Bayesian Networks for Prescreening in Depression: Algorithm Development and Validation.

BACKGROUND: Identifying individuals with depressive symptomatology (DS) promptly and effectively is of paramount importance for providing timely treatment. Machine learning models have shown promise in this area; however, studies often fall short in demonstrating the practical benefits of using these models and fail to provide tangible real-world applications. OBJECTIVE: This study aims to establish a novel methodology for identifying individuals likely to exhibit DS, identify the most influential features in a more explainable way via probabilistic measures, and propose tools that can be used in real-world applications. METHODS: The study used 3 data sets: PROACTIVE, the Brazilian National Health Survey (Pesquisa Nacional de Saúde [PNS]) 2013, and PNS 2019, comprising sociodemographic and health-related features. A Bayesian network was used for feature selection. Selected features were then used to train machine learning models to predict DS, operationalized as a score of ≥10 on the 9-item Patient Health Questionnaire. The study also analyzed the impact of varying sensitivity rates on the reduction of screening interviews compared to a random approach. RESULTS: The methodology allows the users to make an informed trade-off among sensitivity, specificity, and a reduction in the number of interviews. At the thresholds of 0.444, 0.412, and 0.472, determined by maximizing the Youden index, the models achieved sensitivities of 0.717, 0.741, and 0.718, and specificities of 0.644, 0.737, and 0.766 for PROACTIVE, PNS 2013, and PNS 2019, respectively. The area under the receiver operating characteristic curve was 0.736, 0.801, and 0.809 for these 3 data sets, respectively. For the PROACTIVE data set, the most influential features identified were postural balance, shortness of breath, and how old people feel they are. In the PNS 2013 data set, the features were the ability to do usual activities, chest pain, sleep problems, and chronic back problems. The PNS 2019 data set shared 3 of the most influential features with the PNS 2013 data set. However, the difference was the replacement of chronic back problems with verbal abuse. It is important to note that the features contained in the PNS data sets differ from those found in the PROACTIVE data set. An empirical analysis demonstrated that using the proposed model led to a potential reduction in screening interviews of up to 52% while maintaining a sensitivity of 0.80. CONCLUSIONS: This study developed a novel methodology for identifying individuals with DS, demonstrating the utility of using Bayesian networks to identify the most significant features. Moreover, this approach has the potential to substantially reduce the number of screening interviews while maintaining high sensitivity, thereby facilitating improved early identification and intervention strategies for individuals experiencing DS.

'Does it matter how old I feel?' The role of subjective age in a psychosocial intervention for improving depressive symptomatology among older adults in Brazil (PROACTIVE).

OBJECTIVES: Depression is a prevalent mental health condition that also often affects older adults. The PROACTIVE psychosocial intervention was developed to reduce depressive symptomatology among older adults within primary care settings in Brazil. An important psychological marker that affects individuals' aging experience relates to how old people feel. Known as subjective age, this marker has been shown to be a risk factor for experiencing greater depressive symptoms if individuals report feeling older than their (chronological) age. In this study, we perform secondary analyses of the PROACTIVE cluster-randomized controlled trial to examine the role of subjective age. METHOD: The sample included 715 Brazilian older adults (74% female, Mage 68.6, SD = 6.9, age range: 60-94 years) randomized to intervention (n = 360, 74% female, Mage 68.4, SD = 6.6, age range: 60-89 years) or control (n = 355, 74% female, Mage 68.9, SD = 7.2, age range: 60-94 years) arms. Here our primary outcome was depressive symptoms at the 8-month follow-up assessed with the 9-item Patient Health Questionnaire (PHQ-9) as a continuous variable. Our previous analyses demonstrated improved recovery from depression at follow-up in the intervention compared with the control arm. RESULTS: Relevant main effects and interactions in regression models for PHQ-9 presented here found that those reporting older subjective age had worse depressive symptoms at follow-up but that they benefitted more from the intervention when initial levels of depression were high. For participants who reported younger subjective ages the intervention showed positive effects that were independent of initial levels of depression. CONCLUSION: Our findings emphasize the importance of investigating possible underlying mechanisms that can help clarify the impact of mental health interventions.

Self-help mobile messaging intervention for depression among older adults in resource-limited settings: a randomized controlled trial.

