Community Health Workers Deliver Mental Health Intervention to Uninsured Latinx in Baltimore: Evaluation and Lessons Learned in a Pilot Program.

BACKGROUND: Implementation of evidence-based interventions to reduce depression among uninsured Latinx patients who are at high risk of depression are rare. OBJECTIVES: Our goal was to evaluate Strong Minds, a language and culturally tailored, evidence-based intervention adapted from cognitive behavioral therapy (CBT) for mild-moderate depression and anxiety, delivered by community health workers (CHWs) in Spanish to uninsured Latinx immigrants. METHODS: As part of the pilot, 35 participants, recruited from a free community primary care clinic, completed Strong Minds. Assessments and poststudy interviews were conducted. Paired t-tests were used to assess change of depressive symptoms at 3 and 6 months. LESSONS LEARNED: CHW delivery of depression care to this population was feasible and among those who completed the program, preliminary evidence of depression outcomes suggests potential benefit. CHWs had specific training and support needs related to mental health care delivery. CONCLUSIONS: Further implementation studies of depression care interventions using CHWs for underserved Latinx is needed.

Addressing chronic pain disparities between Black and White people: a narrative review of socio-ecological determinants.

A 2019 review article modified the socio-ecological model to contextualize pain disparities among different ethnoracial groups; however, the broad scope of this 2019 review necessitates deeper socio-ecological inspection of pain within each ethnoracial group. In this narrative review, we expanded upon this 2019 article by adopting inclusion criteria that would capture a more nuanced spectrum of socio-ecological findings on chronic pain within the Black community. Our search yielded a large, rich body of literature composed of 174 articles that shed further socio-ecological light on how chronic pain within the Black community is influenced by implicit bias among providers, psychological and physical comorbidities, experiences of societal and institutional racism and biomedical distrust, and the interplay among these factors. Moving forward, research and public-policy development must carefully take into account these socio-ecological factors before scaling up pre-existing solutions with questionable benefit for the chronic pain needs of Black individuals.

The impact of anti-Asian racism on routine activities and mental health among Korean American older adults and their caregivers.

Introduction: Reported anti-Asian discrimination has been on the rise since the COVID-19 pandemic. Nevertheless, limited research addresses the health impact of perceived anti-Asian racism on Asian Americans, especially among older adults, during COVID-19. To address the gap, we examined how the novel coronavirus pandemic affected Korean American older adults, one of the largest Asian subgroups. Specifically, this study addressed the magnitude of racism or discrimination related to the pandemic and impact of anti-Asian racism on negative mental health symptoms among Korean American older adults and their caregivers. Methods: We used survey data collected from 175 Korean American older adults with probable dementia and their primary caregivers (female = 62%, mean age = 71 years) who went through eligibility screening for an ongoing randomized controlled trial involving dyads in the Baltimore-Washington and the New York Metropolitan areas (ClinicalTrials.gov Identifier: NCT03909347). Results: Nearly a quarter of the survey sample reported they were fearful for their safety due to anti-Asian racism related to the pandemic. Additionally, 47% of the respondents indicated changes to routine activities due to anti-Asian racism or discrimination related to COVID-19. The most common changes included avoiding walking alone or physical activities outside, followed by avoiding public transportation or leaving the house to go to any public places such as grocery stores, churches, or schools, not carrying out usual social activities, and avoiding going to health care appointments. Multinomial logistic regression revealed that people who reported changes to routine activities were at least five times more likely (adjusted odds ratio = 5.017, 95% confidence interval = 1.503, 16.748) to report negative mental health symptoms than those who did not. Being fearful for their own safety was not associated with experiencing negative mental health symptoms in the survey sample. Discussion: Study findings indicate that the increased reporting of anti-Asian racism during the COVID-19 pandemic has substantially affected Korean American older adults and their caregivers. The mechanism by which changes to routine activities is related to negative mental health symptoms is unclear, future research is needed to elucidate this pathway. Furthermore, our findings highlight the importance of identifying multi-level strategies to raise awareness of and to mitigate the reported surge of racism.

Increasing the Repertoire for Depression Care: Methods and Challenges of a Randomized Controlled Trial of Peer Support for Vulnerable Older Adults.

