

Unmet psychosocial needs of Pennsylvanians with cancer: 1986-2005.

BACKGROUND: The purpose of the current study was to identify unmet psychosocial needs of cancer survivors, understand the distribution of needs across subgroups, and compare unmet needs in 2005 with those identified by Houts et al. in 1986. METHODS: Using a sequential mixed methods design, qualitative interviews were conducted with 32 cancer survivors or family members to identify the psychosocial needs of people from the time of cancer diagnosis through survivorship. These data were used to modify a needs assessment that was mailed to a stratified random sample of survivors obtained from the Pennsylvania Cancer Registry. RESULTS: A total of 614 survivors returned usable questionnaires. Nearly two-thirds of respondents reported experiencing at least 1 unmet psychosocial need, particularly emotional, physical, and treatment-related needs. It is likely that unmet needs in insurance, employment, information, and home care increased during the 20-year interval between surveys. Demographics associated with increased unmet need included later stage of disease at the time of diagnosis, younger age, more comorbidities, and lower income. CONCLUSIONS: Unmet psychosocial need remains high despite 20 years of effort to address psychosocial issues. This may be due to a mismatch between needs and services. Unmet need may be related to access issues, a lack of awareness of resources, "new" needs that have arisen in a changing healthcare climate, and patient preferences for types of service. Cancer treatment staff should be especially alert for psychosocial problems in younger individuals with an additional illness burden.

Older adult report of change in depressive symptoms as a treatment decision tool.

OBJECTIVES: To evaluate patient reports of changes in depressive symptoms as information that can be used in treatment decision-making. DESIGN: Longitudinal cohort study. SETTING: The Prevention of Suicide in Primary Care Elderly: Collaborative Trial and the Primary Care Research in Substance Abuse and Mental Health for the Elderly trial, multisite studies investigating the effect of depression interventions on outcomes in primary care. PARTICIPANTS: Fifty-six patients aged 60 and older. MEASUREMENTS: Patient demographics were collected from patient reports. Symptoms of depression were measured using the Centers for Epidemiologic Studies Depression Scale (CES-D) and Hamilton Depression Scale (HAM-D). Changes in depressive symptoms were also measured using the Clinical Global Impressions of Change (CGI-C) as rated by patients in ongoing treatment. RESULTS: Patient ratings of CGI-C were significantly correlated with percentage improvement on the HAM-D as rated by the depression care manager (correlation coefficient (r)=0.44, P<.001) and percentage improvement on the CES-D (r=0.38, P=.005). The patient report of at least "much improved" predicted at least 50% treatment response based on HAM-D scale scores, with a sensitivity of 87.5% and a specificity of 74.2%. CONCLUSION: These findings suggest that patients are able to accurately report their degree of improvement in depressive symptoms. Patient report of at least "much improved" can be used as an estimate of at least 50% depression treatment response. In an era of increasingly fragmented clinical care, these findings demonstrate that older adult primary care patients can accurately self-report overall change in depressive symptoms. When results of repeated depression instruments are not available, patient report of depression treatment response can be used to inform depression treatment decision-making.

Posttraumatic stress, depression, and health among older adults in primary care.

OBJECTIVE: The authors examined 1) rates of trauma and posttraumatic stress (PTS) in older adults in primary care; 2) factors related to more posttraumatic stress symptoms; and 3) the influence of posttraumatic stress and depression on health perceptions and negative health behaviors (i.e., suicidal ideation, smoking, and at-risk drinking). METHODS: As part of participation in a study at the Philadelphia VAMC and the University of Pennsylvania, a random subset (N = 2,718) of older adults (age > or = 65 years) with scheduled primary care visits were screened concerning demographics, the General Health Questionnaire-12, suicidal thoughts, alcohol consumption, cigarette smoking, perceived health status, PTS, and cognitive impairment. RESULTS: The rate of trauma in older adult primary care patients was high in both the VA (37%) and university-based clinics (24%). Many older adults reported interference from at least one of the three posttraumatic stress items assessed (VA, 18%; university-based primary care, 8%). In a model including demographic factors, higher PTS and depression were uniquely related to more negative health perceptions. In a model including demographic factors, both higher PTS and depression were uniquely related to higher likelihood of suicidal ideation. In contrast, PTS no longer contributed to a model of smoking once depression was included. Neither PTS nor depression significantly contributed to a model of at-risk drinking. CONCLUSIONS: Trauma and posttraumatic stress are frequent and significant problems for older adults in primary care. Both posttraumatic stress and depression are related to more negative health perceptions and higher likelihood of suicidal ideation.

