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2.  REDUCING SUICIDAL IDEATION AND DEPRESSION IN OLDER PRIMARY CARE PATIENTS: 24-MONTH OUTCOMES OF THE PROSPECT STUDY 
The American journal of psychiatry  2009;166(8):882-890.
Objective
The PROSPECT Study evaluated the impact of a care management intervention on suicidal ideation and depression in older primary care patients. This is the first report of outcomes over a 2-year period.
Method
The subjects (N=599) were older (>=60 years) patients with major or minor depression selected after screening 9,072 randomly identified patients of 20 primary care practices randomly assigned to the PROSPECT intervention or usual care. The intervention consisted of services of 15 trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 24 months.
Results
Intervention patients had a higher likelihood to receive antidepressants and or psychotherapy (84.9–89% vs. 49–59%) and a 2.2 times greater decline in suicidal ideation than usual care patients over 24 months. Treatment response occurred earlier in intervention patients and continued to increase from the 18th to the 24th month, while there was no appreciable increase in usual care patients during the same period. Among patients with major depression, a greater number achieved remission in the intervention than the usual care group at 4 (26.6 vs. 15.2%), 8 (36% vs. 22.5%), and 24 (45.4% vs. 31.5%) months. Patients with minor depression had favorable outcomes regardless of treatment assignment.
Conclusions
Sustained collaborative care maintains high utilization of antidepressant treatment, reduces suicidal ideation, and improves the outcomes of major depression over two years. These observations suggest that sustained collaborative care increases depression-free days.
doi:10.1176/appi.ajp.2009.08121779
PMCID: PMC2838419  PMID: 19528195
Geriatric psychiatry; Outcome Studies; Suicide; Mood Disorders-Unipolar
3.  Using a Bayesian latent growth curve model to identify trajectories of positive affect and negative events following myocardial infarction 
Biostatistics (Oxford, England)  2005;6(1):119-143.
Summary
Positive and negative affect data are often collected over time in psychiatric care settings, yet no generally accepted means are available to relate these data to useful diagnoses or treatments. Latent class analysis attempts data reduction by classifying subjects into one of K unobserved classes based on observed data. Latent class models have recently been extended to accommodate longitudinally observed data. We extend these approaches in a Bayesian framework to accommodate trajectories of both continuous and discrete data. We consider whether latent class models might be used to distinguish patients on the basis of trajectories of observed affect scores, reported events, and presence or absence of clinical depression.
doi:10.1093/biostatistics/kxh022
PMCID: PMC2827342  PMID: 15618532
Cardiovascular disease; Depression; DIC; General growth mixture modeling; Gibbs sampling; Label switching; Model choice
4.  Remission in Depressed Geriatric Primary Care Patients: A Report From the PROSPECT Study 
The American journal of psychiatry  2005;162(4):718-724.
Objective
This study compared time to first remission for elderly depressed patients in primary care for practices that implemented a care management model versus those providing usual care. In addition, it sought to identify risk factors for nonremission that could guide treatment planning and referral to care managers or specialists.
Method
Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) data were analyzed. Participants were older patients (≥60 years) selected following screening of 9,072 randomly identified primary care patients. The present analysis examined patients with major depression and a 24-item Hamilton Depression Rating Scale score of 18 or greater who were followed for at least 4 months (N=215). Primary care practices were randomly assigned to offer the PROSPECT intervention or usual care. The intervention consisted of services of trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 18 months.
Results
First remission occurred earlier and was more common among patients receiving the intervention than among those receiving usual care. For all patients, limitations in physical and emotional functions predicted poor remission rate. Patients experiencing hopelessness were more likely to achieve remission if treated in intervention practices. Similarly, the intervention was more effective in patients with low baseline anxiety.
Conclusions
Longitudinal assessment of depression, hopelessness, anxiety, and physical and emotional functional limitations in depressed older primary care patients is critical. Patients with prominent symptoms or impairment in these areas may be candidates for care management or mental health care, since they are at risk for remaining depressed and disabled.
doi:10.1176/appi.ajp.162.4.718
PMCID: PMC2803683  PMID: 15800144
5.  Stigma and the Acceptability of Depression Treatments Among African Americans and Whites 
Journal of General Internal Medicine  2007;22(9):1292-1297.