OBJECTIVE: Low-income White and older adults of color face barriers to depression care. Our purpose is to describe the methods and challenges encountered during the implementation of a randomized controlled trial to test the effectiveness of a peer support depression care intervention for low-income White and older adults of color during the COVID-19 pandemic. METHODS: Peer Enhanced Depression Care (Peers) is an 8-week community-based intervention that uses peer mentors who are trained and supervised to provide social support and self-care skills to depressed older adults. The effectiveness of the intervention in reducing depression will be evaluated by following a sample of older adults recruited in the community over a 12-month period. Target enrollment is 160 older adults. We hypothesize that participants randomized to the Peer Enhanced Depression Care intervention will experience greater decrease in depressive symptoms compared to participants randomized to the social interaction control. We provide lessons learned regarding the recruitment of BIPOC and White low-income older adults and peer mentors during the COVID-19 pandemic. RESULTS: Recruitment challenges occurred in primary care clinics that were unable to accommodate recruitment efforts during the pandemic. This led to focused outreach to community-based organizations serving older adults. Challenges to participant recruitment have included barriers related to stigma, distrust, as well as unfamiliarity with research. Peer mentor recruitment was facilitated by existing government-supported resources. CONCLUSIONS: This study will provide knowledge regarding the effectiveness, mechanism, and processes of delivering an informal psychosocial intervention such as peer support to a vulnerable older adult population.

Development of the Mental Health Peer Support Questionnaire in colleges and vocational schools in Singapore.

BACKGROUND: A nation-wide mental health peer support initiative was established in college and vocational schools in Singapore. The purpose of this cross-sectional study was to develop and validate a 20-item self-report instrument, the Mental Health Peer Support Questionnaire (MHPSQ), to assess young adults' perceived knowledge and skills in mental health peer support. METHODS: We administered the questionnaire to 102 students who were trained as peer supporters, and 306 students who were not trained as peer supporters (denoted as non-peer supporters), in five college and vocational schools. Exploratory factor analysis and descriptive statistics were conducted. Cronbach's α was used to assess reliability, and independent sample t-tests to assess criterion validity. RESULTS: Exploratory factor analysis indicated a three-factor structure with adequate internal reliability (discerning stigma [α = .76], personal mastery [α = .77], skills in handling challenging interpersonal situations [α = .74]; overall scale [α = .74]). Consistent with establishing criterion validity, peer supporters rated themselves as significantly more knowledgeable and skilled than non-peer supporters on all items except two: (1) letting peer support recipients make their own mental health decisions, and (2) young adults' self-awareness of feeling overwhelmed. Peer supporters who had served the role for a longer period of time had significantly higher perceived awareness of stigma affecting mental health help-seeking. Peer supporters who had reached out to more peer support recipients reported significantly higher perceived skills in handling challenging interpersonal situations, particularly in encouraging professional help-seeking and identifying warning signs of suicide. CONCLUSIONS: The MHPSQ may be a useful tool for obtaining a baseline assessment of young adults' perceived knowledge and skills in mental health peer support, prior to them being trained as peer supporters. This could facilitate tailoring of training programs based on young adults' initial understanding of mental health peer support. Subsequent to young adults' training and application of skills, the MHPSQ could also be applied to evaluate the effectiveness of peer programs and mental health training.

Centering Culture in Mental Health: Differences in Diagnosis, Treatment, and Access to Care Among Older People of Color.

Mental healthcare disparities are routinely documented, yet they remain wider than in most other areas of healthcare services and common mental disorders (depression and anxiety) continue to be one of the highest health burdens for older people of color. To address disparities in mental health services for older people of color, the narrative must move beyond simply documenting these inequities and attain a better understanding of the internalized, interpersonal, systemic, and medical racism that have harmed these communities and excluded them from its services in the first place. It is imperative that researchers, clinicians, and policymakers acknowledge the realities of racism and discrimination as leading causes of mental healthcare disparities. Therefore, this review is a call-to-action. Authors adopt an antiracist and health equity lens in evaluating the differing needs of Blacks/African-Americans, Asian Americans, and Latinos by exploring psychiatric comorbidity, experiences with seeking, accessing, and engaging in treatment, and the unique cultural and psychosocial factors that affect treatment outcomes for these diverse groups. Further, authors offer researchers and practitioners tangible tools for developing and implementing culturally-sensitive, mental health focused interventions for older people of color with special attention placed on cultural adaptations, models of care, prevention, and practical strategies that can be implemented to reduce disparities and increase equity in mental healthcare.

