INTRODUCTION:Approximately 90% of persons with dementia experience behavioral and psychological symptoms of dementia (BPSD). Primary care clinicians often are the main health care professionals managing the care of persons with dementia who exhibit BPSD, yet many lack training and resources needed for management. DETAILD (Dementia Educational Techniques: Academic detaILing and DICE) is an educational intervention designed to enhance clinicians' knowledge, confidence, and implementation of evidence-based practices for recognizing and managing BPSD. OBJECTIVES:This study aimed to identify clinician-level factors that influence the reach, adoption, implementation, and effectiveness of the DETAILD intervention in supporting primary care clinicians in managing BPSD. METHODS:Semistructured qualitative interviews were conducted with 14 clinicians. A framework-guided analysis was used to identify knowledge and practice gaps in BPSD management and factors that affect engagement with the DETAILD program. RESULTS:Clinicians identified gaps in knowledge and self-efficacy related to recognizing and managing BPSD, particularly in applying nonpharmacologic strategies and care planning. Eleven themes emerged that influenced DETAILD's reach, adoption, implementation, and effectiveness, including the need for personalized care approaches, team-wide buy-in, applied learning methods, and training logistics. Clinicians emphasized the benefits of case-based learning and the need for flexible formats and foundational knowledge. CONCLUSIONS:Findings highlight significant gaps in knowledge, confidence, and resources related to BPSD management among primary care clinicians. Identified barriers and facilitators informed adaptations to the DETAILD intervention aimed at enhancing clinician engagement, supporting practice change, and ultimately improving dementia care within primary care settings.

PhenoAge is a multi-system blood-based aging marker that uses common clinical tests of glucose metabolism, inflammation and kidney and liver function. This easily-obtained marker determines whether a person is younger or older on a biological and physiological level than expected by their chronological age. A higher PhenoAge is associated with increased risk of disability, age-related morbidities and all-cause mortality. Its associations with early cognitive changes in midlife is less understood. The aim of this study was to determine whether accelerated PhenoAge in midlife was associated with 10-year cognitive changes in middle-aged to older adults. This longitudinal study is based on N  = 2,630 (54% women; mean age 50 years;Table 1) Beaver Dam Offspring Study (BOSS) participants. We measured baseline blood-based clinical markers of health necessary for calculation of PhenoAge and calculated accelerated PhenoAge (PhenoAgeAccel) as the residual of a linear model with chronological age as the predictor and PhenoAge as the outcome. We tested Trail-making Test B (TMT-B) performance at baseline, 5-year and 10-year follow-up. We used a linear mixed-effects model with PhenoAgeAccel as predictor and TMT-B time as outcome, adjusting for random intercepts, sex and education. We repeated models stratified by sex. We found with every additional year older in PhenoAge compared to chronological age at baseline, participants performed worse on the TMT-B at baseline [complete sample: 0.60 seconds slower, 95% Confidence Interval (0.29,0.91); women: 0.34 (-0.05,0.72); men: 0.91 (0.41,1.42), Figure 1]. Moreover, with every additional year older in PhenoAge compared to chronological age at baseline, participants had a faster decline in TMT-B over the 10-year follow-up [main effect + wave interaction: complete sample: 0.94 seconds slower (0.58,1.29); women: 0.51 (0.08,0.95); men: 1.48 (0.90,2.07);Figure 1]. Accelerated PhenoAge in midlife was associated with cognitive decline over 10 years, overall and in men. Longer follow-up will be needed to investigate sex differences further and to determine whether PhenoAge might be predictive of the onset of cognitive impairment later in life. If confirmed, PhenoAge could become a cost-effective marker of cognitive decline and dementia and might help identify at-risk individuals early. This could inform targeted prevention and treatment methods to promote healthy brain aging.

INTRODUCTION:Health science educators often receive little formal training in teaching methods, which may limit the adoption of evidence-based strategies. Synchronous, less flexible development programs are also difficult for many interprofessional educators to access. METHODS:We designed Education Essentials, a modular, asynchronous curriculum to support foundational teaching skill development across health professions. Guided by growth mindset and experiential learning frameworks and informed by our needs assessment, we developed 9 modules aligned with core teaching domains. RESULTS:As of April 2025, 185 unique learners had enrolled in at least 1 of the first 6 modules, with 110 modules completed. DISCUSSION:This curriculum addresses an institutional need and supports scalable, accessible educator development across clinical, basic science, and interprofessional settings.

Primary care clinicians report limited self-efficacy for managing complex behavioral and psychological symptoms in persons with dementia (BPSD). Complementary approaches, the academic detailing model and the DICE Approach TM , improved self-efficacy for memory clinic clinicians and their teams to identify and manage BPSD. Methods guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) / PRISM (Practical, Robust, Implementation and Sustainability Model) framework are shared for pre-implementation adaptation of this program for generalist primary care. A stakeholder-engaged qualitative study with both current and future program stakeholders was used to identify a) gaps in BPSD management, and b) multi-level barriers and facilitators to the academic detailing model. Framework guided semi-structured interview topics included contextual factors impacting program reach, reasons for adoption and program effectiveness, and barriers and facilitators for implementation. The team completed 14 interviews; 7 with clinicians practicing in primary care integrated memory clinics with prior academic detailing participation (Champions) and among 7 clinician colleagues with no or minimal program experience (Novices). Inductive and deductive qualitative thematic analysis approaches were used, the latter organized by RE-AIM domains and multi-level context. A sample of themes and adaptations for shaping program access and fit (Reach) are shared. 1) Applied learning supports knowledge and self-efficacy for BPSD care. Case-based, experiential learning fits for both experienced and inexperienced clinicians. Champions acknowledge experiential learning builds confidence (facilitator), while Novices note having limited direct care experience (barrier). Adaptations for Novices will include more extensive introduction to identifying and managing BPSD and emphasize building confidence. 2) Improve access to education and materials. Champions noted the challenge to “keep tools at your fingertips” could be overcome with reference materials or templates while Novices highlighted needing access to more structured resources in light of numerous guidelines to follow in primary care. In response, user-friendly BPSD management resource guides to support clinical decisions have been developed. We provide a novel qualitative application RE-AIM/PRISM with both current and future stakeholders to inform adaptations pre-implementation. This approach will aid identifying contextual barriers and facilitators to reach, adoption, implementation, and effectiveness of academic detailing for delivery to generalist primary care teams.

