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1.  Factors associated with help-seeking behaviors in Mexican elderly individuals with depressive symptoms: a cross-sectional study 
International journal of geriatric psychiatry  2013;28(12):10.1002/gps.3953.
Objective
Depression in the elderly is associated with multiple adverse outcomes, such as high health service utilization rates, low pharmacological compliance, and synergistic interactions with other comorbidities. Moreover, the help seeking process, which usually starts with the feeling “that something is wrong” and ends with appropriate medical care, is influenced by several factors.
The aim of this study was to explore factors associated with the pathway of help seeking among older adults with depressive symptoms.
Methods
A cross-sectional study of 60-year or older of community dwelling elderly belonging to the largest health and social security system in Mexico was done. A standardized interview explored the process of seeking health care in four dimensions: depressive symptoms, help seeking, help acquisition and specialized mental health.
Results
A total of 2,322 individuals were studied; from these, 67.14% (n=1,559) were women, and the mean age was 73.18 years (SD=7.02) 57.9% had symptoms of depression, 337 (25.1%) participants sought help, and 271 (80.4%) received help and 103 (38%) received specialized mental health care. In the stepwise model for not seeking help (χ2=81.66, p<0.0001), significant variables were female gender (OR=0.07 95% CI 0.511–0.958 p=0.026), health care use (OR 3.26 CI 95% 1.64–6.488, p=0.001). Number of years in school, difficulty in activities, SAST score and depression as a disease belief were also significant.
Conclusions
Appropriate mental health care is rather complex and is influenced by several factors. The main factors associated with help seeking were gender, education level, recent health service use, and the belief that depression is not a disease. Detection of subjects with these characteristics could improve care of elderly with depressive symptoms.
doi:10.1002/gps.3953
PMCID: PMC3797168  PMID: 23585359
Mental health services; late life depressive symptoms; help-seeking; late life depression care
2.  Body Mass Index and Risk of Incident Hypertension over the Life Course: The Johns Hopkins Precursors Study 
Circulation  2012;126(25):2983-2989.
Background
The obesity-hypertension link over the life course has not been well characterized although the prevalence of obesity and hypertension are increasing in the United States.
Methods and Results
We studied the association of body mass index (BMI) in young adulthood, into middle age, and through late life with risk of developing hypertension in 1132 white men of The Johns Hopkins Precursors Study, a prospective, cohort study. Over a median follow-up period of 46 years, 508 men developed hypertension. Obesity (BMI ≥ 30 kg/m2) in young adulthood was strongly associated with incident hypertension (hazard ratio (HR) = 4.17, 95% CI (2.34-7.42)). Overweight (BMI 25 to < 30 kg/m2) also signaled increased risk (HR = 1.58, 95% CI (1.28-1.96)). Men of normal weight at age 25 years who became overweight or obese at age 45 were at increased risk compared to men of normal weight at both times (HR = 1.57, 95% CI (1.20-2.07)), but not men who were overweight or obese at age 25 years who returned to normal weight at age 45 years (HR = 0.91, 95% CI (0.43-1.92)). After adjusting for time-dependent number of cigarettes smoked, cups of coffee taken, alcohol intake, physical activity, parental premature hypertension and baseline BMI, the rate of change in BMI over the life course, increased the risk of incident hypertension in a dose-response fashion, with the highest risk among men with the greatest increase in BMI (HR = 2.52, 95% CI (1.82-3.49)).
Conclusions
Our findings underscore the importance of higher weight and weight gain in increasing the risk of hypertension from young adulthood, through middle age, and into late life.
doi:10.1161/CIRCULATIONAHA.112.117333
PMCID: PMC3743236  PMID: 23151344
Body Mass Index; Hypertension; Long term follow-up; Longitudinal cohort study; Men
3.  Vascular depression prevalence and epidemiology in the United States 
Journal of psychiatric research  2012;46(4):456-461.
Objective
To examine and describe vascular depression epidemiology in the United States.
Methods
Cross-sectional data from a national probability sample of household resident adults (18-years and older; N = 16,423) living in the 48 coterminous United States were analyzed to calculate prevalence estimates of vascular depression, associated disability and treatment rates. In this study, vascular depression was defined as the presence of cardiovascular and cerebrovascular disease (CVD) and CVD major risk factors (e.g., diabetes, hypertension, heart disease, and obesity) among adults 50-years and older who also met 12-month DSM-IV major depression criteria.
