Depression in Homebound Older Adults: Recent Advances inScreening and Psychosocial Interventions

Namkee G. Choi, PhD1, Jo Anne Sirey, PhD2, and Martha L. Bruce, PhD, MPH3

1The University of Texas at Austin School of Social Work, 1925 San Jacinto Blvd, Austin, TX78712; [email protected]; 512-232-9590; 512-471-9600 (fax)2Department of Psychiatry, Westchester Division, Weill Cornell Medical College, 21 BloomingdaleRoad, White Plains, NY 10605; [email protected]; 914-997-4333; 914-682-6979 (fax)3Department of Psychiatry, Westchester Division, Weill Cornell Medical College, 21 BloomingdaleRoad, White Plains, NY 10605; [email protected]; 914-997-5977

AbstractHomebound older adults are more likely than their ambulatory peers to suffer from depression.Unfortunately, the effectiveness of antidepressant medications alone in such cases is limited.Greater benefits might be realized if patients received both pharmacotherapy and psychotherapy toenhance their skills to cope with their multiple chronic medical conditions, isolation, and mobilityimpairment; however, referrals to specialty mental health services seldom succeed due toinaccessibility, shortage of geriatric mental health providers, and cost. Since a large proportion ofhomebound older adults receive case management and other services from aging services networkagencies, the integration of mental health services into these agencies is likely to be cost-efficientand effective. This review summarizes recent advances in home-based assessment andpsychosocial treatment of depression in homebound recipients of aging services.

KeywordsHomebound older adults; chronic illness; mobility impairment; mental health; depression;depression screening; psychosocial intervention; evidence-based psychotherapy; antidepressantmedication; Older Americans Act; aging service settings; in-home services; PHQ-9; BSI-18;cognitive impairment; problem-solving therapy; telehealth delivery; behavioral activation;PEARLS; Healthy IDEAS; problem adaptation therapy; Beat the Blues

IntroductionDespite projections that overall disability rates in later life will continue to decline [1,2], therapid growth of the older-adult population is likely to increase the number of homeboundolder adults who require in-home support services for their physical, functional, and mentalhealth needs. According to the 2011 U.S. Census data, of 40 million noninstitutionalizedadults age 65 years and older, 9.2 million (23.5%) had ambulatory disability and 6.2 million(15.8%) had independent living disability [3]. In calendar year 2010, the Medicare homehealth care program served just fewer than 3 million older adults and paid out $16.8 billion

Correspondence to: Namkee G. Choi.

DisclosureN.G. Choi: none; J. A. Sirey: none; M.L. Bruce: compensation from McKesson, Inc. for serving as a consultant, and payment forlectures (including service on speakers bureaus) from Dartmouth Medical College.

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Published in final edited form as:Curr Transl Geriatr Exp Gerontol Rep. 2013 March 1; 2(1): 16–23. doi:10.1007/s13670-012-0032-3.

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($5,669 per person) for their home health services, and the Medicare skilled nursing facilityservices served 2.3 million older adults and paid out $25.1 billion ($10,866 per admission)[4]. Home-based care tends to be less costly than institutional care. However, given manyolder adults’ strong preference for aging in place [5], the demand for home-based care forthe chronic physical and mental health problems of the growing numbers of homeboundolder adults will continue to increase, requiring innovative and cost-effective solutions forthis significant public health need.

Epidemiologic and other community-based studies over the past two decades consistentlyfound that older adults who were homebound due to chronic illness and disability sufferedfrom major depressive disorder (MDD) or clinically significant depressive symptoms at arate two to three times higher than that of their ambulatory peers [6–10]. In one study, 13%of homebound older-adult respondents reported suicidal ideation [10], and in other studies,almost half of homebound older adults with MDD reported symptoms of suicidal ideation,including 6% who were actively suicidal [11, 12]. Both persistent and new-onset disabilityincrease the risk for depression [13], and among low-income homebound older adults, socialisolation and financial worries/hardship were also found to be depression risk factors [7, 14].Subsyndromal depressive symptoms are more common than major or minor depressionamong homebound and other community-dwelling older adults, but they, like MDD, areassociated with significantly increased functional and psychosocial impairments and mayrepresent a common and integral part of the long-term course of MDD [15–18]. Regardlessof its severity, untreated late-life depression has serious negative health effects, which inturn results in higher rates of healthcare service utilization, premature institutionalization,and mortality [19,20].

Antidepressant medication use among older adults has significantly increased in recent years[21]. A significant proportion of depressed homebound older adults take antidepressantmedications (e.g., from 11.5% in 2000 to 39.5% in 2007 regardless of diagnosis) [22],mostly prescribed by their primary care physicians; however, many have limited response tomedication alone and remain symptomatic, due in part to subtherapeutic dosing, inadequatemonitoring by the clinicians, and poor patient adherence [23–25]. Thus, despite rapidincrease in the proportion of homebound older adults being prescribed antidepressants,depression remains insufficiently treated and persistent in the majority of these seniors.

Most depressed homebound older adults prefer psychotherapy to pharmacotherapy [26, 27],perhaps because only the former can teach skills to cope with their multiple chronic medicalconditions, disability, social isolation, and limited financial resources [28, 29]. However,referring homebound older adults to specialty mental health services for psychotherapyseldom succeeds due to inaccessibility, shortage of geriatric mental health providers, andcost [30]. Providing in-person psychotherapy is especially expensive for homeboundpatients, given the costs associated with travel (of clinicians to homes or disabled patients tooffices). Despite the high rate of depression among homebound older adults, their mentalhealth needs are largely unmet.

