Too late for early intervention? The Healthy Ageing Service's mental health response.

OBJECTIVES: This paper describes the rationale for and development of an innovative mental health service for people aged over 65 years living in Northern and Eastern Melbourne, Victoria, Australia. CONCLUSION: The Healthy Ageing Service (HAS) was established in July 2020 to provide care for people aged over 65 years experiencing mild-to-moderate mental health concerns. It embraces a prevention and early intervention model of care. It provides primary consultation and brief intervention, secondary consultation, and capacity building to the primary healthcare sector. This innovative service is a Commonwealth-funded partnership between two tertiary mental health service providers that incorporates the recommendations from two major Royal Commissions. It demonstrates a service that acts as a bridge between primary and specialist mental health care, thereby extending mental health services to target the 'missing middle' and is potentially a model for mental health service provision throughout Victoria and Australia.

The effect of COVID-19 on surgical training.

The COVID-19 pandemic has had a huge impact on society, healthcare in general and also on training in surgery. Cancellation of elective procedures, redeployment and establishment of green sites have combined with other factors to create significant gaps in training experience in operative and all other areas of surgery. There are nearly a million cases which have been lost to training since March 2020 and recovery means that tens of thousands of extra training cases have to be performed every month to recover that experience. There are pressures to address huge waiting list backlogs which may squeeze out time for training unless training is considered at the heart of any recovery plan. #NoTrainingTodayNoSurgeonsTomorrow. New, no blame, COVID ARCP outcomes have helped recognize the impact of the pandemic on progression and significant trainee and trainer organizations are united in raising the profile of the training crisis and offering a suite of suggestions on how to speed recovery. Disruption caused by the pandemic has allowed existing simulation and conferencing platforms to finally be widely accepted and the importance of the wider surgical team in supporting surgical training to be realized. New, outcomes-based curricula, with better feedback at their centre, will speed recovery of training trajectories. We should embrace the opportunity for change to help short and medium term recovery and improve the delivery of surgical training into the future.

Cognitive behaviour therapy for insomnia and depression: qualitative reflections from older adults who participated in a randomised controlled trial.

Objectives: To explore the experiences of older adults who participated in a randomised controlled trial (RCT) that tested cognitive behaviour therapy for insomnia and depression.Methods: Focus groups were conducted post treatment for older adults (M age = 75 years; 61% female) who participated in a RCT that tested two experiential interventions targeting comorbid insomnia and depression (cognitive behaviour therapy for insomnia, CBT-I; cognitive behaviour therapy for insomnia plus positive mood strategies, CBT-I+). Six semi-structured focus group interviews (N = 31) were analysed using a qualitative thematic analysis.Results: Interview data were transcribed into 424 sentences and 60 codes were extracted. Thirty-four initial themes emerged, which were transformed into 3 themes and 10 subthemes. The three primary themes were (1) positive experiences, (2) negative experiences, and (3) suggested modifications. The positive subthemes were (1a) therapists, (1b) togetherness, (1c) use of strategies reduced symptoms, and (1d) acceptance. The negative subthemes were (2a) persistent symptoms, (2b) program too condensed, and (2c) attendance obstacles. The suggested modifications were (3a) lengthen program, (3b) multi-dimensional learning, and (3c) multi-modal delivery options.Conclusion: The experiences and suggestions identified in this study strengthen the foundation to advance therapeutic program development for older adults with comorbid insomnia and depression. Future CBT-I programs for older adults may be improved by increasing the length of therapy (e.g. 8 sessions to 12 sessions), adding multi-dimensional learning opportunities (e.g. visual/audio/mentorship), and offering various modes of treatment delivery (e.g. group, individual, internet, telephone).

Cognitive behavior therapy for older adults with insomnia and depression: a randomized controlled trial in community mental health services.

Study Objectives: To investigate whether cognitive behavior therapy was effective for older adults with comorbid insomnia and depression in a community mental health setting, and explore whether an advanced form of cognitive behavior therapy for insomnia produced better outcomes compared to a standard form of cognitive behavior therapy for insomnia. Methods: An 8-week randomized controlled clinical trial was conducted within community mental health services, Victoria, Australia. Seventy-two older adults (56% female, M age 75 ± 7 years) with diagnosed comorbid insomnia and depression participated. Three conditions were tested using a group therapy format: cognitive behavior therapy for insomnia (CBT-I, standard), cognitive behavior therapy for insomnia plus positive mood strategies (CBT-I+, advanced), psychoeducation control group (PCG, control). The primary outcomes were insomnia severity (Insomnia Severity Index) and depression severity (Geriatric Depression Scale). Primary and secondary measures were collected at pre (week 0), post (week 8), and follow-up (week 20). Results: CBT-I and CBT-I+ both generated significantly greater reductions in insomnia and depression severity compared to PCG from pre to post (p < .001), which were maintained at follow-up. Although the differences between outcomes of the two treatment conditions were not statistically significant, the study was not sufficiently powered to detect either superiority of one treatment or equivalence of the two treatment conditions. Conclusion: CBT-I and CBT-I+ were both effective at reducing insomnia and depression severity for older adults. Mental health services that deliver treatment for comorbid insomnia with cognitive behavior therapy may improve recovery outcomes for older adults with depression. Trial Registration: Australian and New Zealand Clinical Trials Registry (ANZCTR); URL: https://www.anzctr.org.au; Trial ID: ACTRN12615000067572; Date Registered: December 12, 2014.