Results
We estimated that about 3.4% or approximately 2.64 million American adults 50-years and older met our criteria for vascular depression. Among adults who met criteria for lifetime major depression, over one-in-five (22.1%) were considered to have the vascular depression subtype. Secondly, vascular depression was associated with significantly increased functional impairment relative to the non-depressed population and adults meeting criteria for major depression alone. Although depression care use was significantly higher among vascular depression respondents relative to those with major depression alone, practice guideline concordant therapy use was not.
Conclusions
Vascular depression appears to be an important public health problem that affects a large portion of the U.S. adult population with major depression, and that it is associated with excess functional impairment without concomitant better depression care.
doi:10.1016/j.jpsychires.2012.01.011
PMCID: PMC3447181  PMID: 22277303
Major depressive disorder; Depression; Vascular depression; Epidemiology; Cardiovascular disease; Stroke
4.  Patient Characteristics Associated with Participation in a Practice-Based Study of Depression in Late Life: The Spectrum Study* 
Objective
An important component of generalizing study results to patients is the extent to which study participants adequately represent individuals targeted for the study. The Spectrum study of depression in older primary care patients was utilized to consider patient characteristics associated with nonparticipation.
Method
Interviewers utilized a validated questionnaire to screen adults aged 65 years and older for depression who presented to one of the participating primary care practices in the Baltimore, Maryland area. Screening interviews included information about sociodemographic factors, functioning, health, and attitudes about depression and its treatment in order to compare participants with persons who declined.
Results
In all, 2,560 adults aged 65 years and older were screened. Comparison of the characteristics of the patients who were eligible for the study (n = 773) with patients who participated fully in the in-home evaluation (n = 355) found that the study sample included proportionately more persons who: 1) were less than 80 years old; 2) completed high school; and 3) reported two or more visits to the practice site within six months of the interview. Among patients who were depressed, no significant differences were found in the characteristics of those who met study eligibility criteria and those who agreed to participate.
Conclusions
Persons over the age of 80 years of age or those with less than a high school education may require tailored strategies for recruitment even when approached by a trained interviewer in a primary care doctor's office.
PMCID: PMC2825041  PMID: 15977944
aged; depression; patient participation; primary health care; research design
5.  PATIENT ETHNICITY AND THE IDENTIFICATION AND ACTIVE MANAGEMENT OF DEPRESSION IN LATE LIFE 
Archives of internal medicine  2005;165(17):1962.
BACKGROUND
Black Americans are more likely to obtain mental health care from primary care than from a mental health specialist. Our objective was to investigate the association of ethnicity with the identification and active management of depression among older patients.
METHODS
Cross-sectional survey 355 older adults with and without significant depressive symptoms. At the index visit, doctor's ratings of depression and reports of active management were obtained on 341 of the 355 patients who completed in-home interviews.
RESULTS
Older black patients were less likely to be identified as depressed than were older whites (unadjusted odds ratio (OR) = 0.40, 95% confidence interval (CI) [0.25, 0.63]) and less likely to be actively managed for depression in the 6 months prior to interview (unadjusted OR = 0.63, 95% CI [0.19, 2.16]). In multivariate models that controlled for potentially influential characteristics such as patient age, gender, marital status, level of education, functional status, physical health, severity of depressive symptoms, severity of anxiety symptoms, attitudes about depression, number of office visits in the last 6 months, and the doctor’s rating of how well they knew the patient, the associations of identification (OR = 0.25, 95% CI [0.17, 0.39]) and management (OR = 0.57, 95% CI [0.19, 1.77]) with patient ethnicity remained substantially unchanged.
CONCLUSIONS
Our study calls attention to the role ethnicity may play in the identification and active management of depression among older primary care patients.
doi:10.1001/archinte.165.17.1962
PMCID: PMC2818737  PMID: 16186465
African-Americans; aged; depression; mental health services; primary health care
6.  The Effect of a Primary Care Practice–Based Depression Intervention on Mortality in Older Adults 
Annals of internal medicine  2007;146(10):689-698.
Background
Few studies have tested the effects of a depression intervention on the risk for death associated with depression.
Objective
To test whether an intervention to improve depression care can modify the risk for death.
Design
Practice-based, randomized, controlled trial.
Setting
20 primary care practices in New York, New York, and Philadelphia and Pittsburgh, Pennsylvania.
Patients
1226 randomly sampled patients identified through a 2-stage, age-stratified (60 to 74 years and ≥75 years) depression screening.
Intervention
Depression care manager working with primary care physicians to provide algorithm-based care.
Measurements
Depression status based on clinical interview and vital status at 5 years by using the National Death Index.
