Mental Health Care for Older AdultsMental Health Care for Older Adultsin Primary Carein Primary Care

University of IowaMarch 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?

2002 2025

20 Million

30 Million

40 Million

50 Million

60 Million

70 Million

US

Adu

lts ≥

65

Year

s O

ld

                      The number of Americans over the age of 65 is expected to grow to 62 million by 2025The number of older adults suffering from mental disorders will rise at a similar, if not faster, growth rate18-28% of elderly population has significant psychiatric symptomsBetween 7,218,000 and 11,228,000 older adults will have significant psychiatric symptoms by 2010

Top 10 Recommendations of White House Conference on Aging DelegatesTop 10 Recommendations of White House Conference on Aging Delegates1.1. Reauthorize the Older Americans Act within the first six months following the 2005 Reauthorize the Older Americans Act within the first six months following the 2005

White House Conference on AgingWhite House Conference on Aging

2.2. Develop a coordinated, comprehensive long-term care strategy by supporting public Develop a coordinated, comprehensive long-term care strategy by supporting public and private sector initiatives that address financing, choice, quality, service delivery, and private sector initiatives that address financing, choice, quality, service delivery, and the paid and unpaid workforceand the paid and unpaid workforce

3.3. Ensure that older Americans have transportation options to retain their mobility and Ensure that older Americans have transportation options to retain their mobility and independenceindependence

4.4. Strengthen and improve the Medicaid program for seniorsStrengthen and improve the Medicaid program for seniors

5.5. Strengthen and improve the Medicare programStrengthen and improve the Medicare program

6.6. Support geriatric education and training for all healthcare professionals, Support geriatric education and training for all healthcare professionals, paraprofessionals, health profession students, and direct care workersparaprofessionals, health profession students, and direct care workers

7.7. Promote innovative models of non-institutional long-term care Promote innovative models of non-institutional long-term care

8.8. Improve recognition, assessment, and treatment of mental illness and depression Improve recognition, assessment, and treatment of mental illness and depression among older Americansamong older Americans

9.9. Attain adequate numbers of healthcare personnel in all professions who are skilled, Attain adequate numbers of healthcare personnel in all professions who are skilled, culturally competent, and specialized in geriatricsculturally competent, and specialized in geriatrics

10.10. Improve state and local based integrated delivery systems to meet 21st century Improve state and local based integrated delivery systems to meet 21st century needs of seniorsneeds of seniors

Top 10 Recommendations of 2005 White House Conference on Aging Top 10 Recommendations of 2005 White House Conference on Aging 1.1. Reauthorize the Older Americans Act within the first six months following the 2005 Reauthorize the Older Americans Act within the first six months following the 2005

White House Conference on AgingWhite House Conference on Aging

2.2. Develop a coordinated, comprehensive long-term care strategy by supporting public Develop a coordinated, comprehensive long-term care strategy by supporting public and private sector initiatives that address financing, choice, quality, service delivery, and private sector initiatives that address financing, choice, quality, service delivery, and the paid and unpaid workforceand the paid and unpaid workforce

3.3. Ensure that older Americans have transportation options to retain their mobility and Ensure that older Americans have transportation options to retain their mobility and independenceindependence

4.4. Strengthen and improve the Medicaid program for seniorsStrengthen and improve the Medicaid program for seniors

5.5. Strengthen and improve the Medicare programStrengthen and improve the Medicare program

6.6. Support geriatric education and training for all healthcare professionals, Support geriatric education and training for all healthcare professionals, paraprofessionals, health profession students, and direct care workersparaprofessionals, health profession students, and direct care workers

7.7. Promote innovative models of non-institutional long-term care Promote innovative models of non-institutional long-term care

8.8. Improve recognition, assessment, and treatment of mental Improve recognition, assessment, and treatment of mental illness and depression among older Americansillness and depression among older Americans

9.9. Attain adequate numbers of healthcare personnel in all professions who are skilled, Attain adequate numbers of healthcare personnel in all professions who are skilled, culturally competent, and specialized in geriatricsculturally competent, and specialized in geriatrics

10.10. Improve state and local based integrated delivery systems to meet 21st century Improve state and local based integrated delivery systems to meet 21st century needs of seniorsneeds 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

0

5

10

15

20

25

%

Setting

Prevalence of Major Depression Diagnosis Among Older Adults

CommunityPrimary CareHomeboundMedical HospitalAssisted LivingHome HealthcareNursing Homes

