A Pilot Study of Brief, Stepped Behavioral Activation for Primary Care Patients with Depressive Symptoms.

In a prior pilot study with primary care patients experiencing depressive symptoms, we observed positive outcomes for a behavioral activation protocol involving one visit and three calls. We aimed to pilot test a stepped version with flexible numbers of contacts. Fifteen primary care patients scoring 5-14 on the Patient Health Questionnaire-9 engaged in the three-tiered telephone-based intervention: (1) two calls (15-20 min each); (2) one 30-60 min encounter followed by two calls; and (3) one to six calls. Participants completed assessments at pre-treatment, post-treatment, and three months later. Participants improved from baseline to post-treatment and three months later for depressive symptoms, anxiety symptoms, and disability. Most participants (9 of 15) engaged in the first tier only, averaging less than one hour of contact, and reported benefits and high satisfaction. This intervention showed preliminary evidence of feasibility, acceptability, satisfaction, and benefits, warranting further pilot testing with primary care personnel.

Screening and Priority-Setting to Determine Home- and Community-Based Aging Services for Older Floridians.

The National Aging Network serves millions of older Americans seeking home- and community-based services, but places others on waitlists due to limited resources. Little is known about how states determine service delivery and waitlists. We therefore conducted a process evaluation and analyzed data from one five-county Area Agency on Aging in Florida, where an algorithm calculates clients' priority scores for service delivery. From 23,225 screenings over 5.5 years, clients with higher priority scores were older, married, living with caregivers, and had more health problems and needs for assistance. Approximately 51% received services (e.g., meals/nutrition, case management, caregiver support), 11% were eligible/being enrolled, and 38% remained on waitlists. Service status was complex due to multiple service enrollments and terminations, funding priorities, and transfers to third-party providers. More research is needed regarding how other states determine eligibility and deliver services, potentially informing national standards that promote optimal health in older Americans.

Enhancing care transitions intervention with peer support to improve outcomes among older adults with co-occurring clinical depression: a pilot study.

The Care Transitions Intervention (CTI) is an evidence-based intervention aimed at supporting the transition from hospital back to the community for patients to ultimately reduce preventable re-hospitalization. In a pilot randomized controlled trial, we examined the preliminary effectiveness of an Enhanced Care Transitions Intervention (ECTI), CTI with the addition of peer support, for a racially/ethnically diverse sample of older adults (age 60+) with co-morbid major depression. We observed a significant decline in health-related quality of life (HRQOL) after being discharged from the hospital among those who received CTI. Additionally, those who received ECTI either maintained HRQOL scores, or, saw improvement in HRQOL scores. Findings suggest the Enhanced Care Transitions Intervention can maintain or improve HRQOL and reduce disparities for older participants from diverse racial/ethnic backgrounds with clinical depression.

Longitudinal Analysis of Mortality for Older Adults Receiving or Waiting for Aging Network Services.

OBJECTIVES: For older adults screened by an Area Agency on Aging (AAA) in the National Aging Network, we aimed to examine the 12-month mortality rate for wait-listed callers compared with those who received services within 12 months, and to assess whether the mortality rate differed according to how quickly they received services. DESIGN: The design was a longitudinal analysis of 3 years of AAA administrative data, using survival analysis. SETTING: The data source was administrative data from an AAA spanning a five-county region in west central Florida. PARTICIPANTS: All older adults (age 60 y and older) screened for service eligibility from July 15, 2013, to August 15, 2015, who completed initial screening during the study period were included (N = 6288). MEASUREMENTS: The outcome was mortality within 12 months of the initial screening. Covariates included demographics, caregiver status, health status, access to healthcare, and AAA service status. RESULTS: In the first survival analysis, the strongest predictor was waiting for services compared with receiving services; waiting increased the odds to die vs not to die by 141%, after controlling for health status and other covariates. In the second survival analysis, those who received services within 0 to 3 months had a higher mortality risk compared with those who received services within 6 to 9 months or 9 to 12 months. CONCLUSION: Older adults placed on aging service waiting lists may be at a greater risk of mortality within 12 months than those receiving services. Given that rapid receipt of services was less protective than receiving services later, those prioritized to receive services quickly may be at very high risk of adverse outcomes. Findings raise the possibility that aging services may lower mortality, although additional services may benefit those waiting long periods for services, as well as those eligible for services rapidly. Research is needed to replicate and extend these findings. J Am Geriatr Soc 68:519-525, 2020.

