Depression in public community long-term care: implications for intervention development.

Abstract

The objective of this paper is to increase understanding of geriatric depression in the public community long-term care system to guide intervention development. Protocols included screening 1,170 new clients of a public community long-term care agency and interviewing all clients with major, dysthymia, or subthreshold depression (n = 299) and a randomly selected subset of nondepressed older adults (n = 315) at baseline, 6-month, and 1 year. Six percent had major depression, one-half of a percent had dysthymia only, and another 19% had subthreshold depression. Over the year observation period, 40% were persistently depressed; 32% were assessed as depressed only at the first observation; and the remainder was intermittently depressed. There were high levels of comorbid medical, functional, and psychosocial conditions. Mental health service use was low, and clients reported attitudinal and other barriers to depression treatment. Findings suggest the need for universal screening for depression with some strategies for triaging the most severely and persistently depressed for treatment. Although there will be challenges to the development of depression interventions, the public community long-term care system has high potential to assist vulnerable older adults receive help with depression.

Full text

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Regular Article
Depression in Public Community Long-Term
Care: Implications for Intervention
Development
Nancy Morrow-Howell, PhD
Enola Proctor, PhD
Sunha Choi, PhD
Lisa Lawrence, MSW
Ashley Brooks, MSW
Leslie Hasche, MSW
Peter Dore, MA
Wayne Blinne, MA
Abstract
The objective of this paper is to increase understanding of geriatric depression in the public
community long-term care system to guide intervention development. Protocols included screening
1,170 new clients of a public community long-term care agency and interviewing all clients with
major, dysthymia, or subthreshold depression (n=299) and a randomly selected subset of non-
depressed older adults (n=315) at baseline, 6-month, and 1 year. Six percent had major depression,
one-half of a percent had dysthymia only, and another 19% had subthreshold depression. Over the
year observation period, 40% were persistently depressed; 32% were assessed as depressed only at
the first observation; and the remainder was intermittently depressed. There were high levels of
comorbid medical, functional, and psychosocial conditions. Mental health service use was low, and
clients reported attitudinal and other barriers to depression treatment. Findings suggest the need
Presented at Improving Chronic Care Quality Conference, Columbia, Missouri, September. 2004.
Address correspondence to Nancy Morrow-Howell, PhD, Center for Mental Health Services Research, Washington University,
Campus Box 1196, St. Louis, MO 63130, USA. Phone: +1-314-9356762. Fax: +1-314-9358511. Email: morrow-howell@wustl.edu.
Enola Proctor, PhD, Center for Mental Health Services Research, Washington University, St. Louis, MO 63130, USA.
Phone: +1-314-9356660. Fax: +1-314-9358511. Email: ekp@wustl.edu.
Sunha Choi, PhD, Assistant Professor, Department of Social Work, SUNY-Binghamton, PO Box 6000 Binghamton, NY
13902-6000, USA. Phone: +1-607-7779156. Fax: +1-607-7775683. Email: shchoi@binghamton.edu.
Lisa Lawrence, MSW, Center for Mental Health Services Research, Washington University, St. Louis, MO 63130, USA.
Phone: +1-314-9356762. Fax: +1-314-9358511. Email: llawrence@wustl.edu.
Ashley Brooks, MSW, Council on Social Work Education, 1725 Duke Street, Suite 500, Alexandria, VA 22314, USA.
Email: abrooks@cswe.org
Leslie Hasche, MSW, Center for Mental Health Services Research, Washington University, St. Louis, MO 63130, USA.
Phone: +1-314-9356762. Fax: +1-314-9358511. Email: lhasche@wustl.edu.
Peter Dore, MA, Center for Mental Health Services Research, Washington University, St. Louis, MO 63130, USA. Phone:
+1-314-9355687. Fax: +1-314-9358511. Email: pdore@wustl.edu.
Wayne Blinne, MA, 208 Melbourne, Columbia, MO 65201, USA. Phone: +1-573-6733165. Email: Wayb7@yahoo.com
Journal of Behavioral Health Services & Research, 2008. c) )2007 National Council for Community Behavioral
Healthcare.
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for universal screening for depression with some strategies for triaging the most severely and
persistently depressed for treatment. Although there will be challenges to the development of
depression interventions, the public community long-term care system has high potential to assist
vulnerable older adults receive help with depression.
