Caring for depression in the dying is complex and challenging – survey of palliative physicians

Background Depression is prevalent in people with very poor prognoses (days to weeks). Clinical practices and perceptions of palliative physicians towards depression care have not been characterised in this setting. The objective of this study was to characterise current palliative clinicians’ reported practices and perceptions in depression screening, assessment and management in the very poor prognosis setting. Methods In this cross-sectional cohort study, 72 palliative physicians and 32 psychiatrists were recruited from Australian and New Zealand Society of Palliative Medicine and Royal Australian and New Zealand College of Psychiatrists between February and July 2020 using a 23-item anonymous online survey. Results Only palliative physicians results were reported due to poor psychiatry representation. Palliative physicians perceived depression care in this setting to be complex and challenging. 40.0% reported screening for depression. All experienced uncertainty when assessing depression aetiology. Approaches to somatic symptom assessment varied. Physicians were generally less likely to intervene for depression than in the better prognosis setting. Most reported barriers to care included the perceived lack of rapidly effective therapeutic options (77.3%), concerns of patient burden and intolerance (71.2%), and the complexity in diagnostic differentiation (53.0%). 66.7% desired better collaboration between palliative care and psychiatry. Conclusions Palliative physicians perceived depression care in patients with very poor prognoses to be complex and challenging. The lack of screening, variations in assessment approaches, and the reduced likelihood of intervening in comparison to the better prognosis setting necessitate better collaboration between palliative care and psychiatry in service delivery, training and research.

Ways Community-Based Organizations Enhance Late-Life Depression Care in Partnership With Clinics

Late-life depression is a serious public health concern in the U.S., especially as the population ages. To improve care coordination and increase the number of providers working to improve depression outcomes, primary care clinics and community-based organizations (CBOs) can partner and improve care. Addressing social determinants of health is one area CBOs can help respond to but there are other ways CBOs can bring value to these partnerships with primary care clinics. As part of a qualitative evaluation of the Care Partners Project, 84 key informant interviews and 20 focus groups were conducted over five years with selected primary care physicians, care managers, administrators and psychiatric consultants. These data were coded and organized using an inductive and deductive thematic analysis approach. CBOs contributed to care through 1) adding new services that focus on clients’ social needs (e.g., assistance locating affordable housing, reliable transportation, applying for social security benefits) that were foundational to effective depression care; 2) strengthening core aspects of existing care; 3) incorporating a lay health workforce to enhance care; and/or 4) adding home visits that supported deeper understanding of patient’s life context, enhanced trust and improved access to care. CBOs can enhance depression care through increasing access and quality of care. Findings can inform conversations about the value CBOs offer when partnering with health care systems and improve partnership efforts. Such conversations are worth revisiting as organizations deepen their connections and work together over time.

516 - A more integrative approach to better match treatments to long-term care residents: Preliminary results of a meta-analysis

Background:Depression is common among long term care (LTC) residents and has a considerable impact on their quality of life. Therefore, there has been an increased interest in interventions aiming at the reduction of depression among LTC residents. These interventions could be described as formal depression care and include psychosocial interventions (e.g., Creative Arts Interventions), psychotherapeutic interventions (e.g., Life Review) and/or (neuro-)biological interventions (e.g., psychopharmacotherapy). Previous research on the effectiveness of formal depression care suggests that treatments should be more individually tailored. Tailoring treatments, however, is a time- consuming process which may hinder the implementation in LTC. A more integrative approach targeting specific groups of nursing home residents is therefore preferred and may benefit both residents and staff. To do so, insight in moderator effects is needed to better understand and better match treatments to specific groups of LTC residents.Objectives:The aim of this study is to provide insight into (1) the effectiveness of interventions, (2) the influence of residents’ characteristics (e.g., residents with cognitive impairment versus residents with physical disabilities) and/or (3) the influence of contextual factors (e.g., group-based versus individual therapy) which may have an impact on the effectiveness of interventions.Eligibility criteria:Various databases (e.g., EBSCO, PubMed, COHRANE Library) are searched using a predefined search string, combining terms concerning our PICO elements (e.g., “Nursing Home Residents” (P), “Treatment” (I), “Depression” (O)). We only include a) randomized controlled trials investigating the use of formal depression treatments (independent variable), b) among LTC residents and, c) having used a standardized measurement tool for, d) depression (dependent variable). Results of this systematic search will be presented.Method of synthesis:Eligible studies will further be screened and assessed for residents’ characteristics and/or contextual factors. A random-effects model will be used to calculate the pooled standardized mean difference (SMD) and to assess the strength of the effects of formal depression treatments on depression. Further subgroup-analysis and meta-regressions will be used to assess the potential moderator effects.Conclusion:To better match treatments to LTC residents, more insight into the effectiveness, moderator effects and core components of the applied interventions is needed.

