ObjectiveLoneliness is a significant and independent risk factor for depression in later life. Particularly in Asian culture, older people may find it less stigmatising to express loneliness than depression. This study aimed to adapt a simple loneliness screen for use in older Chinese, and to ascertain its relevance in detecting depressive symptoms as a community screening tool.Design, setting and participantsThis cross-sectional study was conducted among 1653 older adults aged 60 years or above living in the community in Hong Kong. This was a convenient sample recruited from four local non-governmental organisations providing community eldercare or mental healthcare services. All data was collected by trained social workers through face-to-face interviews.MeasuresLoneliness was measured using an adapted Chinese version of UCLA 3-item Loneliness Scale, depression symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), and social support with emotional and instrumental support proxies (number of people who can offer help). Basic demographics including age, gender, education and living arrangement were also recorded.ResultsThe average loneliness score was 3.9±3.0, and it had a moderate correlation with depressive symptoms (r=0.41, p<0.01). A loneliness score of 3 can distinguish those without depression from those with mild or more significant depressive symptoms, defined as a PHQ-9 score of ≥5 (sensitivity 76%, specificity 62%, area under the curve=0.73±0.01). Loneliness explained 18% unique variance of depressive symptoms, adding to age, living arrangement and emotional support as significant predictors.ConclusionA 3-item loneliness scale can reasonably identify older Chinese who are experiencing depressive symptoms as a quick community screening tool. Its wider use may facilitate early detection of depression, especially in cultures with strong mental health stigma.Trial registration numberClinicalTrials.gov NCT03593889

Background Late-life depression is common, modifiable, yet under-treated. Service silos and human resources shortage contribute to insufficient prevention and intervention. We describe an implementation research protocol of collaborative stepped care and peer support model that integrates community mental health and aged care services to address service fragmentation, using productive ageing and recovery principles to involve older people as peer supporters to address human resource issue. Methods/design This is a non-randomised controlled trial examining the effectiveness and cost-effectiveness of the “Jockey Club Holistic Support Project for Elderly Mental Wellness” (JC JoyAge) model versus care as usual (CAU) in community aged care and community mental health service units in 12 months. Older people aged 60 years and over with mild to moderate depressive symptoms or risk factors for developing depression will be included. JoyAge service users will receive group-based activities and psychoeducation, low-intensity psychotherapy, or high-intensity psychotherapy according to the stepped care protocol in addition to usual community mental health or aged care, with support from an older peer supporter. The primary clinical outcome, depressive symptoms, and secondary outcomes, self-harm risk, anxiety symptoms, and loneliness, will be measured with the Patient Health Questionnaire-9 (PHQ-9), Self-Harm Inventory, Generalized Anxiety Disorder 7-item scale (GAD-7), and UCLA Loneliness 3-item scale (UCLA-3) respectively. Cost-effectiveness analysis will assess health-related quality of life using the EQ-5D-5L and service utilisation using the Client Service Receipt Inventory (CSRI). We use multilevel linear mixed models to compare outcomes change between groups and calculate the incremental cost-effectiveness ratio in terms of quality-adjusted life years. Discussion This study will provide evidence about outcomes for older persons with mental health needs receiving collaborative stepped care service without silos and with trained young-old volunteers to support engagement, treatment, and transitions. Cost-effectiveness findings from this study will inform resource allocation in this under-treated population. Trial registration ClinicalTrials.gov NCT03593889. Registered on 20 July 2018.

Aims Late-life depression has substantial impacts on individuals, families and society. Knowledge gaps remain in estimating the economic impacts associated with late-life depression by symptom severity, which has implications for resource prioritisation and research design (such as in modelling). This study examined the incremental health and social care expenditure of depressive symptoms by severity. Methods We analysed data collected from 2707 older adults aged 60 years and over in Hong Kong. The Patient Health Questionnaire-9 (PHQ-9) and the Client Service Receipt Inventory were used, respectively, to measure depressive symptoms and service utilisation as a basis for calculating care expenditure. Two-part models were used to estimate the incremental expenditure associated with symptom severity over 1 year. Results The average PHQ-9 score was 6.3 (standard deviation, s.d. = 4.0). The percentages of respondents with mild, moderate and moderately severe symptoms and non-depressed were 51.8%, 13.5%, 3.7% and 31.0%, respectively. Overall, the moderately severe group generated the largest average incremental expenditure (US$5886; 95% CI 1126–10 647 or a 272% increase), followed by the mild group (US$3849; 95% CI 2520–5177 or a 176% increase) and the moderate group (US$1843; 95% CI 854–2831, or 85% increase). Non-psychiatric healthcare was the main cost component in a mild symptom group, after controlling for other chronic conditions and covariates. The average incremental association between PHQ-9 score and overall care expenditure peaked at PHQ-9 score of 4 (US$691; 95% CI 444–939), then gradually fell to negative between scores of 12 (US$ - 35; 95% CI - 530 to 460) and 19 (US$ -171; 95% CI - 417 to 76) and soared to positive and rebounded at the score of 23 (US$601; 95% CI -1652 to 2854). Conclusions The association between depressive symptoms and care expenditure is stronger among older adults with mild and moderately severe symptoms. Older adults with the same symptom severity have different care utilisation and expenditure patterns. Non-psychiatric healthcare is the major cost element. These findings inform ways to optimise policy efforts to improve the financial sustainability of health and long-term care systems, including the involvement of primary care physicians and other geriatric healthcare providers in preventing and treating depression among older adults and related budgeting and accounting issues across services.

