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1.  Activities and Adaptation in Late-Life Depression: A Qualitative Study 
Interviews with 27 community-dwelling older adults with depression shed light on activity choices of this population and underscore the need for occupational therapy practitioners to complete a client-centered, qualitative assessment to understand why activities are continued or stopped.
OBJECTIVE. We sought to understand activity choices of older adults when they were depressed.
METHOD. Each community-dwelling participant (n = 27) completed one semistructured interview while in recovery for at least 3 mo. but less than 7 mo. Transcripts were coded to identify relevant themes.
RESULTS. Six themes emerged that explained activities participants continued while depressed, and four themes described activities they stopped.
CONCLUSION. Older adults maintained many instrumental activities of daily living while depressed, and some actively adapted activities so they could continue them. Some intentionally stopped activities to direct limited energy to their highest priority activities. To guide effective intervention, it is critical for occupational therapy practitioners to complete a client-centered qualitative assessment to understand what and, most important, why activities are continued or stopped. Each theme for activities continued and activities stopped lends itself to intervention strategies.
PMCID: PMC4153555  PMID: 25184470
activities of daily living; adaptation, psychological; choice behavior; depressive disorder; motivation; qualitative research
2.  Late-life depression and risk of vascular dementia and Alzheimer’s disease: systematic review and meta-analysis of community-based cohort studies 
The British Journal of Psychiatry  2013;202(5):329-335.
Late-life depression may increase the risk of incident dementia, in particular of Alzheimer’s disease and vascular dementia.
To conduct a systematic review and meta-analysis to evaluate the risk of incident all-cause dementia, Alzheimer’s disease and vascular dementia in individuals with late-life depression in population-based prospective studies.
A total of 23 studies were included in the meta-analysis. We used the generic inverse variance method with a random-effects model to calculate the pooled risk of dementia, Alzheimer’s disease and vascular dementia in older adults with late-life depression.
Late-life depression was associated with a significant risk of all-cause dementia (1.85, 95% CI 1.67-2.04, P<0.001), Alzheimer’s disease (1.65, 95% CI 1.42-1.92, P<0.001) and vascular dementia (2.52, 95% CI 1.77-3.59, P<0.001). Subgroup analysis, based on five studies, showed that the risk of vascular dementia was significantly higher than for Alzheimer’s disease (P = 0.03).
Late-life depression is associated with an increased risk for all-cause dementia, vascular dementia and Alzheimer’s disease. The present results suggest that it will be valuable to design clinical trials to investigate the effect of late-life depression prevention on risk of dementia, in particular vascular dementia and Alzheimer’s disease.
PMCID: PMC3640214  PMID: 23637108
3.  Resting state functional connectivity and treatment response in late-life depression 
Psychiatry research  2013;214(3):10.1016/j.pscychresns.2013.08.007.
Indices of functional connectivity in the default mode network (DMN) are promising neural markers of treatment response in late-life depression. We examined the differences in DMN functional connectivity between treatment-responsive and treatment-resistant depressed older adults. Forty-seven depressed older adults underwent MRI scanning pre- and post- pharmacotherapy. Forty-six never depressed older adults underwent MR scanning as comparison subjects. Treatment response was defined as achieving a Hamilton Depression Rating Scale of 10 or less post-treatment. We analyzed resting state functional connectivity using the posterior cingulate cortex as the seed region-of-interest. The resulting correlation maps were employed to investigate between-group differences. Additionally we examined the association between white matter hyperintensity burden and functional connectivity results. Comparison of pre- and post-treatment scans of depressed participants revealed greater post-treatment functional connectivity in the frontal precentral gyrus. Relative to treatment-responsive participants, treatment-resistant participants had increased functional connectivity in the left striatum. When adjusting for white matter hyperintensity burden, the observed differences lost significance for the PCC-prefrontal functional connectivity, but not for the PCC-striatum functional connectivity. The post-treatment “frontalization” of the DMN connectivity suggests a normalizing effect of antidepressant treatment. Moreover, our study confirms the central role of white matter lesions in disrupting brain functional connectivity.
PMCID: PMC3865521  PMID: 24144505
Late-life depression; Default Mode Network; treatment response; MRI; white matter hyperintensity
4.  Treatment of Post Traumatic Stress Disorder Symptoms in Emotionally Distressed Individuals 
Psychiatry research  2014;220(0):370-375.
