Reflections on Tribalism and Aging.

As a geriatric psychiatrist, I have become interested in gene-culture coevolution to better understand the meaning of aging. This investigation has led me to try to understand tribalism. This essay provides a background on gene-culture coevolution and tribalism from five, of several, comprehensible and recommendable books: The Social Conquest of Earth by Edward O. Wilson,1 The Secret of Our Success by Joseph Henrich,2 Blueprint: The Evolutionary Origins of a Good Society by Nicholas Christakis,3 Humankind: A Hopeful History by Rutger Bregman,4 and Survival of the Friendliest by Brian Hare and Vanessa Woods.5 Reading and rereading these works has changed my understanding of what it means to be human and to have optimism in these times of the problems of tribalism. I hope a summary of these works will stimulate others to further investigate gene-culture evolution, tribalism and aging.

Reflections on Aging and Wisdom.

The author experienced an unexpected finding over 30 years ago. Despite many losses, older primary care patients had less psychiatric symptomatology than younger patients. This has led to a long learning and teaching focus on the positive relationship between aging and wisdom. Some recent research challenges this relationship. To deal with this challenge the author reflects on two related but complex questions with which he has been struggling. Is there an adaptive value of aging? If wisdom is more likely with aging, why? He concludes that aging is culturally adaptive and that wisdom is aging's individual and societal adaptive strength.

RESPECT-PTSD: re-engineering systems for the primary care treatment of PTSD, a randomized controlled trial.

BACKGROUND: Although collaborative care is effective for treating depression and other mental disorders in primary care, there have been no randomized trials of collaborative care specifically for patients with Posttraumatic stress disorder (PTSD). OBJECTIVE: To compare a collaborative approach, the Three Component Model (3CM), with usual care for treating PTSD in primary care. DESIGN: The study was a two-arm, parallel randomized clinical trial. PTSD patients were recruited from five primary care clinics at four Veterans Affairs healthcare facilities and randomized to receive usual care or usual care plus 3CM. Blinded assessors collected data at baseline and 3-month and 6-month follow-up. PARTICIPANTS: Participants were 195 Veterans. Their average age was 45 years, 91% were male, 58% were white, 40% served in Iraq or Afghanistan, and 42% served in Vietnam. INTERVENTION: All participants received usual care. Participants assigned to 3CM also received telephone care management. Care managers received supervision from a psychiatrist. MAIN MEASURES: PTSD symptom severity was the primary outcome. Depression, functioning, perceived quality of care, utilization, and costs were secondary outcomes. KEY RESULTS: There were no differences between 3CM and usual care in symptoms or functioning. Participants assigned to 3CM were more likely to have a mental health visit, fill an antidepressant prescription, and have adequate antidepressant refills. 3CM participants also had more mental health visits and higher outpatient pharmacy costs. CONCLUSIONS: Results suggest the need for careful examination of the way that collaborative care models are implemented for treating PTSD, and for additional supports to encourage primary care providers to manage PTSD.

Problem-solving treatment and coping styles in primary care for minor depression.

Research was undertaken to compare problem-solving treatment for primary care (PST-PC) with usual care for minor depression and to examine whether treatment effectiveness was moderated by coping style. PST-PC is a 6-session, manual-based, psychosocial skills intervention. A randomized controlled trial was conducted in 2 academic, primary care clinics. Those subjects who were eligible were randomized (N = 151), and 107 subjects completed treatment (57 PST-PC, 50 usual care) and a 35-week follow-up. Analysis with linear mixed modeling revealed significant effects of treatment and coping, such that those in PST-PC improved at a faster rate and those initially high in avoidant coping were significantly more likely to have sustained benefit from PST-PC.

Impact of pain on the outcomes of depression treatment: results from the RESPECT trial.

OBJECTIVE: Pain is prevalent in patients with depression. The purpose of this study was to determine the impact of pain on depression treatment outcomes. METHODS: Data was analyzed from a randomized controlled trial comparing a collaborative care intervention to usual care for the treatment of depression in 60 primary care practices. A total of 405 patients with either current major depressive disorder or dysthymia were enrolled, and assessed at baseline, 3, and 6 months. Main measures included the 20-item Hopkins Symptom Check List (HSCL-20) depression score, and the SF-36 pain interference score. RESULTS: Pain severe enough to produce at least moderate interference with daily activities was present in 42% of depressed patients at baseline. Pain outcomes did not differ between intervention and control groups but improved similarly in both over time. However, pain was still at least moderately severe in 32% of patients at 6 months. Both baseline pain and the amount of pain improvement over time were associated with depression remission and response rates. In a multivariate model controlling for age, gender, and medical co-morbidity, depression severity increased with higher pain interference and decreased with the passage of time (p<.0001 for both). There was also a significant pain by time by treatment group interaction (p=.027). The beneficial effects of collaborative care on depression outcome persisted (p=.049) even after controlling for pain interference, time, covariates, and interaction effects. CONCLUSIONS: Pain has a strong negative impact on the response of depression to treatment. Recognizing and optimizing the management of comorbid pain that commonly coexists with depression may be important in enhancing depression response and remission rates.