Scalable solutions to treat depression in older adults in low-resourced settings are urgently needed. The PRODIGITAL-D pragmatic, single-blind, two-arm, individually randomized controlled trial assessed the effectiveness of a mobile messaging psychosocial intervention in improving depressive symptomatology among older adults in socioeconomically deprived areas of Guarulhos, Brazil. Older adults (aged 60+ years) registered with 24 primary care clinics and identified with depressive symptomatology (9-item Patient Health Questionnaire (PHQ-9) scores ≥ 10) received the 6-week Viva Vida intervention based on psychoeducation and behavioral activation (n = 298) or a single message (n = 305). No health professional support was offered. The primary outcome was improvement from depressive symptomatology (PHQ-9 < 10) at 3 months. Of the 603 participants enrolled (mean age = 65.1 years; 451 (74.8%) women), 527 (87.4%) completed the follow-up assessment. In the intervention arm, 109 of 257 (42.4%) participants had an improved depressive symptomatology, compared with 87 of 270 (32.2%) participants in the control arm (adjusted odds ratio = 1.57; 95% confidence interval = 1.07-2.29; P = 0.019). No severe adverse events related to trial participation were observed. These results demonstrate the usefulness of a digital messaging psychosocial intervention in the short-term improvement from depressive symptomatology that can potentially be integrated into primary care programs for treating older adults with depression. Brazilian Registry of Clinical Trials registration: ReBEC ( RBR-4c94dtn ).

Use of WhatsApp by older adults screened for depression in socioeconomically deprived areas of Guarulhos, São Paulo State, Brazil: challenges and possibilities for telehealth.

This study aimed to investigate the relationship between sociodemographic characteristics, depressive symptomatology, mobile phone ownership, and different uses of WhatsApp among older adults enrolled in primary care clinics in Guarulhos, São Paulo State, Brazil. This is a secondary data analysis, using data collected in the screening of participants to be included in the PROACTIVE cluster randomized trial. Individuals aged ≥ 60 years, registered in primary care clinics in Guarulhos, were assessed for sociodemographic characteristics, depressive symptoms according to the PHQ-9, mobile phone ownership, and use of WhatsApp. We performed multiple logistic regression models to investigate characteristics of the potential users of digital interventions. Of 3,356 older adults screened for depression, 45.7% said they use WhatsApp to receive/send messages. In the subsample that presented depressive symptomatology (n = 1,020), 41.9% stated using WhatsApp. Younger older adults and those with better socioeconomic status used more WhatsApp and were more likely to own a mobile phone. Participants with higher levels of symptoms of depression were less likely to use WhatsApp. Gender, age, schooling level, income, and depressive symptomatology are variables associated with the possession of a cell phone and with the use of WhatsApp by the older adults of the sample. These findings can help to implement digital health programs better suited to disadvantaged populations in Brazil and other low- and middle-income countries through mental telehealth interventions using WhatsApp and mobile health services to the older people.

A task-shared, collaborative care psychosocial intervention for improving depressive symptomatology among older adults in a socioeconomically deprived area of Brazil (PROACTIVE): a pragmatic, two-arm, parallel-group, cluster-randomised controlled trial.

BACKGROUND: There is an urgent need to reduce the burden of depression among older adults in low-income and middle-income countries (LMICs). We aimed to evaluate the efficacy of a task-shared, collaborative care psychosocial intervention for improving recovery from depression in older adults in Brazil. METHODS: PROACTIVE was a pragmatic, two-arm, parallel-group, cluster-randomised controlled trial conducted in Guarulhos, Brazil. Primary care clinics (clusters) were stratified by educational level and randomly allocated (1:1) to either enhanced usual care alone (control group) or to enhanced usual care plus the psychosocial intervention (intervention group), which involved a 17-week psychosocial programme based on psychoeducation and behavioural activation approaches. Individuals approached for the initial screening assessment were selected randomly from a list of individuals provided by the Health Secretariat of Guarulhos. Face-to-face baseline assessments were conducted among adults aged 60 years or older registered with one of the primary care clinics and identified with clinically significant depressive symptomatology (9-item Patient Health Questionnaire [PHQ-9] score ≥10). Community health workers delivered the programme through home sessions, supported by a dedicated tablet application. Masking of clinic staff and community health workers who delivered the intervention was not feasible; however, research assistants conducting recruitment and follow-up assessments were masked to trial allocation. The primary outcome was recovery from depression (PHQ-9 score <10) at 8-month follow-up. All primary analyses were performed by intention to treat with imputed data. Adaptations to the protocol were made due to the COVID-19 pandemic; recruitment and intervention home sessions were stopped, and follow-up assessments were conducted by telephone. This trial is registered with the ISRCTN registry, ISRCTN57805470. FINDINGS: We identified 24 primary care clinics in Guarulhos that were willing to participate, of which 20 were randomly allocated to either the control group (ten [50%] clusters) or to the intervention group (ten [50%] clusters). The four remaining eligible clusters were kept as reserves. Between May 23, 2019, and Feb 21, 2020, 8146 individuals were assessed for eligibility, of whom 715 (8·8%) participants were recruited: 355 (49·7%) in the control group and 360 (50·3%) in the intervention group. 284 (80·0%) participants in the control group and 253 (70·3%) in the intervention group completed follow-up at 8 months. At 8-month follow-up, 158 (62·5%) participants in the intervention group showed recovery from depression (PHQ-9 score <10) compared with 125 (44·0%) in the control group (adjusted odds ratio 2·16 [95% CI 1·47-3·18]; p<0·0001). These findings were maintained in the complete case analysis. No adverse events related to the intervention were observed. INTERPRETATION: Although the COVID-19 pandemic altered delivery of the intervention, the low-intensity psychosocial intervention delivered mainly by non-mental health professionals was highly efficacious in improving recovery from depression in older adults in Brazil. Our results support a low-resource intervention that could be useful to reduce the treatment gap for depression among older people in other LMICs. FUNDING: São Paulo Research Foundation and Joint Global Health Trials (UK Department for International Development, Medical Research Council, and the Wellcome Trust).