Older individuals with emotional distress and a history of psychologic trauma are at risk for post traumatic stress disorder (PTSD) and major depression. This study was an exploratory, secondary analysis of data from the study “Prevention of Depression in Older African Americans”. It examined whether Problem Solving Therapy - Primary Care (PST-PC) would lead to improvement in PTSD symptoms in patients with subsyndromal depression and a history of psychologic trauma. The control condition was dietary education (DIET). Participants (n = 60) were age 50 or older with scores on the Center for Epidemiologic Studies -Depression scale of 11 or greater and history of psychologic trauma. Exclusions stipulated no major depression and substance dependence within a year. Participants were randomized to 6–8 sessions of either PST-PC or DIET and followed 2 years with booster sessions every 6 months; 29 participants were in the PST-PC group and 31 were in the DIET group. Mixed effects models showed that improvement of PTSD Check List scores was significantly greater in the DIET group over two years than in the PST-PC group (based on a group*time interaction). We observed no intervention*time interactions in Beck Depression Inventory or Brief Symptom Inventory-Anxiety subscale scores.
PMCID: PMC4253016  PMID: 25107318
Post Traumatic Stress Disorder; Dietary Education; Problem Solving Therapy
5.  Late-life Mental Health Education for Workforce Development: Brain vs. Heart? 
There is a shortage of mental health professionals to care for a growing geriatric population. Though not mutually exclusive, clinical and didactic educational experiences promote cognition, while affective knowledge (attitude) is promoted through non-clinical exposure to seniors. This study evaluates the relative impact of cognition and attitude on career interests among healthcare students.
We developed thirteen interactive, video-documentary “lessons” on late-life mental health presenting didactic material along with stories of actual patients and families. Four of these lessons were viewed at one week intervals by forty-two students from medical school and graduate programs of social work, psychology, and nursing. Knowledge, attitudes, and inclinations towards working with seniors were assessed.
Both cognition and attitudes towards seniors improved. Linear regression shows change in attitude, not cognition, predicts interest in working with seniors.
Educational experiences that promote affective learning may enhance interest in geriatric careers among healthcare students.
PMCID: PMC3594556  PMID: 23567380
Geriatric Education; Workforce development; Late-life mental health education
6.  The Link Between Excessive Quantity of Sleep and Deteriorated Quality of Wakefulness – Implications for the DSM-5 
Annals of neurology  2013;73(6):785-794.
Using population-based data, we document the comorbidities (medical, neurologic and psychiatric) and consequences for daily functioning of excessive quantity of sleep (EQS), defined as a main sleep period or 24-hour sleep duration ≥9 hours accompanied by complaints of impaired functioning or distress due to excessive sleep, and its links to excessive sleepiness.
A cross-sectional telephone study using a representative sample of 19,136 non-institutionalized individuals living in the United States, aged ≥18 (participation rate: 83.2%). The Sleep-EVAL expert system administered questions on life and sleeping habits; health; and sleep, mental and organic disorders (DSM-IV-TR, ICSD-II, ICD-10).
Sleeping at least 9 hours per 24-hour period was reported by 8.4% (95% confidence intervals: 8.0%-8.8%) of participants; EQS (prolonged sleep episode with distress/impairment) was observed in 1.6% (1.4% to 1.8%) of the sample. The likelihood of EQS was 3-12 times higher among individuals with a mood disorder. EQS individuals were 2-4 times more likely to report poor quality of life than non-EQS individuals as well as interference with socio-professional activities and relationships. Although between 33% and 66% of individuals with prolonged sleep perceived it as a major problem, only 6.3% to 27.5% of them reported having sought medical attention.
Excessive Quantity of Sleep is widespread in the general population, co-occurring with a broad spectrum of sleep, medical, neurologic and psychiatric disorders. Therefore, physicians must recognize EQS as a mixed clinical entity indicating careful assessment and specific treatment planning.
PMCID: PMC4142503  PMID: 23846792
7.  Impaired executive function in contemplated and attempted suicide in late life 
Executive deficits may play an important role in late-life suicide. Yet, current evidence in this area is inconclusive and does not indicate whether these deficits are broadly associated with suicidal ideation or specific to suicidal behavior. This study examined global cognition and specifically executive function impairments as correlates of suicidal ideation and suicidal behavior in depressed older adults, with the goal of extending an earlier preliminary study.
Case-control study.
University-affiliated psychiatric hospital.
All were aged 60+: 83 depressed suicide attempters, 43 depressed individuals having suicidal ideation with a specific plan, 54 non-suicidal depressed participants, and 48 older adults with no history of psychiatric disorders.
Global cognitive function - Dementia Rating Scale (DRS), Executive function - Executive Interview (EXIT).