Sustainable impact of a primary care depression intervention.

BACKGROUND: Re-Engineering Systems for Primary Care Treatment of Depression (RESPECT-D) sought to improve patient outcomes by disseminating the 3-component model of depression management. The purpose of this study was to determine whether an integrated model of depression management continued to be used by primary care clinicians after the end of a randomized controlled trial (RCT). METHODS: A descriptive evaluation was conducted at 2 time points. First, during a 12-month period after the end of the RESPECT-D RCT when referrals to care management were determined for each of the 5 participating health care organizations. Second, 3 years after the RCT ended, when clinicians were surveyed about use of the 3-component model. RESULTS: Three organizations continued to support the model with minimal modification. One made a major modification to it and one did not continue to support it. In the 12 months after the RCT, 1039 care management referrals were made. Seventy-one percent of RCT clinicians (n=92) completed the follow-up survey. Of these, 87% reported using the Patient Health Questionnaire-9; 58.9% reported availability of care management and 45.1% reported availability of informal psychiatry consultation. CONCLUSION: Practical clinical interventions can be sustained in primary care practice after the completion of an RCT. Additional resources may be needed to sustain and spread the program.

A fidelity measure for integrated management of depression in primary care.

BACKGROUND: Integrated models of primary care depression management improve outcomes. Subsequent dissemination efforts and their evaluation need a fidelity measure. OBJECTIVES: We sought to develop and validate a fidelity measure using data gathered during routine clinical application of the clinical model. METHODS: Longitudinal outcome data on depression severity were obtained from 224 subjects experiencing major depression or dysthymia and assigned to a 3-component model (3CM) intervention. Data on 10 essential 3CM process-of-care components were obtained from telephone logs maintained by care managers administering 3CM care. Stakeholders (n = 23), including researchers, health care administrators, and care managers, independently rated the importance of the 10 elements distributing 100 points among the elements. Mean ratings were used as weights to construct a fidelity score. Predictive validity was assessed using logistic regression for patient response and remission at 3 and 6 months. RESULTS: 3CM fidelity was high, with a mean of 74.1 at 3 months and 75.9 at 6 months. Given a large gap in the scores' distribution, subjects were classified into zero, low-, and high-fidelity groups. Logistic regressions adjusting for baseline depression found a distinct continuum. Patients that were provided high fidelity 3CM were significantly more likely to achieve treatment response and remission at 3 months. At 6 months, high-fidelity care was again significantly more likely to produce a response, but remission rate did not differ from patients provided low fidelity. CONCLUSIONS: Most patients received a substantially implemented "3CM dose." Even within this high implementation, however, a higher fidelity score was associated with better outcomes. The easily applied measure is a promising tool for monitoring the quality of implementation of integrated care.

Watchful waiting for minor depression in primary care: remission rates and predictors of improvement.

OBJECTIVES: The objectives of this study were to determine remission rates and predictors of improvement for minor depression following a 1-month watchful waiting period in primary care and to describe the watchful waiting processes. METHODS: Prior to randomization into a clinical trial for minor depression, 111 participants were entered into a 1-month watchful waiting period. Depression severity and predictors of improvement were measured at the start of watchful waiting. At the end of watchful waiting, remission rates were calculated and predictor variables were analyzed for their contribution toward predicting improvement. RESULTS: Remission rates were low, ranging from 9% to 13%, depending on the measure. Avoidant coping style and frequency of engaging in active pleasant events at baseline accounted for the majority of change in depression. During watchful waiting, about one fifth of the sample (21%) had at least one contact with their physician and 27% reported using self-initiated treatments. CONCLUSIONS: There is a low likelihood of spontaneous remission for treatment-seeking samples with minor depression in primary care. An avoidant coping style seriously interferes with remission, and engaging in regular active pleasant events confers an advantage. Feasible interventions for primary care that promote activity and decrease avoidant coping styles may improve outcomes. These findings may not generalize to community and non-treatment-seeking samples.

Billing for the Evaluation and Treatment of Adult Depression by the Primary Care Clinician.

Depression is a common problem encountered in primary care practice. There are many barriers that the primary care clinician faces in managing patients with depression. Financial reimbursement is one infrequently addressed barrier that influences how care is provided. This article addresses the coding, documentation, and reimbursement issues that pertain to the treatment of depression in the primary care setting. Coding options are reviewed with specific documentation guidelines. Reimbursement and fee schedule issues are also addressed, including clarification of certain limitations on payment by some payers.

