U.S. Department of Veterans Affairs Public Access Author manuscript J Ment Health Aging. Author manuscript; available in PMC 2016 May 24. Published in final edited form as: J Ment Health Aging. 2002 ; 8(2): 139–149.
VA Author Manuscript
Mental Health Screening of Older Adults in Primary Care Mary J. Davis, PhD, Jennifer Moye, PhD, and Michele J. Karel, PhD VA Boston Health Care System, Brockton Campus, and Department of Psychiatry, Harvard Medical School
Abstract
VA Author Manuscript
In an effort to document mental health outreach in our primary care clinic, 316 veterans (mean age 72) not currently in psychiatric treatment were screened for multiple mental health symptoms. Depressed mood was reported by 18% of the sample, insomnia by 26%, and morbid/suicidal ideation by 6.9% for at least several days during the past 2 weeks. Of those who experienced a loss over the past year (43%), 36% remained affected by the loss. Also reported were anxiety symptoms (29%) and PTSD symptoms (14%). Two-fifths (39%) of patients reported drinking alcohol in the past week, 18% more than 5 days, and 13% more than 3 drinks per sitting. Twentysix percent of the patients reported symptoms warranting intervention; of these, only 39% accepted a treatment referral. While screening for depressed mood and alcohol use is now common in primary care, we found it useful to screen for specific symptoms of depression (including insomnia and suicidal ideation), persisting grief reactions, anxiety, and PTSD in this setting. Further research is necessary to determine factors that underlie some patients’ refusal to accept mental health treatment.
VA Author Manuscript
Older adults who experience psychiatric disorders rarely seek care from mental health specialists; rather, they tend to seek help from their general medical physician (Gallo, Rabins, & Illife, 1997). The primary health care clinic is therefore an important setting for the detection of mental health symptoms and subsequent treatment. Yet, older adults often present with a complex combination of medical, neurological, and psychological symptoms that increase the complexity of identifying and treating psychiatric difficulties (Jeste et al., 1999). As such, primary care providers have been noted to under-diagnose mental health problems and to under-treat such problems when recognized (Unützer et al., 2000). Such under-diagnosis and treatment is costly as older adults with depression, anxiety, and/or alcohol abuse difficulties are more disabled by medical illness, use more health care services, and have higher rates of mortality (Jeste et al., 1999). Fortunately, effective treatments for depression (e.g., Karel & Hinrichsen, 2000), alcohol abuse (e.g., Schonfeld & Dupree; 1995), and anxiety disorders (e.g., Stanley & Beck, 2000) are available for older adults.
Offprints. Requests for offprints should be directed to Jennifer Moye, PhD, Brockton VAMC 3-5-C, 940 Belmont Street, Brockton, MA 02301. ; Email: [email protected]
Davis et al.
Page 2
Screening for Depression
VA Author Manuscript
While only 1% to 2% of community-dwelling elders have major depressive disorder, 8% to 20% report clinically significant depressive symptoms (Gallo & Lebowitz, 1999). Rates of depression are higher in medical settings where up to 35% in primary care settings report minor depression (Gurland, Cross, & Katz, 1996). Identifying symptoms of depression among older adults is critical, considering the increased morbidity and mortality associated with depression including suicide (Conwell et al, 2000); a majority of patients who commit suicide visit their physician within a month of the suicide (Caine, Lyness, & Conwell, 1996).
Screening for Grief Reactions Ten to twenty percent of widowers and widows experience depression during the first year following the death of a.spouse (Zisook & Shuchter, 1993). The negative psychological effects of the death of a spouse may continue for two or more years following the bereavement including increased rates of physical illness, increased alcohol consumption, and early death (Rosenzweig, Prigerson, Miller, & Reynolds, 1997).