Both suicide attempters and suicide ideators performed worse than the two comparison groups on the EXIT, with no difference between suicide attempters and suicide ideators. On the DRS total score, as well as on Memory and Attention subscales, suicide attempters and ideators and non-suicidal depressed subjects performed similarly and were impaired relative to with non-psychiatric control subjects. Controlling for education, substance use disorders, and medication exposure did not affect group differences in performance on either the EXIT or DRS.
Executive deficits, captured with a brief instrument, are associated broadly with suicidal ideation in older depressed adults but do not appear to directly facilitate suicidal behavior. Our data are consistent with the idea that different vulnerabilities may operate at different stages in the suicidal process.
PMCID: PMC3516623  PMID: 23567385
suicide; cognitive; executive function; depression; aged
8.  Response to Antidepressant Medications in Late Life Depression, Across the Spectrum of Cognitive Functioning 
The Journal of clinical psychiatry  2014;75(2):e100-e107.
Depression in later life frequently coexists with cognitive impairment. To inform clinical management of these co-occurring conditions, we examined the hypotheses that, relative to cognitively normal elders meeting DSM-IV criteria for major depression, those with cognitive impairment would require greater intensity of pharmacotherapy to reach criteria for response, and take longer to respond.
Using data from the recent Maintenance Therapies in Late Life Depression (MTLD-3) study, we conducted a series of secondary analyses examining the implications of cognitive impairment for short-term, open-trial pharmacotherapy of late-life depression (major depression in individuals aged 65 years and older). This short-term treatment trial consisted of three steps: initial treatment with an SSRI, subsequent switch to an SNRI if patient did not meet criteria for response, and addition of an atypical antipsychotic (AAP) for non-response to SNRI monotherapy. The first subject entered the MTLD-3 protocol in April 2004, and the last subject exited the protocol in September 2009. We examined data for participants who completed the acute phase of MTLD-3 as responders and received a consensus cognitive diagnosis (N=153) from the University of Pittsburgh Alzheimer’s Disease Research Center, based on National Alzheimer Coordinating Center Uniformed Data Set criteria. We divided participants into three groups, based on cognitive diagnosis: normal cognitive function (N=74), Mild Cognitive Impairment (N=60), and dementia (N=19). For each group, we calculated the proportion of participants who required first (SSRI), second (SNRI), or third-step (add-on AAP) treatment to meet criteria for clinical response (HRSD-17 score ≤ 10 for three consecutive weeks). We compared time to response across groups, and examined patterns of response by inspection of weekly HRSD-17 scores. Finally, we examined correlates of non-response.
The three groups did not differ significantly with respect to time to response (p=0.84), trajectories to response, or intensity of antidepressant pharmacotherapy (p=0.68). Non-response was more strongly correlated with longer index MDE duration (p=0.0015), presence of recurrent depression (p=0.002), and younger current age (p=0.047), rather than with cognitive status (p=0.61).
Cognitive status does not appear to impact short-term pharmacotherapy response variability in individuals whose depression responds to treatment with open-trial antidepressant pharmacotherapy delivered in a supportive, university-based medication clinic.
PMCID: PMC4060895  PMID: 24602256
late life depression; mild cognitive impairment; dementia; treatment response variability
9.  Can performance of daily activities discriminate between older adults with normal cognitive function and those with Mild Cognitive Impairment? 
Our primary aim was to examine whether preclinical disability in performance of cognitively-focused instrumental activities of daily living (C-IADL) tasks can discriminate between older adults with normal cognitive function and those with Mild Cognitive Impairment (MCI). The secondary purpose was to determine the two tasks with the strongest psychometric properties and assess their discriminative ability. Our goal was to generate diagnosis-relevant information about cognitive changes associated with MCI and DSM-5 Mild Neurocognitive Disorder.
Secondary analyses of cross-sectional data from a cohort of individuals diagnosed with normal cognitive function or MCI.
Private home locations in Pittsburgh, PA.
Older adults with remitted major depression (N=157).
Diagnosis of cognitive status was made by the Alzheimer’s Disease Research Center at the University of Pittsburgh. Performance of 8 C-IADL was measured using the criterion-referenced, observation-based Performance Assessment of Self-Care Skills (PASS).
A total of 96 older adults with normal cognitive function (mean age=72.5, SD=5.9) and 61 older adults with MCI (mean age=75.5, SD=6.3) participated. The 8 C-IADL demonstrated 81% accuracy in discriminating cognitive status (area under curve 0.81, p<0.001). Two tasks (shopping and checkbook balancing) were the most discriminating (area under curve 0.80, p<0.001); they demonstrated similar ability, as the 8 C-IADL, to discriminate cognitive status. Assessing performance on these two C-IADL takes 10–15 minutes.