Regional amyloid correlates of cognitive performance in ageing and mild cognitive impairment.

Beta-amyloid deposition is one of the earliest pathological markers associated with Alzheimer's disease. Mild cognitive impairment in the setting of beta-amyloid deposition is considered to represent a preclinical manifestation of Alzheimer's disease. In vivo imaging studies are unique in their potential to advance our understanding of the role of beta-amyloid deposition in cognitive deficits in Alzheimer's disease and in mild cognitive impairment. Previous work has shown an association between global cortical measures of beta-amyloid deposition ('amyloid positivity') in mild cognitive impairment with greater cognitive deficits and greater risk of progression to Alzheimer's disease. The focus of the present study was to examine the relationship between the regional distribution of beta-amyloid deposition and specific cognitive deficits in people with mild cognitive impairment and cognitively normal elderly individuals. Forty-seven participants with multi-domain, amnestic mild cognitive impairment (43% female, aged 57-82 years) and 37 healthy, cognitively normal comparison subjects (42% female, aged 55-82 years) underwent clinical and neuropsychological assessments and high-resolution positron emission tomography with the radiotracer 11C-labelled Pittsburgh compound B to measure beta-amyloid deposition. Brain-behaviour partial least-squares analysis was conducted to identify spatial patterns of beta-amyloid deposition that correlated with the performance on neuropsychological assessments. Partial least-squares analysis identified a single significant (P < 0.001) latent variable which accounted for 80% of the covariance between demographic and cognitive measures and beta-amyloid deposition. Performance in immediate verbal recall (R = -0.46 ± 0.07, P < 0.001), delayed verbal recall (R = -0.39 ± 0.09, P < 0.001), immediate visual-spatial recall (R = -0.39 ± 0.08, P < 0.001), delayed visual-spatial recall (R = -0.45 ± 0.08, P < 0.001) and semantic fluency (R = -0.33 ± 0.11, P = 0.002) but not phonemic fluency (R = -0.05 ± 0.12, P < 0.705) negatively covaried with beta-amyloid deposition in the identified regions. Partial least-squares analysis of the same cognitive measures with grey matter volumes showed similar associations in overlapping brain regions. These findings suggest that the regional distribution of beta-amyloid deposition and grey matter volumetric decreases is associated with deficits in executive function and memory in mild cognitive impairment. Longitudinal analysis of these relationships may advance our understanding of the role of beta-amyloid deposition in relation to grey matter volumetric decreases in cognitive decline.

The benefits and challenges of established peer support programmes for patients, informal caregivers, and healthcare providers.

PURPOSE: Peer support programmes that provide services for various health conditions have been in existence for many years; however, there is little study of their benefits and challenges. Our goal was to explore how existing peer support programmes help patients with a variety of health conditions, the challenges that these programmes meet, and how they are addressed. METHODS: We partnered with 7 peer support programmes operating in healthcare and community settings and conducted 43 semi-structured interviews with key informants. Audiorecordings were transcribed and qualitative analysis was conducted using grounded theory methods. RESULTS: Peer support programmes offer informational and psychosocial support, reduce social isolation, and connect patients and caregivers to others with similar health issues. These programmes provide a supportive community of persons who have personal experience with the same health condition and who can provide practical information about self-care and guidance in navigating the health system. Peer support is viewed as different from and complementary to professional healthcare services. Existing programmes experience challenges such as matching of peer supporter and peer recipient and maintaining relationship boundaries. They have gained experience in addressing some of these challenges. CONCLUSIONS: Peer support programmes can help persons and caregivers manage health conditions but also face challenges that need to be addressed through organizational processes. Peer support programmes have relevance for improving healthcare systems, especially given the increased focus on becoming more patient-centred. Further study of peer programmes and their relevance to improving individuals' well-being is warranted.

Exploring Challenges and Strategies in Partnering With Community-Based Organizations to Advance Intervention Development and Implementation With Older Adults.