Digital psychosocial intervention for depression among older adults in socioeconomically deprived areas in Brazil (PRODIGITAL-D): protocol for an individually randomised controlled trial.

BACKGROUND: Depression in older adults is a challenge for health systems in most low- and middle-income countries (LMICs). Digital strategies for the management of this condition have been emerging worldwide, but the effectiveness of most of them is still unclear, especially among older adults. Thus, we aim to assess the effectiveness and cost-effectiveness of a digital psychosocial intervention to treat depression among older adults living in socioeconomically deprived areas in Guarulhos, Brazil. METHODS: We will conduct a two-arm individually randomised controlled trial with 1:1 allocation ratio. Five hundred older adults aged 60 years or over with depressive symptomatology (9-item Patient Health Questionnaire score, PHQ-9 ≥ 10) and registered with one of the primary care clinics will be recruited to participate in this study. A 6-week digital psychosocial programme, named Viva Vida, will be delivered via WhatsApp to participants allocated to the intervention arm. The Viva Vida will send psychoeducational and behavioural activation audio and visual messages 4 days a week for 6 weeks. The control arm will only receive a single message with general information about depression. The primary outcome will be the proportion of depression recovery (PHQ-9 < 10) assessed at 3 months. The cost-effectiveness of the intervention will be assessed at 5 months. A detailed process evaluation will be used to explore context and important implementation outcomes. DISCUSSION: This programme was based on the PROACTIVE intervention and designed to be delivered without face-to-face contact. If effective, it could be a simple treatment option, appropriate not only when social distancing is required, but it could also be included as a regular public health programme to initiate depression treatment, particularly in LMICs where resources allocated to mental health are scarce. TRIAL REGISTRATION: Registro Brasileiro de Ensaios Clínicos (ReBEC), RBR-4c94dtn. Registered on 22 October 2021 (submitted on 03 August 2021).

A Validation Study of the EQ-5D-5L and ICEpop Capability Measure for Older People Among Older Individuals With Depressive Symptoms in Brazil.

OBJECTIVES: This study aimed to assess the known-groups validity of the EQ-5D-5L and the ICEpop Capability Measure for Older People (ICECAP-O), 2 outcome measures used in economic evaluation, among older adults with depressive symptoms in socioeconomically deprived areas of Brazil. We also explored the role of education and income on responses to these measures. METHODS: This cross-sectional study used baseline data from PROACTIVE, a cluster randomized controlled trial to evaluate a psychosocial intervention for late-life depression among older adults. Participants aged ≥60 years with a 9-item Patient Health Questionnaire score ≥10 were recruited from 20 primary healthcare clinics. Ordered logistic regression models assessed the association between depressive symptoms severity, income, and education and dimension-level responses on the EQ-5D-5L and ICECAP-O. Multivariable regression models investigated the ability of EQ-5D-5L and ICECAP-O scores to discriminate between depressive symptoms severity levels and other characteristics, including education level and household income. RESULTS: A total of 715 participants were included in the study. Depressive symptoms severity was associated with all EQ-5D-5L and ICECAP-O dimensions, except the ICECAP-O enjoyment attribute. In contrast, household income was only associated with the ICECAP-O security attribute. Higher severity of depressive symptoms (9-item Patient Health Questionnaire scores) was also strongly associated with lower (ie, worse) scores on both measures in all models. Education level and household income showed no association with either EQ-5D-5L or ICECAP-O scores. CONCLUSIONS: To best of our knowledge, this is the first study that investigated the validity of these 2 measures among older adults in Brazil. Both EQ-5D-5L and ICECAP-O showed evidence of validity in differentiating depressive symptom severity.