This is the first demonstration of the discriminative ability of preclinical disability in distinguishing MCI from cognitively normal older adults. These findings highlight potential tasks, when measured with the observation-based PASS, which demonstrate increased effort for individuals with MCI. These tasks may be considered when attempting to diagnose MCI or Mild Neurocognitive Disorder in clinical practice and research.
PMCID: PMC4107156  PMID: 24890517
Cognitive Function; Mild Cognitive Impairment; Mild Neurocognitive Disorder; Activities of Daily Living; Instrumental Activities of Daily Living
10.  Communication Profiles of Psychiatric Residents and Attending Physicians in Medication-Management Appointments: A Quantitative Pilot Study 
The authors quantitatively examined differences in psychiatric residents’ and attending physicians’ communication profiles and voice tones.
Audiotaped recordings of 49 resident–patient and 35 attending–patient medication-management appointments at four ambulatory sites were analyzed with the Roter Interaction Analysis System (RIAS). Nonparametric tests were used to compare differences in proportions of speech devoted to relationship-building, activating, and partnering in decision-making processes, and data-gathering/counseling/patient education. Differences in affect expressed by psychiatrists’ voice tones were also examined.
Residents’ visits were twice as long as Attendings’ visits (28.2 versus 14.1 minutes), and residents devoted a significantly greater proportion of their talk to relationship-building (23% versus 20%) and activating/partnering (36% versus 28%) aspects of communication, whereas Attendings devoted a greater proportion to biomedically-related data-gathering/counseling/ patient education (31% versus 20%). Analysis of voice tones revealed that residents were perceived as sounding significantly friendlier and more sympathetic, versus Attendings, who were rated as sounding more dominant and rushed.
These findings show distinct communication profiles and voice-tone differences. Future psychiatric communication research should address the influence of appointment length, psychiatrist/patient characteristics, and other potential confounders on psychiatrist–patient communication.
PMCID: PMC4091875  PMID: 22532197
11.  Coaching in Healthy Dietary Practices in At-Risk Older Adults: A Case of Indicated Depression Prevention 
The American journal of psychiatry  2014;171(5):499-505.
Prevention of major depressive disorder is important because current treatments are only partially adequate in reducing symptom burden and promoting health-related quality of life. Lifestyle interventions may be a desirable prevention strategy for reasons of patient preference, particularly among older patients from minority groups. Using evidence from a randomized depression prevention trial for older adults, the authors found that coaching in healthy dietary practices was potentially effective in protecting at-risk older adults from developing incident episodes of major depression. The authors describe the dietary coaching program (highlighted in a case example) as well as the feasibility and potential efficacy of the program within the context of evidence-based interventions for preventing episodes of major depression and mitigating symptoms of depression. Older adults receiving dietary coaching experienced a low incidence of major depressive episodes and exhibited a 40%–50% decrease in depressive symptoms, as well as enhanced well-being, during the initial 6-week intervention; these gains were sustained over 2 years. The authors also describe why lifestyle interventions like coaching in healthy dietary practices may hold promise as effective, practical, nonstigmatizing interventions for preventing episodes of major depressive disorder in older adults with sub-syndromal depressive symptoms.
PMCID: PMC4083759  PMID: 24788282
12.  Serotonin-norepinephrine reuptake inhibitor therapy in late-life depression is associated with increased marker of bone resorption 
Antidepressants have been associated with increased bone loss and fractures in older adults in observational studies, but the mechanism is unclear. We examined the effects of a serotonin-norepinephrine reuptake inhibitor, venlafaxine, on biomarkers of bone turnover in a prospective treatment study of late-life depression.
76 individuals aged 60 and older with current major depressive disorder received a 12-week course of venlafaxine XR 150-300mg daily. We measured serum C-terminal cross-linking telopeptide of type I collagen (β-CTX) and N-terminal propeptide of type I procollagen (P1NP), measures of bone resorption and formation, respectively, before and after treatment. We then analyzed the change in β-CTX and P1NP within each participant. Venlafaxine levels were measured at the end of the study. We assessed depression severity at baseline and remission status after treatment.
After 12 weeks of venlafaxine, β-CTX increased significantly, whereas P1NP did not significantly change. The increase in β-CTX was significant only in participants whose depression did not remit (increase of 10% in non-remitters versus 4% in remitters). Change in β-CTX was not correlated with serum levels of venlafaxine or norvenlafaxine.