BACKGROUND
Stigma is associated with depression treatment, however, whether stigma differs between depression treatment modalities is not known, nor have racial differences in depression treatment stigma been fully explored.
OBJECTIVE
To measure stigma for four depression treatments and estimate its association with treatment acceptability for African Americans and whites.
DESIGN
Cross-sectional, anonymous mailed survey.
PARTICIPANTS
Four hundred and ninety African-American and white primary care patients.
MEASUREMENTS
The acceptability of four depression treatments (prescription medication, mental health counseling, herbal remedy, and spiritual counseling) was assessed using a vignette. Treatment-specific stigma was evaluated by asking whether participants would: (1) feel ashamed; (2) feel comfortable telling friends and family; (3) feel okay if people in their community knew; and (4) not want people at work to know about each depression treatment. Sociodemographics, depression history, and current depressive symptoms were measured.
RESULTS
Treatment-specific stigma was lower for herbal remedy than prescription medication or mental health counseling (p < .01). Whites had higher stigma than African Americans for all treatment modalities. In adjusted analyses, stigma relating to self [AOR 0.43 (0.20–0.95)] and friends and family [AOR 0.42 (0.21–0.88)] was associated with lower acceptability of mental health counseling. Stigma did not account for the lower acceptability of prescription medication among African Americans.
CONCLUSIONS
Treatment associated stigma significantly affects the acceptability of mental health counseling but not prescription medication. Efforts to improve depression treatment utilization might benefit from addressing concerns about stigma of mental health counseling.
doi:10.1007/s11606-007-0276-3
PMCID: PMC2219769  PMID: 17610120
stigma; depression treatment; patient preferences; ethnicity
6.  Escitalopram for Major Depression in Parkinson’s Disease: An Open-Label, Flexible-Dosage Study 
Depression and antidepressant use are common in Parkinson’s disease, but the benefit of selective serotonin reuptake inhibitor (SSRI) treatment in this population has not been established. The authors treated 14 Parkinson’s disease patients with major depression with escitalopram in an open-label study. Although treatment was well tolerated and correlated with a significant decrease in Inventory of Depressive Symptomatology score, response and remission rates were only 21% and 14%, respectively. However, half of the subjects met Clinical Global Impression-Improvement criteria for response. In Parkinson’s disease, either SSRIs may have limited antidepressant effects, or the use of existing depression diagnostic and rating instruments may be problematic.
doi:10.1176/appi.neuropsych.18.3.377
PMCID: PMC1761053  PMID: 16963587
7.  Test Characteristics of the 15-Item Geriatric Depression Scale and Hamilton Depression Rating Scale in Parkinson Disease 
Objective
The objective of this study was to compare the sensitivity, specificity, and diagnostic accuracy of the 15-item Geriatric Depression Scale (GDS-15) and the Hamilton Depression Rating Scale (HDRS) in patients with Parkinson disease (PD).
Method
A convenience sample of 148 outpatients with idiopathic PD receiving specialty care completed the GDS-15 and were administered the HDRS and Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID) depression module by a research psychiatrist or trained research assistant. Receiver-operating characteristic (ROC) curves were plotted for the GDS-15 and HDRS scores with a SCID diagnosis of a depressive disorder as the state variable.
Results
Thirty-two subjects (22%) were diagnosed with a depressive disorder. The discriminant validity of the GDS-15 and HDRS were both high (ROC area under the curve: 0.92 and 0.91, respectively), with greatest dichotomization for the GDS-15 at a cutoff of 4/5 (87% accuracy, 88% sensitivity, 85% specificity) and the HDRS at a cutoff of 9/10 (83% accuracy, 88% sensitivity, 78% specificity).