Introduction
Depression has long been recognized as a common but treatable psychiatric disorder in late life.1
The effectiveness of pharmacological, electroconvulsive, and psychosocial therapies for older pa-
tients is documented, and consensus statements and practice guidelines identify protocols for their
implementation.2Multicomponent intervention packages have proven effective in primary care
settings, including such programs as Partners in Care,3Improving Mood-Promoting Access to
Collaborative Treatment (IMPACT),4,5Primary Care Research in Substance Abuse and Mental
Health in the Elderly (PRISM-E),6and Prevention of Suicide in Primary Care Elderly Controlled
Trial (Prospect).7
Althoughefficacioustreatmentsfordepressioninlaterlifeexist,mostelderswithdepressionremain
untreated.8Effective interventions can be delivered in both specialty mental health and primary care
settings, but both settings face challenges. Few older adults find their way to mental health
specialists, and there are issues of supply, stigma, and payment for specialty care. Although more
rely on primary care, mental disorder often goes untreated or inadequately treated by nonspecialty
providers.9–11Although improvements have been achieved in depression treatment in primary care
in the last decade, there is still concern about the quality of care and the complexity of the health
care system in ensuring the delivery of evidence-based treatments.12In sum, the challenge in caring
for geriatric depression lies in the service delivery system, not treatment potential.
Older adults with physical disabilities and mental disorder are among those most vulnerable to
problems associated with fragmented systems of care.13Innovative efforts are needed to extend
quality mental health services to settings that serve vulnerable older adults. The Surgeon General’s
report identifies the provision of high-quality mental health services in accessible locations as
essential to creating a more equitable system.14In the case of later-life depression, those locations are
community-based and nonspecialty mental health. The importance of home-based care for mental
disorder among older adults has long been recognized.15
Community long-term care (CLTC) is one of the most rapidly growing social service sectors,
given population aging and the societal value of maintaining independent living. Unlike nursing
homes where researchers have evidenced longstanding interest in mental disorder,16,17community-
based care for functionally dependent elders has more recently become a focus for mental health
intervention research,18–20given the potential to extend mental health treatment to older adults
through this growing service system.
Every U.S. state provides publicly funded CLTC services, which aim to help low-income people
with chronic conditions compensate for functional disabilities and maintain community residence.
Although state regulations vary, in general, clients qualify for public CLTC services through low
incomeandfunctionalimpairment.CLTCclients aredisproportionately womenandethnicminorities.
These public systems of long-term care have great potential to extend mental health treatment to
socially and economically disadvantaged elders who experience high levels of depression and have
historically underutilized mental health care.
The extension of evidence-based treatment models to public CLTC requires an understanding of
this system of care and its client population. The requisite first step is to understand more about
depression in this service context. Thus, this study seeks to answer the following research questions:
1) What is the extent of major, dysthymia, and subthreshold depression among CLTC clients?
2) How persistent are depressive symptoms after clients begin CLTC services?
38 The Journal of Behavioral Health Services & Research35:1 January 2008

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3) What medical, functional, and psychosocial comorbidities do depressed elders in CLTC
experience?
4) What medical and social services are depressed elders using when they begin CLTC services?
5) What are CLTC clients’ attitudes about mental health service use, perceived barriers to
treatment, and previous treatment experiences?
Data come from a sample of older clients of the public community long-term care system in a
Midwesternstate.Persons age 60or older orpersonsage 18–59whorequireassistance withactivities
ofdailylivingconstitutetheclientseligiblefortheseservices.Similartootherstates,Medicaid,Older
Americans Act, and block grant monies are usedto provide personal care, homemaker/chore, nursing
services, transportation, meal, respite, and case management services in home, group home, or day
care settings. Referrals come to the agency from medical and social service agencies, from an abuse/
neglect hotline, and from family, friends, and older adults themselves. A professional case manager
assesses the client face-to-face to determine service eligibility and type and amount of services
needed. The case manager then authorizes the receipt of necessary supportive services. Paraprofes-
sionals, procured through contract arrangements, provide the authorized services of personal care,
nursing, housekeeping, transportation, and meal service. Clients can also be approved for day care
and some residential care. The case manager follows the client and reassesses and adjusts services as
needed over time. The state agency that was the site of this study served 73,802 clients in 2004,
49,899 of which received in-home services.
Methods
Design To ascertain the extent of depression, a cross-sectional survey was used to screen all new
clients to community-based care services in a defined geographic area of the state. The area, which
covers about one-fourth of the state, includes a large urban area, several smaller cities, small towns,
and rural areas. To document comorbid conditions, service use, and attitudes about mental health
treatment, longer interviews were conducted with the group of clients who screened positively for
depression and a randomly selected comparison group of nondepressed clients. To establish the
persistence of depression after entry into the CLTC system, depressed clients were followed over a 1-
year observation period, conducting interviews at entry into the CLTC service system, at 6 months,
and at 1 year.
Clients were solicited into the depressed group if they had a diagnosis of major depressive disorder
or dysthymia, as established by the screening interview of the Diagnostic Interview Schedule (DIS).