One-Visit Behavioral Intervention for Older Primary Care Patients with Mild to Moderate Depressive Symptoms.

OBJECTIVES: We pilot tested a one-visit behavioral intervention with telephone follow-up for older primary care patients with mild to moderate depressive symptoms. METHODS: A total of 16 English-speaking primary care patients aged 60 years and older who scored 5 to 14 on the Patient Health Questionnaire-9 (PHQ-9) engaged in the intervention visit. Outcomes were assessed at baseline and 4 weeks: activity goals, readiness to change (University of Rhode Island Change Assessment), PHQ-9, Generalized Anxiety Disorder-7, World Health Organization Disability Assessment Schedule 2.0, and satisfaction. RESULTS: The 14 participants who completed the study met or exceeded 73% of activity goals on average. They also improved on all outcomes (P < 0.05) with medium (University of Rhode Island Change Assessment, GAD-7) to large effect sizes (PHQ-9, World Health Organization Disability Assessment Schedule 2.0), and they were satisfied. CONCLUSIONS: This pilot study provided preliminary evidence that a one-visit behavioral activation intervention is acceptable and feasible and improves outcomes. If findings are confirmed, then this intervention could be integrated into existing collaborative care programs.

Trajectories of depressive symptoms in community-dwelling older adults: A six-month longitudinal study with monthly assessment.

BACKGROUND: This study aimed to examine six-month trajectories of depressive symptoms and their predictors for community-dwelling older adults. Innovations included monthly assessments, examination of non-linear trajectories, and inclusion of coping styles as predictors. METHOD: Data were derived from a six-month longitudinal study of 144 community-dwelling older adults with depressive symptoms (Short-Geriatric Depression Scale [S-GDS]≥5) with seven waves of data. Descriptive analyses and individual growth curve modeling were conducted. RESULTS: The majority of participants changed symptom levels over time; most participants with severe symptoms at baseline remained at least mildly depressed at six months. Younger participants were more depressed at baseline and improved slightly more than older participants. Those who used more active and emotional support coping had faster improvement and maintained gains, whereas those who used less of these coping styles demonstrated worse symptoms over the six-month follow-up period. LIMITATIONS: The most significant limitations are the convenience sampling methods and relatively small sample size, although the large number of assessments (7 waves) increases precision of the statistical methods used. CONCLUSIONS: Findings suggest that it may be beneficial to target interventions to older adults with more severe depressive symptoms and who display low levels of active and emotional support coping. Behavioral interventions that improve these coping styles may help depressed older adults recover and maintain treatment gains over time.

Drinking behavior among older adults in a planned retirement community: results from The Villages survey.

OBJECTIVES: Research indicates increasing trends among older adults toward heavy and abusive drinking, often associated with depressive symptoms. Possible exceptions are residents of planned retirement communities, whose drinking may be associated with social activities. To better understand these relationships, this study examined the relationship of depressive symptoms and drinking in a large retirement community. METHODS: The Villages, a retirement community in central Florida with a focus on healthy, active living, has almost 90,000 residents. In 2012, a population-based needs assessment was conducted in partnership with University of South Florida Health. In the present study, 11,102 surveys were completed and returned. A structural equation model was utilized to analyze the relationship between depressive symptoms and alcohol use as measured by the three-item Alcohol Use Disorders Identification Test (AUDIT-C). RESULTS: Hazardous drinking was reported in 15.4% of respondents, somewhat higher than the general population of older adults (around 10%). Variables of depressive symptoms, physical activity, total health problems, and poor general health loaded significantly into the factor of depression indicators, which was shown to have a significant, negative correlation with risk of hazardous drinking (λ = 0.16, p < 0.000, R(2) = 0.02). CONCLUSIONS: Results suggest at-risk drinking among respondents was not associated with depression, in contrast to studies of older adults living alone where alcohol abuse was often associated with depression. Implications for successful aging are discussed.