Outcomes: ADL Decline at One Year Follow-up(Home Healthcare Patients)

11.1% 10.6%

21.0%

0%

5%

10%

15%

20%

25%

None Minor Major Depression

% with ADL Decline

Outcomes: Outcomes: Adverse Falls (Home Healthcare Patients Matched by Age, Admission Month, LOS)

05

1015202530354045

% with SOC OASIS

Depression

Cases ControlsAdverse Fall Event

Outcomes:Outcomes: Depression and Re-Hospitalization (Cumulative)(Home Healthcare Patients)

0

2

4

6

8

10

1 2 3 4 5

Months of care

% R

e-H

ospi

taliz

ed

Not Depressed

Depressed

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

Yes

No

Yes

No

0%

20%

40%

60%

80%

100%

Identified TreatedHome Healthcare Patients with

Major Depression

Primary Care can collaborate with MH Specialty to:Primary Care can collaborate with MH Specialty to:

Improve Mental Health Assessment Improve Mental Health Assessment

1.1. Counsel Patients about DepressionCounsel Patients about Depression

2.2. Include Diagnostic AssessmentsInclude Diagnostic Assessments

3.3. Provide Treatment and Care ManagementProvide Treatment and Care Management

Training in Depression ScreeningTraining in Depression Screening

Geriatric Depression Facts (video)Geriatric Depression Facts (video)

Depression Assessment (video)Depression Assessment (video)

Tool KitTool Kit

Field PracticeField Practice

Reminders and Boosters 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

• 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

Facts: Depression Is Caused By:

Non-Depressed Brain Depressed Brain

Reprinted with permission from Mark George, MDBiological Psychiatry Branch, Division of Intramural Research Programs, NIMH, 1993

Challenges in Assessing Depression

• Belief that depression is: • A “normal” and therefore an acceptable part of aging• A “normal” response to illness, disability, isolation• A reflection of poor moral character• Not treatable

• Symptoms overlap with medical illness & treatments• 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 ScreenTwo Item ScreenIn the Context of Physical AssessmentIn the Context of Physical Assessment

1 - 1 - Depressed mood (e.g., feeling sad, tearful)Depressed mood (e.g., feeling sad, tearful)““How has your mood been in the past couple of weeks? How has your mood been in the past couple of weeks? Have you been feeling depressed or down? How about Have you been feeling depressed or down? How about sad or blue?sad or blue?

2 - Loss of Pleasure or interest in Usual Activities2 - Loss of Pleasure or interest in Usual Activities““In the past week, have you found yourself losing interest In the past week, have you found yourself losing interest in your activities [that you are in your activities [that you are ableable to do]?” 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 AssessmentSuicide Risk Assessment

REASSESSREASSESS symptoms at each visit. If symptoms persist after a month of treatment, symptoms at each visit. If symptoms persist after a month of treatment, contact physiciancontact physician

REASSUREREASSURE patients that being depressed is not their fault patients that being depressed is not their fault

SUPPORTSUPPORT patients by reassuring them that they can always call on you or other health patients by reassuring them that they can always call on you or other health care provide for help and supportcare provide for help and support

ENCOURAGEENCOURAGE patients to engage in activities that are pleasant to them and that they patients to engage in activities that are pleasant to them and that they are still able to doare still able to do

REMINDREMIND patients that depression is treatable, but it takes time patients that depression is treatable, but it takes time

REMAINREMAIN positive -- yet matter of fact -- yourself positive -- yet matter of fact -- yourself

Interacting with Depressed Patients

Tool Kit Tool Kit Tool Kit

Video Video

Interactive Learning

Routine Training

Typical AgencyTraining (Partial

Training

FullTraining

Does it Work? Does it Work? Three Study Arms

Agency 1 Agency 2 Agency 3Agencies

Nurses

Random Training Assignment

Patients

FT C PT C FT PT C FT

FT: Full Training; PT: Partial Training; C: Control

Experimental Design

Clinical Action by Level of Nurse TrainingClinical Action by Level of Nurse Training

0%

10%

20%

30%

Percent Clinical

Outcome

Controls Tape Full TrainingNurse Training Condition

01020304050

% O

utco

me

NO YESDepressive Symptoms (SCID)

Clinical Action By Depressive Symptoms

ControlMid-LevelFull Training

http://www.geriu.org/

Depression is treatableDepression is treatable

Antidepressants as effective in older Antidepressants as effective in older patients as younger patients patients as younger patients (Reynolds et al, (Reynolds et al, 2003, JAMA)2003, JAMA)

Psychotherapy also as effective in older Psychotherapy also as effective in older patients as younger patients patients as younger patients (Arean & Cook, (Arean & Cook, 2002 Biol. Psych.)2002 Biol. Psych.)