Majordepressivedisorder,aspertheDiagnosticandStatisticalManualofMentalDisorder(DSM-IV),
exists when a person exhibits five or more specified symptoms every day, most of the day, for at least
2 weeks. Dysthymia, as defined by DSM-IV, is less severe in that two or more depressive symptoms
are required, but duration must be 2 or more years.21Clients were also solicited into the depressed
group for subthreshold depression. That is, they did not meet DSM-IV criteria for major depression
or dysthymia, but had high depressive symptomatology (these instruments are described in detail in
the measurement section). Whereas all clients meeting these criteria for depression were solicited
into the depressed group, only a random sample of nondepressed elders was solicited into the com-
parison group. In an effort to retain a comparison group of nondepressed older adults throughout the
1-year observation period to study service use and outcomes, only clients with modified Center for
Epidemiologic Studies Depression Scale (CES-D) scores less than 5 and no life-time history of
depressionwereselected.Thisstrategydecreasedthelikelihoodthatclientsinthenondepressedgroup
would become depressed in the observation period.
Informed consent was obtained over the telephone and copies of the completed consent forms
mailed to study participants. The study was approved by the Washington University Committee on
Human Subjects (#E99-201). Study participants were paid $20 for completing an interview.
Depression in Public Community Long-Term CareMORROW-HOWELL ET AL. 39

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Sample
older; 2) they qualified for public community-based services by virtue of their level of need for
supportive care and their eligibility for Medicaid; 3) they were their own guardians; 4) their spoken
English was adequate enough to complete the interviews (which were not translated to other lan-
guages); and 5) they were new clients to the system in that a new case record was being opened at the
time of referral to the study. During the study period, 1,170 new clients were screened, and full
baseline interview with 299 depressed clients and 315 nondepressed clients was conducted. Through-
out this paper, the term depressed is used to include clients with major depression, dysthymia, and
subthreshold depression.
Clients eligible for the study met the following criteria: 1) they were 60 years of age or
Recruitment of study participants Study participants were recruited from October 2000 to May
2003. During the assessment of new clients, the case managers obtained client permission for the
researchers to contact them. Of the 2,736 eligible clients who were approached by the case
managers, 1,788 agreed to be contacted by the researchers (65.35% assent rate). The researchers
then called the potential study participants, described the study, and gained informed consent. The
consent rate was 84.34%, leaving 1,508 clients for the screening interview. During that interview
phase, the researchers eliminated those discovered to be ineligible or those who could not be
located (174 or 12%). Also, those who screened positive for cognitive impairment were eliminated
(169 clients or 11%). Thus, 1,170 clients completed the screening interview.
In the study regions, there were 126 case managers, and the researchers could not enlist the full
cooperation of all of them. Although there was widespread support for the study, the case managers
were very difficult to engage because of their very demanding work situation. They have large
caseloads, and the agency was under great stress because of public budget cuts and reorganization.
Anything outside of required duties was given little attention. Additionally, state employees could
not receive incentives for assistance with the study protocols. Also, the case managers did not
approach clients they believed could not participate in the study because of severe illness or very
stressful circumstances. Although the researchers requested record-keeping that documented all
such situations, the records of those eligible clients who were not approached are incomplete. State
records indicated that 7,392 clients could have been eligible for the study during that time period.
Thus, only 37.01% of eligible clients were approached to participate in the study. However, the
state staff calculated descriptive statistics on new clients over the age of 60 in the study time
period, and this sample differed in two ways: the clients referred to the study were younger by
.64 years (F=10.563, pG.02) and were more likely to be African American (χ2=8.1, pG.02) than
all clients eligible for the study in the observation period.
For study participants solicited into the depressed and nondepressed comparison groups,
interviewers continued directly on from the screening interview to collect more information. These
baseline interviews lasted for 1 hour on the average. Table 1 overviews the variables included in
the screening and baseline interviews. The descriptive statistics on the screening variables were
calculated on 1,170 study participants; and for the baseline interview, they were calculated on 299
participants in the depressed group and 315 in the nondepressed group.
Instrumentation and variables Data were collected through telephone interviews when possible,
using the CATI program (computer-assisted telephone interview). About 10% of the interviews
required face-to-face contact because of sensory impairment or other conditions precluding
telephone communication.
The screening interview assessed for depression and suicidality as well as basic demographic
variables. The computerized screening version of the Diagnostic Interview Schedule (DIS) was
used to establish diagnoses of major depression and dysthymia. It is important to note that
assessment protocol called for those clients with double depression to be included in the major
depression group only. The DIS is a well-established instrument for yielding DSM diagnosis
40The Journal of Behavioral Health Services & Research35:1January 2008

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through lay interviewers.22The DIS also has a series of questions about suicidality, and the
interviewers used a protocol established by Life Crisis, the largest suicide prevention hotline in the
state, to assess whether the threat of suicide demanded action outside of the interview protocol. The
modified CES-D23was used to yield a continuous measure of symptom severity. The modified
CES-D consists of the 20 items of the original instrument, but the response options are limited to yes
or no. A score of 9 on the modified CES-D is comparable to 16 on the original version and indicates
probable depression. This cutoff is used to yield a categorization of subthreshold depression.