PhenoAge, a multi-system biomarker uses easily-obtained common clinical blood tests and determines whether a person is younger or older on a biological and physiological level than expected by chronological age. Higher PhenoAge is associated with increased risk of disability, age-related morbidities and all-cause mortality. Its associations with early cognitive changes in midlife are less understood. The aim of this study was to determine whether accelerated PhenoAge in midlife was associated with 10-year cognitive changes in middle-aged to older adults. This longitudinal study is based on N = 2,630 (54% women;mean age 50years) Beaver Dam Offspring Study participants. We measured baseline blood-based clinical markers necessary for calculation of accelerated PhenoAge (PhenoAgeAccel). We tested Trail-making Test B (TMT-B) performance at baseline, 5-year and 10-year follow-up. We used linear mixed-effects model with PhenoAgeAccel as predictor and TMT-B time as outcome, adjusting for random intercepts, education and sex. Models were repeated sex-stratified. With every additional year older in PhenoAge compared to chronological age at baseline, participants performed worse on the TMT-B at baseline [overall:0.60 seconds slower, 95% Confidence Interval (0.29,0.91); women: 0.34(-0.05,0.72); men: 0.91(0.41,1.42)] and had a faster decline in TMT-B over 10-years [overall:0.94 seconds slower (0.58,1.29); women: 0.51(0.08,0.95); men: 1.48(0.90,2.07)]. Accelerated PhenoAge in midlife was associated with 10-year cognitive decline, overall and in men. Longer follow-up will be needed to determine whether PhenoAge might be predictive of cognitive impairment later in life. If confirmed, PhenoAge could become a cost-effective marker of cognitive decline and dementia and help identify at-risk individuals early and inform targeted interventions.

The Wisconsin Alzheimer's Institute Dementia Diagnostic Clinic Network (DDCN) serves as a community of practice for interdisciplinary memory clinics located in primary care- (internal medicine, family medicine, or geriatrics) or specialty-clinics (neurology or psychiatry). We sought to examine differences in medical screenings performed, and suspected etiologies according to practice setting (primary care- vs specialty care-based). Considering that most patients seen in DDCN clinics are referred by their PCPs, this analysis is restricted to those patients, to better understand what additional support primary care teams outside the network may need for making a diagnosis of ADRD. Cross-sectional data submitted by DDCN clinics between 2021 and 2024 was analyzed. Data was collected during the patient's initial visit and included patient sociodemographics, screenings performed/needed, and suspected primary and secondary diagnoses. Data analyzed was only for patients who were referred to DDCN by a PCP. Descriptive analyses included chi-square tests comparing diagnostic experiences by practice-setting; and multivariate logistic regression modeling used to evaluate steps associated with making an ADRD diagnosis by practice will be presented. 17 primary care- and 11 specialty-led clinics submitted data for 2,605 and 1,309 patients, respectively. Significantly different patterns emerged by setting ( p  = 0.001) for patient age, race/ethnicity, education level, reason for visit and suspected clinical syndrome (Table 1). Slightly more patients from DDCN primary care-led clinics were subsequently suspected to have no cognitive impairment (17.2% vs 12.2%). Issues with sleep (e.g. sleep apnea) were identified more frequently in primary care-based DDCN clinics (30.5% vs 20.5%, p  <0.001). Among patients seen in primary-care DDCN clinics, there was a higher proportion of suspected diagnosed with ADRD+depression (13.5% vs 4.0%), ADRD+sleep disorders (14.8% vs 1.2%), sleep disorders (35.2% vs 10.7%) or medication-related cognitive decline (13.8% vs 4.1%) (Table 2). Findings suggest that DDCN primary care-based clinics receive more patients with potentially reversible causes of cognitive decline, suggesting that changes in primary care diagnostic practices could reduce the need for referrals to specialty memory clinics. Increasing the capacity to diagnose and manage reversible causes of cognitive impairment within primary care could potentially lead to reduced wait times for specialty dementia care.

AbstractINTRODUCTIONUnderstanding how a research sample compares to the population from which it is drawn can help inform future recruitment planning. We compared the Wisconsin Alzheimer's Disease Research Center (WADRC) participant sample to the Wisconsin state population (WI‐pop) on key demographic, social exposome, and vascular risk measures.METHODSThe WADRC sample included 930 participants. Population statistics were estimated using several national and state data sources. We compared WADRC to WI‐pop for two age groups, 45–64 years and ≥65 years, separately.RESULTSCompared to WI‐pop, WADRC participants were older and included more women, more Black and American Indian individuals, and fewer Hispanic and Asian individuals. WADRC participants had higher levels of educational attainment, consisted of smaller proportions living in rural areas and disadvantaged neighborhoods, and showed lower vascular risks. Greater differences between WADRC and WI‐pop were found for most metrics in the ≥65 group compared to the 45–64 group.DISCUSSIONThe findings revealed opportunities to increase enrollment from the Hispanic/Latino and Asian American populations, to include participants from a broader range of educational backgrounds, and to enroll more residents from rural areas and disadvantaged neighborhoods, which may lead to a broader distribution of cardiovascular risk factors. Expanding sociodemographic and health profiles represented in the participant candidate pool for study selection and including those who are underrepresented in research may potentially reduce selection bias but not eliminate it. Statistical approaches can be applied to address bias and generalize findings from a study sample to its target population by adjusting for their differences in the joint distribution of covariates. Although research centers have different regional populations and specific recruitment focuses for scientific reasons, evaluating their participant characteristics may help plan engagement efforts to improve the inclusion of underrepresented groups and collaboratively support generalizable research nationwide.Highlights We compared the characteristics of Wisconsin Alzheimer's Disease Research Center (WADRC) participants with the Wisconsin population. Metrics of comparison included demographics, social exposomes, and vascular risks. WADRC participants are different from the Wisconsin population. We explored the implications and causes of the differences. We discussed strategies for engaging and recruiting underrepresented groups.

INTRODUCTION:Nearly 90% of persons living with dementia experience behavioral and psychological symptoms of dementia (BPSD). Primary care clinicians may require more training to address these symptoms. METHODS:We surveyed Wisconsin primary care clinicians to assess their current approaches, needs, and interest in future educational interventions related to managing BPSD. RESULTS:Over 60% of clinicians reported lack of ability or training in managing BPSD, while over 75% expressed interest in educational interventions that included discussion of treatment algorithms or virtual didactics. DISCUSSION:Given the apparent widespread demand and need for educational interventions on BPSD for primary care clinicians, future studies are needed to assess the efficacy of such interventions in improving clinicians' preparedness to care for patients with BPSD.