Screening for Anxiety and Post Traumatic Stress Disorder (PTSD) VA Author Manuscript
While only 5% of older adults have a diagnosable anxiety disorder (Flint, 1994), up to 21 % of older adults have reported anxiety symptoms that do not meet full diagnostic criteria (Himmelfarb & Murrell, 1984). The relative contribution of anxiety versus medical conditions to physical symptomatology can be particularly difficult to differentiate for older adults, such as in pulmonary (Kim et al., 2000) and rheumatological (O’Malley et al., 1998) conditions.
VA Author Manuscript
Because of the massive mobilization for World War II followed closely by Korea, nearly half of the current cohort of older men served in the military, and about half of these were exposed to combat (Spiro, Schnurr, & Aldwin, 1994). One-fifth to one-third of older veterans seen in a medical clinic may report PTSD symptoms (Blake et al., 1990), which is associated with poorer self-reported physical health (Clipp & Elder, 1996). Some World War II and Korean era combat veterans have been asymptomatic until they experience major transitions associated with late life (e.g., retirement) or a serious medical illness (Schnurr & Friedman, 1997).
Screening for Alcohol Abuse Alcohol abuse puts elders at risk for multiple health, cognitive, psychiatric, and interpersonal problems (Substance Abuse and Mental Health Services Administration [SAMSA], 1998). Ten to fifteen percent of older adults treated in primary care clinics have problematic alcohol use (exceeding a recommended one drink: per day) (Adams, Barry, & Fleming, 1996), with older adults who have been separated, divorced, or widowed at increased risk (Bucholz, Sheline, & Helzer, 1995). Regular screening by primary care clinicians is useful as many of those at risk do not seek services for substance abuse problems on their own yet are responsive to brief interventions in medical care settings (Fleming, Barry, Manwell, Johnson, & London, 1997).
J Ment Health Aging. Author manuscript; available in PMC 2016 May 24.
Davis et al.
Page 3
VA Author Manuscript
In consideration of the potential benefits of screening and then treating older medical patients for mental health problems, we describe our efforts to provide such screening of older veterans in a Department of Veterans Affairs primary care clinic. We report the extent of unrecognized or untreated mental health concerns, the feasibility of outreach screening for this population, and the response of patients to a mental health referral. Results are discussed in light of our clinical experience treating medically ill, elderly veterans with late onset mental health problems. A strength of this report is its focus on screening for multiple mental health symptoms, however. Limitations include that we did not collect data to permit the comparison of screening data and subsequent diagnostic interviews.
METHOD Participants Three hundred eighty-two veterans waiting for primary care appointments were approached for mental health screening; 316 completed the interview. Some patients declined to be interviewed. Other interviews were interrupted if the physician became available to see the patient.
VA Author Manuscript
Instruments Demographic Information—Demographic information was obtained by asking patients to report their age, ethnicity, educational attainment, and occupational and marital status as well as current living arrangements.
VA Author Manuscript
Depression—Depression was assessed with the Patient Health Questionnaire of the Primary Care Evaluation of Mental Disorders - Depression Subscale (PHQ/PRIME-MD; Spitzer et al., 1999). The PHQ Depression Subscale uses a 4-point likert scale to rate nine DSM-IV symptoms of major depression over the past two weeks as: not at all, several days, more than half the days, or nearly every day. The PRIME-MD is designed for use by primary care physicians to detect the psychiatric disorders most commonly found in primary care settings. Diagnoses made by primary care physicians using the PRIME-MD versus experienced mental health professionals are comparable (Kappa = .65). In this study, the PHQ was administered in interview format to avoid potential problems with literacy or vision. Grief Reactions—Grief was assessed by asking patients: Have you lost a close friend or family member in the past year? They were also asked: Do you find that it still affects you? Both items were rated as yes/no. Anxiety and Post Traumatic Stress Disorder—Two questions from the PHQ were used to assess anxiety level over the last 4 weeks. The first was: How often have you felt nervous (anxious), on edge, or worried a lot about different things? The second was: How often have you become easily annoyed or irritable? These questions were rated as: not at all, several days, or more than half the days. Additional PHQ questions for anxiety were eliminated as we were not interested in evaluating specific anxiety disorders in this screening study.