To assess the persistence of depression over time, the Jacobson–Traux method24was used as
follows: all study participants with a modified CES-D of 9 or higher (the clinical cut-off for de-
pression) were assessed again after 6 months and 1 year. If the CES-D score dropped below 9 and
dropped by two points or more, they were coded as not being depressed at that observation. (The
researchers also reanalyzed the data with a change score of 3, and the findings were the same.)
Study participants provided information about age, sex, race, education, marital status, and living
alone. Income was abstracted from agency records, and urban residence was determined from zip
code. The Duke Depression Evaluation Schedule (DDES)25was used to ascertain functioning and
Table 1
Sample characteristics (N=1,170)
VariablesFrequency % (n) Means (SD)
Age 72.31 yrs (7.98 yrs); range 58–104;
median: 71.00
Female
Race
Caucasian
African American
Other
Education
0–6th grade
7th–9th grade
10th–12th grade
13th & above
Monthly income
76.75 (898)
71.71 (839)
27.78 (325)
00.51 (006)
9.62 yrs (2.98 yrs); range 0–17; median: 10.00
12.39 (145)
34.70 (406)
41.54 (486)
11.35 (133)
$739.08 ($334.61)a; range: 0–$2,273;
median=$667.00
Marital Status
Married
Separated
Divorced
Widowed
Never married
Living alone
Urban
Clinical Characteristics
Major depression
Dysthymia (no Major)
Sub-threshold depression
23.10 (270)
3.68 (43)
20.62 (241)
47.99 (561)
4.62 (54)
54.02 (632)
43.34 (504)
6.00 (70)
.50 (6)
19.06 (223)
aExtracted from agency record (N=497). Not assessed among “screener only” participants.
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comorbid medical conditions. Seven activities of daily living (e.g., walking, toileting, bathing) and
nine instrumental activities of daily living (e.g., housekeeping, shopping, traveling) were reviewed
with the study participant; and information yielded number and severity of impairments. A list of
14 chronic conditions is also reviewed, yielding the presence of the condition and the severity of
the condition. Summative scores were derived.
Psychosocialcomorbiditieswereassessed with thenumberof lifeeventsusing theDuke Life Event
Scale26and perceived stress during the past 6 months using the DDES.25Respondents reported
whether they had problems affording food (yes/no) and whether they ate alone most of the time
(yes/no), items from the Nutritional Checklist, Bureau of Aging and Long-Term Care Resources.
Social support was assessed through the 11-item Duke Social Support Index (DSSI).27Finally, items
from the WHO-DAS II28and SF-829that capture difficulty in social functioning were included.
Study participants reported use of medical, social, and mental services in the 6 months before the
interview. Interviewers reviewed a list of services and queried about use as well as purpose of the
visit, when applicable. Services included medical doctor, psychiatrist, emergency room, hospital-
ization, nursing home, day care center, senior center, home delivered/congregate meals, home health
care, mental health specialist, and religious leader for a problem in life. To assess attitudes and
perceived barriers to mental health treatment, interviewers utilized questions developed by Leaf and
colleagues30as well as added related items to meet study needs. Responses were yes/no or interval
level, but all items were collapsed to yes/no for analytic purposes.
Univariate statistics were calculated to describe the sample; and independent t tests and chi-
square tests were used to test the difference in comorbidities, service use, attitudes, and perceived
barriers between depressed and nondepressed groups.
Findings
Given that the state agency provides CLTC services to low-income elders, all study participants
are Medicaid eligible. About 90% are also covered by Medicare. Compared to community samples
of older adults, the study sample is disproportionately women, widowed, and African American, as
would be expected in this economically and functionally disadvantaged population. The mean level
of education is below the national average.31
Over 6% (n=70) of the 1,170 clients that participated in the screening interview had a current
diagnosis of major depression. This is at least two times higher than estimates from community-
dwelling samples of older adults.1However, the researchers used a very stringent operationaliza-
tion of current—within the last 30 days—whereas other studies used a more liberal definition of
“current,” usually the last year. About 2% (24) clients had dysthymia, with most of them (18) also
having major depression. Thus, only six clients or .5% had dysthymia only. Another 19% (n=223)
of the sample screened positive for subthreshold depression. Considering all three types of
depression together, 25.5% (299) of the clients in the sample were assessed as depressed.
Whendepressionsymptomsaretrackedovertime,40%oftheparticipantsassessedasdepressedat
screening had symptoms above the cutoff on the CES-D at the second and third observation. Of the
60% who did not have high symptoms throughout the 1-year observation period, three subgroups
emerged: 32% were only assessed as depressed at the first observation; 15% were assessed as
depressed on the first and last observation; and 13% were depressed at the first and second
observation but not the third. In sum, over the 1-year observation period, the largest subgroup was
persistently depressed, whereas the remaining 60% of the sample was evenly divided between those
who were intermittently depressed and those who were depressed only at the first observation.
