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Previous studies show that less than 50% of adults in Canada receive guideline- concordant care for depression and anxiety disorders. Studies on the long-term effects of receiving adequate care for depression and anxiety disorders are scarce, particularly in older adults. This study aimed to assess the 3-year change in health-related quality of life (HRQOL) and satisfaction with life associated with receipt of adequate care for depression and anxiety disorders.
This study was conducted among a sample of 219 older adults recruited in primary care with a common mental disorder (depression or an anxiety disorder) who participated in Quebec’s longitudinal ESA-Services (2011-2016) study. The definition of adequacy of care was based on Canadian guidelines and relevant literature. Administrative and self-reported data were used to measure treatment adequacy at baseline. HRQOL was measured using a Visual Analog Scale (VAS) and satisfaction with life was assessed with the Satisfaction With Life Scale (SWLS). HRQOL and satisfaction with life were measured at baseline and follow-up, 3 years later. Multivariate fixed-effects models were carried out to assess the association between adequacy of care and change in quality of life controlling for individual and healthcare system factors in the overall sample as well as separately for depression and anxiety.
The results showed that 56%, 37% and 40% of participants received adequate pharmacological or psychological treatment for depression, anxiety, and overall. Receipt of adequate treatment was associated with on average 4 more points on the VAS (0-100) and 1.7 points on the SWLS (5-25). After controlling for potential confounders, patients receiving adequate care for depression had on average 11 more points on the VAS. Treatment adequacy for anxiety disorders and depression or anxiety disorders overall were not associated with change in HRQOL or satisfaction with life.
Older adults receiving adequate mental health care had better HRQOL and satisfaction with life. Treatment adequacy for depression was associated with change in quality of life; but not for individuals with anxiety. Future studies should focus on different patient indicators of quality of care which may better predict long-term effects of treatment for people with anxiety.
Training based on the Mental Health Gap Action Programme (mhGAP) is being increasingly adopted by countries to enhance non-specialists’ mental health capacities. However, the influence of these enhanced capacities on referral rates to specialised mental health services remains unknown.
We rely on findings from a longitudinal pilot trial to assess the influence of mental health knowledge, attitudes and self-efficacy on self-reported referrals from primary to specialised mental health services before, immediately after and 18 months after primary care physicians (PCPs) participated in an mhGAP-based training in the Greater Tunis area of Tunisia.
Participants included PCPs who completed questionnaires before (n = 112), immediately after (n = 88) and 18 months after (n = 59) training. Multivariable analyses with linear mixed models accounting for the correlation among participants were performed with the SAS version 9.4 PROC MIXED procedure. The significance level was α < 0.05.
Data show a significant interaction between time and mental health attitudes on referrals to specialised mental health services per week. Higher scores on the attitude scale were associated with more referrals to specialised services before and 18 months after training, compared with immediately after training.
Findings indicate that, in parallel to mental health training, considering structural/organisational supports to bring about a sustainable change in the influence of PCPs’ mental health attitudes on referrals is important. Our results will inform the scale-up of an initiative to further integrate mental health into primary care settings across Tunisia, and potentially other countries with similar profiles interested in further developing task-sharing initiatives.
Examine the association between trauma and daily stressors, post-traumatic stress syndrome (PTSS), anxio-depressive disorders, and suicidal ideation in older adults.
A cross-sectional study.
Setting and Participants:
This study included 1446 older adults recruited in primary care practices (2011–2013) and participating in Quebec’s longitudinal study on health services in the elderly.
Lifetime trauma and PTSS was assessed using the validated PTSS scale for older adults based on scores from the Impact of Events Scale-Revised, number of lifetime traumatic events and interference with daily activities. The presence of an anxio-depressive disorder was based on physician diagnoses. Path analyses were conducted to determine the pathways between trauma, daily stressors, PTSS and anxio-depressive disorders and SI. Analyses were conducted on the overall sample and by sex.
Seven percent and 12% reported SI and PTSS. In males, traumas of sexual assault, violence/stalked, war/combat/imprisonment and daily hassles were directly associated with SI. In females, daily hassles were directly associated with SI. In males, a number of traumas were associated with SI through the mediating effect of PTSS and anxio-depressive disorders. In females, PTSS but not anxio-depressive disorders mediated the relationship between traumas and daily stressors, and suicidal ideation.
The effects of lifetime traumas persist well into older age. Traumas leading to SI differ between males and females as do the pathways and comorbidity with PTSS and anxio-depressive disorders. This highlights differences in etiologic patterns, which may be used in primary care practice to identify symptom profiles of older persons at risk of suicidal ideation.
Studies have shown higher healthcare utilization and costs associated with post-traumatic stress syndrome (PTSS) in veterans and community adult populations. Given the aging population and the impact on health system resources, it is important to understand the economic consequences of PTSS.
The data retained came from 1,456 older adults aged 65 years and over recruited in primary medical clinics in the province of Quebec. PTSS was measured with the PTSS scale. Healthcare services (outpatient, emergency department (ED) visits, and inpatient stay) and medication use were captured separately from provincial administrative databases. Healthcare costs incurred in the past year included costs related to outpatient and ED visits, physician fees, inpatient stay, and medication use. Costs were calculated using a healthcare system perspective. χ2 and Mann–Whitney analyses were used to assess healthcare use. Generalized linear models (GLM) with a gamma distribution (Log Link) were used to evaluate the healthcare costs associated with PTSS.