Psychotherapy for late-life depressionPsychotherapy for late-life depression

27 RCTs to date 27 RCTs to date (Mackin & (Mackin & Areán, 2005; Areán & Cook, 2003)Areán, 2005; Areán & Cook, 2003)

Cognitive Behavioral Cognitive Behavioral TherapyTherapy

Interpersonal TherapyInterpersonal Therapy Problem Solving TherapyProblem Solving Therapy Brief Dynamic TherapyBrief Dynamic Therapy Reminiscence TherapyReminiscence Therapy BibliotherapyBibliotherapy

Common AdaptationsCommon Adaptations

Longer session times.Longer session times.

More sessions.More sessions.

““Say-it, show-it, do-it”/ “Cue and Review”Say-it, show-it, do-it”/ “Cue and Review”

Relying on past experiences to enhance Relying on past experiences to enhance learning.learning.

Involving significant others.Involving significant others.

Problem Solving Therapy versus Reminiscence Problem Solving Therapy versus Reminiscence (Arean et al, 1994)(Arean et al, 1994)

0

5

10

15

20

25

30

Baseline 6 months

PSTRT

F = 4.02, p. <.001

Access barriers Access barriers (Alvidrez & Areán, in press)(Alvidrez & Areán, in press)

Common concerns about psychotherapyCommon concerns about psychotherapy– Stigmatization;Stigmatization;– Fear of mental health settings;Fear of mental health settings;– Being pressured to divulge personal information;Being pressured to divulge personal information;– Too time intensive;Too time intensive;– Working with a therapist from a different background.Working with a therapist from a different background.

Strategies to make therapy more helpfulStrategies to make therapy more helpful– Using a medical model of psychiatric disorders;Using a medical model of psychiatric disorders;– Collaborating with the therapist ;Collaborating with the therapist ;– Integration in to low-stigma settings.Integration in to low-stigma settings.

Barriers to Mental Health Referral Among Older Adults Participating in Home Delivered Meals

Sirey et al., preliminary data

I would be concerned % agree that others will…

Non depressed

Depressed

Exclude me 13% 62% *** Behave different 25% 61% ** Expect less of me 30% 56%

Be critical of me 17% 30% Judge me 21% 46%* Distrust me 13% 39%* Think I was weak 30% 58%* p<.10*p<.05, ** p< .01, ***p<.001

Evidence Based Systems of Care for Evidence Based Systems of Care for Depression in Primary CareDepression in Primary Care

3rd Generation Depression System Change Interventions3rd Generation Depression System Change Interventions

IMPACTIMPACT PROSPECTPROSPECT RESPECTRESPECT

ChangeChange DepressionDepressionSpecialistSpecialist

Depression Depression SpecialistSpecialist TCMTCM

Care MgmtCare Mgmt On-siteOn-site On-siteOn-site Off-siteOff-site

Patient EducationPatient Education YesYes YesYes YesYes

Psychiatric Psychiatric supervisionsupervision Face to faceFace to face Face to faceFace to face TelephoneTelephone

Psychotherapy Psychotherapy supervisionsupervision TelephoneTelephone Face to faceFace to face N/AN/A

Rx algorithmRx algorithm YesYes YesYes NoNo

Managing Any Other Chronic Disease

Managing Antidepressants is Like…..

Monitor Depressive Symptoms

Educate Patient and Family

Monitor Adherence

Monitor Side Effects

Provide Support

Consult or Refer to Agency/Outside Specialist As Needed

Remission (HSCL <.5) from Major Depression Remission (HSCL <.5) from Major Depression IMPACT StudyIMPACT Study

0%

10%

20%

30%

40%

0 3 mos 6 mos 12 mos

Intervention

Usual Care

Unützer et al., JAMA 2002

Remission (HDRS < 10) from Major Depression PROSPECT Study

0%5%

10%15%20%25%30%35%40%

Baseline 4 mo 8 mo 12 mo

Usual Care

Intervention

Bruce et al., JAMA 2004

Remission (HSCL <.5) from Major Depression RESPECT Study

0%5%

10%15%20%25%30%35%40%

Baseline 3 Mos 6 mos

Usual Care

Intervention

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 youThank you

Questions?Questions?