The majority of persons living with dementia (PLWD) experience at least one behavioral and psychological symptoms of dementia (BPSD) during their illness. 1,2 Unmanaged BPSD can result in increased caregiver stress, hospitalization risk, emergency service use, earlier nursing home placement, and decline in quality of life for both PLWD and their caregivers. 3,4,5,10 Due to a lack of trained geriatricians, most individuals with BPSD receive care from primary care clinicians (PCPs) who report lacking the knowledge and self-efficacy to manage these symptoms effectively. 6,7,8 DETAILD (Dementia Educational Techniques: Academic detaILing and DICE) is an intervention designed to enhance knowledge, confidence, and practice changes for better recognition and management of BPSD in primary care teams. 9,10,11 Our purpose was to identify the challenges clinicians face with PLWD and their caregivers in managing BPSD and adopting the DETAILD approach. Guided by the RE-AIM/PRISM framework 12 , semi-structured interviews were conducted with 14 clinicians in primary care settings serving underserved communities. Seven practiced in primary care-integrated memory clinics with extensive DETAILD training, and seven outside those clinics had some to no training. Qualitative analysis was performed on transcribed interview content using inductive and deductive approaches 13 , incorporating both the RE-AIM framework and multi-level domains 14 . Most clinicians interviewed were White (93%), female (65%), physicians (64%), and all were non-Hispanic or Latino. Clinicians practiced in Family Medicine, Internal Medicine and Behavioral Health, in various urban and rural settings. Several themes emerged regardless of DETAILD experience: (1) Need for care planning communication, coordination and collaboration, (2) Need for family and caregiver support/buy-in, (3) Impact of family and household dynamics, and (4) Benefits of patient/family participation in case consultations. Themes identified as barriers only by clinicians with no DETAILD experience include 5) Lack of a diagnosis and (6) Impact of patient trust and understanding on case consultations. This study highlights the barriers PCPs encounter when consulting with patients and their caregivers to manage BPSD. The findings will inform adaptations of DETAILD to increase participation and its impact on practice change, ultimately improving dementia care in primary care settings and enhancing the quality of life for PLWD and their caregivers.

BACKGROUND:The majority of persons living with dementia (PLWD) experience at least one behavioral and psychological symptoms of dementia (BPSD) during their illness.1,2 Unmanaged BPSD can result in increased caregiver stress, hospitalization risk, emergency service use, earlier nursing home placement, and decline in quality of life for both PLWD and their caregivers.3,4,5,10 Due to a lack of trained geriatricians, most individuals with BPSD receive care from primary care clinicians (PCPs) who report lacking the knowledge and self-efficacy to manage these symptoms effectively.6,7,8 DETAILD (Dementia Educational Techniques: Academic detaILing and DICE) is an intervention designed to enhance knowledge, confidence, and practice changes for better recognition and management of BPSD in primary care teams.9,10,11 Our purpose was to identify the challenges clinicians face with PLWD and their caregivers in managing BPSD and adopting the DETAILD approach. METHOD:Guided by the RE-AIM/PRISM framework12, semi-structured interviews were conducted with 14 clinicians in primary care settings serving underserved communities. Seven practiced in primary care-integrated memory clinics with extensive DETAILD training, and seven outside those clinics had some to no training. Qualitative analysis was performed on transcribed interview content using inductive and deductive approaches13, incorporating both the RE-AIM framework and multi-level domains14. RESULT:Most clinicians interviewed were White (93%), female (65%), physicians (64%), and all were non-Hispanic or Latino. Clinicians practiced in Family Medicine, Internal Medicine and Behavioral Health, in various urban and rural settings. Several themes emerged regardless of DETAILD experience: (1) Need for care planning communication, coordination and collaboration, (2) Need for family and caregiver support/buy-in, (3) Impact of family and household dynamics, and (4) Benefits of patient/family participation in case consultations. Themes identified as barriers only by clinicians with no DETAILD experience include 5) Lack of a diagnosis and (6) Impact of patient trust and understanding on case consultations. CONCLUSION:This study highlights the barriers PCPs encounter when consulting with patients and their caregivers to manage BPSD. The findings will inform adaptations of DETAILD to increase participation and its impact on practice change, ultimately improving dementia care in primary care settings and enhancing the quality of life for PLWD and their caregivers.

PhenoAge is a multi-system aging measure based on easily-obtained clinical blood tests. It has been associated with increased risk of disability, age-related morbidities and mortality. Accelerated PhenoAge (PhenoAgeAccel) measures whether an individual is biologically/physiologically aging faster or slower than expected by their chronological age. It is unclear whether PhenoAgeAccel could also be a marker for increased risk of neurodegeneration. Neurofilament light chain (NfL) is a biomarker for general neurodegeneration, measurable in blood. In this study, we aimed to determine whether PhenoAgeAccel is associated with long-term changes in blood-based NfL levels from mid to later life. This longitudinal study is based on N = 1,508 (mean age=49 years, 54% women) Beaver Dam Offspring Study participants. We measured blood-based clinical markers necessary for calculating PhenoAgeAccel at baseline and serum NfL levels at baseline, 5-year and 10-year follow-up. We used linear mixed-effects models with PhenoAgeAccel as predictor and log NfL levels as outcome, adjusting for random intercept, study wave, sex, education, body mass index and kidney diseases. PhenoAgeAccel was not significantly associated with baseline NfL. With every additional year older in PhenoAge compared to chronological age (PhenoAgeAccel) at baseline, participants had faster NfL increases over 10 years [overall: 0.80% faster, 95% Confidence Interval(0.36%,1.25%); women:0.45%(-0.09%,1.00%); men:1.32%(0.57%,2.07%)]. Accelerated PhenoAge in midlife was associated with 10-year increases in NfL, overall and in men. Longer follow-up will be needed to determine whether PhenoAge is predictive of neurodegeneration later in life. PhenoAge could become a potential cost-effective measure to help identify individuals at risk of neurodegeneration and inform early intervention.

