Understanding and Implementing Depression, Anxiety, and Suicide Prevention Evidence-Based Programs

1. Understanding and Implementing Depression, Anxiety, and Suicide Prevention Evidence-Based Programs

2. Suicide Prevention

3. 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.

4. Universal, Selective, and Indicated Suicide Prevention in Older Adults

5. INDICATED PREVENTION • Symptomatic and ‘marked’high risk individuals – interventions to prevent full-blown disorders or adverse outcomes.

6. Recommendations for INDICATED PREVENTION • Because of the close association between depression and suicide in older adults • detection and effective treatment of depression are key • Routine screening for depression • PHQ-9, GDS, or CES-D • Depression treatment is effective at treating depression • And is effective at reducing suicidal ideation in some, and maybe reducing suicide rates • Primary care most common venue

7. 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 Following Up

8. 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)

9. 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

10. 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

11. Community-Integrated Home-Based Depression Treatment for the Elderly

12. Depression Care ManagementCore Components • 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

13. PEARLS: Improvement in Depression 12 Month Results HSCL: Hopkins Symptom Checklist

14. SELECTIVE PREVENTION • High risk groups, though not all members bear risks – prevention through reducing risks.

15. Tele-Help/Tele-Check Servicefor 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

16. UNIVERSAL PREVENTION • Focused on the entire population as the target – prevention through reducing risk and enhancing health.

17. Multi-Layered Suicide Prevention • All residents age ≥ 65 in Yasuzuka, Japan • Pre/post and comparable town reference cohort • 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, Nonsignificantfor men • No change for men or women in reference region OYAMA ET AL., Gerontologist 46:821-826, 2006

18. EFFECT OF MULITLAYERED PREVENTION INITIATIVES ON SUICIDE RATES

19. 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.

20. 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

21. 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

22. Implementation Process Six Stages of Implementation • Exploration and Adoption • Program Installation • Initial Implementation • Full Operation • Innovation • Sustainability

23. 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.

24. 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

25. 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

26. 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

27. 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.

28. 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

29. SAMHSA Older Adult Depression Kit

30. 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.

31. Contact Information Stephen Bartels, M.D., M.S. Geriatric Psychiatry Dartmouth College Phone: (603) 653-3458 E-mail: stephen.j.bartels@dartmouth.edu

32. 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 Research- Michael E. DeBakey Veterans Affairs Medical Center Healthy IDEAS Program Director

33. 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)

34. 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

35. Steps for Implementation • Readiness Assessment : Need, Motivation, Capacity • Leadership Team & Partnership Development • Staff Selection • Program Installation • Pre-Service and In-Service Training • Consultation and Coaching • Program Evaluation

36. 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

37. In support of implementation and pursuit of sustainability….. • States have played activerole 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

38. 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

39. 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 • Stateshave determinedhow 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

40. 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

41. 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: nwilson@bcm.edu

42. Montrose Counseling Center (MCC)

43. Introduction to MCC • Who we are • Mission • Programs

44. 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

45. 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

46. 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

47. 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

48. Lessons Learned in SPRY 1 • The need to promote community awareness and change • Mental Health of elders in general: • Not on the radar.

49. 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

50. 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).