Recent efforts to increase homebound older adults’ access to psychosocial interventionsfocus on integrating mental health provision into existing home-based care offered by agingservices and home healthcare settings and/or on taking advantage of technological advances[31, 32]. In this paper, we review recent advances in assessment and psychosocial treatmentof depression in homebound older adults who are served by the aging services network. Fora summary of new developments in home healthcare service settings, please refer to anearlier work by the last author [33]. Following the definition of “homebound” older adultsby Medicare [34], the term homebound adults in this study refers to older individuals who,

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due to medical conditions and/or mobility-affecting impairments, cannot freely leave theirhome and who require help in doing so.

Aging Services SettingsThe 1965 enactment of the Older Americans Act (OAA) established federal and stateagencies to address the social service needs of the aging population. The goal of the OAAwas to help older adults (age 60 years and older) maintain maximum independence in theirhomes and communities and to promote a continuum of care for vulnerable older adults. Insuccessive amendments, the Act created area agencies on aging (AAAs) and a host ofservice programs. The “aging services network” refers to the agencies, programs, andactivities that are sponsored by the OAA [35]. Major services provided by the aging servicesnetwork include access to services (information and referral, benefits counseling, casemanagement, transportation); nutrition (nutrition counseling and education, congregatemeals and home-delivered meals, or “Meals on Wheels”); home- and community-basedlong-term care (short-term homecare/housekeeping/personal assistance care, adult day care,family caregiver support); disease prevention and health promotion (immunization, fallprevention, medication management); vulnerable-elder rights program (long-term careombudsman, elder abuse and neglect prevention, and legal assistance); and services toNative Alaskans, Native Hawaiians, and Native Americans. Current OAA organizationsinclude 56 state units on aging, 629 area agencies on aging, 243 tribal and Native Americanorganizations, and 30,000 local service organizations [36].

Since a large proportion of homebound older adults are served by aging services networkagencies for case management and other social and health service needs, the integration ofmental health services into aging services is likely to be a cost-efficient and effective way toserve the mental health needs of these vulnerable older adults. As a reflection of theincreasing awareness of the importance of late-life mental health issues, the OAAAmendments of 2006 stipulate funding availability for mental health screening, diagnosis,and treatment as important parts of community-based agencies and strongly encourageOAA-funded agencies to directly provide or purchase mental health services for their clients[37]. Despite this potential funding availability, most aging services network agenciescurrently do not provide depression care for their clients because they lack staff trained indepression intervention. Most agencies also face barriers to referring their clients out fortreatment because of the shortage of mental health professionals who are able and willing toprovide in-home treatment. In recent years, however, some pioneering work has been doneto integrate depression screening as part of case management assessments in aging servicesagencies and to provide home-based depression treatment using telehealth delivery, assummarized below.

Tools for Depression Screening of Homebound Older Adults Served byAging Services

Given the high caseloads of aging service agencies, there is the need to identify the mostefficient depression screening tool. The Patient Health Questionnare-9 [38, 39] has beenwidely used as an effective, efficient depression screening tool for both symptom severityand probable diagnosis in many randomized clinical trials (RCTs) of depression in primarycare settings. The PHQ-9 was also successfully used as an assessment tool to identifydepression in homebound older adults served by homecare agencies or home-deliveredmeals programs [7, 9, 10]. In 2010, Medicare required home healthcare agencies to use arevised version of the Outcome Assessment and Information Set (OASIS) that includes atwo-item version of the PHQ or PHQ-2 [40]. Medicare also integrated the full PHQ-9 intothe revised assessments (MDS 3.0) for nursing home residents in 2011 [41]. Many aging

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services agencies (e.g., in New York City) have begun augmenting their routine assessmentwith the PHQ-9 or the PHQ-2 [42].

A community-academic research partnership in Monroe County, N.Y., evaluated thesensitivity, specificity, positive and negative predictive values, positive and negativelikelihood ratios, and receiver operating characteristic (ROC) curve of the PHQ-2 (scorerange 0–6), the PHQ-9 (score range 0–27), and the two-step PHQ-2/9 (calculation of PHQ-9score among only those subjects who screened positive on the PHQ-2 at a cut point of > 2)in a sample of 378 aging services clients [43]. The standard criterion was the StructuredClinical Interview for DSM-IV-TR. When they used a cut score of 3, the sensitivity andspecificity of the PHQ-2 were 0.80 and 0.78, respectively. The area under the ROC curve(AUC) for the PHQ-2 was 0.87. When they used a cut score of 10, the sensitivity andspecificity of the PHQ-9 were 0.82 and 0.87, respectively, and the AUC was 0.91. Thesensitivity and specificity of the two-stage PHQ-2/9 were 0.81 and 0.89, respectively. Thefindings show that in aging services settings where a false-positive test has high costimplications, the greater specificity of the PHQ-9 makes it more advantageous than thePHQ-2. The PHQ-2/9 also appears to be efficient for an agency to administer. The samecommunity-academic research partnership also evaluated the performance of the PHQ-2 andthe PHQ-9 for aging services clients with cognitive impairment (≥ 2 errors on the Six-ItemScreen) [44]. The PHQ-2, using a cutoff of 3, had a sensitivity of 0.78 and a specificity of0.71, and the PHQ-9, using a cutoff of 10, had a sensitivity of 0.89, a specificity of 0.71, andan AUC of 0.85, indicating that the cognitive status needs to be considered when using thePHQ as a depression screener.

