Predictive modeling of initiation and delayed mental health contact for depression.

BACKGROUND: Depression is prevalent among Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) Veterans, yet rates of Veteran mental health care utilization remain modest. The current study examined: factors in electronic health records (EHR) associated with lack of treatment initiation and treatment delay; the accuracy of regression and machine learning models to predict initiation of treatment. METHODS: We obtained data from the VA Corporate Data Warehouse (CDW). EHR data were extracted for 127,423 Veterans who deployed to Iraq/Afghanistan after 9/11 with a positive depression screen and a first depression diagnosis between 2001 and 2021. We also obtained 12-month pre-diagnosis and post-diagnosis patient data. Retrospective cohort analysis was employed to test if predictors can reliably differentiate patients who initiated, delayed, or received no mental health treatment associated with their depression diagnosis. RESULTS: 108,457 Veterans with depression, initiated depression-related care (55,492 Veterans delayed treatment beyond one month). Those who were male, without VA disability benefits, with a mild depression diagnosis, and had a history of psychotherapy were less likely to initiate treatment. Among those who initiated care, those with single and mild depression episodes at baseline, with either PTSD or who lacked comorbidities were more likely to delay treatment for depression. A history of mental health treatment, of an anxiety disorder, and a positive depression screen were each related to faster treatment initiation. Classification of patients was modest (ROC AUC = 0.59 95%CI = 0.586-0.602; machine learning F-measure = 0.46). CONCLUSIONS: Having VA disability benefits was the strongest predictor of treatment initiation after a depression diagnosis and a history of mental health treatment was the strongest predictor of delayed initiation of treatment. The complexity of the relationship between VA benefits and history of mental health care with treatment initiation after a depression diagnosis is further discussed. Modest classification accuracy with currently known predictors suggests the need to identify additional predictors of successful depression management.

Antidepressant Augmentation: A Review of the Literature and a Review of the Pharmacoeconomic Considerations.

PURPOSE: Antidepressant augmentation strategies for treatment-resistant depression (TRD) are discussed here with an analysis of patient out-of-pocket costs for various medications. The choice of agent ranges from newer atypical antipsychotics (aripiprazole, brexpiprazole, quetiapine) to older agents including buspirone, liothyronine (T3), and lithium. We sought to better understand the differences among these agents to aid in clinical decision making. METHODS: We conducted a focused review of the support for each of the aforementioned agents in antidepressant augmentation. We then compared the approximate out-of-pocket cost for each medication during a typical augmentation trial using the typical prescription costs on ClinCalc.com derived from the Medical Expenditure Panel Survey. We calculated the cost to achieve response for one patient with TRD based on the number needed to treat (NNT). FINDINGS: We observed significant variance in cost to achieve response based on the NNT derived from our review of each of the medications. For example, the overall out-of-pocket cost for one patient to achieve response with aripiprazole (the costliest generic agent) could cover lithium prescriptions for 4 to 5 patients with TRD to achieve response. Although brexpiprazole was estimated separately because of its brand name cost, we estimated that 324 patients receiving lithium could achieve response for same cost of single patient receiving brexpiprazole. IMPLICATIONS: These findings suggest that among augmentation agents, there are differences in cost that may be highly important in clinical decision making. Other issues of medication monitoring may incur additional costs, and brand name medications offer significantly greater complexity and potential out-of-pocket costs to patients. The use of lithium as a first-line agent for TRD should be considered based on low cost, lowest NNT, and data in support of its efficacy.

American Association for Geriatric Psychiatry-Strategic Thinking.

Never has there been a more pressing time for the American Association for Geriatric Psychiatry (AAGP) to articulate a unified strategy to meet the challenges of our aging world. To this end, this report summarizes an AAGP leadership meeting that reviewed the results from a recent membership survey and launched a strategic planning process on behalf of AAGP members and stakeholders. This meeting was the first step in drafting a blueprint for the future that may serve as our guide in the context of finite resources to meet the infinitely complex and growing need for education, research, public advocacy, and clinical practice support. The following report serves to invite our valued colleagues to provide feedback and actively participate in defining our mission. Among the outcomes of the planning session, the following aspirations were identified by the participants 1) assert the AAGP as the "go to" organization for all things related to geriatric mental health, 2) prioritize activities that enhance the inclusivity/diversity of membership, and 3) collaborate across disciplines focused on geriatric mental health. From this initial framework, the group developed four general themes to guide AAGP's strategic future: 1) collaboration, 2) advocacy, 3) inclusivity, 4) high purpose. Inclusivity was further defined as encompassing growth, return on investment, and workforce development. Higher purpose was further defined as encompassing engagement, purpose, branding, communication, and expertise. The AAGP affirmed its commitment to serving the needs of its members and widening its scope of impact in view of staggering demands for better access to geriatric mental healthcare.