Re-engineering systems for the treatment of depression in primary care: cluster randomised controlled trial.

OBJECTIVE: To test the effectiveness of an evidence based model for management of depression in primary care with support from quality improvement resources. DESIGN: Cluster randomised controlled trial. SETTING: Five healthcare organisations in the United States and 60 affiliated practices. PATIENTS: 405 patients, aged > or = 18 years, starting or changing treatment for depression. INTERVENTION: Care provided by clinicians, with staff providing telephone support under supervision from a psychiatrist. MAIN OUTCOME MEASURES: Severity of depression at three and six months (Hopkins symptom checklist-20): response to treatment (> or = 50% decrease in scores) and remission (score of < 0.5). RESULTS: At six months, 60% (106 of 177) of patients in intervention practices had responded to treatment compared with 47% (68 of 146) of patients in usual care practices (P = 0.02). At six months, 37% of intervention patients showed remission compared with 27% for usual care patients (P = 0.014). 90% of intervention patients rated their depression care as good or excellent at six months compared with 75% of usual care patients (P = 0.0003). CONCLUSION: Resources such as quality improvement programmes can be used effectively in primary care to implement evidence based management of depression and improve outcomes for patients with depression.

Going to scale: re-engineering systems for primary care treatment of depression.

BACKGROUND: Recent trials have shown improved depression outcomes with chronic care models. We report the methods of a project that assesses the sustainability and transportability of a chronic care model for depression and change strategy. METHODS: In a randomized controlled trial (RCT), a clinical model for depression was implemented through a strategy supporting practice change. The clinical model is evidence based. The change strategy relies on established quality improvement programs and is informed by diffusion of innovations theory. Evaluation will address patient outcomes, as well as process of care and process of change. RESULTS: Five medical groups and health plans are participating in the trial. The RCT involves 180 clinicians in 60 practices. All practices assigned to the clinical model have implemented it. Participating organizations have the potential to disseminate this clinical model of care to 700 practices and 1,700 clinicians. CONCLUSIONS: It is feasible to implement the clinical model and change strategy in diverse practices. Follow-up evaluation will determine the impact, sustainability, and potential for dissemination. Materials are available through http://www. depression-primarycare.org; more in-depth descriptions of the clinical model and change strategy are available in the online-only appendixes to this article.

Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use.

OBJECTIVE: The authors sought to determine whether integrated mental health services or enhanced referral to specialty mental health clinics results in greater engagement in mental health/substance abuse services by older primary care patients. METHOD: This multisite randomized trial included 10 sites consisting of primary care and specialty mental health/substance abuse clinics. Primary care patients 65 years old or older (N=24,930) were screened. The final study group consisted of 2,022 patients (mean age=73.5 years; 26% female; 48% ethnic minority) with depression (N=1,390), anxiety (N=70), at-risk alcohol use (N=414), or dual diagnosis (N=148) who were randomly assigned to integrated care (mental health and substance abuse providers co-located in primary care; N=999) or enhanced referral to specialty mental health/substance abuse clinics (i.e., facilitated scheduling, transportation, payment; N=1,023). RESULTS: Seventy-one percent of patients engaged in treatment in the integrated model compared with 49% in the enhanced referral model. Integrated care was associated with more mental health and substance abuse visits per patient (mean=3.04) relative to enhanced referral (mean=1.91). Overall, greater engagement was predicted by integrated care and higher mental distress. For depression, greater engagement was predicted by integrated care and more severe depression. For at-risk alcohol users, greater engagement was predicted by integrated care and more severe problem drinking. For all conditions, greater engagement was associated with closer proximity of mental health/substance abuse services to primary care. CONCLUSIONS: Older primary care patients are more likely to accept collaborative mental health treatment within primary care than in mental health/substance abuse clinics. These results suggest that integrated service arrangements improve access to mental health and substance abuse services for older adults who underuse these services.

The depression care manager and mental health specialist as collaborators within primary care.

OBJECTIVE: The authors reviewed the implications of the latest generation of health services research studies on primary care practice system changes for depression management, especially in the roles of care managers and mental health specialists. METHODS: Authors conducted a review of four large, related, multisite trials testing system changes in the delivery of care to depressed, mostly older, primary care patients. RESULTS: These studies confirm that older patients are more likely to accept collaborative mental health treatment within primary care than within mental health specialty care. The study results published to date suggest that these system changes produce better outcomes than usual care for depression in a wide range of patients and healthcare organizations. Two key partners in implementing these system changes are a care manager to assist the primary care physician in patient education, treatment, and treatment monitoring, and a mental health specialist to provide care-manager consultation and collaborative care with the primary care physician for more complex cases. CONCLUSIONS: Most patients with depression first seek attention for their symptoms in primary care, rather than in the mental health specialty sector. Since primary care visits are necessarily brief and pressured by competing demands to manage other medical problems, practice system changes are necessary. For mental health specialists, these studies emphasize the importance of joining and being integrated into primary care. Consultative and supervisory roles allow the specialist to indirectly but effectively serve a larger number of patients.