Our findings suggest that the primary effect of serotonergic antidepressants is to increase bone resorption. However, such an increase in bone resorption seemed to depend on whether or not participants’ depression remitted. Our results are in agreement with prior observational studies reporting increased bone loss in older adults taking serotonergic antidepressants. These negative effects on bone homeostasis could potentially contribute to increased fracture risk in older adults.
PMCID: PMC4066460  PMID: 23358607
13.  Just Say Know: An Examination of Substance Use Disorders among Older Adults in Gerontological and Substance Abuse Journals 
Social work in public health  2013;28(0):377-387.
This article examines the extent to which studies of alcohol abuse, illicit drug use, and prescription drug abuse among older adults appear in the leading gerontological and substance abuse journals. The authors reviewed articles published in the 10 social science gerontological journals and the 10 social science substance abuse journals with the highest 5-year impact factors in PubMed from 2000 to 2010. Articles were selected that presented original research on alcohol, substance, or prescription abuse with older adults aged 50 and older; and were identified through aging and substance abuse-related Medical Subject Headings and word searches of titles and abstracts (N = 634). Full text of each article was reviewed by the authors, and consensus determined inclusion in the final sample. Of the 19,953 articles published respectively in the top 10 gerontological and substance abuse journals, 181 articles met the inclusion criteria of reporting findings related to substance use disorders among older adults. Specifically, 0.9% (102 of 11,700) of articles from the top 10 gerontology journals and 1.0% (79 of 8,253) of articles from the top 10 substance abuse journals met the criteria. Most published articles addressed alcohol misuse/abuse or polysubstance abuse with few articles addressing illicit drug use or the misuse of prescription medications. Less than 1% of articles published in the 10 gerontology journals and the 10 substance abuse journals with the highest 5-year impact scores addressed substance abuse in older adults. Practitioners treating health and/or mental health problems are at a disadvantage in accurately identifying and treating these conditions in older adult populations without a proper understanding of the role of comorbid substance use disorders.
PMCID: PMC4047645  PMID: 23731426
Older adults; substance-related disorders; alcohol-related disorders; bibliometric analysis; prescription drug abuse; addiction
14.  The Long-Term Effects of Conventional and Atypical Antipsychotics in Patients With Probable Alzheimer’s Disease 
The American journal of psychiatry  2013;170(9):1051-1058.
The authors sought to determine the effects of conventional and atypical antipsychotic use on time to nursing home admission and time to death in a group of outpatients with mild to moderate probable Alzheimer’s disease.
The authors examined time to nursing home admission and time to death in 957 patients with the diagnosis of probable Alzheimer’s disease who had at least one follow-up evaluation (mean follow-up time, 4.3 years [SD=2.7]; range, 0.78–18.0 years) using Cox proportional hazard models adjusted for age, gender, education level, dementia severity, hypertension, diabetes mellitus, heart disease, extrapyramidal signs, depression, psychosis, aggression, agitation, and dementia medication use.
A total of 241 patients (25%) were exposed to antipsychotics at some time during follow-up (conventional, N=138; atypical, N=95; both, N=8). Nursing home admission (63% compared with 23%) and death (69% compared with 34%) were more frequent in individuals taking conventional than atypical antipsychotics. In amodel that included demographic and cognitive variables, hypertension, diabetes mellitus, heart disease, incident strokes, and extrapyramidal signs, only conventional antipsychotic use was associated with time to nursing home admission. However, the association was no longer significant after adjustment for psychiatric symptoms. Psychosis was strongly associated with nursing home admission and time to death, but neither conventional nor atypical antipsychotics were associated with time to death.
The use of antipsychotic medications, both conventional and atypical, was not associated with either time to nursing home admission or time to death after adjustment for relevant covariates. Rather, it was the presence of psychiatric symptoms, including psychosis and agitation, that was linked to increased risk of institutionalization and death after adjustment for exposure to antipsychotics.
PMCID: PMC3990263  PMID: 23896958
15.  Preventing Depression 
Jama  2012;307(10):1033-1034.
PMCID: PMC3397158  PMID: 22416097
16.  Depression in Late-Life: a Focus on Prevention 
Depression is a leading cause of disease burden, disability and distress for millions of older adults. Thus, prevention of late-life depression is a priority research area. This article addresses the science of late-life depression prevention with the following: 1) an introduction to the Institute of Medicine framework of universal, selective and indicated prevention as it pertains to late-life depression, with particular attention to successes of indicated and selective prevention in primary care; 2) a discussion of how biomarkers can be integrated into prevention research, using interferon-alpha-induced depression as a model; 3) an outline for expansion of prevention to non-specialist care delivery systems in Low and Middle Income Countries – thus, extending the reach of current successful approaches; 4) a description of a novel approach to simultaneous testing of universal, selective and indicated prevention in late-life depression, with emphasis on study design features required to achieve practical, scalable tests of health impact.
