Transcript Understanding and Implementing Depression, Anxiety, and

Understanding and
Implementing Depression,
Anxiety, and Suicide
Prevention Evidence-Based
Programs
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Suicide Prevention
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Institute of Medicine Terminology:
“LEVELS” OF PREVENTIVE INTERVENTION
“Indicated” – symptomatic and ‘marked’ high risk
individuals – interventions to prevent full-blown
disorders or adverse outcomes.
“Selective” – high risk groups, though not all members
bear risks – prevention through reducing risks.
“Universal” – focused on the entire population as the
target – prevention through reducing risk and
enhancing health.
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Universal, Selective, and Indicated
Suicide Prevention in Older Adults
Universal Prevention
Screening for depression, and
suicidal ideation
- PHQ-9, GDS
- Suicide Risk Screening
Selective/Indicated Prevention
Outreach
Gatekeeper
PATCH
PEARLS and PST
Integrated care of
mental health
problems in a
communitybased setting
Telephonebased support
(TeleHelp
TeleCheck)
PROSPECT/IPT and
IMPACT/PST
Integrated care of
mental health in
primary health
care settings
Harm risk reduction
-Public education reducing access
to fire-arms for at-risk seniors
-Alcohol and medication misuse
Multi-Layered Suicide Prevention
-Mental health education workshops
-Annual, voluntary depression
screening
-referral for treatment
-psychiatric consultation
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INDICATED PREVENTION
Symptomatic and ‘marked’ high risk
individuals – interventions to prevent
full-blown disorders or adverse
outcomes.

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Recommendations for
INDICATED PREVENTION
Because of the close association between depression and
suicide in older adults
• detection and effective treatment of depression are key
2. Routine screening for depression
• PHQ-9, GDS, or CES-D
3. Depression treatment is effective at treating depression
• And is effective at reducing suicidal ideation in some, and
maybe reducing suicide rates
4. Primary care most common venue
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Following Up
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
If any positive response, FOLLOW-UP
• determine passive vs. active ideation
• “In the last 2 weeks, have you had any thoughts of
hurting or killing yourself?”
• If yes = active suicidal ideation, FOLLOW-UP further
Screening tools designed to be used to follow-up the
PHQ-9 suicide item.
• Option: the P4 Screener for Assessing Suicide Risk
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The IMPACT Treatment Model
 Collaborative
care model includes:
• Care manager: Depression Clinical Specialist
– Patient education
– Symptom and Side effect tracking
– Brief, structured psychotherapy: PST-PC
• Consultation / weekly supervision meetings with
– Primary care physician
– Team psychiatrist

Stepped protocol in primary care using antidepressant
medications and / or 6-8 sessions of psychotherapy (PST-PC)
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Outreach Case Identification
Programs
 “Gatekeeper”
Model
• Trains community members to identify and refer
community-dwelling older adults who may need
mental health services
• Identifies isolated elderly who are not receiving
formal mental health services
Florio & Raschko, 1998
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Outreach Programs (Example)
 Psychogeriatric Assessment and Treatment in City
Housing (PATCH) program.
• Serving Older Persons in Baltimore Public Housing
 3 elements
• Train indigenous building workers (i.e., managers, janitors,) to
identify those at risk
• Identification and referral to a psychiatric nurse
• Psychiatric evaluation/treatment in the residents home
 Effective in reducing psychiatric symptoms
» Rabins, et al., 2000
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Community-Integrated Home-Based Depression
Treatment for the Elderly
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Depression Care Management
Core Components
1.
2.
3.
4.
5.
6.
Active Screening to identify depressed patients
Patient education / self-management support
Outcome measurement (e.g., PHQ-9, GDS)
Evidence Based Treatment
• Brief psychotherapy (e.g., PST, IPT)
• Medication Treatment
Psychiatric consultation / caseload supervision
Stepped care
• Increased intensity as needed
• Specialty mental health referral when
necessary
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PEARLS: Improvement in Depression
12 Month Results
HSCL: Hopkins Symptom Checklist
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SELECTIVE PREVENTION
High risk groups, though not all
members bear risks – prevention
through reducing risks.

