Phase-Based Care in Community Mental Health: A Cost-Effective Innovation Using Algorithms, Rating Scales and Treatment Teams for Depression Management.

This retrospective, observational report describes an innovative quality improvement process, Phase-based Care (PBC), that eliminated wait times and achieved positive clinical outcomes in a community mental health center's (CMHC) mood disorder clinic without adding staff. PBC accomplishes this by eliminating the ingrained cultural practice of routinely scheduling stable patients at rote intervals of 1-3 months, regardless of clinical need or medical necessity. Based on four organizational transformations and using mathematical algorithms developed for this process, PBC re-allocates therapy and medical resources away from routinely scheduled appointments and front-loads those resources to patients in an acute phase of illness. To maintain wellness for patients in recovery, lower frequency and intensity approaches are used. This report describes the development of the PBC methodology focusing on the Rapid Recovery Clinic (RRC) comprised of 182 patients with a primary diagnosis of a mood disorder, the largest of the 14 PBC clinics created. Over an 18-month period, wait times were reduced from several months to less than one week and recovery rates, meaning no longer in an acute phase, were 63% and 78% at weeks 6 and 12, respectively for patients who engaged in the program.

Late-life mental health education for workforce development: brain versus heart?

PURPOSE: There is a shortage of mental health professionals to care for a growing geriatric population. Though not mutually exclusive, clinical and didactic educational experiences promote cognition, whereas affective knowledge (attitude) is promoted through nonclinical exposure to seniors. This study evaluates the relative impact of cognition and attitude on career interests among healthcare students. METHODS: We developed 13 interactive, video documentary "lessons" on late-life mental health presenting didactic material along with stories of actual patients and families. Four of these lessons were viewed at 1-week intervals by 42 students from medical school and graduate programs of social work, psychology, and nursing. Knowledge, attitudes, and inclinations toward working with seniors were assessed. RESULTS: Both cognition and attitudes toward seniors improved. Linear regression shows that change in attitude, not cognition, predicts interest in working with seniors. CONCLUSION: Educational experiences that promote affective learning may enhance interest in geriatric careers among healthcare students.

A comparison of the E-BEHAVE-AD, NBRS, and NPI in quantifying clinical improvement in the treatment of agitation and psychosis associated with dementia.

OBJECTIVES: The aim of this study is to compare the Empirical Behavioral Rating Scale (E-BEHAVE-AD), Neurobehavioral Rating Scale (NBRS), and Neuropsychiatric Interview (NPI) in detecting behavioral disturbance and psychotic symptoms in dementia and characterizing changes in response to treatment. DESIGN: Eighty-seven subjects in the randomized controlled trial "Continuation Pharmacotherapy for Agitation of Dementia" were included in this analysis. We compared the detection in, and changes of, both agitation and psychosis, using these three instruments. A receiver operating characteristic analysis was performed to compare the performance of the three instruments in detecting global improvement. RESULTS: The instruments were equally likely to detect agitation. The NBRS was most likely to detect psychosis. Although the NPI best detected improvement in agitation, the instruments were equal for detecting improvement in psychosis. In the receiver operating characteristic analysis for overall clinical improvement in response to treatment, there were no differences in the areas under the correlated curves for the three instruments, but they demonstrated different sensitivity and specificity at different cutoff points for target symptom reduction. The E-BEHAVE-AD performed best at a cut point of 30% target symptom reduction and the NBRS and NPI both performed best at 50%. CONCLUSION: The E-BEHAVE-AD, NBRS, and NPI were more similar than different in characterizing symptoms but differed in detecting response to treatment. Differences in sensitivity and specificity may lead clinicians to prefer a specific instrument, depending on their goal and the expected magnitude of response to any specific intervention.

Treating neuropsychiatric symptoms in dementia with Lewy bodies: a randomized controlled-trial.