BACKGROUND:In 2023, there were 6.7 million Americans living with Alzheimer's disease. The majority of persons living with dementia (PLWD) receive dementia care from primary care providers; however, primary care providers have reported limited training related to behavioral and psychological symptoms of dementia (BPSD) and lacking self-efficacy to manage BPSD. The majority of persons living with dementia experience at least one BPSD, and these symptoms can worsen quality of life and decrease survival. The purpose of our study was to assess the gaps and needs that healthcare professionals face in the identification and management of BPSD, with the goal of informing and tailoring educational programs to address those gaps. METHOD:A survey was content piloted and then disseminated to healthcare providers who are part of the Wisconsin Alzheimer's Institute (WAI) Dementia Diagnostic Clinic Network. Additional respondents were identified through snowball sampling, wherein initial respondents were asked to refer other persons to be surveyed. Respondents were asked to describe their practices with respect to BPSD, to identify gaps and needs for identifying and managing BPSD, and to rate their knowledge of dementia and their skills caring for people living with BPSD. Quantitative and qualitative data will be summarized using mixed methods approaches. RESULT:The survey was completed by 45 healthcare professionals. Many respondents indicated gaps in their individual (53%) and community's (56%) ability to identify and manage BPSD. Gap areas identified included needing an accurate diagnosis, knowledge base related to managing BPSD, lack of access to consultation/resources, and staff training and turnover at facilities. For example, 31% of respondents identified lack of confidence managing sexually inappropriate behaviors, a potential target for future training. These results are preliminary and data collection is ongoing. CONCLUSION:Gaps in the ability to identify and manage BPSD were prevalent among healthcare professionals surveyed. Gaps suggest that healthcare professionals could benefit from educational programming on BPSD, tailored to their needs. The goal of educational programming should be to increase healthcare professionals' knowledge and confidence in identifying and managing BPSD so that they can help improve the lives of PLWD.

In 2023, there were 6.7 million Americans living with Alzheimer's disease. The majority of persons living with dementia (PLWD) receive dementia care from primary care providers; however, primary care providers have reported limited training related to behavioral and psychological symptoms of dementia (BPSD) and lacking self-efficacy to manage BPSD. The majority of persons living with dementia experience at least one BPSD, and these symptoms can worsen quality of life and decrease survival. The purpose of our study was to assess the gaps and needs that healthcare professionals face in the identification and management of BPSD, with the goal of informing and tailoring educational programs to address those gaps. A survey was content piloted and then disseminated to healthcare providers who are part of the Wisconsin Alzheimer's Institute (WAI) Dementia Diagnostic Clinic Network. Additional respondents were identified through snowball sampling, wherein initial respondents were asked to refer other persons to be surveyed. Respondents were asked to describe their practices with respect to BPSD, to identify gaps and needs for identifying and managing BPSD, and to rate their knowledge of dementia and their skills caring for people living with BPSD. Quantitative and qualitative data will be summarized using mixed methods approaches. The survey was completed by 45 healthcare professionals. Many respondents indicated gaps in their individual (53%) and community's (56%) ability to identify and manage BPSD. Gap areas identified included needing an accurate diagnosis, knowledge base related to managing BPSD, lack of access to consultation/resources, and staff training and turnover at facilities. For example, 31% of respondents identified lack of confidence managing sexually inappropriate behaviors, a potential target for future training. These results are preliminary and data collection is ongoing. Gaps in the ability to identify and manage BPSD were prevalent among healthcare professionals surveyed. Gaps suggest that healthcare professionals could benefit from educational programming on BPSD, tailored to their needs. The goal of educational programming should be to increase healthcare professionals’ knowledge and confidence in identifying and managing BPSD so that they can help improve the lives of PLWD.

An academic detailing model has improved self-efficacy of memory clinic clinicians to identify and manage complex behavioral and psychological symptoms in persons with dementia (BPSD). The purpose of this report is to describe a systematic approach to adapting a clinician education program previously delivered in two primary care integrated memory clinics for improving the management of BPSD to also be deliverable outside a memory clinic setting, in generalist primary care clinics. The RE-AIM/PRISM implementation framework guided the approach. Application of the RE-AIM/PRISM framework to the academic detailing program for BPSD was mapped. Framework-guided qualitative interviews were completed with experienced (Champion) and inexperienced (Novice) program stakeholders including questions on perceived gaps in clinical care (BPSD management) and barriers and facilitators to the educational model. Inductive and deductive qualitative thematic analytic approaches were used, the latter organized by RE-AIM domains and multi-level context. Convergence or divergence in organized themes by stakeholder experience shaped examination of fit and interactions among domains, components and strategies of the model for pre-implementation adaptations planning for non-memory clinic primary care clinicians. A pragmatic application of the RE-AIM/PRISM framework was completed for collecting qualitative feedback from stakeholders, identifying multi-level contextual barriers and facilitators, and planning adaptations to our clinician education program. A description of the clinician stakeholders, the approach and one example of a clinician and intervention-level theme identified across RE-AIM domains for the program, self-efficacy in the management of BPSD, and resulting planned adaptations were shared. We provide a novel qualitative application of the RE-AIM/PRISM framework to inform adaptations for an intervention for primary care that incorporates feedback from both current experienced and future inexperienced program stakeholders. This approach can be used to identify multi-level contextual barriers and facilitators to reach, adoption, implementation, and effectiveness of this clinician education programs approach, academic detailing, for future primary care teams.

Increasing understanding of MCI has been identified as a public health priority 1 , however MCI, as a concept, is difficult for professionals, patients, and the public to grasp 2 . There is a need for holistic, person-centered education to support health and wellbeing of persons with MCI and their families 3 (Mpofu 2024). In response to the need for community education the Wisconsin ADRC launched the Healthy Living with Mild Cognitive Impairment (HLMCI) education series to support persons with MCi and their care partners and promote health behaviors known to reduce dementia risk. HLMCI is a quarterly series offering guidance and science-backed strategies for living and coping with a diagnosis of MCI for communities across Wisconsin. Each session is led by the WADRC Medical Director and Clinical Core Co-Leader together with a subject matter expert. Ample time for questions and answers are included in each event. Session topics are selected, guided by the Lancet Commission report on brain health risk factors with preference given to requests from program participants. The program is offered in 7 locations across the state. Including rural communities. In 2024, the most popular topic was “You are More than Your Diagnosis” with 160 registrants. We averaged 112 registrants per session, 28% report a diagnosis of MCI, 35% were care partners and 35% were health or social service professionals. The majority of attendees are women, 45% are URGs. Although the median age of registrants was 55, the programs attract individuals ranging in age from under 35 to over 75; 52 % reported they were interested in finding out if they have amyloid or tau proteins in their brain. Approximately 40% attended 2 or more sessions last year. Satisfaction ratings of the topics and presenters are high ranging from 92 to 94 % across 2024 sessions. Healthy Living with MCI is meeting an unmet need for information and guidance regarding lifestyle changes and activities to support brain health. While the program is designed to support individuals living with mild cognitive impairment, it also provides reliable and unbiased education and support to care partners and health professionals.