Depressive and subthreshold depressive symptomatology among older adults in a socioeconomically deprived area in Brazil.

Depressive and subthreshold depressive symptomatology are common but often neglected in older adults. OBJECTIVE: This study aimed to assess rates of depressive and subthreshold depressive symptomatology, and the characteristics associated, among older adults living in a socioeconomically deprived area of Brazil. METHODS: This study is part of the PROACTIVE cluster randomised controlled trial. 3356 adults aged 60+ years and registered in 20 primary health clinics were screened for depressive symptomatology with the Patient Health Questionnaire-9 (PHQ-9). Depressive status was classified according to the total PHQ-9 score and the presence of core depressive symptoms (depressed mood and anhedonia) as follows: no depressive symptomatology (PHQ-9 score 0-4, or 5-9 but with no core depressive symptom); subthreshold depressive symptomatology (PHQ-9 score 5-9 and at least one core depressive symptom); and depressive symptomatology (PHQ-9 score ≥ 10). Sociodemographic information and self-reported chronic conditions were collected. Relative risk ratios and 95% CIs were obtained using a multinomial regression model. RESULTS: Depressive and subthreshold depressive symptomatology were present in 30% and 14% of the screened sample. Depressive symptomatology was associated with female gender, low socioeconomic conditions and presence of chronic conditions, whereas subthreshold depressive symptomatology was only associated with female gender and having hypertension. CONCLUSIONS: Depressive and subthreshold depressive symptomatology is highly prevalent in this population registered with primary care clinics. Strategies managed by primary care non-mental health specialists can be a first step for improving this alarming and neglected situation among older adults.

Psychometric properties of the PHQ-9 measure of depression among Brazilian older adults.

Objectives: To obtain evidence on the psychometric properties of the Patient Health Questionnaire - 9 (PHQ-9, one of the most extensively used tools for assessing depression) in the Brazilian older population.Method: Data on 3,356 Brazilian adults aged 60+ years living in Guarulhos, São Paulo state were used. The factor structure of the questionnaire was analysed using a factor analysis approach. The questionnaire's measurement equivalence was tested across gender, age, personal income, and education level groups. The scores were compared across groups based on the highest level of equivalence achieved. The questionnaire's internal consistency was analysed considering its factor structure.Results: A one-factor solution was identified as the most adequate factor structure, with the factor explaining 57.6% of the items' variance. The correlation of the resulting latent score with the overall raw sum score in the PHQ-9 was r = 0.96. Measurement equivalence regarding thresholds and loadings was achieved for all tested groups. On average, women, older, less educated, and poorer people had higher latent scores on the depression factor. The measure showed a good internal consistency with Revelle's omega total ωt=0.92.Conclusion: The results suggest that, among Brazilian older adults living in Guarulhos, São Paulo state, the PHQ-9 measures depressive symptomatology equivalently across different sociodemographic subgroups. Moreover, it can be scored using the raw sum of the item scores to adequately reflect different levels of depressive symptomatology.

Use of WhatsApp by older adults screened for depression in socioeconomically deprived areas of Guarulhos, São Paulo State, Brazil: challenges and possibilities for telehealth / Uso do WhatsApp por idosos depressivos em áreas socioeconomicamente carentes de Guarulhos, São Paulo, Brasil: desafios e possibilidades para a telessaúde / Uso de WhatsApp por ancianos deprimidos en áreas desfavorecidas socioeconómicamente en Guarulhos, São Paulo, Brasil: retos y posibilidades de la telesalud