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Tele-Help/Tele-Check Service
for the Elderly
 18,641 service users in Padua, Italy
 January 1, 1988
thru December 31, 1998
 Mean age = 80.0 years
 84% women, 73% lived alone
 Suicides observed = 6
expected = 20.9
SMR = 28.8% (p<.0001)
 Among women
DeLeo et al., Br J Psychiatry 181:226-229, 2002
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UNIVERSAL PREVENTION
Focused on the entire population as
the target – prevention through
reducing risk and enhancing health.

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Multi-Layered Suicide Prevention
 All residents age ≥ 65 in Yasuzuka, Japan
• Pre/post and comparable town reference cohort
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Intervention – 7 yrs
• Mental health education workshops
• Annual, voluntary screening of depression
• 2-stage screening and referral to general practitioner for treatment with
psychiatric consultation available

Results:
• 64% ↓ in suicide risk for women, Nonsignificant for men
– No change for men or women in reference region
OYAMA ET AL., Gerontologist 46:821-826, 2006
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EFFECT OF MULITLAYERED PREVENTION
INITIATIVES ON SUICIDE RATES
MALE
FEMALE
↓
↓
↓
ALL AGES
Rutz et al. (1992)
Gotland Study
Hegerl et al. (2006)
Nuremberg
Szanto et al. (in press)
Hungary
↔
↓
↔
DeLeo et al. (2002)
Telehelp/Telecheck
↔
↓
Oyama et al. (2004)
Joboji
↓
↓
Oyama et al. (2005)
Yuri town
↔
↓
Oyama et al. (2006a)
Yasuzuka
↔
↓
Oyama et al. (2006b)
Matsudai
↔
↓
OLDER ADULTS
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Implementation Principles:
Training & Coaching
Ineffective: Conventional Training “Conferences”
Effective :
 Skill-based and participatory learning
• Provide information, demonstrate specific skills, and rehearse skills with
constructive feedback from trainer

Collaborative and interactive
• Cross-training service providers helps build relationships and improves
training by sharing different areas of expertise
On-going coaching and follow-up is essential
 Cultural and generational competency