PMCID: PMC3982610  PMID: 24729758
17.  Neuroimaging and neurocognitive abnormalities associated with bipolar disorder in old age 
Cognitive dysfunction is prevalent in older adults with bipolar disorder (BD). High white matter hyperintensity (WMH) burden, a marker of white matter disease, detected on T2/fluid-attenuated inversion recovery brain magnetic resonance imaging (MRI) has been consistently reported in BD across all age ranges, including older adults. Yet, whether high WMH burden is related to the excess cognitive impairment present in older adults with BD is unknown. Therefore, we examine whether higher WMH burden is related to worse cognitive function in older adults with BD.
This is a cross-sectional study of 27 non-demented BD patients aged ≥50 years and 12 similarly aged mentally healthy comparators (controls). Subjects underwent both brain MRI and comprehensive neurocognitive assessment. We employed correlational analyses to evaluate the burden of WMH and the relationship between WMH and cognitive function.
Although BD subjects had worse performance in all cognitive domains, BD subjects had less total WMH burden (t[13.4] = −3.57, p = 0.003). In control subjects, higher WMH was related to lower global cognitive function (ρ= −0.57, n= 12, p = 0.05). However, WMH did not correlate with neuropsychological performance in BD subjects. Further, BD and control subjects did not differ with respect to total gray and hippocampal volumes.
Cognitive dysfunction in late-life BD does not appear to be due primarily to processes related to increased WMH or reduced gray matter volume. Future longitudinal studies should examine other potential neuroprogressive pathways such as inflammation, mitochondrial dysfunction, serum anticholinergic burden, and altered neurogenesis.
PMCID: PMC3947373  PMID: 24006234
bipolar disorder; cognition; aging; neuroimaging
18.  Dream Content in Complicated Grief: A Window into Loss-Related Cognitive Schemas Running Head: Dreams in Complicated Grief 
Death studies  2013;37(3):269-284.
Bereavement and its accompanying psychological response (grief) constitute potent experiences that necessitate the reorganization of cognitive-affective representations of lost significant attachment figures during both wakefulness and dreaming. The goals of this preliminary study were to explore whether the dream content of 77 adults with complicated grief (CG) differed from that of a normative sample, and to explore whether CG patients who dream of the deceased differ from CG patients who do not dream of the deceased on measures of daytime emotional distress. CG dreams were characterized by more family and familiar characters including the deceased (in women), and fewer social interactions and emotions compared to norms. Increased representations of familiar characters in CG dreams may reflect attempts to reorganize relational cognitive schemas to compensate for the loss.
PMCID: PMC3929213  PMID: 24524436
19.  Predictors of Adequate Depression Treatment among Medicaid-Enrolled Adults 
Health Services Research  2010;45(1):302-315.
To determine whether Medicaid-enrolled depressed adults receive adequate treatment for depression and to identify the characteristics of those receiving inadequate treatment.
Data Source
Claims data from a Medicaid-enrolled population in a large mid-Atlantic state between July 2006 and January 2008.
Study Design
We examined rates and predictors of minimally adequate psychotherapy and pharmacotherapy among adults with a new depression treatment episode during the study period (N=1,098).
Principal Findings
Many depressed adults received either minimally adequate psychotherapy or pharmacotherapy. Black individuals and individuals who began their depression treatment episode with an inpatient psychiatric stay for depression were markedly less likely to receive minimally adequate psychotherapy and more likely to receive inadequate treatment.
Racial minorities and individuals discharged from inpatient treatment for depression are at risk for receiving inadequate depression treatment.
PMCID: PMC2813450  PMID: 19878343
Depression; quality of care; Medicaid
20.  Cost-Effectiveness of Medicare Drug Plans in Schizophrenia and Bipolar Disorder 
Medicare Part D has a drug coverage gap, imposing risks for discontinuing medications, particularly in mental health disorders where drug costs are high. However, some beneficiaries have generic drug coverage in the gap. We examine the health outcomes and cost-effectiveness of generic drug coverage compared to no gap coverage in patients with bipolar disorder and schizophrenia.
Study Design
Markov model-based cost-effectiveness analysis using identical hypothetical cohorts to examine drug coverage strategies.
The incremental cost-effectiveness of Part D coverage strategies was estimated, using differences in medical costs and quality adjusted life years between plans. Coverage strategy-specific costs and hospitalization rates were obtained from 2007 Medicare data, adjusted for age, sex, race, and health status.