This study aimed to investigate the relationship between sociodemographic characteristics, depressive symptomatology, mobile phone ownership, and different uses of WhatsApp among older adults enrolled in primary care clinics in Guarulhos, São Paulo State, Brazil. This is a secondary data analysis, using data collected in the screening of participants to be included in the PROACTIVE cluster randomized trial. Individuals aged ≥ 60 years, registered in primary care clinics in Guarulhos, were assessed for sociodemographic characteristics, depressive symptoms according to the PHQ-9, mobile phone ownership, and use of WhatsApp. We performed multiple logistic regression models to investigate characteristics of the potential users of digital interventions. Of 3,356 older adults screened for depression, 45.7% said they use WhatsApp to receive/send messages. In the subsample that presented depressive symptomatology (n = 1,020), 41.9% stated using WhatsApp. Younger older adults and those with better socioeconomic status used more WhatsApp and were more likely to own a mobile phone. Participants with higher levels of symptoms of depression were less likely to use WhatsApp. Gender, age, schooling level, income, and depressive symptomatology are variables associated with the possession of a cell phone and with the use of WhatsApp by the older adults of the sample. These findings can help to implement digital health programs better suited to disadvantaged populations in Brazil and other low- and middle-income countries through mental telehealth interventions using WhatsApp and mobile health services to the older people.

Este estudo teve como objetivo investigar a relação entre características sociodemográficas, sintomatologia depressiva, posse de telefone celular e diferentes usos do WhatsApp entre idosos cadastrados em unidades básicas de saúde de Guarulhos, São Paulo, Brasil. Trata-se de uma análise de dados secundários com informações coletadas na triagem dos participantes a serem incluídos neste estudo randomizado em cluster PROATIVO. Indivíduos com 60 anos ou mais, cadastrados em unidades básicas de saúde de Guarulhos, foram avaliados quanto a características sociodemográficas, sintomas depressivos, de acordo com o PHQ-9, posse de telefone celular e uso do WhatsApp. Foram utilizados modelos de regressão logística múltipla para investigar as características dos potenciais usuários de intervenções digitais. Dos 3.356 idosos depressivos, 45,7% usavam o WhatsApp para receber/enviar mensagens. Na subamostra que apresentou sintomatologia depressiva (n = 1.020), 41,9% disseram usar o WhatsApp. Adultos mais jovens e com melhor status socioeconômico usavam mais o WhatsApp e eram mais propensos a possuir um telefone celular. Participantes com níveis mais altos de sintomas de depressão eram menos propensos a utilizar o WhatsApp. Sexo, idade, escolaridade, renda e sintomatologia depressiva são variáveis associadas à posse de telefone celular e ao uso do WhatsApp pelos idosos da população estudada. Esses achados podem ajudar a implementar programas de saúde digital mais adequados para populações desfavorecidas no Brasil e em outros países de baixa e média renda, principalmente intervenções de telessaúde mental que utilizem o WhatsApp e serviços móveis de saúde para idosos.

Este estudio tuvo como objetivo determinar la relación entre las características sociodemográficas, los síntomas depresivos, la tenencia de teléfono celular y los diferentes usos de WhatsApp entre los ancianos inscritos en unidades básicas de salud en Guarulhos, São Paulo, Brasil. Este es un análisis de datos secundarios, que recopiló la información del triaje de los participantes a ser incluidos en este estudio aleatorio en un clúster PROACTIVO. Se evaluaron las características sociodemográficas, los síntomas depresivos según el PHQ-9, la tenencia de celular y el uso de WhatsApp de los participantes de 60 años o más, registrados en unidades básicas de salud de Guarulhos. Se utilizaron los modelos de regresión logística múltiple para identificar las características de los potenciales usuarios de las intervenciones digitales. De los 3.356 ancianos deprimidos, el 45,7% utilizaba WhatsApp para recibir/enviar mensajes. En la submuestra que presentó síntomas depresivos (n = 1.020), el 41,9% dijo usar WhatsApp. Los adultos más jóvenes con mejor nivel socioeconómico usaban más WhatsApp y tenían más probabilidades de tener un teléfono celular. Los participantes con niveles más altos de síntomas de depresión tenían menos probabilidades de usar WhatsApp. El sexo, la edad, la educación, la renta y los síntomas depresivos fueron las variables asociadas a la tenencia de celular y al uso de WhatsApp por parte de los ancianos de la población estudiada. Estos hallazgos pueden ayudar a implementar programas de salud digital que sean más adecuados para las poblaciones desfavorecidas en Brasil y en otros países de bajos y medianos ingresos, en particular las intervenciones de telesalud mental que utilizan WhatsApp y servicios de salud móviles para ancianos.

Acceptability and fidelity of a psychosocial intervention (PROACTIVE) for older adults with depression in a basic health unit in São Paulo, Brazil: a qualitative study.

