Determinants of follow-up care associated with incident antidepressant use in older adults.

OBJECTIVES: To determine the proportion of older adults receiving guideline concordant antidepressant therapy and to determine patient, prescriber and organizational factors associated with adequate antidepressant therapy. METHODS: The study included secondary analyses of data collected in the Étude sur la Santé des Aînés (ESA) Services study on older adults recruited while consulting in primary care clinics in one of the largest health regions of the province of Québec. Antidepressant users (n = 349) were identified from information collected from the Régie de l'Assurance Maladie du Québec (RAMQ) pharmaceutical database which holds information on all drugs dispensed to all residents covered under the public drug plan. Adequacy of antidepressant treatment was measured using three criteria: adequacy of daily dose; length of prescription (≥455 days); and ≥3 visits to the antidepressant-prescribing physician in the first 3 months after initiation of therapy. Multivariate logistic regression analyses were used to study antidepressant treatment adequacy as a function of individual, provider and healthcare system factors. RESULTS: Among the antidepressant users, 44% received an adequate antidepressant treatment filling all three criteria. None of the factors studied were associated with the probability of receiving adequate treatment filling all three criteria. Psychological distress was associated with having an adequate number of visits in the 3 months following initiation. Males and those living in a metropolitan and urban area were less likely to receive an adequate dose. CONCLUSIONS: Future research should consider factors associated with perceived effectiveness and patient treatment preferences that may explain receipt of adequate antidepressant treatment in older adults.

Impact of depression and anxiety disorders on adherence to oral hypoglycemics in older adults with diabetes mellitus in Canada.

The prevalence of diabetes mellitus is increasing in Canada, and nonadherence to oral hypoglycemics is a common problem among older adults. This study aims to document the impact of depression and anxiety disorders on adherence to oral hypoglycemics in older adults with diabetes mellitus. Data used in this study came from the longitudinal Quebec survey on senior's health (Enquête sur la Santé des Ainés), using a representative sample of 2811 older adults aged 65 and over. The final sample for analysis consisted of 301 patients who received oral hypoglycemic pharmacotherapy. Medication adherence was measured with the medication possession ratio. An adapted version of Andersen's behavioral model was used to explain adherence to oral hypoglycemic medication while considering the following predisposing factors: age, gender, and level of education: enabling factors: marital status and income level: and need factors: physical and mental health status. Our explanatory model of oral hypoglycemic medication adherence was tested using a latent growth curve model. The results of the multiple-group analysis did not show any significant difference in oral hypoglycemic medication adherence (p > 0.05). Furthermore, individuals with higher levels of education were less adherent to oral hypoglycemics than those with lower levels of education (p < 0.05). Medication adherence to oral hypoglycemics did not show any significant difference between participants with and without depression and anxiety disorders. Future studies with larger samples are needed to fully explore the association between mental disorders and oral hypoglycemic medication adherence in the older adult populations.

Utilization of healthcare services among elderly with cognitive impairment no dementia and influence of depression and anxiety: a longitudinal study.

OBJECTIVES: Little objective and nationally representative data are available concerning the influence of cognitive impairment no dementia (CIND) on utilization of healthcare services. The main objective was to compare the use of healthcare services over three years, between elders with current or incident CIND and those without CIND. A second objective was to evaluate the effect of depression and anxiety. METHODS: Cross-sectional and longitudinal data from a population-based survey of 2265 older adults living in Quebec (Canada) were used. CIND was identified using normative data for the Mini-Mental State Examination and was linked with medical records from public health insurance plan. Multinomial logistic regressions adjusted for relevant socio-demographic, social network and health-related confounders were conducted for each service. Interaction between CIND and depression/anxiety was also examined. MAIN RESULTS: Current CIND was a predictor of longer anxiolytic/sedative/hypnotic medication use. Incident CIND led to longer hospital stay. Depression raised the likelihood of frequenting geriatricians, psychiatrists or neurologists and emergency department, but lessened the likelihood of visiting general practitioners. The addition of the psychiatric conditions to the incident CIND did not increase the likelihood of consuming antidepressants, while the incident CIND cases without psychiatric conditions increased this likelihood. DISCUSSION: Compared to older adults without CIND, older adults with CIND have a distinct utilization of healthcare services. Multiple evaluations over many years may help to better understand the utilization of healthcare services in individuals with CIND. In the meantime, evaluations of these conditions at key moments could allow a more efficient use of health resources.