Mortality and Associated Risk Factors in Community-Dwelling Persons With Early Dementia.

OBJECTIVE: Examine mortality and associations with baseline characteristics among Veterans with early dementia. METHODS: Participants included dyads of community-based Veterans with early dementia and their caregivers (N=143) enrolled in a previous longitudinal study. Department of Veterans Health Affairs' electronic records were used to retrospectively collect Veteran mortality outcomes, over a 6-year period. Measures included baseline: demographics, dementia-related factors, other comorbid conditions, functioning, and medication use. Associations with baseline characteristics and mortality were examined with bivariate analyses and a series of Cox proportional hazard models. RESULTS: Over 6 years of study follow-up, 53.1% of participants died. The mean time to death was 3.09 years, with a range of 54 days to 5.91 years. Female sex, better cognition, and higher scores on the Tinetti Gait and Balance scale were protective factors in the final multivariable model, adjusting for other characteristics. CONCLUSIONS: While newly diagnosed with early dementia, over half of our sample died in the 6-year follow-up period, with the average death occurring only 3 years after initial diagnosis. The finding of lower mortality associated with better performance on gait/balance testing indicates an important opportunity for focused interventions and early detection of gait and balance changes early during cognitive decline.

Comparison of T1Rho MRI, Glucose Metabolism, and Amyloid Burden Across the Cognitive Spectrum: A Pilot Study.

OBJECTIVE: The pathological cascades associated with the development of Alzheimer's disease (AD) have a common element: acidosis. T1rho MRI is a pH-sensitive measure, with higher values associated with greater neuropathological burden. The authors investigated the relationship between T1rho imaging and AD-associated pathologies as determined by available diagnostic imaging techniques. METHODS: Twenty-seven participants (men, N=13, women, N=14; ages 55-90) across the cognitive spectrum (healthy control subjects [HCs] with normal cognition, N=17; participants with mild cognitive impairment [MCI], N=7; participants with mild AD, N=3) underwent neuropsychological testing, MRI (T1-weighted and T1rho [spin-lattice relaxation time in the rotating frame]), and positron emission tomography imaging ([11C]Pittsburg compound B for amyloid burden [N=26] and [18F]fluorodeoxyglucose for cerebral glucose metabolism [N=12]). The relationships between global T1rho values and neuropsychological, demographic, and imaging measures were explored. RESULTS: Global mean and median T1rho were positively associated with age. After controlling for age, higher global T1rho was associated with poorer cognitive function, poorer memory function (immediate and delayed memory scores), higher amyloid burden, and more abnormal cerebral glucose metabolism. Regional T1rho values, when controlling for age, significantly differed between HCs and participants with MCI or AD in select frontal, cingulate, and parietal regions. CONCLUSIONS: Higher T1rho values were associated with greater cognitive impairment and pathological burden. T1rho, a biomarker that varies according to a feature common to each cascade rather than one that is unique to a particular pathology, has the potential to serve as a metric of neuropathology, theoretically providing a measure for assessing pathological status and for monitoring the neurodegeneration trajectory.

Clinical repetitive transcranial magnetic stimulation for veterans with major depressive disorder.

BACKGROUND: Repetitive transcranial magnetic stimulation (TMS) is a relatively new treatment modality for patients with major depressive disorder (MDD). Numerous studies have demonstrated the efficacy of TMS for MDD in the general population. However, there is limited information regarding clinical outcomes among veterans receiving TMS for MDD. METHODS: The clinical outcome and characteristics of all veterans with MDD who were treated with TMS as outpatients at the James A. Haley Veterans' Hospital from October 2013 to December 2016 were assessed. RESULTS: Among 40 patients who received TMS, there was a significant improvement of depressive symptoms using the Quick Inventory of Depressive Symptomatology-Self-Report (45% response, 20% remission) and the Montgomery-Åsberg Depression Rating Scale (61.9% response, 42.9% remission). In addition to significant improvement in depressive symptoms, self-report of anxiety symptoms and function significantly improved. TMS was generally well tolerated, with only a small percentage of patients discontinuing treatment due to side effects. No seizures or persistent adverse effects were observed or reported. CONCLUSIONS: TMS is an effective and well-tolerated option for MDD in a veteran population with significant treatment resistance and multiple comorbidities.

Relapse risk after discontinuation of risperidone in Alzheimer's disease.