When comparing generic and no gap coverage, generic-only coverage cost less and was more effective than plans with no gap coverage, due mainly to lower hospitalization rates. In sensitivity analyses, generic-only coverage continued to be favored over no gap coverage, unless generic coverage costs increased ≥3% in bipolar disorder and ≥5% in schizophrenia; generic coverage in the gap was also favored in probabilistic sensitivity analyses.
In Medicare Part D, generic drug coverage was cost saving compared to no coverage in bipolar disorder and schizophrenia while improving health outcomes. Policy makers and insurers might consider generic-only coverage, rather than no gap coverage plans, to both conserve health care resources and improve health.
PMCID: PMC3589737  PMID: 23448115
21.  Economic inequalities in the effectiveness of a primary care intervention for depression and suicidal ideation 
Economic disadvantage is associated with depression and suicide. We sought to determine whether economic disadvantage reduces the effectiveness of depression treatments received in primary care.
We conducted differential-effects analyses of the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), a primary care-based randomized, controlled trial for late-life depression and suicidal ideation conducted between 1999 and 2001, which included 514 patients with major depression or clinically significant minor depression.
The intervention effect, defined as change in depressive symptoms from baseline, was stronger among persons reporting financial strain at baseline (differential effect size= −4.5 Hamilton Depression Rating Scale points across the study period; 95% confidence interval = −8.6 to −0.3). We found similar evidence for effect modification by neighborhood poverty, although the intervention effect weakened after the initial 4 months of the trial for participants residing in poor neighborhoods. There was no evidence of substantial differences in the effectiveness of the intervention on suicidal ideation and depression remission by economic disadvantage.
Economic conditions moderated the effectiveness of primary care-based treatment for late-life depression. Financially strained individuals benefitted more from the intervention; we speculate this was because of the enhanced treatment management protocol, which lead to a greater improvement in the care received by these persons. People living in poor neighborhoods experienced only temporary benefit from the intervention. Thus, multiple aspects of economic disadvantage affect depression treatment outcomes; additional work is needed to understand the underlying mechanisms.
PMCID: PMC3523272  PMID: 23232609
22.  Social inequalities in depression and suicidal ideation among older primary care patients 
Depression and suicide are major public health concerns, and are often unrecognized among the elderly. This study investigated social inequalities in depressive symptoms and suicidal ideation among older adults.
Data come from 1,226 participants in PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial), a large primary care-based intervention trial for late-life depression. Linear and logistic regressions were used to analyze depressive symptoms and suicidal ideation over the two-year follow-up period.
Mean Hamilton Depression Rating Scale (HDRS) scores were significantly higher among participants in financial strain (regression coefficient (b)=1.78, 95% confidence interval (CI)=0.67–2.89) and with annual incomes below $20,000 (b=1.67, CI=0.34–3.00). Financial strain was also associated with a higher risk of suicidal ideation (odds ratio=2.35, CI=1.38–3.98).
There exist marked social inequalities in depressive symptoms and suicidal ideation among older adults attending primary care practices, the setting in which depression is most commonly treated. Our results justify continued efforts to understand the mechanisms generating such inequalities, and to recognize and provide effective treatments for depression among high-risk populations.
PMCID: PMC3543515  PMID: 22948560
Depression; suicide; older adulthood; inequalities; primary care
23.  Reward Signals, Attempted Suicide, and Impulsivity in Late-Life Depression 
JAMA psychiatry (Chicago, Ill.)  2013;70(10):10.1001/jamapsychiatry.2013.75.
Suicide can be viewed as an escape from unendurable punishment at the cost of any future rewards. Could faulty estimation of these outcomes predispose to suicidal behavior? In behavioral studies, many of those who have attempted suicide misestimate expected rewards on gambling and probabilistic learning tasks.
To describe the neural circuit abnormalities that underlie disadvantageous choices in people at risk for suicide and to relate these abnormalities to impulsivity, which is one of the components of vulnerability to suicide.
Case-control functional magnetic resonance imaging study of reward learning using a reinforcement learning model.
University hospital and outpatient clinic.
Fifty-three participants 60 years or older, including 15 depressed patients who had attempted suicide, 18 depressed patients who had never attempted suicide (depressed control subjects), and 20 psychiatrically healthy controls.
Components of the cortical blood oxygenation level–dependent response tracking expected and unpredicted rewards.