Results
At baseline, 396 patients met criteria for major depression and 203 patients met criteria for clinically significant minor depression. After a median follow-up of 52.8 months, 223 patients died. Patients with depression in intervention practices were less likely to have died than those in usual care practices (adjusted hazard ratio, 0.67 [95% CI, 0.44 to 1.00]). Risk for death was reduced in patients with major depression (adjusted hazard ratio, 0.55 [CI, 0.36 to 0.84]) but not in patients with clinically significant minor depression (adjusted hazard ratio, 0.97 [CI, 0.49 to 1.92]). The benefit seemed to be almost entirely attributable to a reduction in deaths due to cancer.
Limitations
The mechanism for an effect on deaths due to cancer is unclear. Depression status, cause of death, and vital status might have been misclassified.
Conclusions
Older primary care patients with major depression in practices that implemented depression care management were less likely to die over a 5-year period than were patients with major depression in usual care practices. The effect seemed to be limited to deaths due to cancer. The mechanism for such an effect is unclear and warrants further investigation.
PMCID: PMC2818643  PMID: 17502629
7.  DEPRESSION, CARDIOVASCULAR DISEASE, DIABETES, AND 2-YEAR MORTALITY AMONG OLDER PRIMARY CARE PATIENTS 
Objective
Depression is a major contributor to death and disability, but few follow-up studies of depression have been carried out in the primary care setting. We sought to assess whether depression in older patients is associated with increased mortality after a 2-year follow-up interval and to estimate the population attributable fraction (PAF) of depression on mortality in older primary care patients.
Method
Longitudinal cohort analysis carried out in 20 primary care practices. Participants were identified though a two-stage, age-stratified (60–74; 75+) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of screened negative patients. In all, 1226 persons were assessed at baseline. Vital status at 2 years was the outcome of interest.
Results
Of 1226 persons in the sample, 598 were classified as depressed. After 2 years, 64 persons had died. Persons with depression at baseline were more likely to die at the end of the 2-year follow-up interval than were persons without depression (relative odds 1.81, 95% confidence interval [1.07, 3.05]; Wald χ2 = 4.96, df = 1, p = 0.03), even after accounting for potentially influential covariates such as whether the participant reported a history of myocardial infarction (MI) or diabetes. We estimated the PAF due to depression on mortality to be 13%. By comparison, the PAF on mortality due to baseline report of MI was 11%; diabetes 9%; and any cardiovascular disease 18%.
Conclusions
Among older primary care patients over the course of a 2-year follow-up interval, depression contributed as much to mortality as did MI or diabetes.
doi:10.1176/appi.ajgp.13.9.748
PMCID: PMC2792894  PMID: 16166403
aged; depressive disorder; mortality; prospective studies; risk factors
8.  Depressive Symptoms Impair Everyday Problem-Solving Ability through Cognitive Abilities in Late Life 
Background
The association between depression and functional disability in late life remains unclear. This study aimed to explore the relationship between depressive symptoms and daily functioning through the mediation of cognitive abilities, measured by memory, reasoning, and speed of processing.
Methods
We recruited 2,832 older adults (mean age = 73.6 years, SD = 5.9) participating in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) Study. Structural equation modeling (SEM) was applied to illustrate the relationship between depressive symptoms and everyday problem-solving ability through the mediation of cognitive abilities.
Results
Depressive symptoms were associated with impaired everyday problem-solving ability directly and indirectly mediated via learning and memory, and reasoning. Although depressive symptoms were associated with speed of processing, speed of processing was not significantly related to everyday problem-solving ability.
Conclusions
This study conceptualizes the possible relationships between depressive symptoms and daily functioning with mediation of cognitive abilities and provides a feasible model for the prevention of functional impairment related to geriatric depressive symptoms.
doi:10.1097/JGP.0b013e3181e89894
PMCID: PMC3000466  PMID: 20808123
depression; cognition; everyday function; elderly
9.  Alcohol Consumption and Domain-Specific Cognitive Function in Older Adults: Longitudinal Data From the Johns Hopkins Precursors Study 
Objectives.
The association of alcohol consumption with performance in different cognitive domains has not been well studied.
Methods.
The Johns Hopkins Precursors Study was used to examine associations between prospectively collected information about alcohol consumption ascertained on multiple occasions starting at age 55 years on average with domain-specific cognition at age 72 years. Cognitive variables measured phonemic and semantic fluency, attention, verbal memory, and global cognition.
Results.
Controlling for age, hypertension, smoking status, sex, and other cognitive variables, higher average weekly quantity and frequency of alcohol consumed in midlife were associated with lower phonemic fluency. There were no associations with four other measures of cognitive function. With respect to frequency of alcohol intake, phonemic fluency was significantly better among those who drank three to four alcoholic beverages per week as compared with daily or almost daily drinkers. A measure of global cognition was not associated with alcohol intake at any point over the follow-up.