BACKGROUND: Among patients with Alzheimer's disease who have had a response to antipsychotic medication for psychosis or agitation-aggression, the risk of a recurrence of symptoms after discontinuation of the medication has not been established. METHODS: Patients with Alzheimer's disease and psychosis or agitation-aggression received open-label treatment with risperidone for 16 weeks. Those who had a response to risperidone therapy were then randomly assigned, in a double-blind fashion, to one of three regimens: continued risperidone therapy for 32 weeks (group 1), risperidone therapy for 16 weeks followed by placebo for 16 weeks (group 2), or placebo for 32 weeks (group 3). The primary outcome was the time to relapse of psychosis or agitation. RESULTS: A total of 180 patients received open-label risperidone (mean dose, 0.97 mg daily). The severity of psychosis and agitation were reduced, although there was a mild increase in extrapyramidal signs; 112 patients met the criteria for response to treatment, of whom 110 underwent randomization. In the first 16 weeks after randomization, the rate of relapse was higher in the group that received placebo than in the groups that received risperidone (60% [24 of 40 patients in group 3] vs. 33% [23 of 70 in groups 1 and 2]; P=0.004; hazard ratio with placebo, 1.94; 95% confidence interval [CI], 1.09 to 3.45; P=0.02). During the next 16 weeks, the rate of relapse was higher in the group that was switched from risperidone to placebo than in the group that continued to receive risperidone (48% [13 of 27 patients in group 2] vs. 15% [2 of 13 in group 1]; P=0.02; hazard ratio, 4.88; 95% CI, 1.08 to 21.98; P=0.02). The rates of adverse events and death after randomization did not differ significantly among the groups, although comparisons were based on small numbers of patients, especially during the final 16 weeks. CONCLUSIONS: In patients with Alzheimer's disease who had psychosis or agitation that had responded to risperidone therapy for 4 to 8 months, discontinuation of risperidone was associated with an increased risk of relapse. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT00417482.).

Frontal hypometabolism in elderly breast cancer survivors determined by [(18)F]fluorodeoxyglucose (FDG) positron emission tomography (PET): a pilot study.

PURPOSE: The term "chemobrain" is sometimes used to denote deficits in neuropsychological functioning that may occur as a result of cancer treatment. As breast cancer survivors now commonly reach late life, it is not known whether previous exposure to chemotherapy may affect long-term risk for cognitive impairment. To help address this concern, this study tested whether successfully surviving chemotherapy earlier in life was associated with later differences in brain metabolic function as an older adult compared to controls. This question was examined using positron emission tomography measures of brain glucose metabolism in elderly women cancer survivors. METHODS: Breast cancer survivors (N = 10), currently free of recurrent cancer and without a diagnosis of a cognitive disorder, were compared to matched healthy controls (N = 10). All subjects were imaged at rest with [(18)F]fluorodeoxyglucose. Images were analyzed semi-quantitatively using the Alzheimer's Discrimination Tool and a volume of interest-based approach derived from co-registered magnetic resonance imaging. RESULTS: Relative [(18)F]fluorodeoxyglucose uptake (normalized to global) was significantly lower in the survivors compared with control subjects in bilateral orbital frontal regions, consistent with differences between the groups in cognition and executive function (i.e., Trail Making Test, Part B and mini-mental state examination) and despite no significant differences with respect to age, education, intelligence, or working memory. None of the survivors and only one control manifested a global positron emission tomography score consistent with an Alzheimer's disease metabolic pattern. CONCLUSION: Breast cancer survivors treated with chemotherapy may manifest long-term changes in brain glucose metabolism indicative of subtle frontal hypometabolism, a finding consistent with results from neuropsychological testing and other imaging modalities.

Mental health treatment utilization patterns among 108,457 Afghanistan and Iraq veterans with depression.

People with depression often underutilize mental health care. This study was conceived as a first step toward a clinical decision support tool that helps identify patients who are at higher risk of underutilizing care. The primary goals were to (a) describe treatment utilization patterns, early termination, and return to care; (b) identify factors associated with early termination of treatment; and (c) evaluate the accuracy of regression models to predict early termination. These goals were evaluated in a retrospective cohort analysis of 108,457 U.S. veterans who received care from the Veterans Health Administration between 2001 and 2021. Our final sample was 16.5% female with an average age of 34.5. Veterans were included if they had a depression diagnosis, a positive depression screen, and received general health care services at least a year before and after their depression diagnosis. Using treatment quality guidelines, the threshold for treatment underutilization was defined as receiving fewer than four psychotherapy sessions or less than 84 days of antidepressants. Over one fifth of veterans (21.6%) received less than the minimally recommended care for depression. The odds of underutilizing treatment increased with lack of Veterans Administration benefits, male gender, racial/ethnic minority status, and having received mental health treatment in the past (adjusted OR > 1.1). Posttraumatic stress disorder comorbidity correlated with increased depression treatment utilization (adjusted OR < .9). Models with demographic and clinical information from medical records performed modestly in classifying patients who underutilized depression treatment (area under the curve = 0.595, 95% CI [0.588, 0.603]). Most veterans in this cohort received at least the minimum recommended treatment for depression. To improve the prediction of underutilization, patient factors associated with treatment underutilization likely need to be supplemented by additional clinical information. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Cognitive features 10 or more years after successful breast cancer survival: comparisons across types of cancer interventions.