Results showed a significant difference in the number mental health outpatient visits, the number of total prescriptions and the use (presence of at least one prescription) of antidepressants (ADs) and benzodiazepines (BZDs). The multivariate analyses showed that costs associated with outpatient visits, ED visits, mental health inpatient stays, physician fees, and medication use were significantly associated with the presence of PTSS. The total adjusted healthcare cost difference between groups was significant and reached $838 CAN.
Respondents with PTSS were more likely to be prescribed psychotropic medications and to have higher ambulatory costs but not inpatient services related costs, more research is required to better understand whether the mental health needs of individuals with a probable PTSS are being met.
Contexte : La consommation de benzodiazépines est une pratique courante chez les personnes aînées. Cette consommation peut entraîner un problème de dépendance dont les critères du Manuel diagnostic et statistique des troubles mentaux, 4e édition révisée (DSM-IV-TR) ne s’appliqueraient pas toujours à la situation de l’aîné. Cette recherche vise à examiner l’association entre le sentiment de dépendance aux benzodiazépines et l’utilisation des services de santé par les aînés. Un objectif secondaire consiste à décrire l’utilisation des benzodiazépines chez les aînés vivant dans la communauté.
Méthode : Les données proviennent d’une enquête menée au Québec en 2005-2006 auprès d’un échantillon représentatif de 707 francophones âgés de 65 ans et plus vivant dans la communauté. Le sentiment de dépendance aux benzodiazépines a été évalué par une variable composite intégrant deux questions inspirées du DSM-IV-TR. L’utilisation des services de santé a été mesurée par l’incidence cumulée des consultations auprès des professionnels de la santé au cours d’une période de 12 mois.
Résultats : Les aînés ont consommé au total 745 benzodiazépines parmi lesquelles 117 (16,5 %) avaient une longue demi-vie d’élimination. La proportion d’aînés qui ont rapporté un sentiment de dépendance aux benzodiazépines a été estimée à 35,1 %. Ces aînés n’ont pas significativement davantage utilisé les services de santé pour leurs problèmes de dépendance aux benzodiazépines.
Conclusion : Les résultats de cette étude suggèrent que l’utilisation des benzodiazépines chez les aînés au Québec est loin d’être optimale. Par ailleurs, le besoin ressenti de dépendance ne constitue pas un facteur suffisant pour amener les aînés à utiliser les services de santé pour la prise en charge d’un problème de dépendance. Il existe donc un besoin de recherche afin de mieux cerner les barrières associées à l’utilisation des services de santé par les aînés dépendants aux benzodiazépines.
Background: The objectives of this study were to examine the factors modifying the relationship between cortisol level and prevalent/incident cognitive impairment in older adults and to verify whether these relationships were non-linear.
Methods: Data were collected from 1,226 individuals aged 65 and older by two in-home interviews separated by 12 months. Cortisol level was measured using saliva samples taken at the beginning of the baseline interview before cognitive, mental, and physical health evaluations. Prevalent and incident cognitive impairment were defined using the Mini-Mental State Examination scores according to normative data for age, education level, and sex.
Results: High morning cortisol level increased the risk of incident cognitive impairment in participants with anxiety or depressive episode while low cortisol level increased the risk in participants without anxiety or depressive episode. In high educated participants, but not in low educated participants, high morning cortisol level was associated with prevalent cognitive impairment and high afternoon cortisol level increased the risk of incident cognitive impairment. The results also suggested that lower morning cortisol values could increase the risk of incident cognitive impairment in individuals with few chronic diseases. A curvilinear relationship was observed between morning cortisol and the probability of incident cognitive impairment, but further analyses suggested that it was likely explained by anxiety and depressive episode.
Conclusions: These results suggest that cognitive impairment in older adults is linked to higher or lower cortisol level depending on characteristics such as anxiety, depressive episode, education level, and physical health.
ESA study data were paired with Quebec medical and pharmaceutical services records to document potentially inappropriate benzodiazepines (Bzs) prescriptions among community-dwelling adults aged 65 and older. Results indicate that 32 per cent of respondents took a mean daily dose of 6.1 mg of equivalent diazepam for, on average, 205 days per year. Almost half (48%) of Bzs users received a potentially inappropriate benzodiazepine prescription at least once during the year preceding the survey. About 23 per cent received at least one concomitant prescription of a Bz and another drug that could result in serious interaction. In addition, individuals aged 75 and older were more likely to receive Bzs for a longer period of time than those aged 65–74. Number of pharmacies used was associated with inappropriate Bzs prescriptions. Our results argue in favour of a more integrated health services system, including a regular review of older adults’ drug regimens.
Background: Use of benzodiazepines, common among older people, may lead to substance dependence. DSM-IV-TR criteria for this iatrogenic problem may apply poorly to older persons following a physician-prescribed regimen. This study, first of its kind, aimed to determine the prevalence rate of benzodiazepine dependence in older persons according to DSM-IV-TR and other atypical criteria.
Methods: Descriptive study based on face-to-face interviews conducted in the homes of 2,785 persons aged 65 years or older who were randomly selected from across the province of Quebec, Canada.
Results: Use of benzodiazepines was reported by 25.4% of respondents. Among them, 9.5% met DSM-IV-TR criteria for substance dependence. However, 43% of users reported being dependent, and one third agreed that it would be a good thing to stop taking benzodiazepines.
Interpretation: Benzodiazepine substance dependence is established at one tenth of community-dwelling older persons taking these medications, although a much larger proportion self-labels as dependent.
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