Another screening tool for depression (and anxiety) that has shown promise in its use withhomebound older adults is the Brief Symptom Inventory-18 (BSI-18) [45]. Investigatorsevaluated its factor structure, internal consistency, and concurrent validity in a sample of142 homebound older adults, age 60 years and older, receiving in-home aging services inFlorida. With the DSM-IV as the standard criterion, the BSI-18 depression subscale had anAUC of 0.89, a sensitivity of 0.88, and a specificity of 0.62 when using the cut score of T =50. The AUC for the three-item depression scale was 0.88, its sensitivity was 0.88, and itsspecificity was 0.74 when using a cut score ≥ 3. The ROC analysis of the BSI-18 anxietysubscale yielded an AUC of 0.80 and a sensitivity of 0.88 and a specificity of 0.61 whenusing a T-score of 49. However, because only homebound older adults who had cognitiveability to consent and had no dementia diagnosis were selected to participate, it is not knownif the BSI-18 will be a valid screening tool for those with cognitive impairment.

Treatment of Depression in Homebound Older Adults: Evidence-BasedPsychosocial Interventions

In its 2011 publication on treatment of depression in older adults, the Substance Abuse andMental Health Services Administration (SAMHSA) lists the following psychotherapies asbeing evidence based: cognitive behavioral therapy; behavioral therapy; problem-solvingtherapy; interpersonal therapy; reminiscence therapy; and cognitive bibliotherapy [46]. Ofthese, problem-solving therapy (PST) has a growing evidence base for use with bothambulatory and homebound older adults. Our group recently completed an RCT oftelehealth-delivered PST (tele-PST) for homebound older adults and found it to be aseffective as in-person PST. Other treatments that have been found efficacious for helpinghomebound older adults are PATH (problem-adaptation therapy, PEARLS (Program toEncourage Active, Rewarding Lives for Seniors), and Healthy IDEAS (IdentifyingDepression, Empowering Activities for Seniors). Of these, the latter two (PEARLS andHealthy IDEAS) have been selected (along with the IMPACT program), as evidence-basedprograms for treating late-life depression by the Centers for Disease Control and Prevention

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and the National Association of Chronic Disease Directors. They are multi-component,home-based interventions that collaborate with community-based agencies to providedepression screening, outreach, and treatments such as problem-solving skills training andbehavioral activation in conjunction with geriatric case management and other agingservices[47]. This section also describes these and other recent developments in depressiontreatment for homebound older adults.

Problem-Solving Therapy (PST) and Telehealth-Delivered PST (Tele-PST)Problem-solving therapy is a treatment based on the social problem-solving theory ofdepression, which posits that the relationship between stressors and depression is influencedby the availability of problem-solving skills [48, 49]. People with deficits in problem-solving skills become vulnerable to depression because such deficits lead to ineffectivecoping attempts under high stress levels. Problem-solving therapy facilitates optimisticorientation toward problem-solving and follows seven steps, including appraisal andevaluation of specific “here-and-now” problems, identification of the best possible solutions,and the practical implementation of those solutions, as well as addressing anhedonia andpsychomotor retardation through behavioral activation and increased exposure to pleasantevents [50, 51]. The efficacy of PST-PC (i.e., delivery of PST in fast-paced primary caresettings), alone or in combination with antidepressant medications, has been supported inmultiple RCTs, including the IMPACT study, a multisite RCT of late-life depressiontreatment in primary care settings [52–55]. An RCT that tested efficacy of in-home PST (sixweekly sessions) for older-adult patients of a home healthcare agency in New York foundsignificant reduction in their depressive symptoms over a 6-month period [56].

Given that in-home, in-person PST is unlikely to be sustainable in aging service agenciesdue to its high cost, our group tested the efficacy of tele-PST, or PST sessions delivered viaSkype video call to homebound older adults who were not cognitively impaired.Videoconferenced delivery has several advantages over telephone delivery because its visualcontact, through which the therapist can see the client’s facial expression and bodylanguage, allows most of the benefits of in-person sessions and more effective therapeuticengagement than telephone sessions. Participants (121 low-income homebound olderadults), who had moderately severe and severe depressive symptoms (24-item HamiltonRating Scale for Depression [HAMD] > 15) at baseline, were randomly assigned to sixweekly sessions of tele-PST, in-person PST, and telephone care call (attention control). Alaptop with Skype function and wireless card was loaned to each tele-PST participant. Thefollow-up assessments found (1) that tele-PST and in-person PST participants hadsignificantly lower depression scores than telephone care call participants, and (2) that tele-PST and in-person PST participants were not different from each other. Standardized meandifference effect sizes for HAMD score changes were ESsm = 0.77 for tele-PST and ESsm =0.70 for in-person PST at 12-week follow-up and ESsm = 0.66 for tele-PST and ESsm = 0.45for inperson PST at 24-week follow-up [57]. Although some participants were initiallyhesitant to engage in therapy via videoconferencing, almost all tele-PST participants endedup accepting and liking the teledelivery method. Simple cost analysis showed that tele-delivery cost was lower than in-person delivery cost, including the therapist’s travel timeand mileage. The acceptability, preliminary efficacy, and costsaving potential of tele-PSTpoint to its promise as a depression treatment modality for homebound older adults that canbe integrated into aging service settings.