BACKGROUND: The present study examined the long-term cognitive implications of cancer treatment among breast cancer survivors aged 65 years and older to better understand the long term implications of cancer treatment. METHODS: Fifty-seven women survivors were compared with 30 healthy older female adult comparisons, matched in terms of age and education, with no history of cancer. Cancer survivors were also compared on the basis of treatment intervention, involving chemotherapy (n = 27) versus local therapy through surgery and radiation (n = 30). RESULTS: As a group, the breast cancer survivors scored lower on measures of general cognitive function, working memory, psychomotor speed, and executive function when compared with the normal comparisons. Among the cancer survivors, those who received local therapy scored lower than the other survivors and normal comparisons on measures of verbal learning, visual perception and construction, as well as visual attention and short-term retention. CONCLUSIONS: Our findings suggest that cognitive outcomes may involve greater age-related deficits among older cancer survivors compared with matched healthy subjects.

Improving antipsychotic agent use in nursing homes: development of an algorithm for treating problem behaviors in dementia.

Many issues related to safety and quality care emerge from reports that nearly one in three nursing home residents is treated with antipsychotic medication, a rate that exceeds levels that led to nursing home reform more than 2 decades ago. Atypical antipsychotic medications have become the mainstay of treatment for behavioral problems among residents with dementia, despite federal "black box" warnings about health risks and research demonstrating their limited effectiveness. The purpose of this article is to briefly describe a dissemination research project designed to increase appropriate antipsychotic prescribing for older adults with dementia. A step-wise problem-solving algorithm designed to reduce unnecessary psychotropic medication use is described. Formative evaluation results provided by nursing home personnel are reviewed. Discussion focuses on nursing home culture as an important influence on the adoption of evidence-based practices and changes needed to promote use of behavioral interventions in dementia care and reduction of reliance on antipsychotic medications.

The Value of Extracting Clinician-Recorded Affect for Advancing Clinical Research on Depression: Proof-of-Concept Study Applying Natural Language Processing to Electronic Health Records.

BACKGROUND: Affective characteristics are associated with depression severity, course, and prognosis. Patients' affect captured by clinicians during sessions may provide a rich source of information that more naturally aligns with the depression course and patient-desired depression outcomes. OBJECTIVE: In this paper, we propose an information extraction vocabulary used to pilot the feasibility and reliability of identifying clinician-recorded patient affective states in clinical notes from electronic health records. METHODS: Affect and mood were annotated in 147 clinical notes of 109 patients by 2 independent coders across 3 pilots. Intercoder discrepancies were settled by a third coder. This reference annotation set was used to test a proof-of-concept natural language processing (NLP) system using a named entity recognition approach. RESULTS: Concepts were frequently addressed in templated format and free text in clinical notes. Annotated data demonstrated that affective characteristics were identified in 87.8% (129/147) of the notes, while mood was identified in 97.3% (143/147) of the notes. The intercoder reliability was consistently good across the pilots (interannotator agreement [IAA] >70%). The final NLP system showed good reliability with the final reference annotation set (mood IAA=85.8%; affect IAA=80.9%). CONCLUSIONS: Affect and mood can be reliably identified in clinician reports and are good targets for NLP. We discuss several next steps to expand on this proof of concept and the value of this research for depression clinical research.

Trends in substance abuse treatment 1998-2008: increasing older adult first-time admissions for illicit drugs.

OBJECTIVES: To see whether the percentage of older adults entering substance abuse treatment for their first time was increasing and whether there were changes in the use patterns leading to the treatment episode, particularly an increase in illicit drugs. SETTING: The Treatment Episode Data Sets publicly available from the Substance Abuse Mental Health Services Administration from 1998 to 2008. PARTICIPANTS: Young adults age 30-54 years as a comparison group (N = 3,547,733) and those age 55 years or older (N = 258,542) with a first-time admission for a publicly funded substance abuse treatment. MEASUREMENTS: Demographic and substance use history variables at admission. RESULT: The proportion of older adults going for substance abuse treatment for the first time is increasing relative to younger adults. The pattern of drug use is also changing, with an increasing illicit drug involvement (cocaine and heroin) in older adult admissions. CONCLUSIONS: We know little of these long-time users, their current medical state, cognitive abilities, and psychiatric symptoms after such a long exposure time. Previous studies on heroin and cocaine exposure focused on individuals identified much earlier in life, and the aging long-term users might represent a relatively large but unknown population.