Impact of Mental Disorders on the Association Between Adherence to Antihypertensive Agents and All-Cause Healthcare Costs.

Depression and anxiety are factors associated with poor adherence to medications that lead to increased healthcare costs. The authors hypothesize that these conditions will moderate the association between adherence and healthcare costs. The aim was to examine the healthcare costs associated with adherence to antihypertensive agents in the elderly with and without depression and anxiety. The sample included participants with hypertension and used hypertensive agents (N=926). Medication possession ratio was used to calculate medication adherence. Mean total healthcare costs included costs for inpatient stays, emergency department visits, outpatient visits, physician fees, and outpatient medications. Mental disorders were assessed using a questionnaire based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria. The total healthcare costs were significantly greater for nonadherent participants with depression/anxiety than for adherent participants without depression/anxiety (Δ$1841, P<.0001). This study suggests that treating mental disorders in elderly patients with hypertension will decrease total healthcare costs.

Benzodiazepine use associated with co-morbid post-traumatic stress syndrome and depression in older adults seeking services in general medical settings.

BACKGROUND: Benzodiazepines (BZD) should be limited in older adults. This study aimed to determine the association between BZD use and the presence of a probable post-traumatic stress syndrome (PTSS) and whether this association is dependent on gender and co-morbid physical and mental conditions. METHODS: Data were retained from the Étude sur la Santé des Aînés (ESA) - Services study (2011-2013) and included 1,453 older adults (≥65 years) who completed a face to face at-home interview, who were covered under Quebec's public drug insurance plan, and had given permission to access their Régie de l'Assurance Maladie du Québec (RAMQ) medical and pharmaceutical services data. The presence of a PTSS was measured using the Impact of Event Scale-Revised (IES-R). The use of BZD and antidepressants in the year prior to interview was ascertained from data reported in the RAMQ drug registry. The presence of depression and an anxiety disorder was assessed with the ESA-Questionnaire which was based on DSM-5 criteria. The interaction between PTSS and gender, depression, anxiety, and multi-morbidity was also assessed. RESULTS: The prevalence of PTSS and BZD use reached 4.5% and 31.2%. Participants with PTSS were 1.9 (95% CI = 1.1-3.2) times more likely to use BZD. The presence of depression had a negative impact on the association between BZD use and PTSS (p = 0.04). CONCLUSION: The use of BZD in older adults with PTSS is still prevalent today. Differences in benzodiazepine prescribing practices for more complex co-morbid psychiatric cases needs to be further studied.

Healthcare use and costs associated with post-traumatic stress syndrome in a community sample of older adults: results from the ESA-Services study.

BACKGROUND: Studies have shown higher healthcare utilization and costs associated with post-traumatic stress syndrome (PTSS) in veterans and community adult populations. Given the aging population and the impact on health system resources, it is important to understand the economic consequences of PTSS. METHODS: The data retained came from 1,456 older adults aged 65 years and over recruited in primary medical clinics in the province of Quebec. PTSS was measured with the PTSS scale. Healthcare services (outpatient, emergency department (ED) visits, and inpatient stay) and medication use were captured separately from provincial administrative databases. Healthcare costs incurred in the past year included costs related to outpatient and ED visits, physician fees, inpatient stay, and medication use. Costs were calculated using a healthcare system perspective. χ 2 and Mann-Whitney analyses were used to assess healthcare use. Generalized linear models (GLM) with a gamma distribution (Log Link) were used to evaluate the healthcare costs associated with PTSS. RESULTS: Results showed a significant difference in the number mental health outpatient visits, the number of total prescriptions and the use (presence of at least one prescription) of antidepressants (ADs) and benzodiazepines (BZDs). The multivariate analyses showed that costs associated with outpatient visits, ED visits, mental health inpatient stays, physician fees, and medication use were significantly associated with the presence of PTSS. The total adjusted healthcare cost difference between groups was significant and reached $838 CAN. CONCLUSIONS: Respondents with PTSS were more likely to be prescribed psychotropic medications and to have higher ambulatory costs but not inpatient services related costs, more research is required to better understand whether the mental health needs of individuals with a probable PTSS are being met.

