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

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

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

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

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

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

Effects of a Psychosocial Intervention on Caregivers of Recently Placed Nursing Home Residents: A Randomized Controlled Trial.

Many caregivers continue to provide care and support to their care recipients after institutional placement. A two-group randomized controlled trial was carried out to test the efficacy of a psychosocial intervention for informal caregivers whose care recipients resided in a long-term care facility. The intervention was delivered during the 6 month period following baseline assessment. Follow-up assessments were carried out at 6, 12, and 18 months. Primary outcomes were caregiver depression, anxiety, burden, and complicated grief. Significant time effects were found for all three primary outcomes showing that caregiver depression, anxiety, and burden improved over time. No treatment effects were found for these outcomes. However, complicated grief was significantly lower for caregivers in the treatment condition.

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

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

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

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

Re-emergence of posttraumatic stress disorder nightmares with nursing home admission: treatment with prazosin.

Seniors with a history of emotional trauma decades earlier can experience a recurrence of posttraumatic stress disorder symptoms when transitioning to a nursing home. We present the case of an 86-year-old male Holocaust survivor admitted to a nursing home for physical therapy and rehabilitation 6 weeks after the death of his wife; the patient was expressing a persistent death wish. Despite the multiple risk factors for depression, his distress was specifically related to the reemergence of nightly posttraumatic nightmares. Over the course of 1 week of treatment with 1 mg prazosin at bedtime, his nightmares and his death wish completely resolved. He achieved his rehabilitation goals and was discharged to a community setting. This report highlights the importance of considering posttraumatic stress disorder in nursing home residents with a history of emotional trauma, and understanding how to address these symptoms pharmacologically and nonpharmacologically.

Excessive activation of mTOR in postnatally generated granule cells is sufficient to cause epilepsy.

The dentate gyrus is hypothesized to function as a "gate," limiting the flow of excitation through the hippocampus. During epileptogenesis, adult-generated granule cells (DGCs) form aberrant neuronal connections with neighboring DGCs, disrupting the dentate gate. Hyperactivation of the mTOR signaling pathway is implicated in driving this aberrant circuit formation. While the presence of abnormal DGCs in epilepsy has been known for decades, direct evidence linking abnormal DGCs to seizures has been lacking. Here, we isolate the effects of abnormal DGCs using a transgenic mouse model to selectively delete PTEN from postnatally generated DGCs. PTEN deletion led to hyperactivation of the mTOR pathway, producing abnormal DGCs morphologically similar to those in epilepsy. Strikingly, animals in which PTEN was deleted from ≥ 9% of the DGC population developed spontaneous seizures in about 4 weeks, confirming that abnormal DGCs, which are present in both animals and humans with epilepsy, are capable of causing the disease.

Stayers, leavers, and switchers among certified nursing assistants in nursing homes: a longitudinal investigation of turnover intent, staff retention, and turnover.

PURPOSE: Studies of certified nursing assistant (CNA) turnover in nursing homes are typically cross-sectional and include full-time and part-time workers. We conducted a longitudinal study to evaluate the job factors and work attitudes associated with just full-time staying or leaving. For those who did not stay, we assessed reasons for leaving and satisfaction following job transition. DESIGN AND METHODS: A random sample of CNAs identified through the Pennsylvania Department of Health's CNA registry, working ≥ 30 hr weekly in a nursing facility was surveyed by telephone at baseline and 1 year later. RESULTS: Of the 620 responding to both surveys, 532 (85.8%) remained (stayers), 52 (8.4%) switched to another facility (switchers), and 36 (5.8%) left the industry (leavers). At baseline, switchers reported higher turnover intentions and fewer benefits compared with stayers and left for new opportunities. Leavers had lower job satisfaction and emotional well-being and left for health reasons. Turnover intentions were predicted by low job satisfaction and low emotional well-being. Actual turnover was predicted only by turnover intentions and by the absence of health insurance. Pay was not a predictor of turnover intent or turnover. IMPLICATIONS: There are two distinct groups of CNAs contributing to turnover. Attitudinal factors, such as job satisfaction and emotional well-being, are mediated via turnover intentions to effect actual turnover. Even accounting for methodological differences, this turnover rate is lower than previous studies, which use alternative methods and include part-time workers. This study should help nursing home administrators better understand the work-related factors associated with staff turnover.

Using Audio Computer-Assisted Self-Interviewing and Interactive Voice Response to Measure Elder Mistreatment in Older Adults: Feasibility and Effects on Prevalence Estimates.

Demographic trends indicate an aging population, highlighting the importance of collecting valid survey data from older adults. One potential issue when surveying older adults is use of technology to collect data on sensitive topics. Survey technologies like A-CASI and IVR have not been used with older adults to measure elder mistreatment. We surveyed 903 adults age 60 and older in Allegheny County, Pennsylvania (U.S.) with random assignment to one of four survey modes: (1) CAPI, (2) A-CASI, (3) CATI; and (4) IVR. We assessed financial, psychological, and physical mistreatment, and examined feasibility of A-CASI and IVR, and effects on prevalence estimates relative to CAPI and CATI. Approximately 83% of elders randomized to A-CASI/IVR used each technology, although 28% of respondents in the A-CASI condition refused to use headphones and read the questions instead. A-CASI produced higher six month prevalence rates of financial and psychological mistreatment than CAPI. IVR produced higher six month prevalence rates of psychological mistreatment than CATI. We conclude that, while IVR may be useful, A-CASI offers a more promising approach to the measurement of elder mistreatment.

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

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

Financial exploitation and psychological mistreatment among older adults: differences between African Americans and non-African Americans in a population-based survey.

