Objective: The authors assessed the impact of a shared decision-making (SDM) intervention among elderly depressed minority primary care patients not currently receiving treatment. Methods: A total of 202 English and Spanish-speaking primary care participants aged 65 and older who scored positive on the Patient Health Questionnaire-9 (10) were randomized at the physician level to receive a brief SDM intervention or usual care (UC). Primary analyses focused on patient adherence to either psychotherapy or antidepressant medication, and reduction in depression severity (Hamilton Depression Rating Scale) over 12 weeks. Results: Patients randomized to physicians in the SDM condition were significantly more likely than patients of physicians randomized to UC to receive a mental health evaluation or initiate some form of treatment (39% versus 21%), and to adhere to psychotherapy visits over 12 weeks. There were no differences between groups in adherence to antidepressant medication or in reduction of depressive symptoms. Conclusion: Among untreated elderly depressed minority patients from an inner-city municipal hospital, a brief SDM intervention was associated with greater initiation and adherence to psychotherapy. However, low treatment adherence rates across both groups and the intervention's lack of impact on clinical outcomes highlight the need to provide focused and accessible mental health services to patients choosing active treatments.

The invitation to submit a scientific autobiography to the American Journal of Geriatric Psychiatry is a profound honor and a daunting challenge. Portraying the highlights of professional activities undertaken more than 60 years ago when there was no subspecialty in geriatric psychiatry led me to realize that my career as a clinician, researcher, and mental health planner was conducted within multiple intellectual frameworks requiring both clinical and nonclinical skills. Thus, a career devoted to the care of older persons may include successive interests influenced by emerging psychiatric practices.

IntroductionThe evidence base regarding characteristics of older adults with bipolar disorder (BD) remains limited. The NIH-funded multicenter study Acute Pharmacotherapy of Late-Life Mania (GERI-BD) assessed various clinical domains before and during mood stabilizer treatment in older adults participating in a 9-week, double-blind randomized controlled trial. We describe the rationale for selecting these instruments. MethodsDomains and instruments were selected on the basis of the study design and the participants. The investigators' experience in clinical trials involving young adults with BD or older adults with major depressive disorder, along with open studies of older adults with BD, contributed to the selection process. ResultsWe identified domains and selected instruments that could be used to assess the participants given their diagnostic, treatment history, and medical and mood state characteristics. They were also intended to measure tolerability and efficacy and permit examination of potential moderating and mediating factors. ConclusionsDecisions regarding the assessment domains to be included in the clinical trial highlight the challenges facing researchers studying drug treatments for older adults with BD, or more generally, mood disorders. We suggest that the domains and instruments selected by GERI-BD investigators constitute a toolbox that can be customized for other investigators. Copyright (c) 2017 John Wiley & Sons, Ltd.

OBJECTIVE:Clinicians treating older patients with bipolar disorder with mood stabilizers need evidence from age-specific randomized controlled trials. The authors describe findings from a first such study of late-life mania.METHOD:The authors compared the tolerability and efficacy of lithium carbonate and divalproex in 224 inpatients and outpatients age 60 or older with bipolar I disorder who presented with a manic, hypomanic, or mixed episode. Participants were randomly assigned, under double-blind conditions, to treatment with lithium (target serum concentration, 0.80-0.99 mEq/L) or divalproex (target serum valproate concentration, 80-99 μg/mL) for 9 weeks. Participants with an inadequate response after 3 weeks received open adjunctive risperidone. The authors hypothesized that divalproex would be better tolerated and more efficacious than lithium. Tolerability was assessed based on a measure of sedation and on the proportions of participants achieving target concentrations. Efficacy was assessed with the Young Mania Rating Scale (YMRS).RESULTS:Attrition rates were similar for lithium and divalproex (14% and 18% at week 3 and 51% and 44% at week 9, respectively). The groups did not differ significantly in sedation. Participants in the lithium group tended to experience more tremor. Similar proportions of participants in the lithium and divalproex groups achieved target concentrations (57% and 56%, respectively). A longitudinal mixed model of improvement (change from baseline in YMRS score) favored lithium (change in score, 3.90; 97.5% CI=1.71, 6.09). Nine-week response rates did not differ significantly between the lithium and divalproex groups (79% and 73%, respectively). The need for adjunctive risperidone was low and similar between groups (17% and 14%, respectively).CONCLUSIONS:Both lithium and divalproex were adequately tolerated and efficacious; lithium was associated with a greater reduction in mania scores over 9 weeks.

Collaborative care for depression is more effective in improving treatment outcomes than primary care physicians’ (PCPs) usual care (UC). However, few trials of collaborative care have targeted anxiety.

