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To examine the prevalence and treatment of diagnosed depression among elderly nursing home residents and determine the resident and facility characteristics associated with diagnosis and treatment.
Documented depression, pharmacotherapy, psychotherapy, sociodemographics, and medical characteristics were obtained from Ohio's Minimum Data Set for 76 735 residents in 921 nursing homes. The data were merged with Online Survey Certification and Reporting System data to study the impact of facility characteristics. Chi-squared statistics were used to test group differences in depression diagnosis and treatment. Multiple logistic regressions were used to examine the prevalence of diagnosed depression, and among those diagnosed, of receiving any treatment.
There were 48% of residents who had an active depression diagnosis; among those diagnosed, 23% received no treatment; 74% received antidepressants; 0.5% received psychotherapy; and 2% received both. African Americans, the severely cognitively impaired, and those in government facilities were less likely to be diagnosed. Residents aged 85 and older, African Americans, individuals with severe mental illness, those with severe ADL or cognitive impairment, and individuals living in a facility with 4 or more deficiencies were less likely to receive treatment.
Significant disparities exist both in diagnosis and treatment of depression among elderly residents. Disadvantaged groups such as African Americans and residents with physical and cognitive impairments are less likely to be diagnosed and treated. Our results indicate that work needs to be done in the nursing home environment to improve the quality of depression care for all residents.
Depression is the most burdensome and prevalent mental illness among nursing home (NH) residents.1–3 If untreated, inadequately treated, or unresponsive to treatment, depression can lead to a cascade of other adverse health outcomes such as malnutrition, poor hydration, weakening from physical inactivity, functional decline, decreased quality of life, and ultimately, death.1–6 Among NH residents, prior studies have reported estimates of the prevalence rate for depression (variously defined to include major depressive disorder, other depression diagnoses and/or depressive symptoms) to range from 11% to 78%.7–13 Rates in these NH studies were substantially higher than rates for community-dwelling elderly individuals.1,14–16 Despite this consistent evidence of high rates of underlying depressive symptomatology, we lack sufficient understanding of the extent to which depression among residents is identified by facilities, the predictors of facility-identified depression, and the extent to which treatment is provided for identified depression. Generally, in prior studies, depression among NH residents has been reported to be substantially underdiagnosed8,11,15 and undertreated8,17–20 or inadequately treated.8,20–22 However, as there is rapid evolution of depression identification and treatment patterns among the community-dwelling near-elderly and elderly,23,24 as well as disparities in such care, depression care in nursing homes may be a moving target. To inform efforts at quality improvement, it is important to examine recent patterns of depression identification and treatment in routine care across the full spectrum of nursing homes.
Improving care for depression among NH residents has been a widely acknowledged goal dating back to the 1987 Omnibus Budget Reconciliation Act (OBRA) nursing home reforms.25 In reviewing priorities for quality of care, improvement for vulnerable adults such as those in nursing homes, an expert panel ranked improvement of depression care second only to the overall issue of improved pharmacologic management among 78 conditions and problems considered.26 Similar recommendations were highlighted in the first National Healthcare Quality Report, released by AHRQ in 200327 and in the 2003 American Geriatrics Society/American Association for Geriatric Psychiatry Consensus Statement on Improving the Quality of Mental Health Care in US Nursing Homes.3 Yet many issues remain unresolved regarding adequacy of depression-related care in NHs such as unequal access to specialty care, length of persistent use of antidepressants and proper dosing of antidepressants,21,28 and information on many topics is outdated.