Behavioral Health and Adjustment to College Life for Student Service Members/Veterans.

OBJECTIVE: Increasing numbers of student service members/veterans (SSM/Vs) are enrolling in college. However, little is known about how their previous military experience affects their adjustment to this new role. The present study tested the hypothesis that SSM/Vs who report adjustment problems in college have a higher incidence of posttraumatic stress disorder (PTSD), depression, and other behavioral health problems compared with those who do not report adjustment problems. PARTICIPANTS: SSM/Vs (N = 173) at a large, southeastern, public university completed online surveys that included well-validated screens measuring substance use, depression, PTSD, and other mental disorders. RESULTS: Those reporting difficulties adjusting to university life (28%) reported significantly higher frequencies of behavioral and health problems while in the military, and significantly higher levels of PTSD, depression, and mental health disorders, but no difference in substance use. CONCLUSIONS: Implications for improved behavioral health screening and coordination of university behavioral health services with veterans' health systems are discussed.

Improving home-based providers' communication to primary care providers to enhance care coordination.

OBJECTIVES: Health care system fragmentation is a pervasive problem. Research has not delineated concrete behavioral strategies to guide providers to communicate with personnel in other organizations to coordinate care. We addressed this gap within a particular context: home-based providers delivering depression care management (DCM) to older adults requiring coordination with primary care personnel. Our objective was to pilot test a communication protocol ('BRIDGE - BRinging Inter-Disciplinary Guidelines to Elders') in conjunction with DCM. METHOD: In an open pilot trial (N = 7), home-based providers delivered DCM to participants. Following the BRIDGE protocol, home-based providers made scripted telephone calls and sent structured progress reports to personnel in participants' primary care practices with concise information and requests for assistance. Home-based providers documented visits with participants, contacts to and responses from primary care personnel. A research interviewer assessed participant outcomes [Symptom Checklist-20 (depressive symptoms), World Health Organization Disability Assessment Schedule-12, satisfaction] at baseline, three months, and six months. RESULTS: Over 12 months, home-based providers made 2.4 telephone calls and sent 6.3 faxes to other personnel, on average per participant. Primary care personnel responded to 18 of 22 requests (81.8%; 2 requests dropped, 2 ongoing), with at least one response per participant. Participants' depressive symptoms and disability improved significantly at both post-tests with large effect sizes (d ranged 0.73-2.3). Participants were satisfied. CONCLUSION: Using BRIDGE, home-based providers expended a small amount of effort to communicate with primary care personnel, who responded to almost all requests. Larger scale research is needed to confirm findings and potentially extend BRIDGE to other client problems, professions, and service sectors.

Health risk factors and differences in outcomes between younger and older veterans using VA transitional housing.

OBJECTIVE: This study examined age-related differences in general medical and mental health risk factors for veterans participating in the U.S. Department of Veterans Affairs (VA) Grant Per Diem (GPD) transitional supportive housing program. The subpopulation of older homeless veterans is growing, and little is known about the implications of this fact for health care providers and for supportive programs intended to meet homeless veterans' needs. METHODS: Data were obtained from the VA records of all veterans (N=40,820) who used the GPD program during fiscal years 2003 to 2009. Unconditional adjusted and unadjusted odds ratios for general medical and psychiatric characteristics were calculated and were the primary study focus. Significant predictors of homeless program completion assessed from univariate models were then evaluated in multivariate models. RESULTS: Younger (<55) and older (≥55) homeless veterans reported an equal number of days homeless before enrollment. Younger veterans averaged 19 fewer days in GPD. Older veterans had more general medical problems and approximately $500 more in program costs. CONCLUSIONS: Findings from this study indicate that older homeless veterans are at increased risk of serious medical problems. This group is especially vulnerable to experiencing negative consequences related to homelessness. Addressing these complex needs will allow the VA to provide enhanced care to older homeless veterans.