Discussion.
Results suggest that higher alcohol consumption in midlife may impair some components of executive function in late life.
doi:10.1093/geronb/gbq062
PMCID: PMC3001751  PMID: 20937708
Alcohol; Cognition; Epidemiology; Older adults
10.  Depression and cancer risk: 24 years of follow-up of the Baltimore Epidemiologic Catchment Area sample 
Cancer causes & control : CCC  2009;21(2):191-199.
Objective
The objective was to characterize the relationship between depression and incident cancer. Few studies have employed population-based prospective data on subtypes of cancer to address the question.
Method
A population-based sample of 3,177 cancer-free adults from the Baltimore Epidemiologic Catchment Area Study who have been followed for 24 years. Cox proportional hazards models were used to estimate relative hazards for both overall and subtype-specific cancers among those with a history of depression.
Results
The risk set contained 334 incident cancer cases and 40,530 person-years of observation. DIS/DSM-III major depression was associated with a higher hazard for overall cancer (HR: 1.9, 95% CI: 1.2, 3.0) and a statistically significant increased hazard for breast cancer (HR: 4.4, 95% CI: 1.08, 17.6) among women. There was a positive association between history of depression and prostate cancer, but confidence bounds included the null. No reliable associations were found between colon, lung, or skin cancers and depression. The pattern of results was similar for dysphoria, but not for phobia or any other mental disorder studied.
Conclusions
Results reveal a specificity to the association between depression and hormonally mediated cancers, which provides support to hypotheses about a common biological pathway between depression and cancer. Further research can build on observational studies to examine the mechanisms through which our emotions affect our health.
doi:10.1007/s10552-009-9449-1
PMCID: PMC2872112  PMID: 19885645
Cancer; Depression; Epidemiology; Cohort
11.  TOWARDS PATIENT-CENTERED CARE FOR DEPRESSION: CONJOINT METHODS TO TAILOR TREATMENT BASED ON PREFERENCES 
The patient  2010;3(3):145-157.
Background
Although antidepressants and counseling have been shown to be effective in treating patients with depression, non-treatment or under-treatment for depression is common especially among the elderly and minorities. Previous work on patient preferences has focused on medication versus counseling, but less is known about the value patients place on attributes of medication and counseling.
Objective
Conjoint analysis has been recognized as a valuable means of assessing patient treatment preferences. We examine how conjoint analysis be used to determine the relative importance of various attributes of depression treatment at the group level as well as to determine the range of individual-level relative preference weights for specific depression treatment attributes. In addition we use conjoint analysis to predict what modifications in treatment characteristics are associated with a change in the stated preferred alternative.
Study design
86 adults who participated in an internet-based panel responded to an on-line discrete choice task about depression treatment. Participants chose between medication and counseling based on choice sets presented first for a “mild depression” scenario and then for a “severe depression” scenario. Participants were given 18 choice sets which varied for medication based on type of side effect (nausea, dizziness, and sexual dysfunction) and severity of side effect (mild, moderate, and severe); and for counseling based on frequency of counseling sessions (once per week or every other week) and location of the sessions (mental health professional’s office, primary care doctor’s office or office of a spiritual counselor).
Results
Treatment type (counseling vs. medication) appeared to be more important in driving treatment choice than any specific attribute that was studied. Specifically counseling was preferred by most of the respondents. After treatment type, location of treatment and frequency of treatment were important considerations. Preferred attributes were similar in both the mild and severe depression scenarios. Side effect severity appeared to be most important in driving treatment choice as compared with the other attributes studied. Individual-level relative preferences for treatment type revealed a distribution that was roughly bimodal with 27 participants who had a strong preference for counseling and 14 respondents who had a strong preference for medication.
Conclusion
Estimating individual-level preferences for treatment type allowed us to see the variability in preferences and determine which participants had a strong affinity for medication or counseling.
doi:10.2165/11530660
PMCID: PMC2910930  PMID: 20671803
12.  Resident Physician Burnout: Is There Hope? 
Family medicine  2008;40(9):626-632.
Background
Prevalent among resident physicians, burnout has been associated with absenteeism, low job satisfaction, and medical errors. Little is known about the number and quality of interventions used to combat burnout.
Methods
We performed a systematic review of the literature using MEDLINE and PubMed databases. We included English-language articles published between 1966 and 2007 identified using combinations of the following medical subject heading terms: burnout, intervention studies, program evaluation, internship and residency, graduate medical education, medical student, health personnel, physician, resident physician, resident work hours, and work hour limitations. Additional articles were also identified from the reference lists of manuscripts. The quality of research was graded with the Strength of Evidence Taxonomy (SORT) from highest (level A) to lowest (level C).