To understand the medical, functional, and psychosocial comorbidities of the depressed elders in
this sample, the researchers focused on the depressed clients and compared them to a sample of
nondepressed CLTC clients. As Table 2 shows, levels of functional limitation are high for both
groups, as would be expected given that clients qualify for CTLC services by virtue of need for
42 The Journal of Behavioral Health Services & Research35:1 January 2008

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Table 2
Functioning and comorbid conditions: by depression status
Variables
Percentage or mean (SD)
Bivariate tests
Depressed (N=299)
Not depressed (N=315)
t or χ2
p
Functioning
Total number of functional impairments (range 0–16)a
5.94 (2.96) Range 0–15
4.65 (3.10) Range 0–13
5.19
G.0001
Perceived severity of impairments (higher, more severe, 1–48)
31.53 (6.09) Range 16–48
28.14 (6.70) Range 14–44
6.52
G.0001
Number of ADL impairments (0–7)
0.83 (1.15) Range 0–6
0.61 (0.99) Range 0–5
2.48
0.0136
Number of IADL impairments (0–9)
5.11 (2.22) Range 0–9
4.04 (2.48) Range 0–9
5.54
G.0001
Medical
Self-reported overall health (higher, poorer, range 0–5)
3.63 (1.12) Range 0–5
2.64 (1.18) Range 0–5
10.55
G.0001
Total number of chronic medical conditions (0–14)
5.04 (1.99) Range 1–13
3.96 (1.75) Range 0–11
7.02
G.0001
Perceived severity of chronic medical conditions (higher,
more severe; 0–42)
11.40 (5.35) Range 2–31
7.61 (4.29) Range 0–23
9.69
G.0001
Asthma
20.40
10.29
10.89
0.0010
Diabetes
35.38
35.68
0.0064
0.9398
Heart trouble
59.80
40.57
22.2784
G.0001
Hypertension
72.84
70.67
0.36
0.5518
Arthritis or rheumatism
84.21
75.30
7.3984
0.0066
Stroke
33.11
23.75
6.3001
0.0120
Cancer
12.64
9.65
1.1881
0.2766
Emphysema, chronic bronchitis, or brown lung
34.05
19.43
16.1604
G.0001
Ulcers
20.07
7.17
18.49
G.0001
Hardening of arteries
23.14
13.52
8.5264
0.0037
General neurological problem or Parkinson’s disease
9.63
5.65
3.24
0.0723
Anemia
15.92
8.70
7.0756
0.0077
Glaucoma, cataracts, or other eye problems
51.71
49.46
0.3025
0.5841
aThose who answered that they could not perform the listed tasks (excluding those who reported that they could perform with difficulties).
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Table 3
Psychosocial comorbidities: by depression status
Variables
Percentage or mean (SD)
Bivariate yests
Depressed (N=299)
Not depressed (N=315)
t or χ2
p
Life events / Stress
Perceived stress during the past 6 month
(scale 1–10, higher more stressful)
6.34 (2.99) Range 1–10
3.45 (2.63) Range 1–10
77.75 G.0001
Total number of negative life events, past yeara
1.69 (1.49) Range 0–8
0.93 (1.13) Range 0–4
6.99 G.0001
Hospitalization
66.82
52.51
12.5316 0.0004
Illness or injury that kept the person from usual activities
67.96
52.95
13.212 0.0003
Family member’s illness or injury
34.52
29.27
1.8769 0.1697
Getting divorced or having a important relationship end
8.16
4.51
3.2041 0.0744
Death of a spouse
9.36
4.00
5.5225 0.0204
Child’s or other household member’s leaving home
10.23
6.54
2.6244 0.1059
Death of a loved one (other than a spouse)
32.04
24.89
3.8025 0.0517
Own/family member’s legal problem
13.51
5.78
9.2416 0.0025
Getting retired from work
5.42
4.63
0.16 0.6859
Being unemployed
5.42
2.41
3.2761 0.0707
Considerable improvement in own/family’s financial situation
15.79
12.70
1.1449 0.2836
Considerable deterioration of own/family’s financial situation
39.33
21.97
21.3444 G.0001
Moving
24.15
14.67
8.6436 0.0033
Trouble affording the food needed
45.82
27.56
20.9764 G.0001
Social functioning / Social support
Duke Social Support Index (DSSI, 11–33, higher, more support)
25.31 (4.24) Range 13–31 27.99 (2.97) Range 14–33
9.00 G.0001
Difficulty in dealing with strangers (1:none∼5:extreme/cannot do)
2.08 (1.40) Range 1–5
1.38 (0.98) Range 1–5
6.89 G.0001
Difficulty in maintaining a friendship (1: none; ∼5: extreme/cannot do)
1.56 (1.07) Range 1–5
1.11 (0.47) Range 1–5
6.65 G.0001
Interference with usual social activities because of physical health
or emotional problems (0: not at all; ∼4: extreme/cannot do)c
2.43 (1.35) Range 0–4
1.31 (1.40) Range 0–4
10.08 G.0001
Eating alone most of the time
69.10
58.67
7.0225 0.0080
aThe number of life-events perceived negatively by participants
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supportive services; yet depressed clients had worse physical functioning than nondepressed clients.