Positive outcomes of previous studies of PST with older adults who had mild cognitiveimpairment (MCI) [53,58] present possibilities for using tele-PST with homebound olderadults who have MCI, by using longer sessions and an approach that is more therapist-directed and less client-driven than the protocol for the RCT described above. With the rapidadvance of tele-technology, rapid uptake of computer and Internet use among older adults,

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and potential cost-effectiveness, tele-PST or other telehealth-delivered psychosocialinterventions have strong potential for future implementation and longterm sustainability inaging services settings that serve depressed homebound older adults.

Problem-Adaptation Therapy (PATH)For cognitively impaired homebound older adults, Kiosses and colleagues [59] developedPATH, a 12-week home-delivered intervention designed to address depression and disabilityin this group of older adults. The PATH model is grounded in Lawton’s ecological model ofadaptive functioning [60], which emphasizes the person’s ecosystem, including caregiversand home environment, and uses environmental adaptations to help the person gain a senseof competence within his/her home environment despite various functional and behaviorallimitations. In a RCT with 30 patients assigned to either PATH or in-home supportivetherapy, the developers found that the PATH group demonstrated a greater decrease indepressive symptoms and disability over the 12-week period than did the in-homesupportive therapy group.

Program to Encourage Active, Rewarding Lives for Seniors (PEARLS)The PEARLS program, a community-integrated, home-based depression treatment, wasinitially tested in an RCT with 138 older adults, age 60 years and older, receiving servicesfrom senior service agencies or living in senior public housing and meeting the DSM-IVminor depression or dysthymia diagnostic criteria [61]. The intervention, consisting of eightPST sessions modified to provide greater emphasis on social and physical activation, wascompared to usual care. At 12 months, compared with the usual care group, patientsreceiving the PEARLS intervention were more likely to have at least a 50% reduction indepressive symptoms (43% vs. 15%; odds ratio [OR], 5.21; 95% confidence interval [CI],2.01–13.49), to achieve complete remission from depression (36% vs. 12%; OR, 4.96; 95%CI, 1.79–13.72), and to have greater health-related quality-of-life improvements infunctional well-being (p = .001) and emotional well-being (p = .048). The PEARLS programhas since been developed and implemented as a depression care management programprovided by public and nonprofit aging service agencies and other existing community-based health and social service providers in several states. According to the PEARLSwebsite (www.pearlsprogram.org), the program uses a team-based approach, involvingPEARLS counselors, supervising psychiatrists and medical providers, and in its six to eightin-home sessions, it focuses on teaching clients brief behavioral techniques and skills toempower those who suffer from chronic medical conditions (including epilepsy [62]) anddepression to take action. A recent paper [63] on perspectives from the PEARLS staff andformer clients reported that the community-based agency staff recognized PEARLS as acomprehensive program to help them meet clients’ mental health needs. On the other hand,these agency staff also pointed out the barriers to program implementation with respect torigid eligibility criteria (e.g., not including MDD and other comorbid mental disorders suchas schizophrenia) and time needed for two depression screens (11-item Center forEpidemiologic Studies Depression Scale followed by the PHQ-9), especially with the highcaseloads of case managers who are expected to refer their clients to PEARLS. ThePEARLS program is trying to alleviate these barriers in order to reach a greater number ofdepressed older adults.

Healthy IDEASHealthy IDEAS (http://careforelders.org/default.aspx?menugroup=healthyideas) is a home-based program that integrates depression awareness and management into existing casemanagement services provided to older adults with chronic medical conditions andfunctional impairments. Its components are routine screening and assessment of depressivesymptom severity as part of case management; educating older adults and caregivers about

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depression and self-care; linking older adults to primary care and mental health providersand to active assistance in obtaining further treatment; and coaching and supporting olderadults to manage their depression through a behavioral activation approach that encouragesinvolvement in meaningful activities. Through its linking service, which includesappropriate referrals, better communication, and effective partnerships, the program seeks toimprove the linkage between community aging service providers (e.g., area agencies onaging) and health care professionals. Since the program started in Houston, Tex., it has beenreplicated by service providers in several states. Its outcome study found that participantsshowed reductions in depression severity and self-reported pain, increased knowledge ofhow to get help for depression, increased activity levels, and knowledge of ways to managedepressive symptoms [64].

Other Home-Based Depression Intervention ProgramsBeat the Blues for Older African Americans (BTB)—A randomized trial is nowunderway for the BTB program, which is designed to reduce depressive symptoms andimprove quality of life in 208 African Americans age 55 years and older [65]. . Caremanagers at a senior center screen for depressive symptoms using the PHQ-9, either bytelephone or in person, on two separate occasions over a 2-week period, after which eligibleolder adults are referred to local mental health resources. The intervention group alsoreceives referral to BTB. A licensed senior center social worker trained in BTB meets witheach BTB participant in the participant’s home for up to 10 sessions over 4 months forassessments of care needs, referrals/linkages, depression education, learning of stressreduction techniques, and use of behavioral activation to identify goals and steps to achievethe goals. Although the BTB outcomes are not yet available, the BTB is very promising as ahome-based depression intervention, especially because it utilizes a neighborhood seniorcenter staff to screen depression and provide interventions. The research team reported thetotal costs per participant are $585 for 4 months or $146 per month, indicating that it mayalso be a relatively low-cost program.

