Longitudinal course of substance treatment benefits in older male veteran at-risk drinkers.

BACKGROUND: This investigation aims to determine the 12-month drinking trajectory of older at-risk drinkers in treatment. Furthermore, the drinking trajectory between at-risk drinkers who had met the threshold suggestive of alcohol dependence (problem at-risk drinkers) and those who did not meet this threshold (nonproblematic at-risk drinkers) were compared. METHODS: This investigation is a component of the PRISM-E (Primary Care Research in Substance Abuse and Mental Health for the Elderly) Study, a multisite randomized trial comparing service use, outcomes, and cost between Integrated (IC) versus Enhanced Specialty Referral (ESR) care models for older (65+ years) adults with depression, anxiety, and/or at-risk alcohol consumption. This investigation focuses only on at-risk drinkers, generally defined as exceeding recommended drinking limits, which in the case of older adults has been classified as consuming more than one drink per day. Two hundred fifty-eight randomized older at-risk drinkers were examined, of whom 56% were problem drinkers identified through the Short Michigan Alcohol Screening Test-Geriatric version. RESULTS: Over time, all at-risk drinkers showed a significant reduction in drinking. Problem drinkers showed reductions in average weekly consumption and number of occurrences of binge drinking at 3, 6, and 12 months, whereas nonproblematic drinkers showed significant reductions in average weekly consumption at 3, 6, and 12 months and number of occurrences of binge drinking at only 6 months. IC treatment assignment led to higher engagement in treatment, which led to better binge drinking outcomes for problem drinkers. Despite significant reductions in drinking, approximately 29% of participants displayed at-risk drinking at the end of the study. CONCLUSIONS: Results suggest that older at-risk drinkers, both problem and nonproblematic, show a considerable decrease in drinking, with slightly greater improvement evidenced in problem drinkers and higher engagement in treatment seen in those assigned to IC.

Effect of depression treatment on depressive symptoms in older adulthood: the moderating role of pain.

OBJECTIVES: To investigate whether pain severity and interference with normal work activities moderate the effects of depression treatment on changes in depressive symptoms over time in older adults in primary care. DESIGN: Patient-randomized, clinical trial. SETTING: Multisite: three clinics located in Veterans Affairs Medical Centers. PARTICIPANTS: Adults aged 60 and older (n=524) who screened positive for depression and participated in the Primary Care Research in Substance Abuse and Mental Health for the Elderly Study. INTERVENTION: Integrated care versus enhanced specialty referral care. MEASUREMENTS: Pain severity, the degree to which pain interferes with work inside and outside of the home, and depressive symptoms were examined at baseline and 3, 6, and 12 months. RESULTS: Intention-to-treat analyses revealed that both treatment groups showed reduced depressive symptoms over time, although self-reported pain moderated reductions in depressive symptoms. At higher levels of pain severity and interference with work activities, improvements in depressive symptoms were blunted. Furthermore, pain interference appeared to have a greater effect on depressive symptoms than did pain severity; in individuals with major depression, pain interference fully accounted for the moderating effects of pain severity on changes in depressive symptoms over time. CONCLUSION: Pain and its interference with functioning interfere with recovery from depression. Findings highlight the importance of addressing multiple domains of functioning (e.g., physical and social disability) and the degree to which pain and other forms of physical comorbidity may hinder or minimize treatment-related improvements in depressive symptoms.

Satisfaction with mental health services in older primary care patients.

OBJECTIVE: This study examines whether older adult primary care patients are satisfied with two intervention models designed to ameliorate their behavioral health problems. METHODS: A total of 1,052 primary care patients aged 65 and older with depression, anxiety, or at-risk drinking were randomly assigned to and participated in either integrated care (IC) or enhanced specialty referral (ESR) model and completed the Client Satisfaction Questionnaire (CSQ) administered at three-month follow-up assessment. RESULTS: Older adult patients' satisfaction with IC (mean: 3.4, standard deviation [SD]: 0.60) was significantly higher than that with ESR (mean: 3.2, SD: 0.78), but the absolute difference was modest. Regression results showed that patients who used the IC model, attended the treatment service twice or more, or showed clinical improvement were more likely to express greater satisfaction. Stigma toward mental illness was negatively associated with satisfaction with mental health services. CONCLUSIONS: Older adults are more likely to have greater satisfaction with mental health services integrated in primary care settings than through enhanced referrals to specialty mental health and substance abuse clinics.

Symptoms of depression and anxiety (MHI) following acute medical/surgical hospitalization and post-discharge psychiatric diagnoses (DSM) in 839 geriatric US veterans.