Post-traumatic stress syndrome in a large sample of older adults: determinants and quality of life.

OBJECTIVES: The aims of this study are to assess in a sample of older adults consulting in primary care practices the determinants and quality of life associated with post-traumatic stress syndrome (PTSS). METHOD: Data used came from a large sample of 1765 community-dwelling older adults who were waiting to receive health services in primary care clinics in the province of Quebec. PTSS was measured with the PTSS scale. Socio-demographic and clinical characteristics were used as potential determinants of PTSS. Quality of life was measured with the EuroQol-5D-3L (EQ-5D-3L) EQ-Visual Analog Scale and the Satisfaction With Your Life Scale. Multivariate logistic and linear regression models were used to study the presence of PTSS and different measures of health-related quality of life and quality of life as a function of study variables. RESULTS: The six-month prevalence of PTSS was 11.0%. PTSS was associated with age, marital status, number of chronic disorders and the presence of an anxiety disorder. PTSS was also associated with the EQ-5D-3L and the Satisfaction with Your Life Scale. CONCLUSION: PTSS is prevalent in patients consulting in primary care practices. Primary care physicians should be aware that PTSS is also associated with a decrease in quality of life, which can further negatively impact health status.

DNA methylation and single nucleotide variants in the brain-derived neurotrophic factor (BDNF) and oxytocin receptor (OXTR) genes are associated with anxiety/depression in older women.

BACKGROUND: Environmental effects and personal experiences could be expressed in individuals through epigenetic non-structural changes such as DNA methylation. This methylation could up- regulate or down-regulate corresponding gene expressions and modify related phenotypes. DNA methylation increases with aging and could be related to the late expression of some forms of mental disease. The objective of this study was to evaluate the association between anxiety disorders and/or depression in older women and DNA methylation for four genes related to anxiety or depression. METHODS: Women aged 65 and older with (n = 19) or without (n = 24) anxiety disorders and/or major depressive episode (DSM-IV), were recruited. DNA methylation and single nucleotide variant (SNV) were evaluated from saliva, respectively by pyrosequencing and by PCR, for the following genes: brain-derived neurotrophic factor (BDNF; rs6265), oxytocin receptor (OXTR; rs53576), serotonin transporter (SLC6A4; rs25531), and apolipoprotein E (APOE; rs429358 and rs7412). RESULTS: A greater BDNF DNA methylation was observed in subjects with anxiety/depression compared to control group subjects (Mean: 2.92 SD ± 0.74 vs. 2.34 ± 0.42; p= 0.0026). This difference was more pronounced in subjects carrying the BDNF rs6265 CT genotype (2.99 ± 0.41 vs. 2.27 ± 0.26; p= 0.0006) than those carrying the CC genotype (p= 0.0332); no subjects with the TT genotype were observed. For OXTR, a greater DNA methylation was observed in subjects with anxiety/depression, but only for those carrying the AA genotype of the OXTR rs53576 SNV, more particularly at one out of the seven CpGs studied (7.01 ± 0.94 vs. 4.44 ± 1.11; p= 0.0063). No significant differences were observed for APOE and SLC6A4. CONCLUSION: These results suggest that DNA methylation in interaction with SNV variations in BDNF and OXTR, are associated with the occurrence of anxiety/depression in older women.

Screening instruments for a population of older adults: The 10-item Kessler Psychological Distress Scale (K10) and the 7-item Generalized Anxiety Disorder Scale (GAD-7).

Screening tools that appropriately detect older adults' mental disorders are of great public health importance. The present study aimed to establish cutoff scores for the 10-item Kessler Psychological Distress (K10) and the 7-item Generalized Anxiety Disorder (GAD-7) scales when screening for depression and anxiety. We used data from participants (n = 1811) in the Enquête sur la Santé des Aînés-Service study. Depression and anxiety were measured using DSM-V and DSM-IV criteria. Receiver operating characteristic (ROC) curve analysis provided an area under the curve (AUC) of 0.767 and 0.833 for minor and for major depression when using K10. A cutoff of 19 was found to balance sensitivity (0.794) and specificity (0.664) for minor depression, whereas a cutoff of 23 was found to balance sensitivity (0.692) and specificity (0.811) for major depression. When screening for an anxiety with GAD-7, ROC analysis yielded an AUC of 0.695; a cutoff of 5 was found to balance sensitivity (0.709) and specificity (0.568). No significant differences were found between subgroups of age and gender. Both K10 and GAD-7 were able to discriminate between cases and non-cases when screening for depression and anxiety in an older adult population of primary care service users.