• Population-specific treatment characteristics, values, and beliefs
• Skills for working with culturally diverse older populations.
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Implementation Principles:
Measure What You Do
 Assessment
• Program fidelity
• Process measures
• Outcome measures
 Age-sensitive accommodations and adaptations to
program evaluation should be used
 Programs may require deliberate adaptation,
measuring and attending to fidelity is critical
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Implementation Principles:
Leadership & Administrative Support
Support and guidance for implementation
Reducing barriers
Ensuring adequate supervision
Developing networks and linkages with
related providers and systems
Developing expertise in financing and
organizing services specific to aging,
substance abuse, mental health, and
preventive services
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Implementation Process
Six Stages of Implementation
Exploration and Adoption
 Program Installation
 Initial Implementation
 Full Operation
 Innovation
 Sustainability
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Example:
Stage 1 Exploration and Adoption
A community-based aging services agency
decides to address depression among its
medically-ill, low-income, homebound clients.
Explore available possible programs
 Decision for Adoption of the PEARLS program:
a home-based program for detecting and
managing minor depression and dysthymia
among older adults.
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Example:
Stage 2 Program Installation
Assess organizational readiness to adopt the
PEARLS program
Staffing: redirect and hire social workers
Train the team
Identify local community partners
Set up referral relationships with local
physicians and other community providers
Identify funding and non-reimbursed time
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Example:
Stage 3 Initial Implementation
Case managers and partner agencies begin
identifying and referring depressed,
homebound seniors to the PEARLS program
Begin assessments, treatment planning, and
problem-solving interventions
Establish coordination and communication
between agencies and professionals
Baseline measurements of client status
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Example:
Stage 4 Full Implementation
PEARLS
fully implemented in the new setting
Routine identification of clients in need of
assistance
Routine collaboration between agencies,
interventions
Outcome and fidelity measures at standard
intervals
Evaluation of the effectiveness of the program
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Example:
Stage 5 Innovation
Agency and partner organizations plan to
expand PEARLS to include populations not
currently involved in the program.
Collaborative efforts to adapt the model and
program procedures, and add staff
Monitor fidelity and outcomes to ensure that
the value of the program is sustained.
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Example:
Stage 6 Sustainability
Addition of more partner agencies in a nearby
county
Mentoring system to avoid gaps with new staff
Quarterly meetings track PEARLS process,
fidelity, and outcomes
Data used to justify changes in state policy to
enact stable and expanded funding of
prevention and early intervention
programming
Consumer advocacy & community partnerships
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SAMHSA Older Adult Depression Kit
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EBP Implementation Guide
Bartels SJ, Blow FC, Brockmann
LM, Van Citters AD. A Guide for
Implementing Evidence-Based
Practices to Prevent Substance
Abuse and Mental Health
Problems among Older Adults:
Older Americans Substance
Abuse and Mental Health
Technical Assistance Center;
2008.
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Contact Information
Stephen Bartels, M.D., M.S.
Geriatric Psychiatry
Dartmouth College
Phone: (603) 653-3458
E-mail: [email protected]
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Examples of Vital State Support
for Evidence-Based Programs:
Eyewitness Reports from
Depression Care Management
Nancy L. Wilson
Baylor College of Medicine
Houston Center of Excellence in Health Services ResearchMichael E. DeBakey Veterans Affairs Medical Center
Healthy IDEAS Program Director
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Home-based Depression Care
Management
Intervention components:
Active screening for depression
Measurement-based outcomes
Trained depression care manager
• Client education
• Evidence Based Treatment: PST+ ,
Behavioral Activation
A supervising psychiatrist (clinician)
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Key Steps in Program Implementation
Identifying
Resources
Building the Right Team
Installing the Program
Training and Coaching
Evaluation for Continuous Quality
Improvement and Monitoring Fidelity
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Steps for Implementation
1.
2.
3.
4.
5.
6.
7.
Readiness Assessment : Need, Motivation,
Capacity
Leadership Team & Partnership
Development
Staff Selection
Program Installation
Pre-Service and In-Service Training
Consultation and Coaching
Program Evaluation
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Implementation Process:
Activities and Resources
Agencies or Community Partnerships need:
• Dedicated program leadership: Champion, Supervisors
• Mental/Behavioral Health Expertise for
Training/Coaching
• Effective Linkage & Communication systems with
Treatment Providers
• Practitioners with capacity/ability to incorporate
components into their existing case management
routine with older adults/caregivers
• System for collecting and monitoring depression and
other relevant outcome data
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In support of implementation and
pursuit of sustainability…..
 States have played
active role in exposing key
stakeholders to EBP Approaches
