Namkee Choi, Ph.D.
Duration: 5/1/2005 – 9/31/2005
The goal of the project will be to collect and analyze data from focus groups of informal caregivers and formal community-based social service providers (Meals on Wheels program and neighborhood senior center staff) regarding (1) mental health service needs of low-income and/or home-bound older adults and (2) the types of depression interventions that are culturally competent, acceptable, low-cost, and easy-to-implement in older adults’ homes and neighborhood senior centers. Given that older adults’ depression exacerbates the caregiving stress and burden of their informal caregivers (Langa, Valenstein, Fendrick, Kabeto, & Vijan, 2004; Sewitch, McCusker, Dendukuri, & Yaffe, 2004), it is critical to take informal caregivers’ input into consideration when designing and implementing depression intervention programs. Staff of the Meals and Wheels and More (MOWAM) and 20 senior activity centers/congregate nutrition sites locate in Austin are most likely to be in frequent contact with low-income and/or home-bound older adults and will also be able to provide first-hand knowledge about low-income older adults’ depression and intervention needs. The specific aims of the study are to:
- Explore informal caregivers’ perceived needs for home- and community-based depression intervention services for their older relatives and themselves, with special focus on racial/ethnic differences
- Explore social service providers’ perceived and experienced needs for home- and community-based depression intervention services for their older clients
- Examine informal caregivers and service providers’ preferences for cognitive/psychological, pharmacological, and exercise interventions for depression for their older relatives or clients and the reasons for their preferences
- Explore ways and strategies through which depression interventions can be implemented in older adults’ homes and integrated into existing social service settings
BACKGROUND AND SIGNIFICANCE
Depression among older adults in service-poor low-income urban neighborhood pockets (or isolated rural areas) often goes undetected and untreated because systematic diagnosis and culturally acceptable and effective treatment programs are not available or accessible in these areas. Most of these older adults lack the financial resources, transportation, and social support systems that are critical in enabling them to access mental health treatment. In addition, minority older adults and their informal caregivers, including adult children, do not trust the mental health treatment system and do not feel comfortable with majority white therapists and majority white clients in mental health service settings (Choi & Gonzalez, in press-a; Yang & Jackson, 1998). Although many older adults afflicted with depression tend to turn to their primary care physicians, primary care physicians often lack mental health training (Gallo, Marino, Ford, & Anthony, 1995; Philips & Murrell, 1994; Ray, Raciti & MacLean, 1992).
These older adults’ access to mental health services must be improved, given that older adults with depression, especially mild-to-moderate or subthreshold depression, can be as effectively treated as in the case of their younger counterparts with a combination of psychopharmacology and psychotherapy (AoA, 2001). Even for functionally impaired and/or home-bound older adults, recent outcome studies of home-based depression interventions showed significant reduction in depressive symptoms and improved health status among the participants. Specifically, a recent randomized controlled trial focusing on eight 50-minute sessions of in-home problem-solving treatment (PST) over 19 weeks by masters-level social workers employed by community agencies resulted in a 50% reduction in depressive symptoms and significantly greater improvement in health-related quality of life at 12 months among the intervention group (n=72), compared to the control group, with mild-to-moderate depression or dysthymia and with or without antidepressant medications (Ciechanowski et al., 2004.) Another randomized controlled trial of an 8-week cognitive-behavioral therapy (CBT) for home-bound older caregivers of persons with dementia (CBT) resulted in a significant reduction in depressive symptoms among the intervention group (n=34) at 4 months (Chang, 1999). One randomized controlled trial of an individual package of home-based care for socially isolated and disabled older persons designed by a psychogeriatric team also found a significantly positive impact on the intervention group (n=33) at 6 months (Banerjee, Shamash, Macdonald, & Mann, 1996). A 10 weekly 1.5-hour long CB self-management therapy of a small group of older adults with a diagnosis of major depression was also found to be effective in significantly reducing depression, compared to controls, over a 1-year follow-up period (Rokke, Tomhave, & Jocic, 2000). Several other studies have shown that short-term (<12 weeks) group or individual CBT’s were effective for prevention and treatment of depression in late life (see Cole & Dendukuri, 2004). In addition, studies have found that engagement in regular exercise, because of its physical and psychological benefits, can have depression-moderating effects on older adults (North, McCullagh, & Tran, 1990; Penninx et al., 2002; Scully, Kremer, Meade, Graham, & Dudgeon, 1998). Since depressed older adults are especially likely to be isolated and sedentary, participation on group exercise routines at a senior center or an in-home supervised exercise program will provide them with socialization outlets and psychological benefits.