Elevated movement path tortuosity in voluntary outdoor ambulation in community-dwelling veterans with a history of traumatic brain injury.

OBJECTIVE: In comparison to veterans without a history of traumatic brain injury (TBI), we hypothesized that veterans with past TBI would have slower walking speed and more path tortuosity, TBI symptoms, problems with spatial orientation, and poorer executive function. SETTING: Community nonclinical. PARTICIPANTS: Seventeen males (mean age of 37.2 years) reporting prior TBI and 20 non-TBI (mean age of 42.9 years). The number of years separating date of discharge and testing was 10.8 and 15.4 for the TBI and non-TBI groups, respectively. DESIGN: Small 2 groups without random assignment. MAIN MEASURES: Brief Traumatic Brain Injury Screen, Trail Making Test-B, Clock Drawing Test, walking speed, and distance and path tortuosity in 30 minutes of voluntary outdoor walking wearing a small Global Positioning Systems recorder. RESULTS: Those with TBI reported 4 Brief Traumatic Brain Injury Screen symptoms versus 0.4 for controls (F = 49.1; df = 1,35; P < .001) but did not differ on Trail Making Test-B or the Clock Drawing Test. Veterans with TBI walked shorter distances, 2.33 km versus 2.84 km (F = 4.8; df = 1,35; P < .05), and had greater path tortuosity (fractal D of 1.22 vs 1.15; F = 3.5; df = 1,35; P < .05) but did not differ on travel speed or time spent walking. CONCLUSIONS: Traumatic brain injury has persistent symptomatic effects and significantly affects ambulation and spatial orientation years after the event. These findings corroborate and extend observations linking cognitive impairment and ambulation.

Screening, Brief Intervention, and Referral to Treatment for Older Adults With Substance Misuse.

Objectives. We compared substance use and SBIRT (Screening, Brief Intervention, and Referral to Treatment) services received for older adults screened by the Florida BRITE (BRief Intervention and Treatment of Elders) Project, across 4 categories of service providers. Methods. Staff from 29 agencies screened for substance use risk in 75 sites across 18 Florida counties. Clients at no or low risk received feedback about screening; moderate risk led to brief intervention, moderate or high risk led to brief treatment, and highest severity led to referral to treatment. Six-month follow-ups were conducted with a random sample of clients. Results. Over 5 years (September 15, 2006-September 14, 2011), 85 001 client screenings were recorded. Of these, 8165 clients were at moderate or high risk. Most received brief intervention for alcohol or medication misuse. Differences were observed across 4 categories of agencies. Health educators screening solely within medical sites recorded fewer positive screens than those from mental health, substance abuse, or aging services that screened in a variety of community-based and health care sites. Six-month follow-ups revealed a significant decrease in substance use. Conclusions. The Florida BRITE Project demonstrated that SBIRT can be extended to nonmedical services that serve older adults.

The role of positive alcohol expectancies in underage binge drinking among college students.

OBJECTIVE: This study explored associations between positive alcohol expectancies, and demographics, as well as academic status and binge drinking among underage college students. PARTICIPANTS: A sample of 1,553 underage college students at 3 public universities and 1 college in the Southeast who completed the Core Alcohol and Drug Survey in the Spring 2013 semester. METHODS: A series of bivariate analyses and logistic regression models were used to examine associations between demographic and academic status variables as well as positive alcohol expectancies with self-reported binge drinking. Positive alcohol expectancies were examined in multivariable models via 2 factors derived from principal component analyses. RESULTS: Students who endorsed higher agreement of these 2 emergent factors (sociability, sexuality) were more likely to report an occurrence of binge drinking in the past 2 weeks. CONCLUSIONS: Study results document associations between positive alcohol expectancies and binge drinking among underage students; implications for prevention and treatment are discussed.

College students who endorse a sub-threshold number of DSM-5 alcohol use disorder criteria: alcohol, tobacco, and illicit drug use in DSM-5 diagnostic orphans.