Depressed clients rated their health worse and reported more chronic health conditions. The average
number of chronic conditions reported by the depressed group was over 5, and they reported higher
rates on 8 out of the 13 medical conditions queried.
Table 3 demonstrates that depressed clients report higher levels of stress and have experienced
more negative life events in the past year, including more hospitalizations, deaths of loved ones, and
deterioration of financial situation. Depressed clients reported higher occurrences of 8 out of the 13
negative events queried. It is notable that over 45% of the depressed clients reported trouble affording
food and 70% eat alone most of the time. There is also more social isolation among the depressed
clients, who had significantly worse scores on all the social functioning/social support measures.
Interviewers queried the study participants about the service use in the 6 months before they
began using CLTC services, and in general, use of the medical service sector is high. Almost every
study participant saw a medical doctor in the last 6 months (over 90%). As many as half of the
depressed clients talked to the primary care doctor about mental health issues. Depressed and
nondepressed clients were hospitalized at the same rate; of the 50% of the depressed clients who
were hospitalized in that period, only 2.5% reported the reason for hospitalization as an emotional
condition. This high level of hospitalization reflects both the high levels of medical conditions in
CLTC clients, but also reflects the fact that hospital discharge planners often refer clients to the
state agency. Thirty-two percent of the depressed clients and 23% of nondepressed clients (a
significant difference) used an emergency room in the 6 months before entering the CLTC system.
Depressed clients were more likely to see a psychiatrist (9%) or a mental health specialist (7%).
Almost one-third (28.8%) talked to a religious leader about an emotional problem, as compared to
11% of nondepressed CLTC clients. Use of senior centers, congregate meals, activity programs,
and telephone support services was low for both groups, but a substantial percentage of both
groups used home-delivered meals (29% of depressed group and 25% of nondepressed group),
transportation (21% and 19%), and medical home health services (46% and 40%).
Table 4 reveals that on most items regarding attitudes and perceived barriers to mental health
treatment, depressed and nondepressed clients did not differ. In general, CLTC clients reported
receptivity to mental health treatment. For example, over 90% thought that people with emotional
problems should seek professional help; and almost the same percent reported that they could talk
to a mental heath professional about personal problems. Yet there is also evidence of stigma. A
large number of CLTC clients anticipate negative reaction from others. Depressed clients differed
from nondepressed clients in four items: depressed clients reported to be less likely to seek treatment
if it was not close by and more likely to believe that the problem would get better by itself. They
responded more negatively when asked if they would like to seek treatment in the face of a mental
disorder; and they would avoid treatment because others may find out. Both depressed and
nondepressed clients report that family doctors would be a great help in the face of emotional
problems and over half of both groups indicated that clergy members would also be helpful.
Discussion
Prevalence and persistence
estimates of 1–3% for major depression, 2–4.6%32,33for dysthymia, and 10–15% for subthresh-
old.34This study suggests that major and subthreshold depressions are more prevalent among the
clients of public community long-term care. Given that double depression is subsumed in major
depression group, it is not surprising that only a small number of clients have dysthymia only. The
rates of clinically significant depression (considering these three types of depression together)
found here are similar to those of older adults in other clinical settings. For example, it is estimated
that 17–35% of primary care patients evidence depressive symptoms,3520–27% of older residents
Studies of depression among older adults in the community yield
Depression in Public Community Long-Term CareMORROW-HOWELL ET AL.45

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Table 4
Attitudes and perceived barriers about mental health treatment: by depression status
Variables
%
Bivariate Tests
Depressed (N=299)
Not depressed (N=315)
χ2
P
Situational barriers
Know where to obtain tx. for mental health
41.61
41.14
0.0121
0.9107
Cost of tx. would be more than you could afford
82.34
84.00
0.2601
0.6089
Psychological receptivity:
A mental health professional would understand the kinds of problems
74.31
78.16
1.1664
0.2800
Believe you should always handle mental/emotional problems by yourself
35.59
33.84
0.1849
0.6640
People with mental/emotional problems should seek professional help
92.24
92.83
0.0729
0.7853
Could talk about your most personal problems with a mental
health professional
86.69
90.82
2.4649
0.1164
Would consider obtaining mental health care if the place was not close by
48.83
60.95
7.8961
0.0053
Would like to seek tx. if you had a mental/emotional problem
89.43
94.22
4.0
0.0466
Believe that a mental/emotional problem would get better by itself
23.81
16.83
4.41
0.0360
Anticipated Negative Reactions from Others
If your boss knew you were receiving tx. for a nervous/emotional problem,
it would affect your job
47.16
40.38
2.4649
0.1171
You family would be upset if they knew you were receiving help for a
mental/emotional problem
16.25
17.65
0.1936
0.6572
Someone in your family would object if you wanted to go for treatment of
an emotional problem
10.90
6.67
3.1329
0.0779
Would avoid tx. of mental/emotional problems because of friends
might find out
5.08
1.08
4.2436
0.0474
Other
Feel that most family doctors can be a great help with a mental or
emotional problem
73.31
79.62
3.0276
0.0597
Would find talking to a clergy as useful as talking to a mental
health specialist
53.58
53.46
0.0009
0.9770
46The Journal of Behavioral Health Services & Research 35:1January 2008

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in public housing,18and over 30% of home health care clients report high levels of symptoms of
depression.36These settings have been recognized as promising sites for the development of
depression interventions, given the potential to reach large numbers of older adults with depression.