BACKGROUND: Depression is a common condition in older adults, being often detected and treated initially in primary care. Collaborative care models including, for example, task-shifting and stepped-care approaches have been investigated to overcome the current scarcity of strategies and trained mental health professionals to treat depression. The PROACTIVE study developed a psychosocial intervention, which makes extensive use of technology in an intervention delivered mainly by non-specialists to treat older adults with depression. The aim of this qualitative study is to assess: 1. Health workers' fidelity to the intervention protocol; 2. Acceptability of the psychosocial intervention from the viewpoint of older adult participants; and 3. Perceptions of the psychosocial intervention by the health workers. METHODS: Qualitative methods were used to achieve our aims. The sample included participants (N = 31) receiving the intervention in the pilot trial and health workers (N = 11) working in a Basic Health Unit in the northern area of São Paulo, Brazil. Focus group, non-participant observation and structured interviews were used. Data were analysed using a thematic analysis approach. RESULTS: 1. Health workers' fidelity to the intervention protocol: training, supervision and the structured intervention were crucial and guaranteed health workers' fidelity to the protocol. 2. Acceptability of the psychosocial intervention from the viewpoint of older adult participants: Collaborative care, task-shifting, and stepped-care approaches were well accepted. The structured protocol of the intervention including different activities and videos was important to adherence of older adult participants 3. Perceptions of the psychosocial intervention by the health workers: It was feasible to have the home psychosocial sessions conducted by health workers, who are non-mental health specialists and received 3-day training. Training and supervision were perceived as crucial to support health workers before and during the intervention. Technology served as a tool to structure the sessions, obtain and store patient data, present multi-media content, guarantee fidelity to the protocol and facilitate communication among members of the team. However, extra burden was mentioned by the health workers indicating the need of adjustments in their daily duties. CONCLUSIONS: The PROACTIVE intervention was demonstrated to be feasible and accepted by both health workers and older adult participants. The qualitative assessments suggested improvements in training and supervision to ensure fidelity to protocol. To assess effectiveness a randomised controlled trial of the intervention will be conducted with the addition of improvements suggested by this qualitative study. TRIAL REGISTRATION: The pilot study of which the present study gives support to was registered at the Brazilian Clinical Trials, UTN code: U1111-1218-6717 on 26/09/2018.

Watching TV and Cognition: The SPAH 2-Year Cohort Study of Older Adults Living in Low-Income Communities.

Watching TV is a highly prevalent leisure activity among older adults and, in many cases, the only leisure option of those living in low-income communities. While engaging in leisure activities have proven to protect older adults from cognitive decline, the effects of watching TV on cognition of this population is controversial in the literature. This study investigated the impact of watching TV on global cognitive function, immediate memory, verbal fluency, risk of dementia of amnestic mild cognitive impairment (aMCI) in a cohort of older adults residents of socioeconomically deprived areas of São Paulo, Brazil. We used data from the São Paulo Aging & Health Study (SPAH). Participants aged 65 years or over, with no dementia diagnosis at baseline and who completed the 2-year follow-up assessment were included in this study (n = 1,243). Multivariable linear regression models were performed to assess the effect of watching TV on global cognitive function, immediate memory and verbal fluency. Multivariable logistic regression models were used to evaluate the risk of developing dementia and aMCI. Models were controlled by cognitive performance at baseline, sociodemographic characteristics and functional status. Cognitive performance at baseline and follow-up were similar. Thirty-one participants were diagnosed with dementia, and 23 with aMCI 24 months after inclusion in the study. Watching TV did not show any positive or negative effect on global cognitive function, immediate memory, verbal fluency, risk of dementia and risk of aMCI. It is good news that watching TV did not predict the decline in cognition in elders. However, it is essential to increase opportunities for other leisure activities for low-income and low-educated older adults if we do consider that leisure activities protect cognition decline in older adults. In the coming decades, developing countries will experience the highest burden of dementia and more than fun, public policies to promote leisure activities might be a strategy to alleviate this burden shortly.

Differences in Total Brain Volume between Sexes in a Cognitively Unimpaired Elderly Population.