OBJECTIVE: We addressed the relatively unexplored use of screening scores measuring symptoms of depression and/or anxiety to aid in identifying patients at increased risk for post-discharge DSM-IV Axis I diagnoses. We were unable to find such studies in the literature. METHOD: Elderly veterans without recent psychiatric diagnoses were screened for depression and anxiety symptoms upon admission to acute medical/surgical units using the Mental Health Inventory (MHI). Following discharge, those who had exceeded cut-off scores and had been randomized to UPBEAT Care (Unified Psychogeriatric Biopsychosocial Evaluation and Treatment, a clinical demonstration project) were evaluated for DSM diagnoses. We report on 839 patients, mostly male (96.3%; mean age 69.6 +/- 6.7 years), comparing three groups, i.e. those meeting screening criteria for symptoms of (i) depression only; (ii) anxiety only; and (iii) both depression and anxiety. RESULTS: Despite absence of recent psychiatric history, 58.6% of the 839 patients received a DSM diagnosis post-discharge (21.8% adjustment; 15.4% anxiety; 7.5% mood; and 14.0% other disorders). Patients meeting screening criteria for both depression and anxiety symptoms received a DSM diagnosis more frequently than those meeting criteria for anxiety symptoms only (61.9% vs 49.0%, p = 0.017), but did not differ significantly from those meeting criteria for depressive symptoms only (61.9% vs 56.8%, p = 0.174). Although exceeding the MHI screening cut-off scores for depression, anxiety, or both helped to identify patients with a post-discharge DSM diagnosis, the actual MHI screening scores failed to do so. CONCLUSION: Screening hospitalized medical/surgical patients for symptoms of depression, anxiety, and particularly for the combination thereof, may help identify those with increased risk of subsequent DSM diagnoses, including adjustment disorder.

Measuring medical burden using CIRS in older veterans enrolled in UPBEAT, a psychogeriatric treatment program: a pilot study.

BACKGROUND: A quantitative measure of medical burden is needed to assess medical comorbidities in psychogeriatric patients. The Cumulative Illness Rating Scale (CIRS) is the most widely used instrument for measuring medical burden in psychogeriatric research. Many clinicians, however, are discouraged by the requirement to project the persistence of acute conditions and therefore do not use the scale. The goal of this pilot study was to determine whether the inclusion of acute medical conditions undermines the usefulness of the CIRS. No such comparison was found in the existing literature. METHODS: Included in this study were 95 patients previously enrolled in the Unified Psychogeriatric Biopsychosocial Evaluation and Treatment (UPBEAT) demonstration program. All were male veterans of the U.S. armed forces who were admitted to acute medical or surgical inpatient units and who had positive screening results for anxiety, depression, or alcohol abuse. Two types of retrospective CIRS ratings were made for each patient: one included (CIRS-IP) and the other excluded (CIRS-PH) acute conditions. For each type of rating (CIRS-IP and CIRS-PH), 7 CIRS scores were computed according to methods reported in the literature. Survival time during 24 months of follow-up was used as a measure of health outcome indicating medical burden. RESULTS: With 1 exception, CIRS-IP and corresponding CIRS-PH scores were highly correlated (.70 < r <.99; p <.001). And, for 5 of 7 scores, both CIRS-IP and CIRS-PH were significantly associated with survival time (p <.05). CONCLUSIONS: Results suggest that the CIRS can be used as an indicator of medical burden even with the inclusion of acute conditions. If replicated, these findings may increase CIRS use and thus aid the effort to encourage clinicians working with psychogeriatric patients to use standardized instruments to document medical burden.

Treatment effects from UPBEAT: a randomized trial of care management for behavioral health problems in hospitalized elderly patients.

The purpose of this study was to examine the impact of the Unified Psychogeriatric Biopsychosocial Evaluation and Treatment (UPBEAT) Program, an interdisciplinary mental health care management program, on the behavioral health symptoms of elderly veterans. Participants, 60 years and older, included 2637 veterans recruited from medical/surgical units who screened positively for significant depressive or anxiety symptoms and/or at-risk alcohol drinking. Participants were randomized to UPBEAT or to usual care. Primary outcomes were measured at baseline and at 6, 12, and 24 months. Participant nonadherence to the protocol was common and is a major limitation. There were no differences between UPBEAT and usual care patients on symptom or functional outcomes at any follow-up point. Exploratory analyses suggested that among participants with more physical health problems, there were greater improvements in depressive symptoms in those assigned to UPBEAT care. Despite a theoretical and practically sound intervention, participation was low and treatment outcomes, while generally good, appeared unaffected by the addition of the program.