Depressed elderly participants displayed 2 distinct disruptions of control over reward-guided behavior. First, impulsivity and a history of suicide attempts (particularly poorly planned ones) were associated with a weakened expected reward signal in the paralimbic cortex, which in turn predicted the behavioral insensitivity to contingency change. Second, depression was associated with disrupted corticostriatothalamic encoding of unpredicted rewards, which in turn predicted the behavioral oversensitivity to punishment. These results were robust to the effects of possible brain damage from suicide attempts, depressive severity, co-occurring substance use and anxiety disorders, antidepressant and anticholinergic exposure, lifetime exposure to electroconvulsive therapy, vascular illness, and incipient dementia.
Altered paralimbic reward signals and impulsivity and/or carelessness may facilitate unplanned suicidal acts. This pattern, also seen in gambling and cocaine use, may reflect a primary deficit in the paralimbic cortex or in its mesolimbic input. The overreactivity to punishment in depression may be caused in part by a disruption of appetitive learning in the corticostriatothalamic circuits.
PMCID: PMC3859132  PMID: 23925710
24.  Association of small vessel ischemic white matter changes with BOLD fMRI imaging in the elderly 
Psychiatry research  2012;204(2-3):117-122.
White matter hyperintensities (WMHs) are often identified on T2-weighted magnetic resonance (MR) images in the elderly. The WMHs are generally associated with small vessel ischemic or pre-ischemic changes. However, the association of WMHs with blood oxygen level dependent (BOLD) functional magnetic resonance imaging (fMRI) signal is understudied. In this study, we evaluate how the BOLD signal change is related to the presence of WMHs in the elderly. Data were acquired as part of a study of late-life depression and included elderly individuals with and without major depression. The subjects were pooled because the presence of depression was not significantly associated with task-related BOLD changes, task performance, and WMH distribution. A whole brain voxel-wise regression analysis revealed a significant negative correlation between WMH burden and BOLD signal change during finger-tapping in the parietal white matter. Our observation that WMHs are associated with a significant diminution of the BOLD signal change underscores the importance of considering cerebrovascular burden when interpreting fMRI studies in the elderly. The mechanism underlying the association of WMH and BOLD signal change remains unclear: the association may be mediated by changes in neural activation, changes in coupling between neuronal activity and hemodynamics, or, perhaps, secondary to the effect of the ischemic changes on the sensitivity of the T2* BOLD MR signal.
PMCID: PMC3518674  PMID: 23131524
Functional imaging; structural imaging; white matter hyperintensities; BOLD; aging
25.  Maintenance Treatment of Depression in Old Age: A Randomized, Double-blind, Placebo-Controlled Evaluation of the Efficacy and Safety of Donepezil Combined with Antidepressant Pharmacotherapy 
Archives of general psychiatry  2011;68(1):51-60.
Cognitive impairment in late-life depression is a core feature of the illness.
to test whether donepezil + antidepressant is superior to placebo + antidepressant in (1) improving cognitive performance and instrumental activities of daily living and (2) reducing recurrences of depression over two years of maintenance treatment.
Randomized, double-blind, placebo controlled maintenance trial.
university clinic
Main Outcome Measures
global neuropsychological performance, cognitive instrumental ADL, and recurrent depression.
Donepezil + antidepressant temporarily improved global cognition (treatment by time interaction F = 3.78, df = 2, 126, p = .03), but effect sizes were small (Cohen’s d = 0.27: group difference at 1 year). A marginal benefit to cognitive instrumental ADL was also observed (treatment by time interaction; F = 2.94; df = 2, 137, p = 0.06). The donepezil group was more likely to experience recurrent major depression: 35% [95% CI: 24%, 46%] versus 19% [95% CI: 9%, 29%] (log rank chi squared = 3.97, p = .05); hazard ratio = 2.09 [95% CI: 1.00, 4.41]. Post-hoc subgroup analyses showed that, of 57 participants with mild cognitive impairment, 3/30 on donepezil (10%; 95% CI: 0, 21%) and 9/27 on placebo (33%; 95% CI: 16%, 51%) converted to dementia over two years (Fisher exact p = 0.05). The MCI subgroup had a 44 percent recurrence rate of major depression on donepezil verses 12% on placebo (LR=4.91, p=.03). The subgroup with normal cognition (n = 73) showed no benefit on donepezil or increase in recurrence of major depression.
Whether ChEI should be used as augmentation in the maintenance treatment of late-life depression depends upon a careful weighing of risks and benefits in those with MCI. In cognitively intact patients, donepezil appears to have no clear benefit for preventing progression to MCI/dementia or recurrence of depression.
PMCID: PMC3076045  PMID: 21199965

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