Objective: To describe an electronic, telephone-delivered, suicide risk management protocol (SRMP) that is designed to guide research staff and safely triage study participants who are at risk for self-harm.Methods: We tested the SRMP in the context of the NIH-funded randomized clinical trial "Bypassing the Blues" in which 302 patients who had undergone coronary artery bypass graft surgery (CABG) were screened for depression and assessed by telephone 2-weeks following hospital discharge and at 2-, 4-, and 8-month follow-up. We programmed the SRMP to assign different risk levels based on patients' answers from none to imminent with action items for research staff keyed to each of them. We describe frequency of suicidal thinking, SRMP use, and completion of specific steps in the SRMP management process over the 8-month follow-up period.Results: Suicidal ideation was expressed by 74 (25%) of the 302 study participants in 139 (13%) of the 1069 blinded telephone assessments performed by research staff. The SRMP was launched in 103 (10%) of assessments, and the suicidal risk level was classified as moderate or high in 10 (1%) of these assessments, thereby necessitating an immediate evaluation by a study psychiatrist. However, no hospitalizations, emergency room visits, or deaths ascribed to suicidal ideation were discovered during the study period.Conclusion: The SRMP was successful in systematically and safely guiding research staff lacking specialty mental health training through the standardized risk assessment and triaging research participants at risk for self-harm. Published by Elsevier Inc.

Objective: To determine the 12-month cost-effectiveness of a collaborative care (CC) program for treating depression following coronary artery bypass graft (CABG) surgery versus physicians' usual care (UC).Methods: We obtained 12 continuous months of Medicare and private medical insurance claims data on 189 patients who screened positive for depression following CABG surgery, met criteria for depression when reassessed by telephone 2 weeks following hospitalization (nine-item Patient Health Questionnaire >= 10) and were randomized to either an 8-month centralized, nurse-provided and telephone-delivered CC intervention for depression or to their physicians' UC.Results: At 12 months following randomization, CC patients had $2068 lower but statistically similar estimated median costs compared to UC (P=.30) and a variety of sensitivity analyses produced no significant changes. The incremental cost-effectiveness ratio of CC was -$9889 (-$11,940 to -$7838) per additional quality-adjusted life-year (QALY), and there was 90% probability it would be cost-effective at the willingness to pay threshold of $20,000 per additional QALY. A bootstrapped cost-effectiveness plane also demonstrated a 68% probability of CC "dominating" UC (more QALYs at lower cost).Conclusions: Centralized, nurse-provided and telephone-delivered CC for post-CABG depression is a quality-improving and cost-effective treatment that meets generally accepted criteria for high-value care. (C) 2014 Elsevier Inc. All rights reserved.

Objectives: This is an exploratory analysis of ambulatory and inpatient services utilization by older persons with type I bipolar disorder experiencing elevated mood. The association between type of treatment setting and the person's characteristics is explored within a framework that focuses upon predisposing, enhancing, and need characteristics. Method: Baseline assessments were conducted with the first 51 inpatients and 49 outpatients 60 years of age and older, meeting criteria for type I bipolar disorder, manic, hypomanic, or mixed episode enrolled in the geriatric bipolar disorder study (GERI-BD) study. We compared participants recruited from inpatient versus outpatient settings in regard to the patients' predisposing, enabling, and need characteristics. Results: Being treated in an inpatient rather than an outpatient setting was associated with the predisposing characteristic of being non-Hispanic caucasian (odds ratio [OR]: 0.1; P = .005) and past history of treatment with first-generation antipsychotics (OR: 6.5; P < .001), and the need characteristic reflected in having psychotic symptoms present in the current episode (OR: 126.08; P < .001). Conclusion: Ethnicity, past pharmacologic treatment, and current symptom severity are closely associated with treatment in inpatient settings. Clinicians and researchers should investigate whether closer monitoring of persons with well-validated predisposing and need characteristics can lead to their being treated in less costly but equally effective ambulatory rather than inpatient settings.

Background: Given the association of depression with poorer cardiac outcomes, an American Heart Association Science Advisory has advocated routine screening of cardiac patients for depression using the 2-item Patient Health Questionnaire (PHQ-2) "at a minimum." However, the prognostic value of the PHQ-2 among HF patients is unknown.Methods and Results: We screened hospitalized HF patients (ejection fraction [EF] <40%) that staff suspected may be depressed with the PHQ-2, and then determined vital status at up to 12-months follow-up. At baseline, PHQ-2 depression screen positive patients (PHQ-2+; n = 371), compared with PHQ-2 screen negative patients (PHQ-2; n = 100), were younger (65 vs 70 years) and more likely to report New York Heart Association (NYHA) functional class III/IV than class II symptoms (67% vs. 39%) and lower levels of physical and mental health related quality of life (all P <=.002); they were similar in other characteristics (65% male, 26% mean EF). At 12 months, 20% of PHQ-2+ versus 8% of PHQ-2 patients had died (P = .007) and PHQ-2 status remained associated with both all-cause (hazard ratio [HR] 3.1, 95% confidence interval [CI] 1.4-6.7; P =.003) and cardiovascular (HR 2.7, 95% CI 1.1-6.6; P = .03) mortality even after adjustment for age, gender, EF, NYHA functional class, and a variety of other covariates.Conclusions: Among hospitalized HF patients, a positive PHQ-2 depression screen is associated with an elevated 12-month mortality risk. (J Cardiac Fail 2012;18:238-245)