The majority of persons living with moderate to severe dementia live in their homes despite the challenges of increasing care needs as dementia progresses. Caregivers are not prepared to understand and manage common medical concerns, such as incontinence, dehydration, and impaired mobility. Health care clinicians need training and tools to better prepare caregivers for these responsibilities. The goal of this program was to address this need by developing an educational program for home health clinicians who treat and support persons living with moderate to severe dementia in their homes. Participants included registered nurses, physical therapists, occupational therapists, speech therapists, and social workers from two home health agencies. Trainings were held throughout a two-year period. Outcomes measured included clinician knowledge, attitudes, and self-efficacy gathered via surveys at baseline, immediately after training, and six-months post-training. Outcomes measured also included caregiver burden, caregiver self-efficacy, and use of medical services and community resources gathered via surveys at baseline and six-months post-training. Twenty-one clinicians were trained; 19 completed the baseline survey and 11 completed the post-training survey. The clinicians implemented the caregiver training with 29 caregivers; 24 completed the baseline survey and 11 completed the six-month post-training survey. Clinicians demonstrated improvements in knowledge and self-efficacy post-training. Clinicians experienced significant improvements in attitudes as measured by the Dementia Attitudes Scale post-training, especially in comfort and familiarity with caring for persons living with dementia. Caregivers reported similar levels of caregiver burden and self-efficiency at baseline and six-months post-training. Caregivers reported overall satisfaction with the training they received from home health clinicians. Persons living with dementia and their caregivers are impacted by changes in cognition, function, and physical health as dementia progresses. Home health clinicians are well-positioned to help address these needs. The training provided to clinicians led to improvement in attitudes and confidence in the care of persons with dementia. Family caregivers reported a high level of satisfaction with the training; however, a small sample size and the effects of the COVID-19 pandemic affected the ability to identify changes in caregiver burden, caregiver self-efficacy, and use of medical and social services.

BACKGROUND:The Wisconsin Alzheimer's Institute Dementia Diagnostic Clinic Network (DDCN) serves as a community of practice for interdisciplinary memory clinics located in primary care- (internal medicine, family medicine, or geriatrics) or specialty-clinics (neurology or psychiatry). We sought to examine differences in medical screenings performed, and suspected etiologies according to practice setting (primary care- vs specialty care-based). Considering that most patients seen in DDCN clinics are referred by their PCPs, this analysis is restricted to those patients, to better understand what additional support primary care teams outside the network may need for making a diagnosis of ADRD. METHODS:Cross-sectional data submitted by DDCN clinics between 2021 and 2024 was analyzed. Data was collected during the patient's initial visit and included patient sociodemographics, screenings performed/needed, and suspected primary and secondary diagnoses. Data analyzed was only for patients who were referred to DDCN by a PCP. Descriptive analyses included chi-square tests comparing diagnostic experiences by practice-setting; and multivariate logistic regression modeling used to evaluate steps associated with making an ADRD diagnosis by practice will be presented. RESULTS:17 primary care- and 11 specialty-led clinics submitted data for 2,605 and 1,309 patients, respectively. Significantly different patterns emerged by setting (p = 0.001) for patient age, race/ethnicity, education level, reason for visit and suspected clinical syndrome (Table 1). Slightly more patients from DDCN primary care-led clinics were subsequently suspected to have no cognitive impairment (17.2% vs 12.2%). Issues with sleep (e.g. sleep apnea) were identified more frequently in primary care-based DDCN clinics (30.5% vs 20.5%, p <0.001). Among patients seen in primary-care DDCN clinics, there was a higher proportion of suspected diagnosed with ADRD+depression (13.5% vs 4.0%), ADRD+sleep disorders (14.8% vs 1.2%), sleep disorders (35.2% vs 10.7%) or medication-related cognitive decline (13.8% vs 4.1%) (Table 2). CONCLUSIONS:Findings suggest that DDCN primary care-based clinics receive more patients with potentially reversible causes of cognitive decline, suggesting that changes in primary care diagnostic practices could reduce the need for referrals to specialty memory clinics. Increasing the capacity to diagnose and manage reversible causes of cognitive impairment within primary care could potentially lead to reduced wait times for specialty dementia care.

