The University of California, San Francisco is enrolling patients in a large, multi centered clinical trial that will study methods of treating depression, anxiety and alcohol abuse in older patients. These are common problems in the elderly, but often under-diagnosed.
Generally, older Americans are treated for mental disorders in the primary care setting. Often, the primary care physician treats the problem by prescribing an antidepressant, said Patricia Arean, PhD, UCSF assistant professor of psychiatry and study co- principal investigator. Health care providers treat such problems in the primary care setting because they believe it's hard to encourage older people to accept a referral to go somewhere else for mental health care services, she said. And even if the patients agree to talk to someone outside the primary care setting, there is often a long waiting list that makes it difficult for them to make an appointment. This causes the patient to give up, Arean said.
"But you can't just give someone a prescription. They need to be followed for a period of time, educated about their disorder and on how to manage it," she said. "Providers don't have the time to do that. So the question is 'Do we make mental health services in primary care better or do a better job getting older people into specialty care?'"
Carroll Estes, PhD, UCSF professor in the Institute for Health & Aging, is the principal investigator of the study.
The five -year study will examine two models of service delivery for older patients. The first will integrate mental health services into the medical practice, having a social worker and psychiatrist present in the clinic working side by side with the primary care physician. If a physician recognized signs of depression in a patient, he or she would probably prescribe antidepressants and then have the patient see the in-house psychiatrist who would manage mental health services for that patient.
The second model will have a social worker present in the primary care practice to help the patient find outside mental health services. "So rather than saying here is list of names of people, the social worker would ask them what services they need and help them find the services," Arean said. The patients will be followed for a year, randomized to either arm. Outcomes investigators will look at whether the patients receive the mental health services they need and whether they improve.
"In terms of getting better, we will look at whether their mental illness goes away, does the quality of their life improve, do they feel like their health has improved and are they satisfied with the services," Arean said. About 15 percent of elderly people experience depression at some point and the condition is more chronic in the elderly than in younger people, according to the National Institute of Mental Health. Abuse of alcohol and legal drugs-both prescribed and over the counter-- affects up to 17 percent of adults over 60 years old in the United States, according to the Center for Substance Abuse Treatment.
The American Medical Association called elderly alcoholics a "hidden group" and the National Institute of Mental Health called depression in the elderly widespread and a serious public health concern in recent reports. "Clinical depression is very disabling to older people and suicide rates are higher for older men than in any other age group," Arean said.
Older people who abuse alcohol often use it to cope with mental problems. "There tends to be a downplaying of how much people drink, but we suspect rates of heavy drinking to be fairly high in older patients who use alcohol as a means to cope with depression and anxiety," Arean said. "When you drink to steady your nerves and you do it consistently, you create another problem." UCSF is one of 12 centers participating in the study and will enroll 300 patients. The emphasis will be on elderly African Americans, who may suffer from some of these disorders even more so than other groups, Arean said. "If you look at recent data on younger people, it shows that rates of alcohol abuse and depression tend to be higher for African-Americans," she said. "The same may hold true for older African-Americans."
Patients enrolled in the study will be seen at the Over 60 Health Center in Berkeley, a public health medical clinic geared toward older people. Participants must be at least 65-years old.
For more information, call study coordinator Rowena Nery, MA, UCSF research associate in the department of psychiatry at 415-476-7439. The other study sites are: Dartmouth University in New Hampshire; Sunset Park Family Health Center in Brooklyn, New York; Chinatown Health Clinic in New York City; Chicago Veteran's Affairs Westside Medical Center; University of Pennsylvania in Philadelphia; Miami Veteran's Affairs Medical Center; Veteran's Affairs Medical Center in Little Rock, Arkansas; Philadelphia Veteran's Affairs Medical Center; W.S. Middleton Memorial Veteran's Hospital, Madison, WI; and Unity Health system in Rochester, New York. The Substance Abuse and Mental Health Service Agency funded this study.