Public community long-term care similarly has potential to improve quality of care for depressed
older adults by identifying depression and securing mental health treatment. Like primary care,
CLTC case managers have first contact with those needing mental health care and often maintain
contact with clients over several years.
Given that over 25% of older clients entering the CLTC system report depression, a universal
screening for depression may be warranted. That is, a brief, standardized depression screen could
be added to the formal assessments used by CLTC systems to determine service needs. Whereas
most states systematically query clients about morale or mood, only a few states currently use
standardized screening instruments, like the Geriatric Depression Scale. It is feasible to add a
screen and train workers to use it, but the challenge is following up with those who screened as
depressed. It would not be appropriate to screen without adequate provisions for more thorough
assessment and resources for depression treatment.
Public service systems are generally short on resources, and especially at this time of cutbacks in
public budgets for social services. The CLTC system may not be able to respond to depression in a
quarter of the clients. Triaging of clients for depression treatment may be necessary, based on some
assessment of the urgency of the situation, client preference, and the impact of the depression on
client functioning. Suicidal clients and those with major depression could be the focus for depression
treatment. Medicare and in some cases Medicaid will pay for medical attention for clients diagnosed
with major depression.
Yet most of the depression among CLTC clients, as in other clinical settings, is subthreshold; and
thereareseveralrationales toexcludesubthresholddepressionfromanintervention.Guidelinesonthe
treatment of subthreshold depression are not well established; the condition is not reimbursable by
third party payers without a diagnosis; and there are so many clients with this condition that it may
overload any system of care. However, subthreshold depression is a serious condition with negative
and enduring effects on physical functioning; and thus subthreshold depression may thwart the
achievementoftheprimarygoaloftheCLTCsystem—tomaintainclientfunctioningandindependent
living. Further, over time, these elders are at risk of developing major depression.37,38Thus, there are
compelling reasons to target both CLTC clients with subthreshold as well as major depression.
CLTC clients with subthreshold depression could be triaged so that only a reasonable subgroup
receives depression treatment. Triaging is supported by these data, which suggest that a substantial
amount of clients with subthreshold depression are not assessed as depressed at a 6-month reas-
sessment. It is possible that some watchful waiting period after CLTC services are initiated may be
appropriate, allowing the supportive services, like transportation, day care, and food preparation, to
have a positive effect on everyday lives. Furthermore, some portion of clients withdepression will not
accept interventions, and watchful waiting will again be appropriate.
This study is not able to test why depression does not persist in a substantial portion of this sample,
given its design. There are several potential explanations. First, although reliability of the CES-D is
good,23instability of measurement cannot be ruled out. Second, there is a natural course to de-
pression and, in some cases, symptoms remit without intervention. Third, some CLTC clients will
initiate depression treatment or continue in depression treatment and positive results may be
obtained. Fourth, the health and social services provided by the CLTC service system may aid in the
resolution of depressive symptoms. Further research is clearly warranted on this topic.
Comorbidities The study findings highlight the high levels of medical, functional, and psychosocial
comorbidites that these depressed elders are experiencing. Depression treatment in CLTC must
respond to the competing demands posed by these co-occurring conditions. Some clients may not be
capable of nor prefer addressing mental health needs; instead they invest their capabilities and
Depression in Public Community Long-Term CareMORROW-HOWELL ET AL. 47

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resources in other problems in their lives. Similarly, CLTC case managers may have to deal with
severe housing or safety issues, rendering the inattention to depression a rational choice. Thus,
triaging of depression treatment could also be based on the medical, functional, and psychosocial
conditions of the elder. The remediation of these other conditions may lead to the resolution of some
depressive symptoms. A reassessment of depression over time could identify those whose symptoms
are persistent and who may become better candidates for depression treatment after the resolution of
other pressing problems.
These comorbid conditions also have implications for the source of depression treatment. Clients
with certain medical conditions may be best served in primary care. Previous studies show that
depressed older adults with more physical illness are more likely to receive depression treatment from
primary care.39Thus, in CLTC, case managers can work with primary care doctors to pursue de-
pression treatment. Specialty care may be obtained for more severe cases, with the assistance of
primary care doctor. As these data indicate, social isolation is a common condition among depressed
CLTC clients. The mental health needs of these clients might be met through activity and group
therapies at a day care center or day treatment center.