Results
Out of 190 identified articles, 129 were reviewed. Nine studies met inclusion criteria, only two of which were randomized, controlled trials. Interventions included workshops, a resident assistance program, a self-care intervention, support groups, didactic sessions, or stress-management/coping training either alone or in various combinations. None of the studied interventions achieved an A-level SORT rating.
Conclusions
Despite the potentially serious personal and professional consequences of burnout, few interventions exist to combat this problem. Prospective, controlled studies are needed to examine the effect of interventions to manage burnout among resident physicians.
PMCID: PMC2903755  PMID: 18830837
13.  Bridging Psychiatric and Anthropological Approaches: The Case of “Nerves” in the United States 
Ethos (Berkeley, Calif.)  2009;37(3):282-313.
Psychiatrists and anthropologists have taken distinct analytic approaches when confronted with differences between emic and etic models for distress: psychiatrists have translated folk models into diagnostic categories whereas anthropologists have emphasized culture-specific meanings of illness. The rift between psychiatric and anthropological research keeps “individual disease” and “culture” disconnected and thus hinders the study of interrelationships between mental health and culture. In this article we bridge psychiatric and anthropological approaches by using cultural models to explore the experience of nerves among 27 older primary care patients from Baltimore, Maryland. We suggest that cultural models of distress arise in response to personal experiences, and in turn, shape those experiences. Shifting research from a focus on comparing content of emic and etic concepts, to examining how these social realities and concepts are coconstructed, may resolve epistemological and ontological debates surrounding differences between emic and etic concepts, and improve understanding of the interrelationships between culture and health.
doi:10.1111/j.1548-1352.2009.01054.x
PMCID: PMC2860393  PMID: 20428332
“nerves”; cultural models; metaphor; psychiatry; embodiment
14.  Are higher rates of depression in women accounted for by differential symptom reporting? 
Background
The gender difference in prevalence and incidence rates of depression is one of the most consistent findings in psychiatric epidemiology. We sought to examine whether any gender differences in symptom profile might account for this difference in rates.
Method
This study was a population-based 13-year follow-up survey of community-dwelling adults living in East Baltimore in 1981. Subjects were the continuing participants of the Baltimore Epidemiologic Catchment Area Program. Participants interviewed between 1993 and 1996 with complete data on depressive symptoms and covariates were included (n = 1,727). We applied structural equations with a measurement model for dichotomous data (the MIMIC – multiple indicators, multiple causes – model) to compare symptoms between women and men, in relation to the nine symptom groups comprising the diagnostic criteria for major depression, adjusting for several potentially influential characteristics (namely, age, self-reported ethnicity, educational attainment, marital status, and employment).
Results
There were no significant gender differences in the self-report of depression symptoms even taking into account the higher level of depressive symptoms of women and the influence of other covariates. For example, women were no more likely to endorse sadness than were men, as evidenced by a direct effect coefficient that was not significantly different from the null [adjusted estimated direct effect of gender on report of sadness = 0.105, 95% confidence interval (−0.113, 0.323)].
Conclusions
Men and women in this community sample reported similar patterns of depressive symptoms. No evidence that the presentation of depressive symptoms differs by gender was found.
doi:10.1007/s00127-004-0714-z
PMCID: PMC2830739  PMID: 15052394
depression; gender differences; symptoms
15.  Urinary Incontinence and Psychological Distress in Community-Dwelling Older Adults 
OBJECTIVES
To examine the relationship between urinary incontinence (UI) and psychological distress in older adults. We hypothesized that persons with UI associated with condition-specific functional loss would be most likely to report psychological distress.
DESIGN
A population-based longitudinal survey.
SETTING
Continuing participants in a study of community-dwelling adults who were initially living in East Baltimore in 1981.
PARTICIPANTS
Persons aged 50 and older (n = 781) at follow-up interviews conducted between 1993 and 1996 for whom complete data were available.
MEASUREMENTS
Participants were classified as incontinent if they reported any uncontrolled urine loss within the 12 months preceding the 13-year follow-up interview. Condition-specific functional loss secondary to UI was further assessed based on a series of questions relating directly to participants’ inability to engage in certain activities due to their UI. Psychological distress was assessed using the General Health Questionnaire (GHQ) at interviews in 1981 and at the 13-year follow-up.