Minoritized older adults face multiple health inequities and disparities, but are less likely to benefit from evidence-based health care interventions. With the increasing diversity of the U.S. aging population, there is a great promise for gerontology researchers to partner with racial/ethnic minority organizations and underrepresented communities to develop and implement evidence-based health interventions. Community-Based Participatory Research and Implementation Science offer guidance and strategies for researchers to develop and sustain community partnerships. However, researchers partnering with community organizations continue to face challenges in these collaborations, study outcomes, and sustainability. This may be especially true for those junior in their career trajectory or new to community-engaged research. The purpose of this forum article is to detail critical challenges that can affect gerontology researcher-community partnerships and relationships from the perspective of researchers. Seven challenges (pre- or mid-intervention design, implementation, and postimplementation phases) described within the Equity-focused Implementation Research for health programs framework are identified and discussed. Potential solutions are also presented. Planning for potential obstacles of the researcher-community partnerships can inform innovative solutions that will facilitate successful partnerships, thereby promoting the advancement of collaborative research between academic institutions and community organizations to improve older adult health outcomes.

Positron emission tomography imaging of serotonin degeneration and beta-amyloid deposition in late-life depression evaluated with multi-modal partial least squares.

Depression in late-life is associated with increased risk of cognitive decline and development of all-cause dementia. The neurobiology of late-life depression (LLD) may involve both neurochemical and neurodegenerative mechanisms that are common to depression and dementia. Transgenic amyloid mouse models show evidence of early degeneration of monoamine systems. Informed by these preclinical data, the hypotheses were tested that a spatial covariance pattern of higher beta-amyloid (Aß) and lower serotonin transporter availability (5-HTT) in frontal, temporal, and parietal cortical regions would distinguish LLD patients from healthy controls and the expression of this pattern would be associated with greater depressive symptoms. Twenty un-medicated LLD patients who met DSM-V criteria for major depression and 20 healthy controls underwent PET imaging with radiotracers for Aß ([11C]-PiB) and 5-HTT ([11C]-DASB). A voxel-based multi-modal partial least squares (mmPLS) algorithm was applied to the parametric PET images to determine the spatial covariance pattern between the two radiotracers. A spatial covariance pattern was identified, including higher Aß in temporal, parietal and occipital cortices associated with lower 5-HTT in putamen, thalamus, amygdala, hippocampus and raphe nuclei (dorsal, medial and pontine), which distinguished LLD patients from controls. Greater expression of this pattern, reflected in summary 5-HTT/Aß mmPLS subject scores, was associated with higher levels of depressive symptoms. The mmPLS method is a powerful approach to evaluate the synaptic changes associated with AD pathology. This spatial covariance pattern should be evaluated further to determine whether it represents a biological marker of antidepressant treatment response and/or cognitive decline in LLD patients.

Engaging an Asian Immigrant Older Adult in Depression Care: Collaborative Care, Patient-Provider Communication and Ethnic Identity.

Minority older adults face multiple barriers when trying to access mental health services and often present with more severe symptoms of mental health conditions. We describe the multilevel factors that contributed to the engagement of an Asian immigrant older adult with depression. Systems-level innovations such as collaborative care in primary care can increase access to care for all, including minority older adults; however, one size fits all interventions may not meet the needs of communities of older adults with different life experiences, language needs, norms and values regarding help-seeking for mental health. Health outcomes remain unequal , suggesting the need to tailor interventions for minority older adults. For the patient, specific factors related to language and ethnic concordance between patient and healthcare provider, communication behaviors, ethnic identity, and social norms may be important to take into account. The recognition of the heterogeneity of patients and the limitations of cultural competence approaches defined as broad, general knowledge about ethnic cultures may be needed. A need to learn continuously from clinical experience and adopt a patient-oriented model of communication and decision-making may successfully engage Asian immigrant older adults in depression care services.

Molecular imaging of beta-amyloid deposition in late-life depression.

Late-life depression (LLD) is associated with an increased risk of all-cause dementia and may involve Alzheimer's disease pathology. Twenty-one LLD patients who met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria for a current major depressive episode and 21 healthy controls underwent clinical and neuropsychological assessments, magnetic resonance imaging to measure gray matter volumes, and high-resolution positron emission tomography to measure beta-amyloid (Aß) deposition. Clinical and neuropsychological assessments were repeated after 10-12 weeks of Citalopram or Sertraline treatment (LLD patients only). LLD patients did not differ from healthy controls in baseline neuropsychological function, although patients improved in both depressive symptoms and visual-spatial memory during treatment. Greater Aß in the left parietal cortex was observed in LLD patients compared with controls. Greater Aß was correlated with greater depressive symptoms and poorer visual-spatial memory, but not with improvement with treatment. The study of LLD patients with prospective measurements of mood and cognitive responses to antidepressant treatment is an opportunity to understand early neurobiological mechanisms underlying the association between depression and subsequent cognitive decline.

Molecular imaging of the serotonin transporter availability and occupancy by antidepressant treatment in late-life depression.

Patients with late-life depression (LLD) have a more variable response to pharmacotherapy relative to patients with mid-life depression. Degeneration of the serotonergic system and lower occupancy of the initial target for antidepressant medications, the serotonin transporter (5-HTT), may contribute to variability in treatment response. The focus of this study was to test the hypotheses that lower cortical and limbic serotonin transporter (5-HTT) availability in LLD patients relative to controls and less 5-HTT occupancy by antidepressant medications would be associated with less improvement in mood and cognition with treatment in LLD patients. Twenty LLD patients meeting DSM-IV criteria for a current major depressive episode and 20 non-depressed controls underwent clinical and neuropsychological assessments, magnetic resonance imaging to measure gray matter volumes and high-resolution positron emission tomography (PET) scanning to measure 5-HTT before and after 10-12 weeks of treatment with Citalopram or Sertraline (patients only). Prior to treatment, 5-HTT was lower in LLD patients relative to controls in mainly temporal cortical and limbic (amygdala and hippocampus) regions. Gray matter volumes were not significantly different between groups. 5-HTT occupancy was detected throughout cortical, striatal, thalamic and limbic regions. The magnitude of regional 5-HTT occupancy by antidepressants was 70% or greater across cortical and sub-cortical regions, consistent with the magnitude of 5-HTT occupancy observed in mid-life depressed patients. Greater regional 5-HTT occupancy correlated with greater improvement in depressive symptoms and visual-spatial memory performance. These data support the hypothesis that serotonin degeneration and variability in 5-HTT occupancy may contribute to heterogeneity in treatment response in LLD patients.

Neurotransmitters and Neurometabolites in Late-Life Depression: A Preliminary Magnetic Resonance Spectroscopy Study at 7T.

BACKGROUND: Magnetic resonance spectroscopy (MRS) methods have quantified changes in levels of neurotransmitters and neurometabolites in patients with major depression across the lifespan. The application of 7T field strengths and greater have not been a major focus of study in patients with late-life depression (LLD). METHODS: Nine LLD patients who met DSM-IV criteria for a current major depressive episode and nine non-depressed, healthy, age-matched controls underwent clinical and neuropsychological assessment and single-voxel 7T 1H-MRS at baseline and after 10-12 weeks of antidepressant treatment (Citalopram; patients only). Spectra were acquired from two brain regions implicated in both depressive symptoms and neuropsychological deficits in LLD, the anterior (ACC) and posterior cingulate (PCC). Levels of γ-aminobutyric acid (GABA), glutamate (Glu), glutathione (GSH), N-acetylaspartylglutamate (NAAG), N-acetylaspartate (NAA), and myo-inositol (mI) were quantified relative to total creatine (tCr) using linear-combination modeling. RESULTS: Baseline Glu/tCr levels were not significantly different between groups. Decreased Glu/tCr levels after Citalopram treatment were observed in a subset of LLD patients. Exploratory analyses showed that LLD patients had lower NAA levels in the PCC relative to controls. Higher levels of ml in the LLD patients relative to the controls and decreases after Citalopram treatment had large effect sizes but were not statistically significant. Further, decreases in PCC Glu/tCr and increases in ACC GSH/tCr were associated with improvement in depressive symptoms. LIMITATIONS: Sample size. CONCLUSIONS: These preliminary results suggest a role of neurochemicals and neurometabolites in the neurobiology of LLD and antidepressant treatment response.