Individual and area-level factors correlated with death by suicide in older adults.

OBJECTIVE: To determine the influence of individual and area-level characteristics associated with suicide in older adults. METHOD: This study used two complementary data sources. The first used administrative data from the Quebec Coroner's office and included information on suicide deaths in older adults aged 65years and over who died by suicide between 2000 and 2005 (n=903 persons). The second data source, which was used to identify the control group, came from a longitudinal study on seniors' health that was conducted in Quebec between 2004 and 2005 (n=2493 persons). Logistic regression analyses were used to test for associations between suicide and individual and area-level level characteristics. RESULTS: Suicide was associated with male gender, age, the presence of a physical and mental disorder and the use of health services. At the area-level level, suicide was associated with a higher population density, concentration of men, lower rates of education and higher rate of unemployment. Gender specific analyses also showed different patterns of associations on suicide risk. CONCLUSIONS: Suicide in older adults is associated with area-level and individual characteristics. This suggests that policies targeting only one level of risk factors are less likely to significantly influence suicide among this population.

Dyadic Adjustment Scale: a validation study among older French-Canadians living in relationships.

The principal objective of this study, the first of its kind to use this population, is to describe the factor analysis and validity of the Dyadic Adjustment Scale (EAD) among 895 French Canadian seniors living as couples. A confirmatory factor analysis was carried out using structural equation modeling. Results support Spanier's hierarchical model questionnaire (1976). Results also indicate evidence of validity and reliability satisfactorily set aside for the Affective Expression subscale having a lower Cronbach alpha coefficient. The results also indicate strong validity of the scale according to indices of convergent and discriminant validity. Finally, a discussion is presented addressing considerations to be taken into account for using the questionnaire among older couples.

Association between perceived social stigma against mental disorders and use of health services for psychological distress symptoms in the older adult population: validity of the STIG scale.

OBJECTIVES: To document the reliability, construct and nomological validity of the perceived Social Stigmatisation (STIG) scale in the older adult population. DESIGN: Cross-sectional survey. SETTING: Primary medical health services clinics. PARTICIPANTS: Probabilistic sample of older adults aged 65 years and over waiting for medical services in the general medical sector (n = 1765). MEASUREMENTS: Perceived social stigma against people with a mental health problem was measured using the STIG scale composed of seven indicators. RESULTS: A second-order measurement model of perceived social stigma fitted adequately the observed data. The reliability of the STIG scale was 0.83. According to our results, 39.6% of older adults had a significant level of perceived social stigma against people with a mental health problem. RESULTS showed that the perception of social stigma against mental health problems was not significantly associated with a respondent gender and age. RESULTS also showed that the perception of social stigma against the mental health problems was directly associated with the respondents' need for improved mental health (b = -0.10) and indirectly associated with their use of primary medical health services for psychological distress symptoms (b = -0.07). CONCLUSION: RESULTS lead us to conclude that social stigma against mental disorders perceived by older adults may limit help-seeking behaviours and warrants greater public health and public policy attention. Also, results lead us to conclude that physicians should pay greater attention to their patients' attitudes against mental disorders in order to identify possible hidden mental health problems.

Adherence to Oral Antihyperglycemic Agents Among Older Adults With Mental Disorders and Its Effect on Health Care Costs, Quebec, Canada, 2005-2008.