Antidepressants have been shown to be safe and efficacious in the treatment of geriatric depression1,3,9,29 and have been widely used in the nursing home population.3,21,29–36 Psychotherapy constitutes an alternative modality, particularly when antidepressant treatment is not acceptable to residents or their families, a situation that may be more frequent for African American elders.37
One critical issue in the care of NH residents with depression is the role of mental health specialists such as psychiatrists or psychologists. Psychiatric evaluation can be important in differential diagnosis and optimizing use of psychotropic treatment, including adjustment of regimens and dosages for initially unresponsive residents, and decisions on need for psychiatric hospitalization. In their 2003 consensus statement, the American Geriatrics Society and American Association for Geriatric Psychiatry recommended that residents who have depression with psychotic features who have not responded to 6 or more weeks of treatment be referred to mental health professionals.3
Surprisingly little information is available about the extent and predictors of mental health services use for depressed NH residents; disparities in such care; and variations across facilities.18,19 Greater prevalence of identified depression among nursing home residents has been shown to be associated with younger age, being female, having ever been married, white non-Hispanic ethnicity, higher cognitive function, heart disease, and Parkinson's disease,7 using data from the 1996 Medical Expenditure Panel Survey-Nursing Home Component.
Although dated, the few prior studies on this topic indicate low overall rates of specialty care use; sharp disparities by race/ethnicity, age, and other socioeconomic factors; and very limited access to care in rural areas.18,24,38 Residents 85 and older, those with severe cognitive impairment, and black residents were less likely to receive antidepressants once depression has been identified.8 Residents who receive care from mental health specialists tend to be younger; live in the Northeast; and have schizophrenia, dementia, or other mental disorder.17 Other results report that residents with depression, schizophrenia, or psychosis are more likely to receive specialist mental health services, while those with more ADL (activities of daily living) limitations, and older residents, as well as those residing in government NHs, or homes run by chains, are less likely to receive specialist mental health services.18,19
While geriatric depression has traditionally been considered much underdiagnosed, Crystal and colleagues recently reported that the depression diagnosis rate more than doubled among community-dwelling elderly individuals between 1992 and 1998, increasing by 107%,23 with concomitant increases in antidepressant use. Rapidly evolving patterns of depression identification and treatment in the NH setting create a critical need for more current analyses. In this study, we used a merged Minimum Data Set (MDS) and online Survey Certification and Reporting (OSCAR) data set to assess the prevalence of diagnosed depression among elderly nursing home residents, and subsequently, to examine the rate of treatments (pharmacotherapy and psychotherapy) they received. Additionally, we examined whether disparities in diagnosis and treatment exist and described how both resident-and facility-level characteristics are associated with such differences.
In this study, the 2000 Ohio Long-term Care MDS was used as the source of NH resident information. These data were merged with the OSCAR data to obtain nursing home facility characteristics. The research protocol was approved by Rutgers, the State University of New Jersey's Institutional Review Board. The MDS is a nationally standardized 350-item summary screening and assessment tool designed to collect data on nursing home residents including their physical, psychological, and psychosocial functioning, active clinical diagnoses, health conditions, treatments and services received, demographics, payer source, and advance directives.39 All Medicare- and Medicaid-certified nursing facilities are required to use the MDS to assess each resident, first upon admission and then on a quarterly and annual basis and when there is “significant change” in the resident's health status and needs.40 OSCAR is a uniform computerized database maintained by the Centers for Medicaid and Medicare Services (CMS) containing information on all Medicare/Medicaid-certified NHs including facility characteristics and staffing data; aggregated resident characteristics; and survey deficiencies. The information in OSCAR is collected by state licensure and certification agencies as part of the yearly Medicare/Medicaid certification process.
In the current study, the sample includes all residents 65 or older who had been in an Ohio NH for at least 3 months in 2000, but excluded those who were comatose or those living in a hospital-based NH, as research has suggested that hospital-based nursing homes might have a different case-mix than freestanding ones.41–43 When there was more than one assessment for each resident within the year, we chose the assessment closest to the end of the year. Facility characteristics were drawn from the OSCAR data closest to the MDS assessment date. The final sample included 76 735 residents in 921 nursing homes.