Telemonitor-Based Depression Care Management—Sheeran and colleagues [66]tested the feasibility, acceptability, and preliminary clinical outcomes of telemonitor-baseddepression care management for homebound older adults served by homecare serviceagencies in New York, Vermont, and Miami. The 48 participating older adults, bothEnglish- and Spanish-speaking, were already receiving telemonitoring as part of their homehealthcare services, and the research team leveraged the existing telemonitor platform toincorporate evidence-based depression care management by programming questions andeducational information on depressive symptoms (PHQ-2 administered via telemonitor),antidepressant adherence, and side effects for up to 3 weeks. Questions regardingantidepressant treatment were developed to use the same format that home telemonitorstypically use for other disease management. Telehealth homecare nurses were trained asdepression care managers, and the training was built on a depression care managementprotocol developed as part of an academic-practice partnership for in-person homehealthcare [67]. The results of this pilot study supported the feasibility and positive clinicaloutcomes (depression severity) of using homecare’s existing telemonitoring technology todeliver depression care management to homebound older adults. Although these findingsrequire rigorous testing in a RCT, they suggest that the delivery model is promising.

ConclusionsDue to their chronic medical conditions and the social isolation caused by mobilityimpairment, homebound older adults are more vulnerable to depression than theirambulatory peers. However, their homebound state is a barrier to detection and treatment of

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their depression. Regardless of symptom severity, untreated depression in late life has beenfound to lead to further impairments in physical and psychosocial function and higherhealthcare costs among older adults. The high prevalence rate of depression in homeboundolder adults is a significant public health problem. This summary of recent trends focused ontwo approaches to this problem: (1) the growing effort to integrate depression screening intoroutine case management assessments of aging services agencies that already serve thesehomebound older adults and (2) effective and efficient psychosocial interventions that alsocan be provided by the aging services agency staff, or by licensed mental healthprofessionals in partnership with aging service agencies. The integration of depressionscreening into routine aging service assessment has potential to maximize reach to thisgroup of older adults suffering from the costly burden of depression along with othermedical problems. The evidence base of short-term psychosocial interventions for late-lifedepression is expanding, and the AoA and SAMHSA jointly call for the integration of theseevidence-based interventions into aging services and for the utilization of technology toimprove effectiveness and efficiency. Our review identified a few innovative and promisingapproaches that have potential to be integrated into aging services.

In sum, there is a solid accumulated knowledge base regarding the potential effectiveness ofthe integration of mental health services into aging services settings. However, a remainingchallenge is to find effective and efficient strategies not just to disseminate but also tosupport the uptake, implementation and sustainability of these interventions in routine careof aging service agencies [68, 69]. At system level, major challenges include the overallgeriatric mental health workforce shortage [70], insurance limitations (e.g., Medicare’srestricted payment rules for telemental health delivery) and other uncertainties regardingfunding streams, and staff shortage and high caseload in most aging service settings. Alongwith developing geriatric mental health workforce, implementation of evidence-basedinterventions requires dealing with issues related to licensing of interventionists, fidelitymonitoring, and financial and other sustainability [71]. Future research needs to identify themost cost-effective, efficient, and sustainable ways to meet the treatment need of depressedhomebound older adults.

AcknowledgmentsM.L. Bruce is supported by a grant from the National Institute of Mental Health (NIMH).

References1. He, W.; Sengupta, M.; Veikoff, VA.; DeBarros, KA. 65+ in the United States: 2005. U.S. Census

Bureau, Current Population Reports, P23-209. Washington, D.C.: U.S. Government Printing Office;2005.

2. Jacobs JM, Maaravi Y, Cohen A, et al. Changing profile of health and function from age 70 to 85years. Gerontol. 2012; 58:312–321.

3. United States Census Bureau. [Accessed October 2012] Table 35. Persons 65 Years and Over—Living Arrangements and Disability Status, 2009. Statistical Table Based on data from the 2009American Community Survey. Available at http://www.census.gov/compendia/statab/2012/tables/12s0035.pdf.

4. Centers for Medicare and Medicaid Services. [Accessed October 2012] Medicare and MedicaidSupplemental Statistics, 2011. Tables 7.2 Persons Served, Visits, Total Charges, Visit Charges, andProgram Payments for Medicare Home Health Agency Services: Calendar Year 2010; and Table 6.2Covered Admissions, Covered Days of care, Covered Charges, and Program Payments for SkilledNursing Facilities Used by Medicare Beneficiaries: Calendar Year 2010. Available at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareMedicaidStatSupp/2011.html.