OBJECTIVES: Diagnostic orphans (DOs) represent a group of individuals with no formal diagnosis, despite endorsing some criteria of an alcohol use disorder (AUD). Prior research has indicated that rates of DSM-IV DOs in college are high and closely resemble those with an alcohol abuse diagnosis across pertinent alcohol use risk factors. However, significant changes to the DSM-IV AUD criteria have been made for the current DSM-5 manual, which may impact how DOs are classified. This study examined the unique alcohol and illicit drug use characteristics of a group of 2,620 DSM-5 DOs in college and tested whether DOs differed from those with and without a DSM-5 AUD across pertinent alcohol and drug use risk factors. METHODS: Participants were 2,620 DSM-5 DO undergraduate college students, between the ages of 18 and 30, recruited from three public universities in the Southeastern, United States. RESULTS: Diagnostic orphans represented 19.6% (n = 506) of the sample; with the most frequently endorsed criteria being tolerance and consuming alcohol in hazardous situations. DOs reported significantly greater alcohol consumption, alcohol and drug related problems, and illicit drug use compared to those with no DSM-5 AUD diagnosis. Alternatively, DOs reported significantly lower alcohol use and illicit drug use compared to those with a DSM-5 AUD. CONCLUSION: The present findings indicate that DSM-5 DOs in college represent a distinct group of drinkers relative to those with and without a DSM-5 AUD. Current screening initiatives should target this group to prevent future escalation of problem drinking.

Six-month utilization of psychotherapy by older adults with depressive symptoms.

We explored psychotherapy utilization patterns for community-dwelling older adults with depressive symptoms identified during a statewide initiative designed for identifying risk of substance misuse. Individuals screening negative for substance misuse, but positive for depressive symptoms, agreed to participate in monthly interviews conducted over 6 months (n = 144). Results showed that 39 (27%) received psychotherapy, of which nearly two-thirds reported four or fewer visits. Mental health counselors were the most frequently reported service providers (50-62.5%). Location of service varied considerably. This study documents low rates of psychotherapy use and few visits. Current efforts to increase psychotherapy access are discussed.

Testing the Assumption of Measurement Invariance in the SAMHSA Mental Health and Alcohol Abuse Stigma Assessment in Older Adults.

This study examined the assumption of measurement invariance of the SAMSHA Mental Health and Alcohol Abuse Stigma Assessment. This is necessary to make valid comparisons across time and groups. The data come from the Primary Care Research in Substance Abuse and Mental Health for Elderly trial, a longitudinal multisite, randomized trial examining two modes of care (Referral and Integrated). A sample of 1,198 adults over the age of 65 who screened positive for depression, anxiety, and/or at-risk drinking was used. Structural equation modeling was used to assess measurement invariance in a two-factor measurement model (Perceived Stigma, Comfort Level). Irrespective of their stigma level, one bias indicated that with time, respondents find it easier to acknowledge that it is difficult to start treatment if others know they are in treatment. Other biases indicated that sex, mental quality of life and the subject of stigma had undue influence on respondents' feeling people would think differently of them if they received treatment and on respondents' comfort in talking to a mental health provider. Still, in the present study, these biases in response behavior had little effect on the evaluation of group differences and changes in stigma. Stigma decreased for patients of both the Referral and Integrated care groups.

Reasons for psychiatric medication prescription for new nursing home residents.