J Ment Health Aging. Author manuscript; available in PMC 2016 May 24.
Davis et al.
Page 4
VA Author Manuscript
Seven questions based on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders fourth edition (APA, 1994) were used to assess Symptoms of Post Traumatic Stress Disorder about military or other trauma. These questions focused on military experiences of combat or having been involved with injured or dying servicemen, and whether veterans currently have distressing memories, dreams, acts or feelings of recurrence, psychological distress, or physiologic reactivity upon exposure to traumatic cues, in relation to military or other trauma. Alcohol Use—Five questions adapted from the Alcohol Use Disorders Identification Test (AUDIT) (Babor, de la Fuente, Saunders, & Grant, 1992) were used to assess current alcohol abuse focusing on frequency and quantity in drinking as well as social concerns about drinking. We did not include questions focusing on alcohol dependence (e.g., “How often during the last 6 months have you needed a drink in the morning to get yourself going after a heavy drinking sessions?”) as we have found these apply to only a small number of older adults. Procedure
VA Author Manuscript
Lists of potential participants were reviewed by hospital computer on the day prior to the participants’ primary care appointment to identify those patients 60 years of age and older who were not currently in mental health treatment.
VA Author Manuscript
Working from this list of potential participants, patients were approached while waiting for an appointment if they were expecting at least a 15-minute wait to see the physician (as assessed by the clinic clerk). The interviewer was a clinical psychology graduate student who had completed a full-time internship and three years of geriatric mental health screening experience. Patients were informed that the Medical Center’s Geriatric Mental Health Clinic was interviewing older adults to assess if they might be experiencing difficulties which could be improved by appropriate treatment. Patients were also informed that participation in the screening interview was entirely voluntary and that refusal to participate would not affect their provision of care at the Medical Center. Patients who agreed to participate were screened in a private room. Interviews were terminated if the physician became available to see the patient. Most interviews were completed in 15 minutes. At the end of the interview, all patients were asked whether they would like a referral to the Geriatric Mental Health clinic to discuss any issues further. If more urgent risk issues were identified (e.g., suicidal thoughts), the primary care provider was notified and further evaluation by a staff psychiatrist or psychologist was conducted as indicated. Following the interview, all participants were rated by the interviewer as to whether they needed mental health services on the basis of interview responses; notation was made of whether participants agreed or declined to be contacted by a provider in our clinic. Those patients who expressed an interest in a referral were contacted by a provider in the Medical Center’s Geriatric Mental Health Clinic.
J Ment Health Aging. Author manuscript; available in PMC 2016 May 24.
Davis et al.
Page 5
RESULTS Sample Characteristics
VA Author Manuscript
Three hundred and sixteen patients completed the interview, with a mean age of 72.1 years, (SD = 6.4) and educational level of 11.7 years (SD = 3.0). Most were Caucasian (94.9%), 4.8% were African American and .3% were Hispanic. The majority of participants were married (54.5%), 18.8% were widowed, 17.8% were divorced, 5.1% were never married, and 3.5% were separated. Many patients reported living with a spouse (43.2%), while 30.2% lived alone and 26.6% had other living arrangements. The majority were retired (71.5%), 19.2% were working part time, 3.2% were working full time, and 6.1% held regular volunteer positions. Depression Six percent of patients reported lost interest or pleasure, and 9% more described feeling down, depressed, or hopeless more than half the days in the past two weeks (see Table 1). Almost 7% said they had thought they’d be better off dead or had thoughts of hurting themselves at least several days in the past two weeks.