Conclusions
The GDS-15 performs well as a screening instrument and in distinguishing depressed from nondepressed patients in PD. Its test characteristics are comparable to the HDRS. Because it is a brief instrument and can be self-administered, it is an excellent depression screening tool in this population.
doi:10.1097/01.JGP.0000192488.66049.4b
PMCID: PMC1571046  PMID: 16473982
Parkinson disease; depression; Geriatric Depression Scale
8.  Antidepressant Studies in Parkinson’s Disease 
The objective of this study was to determine effect sizes for both antidepressant treatment and placebo for depression in Parkinson’s disease (PD), and to compare the findings with those reported in elderly depressed patients without PD. Recent reviews have concluded that there is little empiric evidence to support the use of antidepressants in PD; however, available data has not been analyzed to determine the effect size for antidepressant treatment in PD depression. A literature review identified antidepressant studies in PD. Suitable studies were analyzed using meta-analytic techniques, and effect sizes were compared with those from antidepressant studies in elderly patients without PD. Large effect sizes were found for both active treatment and placebo in PD, but there was no difference between the two groups. In contrast, active treatment was superior to placebo in depressed elderly patients without PD. In PD, increasing age and a diagnosis of major depression were associated with better treatment response. Results also suggest that newer antidepressants are well tolerated in PD. Despite the high prevalence of depression and antidepressant use in PD, controlled treatment research has been almost non-existent. Meta-analysis results suggest a large but nonspecific effect for depression treatment in PD. In addition, PD patients may benefit less from antidepressant treatment, particularly selective serotonin reuptake inhibitors, than do elderly patients without PD.
doi:10.1002/mds.20555
PMCID: PMC1989731  PMID: 15954137
Parkinson’s disease; depression; antidepressive agent; treatment; effect size; meta-analysis
9.  Screening, Assessment, and Management of Depression in VA Primary Care Clinics 
Objectives
The purpose of this project was to assess the utility and feasibility of a telephone-based systematic clinical assessment service, the Behavioral Health Laboratory (BHL), in the context of primary care. The BHL is a clinical service that provides primary care providers with an assessment and a summary of mental health and substance abuse (MH/SA) symptoms and provides treatment decision support, including triage to specialty MH/SA services. The BHL was implemented to assist in the evaluation of patients who screened positively for depression at an annual clinical appointment or who were identified through routine care.
Methods
Results from systematic screening of primary care patients were extracted during a period of 6 months prior to implementation of the BHL and after implementation of the BHL. Descriptive results of the 580 evaluations conducted during this time were available.
Results
Results suggest an association between the implementation of the BHL and an increase in the proportion of patients screened for depression in primary care. In addition, there was an increase in the proportion of patients who screened positively (2.8% vs 7.0%). The BHL was successful in providing a comprehensive assessment for 78% of those referred. Significant co-occurring mental illness and substance misuse were found among those assessed.
Conclusions
Introducing the BHL into primary care was associated with an apparent change in clinical practice in primary care at the Philadelphia VA Medical Center. Not only were more patients identified, the broad-based approach of the BHL identified significant comorbidity with alcohol misuse, illicit drugs, and suicidal ideation, symptoms likely to have been missed in routine clinical practice. The BHL offers a practical, low-cost method of assessment, monitoring, and treatment planning for patients identified in primary care with MH/SA needs.
doi:10.1111/j.1525-1497.2005.0267.x
PMCID: PMC1484620  PMID: 16423122
depression; primary care; adult; elderly
10.  Depression in late life: psychiatric-medical comorbidity 
The links between late-life depression and the medical comorbidities that are often associated with it can be divided into two paths. The path from medical illness to depression reflects general mechanisms related to stress, disability, and loss, as well as more specific physiological mechanisms, including those related to subclinical cerebrovascular disease, adverse drug effects, and endocrine/metabolic effects. Similarly the path from depression to medical illness includes general mechanisms related to self-neglect, decreased adherence to medical treatments, maladaptive health-related behaviors, and, possibly, more specific physiological mechanisms including those related to altered endocrine and autonomic functions, in the clinical context, these two paths can interact to constitute a vicious cycle. With further research, it should be possible to translate current understanding in these areas into advances in both basic knowledge and treatments that could initiate virtuous cycles with beneficial effects for both menial and physical health.
PMCID: PMC3181575  PMID: 22033660
major depression; vascular depression; chemically induced depression; hypercortisolemia; heart rate; cytokine

Results 1-10 (10)