Advancing cognitive behaviour therapy for older adults with comorbid insomnia and depression.

Insomnia and depression are two of the most common mental health problems that negatively impact older adults. The burden associated with these highly comorbid conditions requires an innovative approach to treatment. There have been significant advancements in the field of cognitive behaviour therapy for insomnia (CBT-I) over recent years. CBT-I has evolved from targeting homogenous insomnia samples to now showing promising results for comorbid insomnia. CBT-I is not only effective at treating comorbid insomnia, but can also have a positive impact on depression severity. Despite these important clinical developments, limited research has explored whether modifying CBT-I programmes to specifically target comorbid depression could improve outcomes for older populations. This paper reviews recent literature and provides therapeutic recommendations to advance CBT-I for older adults with comorbid insomnia and depression.

Cognitive behaviour therapy for older adults experiencing insomnia and depression in a community mental health setting: Study protocol for a randomised controlled trial.

BACKGROUND: Cognitive behaviour therapy for insomnia (CBT-I) is a well-established treatment; however, the evidence is largely limited to homogenous samples. Although emerging research has indicated that CBT-I is also effective for comorbid insomnia, CBT-I has not been tested among a complex sample of older adults with comorbid insomnia and depression. Furthermore, no study has explored whether modifying CBT-I to target associated depressive symptoms could potentially enhance sleep and mood outcomes. Therefore, this study aims to report a protocol designed to test whether an advanced form of CBT for insomnia and depression (CBT-I-D) is more effective at reducing insomnia and depressive symptoms compared to a standard CBT-I and psychoeducation control group (PCG) for older adults in a community mental health setting. METHODS/DESIGN: We aim to recruit 150 older adults with comorbid insomnia who have presented to community mental health services for depression. Eligible participants will be randomly allocated via block/cluster randomisation to one of three group therapy conditions: CBT-I, CBT-I-D, or PCG. Participants who receive CBT-I will only practice strategies designed to improve their sleep, whereas participants who receive CBT-I-D will practice additional strategies designed to also improve their mood. This trial will implement a mixed-methods design involving quantitative outcome measures and qualitative focus groups. The primary outcome measures are insomnia and depression severity, and secondary outcomes are anxiety, hopelessness, beliefs about sleep, comorbid sleep conditions, and health. Outcomes will be assessed at pre-intervention (week 0), post-intervention (week 8), and 3-month follow-up (week 20). DISCUSSION: This CBT study protocol has been designed to address comorbid insomnia and depression for older adults receiving community mental health services. The proposed trial will determine whether CBT-I is more effective for older adults with comorbid insomnia and depression compared to a PCG. It will also establish whether an advanced form of CBT-I-D generates greater reductions in insomnia and depression severity compared to standard CBT-I. The results from the proposed trial are anticipated to have important clinical implications for older adults, researchers, therapists, and community mental health services. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN: 12615000067572 , Date Registered 12 December 2014.

Evaluation of a Rural-Based Community Aged Intensive Recovery Program for Older Adults With Severe Mental Illness.

Community Aged Intensive Recovery (CAIR) programs are an integral part of Aged Persons Mental Health Services (APMHS); however, no study has investigated whether a rural-based intensive program benefits older clients with severe mental illness. The current sample comprised 119 older adults who were being managed by a CAIR program from July 2011 to June 2013. Three key results were found: (a) approximately three quarters of clients admitted to the CAIR program remained treated in the community; (b) the program assisted in significantly reducing the level of psychiatric symptom severity from CAIR entry to CAIR exit; and (c) the APMHS team with the CAIR program had a lower psychiatric inpatient rate compared to the APMHS team without the program. The current study highlights the importance of delivering effective rural-based CAIR programs to older adults experiencing severe mental illness.

A psychological pathway from insomnia to depression among older adults.

BACKGROUND: Higher levels of insomnia predict greater depression severity among older adults; however, the psychological mechanisms underlying this relationship are unclear. This study tested a path model that explored whether dysfunctional beliefs about sleep and hopelessness mediated the relationship from insomnia to depression. It was hypothesized that insomnia would predict depression, both directly and indirectly, via dysfunctional beliefs about sleep and hopelessness. METHODS: A community sample of 218 independent-living Australian older adults aged from 65 to 96 years completed a self-report questionnaire package. From the initial 218 participants, 171 completed a measure of depression three months later. RESULTS: Path analysis demonstrated that maladaptive sleep beliefs and hopelessness partly explained how insomnia influenced depression, irrespective of the presence of obstructive sleep apnea and/or restless legs syndrome. CONCLUSIONS: An older adult's beliefs about sleep and sense of hopelessness were important psychological factors that helped explain how insomnia related to depression.