A resident was considered to have diagnosed depression on an MDS assessment (Section Iee. Disease Diagnoses: Depression) if there was an “active” physician-documented depression diagnosis in the resident's clinical record using a 7-day look-back period. An “active” diagnosis is defined as having “a relationship to current ADL status, cognitive status, mood and behavior status, medical treatments, nursing monitoring, or risk of death.”40
Our analysis showed that among residents without a depression diagnosis, 15% received antidepressant therapy and 1.3% received psychotherapy (data not shown). Some of these individuals may have unrecorded depression, but these treatments are also widely used for conditions or symptoms other than depression. Because the objective of the current study was to examine the pattern of treatment among depressed residents, we focused on the treatment (antidepressant and/or psychotherapy) received by residents with diagnosed depression. Depression treatment was defined dichotomously as any antidepressant, psychosocial therapy, or group therapy received by the resident during the 7 days prior to the assessment. Our analysis showed that among those who received depression treatment, less than 1% had psychotherapy as the sole mode of treatment. Given that such a small portion of the depressed elderly residents received psychotherapy as their sole treatment, we determined that it is more meaningful to combine antidepressant therapy and psychotherapy together to examine any treatment as our outcome of interest, rather than to conduct separate analyses of antidepressant therapy and psychotherapy. Because of the low proportion of residents receiving psychotherapy only, our findings on predictors of treatment are dominated by variations in antidepressant use.
Sociodemographic characteristics included resident's gender, age (categorized as 65 to 74, 75 to 84, and 85 or older to allow for nonlinear age effects), race/ethnicity (white, African American, and other), education level (less than high school, high school graduate, and college graduate or above), and marital status at assessment (never married, married, widowed, and separated/divorced).
Physical and mental comorbidities were extracted from the Disease Diagnoses section of the MDS. Individual physical comorbidities were summed to create a summary measure of burden of physical comorbidity, which included arthritis, diabetes, hypertension, cancer, stroke, congestive heart failure, and chronic obstructive pulmonary disease (COPD). The number of conditions was categorized into none, 1–2, 3–4, and 4+. Comorbid severe mental illness (SMI) was defined as having an active diagnosis of schizophrenia or bipolar disorder. Physical function was measured using the hierarchical activities of daily living (ADL) scale developed and validated by Morris et al44 using 7 MDS ADL self-performance variables. Chronic cognitive impairment was constructed using the Cognitive Performance Scale, which assigns residents into cognitive performance categories (from intact to severely impaired).
Nursing home size was measured by number of beds (categorized as less than 50, 50–99, 100–199, and 200+), occupancy rate (percentage of beds occupied on the day of the survey), and NH location (rural or urban). Ownership type was classified into government, for profit, or not for profit, and Medicaid ratios represent the proportion of residents whose care was paid for by Medicaid. We also distinguished NHs that had a multifacility chain affiliation from freestanding facilities. Another dichotomous control variable was provision of onsite mental health services. Staffing was measured as total nursing hours (RNs, LPNs, and NAs) per resident per day. Aggregate facility acuity level was measured with an acuity index that is a sum of an ADL index (proportion of residents dependent in eating, toileting, transferring, ambulation) and a special treatments index (proportion of residents requiring respiratory care, suctioning, IV therapy, tracheostomy care, or parenteral feeding).45–47 Since occupancy rates, total nursing hours, Medicaid ratios and the acuity index were not distributed uniformly across their range, we categorized the rates into quartiles. Data on facility deficiencies represent the number of deficiencies recorded in OSCAR across the 17 major areas used in the survey process,48 categorized into 0–2, 3–4, and greater than 4 deficiencies, to allow for nonlinear effects.
Bivariate group differences in rates of outcomes (diagnosis of depression and any treatment among those diagnosed with depression) were tested across resident and facility characteristics using chi-square analyses. Robust multiple logistic regressions were then performed to determine the adjusted effects of the covariates on a resident's probability of receiving a depression diagnosis, and if depressed, on the probability of receiving any treatment (antidepressant only, psychotherapy only, or both antidepressant therapy and psychotherapy). Both the bivariate analysis and logistic regressions adjusted for clustering of residents within facilities and were done using SAS-callable SUDAAN V8.0.49
The characteristics of Ohio elderly nursing home residents in 2000 are presented in the first 2 columns of Table 1. Most were female (75%), white (89%), and widowed (64%). Physical comorbidity was prevalent, with 90% having at least 1 chronic physical illness. Over 75% were dependent in ADL activities, and 81% had at least some cognitive impairment. The model resident lived in a for-profit (74%) facility in an urban area (78%) with 100 to 199 (62%) residents.
Table 1 shows the prevalence of diagnosed depression among residents by sociodemographic characteristics as well as the characteristics of the facility in which they lived. Forty-eight percent of the elderly residents (N = 36 888) were documented as having a depression diagnosis. Bivariate analyses showed that rates of depression diagnosis varied significantly by most of the resident characteristics including gender, age, race/ethnicity, education, marital status, presence of physical comorbid conditions, ADL status, and cognitive impairment status. However, only 2 facility characteristics (percentage of residents in the facility with Medicaid as the primary payer, and number of facility deficiencies) showed significant differences in the bivariate analyses. Results from the multiple logistic regression on diagnosis of depression confirmed the results from the bivariate analysis. When controlling for other factors, being female, having higher education achievement, and ever being married were associated with significantly higher likelihood of being diagnosed with depression. African Americans were about half as likely as whites to have a depression diagnosis (OR = 0.52, 95% CI = [0.48, 0.57]). Older age was also associated with lower likelihood of having a depression diagnosis (aged 75–84: OR = 0.91, 95% CI = [0.87, 0.95]; aged 85 and older: OR = 0.66, 95% CI = [0.63, 0.70]). While physical comorbidity was associated with higher odds of being diagnosed with depression, comorbid SMI did not have a significant impact. Compared to elderly residents independent in ADLs, those who were dependent, but not totally dependent, were more likely to be diagnosed with depression (OR = 1.32, 95% CI = [1.21,1.44]). The impact of cognitive impairment on the odds of receiving a depression diagnosis was not monotonic, with odds of diagnosis highest among those with some impairment, lowest among those with severe impairment, and intermediate among those with no impairment.
Similar to the results from the bivariate analyses, few facility characteristics had impact on the resident's likelihood of being diagnosed with depression. Residents in facilities with the highest quartile of total nursing hours per resident per day were more likely to have a depression diagnosis than those in the lowest quartile (OR = 1.09, 95% CI = [1.01, 1.18]). Residents living in government-owned facilities were significantly less likely to be diagnosed with depression than those in for-profit facilities (OR = 0.88, 95% CI = [0.78, 0.99]). Residents in facilities with a high number of deficiencies (8+) were less likely to be diagnosed with depression than those in facilities with a very low number of deficiencies (0–2) (OR=0.92, 95% CI = [0.86, 0.99]).
Table 2 presents results on the rates of any depression treatment (antidepressant and/or psychotherapy or group therapy) received by elderly residents diagnosed with depression. In general, 77% received either an antidepressant or psychotherapy within the 7 days prior to the assessment. The bivariate analyses of any treatment showed that significant subgroup differences exist for all of the resident variables. Older age, minority race/ethnicity, comorbid SMI, total ADL dependence, and severe cognitive impairment were associated with significantly lower rates of depression treatment, while higher educational achievement, ever being married, and physical comorbidities were associated with significantly higher treatment rates. Similar to the findings on the depression diagnosis, few facility characteristics, except for percentage of residents with Medicaid as primary payer and number of deficiencies, had significant impact on treatment rates.
Multiple logistic regression results on any use were consistent with these findings. When controlling for other factors, compared to their counterparts, older residents (aged 75–84: OR = 0.90, 95% CI = [0.82, 0.97]; aged 85 and oldr: OR = 0.71, 95%CI = [0.65, 0.77]), African Americans (OR = 0.80, 95% CI = [0.72, 0.89]), residents with SMI (OR = 0.75, 95% CI = [0.68, 0.93]), residents with total ADL dependence (OR = 0.50, 95% CI = [0.42, 0.60]), and residents with severe cognitive impairment (OR = 0.60, 95% CI = [0.54, 0.66]) were significantly less likely to receive depression treatment, while residents with higher education (high school: OR = 1.07, 95% CI = [1.01, 1.14]; college and above: OR = 1.12, 95% CI = [1.03, 1.22]), married or widowed residents (OR = 1.22, 95% CI = [1.09, 1.36], and OR = 1.16, 95% CI = [1.05, 1.29]), and more comorbid physical conditions were associated with significantly higher odds of receiving any treatment. The only facility characteristic that was significant in the regression was the number of deficiencies. Compared with residents living in facilities with 0 to 2 deficiencies, those living in facilities with 5 or more deficiencies were significantly less likely to be treated.
