The effect of major and minor depression on Medicare home healthcare services use.

OBJECTIVES: To examine the associations between major and minor depression and categories of Medicare home healthcare use. DESIGN: Observational prospective study (1997-1999). SETTING: Visiting nurse agency in suburban New York State. PARTCIPANTS: Five hundred thirty-nine new Medicare admissions aged 65 and older (mean age 78.4), 65.1% female, and 15.0% nonwhite. Approximately 13.5% were diagnosed with major depression and another 10.8% with minor depression. MEASUREMENTS: Consensus "best estimate"Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses for major and minor depression assessed using Structured Clinical Interviews for DSM-IV (SCID) plus medical charts. RESULTS: Major and minor depression appear to have little association with probability and amount of use of the types of Medicare home health care (skilled nurse, home health aide, therapist (physical, occupational, and speech), and medical social services). Overall, patients with minor depression appear to have utilization similar to that of patients with major depression. CONCLUSION: It seems likely that any potential incremental depression effect on utilization is being offset by the transitional medical state of the patients that entered Medicare home healthcare directly from a hospital, nursing home, or rehabilitation facility, and the overall severity of disability and chronic illness present in long-term home healthcare patients. Further research is required to determine whether similar findings occur in other home healthcare agencies and whether these are present under the current Medicare Prospective Payment System reimbursement mechanism.

Major depression and emergency medical services utilization in community-dwelling elderly persons with disabilities.

OBJECTIVE: To examine the association between major depression and emergency medical services (EMS) use by community-dwelling older adults with disabilities. METHODS: A prospective observational.study including 1,444 participants age 65+ in 19 counties in three US states that participated in the Medicare Primary and Consumer-Directed Care Demonstration. Eligibility criteria included needing or receiving help with either 2+ activities of daily living (ADLs) or 3+ instrumental ADLs, and having received recent significant healthcare services use. The presence of major depression was measured at baseline by the MINI Major Depressive Episode module. EMS utilization data for the following 2 years were obtained from a daily journal concurrently completed by each subject or a caregiver. RESULTS: More persons with major depression (43%) than without (35%) reported EMS use. When other factors were controlled in a logistic regression model, this effect was no longer statistically significant. However, of those with at least one episode of EMS transport, the depressed reported significantly (25%) more episodes (mean = 2.10) than the non-depressed (mean = 1.68). Major depression was significantly associated with more EMS episodes in both Poisson (Z = 1.99; p = 0.047) and ordinary least squares (t = 2.08; p = 0.038) regression models. CONCLUSIONS: Depressed disabled older adults who utilize EMS have more EMS episodes than those without depression. This higher use may be driven in part by affective illness. Research is needed to determine whether more EMS episodes are necessary to address symptoms of major depression, especially suicidal ideation, or whether they are due to other illnesses that are exacerbated by symptoms of major depression.

Major depression and disability in older primary care patients with heart failure.

The purpose of this study was to examine the association between dependence in activities of daily living (ADL) and instrumental ADL (IADL) and major depression among 415 community-dwelling primary care patients age 65+ with heart failure and significant ADL or IADL dependence. Main findings include (1) a progressive increase in depression prevalence from 0% for no IADL dependence to about 40% for 6 IADL dependencies (P < .001), (2) a steady rise in depression prevalence to 40% for 6 ADL dependencies following a "floor effect" at about 10% for 0 to 2 ADL dependencies (P < .001), and (3) the association in a logistic regression model of major depression with number of IADL dependencies (P = .016) but not with number of ADL dependencies (P = .602). Our principal conclusion is that the progressively greater likelihood of major depression as the number of IADL dependencies increases has important clinical, personal, social, and public health relevance.

Correlates of late-life major depression: a comparison of urban and rural primary care patients.

OBJECTIVE: The objective of this study was to determine whether factors associated with depression differ between elderly residents of rural and urban areas. METHODS: The research design was cross-sectional and observational. The study subjects consisted of 926 Medicare primary care patients (650 urban and 276 rural) who were age 65+ and cognitively intact and had enrolled in a randomized, controlled Medicare demonstration. Major depression was identified by the Mini International Neuropsychiatric Interview. A logistic regression model was estimated that included a rural-urban indicator variable, additional independent variables, and interaction terms between the rural-urban indicator and independent variables that were significant at p <0.10. RESULTS: A total of 8.3% of the rural and 14.8% of the urban patients were identified as having major depression. Reporting 0-1 close friends (odds ratio [OR]: 6.86; 95% confidence interval [CI]: 2.18-21.58), 2+ emergency room visits during the past 6 months (OR: 4.00; 95% CI: 1.19-13.43), and more financial strain (OR: 1.50; 95% CI: 1.01-2.23) were associated with significantly higher likelihood of major depression among rural as compared with urban patients. The SF-36 Physical Component Summary score had a curvilinear relationship with major depression and was higher for urban patients. The predicted probability for major depression is lower for the rural patients when financial strain is low, about the same for rural and urban patients when strain is intermediate, and higher for rural patients when strain is high. CONCLUSIONS: Clinicians in rural areas should be vigilant for major depression among patients with very few close friends, several recent emergency department visits, and financial strain.

Psychometric properties of the 15-item geriatric depression scale in functionally impaired, cognitively intact, community-dwelling elderly primary care patients.

OBJECTIVES: To examine the psychometric properties of the 15-item Geriatric Depression Scale (GDS-15), a brief depression screening measure. DESIGN: Cross-sectional. SETTING: Nineteen counties in western New York, West Virginia, and Ohio. PARTICIPANTS: Nine hundred sixty functionally impaired, cognitively intact, community-dwelling primary care patients aged 65 and older. MEASUREMENTS: The GDS-15, major depression as measured using the Mini-International Neuropsychiatric Interview, depressed mood, life satisfaction, suicidal ideation, and reported suicide attempts. RESULTS: Exploratory factor analyses suggested a two-factor structure for the GDS-15 in this category of patients, with component subscales assessing depression and positive affect. Cronbach alpha coefficients provide evidence for moderate, although acceptable, internal consistency reliability. Significant associations between the GDS-15 and measures of depressed mood, life satisfaction, and suicidal ideation demonstrated construct validity, whereas acceptable sensitivity and specificity to discriminate between depressed and nondepressed patients demonstrated criterion validity. Internal consistency reliability and construct validity did not differ significantly between patients with low and high functional impairment. A significant weakness of the scale is its low correlation with suicide attempt status. CONCLUSION: In general, this study provides evidence of impressive psychometric properties of the GDS-15 when administered to a sample of functionally impaired, cognitively intact, community-dwelling primary care patients.