OBJECTIVES: Although a large number of studies have shown brain volumetric differences between men and women, only a few investigations have analyzed brain tissue volumes in representative samples of the general elderly population. We investigated differences in gray matter (GM) volumes, white matter (WM) volumes, and intracranial volumes (ICVs) between the sexes in individuals older than 66 years using structural magnetic resonance imaging (MRI). METHODS: Using FreeSurfer version 5.3, we obtained the ICVs and GM and WM volumes from the MRI datasets of 84 men and 92 women. To correct for interindividual variations in ICV, GM and WM volumes were adjusted with a method using the residuals of a least-square-derived linear regression between raw volumes and ICVs. We then performed an analysis of covariance comparing men and women, including age and years of schooling as confounding factors. RESULTS: Women had a lower socioeconomic status overall and fewer years of schooling than men. The comparison of unadjusted brain volumes showed larger GM and WM volumes in men. After the ICV correction, the adjusted volumes of GM and WM were larger in women. CONCLUSION: After the ICV correction and taking into account differences in socioeconomic status and years of schooling, our results confirm previous findings of proportionally larger GM in women, as well as larger WM volumes. These results in an elderly population indicate that brain volumetric differences between sexes persist throughout the aging process. Additional studies combining MRI and other biomarkers to identify the hormonal and molecular bases influencing such differences are warranted.

A collaborative care psychosocial intervention to improve late life depression in socioeconomically deprived areas of Guarulhos, Brazil: the PROACTIVE cluster randomised controlled trial protocol.

BACKGROUND: The elderly population has been growing in most low- and middle-income countries (LMIC), and depression is a common condition among these populations. The lack of integration between mental health and primary healthcare services and the shortage of mental health specialists in the public health system contribute to underdiagnosis and undertreatment of depression. One of the strategies to reduce this gap is task shifting and collaborative care treatments. This study therefore aims to evaluate the effectiveness and cost-effectiveness of a collaborative care psychosocial intervention to improve the clinical management of depression among elderly people in poor neighbourhoods in Guarulhos, Brazil. METHODS: Two-arm, cluster randomised controlled trial with Basic Health Units as the clusters and a 1:1 allocation ratio. Twenty Basic Health Units have been randomly selected and randomised to control or intervention arms. We aim to recruit 1440 adults (72 per cluster) aged 60 years or over identified with depression (9-item Patient Health Questionnaire (PHQ-9) score ≥ 10). The control arm participants will receive an enhanced usual care, while the intervention arm participants will receive an enhanced usual care and a 17-week psychosocial intervention programme delivered at home by community health workers with the help of an application installed on tablet computers. The primary outcome is the proportion with depression recovery (PHQ-9 < 10) at 8 months' follow-up. We will also assess the maintenance of any earlier clinical gains and the cost-effectiveness of the intervention at 12 months. DISCUSSION: This is the first randomised trial to investigate a collaborative care intervention to treat depression among poor elderly in LMIC/Latin America. This is a major public health problem worldwide, but in these countries, there are no locally tested, evidence-based interventions available to date. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number ISRCTN57805470 . Registered on 25 April 2019.

Prevalence of Older Adult Disability and Primary Health Care Responsiveness in Low-Income Communities.

In Brazil and in most low- and middle-income countries (LMICs), information about how prepared the health care system is for the rapid aging of the population is scarce. We investigated the prevalence of disability and areas of life affected by disability among elders of the public primary health care in São Paulo and Manaus, Brazil. We investigated whether people with disability visited a primary care professional more frequently, the individual characteristics associated with disability, and differences by city. We randomly selected participants aged ≥60 years (n = 1375). The main outcome was disability, evaluated with the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0). Exposure variables were consultation with a family physician, sociodemographic characteristics, health status, social support, and lifestyle. The prevalence of global disability was higher in Manaus (66.2% vs. 56.4% in São Paulo). In both cities, participation and mobility were the areas of life most affected by disability. The number of consultations with a family physician was not associated with disability. The high prevalence of disability and associated risk factors indicates that public primary health care is not meeting the needs of elders in both cities. It is warning because most elders in LMICs live in more underserved communities compared to Brazil.

Differences in total brain volume between sexes in a cognitively unimpaired elderly population

OBJECTIVES: Although a large number of studies have shown brain volumetric differences between men and women, only a few investigations have analyzed brain tissue volumes in representative samples of the general elderly population. We investigated differences in gray matter (GM) volumes, white matter (WM) volumes, and intracranial volumes (ICVs) between the sexes in individuals older than 66 years using structural magnetic resonance imaging (MRI). METHODS: Using FreeSurfer version 5.3, we obtained the ICVs and GM and WM volumes from the MRI datasets of 84 men and 92 women. To correct for interindividual variations in ICV, GM and WM volumes were adjusted with a method using the residuals of a least-square-derived linear regression between raw volumes and ICVs. We then performed an analysis of covariance comparing men and women, including age and years of schooling as confounding factors. RESULTS: Women had a lower socioeconomic status overall and fewer years of schooling than men. The comparison of unadjusted brain volumes showed larger GM and WM volumes in men. After the ICV correction, the adjusted volumes of GM and WM were larger in women. CONCLUSION: After the ICV correction and taking into account differences in socioeconomic status and years of schooling, our results confirm previous findings of proportionally larger GM in women, as well as larger WM volumes. These results in an elderly population indicate that brain volumetric differences between sexes persist throughout the aging process. Additional studies combining MRI and other biomarkers to identify the hormonal and molecular bases influencing such differences are warranted.