In this paper, we described patterns of identification of depression (diagnosis) and its treatment among long-stay nursing home residents aged 65 and older. We also determined characteristics of residents and facilities that predict whether a resident received a depression diagnosis and subsequent treatment.
Our results indicate that the oldest-old are approximately a third less likely than those age 65 to 75 to be diagnosed; those with very severe cognitive impairment are a third less likely to be diagnosed than cognitively intact residents; and African Americans are half as likely as whites to be diagnosed with depression. It is beyond the scope of this paper to determine the relative contribution to these differences of differential underdiagnosis (or overdiagnosis), versus actual variations in rates of depression. Results also indicate that residents in facilities with more than 4 deficiencies were less likely to be diagnosed with depression.
There are also significant disparities in the likelihood of treatment for identified depression, with those who are cognitively impaired, non-white, and those with more ADL dependency being less likely to receive treatment among persons diagnosed with depression. There is a pressing need to better understand why those who are more physically and psychologically dependent are less likely to receive treatment, and to address these disparities. What, for example, are the roles of resident and family preferences; residents' physicians; nursing staff; consultant pharmacists; and other actors in decisions on treatment? What are the most appropriate measures of depression care quality for use as benchmarks for quality improvement? Does depression manifest itself in different ways among African American residents, and what other factors are involved in the lower rates of identified depression and, once identified, of depression treatment among these residents?
Much more research is needed on the identification and treatment of depression among nursing home residents. Ideally, such research would use data that combine independent, structured researcher assessments of underlying depression symptoms with detailed information on facility recognition and treatment; however, few such data are available on large, recent, generalizable populations of facilities. Existing data such as the MDS provide important clues, but are subject to significant limitations. One limitation of using the MDS as a data source is that treatments (antidepressant and/or psychotherapy) received by the resident were examined only during the seven days prior to the assessment, and no detailed pharmaceutical data were reported, such as medication name and dosage. Among NH residents generally, both for those diagnosed with depression and those who are not, psychotherapy was received rather infrequently. A possible explanation may be that antidepressant therapy is cheaper and easier to administer than psychotherapy. The low frequency of psychotherapy is not unexpected in this population because many nursing homes do not directly employ or contract with psychiatrists or other mental health professionals. Also, as psychotherapy was not likely to be provided on a daily basis, the 7-day look-back period using MDS data limited our ability to identify psychotherapy users.
Additionally, more information about the types of treatment that residents receive would improve the study. The antidepressants as a class are recorded on the MDS, but we did not have access to particular drug names and also did not know much about the type of or reasons for pharmacotherapy offered (whether it was to treat depression; whether a resident receives an antidepressant because of sleep problems; whether a resident is prescribed a stimulant for depressive symptoms; whether the resident is on hospice; whether a resident has been offered therapies other than antidepressants; and whether a resident has a strong social network). We are able to identify the total number of medications that a resident is taking, but do not know the type of concomitant medications.