VA Author Manuscript
The most commonly endorsed symptoms were trouble falling asleep and feeling tired or having little energy. But such endorsement was not always associated with depressed mood or low interest/pleasure. Of those complaining of insomnia, only 24% also complained of associated mood or lost interest/pleasure; of those complaining of fatigue or anergy, only 30% also complained of the associated symptoms. Overall, 9% of patients endorsed 5 or more symptoms on the PRIME-MD (including lost interest or depressed mood) over at least several days, and 1% endorsed 5 or more symptoms nearly every day. Grief One hundred and thirty-six (43%) participants lost a close friend or family member in the past year; 51 (39% of those who lost someone; 16% of the total sample) report still being affected by the loss. Anxiety and Post Traumatic Stress Disorder
VA Author Manuscript
Many participants reported mild anxiety symptoms. About one-fourth described feeling nervous, on edge, or worrying (21.4% several days in the past month, 7.5% more than half the days). About one-third reported feeling easily annoyed or irritable (28.5% several days, 6.3% more than half the days). About two-fifths of the participants were either in combat or involved in some way with injured or dying servicemen (see Table 2). Fourteen percent of the total sample acknowledged having distressing memories of the war; 13% reported having distressing memories about other unusually scary or difficult life experiences; 10% reported distressing dreams related to the war or other traumatic experiences. Fewer reported experiencing a recapitulation of traumatic events or feeling physically or emotionally distressed when reminded of such events.
J Ment Health Aging. Author manuscript; available in PMC 2016 May 24.
Davis et al.
Page 6
Alcohol Use Most participants were not currently drinking alcohol (see Table 3). However, about 17% reported drinking more than 5 days per week, and about 5% reported drinking more than five drinks per sitting. For some, health care professionals (12.2% of the sample) or others (5.5%) had suggested cutting down or have expressed concern.
VA Author Manuscript
Relationship Between Mental Health Symptoms General anxiety symptoms were correlated with depressive symptoms (r = .47, p < .001). Endorsement of general anxiety and specific PTSD symptoms (having had distressing dreams, memories, recapitulation, and/or reactivity) were also correlated (r = .21; p < .001), but not depressive symptoms and PTSD. An ongoing grief reaction, (i.e., being “still affected” by a loss) was associated with more anxiety (t = 2.24, p < .05) and depression (t = 3.58, p than 1/2 the days*
Lost interest or pleasure in doing things
87.2%
6.7%
6.1%
Felt down, depressed, or hopeless
73.8%
17.3%
9.0%
Trouble falling or staying asleep
66.6%
12.2%
21.2%
Tired or had little energy
66.8%
13.7%
19.5%
Poor appetite or overeating
89.5%
4.8%
5.7%
Felt bad about self or a failure or had let self/family down
89.2%
8.0%
Trouble concentrating on things, such as reading the newspaper or watching TV
87.8%
7.4%
Moving or speaking so slowly that other people noticed
88.5%
6.7%
Thoughts that would be better off dead or of hurting self in some way
92.7%
5.7%
2.9% 4.8% 4.4% 1.2%
*
In this table the response categories “more than 1/2 the days” and “nearly every day” are collapsed in column three to “more than 1/2 the days.”
VA Author Manuscript J Ment Health Aging. Author manuscript; available in PMC 2016 May 24.
Davis et al.
Page 13
TABLE 2
VA Author Manuscript
PTSD Symptoms. When in the military, ever in combat?
42.5%
Ever in some way involved with injured or dying servicemen?
41.6%
Ever have distressing memories about the war?
14.2%
Ever have distressing memories about other unusually scary or difficult experiences in your life?
13.3%
Have distressing dreams?
10.0%
Ever feel like it (the war or other scary and difficult experience) is recurring or happening again?
3.3%
Feel physically or emotionally distressed or reactive when something reminds you of it?
2.6%
VA Author Manuscript VA Author Manuscript J Ment Health Aging. Author manuscript; available in PMC 2016 May 24.
Davis et al.
Page 14
TABLE 3
VA Author Manuscript
Alcohol Use. Item
Distribution
When was last drink of beer, wine, whiskey, or other liquor?