Practice effects predict cognitive outcome in amnestic mild cognitive impairment.

OBJECTIVE: Practice effects on cognitive tests have been shown to further characterize patients with amnestic mild cognitive impairment (aMCI) and may provide predictive information about cognitive change across time. We tested the hypothesis that a loss of practice effects would portend a worse prognosis in aMCI. DESIGN: Longitudinal, observational design following participants across 1 year. SETTING: Community-based cohort. PARTICIPANTS: Three groups of older adults: 1) cognitively intact (n = 57), 2) aMCI with large practice effects across 1 week (MCI + PE, n = 25), and 3) aMCI with minimal practice effects across 1 week (MCI - PE, n = 26). MEASUREMENTS: Neuropsychological tests. RESULTS: After controlling for age and baseline cognitive differences, the MCI - PE group performed significantly worse than the other groups after 1 year on measures of immediate memory, delayed memory, language, and overall cognition. CONCLUSIONS: Although these results need to be replicated in larger samples, the loss of short-term practice effects portends a worse prognosis in patients with aMCI.

12-month herbal medicine use for mental health from the national Comorbidity Survey Replication (NCS-R).

BACKGROUND: Herbal medicine is widely used by individuals with mental health problems, although research on their health characteristics and health care utilization patterns­including concomitant treatment with conventional mental health care and psychotropic medication­remains limited. METHODS: We gathered data from the National Comorbidity Survey Replication (NCS-R), a representative survey of US adults in which diagnoses of mental disorders were based on a fully structured diagnostic interview. RESULTS: Our analysis found that NCS-R respondents with mental disorders were significantly more likely to have used herbal medicines for mental health problems than respondents who did not meet criteria for a mental disorder. Users of herbal medicines for mental health problems were likely to utilize conventional health care as well, particularly conventional psychiatric medication. Herbal use also was associated with having multiple comorbid medical problems. CONCLUSIONS: A substantial proportion of US adults use herbal medicine to treat mental health problems. Herbal medicine is frequently used concomitantly with conventional health care, including prescription psychotropic medication. Herbal use also is associated with having multiple chronic medical problems. These factors increase the potential for interactions between herbal medicines and psychiatric and nonpsychiatric medications.

Neuropsychological outcomes of older breast cancer survivors: cognitive features ten or more years after chemotherapy.

The authors examined the long-term cognitive implications of cancer treatment among breast cancer survivors over 65 years old who received treatment during midlife. Thirty women survivors were matched with 30 noncancer, healthy older adults in terms of age, education, and IQ. The cancer survivors scored significantly lower in the cognitive domains of executive functioning, working memory, and divided attention, reflecting potential dysfunction in frontal-subcortical brain regions. Our findings suggest that among breast cancer survivors who remain disease-free for more than a decade, the previous cancer treatment may further augment cognitive dysfunction associated with age-related brain changes.

Anxiety, depression, and cognitive impairment in dementia-specific and traditional assisted living.

With the rapid growth of the assisted living (AL) industry, the number of AL residences providing dementia care continues to increase. The purpose of this article is to describe and compare demographic characteristics; frequency and type of psychiatric diagnoses; level of cognition, depression, and anxiety symptoms; and use of psychotropic medication among older adults in dementia-specific assisted living (DSAL) and traditional assisted living (TAL) residences. Secondary analysis of screening data collected during a cross-sectional, descriptive pilot project compared 18 participants from two DSAL facilities and 28 participants from three TAL facilities. DSAL participants with dementia were more cognitively impaired than TAL participants with dementia (p < 0.001) and used more antipsychotic (67%), anxiolytic (60%), antidepressant (53%), and cognitive-enhancing (87%) medications. No statistically significant differences in demographic factors or levels of anxiety or depression were observed among residents in either setting.

Palliative Care for Dementia: 2020 Update.

Dementia management is complicated by neuropsychiatric symptoms such that the longitudinal care of a psychiatrist or other mental health provider is often an essential part of patient care and a major source of family support. Given the importance of end-of-life continuity of care, the involvement of psychiatry in palliative and hospice services affords an important opportunity for growth. Common challenges involve sharing prognostic information with patients and families to aid in advance planning, and management of persistent pain and nutritional issues. Future research will yield important new insights and guidelines for care.