Choi et al. Page 8

Curr Transl Geriatr Exp Gerontol Rep. Author manuscript; available in PMC 2014 March 01.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

5. Wiles JL, Leibing A, Guberman N, et al. The meaning of "aging in place" to older people.Gerontologist. 2012; 52:357–366. [PubMed: 21983126]

6. Bruce ML, McVay J, Raue PJ, et al. Major depression in elderly home health care patients. Am JPsychiatry. 2002; 159:1367–1374. [PubMed: 12153830]

7. Choi NG, Teeters M, Perez L, et al. Severity and correlates of depressive symptoms amongrecipients of Meals in Wheels: Age, gender, and racial/ethnic difference. Aging Ment Health. 2010;14:145–154. [PubMed: 19946802]

8. Cohen-Mansfield J, Shmotkin D, Hazan H. The effect of homebound status on older adults. J AmGeriatr Soc. 2010; 58:2358–2362. [PubMed: 21087220]

9. Ell K, Unützer J, Aranda M, et al. Routine PHQ-9 depression screening in home health care:Depression prevalence, clinical and treatment characteristics, and screening implementation. HomeHealth Care Services Quart. 2005; 24:1–19.

10. Sirey JA, Bruce ML, Carpenter M, et al. Depressive symptoms and suicidal ideation among olderadults receiving home-delivered meals. Int J Geriatr Psychiatry. 2008; 23:1306–1311. [PubMed:18615448]

11. Raue PJ, Meyers BS, Rowe JL, et al. Suicidal ideation among elderly homecare patients. Int JGeriatr Psychiatry. 2007; 22:32–37. [PubMed: 16955449]

12. Rowe JL, Conwell Y, Schulberg HC, Bruce ML. Social support and suicidal ideation in olderadults utilizing home healthcare services. Am J Geriatr Psychiatry. 2006; 14:758–766. [PubMed:16943173]

13. Weinberger ML, Raue PJ, Meyers BS, Bruce ML. Predictors of new onset depression in medicallyill, disabled older adults at 1 year follow-up. Am J Geriatr Psychiatry. 2009; 17:802–809.[PubMed: 19700952]

14. Johnson CM, Sharkey JR, Dean WR. Indicators of material hardship and depressive symptomsamong homebound older adults living in North Carolina. J Nutrition Grontol Geriatr. 2011;30:154–168.

15. Lyness JM, Kim J, Tang W, et al. The clinical significance of subsyndromal depression in olderprimary care patients. Am J Geriatr Psychiatry. 2007; 15:214–223. [PubMed: 17213374]

16. Lyness JM. Naturalistic outcomes of minor and subsyndromal depression in older primary carepatients. Int J Geriatr Psychiatry. 2008; 23:773–781. [PubMed: 18200611]

17. Cui X, Lyness JM, Tang W, et al. Outcomes and predictors of late-life depression trajectories inolder primary care patients. Am J Geriatr Psychiatry. 2008; 16:406–415. [PubMed: 18448851]

18. Lyness JM, Chappman BP, McGriff J, et al. One-year outcomes of minor and subsyndromaldepression in older primary care patients. Int Psychogeriatr. 2009; 21:60–68. [PubMed: 18786280]

19. Katon WJ, Lin E, Russo J, et al. Increased medical care costs of a population-based sample ofdepressed elderly patients. Arch Gen Psychiatry. 2003; 60:897–903. [PubMed: 12963671]

20. Unutzer J, Schoenbaum M, Katon WJ, et al. Healthcare costs associated with depression inmedically ill fee-for-service Medicare participants. J Am Geriatr Soc. 2009; 57:506–510.[PubMed: 19175438]

21. Akincigil A, Olfson M, Walkup JT, et al. Diagnosis and treatment of depression in oldercommunity-dwelling adults 1992–2005. J Am Geriatr Soc. 2011; 59:1042–1051. [PubMed:21649631]

22. Weissman J, Meyers BS, Ghosh S, Bruce ML. Demographic, Clinical and Functional FactorsAssociated with Antidepressant Use in the Home healthcare Elderly. Am J Geriatr Psychiatry.2011; 19:1042–1045. [PubMed: 21989320]

23. Choi NG, Bruce ML, Marinucci ML, et al. Self-reported antidepressant use among depressed,lowincome homebound older adults: Class, type, correlates, and perceived effectiveness. BrainBehav. 2012; 2:176–186.

24. Kales HC, Nease DE Jr, Sirey JA, et al. racial differences in adherence to antidepressant treatmentin late life. Am J Geriatr Psychiatry. 2012 Oct 10. Epub ahead of print. PMID-23060311.

25. Maust DT, Oslin DW, Thase ME. Going Beyond Antidepressant Monotherapy for IncompleteResponse in Nonpsychotic Late-Life Depression: A Critical Review. Am J Geriatr Psychiatry.2012 Oct 5. Epub ahead of print. PMID: 23044641.

Choi et al. Page 9

Curr Transl Geriatr Exp Gerontol Rep. Author manuscript; available in PMC 2014 March 01.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

26. Gum AM, Areán PA, Hunkeler E, et al. Depression treatment preferences in older primary carepatients. Gerontologist. 2006; 46:14–22. [PubMed: 16452280]

27. Choi N, Morrow-Howell N. Older adults’ attitudes toward depression treatment modalities:Within-group differences and comparison with their caregivers. Aging Ment Health. 2007;11:422–433.