< 1 week
39.2
< 1 month
8.0
> 1 month
52.8
> 5 days
17.4
How many days a week drink?
How many drinks in one sitting?
Percent
3–4 days
5.7
1–2 days
16.7
None/less often
60.4
> 5 drinks
4.7
3–4 drinks
8.0
1–2 drinks
40.7
None/fewer
46.7
VA Author Manuscript VA Author Manuscript J Ment Health Aging. Author manuscript; available in PMC 2016 May 24.
VA Author Manuscript
Mental Health Screening of Older Adults in Primary Care Mary J. Davis, PhD, Jennifer Moye, PhD, and Michele J. Karel, PhD VA Boston Health Care System, Brockton Campus, and Department of Psychiatry, Harvard Medical School
Abstract
VA Author Manuscript
In an effort to document mental health outreach in our primary care clinic, 316 veterans (mean age 72) not currently in psychiatric treatment were screened for multiple mental health symptoms. Depressed mood was reported by 18% of the sample, insomnia by 26%, and morbid/suicidal ideation by 6.9% for at least several days during the past 2 weeks. Of those who experienced a loss over the past year (43%), 36% remained affected by the loss. Also reported were anxiety symptoms (29%) and PTSD symptoms (14%). Two-fifths (39%) of patients reported drinking alcohol in the past week, 18% more than 5 days, and 13% more than 3 drinks per sitting. Twentysix percent of the patients reported symptoms warranting intervention; of these, only 39% accepted a treatment referral. While screening for depressed mood and alcohol use is now common in primary care, we found it useful to screen for specific symptoms of depression (including insomnia and suicidal ideation), persisting grief reactions, anxiety, and PTSD in this setting. Further research is necessary to determine factors that underlie some patients’ refusal to accept mental health treatment.
VA Author Manuscript
Older adults who experience psychiatric disorders rarely seek care from mental health specialists; rather, they tend to seek help from their general medical physician (Gallo, Rabins, & Illife, 1997). The primary health care clinic is therefore an important setting for the detection of mental health symptoms and subsequent treatment. Yet, older adults often present with a complex combination of medical, neurological, and psychological symptoms that increase the complexity of identifying and treating psychiatric difficulties (Jeste et al., 1999). As such, primary care providers have been noted to under-diagnose mental health problems and to under-treat such problems when recognized (Unützer et al., 2000). Such under-diagnosis and treatment is costly as older adults with depression, anxiety, and/or alcohol abuse difficulties are more disabled by medical illness, use more health care services, and have higher rates of mortality (Jeste et al., 1999). Fortunately, effective treatments for depression (e.g., Karel & Hinrichsen, 2000), alcohol abuse (e.g., Schonfeld & Dupree; 1995), and anxiety disorders (e.g., Stanley & Beck, 2000) are available for older adults.
Offprints. Requests for offprints should be directed to Jennifer Moye, PhD, Brockton VAMC 3-5-C, 940 Belmont Street, Brockton, MA 02301. ; Email: [email protected]
Davis et al.
Page 2
Screening for Depression
VA Author Manuscript
While only 1% to 2% of community-dwelling elders have major depressive disorder, 8% to 20% report clinically significant depressive symptoms (Gallo & Lebowitz, 1999). Rates of depression are higher in medical settings where up to 35% in primary care settings report minor depression (Gurland, Cross, & Katz, 1996). Identifying symptoms of depression among older adults is critical, considering the increased morbidity and mortality associated with depression including suicide (Conwell et al, 2000); a majority of patients who commit suicide visit their physician within a month of the suicide (Caine, Lyness, & Conwell, 1996).
Screening for Grief Reactions Ten to twenty percent of widowers and widows experience depression during the first year following the death of a.spouse (Zisook & Shuchter, 1993). The negative psychological effects of the death of a spouse may continue for two or more years following the bereavement including increased rates of physical illness, increased alcohol consumption, and early death (Rosenzweig, Prigerson, Miller, & Reynolds, 1997).