OBJECTIVES: This article focuses on justification of psychoactive medication prescription for NH residents during their first three months post-admission. METHOD: We extracted data from 73 charts drawn from a convenience sample of individuals who were residents of seven nursing homes (NHs) for at least three months during 2009. Six focus groups with NH staff were conducted to explore rationales for psychoactive medication usage. RESULTS: Eighty-nine percent of the residents who received psychoactive medications during the first three months of residence had a psychiatric diagnosis, and all residents who received psychoactive medications had a written physician's order. Mental status was monitored by staff, and psychoactive medications were titrated based on changes in mental status. One concern was that no Level II Preadmission Screening and Annual Resident Review (PASRR) evaluations were completed during the admissions process. Further, while 73% had mental health diagnoses at admission, 85% of the NH residents were on a psychoactive medication three months after admission, and 19% were on four or more psychoactive medications. Although over half of the residents had notes in their charts regarding non-psychopharmacological strategies to address problem behaviors, their number was eclipsed by the number receiving psychopharmacological treatment. CONCLUSIONS: While the results suggest that NHs may be providing more mental health care than in the past, psychopharmacological treatment remains the dominant approach, perhaps because of limited mental health training of staff, and lack of diagnostic precision due to few trained geriatric mental health professionals. A critical review of the role of the PASRR process is suggested.

Attitudes toward mental health services in Hispanic older adults: the role of misconceptions and personal beliefs.

Focusing on misconceptions and personal beliefs associated with depression, the present study explored predictors of attitudes toward mental health services in a sample of 297 Hispanic older adults living in public housing (M age = 76.0 years, SD = 7.74). Results from a hierarchical regression analysis showed that negative attitudes towards mental health services were predicted by advanced age, belief that having depression would make family members disappointed, and belief that counseling brings too many bad feelings such as anger and sadness. Findings suggest that interventions designed to promote positive attitudes toward mental health services of older Hispanics should address misconceptions and personal beliefs.

Six-month longitudinal patterns of mental health treatment utilization by older adults with depressive symptoms.

OBJECTIVE: Aims of the study were to describe behavioral health treatment utilization patterns of community-dwelling older adults with depressive symptoms over a six-month period and to identify factors associated with treatment use, guided by a theoretical model emphasizing the dynamic nature of treatment use patterns over time and social context. METHODS: A total of 144 participants ≥65 years old with depressive symptoms completed an in-person baseline interview and six monthly telephone follow-up interviews. Outcomes at each follow-up included the use of antidepressants or counseling. Covariates included personal and social context variables. RESULTS: Approximately half of the participants (N=70, 48%) received no formal treatment (antidepressant prescription or counseling). Treatment use or nonuse did not change for most participants. More participants with severe symptoms received antidepressants (25%-37%) than did those with milder symptoms (10%-14%), although more participants in the latter group started (milder, 62%,versus severe, 49%) and stopped (milder, 77%, versus severe, 26%) antidepressant treatment at least once. Fewer individuals received counseling overall, with no clear patterns by symptom severity. In multivariate longitudinal analyses, treatment use at follow-up was independently associated with younger age, current major depressive episode, baseline use of antidepressant, intention to begin a new treatment at baseline, and receipt of advice to seek treatment. CONCLUSIONS: Over a six-month period, most older adults with depressive symptoms in this study continued their use or nonuse of mental health treatment. Demographic, need, attitudinal, and social variables were related to treatment use over time. Addressing intentions and providing advice may facilitate treatment seeking.

Factors associated with mental health service use in Latino and Asian immigrant elders.

OBJECTIVES: The purpose of this study was to examine factors associated with the mental health service use of Latino and Asian immigrant elders. Adapting Andersen's behavioral health model of health service utilization, predisposing, enabling, and mental health need factors were considered as potential predictors for use of mental health services. METHOD: Data were drawn from a nationally representative dataset, the National Latino and Asian American Survey (NLAAS). Hierarchical logistic regression analyses of mental health service use were conducted for Latino (N = 290) and Asian (N = 211) immigrant elders. RESULTS: For both groups of immigrant elders, poor self-rated mental health was associated with significantly greater mental health service use, even after controlling for all other variables. For Latinos, use of mental health services was significantly associated with both predisposing factors (being younger and female) and mental health need factors (having any mood disorders and poor self-rated mental health). Among Asians, only mental health need factors (having any mood disorders and poor self-rated mental health) significantly affected mental health service use. In addition, poor self-rated mental health mediated the association between mood disorders and mental health service use only in Latino immigrant elders. CONCLUSION: Results highlight an important role of self-rated mental health as a potential barrier in the use of mental health services, and suggest intervention strategies to enhance service use.