Methodology and baseline characteristics of a randomized controlled trial testing a health care professional and peer-support program for patients with chronic obstructive pulmonary disease: The BREATHE2 study.

BACKGROUND: Self-management support (SMS) for patients with COPD can improve health-related quality of life (HRQOL). However, it remains unclear what SMS strategies are most effective. Using peer support to advance self-management is promising, as peer supporters possess credibility and can serve as role models. METHODS: We conducted a single-blinded RCT comparing the effectiveness of two strategies to support patients with COPD. The strategies were 'Health Care Professional (HCP)' and 'HCP Plus Peer' support. Peer support was provided by patients with COPD who have stopped smoking, completed an acute pulmonary rehabilitation program, and met the requirements for becoming a peer supporter. We enrolled patients receiving treatment at inpatient and outpatient settings. Patients were encouraged to invite one family-caregiver to enroll with them. The primary outcome measure was the change in HRQOL at 6 months post enrollment. Secondary outcomes included COPD-related and all-cause hospitalizations and ED visits. Caregiver outcomes included preparedness for caregiving, caregiver stress, and coping. RESULTS: A total of 292 patients as well as 50 family-caregivers were enrolled. The average patient age was 67.3 yrs. (SD 9.4), 61% were female and 26% were African-Americans. The majority of caregivers were females (68%) and were a spouse/partner (58%). DISCUSSION: This study tested a dual strategy for providing support to patients with COPD that incorporates peer and health care professional support. The study had minimal exclusion criteria. If shown effective, the study offers a program of peer support that can be readily implemented in health care settings.

Perspectives on Training Needs for Geriatric Mental Health Providers: Preparing to Serve a Diverse Older Adult Population.

An increasingly diverse population of older adults requires a diverse workforce trained to address the problem of differential healthcare access and quality of care. This article describes specific areas of training focused on addressing health disparities based on ethnic differences. Culturally competent care by mental health providers, innovative models of mental health service delivery such as collaborative care, and expansion of the mental health workforce through integration of lay health workers into professional healthcare teams, offer potential solutions and require training. Cultural competency, defined as respect and responsiveness to diverse older adults' health beliefs, should be an integral part of clinical training in mental health. Clinicians can be trained in avoidance of stereotyping, communication and development of attitudes that convey cultural humility when caring for diverse older adults. Additionally, mental health clinicians can benefit from inter-professional education that moves beyond professional silos to facilitate learning about working collaboratively in interdisciplinary, team-based models of mental health care. Finally, familiarity with how lay health workers can be integrated into professional teams, and training to work and supervise them are needed. A growing and diversifying population of older adults and the emergence of innovative models of healthcare delivery present opportunities to alleviate mental health disparities that will require relevant training for the mental health workforce.

Neurometabolites and associations with cognitive deficits in mild cognitive impairment: a magnetic resonance spectroscopy study at 7 Tesla.

The levels of several brain metabolites were investigated in the anterior cingulate cortex (ACC) and posterior cingulate cortex (PCC) in 13 healthy controls (HC) and 13 patients with mild cognitive impairment (MCI) using single-voxel magnetic resonance spectroscopy at 7T. Levels of γ-aminobutyric acid (GABA), glutamate (Glu), glutathione (GSH), N-acetylaspartylglutamate (NAAG), N-acetylaspartate (NAA), and myo-inositol (mI) were quantified relative to total creatine (tCr). The effect of diagnosis on metabolite levels, and relationships between metabolite levels and memory and executive function, correcting for age, were investigated. MCI patients showed significantly decreased GABA/tCr (ACC, PCC), Glu/tCr (PCC), and NAA/tCr (PCC), and significantly increased mI/tCr (ACC). In the combined group, worse episodic verbal memory performance was correlated with lower Glu/tCr (PCC), lower NAA/tCr (PCC), and higher mI/tCr (ACC, PCC). Worse verbal fluency performance was correlated with lower GSH/tCr (PCC). In summary, MCI is associated with decreased GABA and Glu, most consistently in the PCC. Further studies in larger patient samples should be undertaken to determine the utility of 7T magnetic resonance spectroscopy in detecting MCI-related neurochemical changes.