Screening for Anxiety and Post Traumatic Stress Disorder (PTSD) VA Author Manuscript
While only 5% of older adults have a diagnosable anxiety disorder (Flint, 1994), up to 21 % of older adults have reported anxiety symptoms that do not meet full diagnostic criteria (Himmelfarb & Murrell, 1984). The relative contribution of anxiety versus medical conditions to physical symptomatology can be particularly difficult to differentiate for older adults, such as in pulmonary (Kim et al., 2000) and rheumatological (O’Malley et al., 1998) conditions.
VA Author Manuscript
Because of the massive mobilization for World War II followed closely by Korea, nearly half of the current cohort of older men served in the military, and about half of these were exposed to combat (Spiro, Schnurr, & Aldwin, 1994). One-fifth to one-third of older veterans seen in a medical clinic may report PTSD symptoms (Blake et al., 1990), which is associated with poorer self-reported physical health (Clipp & Elder, 1996). Some World War II and Korean era combat veterans have been asymptomatic until they experience major transitions associated with late life (e.g., retirement) or a serious medical illness (Schnurr & Friedman, 1997).
Screening for Alcohol Abuse Alcohol abuse puts elders at risk for multiple health, cognitive, psychiatric, and interpersonal problems (Substance Abuse and Mental Health Services Administration [SAMSA], 1998). Ten to fifteen percent of older adults treated in primary care clinics have problematic alcohol use (exceeding a recommended one drink: per day) (Adams, Barry, & Fleming, 1996), with older adults who have been separated, divorced, or widowed at increased risk (Bucholz, Sheline, & Helzer, 1995). Regular screening by primary care clinicians is useful as many of those at risk do not seek services for substance abuse problems on their own yet are responsive to brief interventions in medical care settings (Fleming, Barry, Manwell, Johnson, & London, 1997).
J Ment Health Aging. Author manuscript; available in PMC 2016 May 24.
Davis et al.
Page 3
VA Author Manuscript
In consideration of the potential benefits of screening and then treating older medical patients for mental health problems, we describe our efforts to provide such screening of older veterans in a Department of Veterans Affairs primary care clinic. We report the extent of unrecognized or untreated mental health concerns, the feasibility of outreach screening for this population, and the response of patients to a mental health referral. Results are discussed in light of our clinical experience treating medically ill, elderly veterans with late onset mental health problems. A strength of this report is its focus on screening for multiple mental health symptoms, however. Limitations include that we did not collect data to permit the comparison of screening data and subsequent diagnostic interviews.
METHOD Participants Three hundred eighty-two veterans waiting for primary care appointments were approached for mental health screening; 316 completed the interview. Some patients declined to be interviewed. Other interviews were interrupted if the physician became available to see the patient.
VA Author Manuscript
Instruments Demographic Information—Demographic information was obtained by asking patients to report their age, ethnicity, educational attainment, and occupational and marital status as well as current living arrangements.
VA Author Manuscript
Depression—Depression was assessed with the Patient Health Questionnaire of the Primary Care Evaluation of Mental Disorders - Depression Subscale (PHQ/PRIME-MD; Spitzer et al., 1999). The PHQ Depression Subscale uses a 4-point likert scale to rate nine DSM-IV symptoms of major depression over the past two weeks as: not at all, several days, more than half the days, or nearly every day. The PRIME-MD is designed for use by primary care physicians to detect the psychiatric disorders most commonly found in primary care settings. Diagnoses made by primary care physicians using the PRIME-MD versus experienced mental health professionals are comparable (Kappa = .65). In this study, the PHQ was administered in interview format to avoid potential problems with literacy or vision. Grief Reactions—Grief was assessed by asking patients: Have you lost a close friend or family member in the past year? They were also asked: Do you find that it still affects you? Both items were rated as yes/no. Anxiety and Post Traumatic Stress Disorder—Two questions from the PHQ were used to assess anxiety level over the last 4 weeks. The first was: How often have you felt nervous (anxious), on edge, or worried a lot about different things? The second was: How often have you become easily annoyed or irritable? These questions were rated as: not at all, several days, or more than half the days. Additional PHQ questions for anxiety were eliminated as we were not interested in evaluating specific anxiety disorders in this screening study.