Sensitivity to psychotropic medications presents a therapeutic challenge when treating neuropsychiatric symptoms in patients with dementia with Lewy bodies (DLB). We compared under randomized, double-blinded conditions the tolerability and efficacy of citalopram and risperidone in the treatment of behavioral and psychotic symptoms in patients with DLB and Alzheimer disease (AD). Thirty-one participants with DLB and 66 with AD hospitalized for behavioral disturbance were treated under randomized, double-blind conditions with citalopram or risperidone for up to 12 weeks. Neuropsychiatric symptoms were assessed with the nursing home version of the Neuropsychiatric Inventory (NPI) and the Clinical Global Impression of Change (CGIC). Side effects were measured using the UKU Side Effect Rating Scale. A significantly higher proportion of participants with DLB (68%) than with AD (50%) discontinued the study prematurely. Discontinuation rates were comparable in DLB participants treated with citalopram (71%) or risperidone (65%). However, participants with DLB randomized to risperidone experienced a higher overall burden of side effects. Scores on the NPI and the CGIC worsened in DLB participants and improved in those with AD. Most patients with behavioral disturbances or psychosis associated with DLB tolerate citalopram or risperidone poorly and do not seem to benefit from either medication.

Web-based training and interrater reliability testing for scoring the Hamilton Depression Rating Scale.

Despite the importance of establishing shared scoring conventions and assessing interrater reliability in clinical trials in psychiatry, these elements are often overlooked. Obstacles to rater training and reliability testing include logistic difficulties in providing live training sessions, or mailing videotapes of patients to multiple sites and collecting the data for analysis. To address some of these obstacles, a web-based interactive video system was developed. It uses actors of diverse ages, gender and race to train raters how to score the Hamilton Depression Rating Scale and to assess interrater reliability. This system was tested with a group of experienced and novice raters within a single site. It was subsequently used to train raters of a federally funded multi-center clinical trial on scoring conventions and to test their interrater reliability. The advantages and limitations of using interactive video technology to improve the quality of clinical trials are discussed.

The association between changes in health status and nursing home resident quality of life.

PURPOSE: Previous research on nursing home resident quality of life (QOL) has mainly been cross-sectional. This study examined the association between changes in QOL and changes in resident clinical factors. DESIGN AND METHODS: A longitudinal study of resident QOL was conducted in two nursing homes. Self-report interviews using a multidimensional measure of QOL were linked with clinical data from the Minimum Data Set. Five waves of interviews were conducted at 6-month intervals. RESULTS: Residents with one or more Stage II or higher pressure ulcers for two consecutive 6-month periods reported declines in autonomy, security, and spiritual well-being QOL domains; those with declines in physical disability reported declines in the dignity domain. Increases in depressive symptoms were associated with decreases in comfort, meaningful activities, and food enjoyment domains, and increases in pain were associated with decreases in functional competence and dignity domains. IMPLICATIONS: There is evidence of an association between physical health and self-reported QOL. However, not every dimension of QOL exhibited the same pattern. Further research is needed on the link between specific clinical factors and aspects of QOL.

Perception gap in quality-of-life ratings: an empirical investigation of nursing home residents and caregivers.

PURPOSE: Several studies have previously documented the existence of a perception gap-the extent to which quality-of-life ratings provided by nursing home residents and caregivers diverge. In this study we use Helson's adaptation-level theory to investigate three types of antecedents: (a) focal factors, (b) background factors, and (c) residual factors. DESIGN AND METHODS: We calculated the perception gap for 11 quality-of-life domains. Caregivers rated both job satisfaction and their perception of quality of life of residents in the unit where they provided service. Concurrently, residents from these units completed quality-of-life interviews. We computed the perception gap by subtracting the residents' ratings from the caregivers' ratings for each quality-of-life domain. We conducted a hierarchical linear model using 3,850 observations to predict the perception gap. RESULTS: Caregivers perceive quality of life to be lower than residents do across all domains fairly consistently. Caregiver demographics do not directly predict the perception gap. However, satisfaction with work, pay, and promotion were significant predictors (p <.05), and satisfaction with supervisor was a marginally significant predictor (p <.10), of the perception gap. As satisfaction with these job dimensions increased, the perception gap decreased. Additional models show that several caregiver demographics directly influence job-satisfaction dimensions, though they did not influence the perception gap. IMPLICATIONS: Job-satisfaction dimensions, rather than caregiver characteristics, are the appropriate predictors of the perception gap. However, caregiver demographics exert their influence indirectly by means of job satisfaction. A key finding is that higher job satisfaction leads to a smaller perception gap. Helson's adaptation-level theory appears to be a useful approach for understanding the antecedents of the perception gap.

Determinants of staff job satisfaction of caregivers in two nursing homes in Pennsylvania.