28. Areán PA, Reynolds CF. The impact of psychosocial factors on late-life depression. BiolPsychiatry. 2005; 58:277–282. [PubMed: 16102545]

29. Cohen A, Houck PR, Szanto K, et al. Social inequalities in response to antidepressant treatment inolder adults. Arch Gen Psychiatry. 2006; 63:50–56. [PubMed: 16389196]

30. Choi NG, Lee A, Goldstein M. Meals on Wheels: Exploring Potential for and Barriers toIntegrating Depression Intervention for Homebound Older Adults. Home Health Care ServicesQuarterly. 2011; 30:214–230. [PubMed: 22106903]

31. Substance Abuse and Mental Health Services Administration Older Americans Behavioral HealthTechnical Assistance Center. Older Americans behavioral health issue brief: Series overview.2012Accessed October 2012Available at http://www.aoa.gov/AoARoot/AoA_Programs/HPW/Behavioral/docs/OA_Issue_BriefSeriesOverview.pdf. This overview emphasizes the significanceof the integration of aging services and mental health services and utilization of technology indoing so

32. Substance Abuse and Mental Health Services Administration Older Americans Behavioral HealthTechnical Assistance Center. Older Americans behavioral health issue brief 1. 2012AccessedOctober 2012Available at http://www.aoa.gov/AoARoot/AoA_Programs/HPW/Behavioral/docs/OA_IssueBrief1_ServicesNetwork_508_12JUN07_dr.pdf. This issue brief is one of the seriesproduced by the SAMHSA about older adults’ mental health issues

33. Bazelais, KN.; Pickett, YR.; Bruce, ML. Late-life mood disorders and home-based services andinterventions. In: Lavrezsky, H.; Sajatovi, M.; Reynolds, C., editors. In Late-life mood disorders.New York: Oxford University Press; In press.

34. Centers for Medicare and Medicaid Services. [Accessed October 2012] Definition of Homebound.Available at http://www.medicare.gov/homehealthcompare/Resources/Glossary.aspx?toolAudiance=HHC&Language=English&TermID=0026.

35. O’Shaughnessy CV. The Aging Services Network: Accomplishments and Challenges in Serving aGrowing Elderly Population. National Health Policy Forum background paper. 2008 Apr 11.Available at http://www.nhpf.org/library/background-papers/BP_AgingServicesNetwork_04-11-08.pdf.

36. [Accessed October 2012] Administration on Aging. Facts. 2012. Available at http://www.aoa.gov/aoaroot/Press_Room/Products_Materials/fact/pdf/AoA_Factsheet.pdf.

37. Administration on Aging. [Accessed October 2012] Outline of 2006 Amendments to the OlderAmericans Act. 2011. Available at http://www.aoa.gov/aoaroot/aoa_programs/oaa/oaa.aspx.

38. Kroenke K, Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. PsychiatAnn. 2002; 32:509–515.

39. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure.J Gen Inter Med. 2001; 16:606–813.

40. Sheeran T, Reilly CF, Raue PJ, et al. The PHQ-2 on OASIS-C: A new resource for identifyinggeriatric depression among home health patients. Home Healthc Nurse. 2010; 28:92–102.[PubMed: 20147803]

41. Saliba D, DiFilippo S, Edelen MO, et al. Testing the PHQ-9 interview and observational versions(PHQ-9 OV) for MDS 3.0. J Am Med Dir Assoc. 2012; 13:618–625. [PubMed: 22796361]

42. Berman, J.; Furst, LM. Depressed older adults: Education and screening. New York: Springer;2010.

43. Richardson TM, He H, Podgorski C, et al. Screening depression aging service clients. Am J GeriatrPsychiatry. 2010; 18:1116–1123. [PubMed: 20808102]

44. Boyle LL, Richardson TM, He H, et al. How do the PHQ-2, the PHQ-9 perform in aging servicesclients with cognitive impairment? Int J Geriatr Psychiatry. 2011; 26:952–960. [PubMed:21845598] This paper reports the first systematic evaluation of PHQ-2 and PHQ-9 among olderadults served by aging-service agencies

Choi et al. Page 10

Curr Transl Geriatr Exp Gerontol Rep. Author manuscript; available in PMC 2014 March 01.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

45. Petkus AJ, Gum AM, Small B, et al. Evaluation of the factor structure and psychometric propertiesof the brief Symptom Inventory-18 with homebound older adults. Int J Geriatr Psychiatry. 2010;25:578–587. [PubMed: 20013879]

46. U.S Department of Health and Human Services, Substance Abuse and Mental Health Services,Center for Mental Health Services Administration. The Treatment of Depression in Older Adults:Selecting Evidence-Based Practices for Treatment of Depression in Older Adults. HHSPubNoSMA 11-4631. Rockville, MD: 2011.

47. Centers for Disease Control and Prevention and National Association of Chronic DiseaseDirectors. The State of Mental Health and Aging in America Issue Brief 2: Addressing Depressionin Older Adults: Selected Evidence-Based Programs. 2009Atlanta, GANational Association ofChronic Disease Directors This issue brief provides a summary of selected evidence-basedpsychotherapies for late-life depression

48. D’Zurilla, TJ. Problem-solving therapy: A social competence approach to clinical intervention.New York: Springer; 1986.

49. Nezu, AM.; Nezu, CM.; Perri, MG. Problem-solving therapy for depression: Theory, research, andclinical guidelines. New York: John Wiley & Sons; 1989.

50. D’Zurilla, TJ.; Nezu, AM. Problem-Solving Therapy: A positive approach to clinical intervention.New York: Springer; 2007.

51. Mynors-Wallis, L. Problem-solving treatment for anxiety and depression: A practical guide. NewYork: Oxford University Press; 2005.

