Mental Health Care for Older Adults
in Primary Care
University of Iowa
March 29, 2006
Martha L. Bruce, Ph.D., M.P.H.
Professor of Sociology in Psychiatry
Weill Medical College of Cornell University
Why Focus on Geriatric Mental Health?
The number of Americans
The number of older adults
suffering from mental
disorders will rise at a similar,
if not faster, growth rate
18-28% of elderly population
has significant psychiatric
symptoms
Between 7,218,000 and
11,228,000 older adults will
have significant psychiatric
symptoms by 2010
US Adults ≥ 65 Years Old
over the age of 65 is expected
to grow to 62 million by 2025
70 Million
60 Million
50 Million
40 Million
30 Million
20 Million
2002
2025
Top 10 Recommendations of White House Conference on Aging Delegates
1.
Reauthorize the Older Americans Act within the first six months following the 2005
White House Conference on Aging
2.
Develop a coordinated, comprehensive long-term care strategy by supporting public
and private sector initiatives that address financing, choice, quality, service delivery,
and the paid and unpaid workforce
3.
Ensure that older Americans have transportation options to retain their mobility and
independence
4.
Strengthen and improve the Medicaid program for seniors
5.
Strengthen and improve the Medicare program
6.
Support geriatric education and training for all healthcare professionals,
paraprofessionals, health profession students, and direct care workers
7.
Promote innovative models of non-institutional long-term care
8.
Improve recognition, assessment, and treatment of mental illness and depression
among older Americans
9.
Attain adequate numbers of healthcare personnel in all professions who are skilled,
culturally competent, and specialized in geriatrics
10.
Improve state and local based integrated delivery systems to meet 21st century
needs of seniors
Top 10 Recommendations of 2005 White House Conference on Aging
1.
Reauthorize the Older Americans Act within the first six months following the 2005
White House Conference on Aging
2.
Develop a coordinated, comprehensive long-term care strategy by supporting public
and private sector initiatives that address financing, choice, quality, service delivery,
and the paid and unpaid workforce
3.
Ensure that older Americans have transportation options to retain their mobility and
independence
4.
Strengthen and improve the Medicaid program for seniors
5.
Strengthen and improve the Medicare program
6.
Support geriatric education and training for all healthcare professionals,
paraprofessionals, health profession students, and direct care workers
7.
Promote innovative models of non-institutional long-term care
8.
Improve recognition, assessment, and treatment of mental
illness and depression among older Americans
9.
Attain adequate numbers of healthcare personnel in all professions who are skilled,
culturally competent, and specialized in geriatrics
10.
Improve state and local based integrated delivery systems to meet 21st century
needs of seniors
Good Mental Health is the Foundation for
Overall Health, Quality of Life and Independence
Factors that increase risk of depression:
•
•
•
•
•
•
Medical Illness (cardiovascular disease)
Disability
Cognitive Decline
Social Isolation
Loss And Other Negative Events
Genetic Vulnerability
Depression increases the risk of:
•
•
•
•
•
•
•
Medical Illness
Disability
Social Isolation
Cognitive Decline
Loss Of Independence
Relocation/Institutionalization
Suicide And Deaths From Other Causes
Severe Mental Illness
Does Not Protect From Aging-Related Losses
Residents of “Adult Homes” with
History of Mental Illness:
•
Chronic Medical Conditions (diabetes, hypertension)
•
Declining Self-Care abilities
•
Declining Outside Interests
•
Loss of Parents, Siblings
•
Decline in Decision Making abilities
Prevalence of Major Depression
Diagnosis Among Older Adults
25
20
Community
Primary Care
Homebound
Medical Hospital
Assisted Living
Home Healthcare
Nursing Homes
15
%
10
5
0
Setting
Outcomes: ADL Decline at One Year Follow-up
(Home Healthcare Patients)
25%
21.0%
20%
% with ADL
Decline
15%
11.1%
10.6%
None
Minor
10%
5%
0%
Major Depression
Outcomes: Adverse Falls
(Home Healthcare Patients Matched by Age, Admission Month, LOS)
% with SOC
OASIS
Depression
45
40
35
30
25
20
15
10
5
0
Cases
Controls
Adverse Fall Event
Outcomes: Depression and Re-Hospitalization (Cumulative)
(Home Healthcare Patients)
10
% Re-Hospitalized
8
Depressed
6
4
Not Depressed
2
0
1
2
3
Months of care
4
5
Outcomes: Depression and Medicare Part D Benefits
(Congregate Meal Recipients)
What Is the Evidence Base for Geriatric Mental Health?
Depression
•
Treatment: Efficacious medication and psychotherapy
treatments for mild to moderate depression\
•
•
NIH research on complex depressions (severe, psychotic
features, bipolar, executive dysfunction)
Primary Care:
• Detection and Screening
• Collaborative Care Models
• Care Management Models
• PROSPECT
• IMPACT
• PRISM-E
Outreach Models
Depression Remains Typically Overlooked and Untreated
100%
80%
60%
No
No
40%
20%
Yes
Yes
0%
Identified
Treated
Home Healthcare Patients with
Major Depression
Primary Care can collaborate with MH Specialty to:
Improve Mental Health Assessment
1. Counsel Patients about Depression
2. Include Diagnostic Assessments
3. Provide Treatment and Care Management
Training in Depression Screening

Geriatric Depression Facts (video)

Depression Assessment (video)

Tool Kit

Field Practice

Reminders and Boosters
First: What is Major Depressive Disorder?
A syndrome of 5+ symptoms lasting > two weeks
• Symptoms must include:
• Depressed or sad mood
OR
• Decreased interest or pleasure in activities
• Other symptoms include:
• Significant changes in appetite or weight
• Sleep disturbances
• Restlessness or sluggishness
• Fatigue or loss of energy
• Lack of concentration or indecision
• Feelings of worthlessness or inappropriate guilt
• Thoughts of death or suicide
Facts: Depression Is Caused By:
•
Multiple factors interacting with each other.



•
•
Genetics
Medical illness (especially cardiovascular)
Psychological trauma.
Depression can occur without any obvious stressful event.
Depression is a Biological Illness
Reprinted with permission from Mark
George, MD
Biological Psychiatry Branch, Division of
Intramural Research Programs, NIMH,
1993
Non-Depressed Brain
Depressed Brain
Challenges in Assessing Depression
•
Belief that depression is:
•
•
•
•
•
Symptoms overlap with medical illness & treatments
•
•
•
A “normal” and therefore an acceptable part of aging
A “normal” response to illness, disability, isolation
A reflection of poor moral character
Not treatable
Misattribution of physical symptoms to depression
Misattribution of depression symptoms to medical illness
Masked by :
•
•
•
•
•
“Atypical symptoms”
Anxiety, worry,
disability,
pain,
cognitive impairment
Training in Depression Screening
(Home Healthcare Nurses)
Assessment Approach must:
• Add as little as possible burden or time
• Be similar to assessments
• Not stigmatize depression
• Rely on nurses’ knowledge and clinical judgment
Use the Two-Item Screen as a platform
• Training in making them sensitive with older
adults
• Follow-up questions ONLY when clinically
relevant
Two Item Screen
In the Context of Physical Assessment
1 - Depressed mood (e.g., feeling sad, tearful)
“How has your mood been in the past couple of weeks?
Have you been feeling depressed or down? How about
sad or blue?
2 - Loss of Pleasure or interest in Usual Activities
“In the past week, have you found yourself losing interest
in your activities [that you are able to do]?”
If Yes to either question, ask:
• “How long have you been feeling this way?”
•
Two weeks or more?
• “How much of the day?”
• Much of the day (not just transient thoughts)?
Training Video
Suicide Risk Assessment
Interacting with Depressed Patients
REASSESS symptoms at each visit. If symptoms persist after a month of treatment,
contact physician
REASSURE patients that being depressed is not their fault
SUPPORT patients by reassuring them that they can always call on you or other health
care provide for help and support
ENCOURAGE patients to engage in activities that are pleasant to them and that they
are still able to do
REMIND patients that depression is treatable, but it takes time
REMAIN positive -- yet matter of fact -- yourself
Does it Work? Three Study Arms
Interactive
Learning
Tool Kit
Routine
Training
Video
Video
Tool Kit
Tool Kit
Typical Agency
Training (Partial
Training
Full
Training
Experimental Design
Agencies
Agency 1
Agency 2
Agency 3
Nurses
Random
Training
Assignment
FT
C
PT
Patients
FT: Full Training; PT: Partial Training; C: Control
C
FT
PT
C
FT
Clinical Action by Level of Nurse Training
30%
Percent
Clinical
Outcome
20%
10%
0%
Controls
Tape
Full Training
Nurse Training Condition
Clinical Action By Depressive Symptoms
% Outcome
50
Control
Mid-Level
Full Training
40
30
20
10
0
NO
YES
Depressive Symptoms (SCID)
http://www.geriu.org/
Depression is treatable
 Antidepressants as effective in older
patients as younger patients (Reynolds et al,
2003, JAMA)
 Psychotherapy also as effective in older
patients as younger patients (Arean & Cook,
2002 Biol. Psych.)
Psychotherapy for late-life depression