BACKGROUND: Job satisfaction is important for nursing home staff and nursing home management, as it is associated with absenteeism, turnover, and quality of care. However, we know little about factors associated with job satisfaction and dissatisfaction for nursing home workers. METHODS: In this investigation, we use data from 251 caregivers (i.e., Registered Nurses, Licensed Practical Nurses, and Nurse Aides) to examine: job satisfaction scores of these caregivers and what characteristics of these caregivers are associated with job satisfaction. The data were collected from two nursing homes over a two and a half year period with five waves of data collection at six-month intervals. The Job Description Index was used to collect job satisfaction data. RESULTS: We find that, overall nursing home caregivers are satisfied with the work and coworkers, but are less satisfied with promotional opportunities, superiors, and compensation. From exploratory factor analysis three domains represented the data, pay, management, and work. Nurse aides appear particularly sensitive to the work domain. Of significance, we also find that caregivers who perceived the quality of care to be high have higher job satisfaction on all three domains than those who do not. CONCLUSION: These results may be important in guiding caregiver retention initiatives in nursing homes. The finding for quality may be especially important, and indicates that nursing homes that improve their quality may have a positive impact on job satisfaction of staff, and thereby reduce their turnover rates.

Ability, incentives, and management feedback: organizational change to reduce pressure ulcers in a nursing home.

OBJECTIVE: Quality improvement (QI) processes in nursing homes are highly variable and often ineffective. This study evaluated an innovative QI process to reduce pressure ulcers (PUs) in a nursing home with a high rate of PUs. DESIGN: This was a 48-week, longitudinal study comparing the incidence of PUs during 12-week baseline and intervention and post-intervention periods. SETTING: Not-for-profit, 136-bed nursing home in urban Western Pennsylvania. PATIENTS OR OTHER PARTICIPANTS: All residents and all staff at the nursing home participated in this study. INTERVENTIONS: The intervention consisted of 3 components: Ability enhancement, incentivization, and management feedback. To enhance ability, all staff members completed a computer-based interactive video education program on PU prevention and were mandated to use penlights to promote early detection. Incentivization included $75 for each staff member if the desired reduction in PU incidence was achieved. Management feedback provided real-time information of staff"s adherence to the mandated training. MAIN OUTCOME MEASURES: Outcome measures consisted of staff's adherence to mandated training and the incidence of new PUs during the baseline period compared to the intervention and post-intervention periods. RESULTS: Management responded to noncompliance with training with both rewards and stepped discipline. Adherence to protocol, as measured by training compliance, was 100%. There was a significant reduction (P < .05) in the incidence of stage 2 or worse PUs during the intervention period. During the post-intervention periods, the effect was lost. CONCLUSION: An innovative QI initiative resulted in a significant decrease in PUs in 1 facility. This intervention was not sustainable when the 3 components of the QI intervention were no longer actively maintained.

Dextromethorphan-induced delirium and possible methadone interaction.

INTRODUCTION: Dextromethorphan is a commonly used antitussive agent that can be purchased over the counter. It is metabolized primarily by the cytochrome P450 (CYP) 2D6 isozyme. Methadone has been found to inhibit CYP2D6, indicating a potential for interaction with dextromethorphan. CASE SUMMARY: An 83-year-old woman was evaluated for delirium, hypersomnia, confusion, lethargy, impaired concentration, and poor food intake. Symptoms resolved soon after discontinuing dextromethorphan. DISCUSSION: Vulnerability to delirium was potentially caused by coadministration of methadone, which can inhibit the CYP2D6 isozyme. CONCLUSION: Evaluation of delirium should include close investigation of the patient's medications for potential interactions with dextromethorphan.

Population pharmacokinetics as a method to detect variable risperidone exposure in patients suffering from dementia with behavioral disturbances.

OBJECTIVE: This study was intended to compare the consistency of risperidone exposure in patients who have dementia and behavioral disturbances treated in a psychiatric hospital versus a community care setting. METHODS: Population pharmacokinetic modeling was used to assess the consistency of risperidone exposure in Alzheimer's disease patients with agitation. The ratio of predicted to observed drug concentrations (Cpred/Cobs) derived from this model was used to compare exposure in the inpatient versus long-term/home care settings using both the mean and the variance of this term across groups. RESULTS: The modeled Cpred/Cobs ratios had a much higher within-subject variance in the inpatients than in the community care patients (117.03% vs 72.35%; P < 0.001). The central tendencies of the Cpred/Cobs ratios across the 2 groups were not significantly different. CONCLUSIONS: Exposure to risperidone was more variable in a psychiatric hospital than in a community care setting. Future research may help to identify the specific contributors to the increased variance observed in this pilot study.