PURPOSE: to examine racial differences in (a) the prevalence of financial exploitation and psychological mistreatment since turning 60 and in the past 6 months and (b) the experience-perpetrator, frequency, and degree of upset-of psychological mistreatment in the past 6 months. DESIGN AND METHODS: random digit dial telephone recruitment and population-based survey (telephone and in-person) of 903 adults aged 60 years and older in Allegheny County (Pittsburgh), Pennsylvania (693 non-African American and 210 African American). Covariates included sex, age, education, marital status, household composition, cognitive function, instrumental activities of daily living/activities of daily living difficulties, and depression symptoms. RESULTS: prevalence rates were significantly higher for African Americans than for non-African Americans for financial exploitation since turning 60 (23.0% vs. 8.4%) and in the past 6 months (12.9% vs. 2.4%) and for psychological mistreatment since turning 60 (24.4% vs. 13.2%) and in the past 6 months (16.1% vs. 7.2%). These differences remained once all covariates were controlled in logistic regression models. There were also racial differences in the experience of psychological mistreatment in the past 6 months. Risk for clinical depression was also a consistent predictor of financial exploitation and psychological mistreatment. IMPLICATIONS: although the results will need to be replicated in national surveys, the study suggests that racial differences in elder mistreatment are a potentially serious issue deserving of continued attention from researchers, health providers, and social service professionals.

Serotonin transporter triallelic genotype and response to citalopram and risperidone in dementia with behavioral symptoms.

The risk/benefit ratio of pharmacotherapy for behavioral symptoms of dementia is questionable: second-generation antipsychotics are poorly tolerated, and the efficacy of alternative treatments, for example, selective serotonin-reuptake inhibitors (SSRIs), is uncertain. Biomarkers of treatment response may improve this risk/benefit ratio. The length polymorphism of the serotonin transporter promoter gene (5-HTTLPR/SLC6A4) may moderate tolerability of SSRIs and expression of behavioral symptoms in dementia. We assessed the effect of 5-HTTLPR on tolerability and efficacy of citalopram and risperidone in a 12-week randomized controlled trial, which included nondepressed patients with dementia hospitalized for behavioral or psychotic symptoms. Genotypes including the A/G polymorphism of the L allele (rs25531) were determined in 92 of 103 participants. We used pattern-mixture models to account for dropout. Low-expression alleles (S and Lg) predicted greater early and overall side effects of citalopram and early treatment discontinuation. These results remained unchanged after excluding African-American participants and in covariate analyses. Unexpectedly, low-expression alleles seemed to predict greater early side effects of risperidone (but not early discontinuation) and poorer early response of psychosis symptoms to risperidone. In conclusion, 5-HTTLPR may be a useful biomarker of SSRI intolerance in dementia. Our findings of intolerance of a second-generation antipsychotics and persistence of psychosis in patients with low-expression alleles needs to be replicated.

A dual-driver model of retention and turnover in the direct care workforce.

PURPOSE: The purpose of this study was to understand the factors associated with turnover and retention of direct care workers. We hypothesize that a dual-driver model that includes individual factors, on-the-job factors, off-the-job factors, and contextual factors can be used to distinguish between reasons for direct care workforces (DCWs) staying on the job or leaving the job. DESIGN AND METHODS: We conducted 7 focus groups with 47 participants. We identified key themes they used to describe their experiences focusing on differences between stayers (had been in the same job for at least 3 years) and leavers (had changed jobs within the past 3 years). RESULTS: Five major themes associated with turnover were identified as follows: (a) lack of respect, (b) inadequate management, (c) work or family conflicts, (d) difficulty of the work, and (e) job openings. Themes associated with retention were as follows: (a) being "called" to service, (b) patient advocacy, (c) personal relationships with residents, (d) religion or spirituality, (e) haven from home problems, and (f) flexibility. Themes associated with turnover were different from those associated with retention. IMPLICATIONS: DCW turnover and retention are complex, multifactorial issues. Efforts to stabilize the DCW must address the issues associated with retention as well as those associated with turnover. Specifically, factors that promote retention may be qualitatively different than those that prevent turnover. Treating retention and turnover as simply the obverse of each other may be misleading in addressing the underlying problem of job stability among DCWs.

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

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

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

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

A double-blind comparison of citalopram and risperidone for the treatment of behavioral and psychotic symptoms associated with dementia.

OBJECTIVE: To compare citalopram and risperidone for the treatment of psychotic symptoms and agitation associated with dementia, with a priori hypotheses that risperidone would be more efficacious for psychosis and citalopram for agitation. METHODS: A 12-week randomized, controlled trial in nondepressed patients with dementia hospitalized because of behavioral symptoms (N = 103) was conducted at the University of Pittsburgh Medical Center. Participants were consecutively recruited on an inpatient unit if they had at least one moderate to severe target symptom (aggression, agitation, hostility, suspiciousness, hallucinations, or delusions). Once they improved sufficiently, they were discharged to nursing homes, personal care homes, or residential homes for continued treatment. Planned pre-post and mixed model analyses of the main outcome measures of Neurobehavioral Rating Scale and Side Effect Rating Scale at baseline and at weekly/biweekly intervals were conducted. RESULTS: Completion rates did not differ for citalopram and risperidone (overall completion rate: 44%). Agitation symptoms (aggression, agitation, or hostility) and psychotic symptoms (suspiciousness, hallucinations, or delusions) decreased in both treatment groups but the improvement did not differ significantly between the two groups. There was a significant increase in side effect burden with risperidone but not with citalopram such that the two groups differed significantly. CONCLUSION: No statistical difference was found in the efficacy of citalopram and risperidone for the treatment of either agitation or psychotic symptoms in patients with dementia. These findings need to be replicated before citalopram or other serotonergic antidepressants can be recommended as alternatives to antipsychotics for the treatment of agitation or psychotic symptoms associated with dementia.

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

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