INTRODUCTION: Nonadherence to oral antihyperglycemic agents (OHAs) leads to an increase in use of health care resources and overall expenditures due to type 2 diabetes and its complications. People with type 2 diabetes are almost twice as likely to have anxiety and depression as the general population. Our aim was to examine health care costs associated with adherence to OHAs and the effect of depression and anxiety disorders on these in older adults with type 2 diabetes. METHODS: We used data from a representative sample (N = 2,811) of community-dwelling adults in Quebec aged 65 years or older who participated in the Étude sur la Santé des Aînés survey. The final sample consisted of 301 participants who were diagnosed with type 2 diabetes and who were taking OHAs. Total health care costs were calculated as the sum of the costs of hospitalizations and outpatient clinic services. Adherence to OHAs was measured using the medication possession ratio. Depression and anxiety disorders were assessed using criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. We also analyzed data by the Charlson Comorbidity Index, age, sex, education, and marital status, using generalized linear models. RESULTS: Nonadherence among people without depression or anxiety was associated with higher total health care costs ($4,477; 95% confidence interval [CI], $3,754-$5,201; P < .001), as was nonadherence among people with depression or anxiety ($11,124; 95% CI, $9,685-$12,562; P < .001). CONCLUSION: Improving adherence to OHAs among people with type 2 diabetes, particularly those with underlying mental disorders such as depression or anxiety, can decrease health care costs.

[Association between anxiety and cognitive decline in community-dwelling elderly]. / Association entre l'anxiété et le déclin cognitif chez les personnes âgées vivant dans la communauté.

The present study was conducted to determine whether anxiety among community-dwelling elders is associated with cognitive decline over a period of one year as well as to verify whether there are sex differences in the association between anxiety and cognitive decline. Participants (n=1942) were community-dwelling adults aged 65-96 years assessed at study entry (T0) and one year later (T1). Anxiety was identified with a semi-structured interview and cognitive functioning was assessed using the Mini-Mental State Examination. Results revealed that the presence of a clinically significant anxiety disorder did not predict cognitive decline in men and women. Subclinical anxiety symptoms predicted cognitive decline in women only. Moreover, for men, the presence of symptoms from at least two anxiety disorders predicted cognitive decline. For women, cognitive decline was predicted by the presence of symptoms from one anxiety disorder only. Overall, the results illustrate the role of anxiety in cognitive decline in community-dwelling older adults.

[The effect of age, gender and socioeconomic status on the use of services for psychological distress symptoms in the general medical sector: Results from the ESA research program on mental health and aging]. / L'effet de l'âge, du genre et du statut socioéconomique sur l'utilisation des services de médecine générale pour des symptômes de détresse psychologique: Résultats du programme de recherche ESA sur la santé mentale et le vieillissement.

OBJECTIVES: The objective of this study was, first, to document the psychometric characteristics of a measure of the older adults' socioeconomic status and, secondly, to test the effect of the socioeconomic status on the association between the older adults perceived need to improve their mental health and their use of services in the general medical sector for psychological distress symptoms taking into account the effect of age and gender. METHOD: Data used in this study come from the ESA study (Enquête sur la santé des ainés) on mental health and aging, conducted in 2005-2008 using a probabilistic sample (n=2811) of the older adult population aged 65 years and over living at home in Quebec. RESULTS: Our results showed that a measurement model of the older adults' socioeconomic status including an individual-level (SES_I) and an area/contextual-level dimension of socioeconomic deprivation (SES_C) was plausible. The reliability of the SES index used in the ESA research program was .92. Our results showed that women (b=-.43) and older people (b=-.16) were more at risk to have a disadvantaged socioeconomic status. However, our results did not show evidence of a significant association between the older adults' socioeconomic status, their perception of a need to improve their mental health and the use of medical services for psychological distress symptoms in the general medical sector in the older adult population in Quebec. CONCLUSION: Our results do not support the idea suggested in other studies that socioeconomic status has an effect on the older adults use of services for psychological distress symptoms in the general medical sector and suggest that in a context where medical health services are provided under a public insurance programme context, the socioeconomic status does not influence access to services in the general medical sector in the older adult population.

Family violence among older adult patients consulting in primary care clinics: results from the ESA (Enquête sur la santé des aînés) services study on mental health and aging.