Preparedness for death and adjustment to bereavement among caregivers of recently placed nursing home residents.

BACKGROUND: Preparedness for death as a predictor of post-bereavement adjustment has not been studied prospectively. Little is known about pre-death factors associated with feeling prepared prior to the death of a loved one. OBJECTIVE: Our aim was to prospectively assess the role of preparedness for death as a predictor of post-bereavement adjustment in informal caregivers (CGs) who experienced the death of their loved one and to identify predictors and correlates of complicated grief, depression, and preparedness for death among informal CGs. METHODS: We conducted a prospective, longitudinal study using data collected for a randomized trial testing the efficacy of an intervention for CGs of recently placed care recipients (CRs). Subjects were 217 informal CGs of care recipients recently placed in nursing homes, and they were followed for 18 months. CGs were assessed in person by certified interviewers at 6-month intervals. Eighty-nine CGs experienced the death of their loved one in the course of the study. Measurements used included preparedness for death, advance care planning (ACP), complicated grief, depression, and sociodemographic characteristics. RESULTS: CGs who reported feeling more prepared for the death experienced lower levels of complicated grief post-bereavement. A multivariate ordinal logistic regression model showed that spouses as opposed to adult child CGs were less prepared for the death, depressed CGs were less prepared, and patients who engaged in ACP had CGs who felt more prepared. CR overt expressions about wanting to die was also related to higher levels of preparedness in the CG. CONCLUSIONS: We show prospectively that preparedness for death facilitates post-bereavement adjustment and identify factors associated with preparedness. ACP can be an effective means for preparing informal CGs for the death of their CRs.

Goal Attainment Scaling (GAS) in geriatric primary care: a feasibility study.

OBJECTIVE: Evaluate the feasibility of generating patient-centered goals using GAS with older adults who have multiple chronic conditions, recruited through primary care. METHOD: Adults age 65+ (N=27) were recruited from a geriatric primary care center. Participants were asked to identify 2-4 activity-based goals and set attainment levels using GAS. At 8 weeks, participants were asked to rate current level of their goal performance. Physician surveys were used to evaluate if goals were realistic and feasible, and patient surveys were implemented to evaluate satisfaction. GAS T-scores were used to quantify change in goal achievement. RESULTS: Ninety-three percent (n=25) of participants were able to establish a minimum of two goals using GAS. 100% of participants were able to rate goal performance at follow-up. Physician survey results identified 100% of goals realistic and 93% achievable and 100% of participants were either neutral or satisfied with the process. Significant improvement was reported in GAS change scores (t(24)=6.54, p<0.001). CONCLUSION: Findings support the feasibility of GAS for older adults with multiple chronic conditions in geriatric primary care as a strategy to facilitate patient-centered care and suggest that the process of personalized goal-setting itself may facilitate goal attainment.

Actors' portrayals of depression to test interrater reliability in clinical trials.

OBJECTIVE: This study determined if actors could portray depressed patients to establish the interrater reliability of raters using the Hamilton Depression Rating Scale (HDRS). METHOD: Actors portrayed depressed patients using scripts derived from HDRS assessments obtained at three points during treatment. Four experienced raters blindly viewed videotapes of two patients and two actors. They guessed if each interviewee was a patient or an actor and rated the certainty of their guesses. For each interview, they also rated the realism of the portrayal and completed the HDRS. RESULTS: Experienced raters could not distinguish actors and patients better than chance and were equally certain of their right and wrong guesses. Actors and patients received high scores on the realism of their portrayals. The HDRS scores of the actor-patient pairs were correlated. CONCLUSIONS: Actors can effectively portray depressed patients. Future studies will determine if actors can accurately portray patients with anxiety and psychosis.

Interrater reliability in clinical trials of depressive disorders.