Service use and attitudes Study findings show that older adults in CLTC find primary care doctors
and religions leaders most helpful and that these professionals are frequently used. Thus, partnering
with primary care for the treatment of depression seems promising. Case managers or other
professional staff may be in a position to screen a large number of people and to initiate efforts to
secure depression care. They could perform monitoring, support, and linking roles that may ensure
the adequate treatment of depression initiated by primary care providers.
The literature speaks of the importance of religious leaders, the frequency with which older adults
turn to them for counsel, and the underdeveloped referral network that they utilize in securing
specialized mental health treatment.40–43Perhaps depression treatment through CLTC could be
augmented by strategies to include religious leaders as partners in motivating, educating, and
supporting depressed clients who need specialty treatment.
Findings of studies reveal that depressed elders in the CLTC system lack treatment optimism,
experience stigma, and perceive multiple barriers—all of which play a part in the underutilization of
services. Indeed, psychoeducation and motivational interviewing have been identified as necessary
components of intervention packages that have been tested among depressed older adults. The CLTC
system offers the possibility of involving a wide variety of professionals and paraprofessionals in
motivating and supporting depression treatment.
States vary into the personnel deployment patterns in CLTC; generally, however, these CLTC
systems rely on case managers to assess and arrange supportive services, and then a variety of
paraprofessionals provide the necessary assistance with activities of daily living. These paraprofes-
sionals include personal care aides for grooming, bathing, meal preparation, etc; chore workers for
housekeeping; drivers for door-to-door transportation services. These home care personnel provide
high levels of hands-on service to clients; yet they are generally not trained to deal with depression.
These aides see their clients several times a week and, with training and individualized instruction,
could be instrumental in supporting clients in depression treatment. In addition to medication and
symptoms monitoring, they could motive the client to continue in their treatment and assist the client
with daily routines of grooming, exercise, etc.
Limitations
the study. Study staff continually dealt with the challenge of training and motivating case
managers in a large geographic area to use study protocols. Despite high interest in the study
findings, case managers did not prioritize these referral protocols in their busy schedules. The
researchers were able to obtain state data and confirm that the clients that were referred to the
study were similar to those who were not referred but could have been. Nonetheless,
As reported in the method section, all eligible CLTC clients were not referred to
48 The Journal of Behavioral Health Services & Research35:1 January 2008

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generalizability is constrained in unknowable ways. Given that case managers tended not to
refer clients that they thought too ill or limited in capacity, it is possible that depressed clients
were under referred. On the other hand, it is possible that case managers were more likely to
refer those clients they thought to be depressed because of the focus on the study. Thus, the
effects of referral patterns on generalizability of depression rates are not known. Another
limitation stems from the fact that the study only focused on depression and eliminated other
sections of the DIS. In doing so, the findings cannot speak to other psychiatric disorders
among other comorbid conditions. Of course, a fuller assessment of mental health will be an
important part of interventions protocols that are developed for the CLTC system. Finally, it
must be noted that the decision to include clients with no depression history and very low
CES-D scores in the comparison group achieved the study purposes, but may accentuate the
differences between the groups on comorbid conditions, service use, and attitudes/barriers.
Implications for Behavioral Health and Future Research
This study of a public community long-term care system documents the high prevalence of
depression and the comorbid medical, functional, and psychosocial demands that will
complicate its assessment and treatment. The high prevalence suggests that universal screening
may be warranted. Yet, given that symptoms did not persist for many of the clients who were
assessed as depressed at baseline, some strategy for triaging via fuller assessment of severity
and duration may be necessary. Given that case managers in public CLTC report a need for
more knowledge about depression43and that depression often goes unnoted in agency records,44
more systematic training in assessment is needed. Perhaps the co-location of a mental health
specialist would be a more effective strategy to identify and target depressed older adults for
treatment. There is evidence that attitudinal and other barriers to depression treatment are
prevalent among CLTC clients and motivation and ongoing support for depression treatment will
be needed. Family members could be included in psychoeducational interventions to increase the
potential of engaging clients in treatment.45CLTC clients are often more comfortable with
primary care providers, and primary care doctors are logical partners with CLTC case managers.
Yet communication protocols must be refined so that more successful partnerships are
established. Also, given the frequency with which CLTC clients report contact with religious
leader around personal problem, these professionals could be included as important sources of
motivation and support. It is important to note that each of these potential interventions,
including screening, triaging, psychoeducation for clients and families, communication protocols
with primary care, and partnerships with clergy, require adaptation and tailoring to this system of
care and its clients. Thus, there is need for intervention development and implementation
research. Although there will be challenges to the development of depression interventions, the
public community long-term care system has high potential to assist vulnerable older adults
receive help with depression.
Acknowledgment
This study was funded by the National Institute on Aging, R01 AG17451, 1999–2003.
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