ODDC- Mental Health Issues at the Lifespan Conference

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TITLE: Mental Health Issues at the Lifespan Conference: Depression; Mental Health Issues and Chronic Disease; Anxiety and Substance Abuse Disorders: Relationship With Disability; Life Satisfaction and Aging With a Disability.

Speakers: Bryan J. Kemp, Ph.D., Ranchos Los Amigos National Rehabilitation Center, Clinical Professor of Medicine, University of California, Irvine; Charles H. Bombardier, Ph.D., University of Washington School of Medicine; Michael Von Korff, Sc.D. Center for Health Studies, Group Health Cooperative of Puget Sound and James S. Krause, Ph.D., Medical University of South Carolina. (Katherine Cargill-Willis 10/7/04)

Kathy’s Note: This is a summary of four sessions on depression. Since the lectures were so similar, I decided to organize the paper based on subject not by speaker.

Depression: Depression is related to the ability to cope with changes and losses. Risk factors for the general public include:

Low income
Lack of adequate health insurance
Health problems
Minority group status
How people relate to specific areas of life, those that are most strongly related to the condition itself or to social circumstances.

Depression is not related to:

Nature or severity of impairment
Current age or age of onset
Duration of impairment
How impairment affects activities for daily living or instrumental activities for daily living

Depression can impact:

Life expectancy
Secondary Medical problems
The degree of the disability
The care-giving system
Quality of Life
Function and community activities

Across Disability Groups: While depression is higher among people with disabilities compared to those without, there is little relationship between the degree of the disability and rate of depression. Among people without disabilities ten percent had moderate depression and five percent had major depression.

18% of people with Post-Polio had moderate depression and 22% had major depression.
20% of people with cerebral palsy had moderate depression and 40% had major depression.
20% of people who had a spinal cord injury had moderate depression and 40% had major depression.
35% of people who had a stroke had moderate depression and almost 60% had major depression.
10% to 15%t of people with diabetes have major depression
10% to 77% of people with traumatic brain injury have major depression
15% to 23% of people with coronary heart disease have major depression
27% to 51% of people who have multiple sclerosis have major depression

Assessment and Treatment of People with Disabilities who are Depressed: Fewer than ten percent of people with disabilities who are depressed are properly treated because:

The symptoms of depression overlap with symptoms of chronic disease
Clinicians and others “normalize” depression
Clinicians believe depression is untreatable because of the disability

Chronic Disease and Mental Health: Mental health problems increase the risk of developing diabetes, heart disease and stroke. Depression also increases the risk of substance abuse, which increases the risk of spinal cord injury and traumatic brain injury. It also has a negative effect on the course and progress of chronic diseases. Therefore, depression is comobid with (negatively contributes to) increased medical utilization, high cost of medical care, more severe symptoms, greater functional impairment, less likelihood of obeying doctors’ orders, and increased mortality. Chronic disease management involves the delegation of responsibility by the primary care doctor to team members for ensuring that patients receive proven clinical and self management support services. There are several treatment systems:

Case management
Stepped Care: Intervention consisting of educating and activating patients with depression, bolstering the functions of primary care physicians, and providing on-site psychiatric consultations.
Three-Component Model: Clinician and office education create a prepared practice that is predisposed to providing evidence-based depression management. Enabling elements include the telephone care managers, who are trained to promote adherence to a management plan, and a supervising psychiatrist.
Quality-Improvement programs: has four components, including (1) institutional commitment to the program; (2) training local leaders, including a primary care clinician, a nursing supervisor & a mental health specialist, to implement the interventions; (3) training of staff in clinical assessment, patient education & activation; & (4) identification of depressed patients. There are two quality improvement interventions and both had the same goal of improving rates of initiation & adherence to a course of treatment.

Medication: offered enhanced resources for supporting medication management.
Psychotherapy: providing psychotherapy patients with depression.

Anxiety and Substance Use Disorders: Anxiety disorders and substance use disorder frequently co-exist with mood disorders and chronic physical disorders. People who have anxiety or substance use disorders and mood disorder:

Are more severe
Have a less favorable prognosis
Are associated with greater disability

Among those with physical disabilities (chronic physical disorders):

Mood disorders are associated with disability after controlling for physical disease disability.
Little is known about anxiety or substance disorder and disability controlling for physical disability.