OBJECTIVE: The goal of this study was to review the reported methods of rater training, assessment of interrater reliability, and rater drift in clinical trials of treatments for depressive disorders. METHOD: Two psychiatrists independently identified all original reports of clinical trials relevant to depressive disorders published between 1996 and 2000 in the American Journal of Psychiatry and the Archives of General Psychiatry. Reported methods of rater training, assessment of interrater reliability, and rater drift were systematically summarized. RESULTS: Sixty-three original papers met criteria for inclusion. Only 11 (17%) of the studies reported the number of raters. Only two (9%) of the 22 multicenter and four (10%) of the 41 single-center trials documented rater training. Only nine (22%) of the single-center trials and three (14%) of the multicenter trials reported interrater reliability, despite a median number of five raters (range=2-20). Only three (5%) of the 63 articles reported rater drift. CONCLUSIONS: Few published reports of clinical trials of treatments for depressive disorders document adequately the number of raters, rater training, assessment of interrater reliability, and rater drift.

Comparison of citalopram, perphenazine, and placebo for the acute treatment of psychosis and behavioral disturbances in hospitalized, demented patients.

OBJECTIVE: Until recently, conventional antipsychotics were the standard pharmacotherapy for psychosis and behavioral disturbances associated with dementia. This double-blind, placebo-controlled study compared the acute efficacy of the selective serotonin reuptake inhibitor citalopram and the neuroleptic perphenazine with placebo for the treatment of psychosis and behavioral disturbances in nondepressed patients with dementia. METHOD: Eighty-five hospitalized patients with at least one moderate to severe target symptom (aggression, agitation, hostility, suspiciousness, hallucinations, or delusions) were randomly assigned to receive either citalopram, perphenazine, or placebo under double-blind conditions for up to 17 days. RESULTS: Patients treated with citalopram or perphenazine showed statistically significant improvement on several Neurobehavioral Rating Scale factor scores. Compared to those receiving placebo, only patients treated with citalopram showed significantly greater improvement in their total Neurobehavioral Rating Scale score as well as in the scores for the agitation/aggression and lability/tension factors. Side effect scores were similar among the three treatment groups. CONCLUSIONS: Citalopram was found to be more efficacious than placebo in the short-term hospital treatment of psychotic symptoms and behavioral disturbances in nondepressed, demented patients.

Neuroleptic-Induced Parkinsonism in Elderly Patients Diagnosed With Psychotic Major Depression and Dementia of the Alzheimer Type.

The authors prospectively examined elderly patients diagnosed with major depression with psychotic features (MD-P) and patients diagnosed with dementia of the Alzheimer Type (DAT) for neuroleptic-induced parkinsonism (NIP) during perphenazine treatment. Baseline parkinsonian symptoms did not differ between groups. With treatment, mean NIP score doubled in DAT patients but remained unchanged in the MD-P group. The difference between groups was highly significant and remained so after the effects of age, perphenazine dose, and duration of perphenazine treatment were controlled. Although the mechanisms underlying these differences in NIP development remain to be determined, clinical guidelines for neuroleptic dosages in elderly patients need to account for variability in neuroleptic tolerance between diagnostic groups.

The Pittsburgh Agitation Scale: A User-Friendly Instrument for Rating Agitation in Dementia Patients.

There are many rating instruments designed to assess symptoms of agitation in patients with dementia. Most scales require that raters assess multiple specific behaviors over several days, limiting the use of such scales to clinical staff who have direct contact with patients but do not have the time to complete a comprehensive assessment following each period of observation. Also, scales that assess behavior over several days must rely on "secondhand" information describing behaviors not directly observed by the rater. The Pittsburgh Agitation Scale (PAS) is an easy-to-use instrument, based on direct observations of the patient, that was developed to monitor the severity of agitation associated with dementia. Interrater reliability and measures of validity have been established with clinical staff on a busy psychogeriatric inpatient unit and with research personnel in a nursing home setting.

Personality Disorders in Elderly Inpatients With Major Depression.

We studied 154 patients with major depression, with and without personality disorder (PD), consecutively admitted to a geriatric unit and compared their characteristics and responses to acute inpatient treatment. Thirty-seven patients (24%) met DSM-III-R criteria for PD. PD not otherwise specified and dependent PD were the most frequent PD diagnoses, whereas dramatic cluster PDs were rare. Patients with PD were significantly more likely to have had 1) recurrent depression, 2) an earlier age at first episode, and 3) a concurrent anxiety disorder. There was a higher proportion of patients with PD to have 1) never married, 2) separated or divorced, or 3) attempted suicide. During inpatient stays of similar lengths, both groups received similar treatment and improved to a similar and significant extent.