Application of a depression management office system in community practice: a demonstration.

BACKGROUND: Recent studies provide new insights about strategies that improve depression outcomes. We explored the feasibility of implementing these strategies in community practices. METHODS: Clinicians followed an office system approach to management of depression. There were no controls. The office system was based on established routines performed by a primary care clinician working in a prepared practice, a telephone care manager, and a collaborating psychiatrist, all using a common severity monitoring tool. Five practices with 18 clinicians participated. Sixty-six adult patients had depression diagnosed, and 60 (91%) received care according to the model through 8 weeks of follow-up visits. Depression outcomes were assessed using PHQ-9. RESULTS: At baseline, 48 (80%) patients met criteria for major depressive disorder, chronic depression, or both, while others had less severe symptoms. Of 32 patients with moderately severe or severe depression, the 8-week follow-up severity score decreased by > or = 50% for 23 (70%). Of patient barriers to adherence, ambivalence about treatment and medication side effects were most common. Most patients received three care manager telephone calls requiring 6 to 10 minutes each. CONCLUSION: Application of the office system was feasible in this demonstration project. If results are confirmed in further studies, this approach will be appropriate for widespread application.

Patient beliefs predict response to paroxetine among primary care patients with dysthymia and minor depression.

BACKGROUND: Dysthymia and minor depression are common problems in primary care, but it is not known how patient health beliefs shape response to antidepressant treatment of these less severe forms of depression. METHODS: Three hundred thirty-three primary care patients with dysthymia or minor depression received at least 4 weeks of paroxetine or placebo in a multicenter, randomized controlled 11-week trial. Patient health beliefs and other characteristics were examined as predictors of treatment adherence and depression remission. RESULTS: Patient beliefs were not predictive of adherence to paroxetine or placebo. Patients with less endorsement of biological beliefs about their condition (odds ratio [OR] = 3.40), higher perceived general health (OR = 3.38), meeting criteria for dysthymia (OR = 2.37), and age younger than 60 years (OR = 2.68) were more likely to achieve remission on paroxetine. Patient beliefs did not predict remission on placebo. Those with lower severity of depression symptoms at baseline (OR = 2.70) and women (OR = 2.18) were most likely to achieve remission on placebo. CONCLUSIONS: Our results suggest that patients with dysthymia or minor depression are more likely to respond to antidepressant medication if they do not see their depression as a biological illness and see themselves as generally healthy. It is clearly not necessary for patients to believe that their dysthymia or minor depression is biological to respond to antidepressant medication.

Measures to Assess the Noncognitive Symptoms of Dementia in the Primary Care Setting.

Noncognitive symptoms associated with Alzheimer's disease and related dementias include psychosis, mood disturbances, personality changes, agitation, aggression, pacing, wandering, altered sexual behavior, changed sleep patterns, and appetite disturbances. These noncognitive symptoms of dementia are common, disabling to both the patient and the caregiver, and costly. Primary care physicians will often play a major role in diagnosing and treating dementia and related disorders in the community. Accurate recognition and treatment of noncognitive symptoms is vital. A brief, user-friendly assessment tool would aid in the clinical management of noncognitive symptoms of dementia. Accordingly, we reviewed the available measures for their relevance in a primary care setting. Among these instruments, the Neuropsychiatric Inventory-Questionnaire seems most appropriate for use in primary care and worthy of further investigation.

Evidence-based practices in geriatric mental health care: an overview of systematic reviews and meta-analyses.

At least 20% of people over the age of 65 suffer from mental disorders. It is anticipated that the number of older Americans with psychiatric disorders will double over the next 30 years. There is, however, substantial unmet need. The recent Surgeon General's Report on Mental Health, a Report on Mental Health from the Administration on Aging, and an expert consensus statement underscore the need to plan for the challenge of providing services for elderly people with major mental disorders. Among the greatest challenges is the expertise gap that affects clinicians practicing in routine clinical settings. This gap reflects inadequate training in geriatrics and a failure to incorporate contemporary clinical research findings and known evidence-based practices (EBPs) into usual care. This article provides an overview of the emerging evidence-base supporting the efficacy of empirically-validated geriatric mental health interventions for major geriatric mental health disorders, including systematic EBP reviews, meta-analytic studies, and expert consensus statements. Cautions and limitations regarding the reliance on randomized, controlled trials, meta-analyses, and systematic reviews also are presented.