• Hearing Information from Peers
• Use Existing Forums to Present Models with
thoughts about how to advance
 States have organized cross-agency, intrastate calls
and webinars to allow technical assistance for
implementation activities
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In support of implementation and
pursuit of sustainability…..
 States have cultivated partnerships that flow
downstream: Ohio, Missouri, Oklahoma, NC
• Support training of workforce in mental health
and aging: regional trainings for staff
– Program models
– Suicide Risk Assessment and Response
• Create connections which have mutual benefits
for aging and behavioral health networks
– AAAs and ADRCs: link all ages, disabilities to services
– Suicide Hotlines, Crisis Team support for aging services
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In support of implementation and
pursuit of sustainability…..
 States have modified assessment tools and
reporting systems to substitute valid
screening/outcome tools
• Depression/Suicide Risk/Alcohol/Substance Use
Tools
 States have determined how to reimburse program
functions within existing funding mechanisms
• Billable units for Medicaid, state programs
• Title III-D funds-AoA
• Mental health funding of training, coaching
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In support of implementation and
pursuit of sustainability…..
 States have mobilized linkages to evaluation
expertise within state or affiliated academic
partners
• Track outcomes of value and interest to support
delivery and for funders
• Track process to measure fidelity
• Create efficient summary tools for data
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Contact Information
Nancy L. Wilson, M.A., M.S.W., LCSW
Associate Professor of Medicine-Geriatrics
Baylor College of Medicine
Houston Center of Excellence in Health Services Research
Phone: (713) 794-8520
E-mail: [email protected]
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Montrose Counseling Center (MCC)
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Introduction to MCC
Who we are
Mission
Programs
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Lessons Learned From 34 Years
Experience
A successful program will:
• be an LGBT dedicated program
• have the Trust
• have a community presence
Issues:
• What it means to be LGBT affirming
• Need and challenge to be affordable
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Seniors Preparing for Rainbow Years
(SPRY)
First SPRY grant: Targeted Capacity Expansion
grant for mental health services for GLBT
elders
• Outreach, Peer Support Groups, Peer
Individual Counseling, Counseling with a
Licensed Therapist, Case Management,
Psychiatry
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Lessons Learned in SPRY 1
2-fold GLBT elder resistance
Importance of outreach
Need to build trust
Value of peer support groups
For those who needed it, when they actually
tried traditional counseling, they did very well
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Lessons Learned in SPRY 1
Potential of social programming to be
therapeutic, address isolation, etc.
Cultural competency on elder and elder
mental health issues
Paradigm shift for MCC
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Lessons Learned in SPRY 1
The need to promote community awareness
and change
Mental Health of elders in general:
• Not on the radar.
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How did we transform our services?
Embracing a continuum of services beyond
traditional psychotherapy
Our 13-fold increase in elder clients
Our awareness of the need for social
programs for GLBT seniors
Openness to new models
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How did we transform our services?
Sustainability:
• Appointed to the Area Planning Advisory
Council (APAC) for Harris County Area
Agency on Aging
• AAA involvement leading to partial funding
• Using licensed therapists and case
managers able to bill Medicare, Medicaid
and insurances (a two-edged sword).
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Current SAMHSA Grant SPRY 2
SAMHSA Older Adult TCE Grant
• Suicide and prescription drug abuse
prevention for GLBT elders.
• Social awareness and prevention
programs: Advertising campaign,
QPR*, Adult Meducation*, Get
Connected*
(*Evidence-based)
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Current Grant Description
Volunteer Peer Advocates: Screening for
depression (as suicide prevention) and
prescription drug abuse—PHQ-2, CAGE-AIDE*.
Referral into treatment.
Healthy IDEAS*: an evidenced-based
depression treatment. Alcohol and drug abuse
treatment if needed, psychiatric referral if
needed.
Sustainability
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Current Challenges of SPRY 2
The ol’ paradigm shift:
• Suicide and prescription drug abuse
prevention instead of treatment?
• Healthy IDEAS: a challenge for traditional
mental health organizations and providers.
• Volunteer outreach workers: good for
sustainability but more difficult to start so
far, less hours per person.
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Where We Are Today
MCC is attempting to address the needs a
marginalized, underserved and high-risk elder
population that is very difficult to reach,
especially with traditional mental health
providers and programs.
We are piloting programs, such as using
volunteer outreach workers, we feel are
unique.
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Where We Are Today
In a context of serious financial challenges:
• How do we serve our clients?
• How do we reach out to the underserved?
• How do we fund our client services?
• How can state and federal agencies help?
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Contact Information
Christopher E. Kerr, M.Ed., LPC
Clinical Director
Montrose Counseling Center
Phone: (173) 800-0862
E-mail: [email protected]
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