Background There is an ample body of literature examining the experiences and outcomes of peer support services for mental health recovery in western countries. However, formal peer support is only recently adapted and piloted to alleviate depression among older people, and little is known about how the peer-to-peer model might be lived out in the older Chinese population. This qualitative study investigated peer supporters’ (PS) perspectives of their roles and experiences of rendering formal peer support to community-dwelling older adults at risk of or living with depression in Hong Kong. Methods The study adopted a qualitative design. Five semi-structured focus groups were conducted with 27 trained peer supporters between ages 54–74 (21 females and 6 males) who had provided peer-to-peer support to older adults at risk of or living with depression in the community for at least 12 months. Thematic analysis was employed to derive content and meanings from the focus group transcripts. Results Participants’ mean age was 61.9 years; two-thirds of them were retired and the rest still engaged in part-time or full-time employment. Four themes were identified in relations to the roles and experiences in rendering the peer support services: (1) peerness in health and age-related lived experiences; (2) companionship, social and emotional ties beyond formal support; (3) meaningful roles to facilitate older people’s functional ability; and (4) hopes and actions against the undesirable outcomes of aging. Being a PS might provide meaningful roles for persons in transition to or living in late adulthood, and enable community-dwelling older adults with depression to maintain functional ability. On the other hand, defining the concept of ‘peer’ beyond the shared experience of mental distress, ensuring a healthy boundary between the peers and the service users, maintaining a careful balance between time-limited formal support and stable social ties, and providing self-management training and on-going support appear crucial. Conclusions This study of PS’ perspectives and experiences offer insights into the age-specific dimension of the peer relationship. Despite the promising effects it might offer, careful implementation of peer support among older adults is warranted to safeguard against the ensuing loss of meaningful social ties and the potential emotional distress.

Background and Objectives Health and mental health interventions, such as psychotherapy and exercise programs, delivered via information and communication technology (ICT) may improve service access. However, adjustment among older people and in synchronous group interventions is more challenging. Technology affordance concerns the possibilities engendered by technology for various users and purposes and can help understand challenges in ICT-delivered groups and identify possible solutions. Research Design and Methods Adopting a multiple triangulation approach, we observed ICT-delivered groups of acceptance and commitment therapy and exercise for older people with depressive symptoms, conducted focus groups with older people who had received group psychotherapy with or without an exercise component, and obtained clinical notes from interventionists. We conducted a thematic analysis on the observation notes, focus group transcriptions, and clinical notes. Results Four focus groups were conducted with 22 participants (mean age = 72.6 years, SD = 7.2, 86% female). We identified three challenges: (1) seeing-be seen dilemma, (2) speaking-hearing dilemma, and (3) blurred therapy-home boundary, and two solutions: (1) maneuvering layouts and collaborative tools, and (2) cross-platform mediated strategies. Participants struggled to observe the interventionist while simultaneously demonstrating their posture in front of a camera. Remaining silent and moderated turn-taking allowed for clearer hearing but limited interactions. Interruptions from the background environment and intersections of family living spaces disrupted audio-visual communication and jeopardized the sense of security. As a solution, interventionists maneuvered layouts and collaborative tools on teleconferencing applications to achieve intervention goals and provided support through different media. Discussion and Implications The identified challenges and potential solutions can be understood from interactivity, portability, temporality, persistence, and multimediality. Technology affordance can guide ICT-delivered group design by matching the affordance of various technologies and communication media with the characteristics of the intervention and users to enhance efficacy and avoid an unnecessary digital divide.