Depression is often underrecognized or undertreated because it occurs in the context of other physical and social problems9,29 especially when age is often accompanied by social isolation, withdrawal, prolonged bereavement, and economic problems.51 It is well established that psychiatric disorders such as depression tend to co-occur with chronic general medical illnesses. Functional impairment and comorbidity, both physical and mental, are likely to have an effect on treatment and diagnosis of depression, although through opposing mechanisms. On the one hand, it is likely that patients with many comorbidities may have stronger ties to the health care system and may be more likely to view psychological distress as a medical problem. They may be more likely to receive a depression diagnosis because of their more frequent interaction with health care professionals. Conversely, depression may be undertreated because providers may be concerned about the side effects or interaction of the antidepressants with one or more other pharmacological treatments the patient is receiving for his or her comorbid conditions.23
Another limitation of our study is the lack of specificity in the diagnosis and treatment of depression as indicated on the MDS. Our results indicate the prevalence of depression among NH residents as documented in the MDS as 48%, which is fairly high, compared to a study that found fewer than 20% of residents to have major depression (as measured through direct resident interview via the Geriatric Depression Scale) or symptoms of depression.11 Our relatively high prevalence rate may be due to the way in which depression is measured in the MDS as our study relies on a documented depression diagnosis in the MDS assessment, but providers may enter a diagnosis of depression on a resident's chart for a range of depressive disorders from mild depression that may accompany other comorbid conditions afflicting elderly nursing home residents to more serious cases of major depression. More detail on the type and severity of the depression as well as the type of pharmacotherapy offered would be useful, but since the MDS is our sole data source for resident variables and we did not have access to MDS Section U (specific medication name and dose), our specification of both diagnosis and treatment is limited to that information that is captured in routine MDS assessments.
With systemwide automated reporting of MDS data now in place, new opportunities exist to use these data to address important research needs as well as for regulation and quality improvement of nursing facilities. The Center for Health Systems Research and Analysis (CHSRA) originally developed quality indicators for use by individual facilities for quality improvement efforts including 2 depression measures: the prevalence of symptoms of depression and the prevalence of depression without antidepressant therapy. These indicators are used in connection with the survey process and for internal quality improvement. Prevalence of symptoms of depression and prevalence of depression with no antidepressant therapy have been used as 1 of 24 MDS quality indicators that individual facilities can have been using for quality improvement efforts since the late 1990s50; however, depression measures were not included among the original publicly reported quality measures for nursing home residents on the Centers for Medicare and Medicaid (CMS) Web page: Nursing Home Compare (www.cms.gov). Following the National Quality Forum recommendations in 2003, percent of residents who have become more depressed or anxious was added to Nursing Home Compare beginning in January 2004. The data used in this study are from 2000–2001 Ohio MDS data when MDS data were newly automated and depression was not yet publicly reported on the CMS Nursing Home Compare web site. Future research should address longitudinal changes in documentation of depression throughout this period to assess whether changes in public reporting has an impact on the reliability and validity of the documentation of depression diagnoses and symptoms on individual resident MDS assessments.
Our finding that elderly depressed residents with some cognitive impairment were as likely to receive psychotherapy as those with intact cognitive ability was consistent with findings from Abraham et al,51 who reported that residents with mild to moderate cognitive impairment were likely to benefit from psychotherapy. Nevertheless, further analyses linking the MDS to Medicaid or Medicare claims would certainly allow for more detailed exploration of initialization and persistence in pharmacotherapy and psychotherapy among nursing home residents.
The cross-sectional design is another limitation of this study. Data used in this analysis are a snapshot of long-stay residents and do not support analysis of longitudinal results. We do not know whether a resident's depression is chronic, or if his or her depression diagnosis represents a new episode. Our analyses were limited to long-stay residents who had been in the facility for at least 3 months; short-stay residents were excluded. We made no attempt to compare results between residents who were long versus short-stay. These are topics for future research. Finally, our results represent nursing home residents in only one state and therefore may not be generalizable to the whole nation.
Despite these limitations, our findings tend to dispel the longstanding belief that depression is substantially underdiagnosed and undertreated among NH residents. Our findings indicate a very substantial rate both of depression identification and of antidepressant treatment for depression among NH residents, perhaps as a result of general increases in awareness of depression among the elderly, and of the positive potential of available treatments. However, many questions are left unanswered. Do lower treatment rates for cognitively impaired individuals signify appropriate treatment, or that this subpopulation of NH residents is being undertreated? Is depression care quality related to other measures of quality, as suggested by the association between number of deficiencies and lower treatment rates? And with relatively high rates of depression, treatment now common in nursing home settings, how successful are these treatments in improving outcomes for residents? Further work needs to be done to assess the quality of depression care in nursing homes to determine the optimal treatment for all NH residents.
Funded by National Institute of Mental Health Grant 1-RO1 MH076206 and AHRQ Grant R24-HS011825.