517 - Informal and Formal Depression Care in Nursing Homes (InFormeD): Study protocol of a six month cohort study to better match treatment with residents

Background:Depression is common among nursing home residents and has a considerable impact on their quality of life. Therefore, there has been an increased interest in interventions aiming at the reduction of depression among nursing home residents. These interventions could be categorized into formal and informal depression care. Formal care includes psychosocial, psychotherapeutic and/or (neuro-)biological interventions. Informal care can be provided by nursing home staff, alongside the formal care (e.g., letting sunlight into the room when one believes in the positive effects of daylight). Although many studies have been done about depression treatment in nursing homes, there is still a lack of insight into the effectiveness of interventions and how they differ among specific target groups (e.g., residents with cognitive impairment versus residents with physical disabilities). Moreover, research into informal care is rather rare. More insight is needed into the effect of formal and informal depression care and the mutually reinforcing effects of those strategies on nursing home residents. This insight is essential to better match treatments with residents and to provide a more comprehensive approach to counter depression.Objectives:The aim of this study is to gain insight in the use of formal and informal depression care and their associations with depression among nursing home residents.Design:A six month cohort study will be conducted.Method:Residents will be recruited in nursing homes across the Netherlands and Flanders (Belgium). To measure formal and informal care, newly developed tools will be cross-culturally validated: one to assess the provided formal care in nursing homes, two tools for measuring the used informal strategies. Depression outcomes will be measured with the Geriatric Depression Scale, Cornell Scale for Depression in Dementia, and the Nijmegen-Observer-Rated Depression-scale). Baseline measurements and cross- sectional analyses will be performed and repeated after six months. The intended associations will be assessed using multiple regression analysis.Conclusion:To develop a good depression care policy, a more comprehensive approach is needed and may benefit both residents and staff.

Stepped care for depression at integrated chronic care centers (IC3) in Malawi: study protocol for a stepped-wedge cluster randomized controlled trial

Background Malawi is a low-income country in sub-Saharan Africa that has limited resources to address a significant burden of disease—including HIV/AIDS. Additionally, depression is a leading cause of disability in the country but largely remains undiagnosed and untreated. The lack of cost-effective, scalable solutions is a fundamental barrier to expanding depression treatment. Against this backdrop, one major success has been the scale-up of a network of more than 700 HIV clinics, with over half a million patients enrolled in antiretroviral therapy (ART). As a chronic care system with dedicated human resources and infrastructure, this presents a strategic platform for integrating depression care and responds to a robust evidence base outlining the bi-directionality of depression and HIV outcomes. Methods We will evaluate a stepped model of depression care that combines group-based Problem Management Plus (group PM+) with antidepressant therapy (ADT) for 420 adults with moderate/severe depression in Neno District, Malawi, as measured by the Patient Health Questionnaire-9 (PHQ-9) and Mini-International Neuropsychiatric Interview (MINI). Roll-out will follow a stepped-wedge cluster randomized design in which 14 health facilities are randomized to implement the model in five steps over a 15-month period. Primary outcomes (depression symptoms, functional impairment, and overall health) and secondary outcomes (e.g., HIV: viral load, ART adherence; diabetes: A1C levels, treatment adherence; hypertension: systolic blood pressure, treatment adherence) will be measured every 3 months through 12-month follow-up. We will also evaluate the model’s cost-effectiveness, quantified as an incremental cost-effectiveness ratio (ICER) compared to baseline chronic care services in the absence of the intervention model. Discussion This study will conduct a stepped-wedge cluster randomized trial to compare the effects of an evidence-based depression care model versus usual care on depression symptom remediation as well as physical health outcomes for chronic care conditions. If determined to be cost-effective, this study will provide a model for integrating depression care into HIV clinics in additional districts of Malawi and other low-resource settings with high HIV prevalence. Trial registration ClinicalTrials.govNCT04777006. Registered on 1 March, 2021

Personal and Perceived Depression Stigma in Individuals Affected by Depression and Relatives: Results of a Survey among Attendees of a German Depression Congress

Background: Depression stigma is a clinically relevant factor negatively affecting the help-seeking process and depression care. Relatives of individuals suffering from depression play an important role in service utilization and in depression treatment, but little is known about their depression stigma compared to the stigma of individuals affected. Aims: We investigated whether individuals with depression, relatives and individuals being both - affected and relative - differ in depression stigma. Methods: Paper-pencil questionnaire data of 216 study participants from a German depression congress in 2017 were analyzed using Kruskal-Wallis tests to investigate subgroup differences and Mann-Whitney-U tests for post-hoc comparisons. Ordinal logistic generalized regression models with the dependent variables being the stigma sum scores and the independent variables “group”, “gender” and “age” were computed. Results: Participants being a relative of an individual with depression, being affected by depression or being both - relative and affected - reported comparable personal and perceived depression stigma. There was a statistical trend for group differences in personal stigma in the total sample, due to significantly lower personal stigma in male participants being affected by depression compared to male participants having a family member affected. Conclusions: Relatives of individuals with depression appear to have similar stigmatizing attitudes as affected individuals themselves. Potential differences in personal stigma in male relatives compared to male patients require further research, since they have implications for anti-stigma activities as well as for depression care.

Exploring Treatment for Depression in Parkinson’s Patients: A Cross-Sectional Analysis

Depression is a highly prevalent, often underrecognized and undertreated comorbidity of Parkinson’s disease closely correlated to health-related quality of life. National trends in depression care for patients with Parkinson’s disease are not well documented. This paper identifies a cohort of patients with Parkinson’s disease from nationally representative survey data and analyzes trends in depression care. Using data from the 2005–2006 through 2015–2016 waves of the National Health and Nutrition Examination Survey (NHANES), individuals were classified as Parkinson’s patients by reported medication use. PHQ-9 scores were used to identify individuals screening positive for depression. A composite treatment variable examined the reported use of mental health services and antidepressant medication. Survey participants with probable PD screened positive for depression, reported the use of antidepressant medication, and reported visits to mental health services more frequently than the control group. Survey participants with PD who screened positive for depression were more likely to report limitations in physical functioning due to an emotional problem than controls. While depression is highly prevalent among individuals with Parkinson’s disease, they are more likely to receive any treatment. Further research is required to investigate differences in patterns of treatment, contributing factors of emotions to limitations in physical functioning, and appropriate interventions.