52. Areán PA, Hegel MT, Vannoy S, et al. Effectiveness of problem-solving therapy for older, primarycare patients with depression: Results from the IMPACT study. Gerontologist. 2008; 48:311–324.[PubMed: 18591356]

53. Areán PA, Raue PJ, Mackin S, et al. Problem-solving therapy and supportive therapy in olderadults with major depression and executive dysfunction. Am J Psychiat. 2010; 167:1391–1398.[PubMed: 20516155] The paper reports the findings of a large randomized clinical trial thatexamined the effectiveness of inperson problem-solving therapy vis-à-vis supportive therapy forolder adults with mild cognitive impairments

54. Alexopoulos GS, Raue PJ, Kiosses DN, et al. Problem-solving therapy and supportive therapy inolder adults with major depression and executive dysfunction: Effect on disability. Arch GenPsychiatry. 2011; 68:33–41. (2011). [PubMed: 21199963]

55. Cuijpers PA, van Straten A, Warmerdam l. Problem-solving therapies for depression: Ametaanalysis. Eur Psychiatry. 2007; 22:9–15. [PubMed: 17194572]

56. Gellis Z, McGinty J, Horowitz A, et al. Problem-solving therapy for late-life depression in homecare: A randomized field trial. Am J Geriatr Psychiatry. 2007; 15:968–978. [PubMed: 17846101]

57. Choi NG, Hegel MT, Marti CM, et al. Telehealth Problem-Solving Therapy for Depressed Low-Income Homebound Older Adults: Acceptance and Preliminary Efficacy. Am J Geriatr Psychiatry.2012 Aug 31. Epub ahead of print. PMID-22948295. This paper reports the feasibility and efficacyof home-based telehealth-delivered problem-solving therapy for depressed, low-incomehomebound older adults

58. Alexopoulos GS, Raue P, Areán PA. Problem-solving therapy versus supportive therapy ingeriatric major depression with executive dysfunction. Am J Geriatr Psychiatry. 2003; 11:46–51.[PubMed: 12527539]

59. Kiosses DN, Arean PA, Teri L, Alexopoulos GS. Home-delivered problem adaption therapy(PATH) for depressed, cognitively impaired, disabled elders: A preliminary study. Am J GeriatrPsychiatry. 2010; 18:988–998. [PubMed: 20808092] This paper reports the feasibility and efficacyof findings of a small randomized controlled trial of the PATH program for homebound,cognitively impaired older adults and their caregivers

60. Lawton, MP.; Windely, PG.; Byerts, TO. Aging and the environment: Theoretical approaches.New York: Springer; 1982.

61. Ciechanowski P, Wagner E, Schmaling K, et al. Community-integrated home-based depressiontreatment in older adults. JAMA. 2004; 29:1569–1577. [PubMed: 15069044]

Choi et al. Page 11

Curr Transl Geriatr Exp Gerontol Rep. Author manuscript; available in PMC 2014 March 01.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

62. Chaytor N, Ciechanowski P, Miller JW, et al. Long-term outcomes of the PEARLS randomizedtrial for the treatment of depression in patients with epilepsy. Epilepsy Behav. 2011; 20:545–549.[PubMed: 21333607]

63. Steinman L, Cristofalo M, Snowden M. Implementation of an evidenced-based depression caremanagement program (PEARLS): Perspectives from staff and former clients. Prev Chronic Dis.2012; 9:110250. DOI. Available at http://dxdoiorg/105888/pcd9110250. This paper reportsbarriers to PEARLS delivery and recommended solutions by aging service agency staff

64. Quijano LM, Stanley MA, Petersen NJ, et al. Healthy IDEAS: A depression intervention deliveredby community based case managers serving older adults. J Applied Gerontol. 2007; 26:139–156.

65. Gitlin LN, Harris LF, McCoy M, et al. A community-integrated home based depressionintervention for older African Americans: description of the Beat the Blues randomized trial andintervention cost. BMC geriatrics. 2012; 12:4. [PubMed: 22325065]

66. Sheeran T, Lotterman J, Brown S, et al. Feasibility and impact of telemonitor-based depressioncare management for geriatric homecare patients. Telemed e-Health. 2011; 17:620–626.

67. Bruce ML, Raue PJ, Sheeran T, et al. Depression care for patients at home (DepressionCAREPATH): Protocols and implementation, Part 2. Home Healthc Nurse. 2011; 29(8):480–489.[PubMed: 21881429]

68. Bruce, ML.; Raue, PJ.; Reilly, CG., et al. Developing and piloting a web-based, long-distanceimplementation strategy for depression care in home healthcare patients. Presented at the NationalInstitutes of Health Dissemination and Implementation Conference; Washington DC: 2012 Mar22.

69. Aarons GA, Hurlburt M, Horwitz SM. Advancing a conceptual model of evidence-based practiceimplementation in public service sectors. Adm Policy Ment Health. 2011; 38(1):4–23. [PubMed:21197565]

70. Institute of Medicine. The Mental Health and Substance Use Workforce for Older Adults: InWhose Hands? A Consensus Report. Washington, DC: National Academies Press; 2012 Jul 10.

71. Areán PA, Raue PJ, Sirey JA, Snowden M. Implementing evidence-based psychotherapies insettings serving older adults: Challenges and solutions. Psych Serv. 2012; 63:605–607.

Choi et al. Page 12

Curr Transl Geriatr Exp Gerontol Rep. Author manuscript; available in PMC 2014 March 01.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript