Background Despite their high rates of depression, homebound older adults have limited access to evidence-based psychotherapy. The purpose of this paper was to report both depression and disability outcomes of telehealth problem-solving therapy (tele-PST via Skype video call) for low-income homebound older adults over 6 months postintervention. Methods A 3-arm randomized controlled trial compared the efficacy of tele-PST to in-person PST and telephone care calls with 158 homebound individuals who were aged 50+ and scored 15+ on the 24-item Hamilton Rating Scale for Depression (HAMD). Treatment effects on depression severity (HAMD score) and disability (score on the WHO Disability Assessment Schedule [WHODAS]) were analyzed using mixed-effects regression with random intercept models. Possible reciprocal relationships between depression and disability were examined with a parallel-process latent growth curve model. Results Both tele-PST and in-person PST were efficacious treatments for low-income homebound older adults; however the effects of tele-PST on both depression and disability outcomes were sustained significantly longer than those of in-person PST. Effect sizes (dGMA-raw) for HAMD score changes at 36 weeks were 0.68 for tele-PST and 0.20 for in-person PST. Effect sizes for WHODAS score changes at 36 weeks were 0.47 for tele-PST and 0.25 for in-person PST. The results also supported reciprocal and indirect effects between depression and disability outcomes. Conclusions The efficacy and potential low cost of tele-delivered psychotherapy show its potential for easy replication and sustainability to reach a large number of underserved older adults and improve their access to mental health services.

Objective-We examined the association of treatment preferences with treatment initiation, adherence, and clinical outcome among depressed mid-life and elderly primary care patients.Methods-60 primary care participants meeting DSM-IV criteria for major depression were randomized to receive treatment congruent or incongruent with their primary stated preference. Participants received either 20 weeks of escitalopram as monitored by a care manager, or 12 weekly sessions of interpersonal psychotherapy followed by 2 monthly booster sessions. Adherence to treatment and depression severity were reassessed at weeks 4, 8, 12, and 24.Results-Participants expressed stronger preferences for psychotherapy than antidepressant medication. Preference strength was a more sensitive measure of outcomes than congruence versus incongruence of preference with the assigned treatment. Across age groups, preference strength was significantly associated with treatment initiation and 12-week adherence rate, but not with depression severity or remission.Conclusions-A continuous measure of preference strength may be a more useful measure in clinical practice than preferences per se. Future research should focus on whether and how greater facilitation of the patient-clinician treatment decision-making process influences clinical outcome.Treatments of depression in primary care settings are effective yet most depressed adults (1), particularly older ones (2), do not receive appropriate care. Even when guideline-based treatments are provided, patients often do not fully participate in them. Not surprisingly, therefore, randomized clinical trials have reported substantially poorer outcomes for "intent to treat" than "treatment completer" cohorts (3), indicating a need for strategies that maximize treatment participation.A patient's decision not to initiate or complete treatment may stem from disappointment or dissatisfaction with the treatment offered by the clinician. While medications are the predominant intervention offered depressed primary care patients, 50%-86% of them prefer a psychosocial intervention (4-7). Thus, many patients conceivably refuse treatment offered in primary care because psychotherapy is not an available option.In psychiatric outpatient settings, treatment preferences have been addressed through "negotiated treatment plans" whereby clinicians elicit patient requests and encourage their participation in treatment planning. Patient reports of greater participation in such negotiations have been associated with greater levels of satisfaction, sense of feeling helped, and adherence to treatment plans (8,9). Studies of mid-life patients in the primary care sector have endorsed the value of a negotiated treatment plan and the importance of patients playing active rather than passive roles in formulating it. Such participation enhances the patient's likelihood of initiating treatment and his/her satisfaction with it (10-12).Despite these benefits, the few studies examining treatment negotiation and clinical outcome have...

Initial depression severity and receiving adequate pharmacotherapy predict early recovery in individuals with major depression seeking outpatient treatment. A minority of persons receive intensive antidepressant treatment. Less severe personality dysfunction and being married predicts early recovery among persons with less severe depression.

Objective This study evaluated the association between depression and hospitalization among geriatric home care patients. Methods A sample of 477 patients newly admitted to home care over two years was assessed for depression. Bivariate and logistic regression analyses examined the likelihood of hospitalization during a 60-day home care episode. Results The hospitalization rate was similar for the 77 depressed patients and 400 nondepressed patients (about 7%). However, mean time to hospitalization was 8.4 versus 19.5 days after start of care, respectively. Hospitalization risk was significantly higher for depressed patients during the first few weeks. A main effect for depression and a depression-by-time interaction was found when analyses controlled for medical comorbidity, cognitive status, age, gender, race, activities of daily living and instrumental activities of daily living, and referral to home care after hospitalization. Conclusions Depression appears to increase short-term risk of hospitalization for geriatric home care patients immediately after starting home care.

Objective This study examined the rate and predictors of major depression six months after outpatient mental health admission. Methods Assessments were conducted at admission and three and six months later among 166 participants. Antidepressant treatment adequacy and depression outcomes were assessed at follow-ups. Results Predictors of major depression at six months included nonremission status at three months (odds ratio [OR]=3.56, p=.003), inadequacy of early pharmacotherapy (OR=2.73, p=.009), worse physical functioning measured by the 36-Item Short-Form Health Survey (OR=.975, p<.001), and being unmarried (OR=2.54, p=.031). Conclusions The findings support the effects of baseline physical disability, marital status, early treatment adequacy, and early remission on the course of major depression. The identification of individuals who do not receive intensive pharmacotherapy or who have not recovered by three months may provide opportunities for interventions to optimize six-month outcomes and to prevent the development of a persistent depression.