Pilot study of a two-arm non-randomized controlled cluster trial of a psychosocial intervention to improve late life depression in socioeconomically deprived areas of São Paulo, Brazil (PROACTIVE): feasibility study of a psychosocial intervention for late life depression in São Paulo.

BACKGROUND: Depression is a common and recurrent condition among older adults and is associated with poor quality of life and increased health care utilization and costs. The purpose of this pilot study was to assess the feasibility of delivering a psychosocial intervention targeting depression, and to develop the procedures to conduct a cluster randomized controlled trial among older adults registered with primary care clinics in poor neighbourhoods of São Paulo, Brazil. METHODS: We conducted a pilot study of a two-arm cluster, non-randomized controlled trial. Two primary care clinics adhering to the Family Health Strategy were allocated to either the intervention or the control arm. In the control arm, patients received enhanced usual care consisting of staff training for improved recognition and management of depression. In the intervention arm, alongside the enhanced usual care, patients received a 17-week psychosocial intervention delivered by health workers assisted with an application installed in a tablet. RESULTS: We randomly selected 579 of 2020 older adults registered in the intervention clinic to participate in the study. Among these individuals, 353 were assessed for depression and 40 (11.0%) scored at least 10 on the PHQ-9 and were therefore invited to participate. The consent rate was 33/40 (82%) with a resulting yield of 33/579 (5.7%). In the control arm, we randomly selected 320 older adults among 1482 registered in the clinic, 223 were assessed for depression and 28 (12.6%) scored 10 or above on the PHQ-9. The consent rate was 25/28 (89%), with a resulting yield of 25/320 (7.8%). Of the 33 who consented in the intervention arm, 19 (59.4%) completed all sessions. The mean PHQ-9 at follow-up (approximately 30 weeks after inclusion) were 12.3 (SD = 3.7) and 3.8 (SD = 3.9) in the control and intervention arms, respectively. Follow-up rates were 92 and 94% in control and intervention arms, respectively. CONCLUSIONS: Identification and engagement of clinics, randomization, recruitment of individuals, measures, and baseline and follow-up assessments all proved to be feasible in primary care clinics in São Paulo, Brazil. Results support the development of a definitive cluster randomized controlled trial. TRIAL REGISTRATION: This study was retrospectively registered with Registro Brasileiro de Ensaios Clínicos (ReBEC), number RBR-5nf6wd . Registered 06 August 2018.

Corpus callosum volumes in the 5 years following the first-episode of schizophrenia: Effects of antipsychotics, chronicity and maturation.

Background: White matter (WM) structural changes, particularly affecting the corpus callosum (CC), seem to be critically implicated in psychosis. Whether such abnormalities are progressive or static is still a matter of debate in schizophrenia research. Aberrant maturation processes might also influence the longitudinal trajectory of age-related CC changes in schizophrenia patients. We investigated whether patients with first-episode schizophrenia-related psychoses (FESZ) would present longitudinal CC and whole WM volume changes over the 5 years after disease onset. Method: Thirty-two FESZ patients and 34 controls recruited using a population-based design completed a 5-year assessment protocol, including structural MRI scanning at baseline and follow-up. The linear effects of disease duration, clinical outcome and antipsychotic (AP) use over time on WM and CC volumes were studied using both voxelwise and volume-based morphometry analyses. We also examined maturation/aging abnormalities through cross-sectional analyses of age-related trajectories of total WM and CC volume changes. Results: No interaction between diagnosis and time was observed, and clinical outcome did not influence CC volumes in patients. On the other hand, FESZ patients continuously exposed to AP medication showed volume increase over time in posterior CC. Curve-estimation analyses revealed a different aging pattern in FESZ patients versus controls: while patients displayed a linear decline of total WM and anterior CC volumes with age, a non-linear trajectory of total WM and relative preservation of CC volumes were observed in controls. Conclusions: Continuous AP exposure can influence CC morphology during the first years after schizophrenia onset. Schizophrenia is associated with an abnormal pattern of total WM and anterior CC aging during non-elderly adulthood, and this adds complexity to the discussion on the static or progressive nature of structural abnormalities in psychosis.