27 RCTs to date (Mackin & Areán,
2005; Areán & Cook, 2003)

Cognitive Behavioral
Therapy





Interpersonal Therapy
Problem Solving Therapy
Brief Dynamic Therapy
Reminiscence Therapy
Bibliotherapy
Common Adaptations
 Longer session times.
 More sessions.
 “Say-it, show-it, do-it”/ “Cue and Review”
 Relying on past experiences to enhance
learning.
 Involving significant others.
Problem Solving Therapy versus Reminiscence
(Arean et al, 1994)
30
25
20
PST
RT
15
10
5
0
Baseline
6 months
F = 4.02, p. <.001
Access barriers (Alvidrez & Areán, in press)
 Common concerns about psychotherapy
–
–
–
–
–
Stigmatization;
Fear of mental health settings;
Being pressured to divulge personal information;
Too time intensive;
Working with a therapist from a different background.
 Strategies to make therapy more helpful
– Using a medical model of psychiatric disorders;
– Collaborating with the therapist ;
– Integration in to low-stigma settings.
Barriers to Mental Health Referral Among Older Adults
Participating in Home Delivered Meals
I would be concerned %
agree that others will…
Exclude me
Behave different
Expect less of me
Be critical of me
Judge me
Distrust me
Think I was weak

Non
depressed
13%
25%
30%
17%
21%
13%
30%
Depressed
62% ***
61% **
56% 
30%
46%*
39%*
58%*
p<.10*p<.05, ** p< .01, ***p<.001
Sirey et al., preliminary data
Evidence Based Systems of Care for
Depression in Primary Care
3rd Generation Depression System Change Interventions
IMPACT
Change
Care Mgmt
Patient Education
Psychiatric
supervision
Psychotherapy
supervision
Rx algorithm
PROSPECT
RESPECT
Depression
Specialist
Depression
Specialist
TCM
On-site
On-site
Off-site
Yes
Yes
Yes
Face to face
Face to face
Telephone
Telephone
Face to face
N/A
Yes
Yes
No
Managing Any Other Chronic Disease
Monitor Depressive Symptoms
Educate Patient and Family
Monitor Adherence
Monitor Side Effects
Provide Support
Managing Antidepressants is Like…..
Consult or Refer to Agency/Outside Specialist As Needed
Remission (HSCL <.5) from Major Depression
IMPACT Study
40%
Intervention
30%
20%
10%
Usual Care
0%
0
3 mos
6 mos
12 mos
Unützer et al., JAMA 2002
Remission (HDRS < 10) from Major Depression
PROSPECT Study
40%
35%
Intervention
30%
25%
20%
Usual Care
15%
10%
5%
0%
Baseline
4 mo
8 mo
12 mo
Bruce et al., JAMA 2004
Remission (HSCL <.5) from Major Depression
RESPECT Study
40%
35%
Intervention
30%
25%
20%
15%
Usual Care
10%
5%
0%
Baseline
3 Mos
6 mos
Dietrich et al., BMJ 2004
Cultural and Ethnic Diversity
 Little evidence that prevalence of mental illness varies
 especially taking into account ….
 Setting
 Medical burden and disability
 Socioeconomic environment
 Immigration and social networks
 Lots of evidence that access to quality mental health care varies
 for example:
 “Impacted” Adult homes disproportional ethnic minorities
 Black HC patients half as likely to be treated for depression
 Insufficient understanding of definitions of “quality” care
 Evidence of racial/ethnic variation in .…
 Treatment preferences (prayer)
 Attitudes and beliefs about mental illness and treatment
 Family involvement
 Preferred types of providers
Thank you
Questions?