RESULTS
Persons with UI were more likely to experience psychological distress as measured by the GHQ than were persons without UI (unadjusted odds ratio (OR) = 1.74, 95% confidence interval (CI) = 1.13–2.68). Persons with condition-specific functional loss secondary to UI were substantially more likely to have psychological distress as measured by the GHQ than were persons without UI (unadjusted OR = 4.02, 95% CI = 1.86–8.70). In multivariate models that controlled for potentially influential characteristics such as age, gender, ethnicity, and chronic medical conditions the association between condition-specific functional loss secondary to UI and psychological distress remained statistically significant. Among people with UI, persons with persistently elevated GHQ scores were much more likely to report condition-specific functional impairment from UI (adjusted OR = 6.55, 95% CI = 1.94–22.12).
CONCLUSION
Individuals with UI, especially when incontinence was associated with condition-specific functional loss, were more likely to have psychological distress than were other older adults. Our findings support a general conceptual model that condition-specific functional impairment mediates the relationship between a chronic medical condition and psychological distress.
PMCID: PMC2827934  PMID: 11943045
urinary incontinence; older adults; psychological distress; depression; functional status
16.  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
17.  ANXIETY DISORDERS AND DISABILITY SECONDARY TO URINARY INCONTINENCE AMONG ADULTS OVER AGE 50* 
Objective:
No previous research has investigated whether there is an association between anxiety disorders and urinary incontinence. We hypothesized that anxiety disorders would be associated with increased urinary incontinence related disability.
Method:
Continuing participants who were aged 50 years and older in a longitudinal study of community-dwelling adults who were initially living in East Baltimore in 1981 (n = 787). Participants were classified as incontinent if any uncontrolled urine loss within the 12 months prior to the interview was reported. Urinary incontinence related functional loss was further assessed based on a series of questions relating directly to participants' inability to engage in certain activities due to their urinary incontinence. Anxiety disorders were assessed with standardized interviews.
Results:
Persons meeting criteria for an anxiety disorder were no more likely to have urinary incontinence than were persons without anxiety disorders (unadjusted odds ratio (OR) = 1.36, 95 percent confidence interval (CI) [0.96, 1.93]). Among people with urinary incontinence (n = 159), persons meeting criteria for anxiety disorders in 1981 and in 1994 were much more likely to report urinary incontinence related functional impairment in 1994 (adjusted OR = 6.51, 95 percent CI [1.42, 29.86]).
Conclusions:
Individuals with changes in day-to-day routines or activities secondary to urinary incontinence were more likely to meet criteria for an anxiety disorder than were other older adults. Further studies must tease out the temporal relationship and whether early detection of urinary incontinence and associated anxiety improves quality of life and functioning.
PMCID: PMC2826159  PMID: 12269595
Urinary incontinence; anxiety; functional impairment; aged
18.  Chronic Medical Conditions and Wishes to Die Among Older Primary Care Patients* 
Objective
To determine the prevalence of wishes to die and the medical correlates of wishes to die among primary care patients aged 65 years and older.
Method
Three-hundred and fifty-five adults with and without significant depressive symptoms who were screened in primary care offices and invited to participate completed a baseline in-home assessment. Participants were interviewed using standardized measures of medical conditions, functional status, and psychological status. Thoughts of death and wishes to die were assessed with standard questions from the Composite International Diagnostic Interview (CIDI) Depression Section.
Results
The weighted point prevalence of thoughts of death was 9.7% and 6.1% for the wish to die. Several medical conditions were associated with a wish to die, for example myocardial infarction (MI). In multivariate models that adjusted for potentially influential characteristics, the association between a history of MI and the wish to die remained statistically significant (odds ratio (OR) = 3.32, 95% confidence interval (CI) (1.26, 8.75).
Conclusions
Thoughts of death and a wish to die are common in older primary care patients and were more likely among persons with chronic medical conditions. Persons with a history of myocardial infarction may be particularly vulnerable to a wish to die.
PMCID: PMC2825743  PMID: 17154148
aged; comorbidity; primary health care; suicide; myocardial infarction
19.  Computer-assisted assessment of depression and function in older primary care patients 
Summary
We wanted to test the psychometric reliability and validity of self-reported information on psychological and functional status gathered by computer in a sample of primary care outpatients. Persons aged 65 years and older visiting a primary care medical practice in Baltimore (n = 240) were approached. Complete baseline data were obtained for 54 patients and 34 patients completed 1-week retest follow-up. Standard instruments were administered by computer and also given as paper and pencil tests. Test–retest reliability estimates were calculated and comparisons across mode of administration were made. Separately, an interviewer administered a questionnaire to gauge patient attitudes and feelings after using the computer. Most participants (72%) reported no previous computer use. Nevertheless, inter-method reliability of the GDS15 at baseline (0.719, n = 47), intra-method reliability of the computer in time (0.797, n = 31), inter-method reliability of the CESDR20 at baseline (0.740, n = 53), and the correlation between the CESDR20 computer version at baseline and follow-up (0.849, n = 34) were all excellent. The inter-method reliability of the CESDR20 at follow-up (0.615, n = 37) was lower but still acceptable. Although 28% were anxious prior to using the computer testing system, that percent decreased to 19% while using the system. The efficiency and reliability in comparison to the paper instruments were good or better. Even though most participants had not ever used a computer prior to participating in the study, they had generally favorable attitudes toward the use of computers, and also reported having favorable experience with the computer testing system.
