Engage, Assess, Treat: Strategies for the Aging Network to Address Behavioral Health Jo Anne Sirey, Ph.D. Department of Psychiatry Institute for Geriatric Psychiatry Weill Cornell Medicine W E I L L . C O R N E L L . E D U
3 Funding Funding • National Institute of Mental Health - ALACRITY P50113838, R01MH087562 • NYC Department for the Aging – Contract# 20191406829 and 20171416622 • No conflicts W E I L L . C O R N E L L . E D U
Background: Need for services • Tremendous mental health need expected with the aging population – 20.4 percent of adults aged 65 and older met criteria for a mental disorder, including dementia during the previous 12 months (Karel, Gatz & Smyer, 2012). • Older adults underutilize mental health services: – inadequate insurance coverage; workforce shortage; lack of coordination among primary care and mental health providers – stigma surrounding mental health and its treatment; denial of problems; and access barriers (Bartels et al., 2004). • Older adults often prefer psychotherapy to psychiatric medications (Koh et al., 2010; Areán et al., 2002). • Need alternatives to serve the mental health needs of older adults. W E I L L . C O R N E L L . E D U
Why not seek mental health care? • Depression viewed as a natural part of aging. • Heterogeneity of depression (doesn’t look as expected) • Hard to self-identify • Unaware of the deleterious outcomes – Leads to disability (Murray et al., 2012) – suicide (Conwell et al., 2010) & non-suicide mortality (Gallo et al., 2005) – excess use of health care, increased placement in nursing homes and higher annual health care costs (Barry, Murphy, & Gill, 2011; Charney et al., 2003; Eggermont et al., 2012). • Lack of awareness of available services • Services not accessible (too far, not in my language, too costly) • Most important --- beliefs about symptoms and treatment W E I L L . C O R N E L L . E D U
Attitudes can drive access • Among persons with objective mental health need, attitudinal barriers were more common than structural barriers in the WHO International mental health surveys (Andrade et al., 2013). – Low perceived need is the most common barrier to access • Stigma is associated with early drop-out and nonadherence among depressed ambulatory older adults (Sirey et al., 2001) • In depressed homebound older adults, older age, race and greater anticipated stigma was associated with lower likelihood of a mental health referral by aging staff (Sirey, Franklin, McKenzie, 2014) W E I L L . C O R N E L L . E D U
7 Depression screening increases detection • If done systematically, it can reduce bias – Offered in 26 languages • Screening tools offers a language to discuss need • PHQ-9 is a mirrors the DSM-V criteria for depression – Easily administered – Provide cut-off scores and severity – Can be done as a self-report • It is not a diagnosis; it is a recommendation for follow-up W E I L L . C O R N E L L . E D U
8 1/22/2019 Screening • Can be done easily, and at any time • Do not need a mental health background to screen – Can use PHQ-8 if not want to screen for suicide – Still use 10 or greater to identify major depression • Cornell offers free on-line training at: https://mentalhealthtrainingnetwork.org/PHQ • Track using simple programs like Excel W E I L L . C O R N E L L . E D U
9 Engagement in care: Sometimes screening and a referral is not enough W E I L L . C O R N E L L . E D U
Getting into mental health care Provider factors Background - - age, gender - race/ethnicity - language - symptoms Treatment Early - functioning Outcomes Decision-Making / Initiation and - medical burden Depression Treatment Treatment - cost Acceptance engagement self- - accessibility and identified - prior experience participation Depression Modifiable Individual Factors Referred identified by for community Attitudes and Beliefs: knowledge and acceptance of evaluation worker or depression, perceived need for treatment, stigma health care Treatment Preferences: desire for type of treatment, professional or desire for type of provider, fears, myths family member Treatment Expectations: treatment regimen, effectiveness, speed of response, treatment safety W E I L L . C O R N E L L . E D U
11 1/22/2019 Can we improve engagement rates? Building on screening to detect, the goal is to help older adults with depression and suicidal ideation initiate care Goal was to support treatment initiation, a first visit with a provider who can offer care Crossing service systems Challenges include availability of services, but even when available, referrals are difficult W E I L L . C O R N E L L . E D U