Back to table of contents Previous article Next article EditorialsFull AccessOptimizing the Treatment of Late-Life DepressionArt Walaszek, M.D.Art Walaszek, M.D.Published Online:1 Jan 2024https://doi.org/10.1176/appi.ajp.20230919AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Late-life depression (LLD) is a major clinical and public health concern. The worldwide prevalence of major depressive disorder (MDD) in adults age 75 and older is 7.2% (1). With the number of older adults projected to increase from 962 million in 2017 to 2.08 billion in 2050, clinicians around the world should expect to care for many more older adults with depression (2). Depression affects quality of life and the ability to live independently, and it increases mortality (3). Up to 87% of older adults who die by suicide meet criteria for MDD (4), suggesting that effectively treating depression can save lives. Racial, ethnic, and sexual minority older adults face additional challenges. For example, racial minority older adults are less likely than White older adults to have their depression recognized, to receive prescriptions for antidepressants, and to receive specialty mental health care (5).Clinicians can choose from among a number of evidence-based interventions for LLD, including psychotherapy, bright light therapy, exercise, antidepressants, transcranial magnetic stimulation, and electroconvulsive therapy (6). Antidepressants are modestly effective for LLD, with a response rate of 51% (7). People age 65 and older treated with antidepressants experience less suicidality than those given placebo (8). Older adults are at increased risk of antidepressant side effects, including falls, fractures, blood pressure changes, prolongation of the QT interval (with citalopram), SIADH/hyponatremia, and weight change. A systematic review and meta-analysis of antidepressant trials in older adults found an increased risk of adverse events with serotonin-norepinephrine reuptake inhibitors (SNRIs) relative to placebo, resulting in a number-needed-to-harm of 10 (9). The American Geriatrics Society Beers Criteria for potentially inappropriate medication use in older adults note that selective serotonin reuptake inhibitors (SSRIs), SNRIs, mirtazapine, and tricyclic antidepressants—that is, virtually all of the most commonly used antidepressants—are "drugs to be used with caution in older adults" (10). For older adults with mild to moderate depression, the U.S. VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder recommends evidence-based psychotherapy (for example, cognitive-behavioral therapy or interpersonal psychotherapy) over antidepressants given such safety concerns; the authors aptly note that it is a misconception that older adults are not good candidates for psychotherapy (11).Most older adults seek care for depression from their primary care providers. In fact, 12.3% of primary care visits by older adults in 2012 resulted in an antidepressant prescription (up from 9.9% in 2005) (12). SSRIs were most commonly prescribed (63.3%); tricyclic antidepressants and monoamine oxidase inhibitors were least commonly prescribed (13.1% total for the two drug classes) (12). Unfortunately, only 0.2% of primary care visits resulted in a referral to psychotherapy (12).Antidepressants are associated with risks in older adults—but so is depression itself. Alternatives like evidence-based psychotherapy are often unavailable. This begs the question: In situations where the benefits of an antidepressant outweigh the risks, which antidepressant should a clinician choose?Choosing the First AntidepressantIn this issue of the Journal, Ishtiak-Ahmed and colleagues (13) advance our understanding of how to select an antidepressant in previously untreated older adults with depression. The authors used data from two national registers in Denmark (one tracking all people born and living in Denmark since 1968 and the other tracking all prescriptions redeemed in pharmacies in Denmark since 1995) to identify patterns of older adults' antidepressant use for the indication of depression. This group has previously reported a high rate of possible off-label use of antidepressants among older adults in Denmark (14); they also found that 73% of older adults in Denmark who received antidepressant prescriptions had polypharmacy (taking five or more medications), most commonly with other agents acting on the nervous system (89%) (15).In this study, the authors associated the use of specific antidepressants with treatment outcomes: discontinuation, switching, augmentation, psychiatric care, suicide attempts, falls, cardiovascular events, and all-cause mortality. They included 96,737 older adults who took their first antidepressant for depression between 2006 and 2017. The authors limited the study to the 10 most commonly prescribed antidepressants in Denmark (in descending order): citalopram, mirtazapine, escitalopram, sertraline, mianserin (available in Europe, India, and Australia, but not in the United States or Canada), amitriptyline, venlafaxine, duloxetine, fluoxetine, and paroxetine. Sertraline was used as the reference against which other antidepressants were compared because Danish guidelines recommend it as the first-choice treatment for depression. Limitations of the study included the generalizability of the findings to countries outside Denmark and the inability to control for important confounders, such as the severity of depression and the use of alcohol and other substances, and not collecting data regarding the reason for discontinuation (the antidepressant may have been intolerable or ineffective or depression may have remitted, leading a person to choose, not unreasonably, to stop the antidepressant).During 1 year of follow-up, 43.5% of subjects discontinued their initial antidepressant, 20.4% had their initial antidepressant augmented with a second agent (another antidepressant, lithium, or an antipsychotic), and 4.9% switched to another antidepressant. Overall, those who received prescriptions for sertraline seemed to fare best with respect to the selected outcomes, and those who received prescriptions for venlafaxine, mirtazapine, and escitalopram fared worst. The authors note that a previous study (16) using a different methodology—a systematic review and meta-analysis comparing antidepressants in adults of all ages—instead found that venlafaxine, mirtazapine, and escitalopram were more effective than other antidepressants in head-to-head trials. Surprisingly, Ishtiak-Ahmed et al. found that amitriptyline and paroxetine had better overall outcomes than all except sertraline and citalopram (13). I recommend avoiding amitriptyline and paroxetine in older adults because of their anticholinergic burden and, in the case of amitriptyline, the risk of orthostatic hypotension and cardiac effects. Ishtiak-Ahmed and colleagues ultimately agree with Danish prescribing guidelines that sertraline should be the first choice for treatment of LLD (13).How does this compare with the existing guidance on selecting an antidepressant? Although not specific to older adults, the aforementioned VA/DoD guidelines state that clinicians should consider patient preference, the side effect profile of the medication, family history of response to antidepressants (i.e., when possible, select an antidepressant that family members have responded to), comorbid medical problems, currently prescribed medications, and cost (11). For patients who have previously been treated with antidepressants, history of prior response can guide treatment choice (11). Patients with current or past hyponatremia should be offered