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Understanding and Implementing Depression,

Anxiety, and Suicide Prevention Evidence-Based

Programs

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Suicide Prevention

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Institute of Medicine Terminology:“LEVELS” OF PREVENTIVE INTERVENTION

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.

“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.

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Universal, Selective, and Indicated Suicide Prevention in Older Adults

Universal Prevention Selective/Indicated Prevention

Screening for depression, and suicidal ideation

- PHQ-9, GDS - Suicide Risk Screening

Harm risk reduction-Public education reducing access

to fire-arms for at-risk seniors-Alcohol and medication misuse

Outreach Gatekeeper PATCH

PEARLS and PSTIntegrated care of

mental health problems in a community-based setting

Multi-Layered Suicide Prevention-Mental health education workshops-Annual, voluntary depression screening-referral for treatment -psychiatric consultation

Telephone-based support (TeleHelp TeleCheck)

PROSPECT/IPT and IMPACT/PST

Integrated care of mental health in primary health care settings

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INDICATED PREVENTION

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

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Recommendations for INDICATED PREVENTION

1. Because of the close association between depression and suicide in older adults• detection and effective treatment of depression are key

2. Routine screening for depression• PHQ-9, GDS, or CES-D

3. Depression treatment is effective at treating depression1. And is effective at reducing suicidal ideation in some, and

maybe reducing suicide ratesè Primary care most common venue

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Following Up

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

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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)

The IMPACT Treatment Model

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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

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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

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Community-Integrated Home-Based Depression Treatment for the Elderly

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Depression Care ManagementCore Components

1. Active Screening to identify depressed patients 2. Patient education / self-management support3. Outcome measurement (e.g., PHQ-9, GDS)4. Evidence Based Treatment

• Brief psychotherapy (e.g., PST, IPT)• Medication Treatment

5. Psychiatric consultation / caseload supervision6. Stepped care

• Increased intensity as needed• Specialty mental health referral when necessary

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HSCL: Hopkins Symptom Checklist

PEARLS: Improvement in Depression 12 Month Results

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SELECTIVE PREVENTION

High risk groups, though not all members bear risks – prevention through reducing risks.

15DeLeo et al., Br J Psychiatry 181:226-229, 2002

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

Tele-Help/Tele-Check Servicefor the Elderly

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UNIVERSAL PREVENTION

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

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Multi-Layered Suicide PreventionMulti-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, Nonsignificant for men

– No change for men or women in reference region

OYAMA ET AL., Gerontologist 46:821-826, 2006

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, Nonsignificant for men

– No change for men or women in reference region

OYAMA ET AL., Gerontologist 46:821-826, 2006

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EFFECT OF MULITLAYERED PREVENTION INITIATIVES ON SUICIDE RATES

MALE FEMALE

ALL AGES

Rutz et al. (1992) Gotland Study ↔ ↓Hegerl et al. (2006) Nuremberg ↓ ↓Szanto et al. (in press) Hungary ↔ ↓OLDER ADULTS

DeLeo et al. (2002) Telehelp/Telecheck ↔ ↓Oyama et al. (2004) Joboji ↓ ↓Oyama et al. (2005) Yuri town ↔ ↓Oyama et al. (2006a) Yasuzuka ↔ ↓Oyama et al. (2006b) Matsudai ↔ ↓

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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 expertiseOn-going coaching and follow-up is essentialCultural and generational competency

• Population-specific treatment characteristics, values, and beliefs• Skills for working with culturally diverse older populations.

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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

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Implementation Principles: Leadership & Administrative Support

Support and guidance for implementationReducing barriersEnsuring adequate supervisionDeveloping networks and linkages with related

providers and systemsDeveloping expertise in financing and

organizing services specific to aging, substance abuse, mental health, and preventive services

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Implementation Process

Six Stages of Implementation

Exploration and Adoption Program Installation Initial Implementation Full Operation Innovation Sustainability

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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.

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Example:Stage 2 Program Installation

Assess organizational readiness to adopt the PEARLS program

Staffing: redirect and hire social workersTrain the teamIdentify local community partners Set up referral relationships with local

physicians and other community providersIdentify funding and non-reimbursed time

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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

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Example:Stage 4 Full Implementation

PEARLS fully implemented in the new settingRoutine identification of clients in need of

assistanceRoutine collaboration between agencies,

interventionsOutcome and fidelity measures at standard

intervals Evaluation of the effectiveness of the program

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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.