These previous studies suggest potential effectiveness of relatively brief, low-cost, and home- or senior-center-based depression interventions for low-income older adults who have chronic health problems. However, they did not examine racial/ethnic differences in intervention effectiveness and older adults’ and their caregivers’ perceptions about the acceptability of and preferences for different types of interventions. Because mental illness is a subjective experience that is deeply influenced by an individual’s cultural values and norms, individual perceptions of the relevance and beneficence of these programs are likely to vary (Angel, R. J. & Angel, J. L., 1995; DHHS, 1999; Lewis-Fernandez & Diaz, 2002; Williams & Harris-Reid, 1999). Neither did the previous studies investigate how these interventions could be integrated into existing social services and how social service providers could be trained to provide these interventions for their older clients. By assessing both informal caregivers’ and formal social service providers’ perceived and experienced mental health service gaps and training needs, we believe that there will be a better chance of offering depression intervention programs that are more accessible, acceptable, and thus more effective.
With its 2.8 million noninstitutionalized residents aged 60 years or older, Texas has the fourth largest older-adult population behind California, Florida, and New York, the second largest Hispanic older population, and the third largest African American older population in the nation. With the growing number of older Texans, depression is a serious health problem especially among low-income older Texans. For example, recent data from clients’ intake assessment and reassessment for the Meals on Wheels and More (MOWAM–Austin’s home-delivered meal program) showed that 23% of the 1,500 clients aged 60 and older (32% African American and 27% Hispanic or Latino) self-reported that they felt sad or depressed. The MOWAM staff believes that the actual prevalence of depression is likely to be even higher given that many older adults are not self-aware and/or are reluctant to acknowledge their depression. Over 80% of these older adults have income below 150% of the official poverty line, a majority of them live alone, lack informal social support, and are not receiving any metal health care. The City of Austin’s Senior Programs Manager also reports that a significant proportion of older adults who attend senior centers in low-income neighborhoods of Austin suffer from depression, but a majority of them have no access to mental health services. The Senior Programs Manager emphasized a dire need for systematic depression screening and intervention programs for low-income older adults who come to senior centers for congregate meals and/or activities.
Currently, staff in these social service agencies, lacking in mental health training and resources, do not provide systematic depression assessment, referral, or intervention. However, the MOWAM Board of Directors and staff have recently identified the addition of mental health services for their clients as one of the top priority goals in their 5-year strategic planning. (The PI has worked as a member of the MOWAM Board of Directors and volunteer expert consultant for client services for the past 2.5 years.) Considering that the MOWAM care managers (BA- or BSW-level social workers) are already providing in-home assessments and frequent home visits for basic needs services, they will be able to provide systematic depression screening and interventions with proper training and supervision from qualified mental health professionals. The MOWAM Board of Directors are hoping to find funding to hire 2 MSW-level social workers in the future. In addition to over 3,000 volunteers who deliver noon-day meals, MOWAM also has hundreds of volunteers who help home-bound older adults with grocery shopping (Groceries-To-Go program), transportation to medical appointments (Medi-Wheels program), minor home repairs (Handy Wheels program), and telephone check-ups and companionship (Care Calls program). (These programs are components of the MOWAM.) The care calls volunteers are especially trainable as peer counselors or home-based exercise trainers/supervisors for home-bound MOWAM clients. As for senior centers/congregate nutrition sites, lack of financial resources has hampered staff training for mental health services, but the city-wide Senior Programs Manager and the senior center site managers are well aware of the potential benefits of providing depression screening and interventions such as group CBT/PST sessions and exercise classes at multiple locations (20 centers) and are willing to collaborate with the PI in finding ways to bring such benefits to older adults who suffer from depression.
To achieve the study aims, we will use separate focus group discussions with three groups of participants: informal caregivers of older adults who are MOWAM program clients; care managers of MOWAM programs; and senior center staff. Focus group research is chosen because the primary goal of the study is to explore the degree of consensus on the extent of the need for depression interventions for older adults, to evaluate the types of interventions that are acceptable to informal caregivers and social service providers, and to brainstorm and develop strategies of integrating mental health services into existing services provided by MOWAM and senior centers. Focus groups are ideal methods to explore consensus and to evaluate or develop a particular program of activity (Morgan & Kreuger, 1993; Race, Hotch, & Parker, 1994). Interaction among group members who share similar experiences during organized discussions is likely to enable participants to ask questions of one another and to reevaluate and reconsider their own understandings of their specific experiences (Gibbs, 1997; Kitzinger, 1994, 1995). The organized discussions will thus be likely to help the participants, especially MOWAM and senior center staff, work collaboratively to come up with possible strategies and solutions for meeting mental health needs of their clientele and can become a forum of change (see Race et al., 1994).
The discussion topics will include the participants’ perceptions of mental health needs of their older adult relatives or clients; their current coping, referral, and intervention strategies; preferred depression intervention programs that they desire to see at senior centers or in older adults’ homes for home-bound older adults; resource, skills, and training needs for implementing center-based or in-home depression intervention programs. Respective focus groups for informal caregivers, MOWAM staff, and senior center staff will meet for two sessions: one for the discussion of the needs of older adult relatives or clients and the other for the discussion of their preferences for and perceived acceptability of interventions programs and strategies to implement the programs.
Center for Mental health Services Research, George Warren Brown School of Social Work, Washington University at St. Louis