Depression Among persons Aging with a Disability:

Background of Life Satisfaction:

Life satisfaction has been a widely used construct for decades, but it still requires greater attention to measurement and psychometrics
Life satisfaction has been primarily investigated among the aging population as a means of monitoring the impact of age related changes on well-being.
Life satisfaction is a legitimate rehabilitation goal and should become the focus of intervention based on outcomes research.
Severity of impairment is generally unrelated to satisfaction, suggesting that more individual factors are important.
Natural transition to utilize this construct in the area of disability.
Greater focus on quality of life as a measure of importance to all populations.

Assumption: Disability is associated with low levels of life satisfaction, but mean differences in life satisfaction ratings between disabled and non-disabled populations do not account for people’s ability to lead satisfying lives.

Potential Aging Issues:

Increased prevalence of chronic diseases
Greater vulnerability of side effects
Poly- Pharmacy- people using many medications or several medications in the same class
Less likely to follow doctors’ orders
Bias by both the doctor and the patient that depression is a part of aging
Lower prevalence of major depressive disorders in later life
Higher prevalence of major depressive disorders associated with more recent decade of birth

Components of Aging:

Age at disability onset
Time since onset
Environmental factors
The use of aging studies requires sensitive designs and careful attention to methodical issues.

Barriers to Effective Treatment:

Under-recognition of mental health problems
Recognition does not improve treatment
Inadequate treatment and follow-up
Systems are not oriented toward mental health or chronic care
There are financial and other disincentives
Systems level solutions are necessary

Gaps in Research:

There has been limited cross-sectional or longitudinal research to determine whether the prevalence, impact or treatment of mental health problems in people with chronic health diseases differs across the lifespan. Such research should consider time since onset of disease or disability and societal participation, such as job loss, along with age.
There have been few studies concerning the effectiveness of different forms of treatment on depression among persons who have a disability or on the consequences of treatment on outcomes besides depression. In one study, treatment with medication and psychotherapy was proven to be effective and resulted in improvement in community activities and life satisfaction.
Fewer studies have examined the prevalence and impact of mental health problems among people with diabetes, spinal cord injury, traumatic brain injury and multiple sclerosis.
Fewer studies have investigated anxiety disorders, alcohol and drug abuse, or sub-clinical disorders, such as minor depression, neuroticism, anger or denial.
Extend efficacy and safety studies of valid MH treatments to other chronic disease groups across the lifespan.
Study the impact of alternative therapies such as exercise or tailored rehabilitation on MH problems across the lifespan.
Adapt interventions to primary care settings
Determine what changes in the health care delivery system improve treatment effectiveness in real-life setting across the lifespan.
Study what change in health care financing and organization can sustain effective systems of treatment.

Research Priorities:

Test a model of stress and coping as it relates to the development and maintenance of depression among people with a disability.
Determine the effects of the onset of depression on the development of physical illnesses in persons with a disability
Determine difference in coping among persons who develop depression and those do not.
Test various forms of treatment on the effectiveness of recovery from depression among people with a disability
Determine the effects of depression on the health and well-being of persons with a disability.
Treatment efficacy generally equivalent
Understanding and describing disability among people with anxiety disorders and substance use disorders requires:

Accounting for the independent and joint effects of combining mood disorders and chronic physical disorders
Population-based data and analytic approaches that yield understanding of how mood, anxiety, substance abuse disorders and common chronic physical disorder jointly affect the social role disability are needed to guide public health efforts to ameliorate the world-wide increase in disability occurring with increased longevity in most parts of the world.

Conceptualize life satisfaction as a multi-dimensional construct that must be measured in multiple levels including an overall score, factor or scale scores, and single life issues.
Develop and utilize psychometrically sound measures of life satisfaction, avoid using measures simply because of length or history of use
Measure life satisfaction in conjunction with pathologic, depression, and other risk factors or other stressors
Utilize sophisticated aging designs that can identify all three aging components.
Develop and test interventions to enhance life satisfaction

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