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Example:Stage 6 Sustainability

Addition of more partner agencies in a nearby county

Mentoring system to avoid gaps with new staffQuarterly 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

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SAMHSA Older Adult Depression Kit

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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.

EBP Implementation Guide

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Contact Information

Stephen Bartels, M.D., M.S.Geriatric PsychiatryDartmouth College

Phone: (603) 653-3458E-mail: stephen.j.bartels@dartmouth.edu

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Examples of Vital State Support for Evidence-Based Programs:Eyewitness Reports from

Depression Care Management

Nancy L. WilsonBaylor College of Medicine

Houston Center of Excellence in Health Services Research- Michael E. DeBakey Veterans Affairs Medical Center

Healthy IDEAS Program Director

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Intervention components:Active screening for depressionMeasurement-based outcomesTrained depression care manager

• Client education• Evidence Based Treatment: PST+ ,

Behavioral ActivationA supervising psychiatrist (clinician)

Home-based Depression Care Management

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Key Steps in Program Implementation

Identifying ResourcesBuilding the Right TeamInstalling the Program Training and CoachingEvaluation for Continuous Quality

Improvement and Monitoring Fidelity

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Steps for Implementation

1. Readiness Assessment : Need, Motivation, Capacity

2. Leadership Team & Partnership Development

3. Staff Selection4. Program Installation 5. Pre-Service and In-Service Training6. Consultation and Coaching7. Program Evaluation

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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

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In support of implementation and pursuit of sustainability…..

States have played active role 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

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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

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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 States have determined how 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

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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

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Contact Information

Nancy L. Wilson, M.A., M.S.W., LCSWAssociate Professor of Medicine-Geriatrics

Baylor College of MedicineHouston Center of Excellence in Health Services Research

Phone: (713) 794-8520E-mail: nwilson@bcm.edu

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Montrose Counseling Center (MCC)

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Introduction to MCC

Who we are MissionPrograms

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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

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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

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Lessons Learned in SPRY 1

2-fold GLBT elder resistance Importance of outreach Need to build trust Value of peer support groupsFor those who needed it, when they actually

tried traditional counseling, they did very well

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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

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Lessons Learned in SPRY 1

The need to promote community awareness and change

Mental Health of elders in general: • Not on the radar.

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How did we transform our services?

Embracing a continuum of services beyond traditional psychotherapy

Our 13-fold increase in elder clientsOur awareness of the need for social programs

for GLBT seniorsOpenness to new models

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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).

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Current SAMHSA Grant SPRY 2

SAMHSA Older Adult TCE Grant• Suicide and prescription drug abuse

prevention for GLBT elders.• Social awareness and prevention

programs: Advertising campaign, QPR*, Adult Meducation*, Get Connected*

(*Evidence-based)

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Current Grant Description

Volunteer Peer Advocates: Screening for depression (as suicide prevention) and prescription drug abuse—PHQ-2, CAGE-AIDE*. Referral into treatment.

Healthy IDEAS*: an evidenced-based depression treatment. Alcohol and drug abuse treatment if needed, psychiatric referral if needed.

Sustainability

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Current Challenges of SPRY 2

The ol’ paradigm shift:• Suicide and prescription drug abuse

prevention instead of treatment? • Healthy IDEAS: a challenge for traditional

mental health organizations and providers.• Volunteer outreach workers: good for

sustainability but more difficult to start so far, less hours per person.

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Where We Are Today

MCC is attempting to address the needs a marginalized, underserved and high-risk elder population that is very difficult to reach, especially with traditional mental health providers and programs.

We are piloting programs, such as using volunteer outreach workers, we feel are unique.

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Where We Are Today

In a context of serious financial challenges:• How do we serve our clients?• How do we reach out to the underserved?• How do we fund our client services?• How can state and federal agencies help?

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Contact Information

Christopher E. Kerr, M.Ed., LPCClinical Director

Montrose Counseling CenterPhone: (173) 800-0862

E-mail: life@montrosecounselingcenter.org