PMCID: PMC2812865  PMID: 14757259
Primary care; Depression; Computerized assessment; Geriatrics
20.  THE ROLE OF PATIENT PERSONALITY IN THE IDENTIFICATION OF DEPRESSION IN OLDER PRIMARY CARE PATIENTS 
SUMMARY
Background
Our aim was to evaluate whether personality factors significantly contribute to the identification of depression in older primary care patients, even after controlling for depressive symptoms.
Methods
We examined the association between personality factors and the identification of depression among 318 older adults who participated in the Spectrum study.
Results
High neuroticism (unadjusted odds ratio (OR) 2.36, 95% confidence interval (CI) [1.42, 3.93]) and low extraversion (adjusted OR 2.24, CI [1.26, 4.00]) were associated with physician identification of depression. Persons with high conscientiousness were less likely to be identified as depressed by the doctor (adjusted OR 0.45, CI [0.22, 0.91]).
Conclusion
Personality factors influence the identification of depression among older persons in primary care over and above the relationship of depressive symptoms with physician identification. Knowledge of personality may influence the diagnosis and treatment of depression in primary care.
doi:10.1002/gps.1791
PMCID: PMC2810143  PMID: 17407104
aged; depression; diagnosis; personality; primary health care
21.  PERSONAL CHARACTERISTICS OF OLDER PRIMARY CARE PATIENTS WHO PROVIDE A BUCCAL SWAB FOR APOE TESTING AND BANKING OF GENETIC MATERIAL: THE SPECTRUM STUDY 
Community genetics  2004;7(4):202-210.
OBJECTIVE
To determine the personal characteristics and reasons associated with providing a buccal swab for APOE genetic testing in a primary care study.
METHODS
The study sample consisted of 342 adults aged 65 years and older recruited from primary care settings.
RESULTS
In all, 88% of patients agreed to provide a DNA sample for APOE genotyping and 78% of persons providing a sample agreed to banking of the DNA. Persons aged 80 years and older and African-Americans were less likely to participate in APOE genotyping. Concern about confidentiality was the most common reason for not wanting to provide a DNA sample or to have DNA banked.
CONCLUSION
We found stronger relationships between sociodemographic variables of age and ethnicity with participation in genetic testing than we did between level of educational attainment, gender, function, cognition, and affect.
doi:10.1159/000082263
PMCID: PMC2804857  PMID: 15692195
older adults; participant recruitment; race; genetic testing; apolipoprotein E
22.  The Role of Physicians in Assessing Older Drivers: Barriers, Opportunities, and Strategies 
Background
Evaluation of the older driver is a difficult task for primary care physicians. We investigated the physician-perceived barriers to assessing older drivers in primary care practice.
Methods
Twenty family physicians whose patients had completed a clinical questionnaire and neuropsychological tests participated in one of 2 focus groups. Physicians were asked about barriers to assessing older drivers in primary care and the usefulness of neuropsychological tests for assessing driving ability.
Results
A number of themes emerged related to barriers in the assessment of the older driver. Major themes included concerns about being liable for the results of driving related screening and about patients reacting unfavorably to a driving assessment including cognitive tests. Physicians uniformly agreed that a protocol to guide driving assessment would be useful.
Conclusions
Physicians encounter a number of barriers to assessing older drivers but recognize the importance of driving within the context of geriatric functional assessment.
PMCID: PMC2804856  PMID: 15014051
23.  THE ROLE OF CARDIOVASCULAR DISEASE IN THE IDENTIFICATION AND MANAGEMENT OF DEPRESSION BY PRIMARY CARE PHYSICIANS 
OBJECTIVE
To describe the influence of cardiovascular disease (CVD) on identification and management of depression by primary care physicians.