IMPROVING MENTAL HEALTH TREATMENT INITIATION: THE OPEN DOOR STUDY (R01 NIMH 079265) W E I L L . C O R N E L L . E D U
13 1/22/2019 Open Door intervention • Open Door is a brief intervention to improve treatment initiation among homebound older adults with depression • 3 brief sessions delivered in the home to set a goal, identify barriers, and support treatment initiation • Design: Randomized controlled trial where Open Door is compared to an attention control referral condition • Sample: Case management clients who screen positive for depression • Bronx and Westchester County W E I L L . C O R N E L L . E D U
Open Door Intervention • After research assessment: 1) recommend referral 2) conduct barriers assessment 3) define a personal goal 4) provide education about depression, treatment options and identify preferences 5) Collaboratively problem solve to address the barriers to care. • Three sessions in the home – First session is evaluation/baseline assessment and referral – Two additional follow-up visits were brief – Additional telephone call if needed • Tested in a randomized controlled trial against a control with a referral and support (same number of visits). W E I L L . C O R N E L L . E D U
15 Open Door results • Controlling for gender, Open Door and depression severity predicted treatment initiation (Model Chi square = 14.30, df=2, p=.001). (Sirey et al, 2015) – 74% of Open Door clients versus 56% of support initiated care • Among the 43 clients with suicidal ideation, those in Open Door were more likely to initiate than those clients in the control group (90.9% vs. 66.7%, p=.06) • Initiation rates of Black clients is better than White clients (82.4% vs.72%) but not significant • Need and intervention predict initiation W E I L L . C O R N E L L . E D U
16 Summary • Adding screening into routine assessments or paperwork increases detection • However, it requires tracking, and follow up • Open Door approach is a way of standardizing the referral process and increase the likelihood of treatment initiation W E I L L . C O R N E L L . E D U
New service delivery models: Integrating mental health into aging services SMART-MH TRIO W E I L L . C O R N E L L . E D U
18 SMART-MH • Arrives in NYC October 29, 2012 • About 17 percent of New York City’s total land mass, or 51 square miles, was flooded • Redesign the flood lines in NYC W E I L L . C O R N E L L . E D U
Hurricane Sandy – why older adults? They were : -trapped in apartments without electricity -lost services -poorer communication -highest mortality W E I L L . C O R N E L L . E D U
20 1/22/2019 Sandy Mobilization Assessment Referral and Treatment for Mental Health • Disaster work has a history of launching new evidence- based models • A service delivery project funded by FEMA via a large New York State Block Grant (1.2 million) to design services • Partners include New York City Department for the Aging (DFTA), Aging in New York Fund (503c) & Hunter College W E I L L . C O R N E L L . E D U
SMART-MH design • Service delivery model components: – Outreach to community (senior centers, faith based communities) – Brief needs assessment – Referral made using Open Door – Offer a brief psychotherapy to adults with depression (PHQ-9) • Needs assessment data – PHQ-9 and suicide risk – Storm impact • Data collected in Chinese, Russian, Spanish or English • Entered in DFTA database with analysis done with de- identified dataset W E I L L . C O R N E L L . E D U
SMART-MH goals Identify the current mental health needs of NYC older adults living in areas impacted by Superstorm Sandy (11/1/14-9/31/16) Test a service delivery model a) To improve identification and engagement among older adults who cannot not access care b) To bring a brief psychotherapy developed from neurobiological models of depression to the community W E I L L . C O R N E L L . E D U
23 ENGAGE therapy - 6 sessions offered • Engage is a treatment for late-life depression developed to match the skills of community clinicians • Based on the theory that depression is associated with dysfunction in positive valence systems in the brain • Engage uses "reward exposure" (exposure to meaningful activities) and assumes that repeated activation of reward networks will normalize these systems. W E I L L . C O R N E L L . E D U
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