Older patients' aversion to antidepressants. A qualitative study.

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 seem 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.

Personal characteristics and depression-related attitudes of older adults and participation in stages of implementation of a multi-site effectiveness trial (PRISM-E).

BACKGROUND: No study has assessed attitudes about depression and its treatment and participation at each step of recruitment and implementation of an effectiveness trial. Our purpose was to determine the association between personal characteristics and attitudes of older adults about depression with participation at each step of the Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) treatment effectiveness trial. METHODS: Information on personal characteristics and attitudes regarding depression and its treatment were obtained from all potential participants in PRISM-E. RESULTS: Persons who reported better social support were more likely to complete a baseline interview, but were less likely to meet with the mental health professional carrying out the intervention. Attitudes about taking medicines were significantly associated with uptake of the intervention, but not with earlier phases of recruitment. Persons were much more likely to have a visit with the mental health professional for treatment of depression if they were willing to take medicine for depression but did not endorse waiting for the depression to get better [odds ratio (OR) = 3.16, 95% confidence interval (CI) = 1.48-6.75], working it out on one's own (OR = 5.18, 95% CI = 1.69-15.85), or talking to a minister, priest, or rabbi (OR = 2.01, 95% CI = 1.02-3.96). CONCLUSION: Social support and other personal characteristics may be the most appropriate for tailoring recruitment strategies, but later steps in the recruitment and implementation may require more attention to specific attitudes towards antidepressant medications.

Importance of subsyndromal symptoms of depression in elderly patients.

OBJECTIVE: There is a debate about the importance of subsyndromal symptoms of depression (SSD). The current study examined the cross-sectional and longitudinal significance of SSD in geriatric subjects both with and without a past history of major depression. METHODS: Elderly primary-care subjects with SSD, both with (SSD+; N=54) and without (SSD-; N=204) a history of major depression, were compared with subjects with major depression (MDD; N=111), minor depression (MinD; N=74), and symptom-free comparison subjects (N=59). Assessment domains included physical and psychological disability, health-care utilization, hopelessness, death and suicidal ideation, and a diagnostic evaluation at a 3-month follow-up. RESULTS: Both subjects with SSD+ and SSD- differed from the symptom-free comparison subjects on measures of psychological disability, hopelessness, and death ideation, with SSD+ subjects being more severely psychologically disabled than SSD- subjects. There were few differences between SSD+ and MinD subjects or those with MDD, except on measures of psychological disability. Finally, more than 24% of SSD+ subjects progressed to meet criteria of MDD, MinD, or dysthymia over a 3-month period. Utilization of outpatient services did not differ among any of the depression groups or comparison subjects. CONCLUSIONS: SSD (with or without a past history of MDD) is associated with significant disability. Moreover, the risk of developing a diagnosis of MDD, MinD, or dysthymia is substantially elevated in subjects with a past history of MDD.

Gambling among older, primary-care patients: an important public health concern.

OBJECTIVES: Authors assessed the prevalence rate of gambling in a sample of elderly patients (over age 65) and evaluated the sociodemographic characteristics, health, cognitive status, and psychiatric comorbidities of elderly gamblers. METHODS: This study is a cross-sectional survey of gambling habits. A random sample of older adults with a scheduled primary-care clinic appointment was selected and screened with the General Health Questionnaire and questions about suicidality and alcohol use. Also, participants were asked about their gambling habits. RESULTS: Of 843 screened patients completing the gambling questionnaire, 69.6% reported that they had participated in at least one gambling activity in the last year. At-risk gamblers were defined as those who reported having bet more than $100 on a single bet and/or having bet more than they could afford to lose in the last year. Of those responding, 10.9% were identified as at-risk gamblers. The strongest predictors of at-risk gambling behavior were being a binge drinker, presence of current posttraumatic stress disorder symptoms, minority race/ethnicity, and being a VA clinic patient. Subjects with mild-to-moderate cognitive impairment were just as likely as those without impairment to gamble and to report at-risk gambling behavior. At-risk gambling behavior was not significantly associated with gender, current or past depressive symptoms, or cigarette smoking. CONCLUSIONS: These data raise a significant public health concern that gambling behaviors are prevalent in older adults. Additional research is needed to further define the determinants of gambling behavior in older adults and evaluate the social, health, and economic costs and benefits of gambling by older adults, especially among those groups determined to be at risk.