METHOD
Three hundred and fifty-five adults with and without significant depressive symptoms who were screened in primary care offices and invited to participate, completed a baseline in-home assessment. CVD was assessed by self-report and psychological status was assessed with commonly used, validated standard questionnaires. At the index visit, doctor’s ratings of depression and reports of active management were obtained on 340 of the 355 patients who completed in-home interviews.
RESULTS
Older adults who reported heart failure were more likely to be identified as depressed than were older adults who did not report heart failure (unadjusted odds ratio (OR) = 2.34, 95% confidence interval (CI) [1.13, 4.85]; Wald χ2 = 5.20, df = 1, p = 0.023). In multivariate models that controlled for potentially influential characteristics such as age, marital status, education, ethnicity, functional status, level of depression, cognitive impairment, attitudes about depression, use of medical care, and number of medications, the findings remained statistically significant. Among older adults identified as depressed, older adults with heart failure were significantly less likely to be actively managed for depression than were older adults without heart failure (unadjusted OR = 0.33, 95% CI [0.14, 0.76]; Wald χ2 = 6.73, df = 1, p = 0.009). After controlling for potentially influential covariates, these findings remained substantially unchanged.
CONCLUSIONS
CVD, in particular heart failure, may influence the identification and management of depression among older patients by primary care physicians. The findings underlie the importance of developing interventions that integrate the management of depression and CVD in primary care settings.
doi:10.1097/01.JGP.0000192479.82189.e1
PMCID: PMC2796080  PMID: 16407584
Depression; treatment; diagnosis; ischemic heart disease; primary health care
24.  Depressive Symptoms Among Older Adults in Mexico City 
Journal of General Internal Medicine  2008;23(12):1973-1980.
ABSTRACT
BACKGROUND
Ageing and depression are associated with disability and have significant consequences for health systems in many other developing countries. Depression prevalence figures among the elderly are scarce in developing countries.
OBJECTIVE
To estimate the prevalence of depressive symptoms and their cross-sectional association with selected covariates in a community sample of Mexico City older adults affiliated to the main healthcare provider.
DESIGN
Cross-sectional, multistage community survey.
PARTICIPANTS
A total of 7,449 persons aged 60 years and older.
MEASUREMENTS
Depression was assessed using the 30-item Geriatric Depression Scale (GDS); cognitive impairment, using the Mini-Mental State Examination; and health-related quality of life with the SF-36 questionnaire.
MAIN RESULTS
The prevalence of significant depressive symptoms was estimated to be 21.7%, and 25.3% in those aged 80 and older. After correcting for GDS sensitivity and specificity, major depression prevalence was estimated at 13.2%. Comparisons that follow are adjusted for age, sex, education and stressful life events. The prevalence of cognitive impairment was estimated to be 18.9% in depressed elderly and 13.7% in non-depressed. SF-36 overall scores were 48.0 in depressed participants and 68.2 in non-depressed (adjusted mean difference = −20.2, 95% CI = −21.3, −19.1). Compared to non-depressed elderly, the odds of healthcare utilization were higher among those depressed, both for any health problem (aOR 1.4, 95% CI = 1.1, 1.7) and for emotional problems (aOR 2.7, 95% CI = 2.2, 3.2).
CONCLUSIONS
According to GDS estimates, one of every eight Mexican older adults had major depressive symptoms. Detection and management of older patients with depression should be a high priority in developing countries.
doi:10.1007/s11606-008-0799-2
PMCID: PMC2596501  PMID: 18818976
aged; depression; comorbidity; primary healthcare
25.  A Mixed-Methods Approach to Understanding Loneliness and Depression in Older Adults 
Objectives
Depression in late life may be difficult to identify, and older adults often do not accept depression treatment offered. This article describes the methods by which we combined an investigator-defined definition of depression with a person-derived definition of depression in order to understand how older adults and their primary care providers overlapped and diverged in their ideas about depression.
Methods
We recruited a purposive sample of 102 persons aged 65 years and older with and without significant depressive symptoms on a standardized assessment scale (Center for Epidemiologic Studies–Depression scale) from primary care practices and interviewed them in their homes. We applied methods derived from anthropology and epidemiology (consensus analysis, semi-structured interviews, and standardized assessments) in order to understand the experience and expression of late-life depression.
Results
Loneliness was highly salient to older adults whom we asked to describe a depressed person or themselves when depressed. Older adults viewed loneliness as a precursor to depression, as self-imposed withdrawal, or as an expectation of aging. In structured interviews, loneliness in the week prior to interview was highly associated with depressive symptoms, anxiety, and hopelessness.
Discussion
An improved understanding of how older adults view loneliness in relation to depression, derived from multiple methods, may inform clinical practice.
PMCID: PMC2782769  PMID: 17114313

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