bupropion or mirtazapine, which are less likely than SSRIs and SNRIs to cause or exacerbate hyponatremia (17). For patients with dementia, citalopram has the strongest evidence base (albeit for agitation rather than depression) but is associated with QT interval prolongation (and carries an FDA black box warning about this) (18).Pharmacogenetic testing raises the possibility of precision medicine in LLD. A systematic review of pharmacogenetic studies of antidepressant response, plasma levels, and tolerability in people age 50 and older found that slow metabolizers at CYP 2D6 had higher plasma levels of relevant antidepressants and required lower doses than normal metabolizers (19). People with the L/L genotype of SLC6A4 5-HTTLPR may be more likely to respond to antidepressants than carriers of an S allele (19). The largest prospective study to date of pharmacogenetics in older adults (N=206) found no difference in depression severity, the primary outcome measure, at 8 weeks in those receiving pharmacogenetics-guided care compared with treatment as usual, although there were statistically significant differences in response rate (29.6% vs. 16.1%) and remission rate (20.1% vs. 7.4%) (20). While these data are promising, additional studies are needed, especially with respect to the cost-effectiveness of pharmacogenetics.Improving the Care of Older Adults With DepressionSo, where does this leave us? First, primary care providers should screen all their patients who are age 65 and older for depression (21). Although the U.S. Preventive Services Task Force recommendations are silent regarding which instrument to use and how often to use it, I recommend using the PHQ-9 annually. Patients who screen positive (e.g., a PHQ-9 score ≥5) should undergo further evaluation to establish the diagnosis, to evaluate the risk of suicide, and to address medical and substance-related issues that could be causing depression, for example, hypothyroidism, obstructive sleep apnea, dementia, alcohol or cannabis use, or medication side effects. Bipolar disorder should be screened for, since the treatment of bipolar depression is very different from the treatment of MDD.Older adults who are found to have mild to moderate MDD (a PHQ-9 score of 5–14) should be offered evidence-based psychotherapy, namely, cognitive-behavioral therapy, interpersonal psychotherapy, problem-solving therapy, or mindfulness-based cognitive therapy (6). Patients with LLD may also benefit from exercise and bright light therapy (22, 23). Patients and their families should be informed of resources like the 988 Suicide and Crisis Lifeline (in the United States).Clinicians should consider prescribing an antidepressant to older adults with moderate to severe depression (a PHQ-9 score ≥10), carefully weighing risks (falls, hyponatremia, etc.), benefits, and drug-drug and drug-disease interactions. The first antidepressant should probably be sertraline or escitalopram, since these have been extensively studied in older adults, are generally well tolerated, and are unlikely to result in drug-drug interactions (24). Clinicians should educate patients about taking the antidepressant daily and for an adequate duration and about reporting any side effects. Clinicians should start low, go slow, but go—that is, titrate the medication to an effective dose—all the while being attentive to side effects and monitoring treatment outcome.Many older adults will not tolerate or benefit adequately from the first antidepressant they take. In fact, 11% of Medicare beneficiaries with MDD have failed to respond to two or more antidepressant trials of adequate dose and duration (25). Reasonable next steps include switching to another antidepressant, combining antidepressants (e.g., an SSRI and bupropion), and augmenting with aripiprazole, lithium, or methylphenidate (6). The OPTIMUM study compared five interventions in people age 60 and older with MDD who had not responded to two or more antidepressant trials (26). Adding aripiprazole (starting at 2.5 mg/day, maximum of 15 mg/day) or adding bupropion (starting at 150 mg/day, target dosage of 300 mg/day, maximum dosage of 450 mg/day) to the current antidepressant was most effective (remission rates of 28.9% and 28.2%, respectively). Surprisingly, aripiprazole was better tolerated than bupropion, with subjects having fewer falls. Switching to bupropion, adding lithium, and switching to nortriptyline were less effective strategies (remission rates of 19.3%, 18.9%, and 21.5%, respectively). We have a long way to go in developing the evidence base for a fully fleshed out algorithm for treatment-resistant LLD, including the role of ketamine and esketamine.Older adults with severe depression, bipolar depression, or an elevated risk of suicide should be referred to a psychiatrist and may benefit from psychiatric hospitalization and/or electroconvulsive therapy. Primary care clinics, federally qualified health centers, and rural health clinics that have not yet done so should consider implementing the collaborative care model, which reduces depression and suicidality in older adults (27, 28).Changes in public policy and the funding of mental health services will be needed to address the growing number of older adults with depression. Fewer and fewer U.S. psychiatrists—now down to 55%—accept Medicare, the health care insurance that the vast majority of older Americans have (29). Medicare's low reimbursement rates and high administrative burden may affect psychiatrists' participation in Medicare and may also decrease the number of physicians interested in primary care or geriatrics (30). Black and Hispanic Medicare beneficiaries have worse depression outcomes than their White counterparts (31). Older adults who live in rural areas or who reside in long-term care facilities have especially poor access to psychiatrists (29, 32). Improving depression outcomes in older adults will require addressing these health care disparities.The U.S. Centers for Medicare and Medicaid Services (CMS) has recently taken steps to improve access to mental health services for older adults. As of January 2024, CMS will allow marriage and family therapists, mental health counselors, and addiction counselors who also qualify as mental health counselors to enroll in Medicare, potentially expanding the mental health workforce for older adults by up to 400,000 therapists (33). CMS will also cover intensive outpatient services, which could provide depressed older adults an additional level of care between hospitalization and routine outpatient care (33). CMS has acknowledged "that there is a systemic undervaluation of work estimates for behavioral health services" that "could serve as an economic deterrent to furnishing these kinds of services and be a contributing factor to the workforce shortage" (34) but for 2024 has proposed only limited increases in reimbursement for mental health services (33) and no reduction of administrative burden. Congress will have to act to make more substantial changes.Ishtiak-Ahmed and colleagues highlight the importance of careful selection of the first antidepressant for LLD (13). In addition, we need to make clinical and public policy changes that ensure that all older adults with depression are identified, correctly diagnosed, and offered evidence-based treatment.Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison.Send correspondence to Dr. Walaszek ([email protected]).Dr. Walaszek receives book royalties from American Psychiatric Association Publishing.References1. Luppa M, Sikorski C, Luck T, et al.: Age- and gender-specific prevalence of depression in latest-life: systematic review and meta-analysis. J Affect Disord 2012; 136:212–221Crossref, Medline, Google Scholar2. Population Division, Department of Economic and Social Affairs, United Nations: World Population Ageing 2017: Highlights (ST/ESA/SER.A/397). New York, United Nations. https://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2017_Highlights.pdfGoogle Scholar3. Fiske A, Wetherell JL, Gatz M: Depression in older adults. Annu Rev Clin Psychol 2009; 5:363–389Crossref, Medline, Google Scholar4. Conwell Y, Thompson C: Suicidal behavior in elders. Psychiatr Clin North Am 2008; 31:333–356Crossref, Medline, Google Scholar5. Mansour R, Tsamakis K, Rizos E, et al.: Late-life depression in people from ethnic minority backgrounds: differences in presentation and management. J Affect Disord 2020; 264:340–347Crossref, Medline, Google Scholar6. Borisovskaya A, Chmelik E, Bryson W, et al.: Management of late-life depression and anxiety; in Late-Life Depression and Anxiety. Edited by Walaszek A. Washington, DC, American Psychiatric Association Publishing, 2022, pp 213–302Google Scholar7. Gutsmiedl K, Krause M, Bighelli I, et al.: How well do elderly patients with major depressive disorder respond to antidepressants: a systematic review and single-group meta-analysis. BMC Psychiatry 2020; 20:102Crossref, Medline, Google Scholar8. Stone M, Laughren T, Jones ML, et al.: Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration. BMJ 2009; 339:b2880Crossref, Medline, Google Scholar9. Sobieraj DM, Martinez BK, Hernandez AV, et al.: Adverse effects of pharmacologic treatments of major depression in older adults. J Am Geriatr Soc 2019; 67:1571–1581Crossref, Medline, Google Scholar10. 2023 American Geriatrics Society Beers Criteria Update Expert Panel: American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2023; 71:2052–2081Crossref, Medline, Google Scholar11. Management of Major Depressive Disorder Work Group: VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder, Version 4.0. Washington, DC, US Department of Veterans Affairs, US Department of Defense, 2022Google Scholar12. Maust DT, Blow FC, Wiechers IR, et al.: National trends in antidepressant, benzodiazepine, and other sedative-hypnotic treatment of older adults in psychiatric and primary care. J Clin Psychiatry 2017; 78:e363–e371Crossref, Medline, Google Scholar13. Ishtiak-Ahmed K, Musliner KL, Christensen KS, et al.: Real-world evidence on clinical outcomes of commonly used antidepressants in older adults initiating antidepressants for depression: a nationwide cohort study in Denmark. Am J Psychiatry 2024; 181:47–56Abstract, Google Scholar14. Ishtiak-Ahmed K, Liu X, Christensen KS, et al.: Treatment indications and potential off-label use of antidepressants among older adults: a population-based descriptive study in Denmark. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5841Crossref, Google Scholar15. Ishtiak-Ahmed K, Köhler-Forsberg O, Mortensen EL, et al.: Concurrent use of polypharmacy and potentially inappropriate medications with antidepressants in older adults: a nationwide descriptive study in Denmark during 2015–2019. Gen Hosp Psychiatry 2023; 82:66–74Crossref, Medline, Google Scholar16. Cipriani A, Furukawa TA, Salanti G, et al.: Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet 2018; 391:1357–1366Crossref, Medline, Google Scholar17. Pinkhasov A, Xiong G, Bourgeois JA, et al.: Management of SIADH-related hyponatremia due to psychotropic medications: an expert consensus from the Association of Medicine and Psychiatry. J Psychosom Res 2021; 151:110654Crossref, Medline, Google Scholar18. Farina N, Morrell L, Banerjee S: What is the therapeutic value of antidepressants in dementia? A narrative review. Int J Geriatr Psychiatry 2017; 32:32–49Crossref, Medline, Google Scholar19. Marshe VS, Islam F, Maciukiewicz M, et al.: Pharmacogenetic implications for antidepressant pharmacotherapy in late-life depression: a systematic review of the literature for response, pharmacokinetics and adverse drug reactions. Am J Geriatr Psychiatry 2020; 28:609–629Crossref, Medline, Google Scholar20. Forester BP, Parikh SV, Weisenbach S, et al.: Combinatorial pharmacogenomic testing improves outcomes for older adults with depression. Am J Geriatr Psychiatry 2020; 28:933–945Crossref, Medline, Google Scholar21. O'Connor E, Henninger M, Perdue LA, et al.: Screening for Depression, Anxiety, and Suicide Risk in Adults: A Systematic Evidence Review for the US Preventive Services Task Force. Rockville, MD, Agency for Healthcare Research and Quality, 2023. (Evidence Synthesis No 223). https://www.ncbi.nlm.nih.gov/books/NBK592805/Google Scholar22. Klil-Drori S, Klil-Drori AJ, Pira S, et al.: Exercise intervention for late-life depression: a meta-analysis. J Clin Psychiatry 2020; 81:19r12877Crossref, Medline, Google Scholar23. Zhao X, Ma J, Wu S, et al.: Light therapy for older patients with non-seasonal depression: a systematic review and meta-analysis. J Affect Disord 2018; 232:291–299Crossref, Medline, Google Scholar24. Lenze EJ, Ajam Oughli H: Antidepressant treatment for late-life depression: considering risks and benefits (editorial). J Am Geriatr Soc 2019; 67:1555–1556Crossref, Medline, Google Scholar25. Pilon D, Joshi K, Sheehan JJ, et al.: Burden of treatment-resistant depression in Medicare: a retrospective claims database analysis. PLoS One 2019; 14:e0223255 [see erratum, PLoS One 2021; 16:e0249731]Crossref, Medline, Google Scholar26. Lenze EJ, Mulsant BH, Roose SP, et al.: Antidepressant augmentation versus switch in treatment-resistant geriatric depression. N Engl J Med 2023; 388:1067–1079Crossref, Medline, Google Scholar27. Unützer J, Katon W, Callahan CM, et al.: Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002; 288:2836–2845Crossref, Medline, Google Scholar28. Bruce ML, Ten Have TR, Reynolds CF, et al.: Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA 2004; 291:1081–1091Crossref, Medline, Google Scholar29. Oh S, McDowell A, Benson NM, et al.: Trends in participation in Medicare among psychiatrists and psychiatric mental health nurse practitioners, 2013–2019. JAMA Netw Open 2022; 5:e2224368Crossref, Medline, Google Scholar30. Berenson RA, Goodson JD: Finding value in unexpected places: fixing the Medicare Physician Fee Schedule. N Engl J Med 2016; 374:1306–1309Crossref, Medline, Google Scholar31. Odlum M, Moise N, Kronish IM, et al.: Trends in poor health indicators among Black and Hispanic middle-aged and older adults in the United States, 1999–2018. JAMA Netw Open 2020; 3:e2025134Crossref, Medline, Google Scholar32. Ulyte A, Mehrotra A, Huskamp HA, et al.: Specialty care after transition to long-term care in nursing home. J Am Geriatr Soc 2023; 71:1058–1067Crossref, Medline, Google Scholar33. Sheshamani M, Jacobs D: Important New Changes to Improve Access to Behavioral Health in Medicare. Baltimore, Center for Medicare and Medicaid Services, 2023. https://www.cms.gov/blog/important-new-changes-improve-access-behavioral-health-medicareGoogle Scholar34. US Department of Health and Human Services: Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program. 88 Federal Register 52,262 (August 7, 2023)Google Scholar FiguresReferencesCited byDetailsCited byImproving Clinical Outcomes and Informing New InterventionsNed H. Kalin, M.D.1 January 2024 | American Journal of Psychiatry, Vol. 181, No. 1 Volume 181Issue 1 January 01, 2024Pages 7-10 Metrics KeywordsAntidepressantsDrug/Psychotherapy CombinationEpidemiologyGeriatric PsychiatryDepressive DisordersMajor Depressive DisorderPDF download History Accepted 14 November 2023 Published online 1 January 2024 Published in print 1 January 2024