Objective: To determine the nature of telephone-delivered collaborative care intervention provided to patients younger than and older than 60 years experiencing clinically significant depressive symptoms after coronary artery bypass graft (CABG) surgery and whether patient age is related to response and remission rates and delivery of care at 8-month follow-up. Design: Exploratory post-hoc analysis of data collected in a randomized controlled trial (RCT). Setting: Seven Pittsburgh-area general hospitals. Participants: Fifty-eight depressed post-CABG patients younger than 60 and 92 comparable patients age 60 years and older randomized to the RCT's intervention arm. Measurements: Components of collaborative care provided to patients over the 8-month study period and Hamilton Rating Scale for Depression scores at 8-month follow-up to determine response and remission status. Results: There were no differences in the cumulative 8-month rates at which the components of collaborative care were delivered to the two age groups. Similar response and remission rates were also achieved by these groups. Conclusion: Older and younger patients experiencing clinical depression after CABG surgery can be treated with comparable components of collaborative care, and both age groups will achieve clinical outcomes that do not differ significantly from each other. (Am J Geriatr Psychiatry 2011; 19: 871-880)

PURPOSE:Mood and anxiety disorders are the most common psychiatric conditions seen in primary care, yet they remain underdetected and undertreated. Screening tools can improve detection, but available instruments are limited by the number of disorders assessed. We wanted to assess the feasibility and diagnostic validity of the My Mood Monitor (M-3) checklist, a new, 1-page, patient-rated, 27-item tool developed to screen for multiple psychiatric disorders in primary care.METHODS:We enrolled a sample of 647 consecutive participants aged 18 years and older who were seeking primary care at an academic family medicine clinic between July 2007 and February 2008. We used a 2-step scoring procedure to make screening more efficient. The main outcomes measured were the sensitivity and specificity of the M-3 for major depression, bipolar disorder, any anxiety disorder, and post-traumatic stress disorder (PTSD), a specific type of anxiety disorder. Using a split sample technique, analysis proceeded from determination of optimal screening thresholds to assessment of the psychometric properties of the self-report instrument using the determined thresholds. We used the Mini International Neuropsychiatric Interview as the diagnostic standard. Feasibility was assessed with patient and physician exit questionnaires.RESULTS:The depression module had a sensitivity of 0.84 and a specificity of 0.80. The bipolar module had a sensitivity of 0.88, and a specificity of 0.70. The anxiety module had a sensitivity of 0.82 and a specificity of 0.78, and the PTSD module had a sensitivity of 0.88 and a specificity of 0.76. As a screen for any psychiatric disorder, sensitivity was 0.83 and specificity was 0.76. Patients took less than 5 minutes to complete the M-3 in the waiting room, and less than 1% reported not having time to complete it. Eighty-three percent of clinicians reviewed the checklist in 30 or fewer seconds, and 80% thought it was helpful in reviewing patients' emotional health.CONCLUSIONS:The M-3 demonstrates utility as a valid, efficient, and feasible tool for screening multiple common psychiatric illnesses, including bipolar disorder and PTSD, in primary care. Its diagnostic accuracy equals that of currently used single-disorder screens and has the additional benefit of being combined into a 1-page tool. The M-3 potentially can reduce missed psychiatric diagnoses and facilitate proper treatment of identified cases.

AIM:This report considers the conceptual and methodological concerns confronting clinical investigators seeking to generate knowledge regarding the tolerability and benefits of pharmacotherapy in geriatric bipolar disorder (BD) patients. METHOD:There is continuing need for evidence-based guidelines derived from randomized controlled trials that will enhance drug treatment of geriatric BD patients. Therefore, we present the complex conceptual and methodological choices encountered in designing a multisite clinical trial and the decisions reached by the investigators with the intention that study findings be pertinent to, and can facilitate, routine treatment decisions. RESULTS:Guided by a literature review and input from peers, the tolerability and antimanic effects of lithium and valproate were judged to be the key mood stabilizers to investigate with regard to treating bipolar I disorder manic, mixed, and hypomanic states. The patient selection criteria are intended to generate a sample that not only experiences common treatment needs but also represents the variety of older patients seen in university-based clinical settings. The clinical protocol guides titration of lithium and valproate to target serum concentrations, with lower levels allowed when necessitated by limited tolerability. The protocol emphasizes initial monotherapy. However, augmentation with risperidone is permitted after three weeks when indicated by operational criteria. CONCLUSIONS:A randomized, controlled trial that both investigates commonly prescribed mood stabilizers and maximizes patient participation can meaningfully address high-priority clinical concerns directly relevant to the routine pharmacologic treatment of geriatric BD patients.

Objective: We suggest that clinicians consider models of shared decision-making (SDM) for their potential ability to improve the treatment of major depression in the primary care setting and overcome limitations of collaborative care and other interventions.Methods: We explore the characteristics and techniques of patient clinician SDM, with particular emphasis on this model's relevance to the unique treatment concerns of depressed older adults.Results: We describe a SDM intervention to engage older adults in depression treatment in the primary care sector.Conclusions: It is timely to examine SDM models for elderly depressed primary care patients given their potential ability to improve treatment adherence and clinical outcomes. Copyright (C) 2009 John Wiley & Sons, Ltd.