OBJECTIVE: To document the reliability and construct validity of the Family Violence Scale (FVS) in the older adult population aged 65 years and older. METHOD: Data came from a cross-sectional survey, the Enquête sur la santé des aînés et l'utilisation des services de santé (ESA Services Study), conducted in 2011-2013 using a probabilistic sample of older adults waiting for medical services in primary care clinics (n = 1765). Family violence was defined as a latent variable, coming from a spouse and from children. RESULTS: A model with 2 indicators of violence; that is, psychological and financial violence, and physical violence, adequately fitted the observed data. The reliability of the FVS was 0.95. According to our results, 16% of older adults reported experiencing some form of family violence in the past 12 months of their interview, and 3% reported a high level of family violence (FVS > 0.36). Our results showed that the victim's sex was not associated with the degree of violence (ß = 0.02). However, the victim's age was associated with family violence (ß = -0.12). Older adults, aged 75 years and older, reported less violence than those aged between 65 and 74 years. CONCLUSION: Our results lead us to conclude that family violence against older adults is common and warrants greater public health and political attention. General practitioners could play an active role in the detection of violence among older adults.

Association between skin conditions and depressive disorders in community-dwelling older adults.

BACKGROUND: Depression is frequently observed in dermatologic patients. However, the association between depressive disorders and skin conditions has rarely been explored through population-based studies, especially within older-adult populations. OBJECTIVE: To test this association in a representative sample of an older-adult population. METHODS: Data came from the Survey on the Health of the Elderly (Enquête sur la Santé des Aìnés [ESA]), a longitudinal survey conducted in Quebec among 2,811 older adults. Cross-lagged panel models were used to simultaneously examine cross-sectional and longitudinal relationships between the presence of skin conditions and depressive disorders. RESULTS: The prevalence of skin conditions was 13%, and the prevalence of depressive disorders among participants presenting with skin conditions was 11%. Our results indicated significant cross-sectional correlation (ζ  =  0.20) between skin conditions and depressive disorders, but no longitudinal association was observed. CONCLUSION: Our results reinforce the hypothesis that skin conditions and depressive disorders are concurrently associated in older adults. However, no evidence of the predictive effect of skin problems on depression (and vice versa) was found in our community sample. Despite the deleterious effect of the coexistence of these problems in older adults, studies are lacking. This article highlights the importance of this issue and emphasizes the need for further research on this topic.

Gender differences in general and specialty outpatient mental health service use for depression.

BACKGROUND: This study ascertained gender-specific determinants of outpatient mental health (MH) service use for depression to highlight any gender disparities in barriers to care and explain how depressed men and women in need of care might differ in their help-seeking behaviour. METHODS: Data used in this study came from the Canadian Community Health Survey on Mental Health and Well Being, cycle 1.2 (CCHS 1.2) conducted by Statistics Canada in 2002 (N = 36,984). The sample was limited to respondents filling criteria for a probable major depression in the 12 months prior to the interview (n = 1743). Gender-specific multivariate logistic regression analyses were carried out. RESULTS: The results showed that 54.3% of respondents meeting criteria for major depression had consulted for mental health reasons in the year prior to interview. When looking at type of outpatient mental health service use, males were more likely to consult a general practitioner and a mental health specialist in the past year as opposed to females. However, females were more likely to consult a general practitioner only as opposed to no service use than males. Gender specific differences in determinants associated with outpatient service use included for males, lower adjusted household income, and for females, a younger age, the presence of social support, self-reported availability barriers, the presence of self-reported suicidal thoughts or attempt and a poorer self- perceived mental health. CONCLUSIONS: Continued efforts to promote access to mental health care are needed for men and women affected by depression, and this, to target specific vulnerable populations and increase utilization rates.

Skin conditions in community-living older adults: prevalence and characteristics of medical care service use.

BACKGROUND: There are considerable gaps in the knowledge of the global epidemiology of skin conditions in the geriatric population. OBJECTIVE: This study attempted to (1) determine the frequency of skin conditions, (2) evaluate the agreement between two different data sources of information (self-report versus administrative), and (3) document medical care service use for skin conditions in a representative sample of community-dwelling older adults. METHODS: A secondary analysis using data from a longitudinal population-based health survey conducted in Quebec (2005-2008) within a sample of 2,811 community-dwelling older adults. RESULTS: Our results highlighted a high prevalence rate of self-reported (13%) and diagnosed skin conditions (21%). Agreement between data sources was low (kappa < 0.20). Most dermatologic-related medical visits were made to dermatologists (almost 60%). CONCLUSION: The epidemiology of skin conditions in the geriatric population is an under researched field, despite its important prevalence and relevance as a source of information for assessing the health care needs of older adults.