Treatment outcomes in depression: comparison of remote treatment through telepsychiatry to in-person treatment.

OBJECTIVE: Telepsychiatry is an increasingly common method of providing psychiatric care, but randomized trials of telepsychiatric treatment compared to in-person treatment have not been done. The primary objective of this study was to compare treatment outcomes of patients with depressive disorders treated remotely by means of telepsychiatry to outcomes of depressed patients treated in person. Secondary objectives were to determine if patients' rates of adherence to and satisfaction with treatment were as high with telepsychiatric as with in-person treatment and to compare costs of telepsychiatric treatment to costs of in-person treatment. METHOD: In this randomized, controlled trial, 119 depressed veterans referred for outpatient treatment were randomly assigned to either remote treatment by means of telepsychiatry or in-person treatment. Psychiatric treatment lasted 6 months and consisted of psychotropic medication, psychoeducation, and brief supportive counseling. Patients' treatment outcomes, satisfaction, and adherence and the costs of treatment were compared between the two conditions. RESULTS: Hamilton Depression Rating Scale and Beck Depression Inventory scores improved over the treatment period and did not differ between treatment groups. The two groups were equally adherent to appointments and medication treatment. No between-group differences in dropout rates or patients' ratings of satisfaction with treatment were found. Telepsychiatry was more expensive per treatment session, but this difference disappeared if the costs of psychiatrists' travel to remote clinics more than 22 miles away from the medical center were considered. Telepsychiatry did not increase the overall health care resource consumption of the patients during the study period. CONCLUSIONS: Remote treatment of depression by means of telepsychiatry and in-person treatment of depression have comparable outcomes and equivalent levels of patient adherence, patient satisfaction, and health care cost.

Some predictors of psychiatric consultation in nursing home residents.

OBJECTIVE: Despite the high rate of psychiatric disorders in nursing homes, research indicates that psychiatric consultation is requested infrequently. The authors sought to determine the rate of psychiatric consultation in a nursing home population and to assess what factors were related to a consultation request. METHODS: Subjects were recruited from a stratified random sample of 59 nursing homes across Maryland. All new admissions age 65 years and older from September 1992 through March 1995 were eligible for the study. A total of 2,285 subjects were included in the study. Variables examined were factor scores from the Cornell Scale for Depression in Dementia and the Psychogeriatric Dependency Rating Scale (Behavioral Subscale), nursing home characteristics, and whether the resident had a psychiatric consultation within 90 days of admission. RESULTS: Twenty percent of the residents (N=404) had a psychiatric consultation. There was no significant association with demographic variables. Behaviors that triggered a psychiatric consultation included agitation, physical/verbal abuse, wandering, and manic/destructive acts. A psychiatric consultation was also requested when residents displayed anxiety. Surprisingly, depression in retarded and psychotic residents did not trigger a psychiatric consult. CONCLUSION: As expected, behavioral problems and agitation are common reasons for a psychiatric consultation. However, the resident who is depressed, particularly the quiet or retarded depressed resident, may be overlooked. In this context, it is important for the nursing staff to recognize that lethargy and social withdrawal may be signs of depression, and a referral to a psychiatrist may be in order.

Association of depression with agitation in elderly nursing home residents.

Agitation is a serious problem for elderly individuals with dementia. It is often the major reason for admission to a restrictive environment such as a nursing home or hospital. The objectives of the current study were to (1) identify the components of agitation embedded in the Psychogeriatric Dependency Rating Scale (PGDRS) and (2) find race, gender, depression, and cognitive deficits associated with the factors extracted from the PGDRS in demographic variables and clinical variables. The study sample comprised 2285 subjects who were admitted to 59 nursing homes across Maryland. The factor analysis of the PGDRS confirmed that agitation is made up of a number of different elements ranging from physical and/or verbal aggression to wandering. Correlates of these elements varied, as did possible treatments. For example, physical and/or verbal aggression often accompanied severe depression, suggesting that treating the depression may alleviate this problem. However, wandering and psychotic behavior may be less amenable to existing treatments as these behaviors were associated with severe cognitive impairment.

Depressive Symptoms Among Community-Dwelling Oldest-Old Residents in Israel.

The authors examined the rate and correlates of depressive symptoms among community-dwelling oldest-old citizens in Israel with a sample of about 1,200 Jewish Israelis age 75-94. The estimated national rate of depressive symptoms was 43.5%. Significantly higher rates of depressive symptoms were found in women (52%, vs. 29.5% for men) and those of low educational level, low income, and Middle Eastern or North African origin. Having more depressive symptoms was associated with 1) all measures of impaired health status; 2) the psychosocial factors of living alone or with a nonspouse, having no available caretaker, and social and physical inactivity; 3) the following health behavior and habits: poor sleep, skipping meals, sexual inactivity, and drinking no alcohol; and 4) traumatic life events and immigration after age 20. The rate of depressive symptoms is relatively high among oldest-old citizens in Israel, possibly because of the immigrant nature of this population.

Levodopa Dependence and Hypersexuality in an Older Parkinson's Disease Patient.

The authors discuss the relationship between dopaminergic medication abuse and hypersexuality. Tin's is the first reported case of levodopa dependence mediated and reinforced by hypersexuality. The medication abuse started in an attempt to control parkinsonian symptoms but eventually led to high-risk, uncontrollable sexual behavior.

Significant life Events and PTSD in Elderly World War II Veterans.

The authors reviewed clinic records of 20 WWII veterans referred for evaluation of posttraumatic stress disorder (PTSD). Twelve patients qualified for a diagnosis of PTSD, and eight reported several symptoms of PTSD. The most frequent symptoms were insomnia (80%), nightmares (75%), and irritability (65%). Fourteen veterans had an exacerbation of symptoms occurring with life stresses, including retirement, deteriorating health, or death of a loved one. The authors conclude that elderly WWII combat veterans should be monitored for changes in PTSD symptoms when significant stressful life events occur.

Continuous vs. Targeted Medication in Older Schizophrenic Outpatients.

The authors compared targeted as opposed to continuous neuroleptic medication for the treatment of older (over age 50) schizophrenic outpatients. Patients in the continuous medication group (n = 17) received maintenance neuroleptic medication throughout the 12-month study period. Those in the targeted group (n = 14) received medication only during periods of prodrome. Significantly fewer maintenance patients had at least one prodromal episode, and fewer experienced relapse, compared to the targeted medication group. No significant differences were found in the rate of hospitalization between the groups. Patients in the targeted group took, cumulatively, less medication. There were no significant differences between the two groups on measures of symptoms, side effects, or quality of life. A targeted medication approach was therefore judged inferior to maintenance medication for older schizophrenic outpatients.