J Ment Health Aging. Author manuscript; available in PMC 2016 May 24.
Davis et al.
Page 4
VA Author Manuscript
Seven questions based on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders fourth edition (APA, 1994) were used to assess Symptoms of Post Traumatic Stress Disorder about military or other trauma. These questions focused on military experiences of combat or having been involved with injured or dying servicemen, and whether veterans currently have distressing memories, dreams, acts or feelings of recurrence, psychological distress, or physiologic reactivity upon exposure to traumatic cues, in relation to military or other trauma. Alcohol Use—Five questions adapted from the Alcohol Use Disorders Identification Test (AUDIT) (Babor, de la Fuente, Saunders, & Grant, 1992) were used to assess current alcohol abuse focusing on frequency and quantity in drinking as well as social concerns about drinking. We did not include questions focusing on alcohol dependence (e.g., “How often during the last 6 months have you needed a drink in the morning to get yourself going after a heavy drinking sessions?”) as we have found these apply to only a small number of older adults. Procedure
VA Author Manuscript
Lists of potential participants were reviewed by hospital computer on the day prior to the participants’ primary care appointment to identify those patients 60 years of age and older who were not currently in mental health treatment.
VA Author Manuscript
Working from this list of potential participants, patients were approached while waiting for an appointment if they were expecting at least a 15-minute wait to see the physician (as assessed by the clinic clerk). The interviewer was a clinical psychology graduate student who had completed a full-time internship and three years of geriatric mental health screening experience. Patients were informed that the Medical Center’s Geriatric Mental Health Clinic was interviewing older adults to assess if they might be experiencing difficulties which could be improved by appropriate treatment. Patients were also informed that participation in the screening interview was entirely voluntary and that refusal to participate would not affect their provision of care at the Medical Center. Patients who agreed to participate were screened in a private room. Interviews were terminated if the physician became available to see the patient. Most interviews were completed in 15 minutes. At the end of the interview, all patients were asked whether they would like a referral to the Geriatric Mental Health clinic to discuss any issues further. If more urgent risk issues were identified (e.g., suicidal thoughts), the primary care provider was notified and further evaluation by a staff psychiatrist or psychologist was conducted as indicated. Following the interview, all participants were rated by the interviewer as to whether they needed mental health services on the basis of interview responses; notation was made of whether participants agreed or declined to be contacted by a provider in our clinic. Those patients who expressed an interest in a referral were contacted by a provider in the Medical Center’s Geriatric Mental Health Clinic.
J Ment Health Aging. Author manuscript; available in PMC 2016 May 24.
Davis et al.
Page 5
RESULTS Sample Characteristics
VA Author Manuscript
Three hundred and sixteen patients completed the interview, with a mean age of 72.1 years, (SD = 6.4) and educational level of 11.7 years (SD = 3.0). Most were Caucasian (94.9%), 4.8% were African American and .3% were Hispanic. The majority of participants were married (54.5%), 18.8% were widowed, 17.8% were divorced, 5.1% were never married, and 3.5% were separated. Many patients reported living with a spouse (43.2%), while 30.2% lived alone and 26.6% had other living arrangements. The majority were retired (71.5%), 19.2% were working part time, 3.2% were working full time, and 6.1% held regular volunteer positions. Depression Six percent of patients reported lost interest or pleasure, and 9% more described feeling down, depressed, or hopeless more than half the days in the past two weeks (see Table 1). Almost 7% said they had thought they’d be better off dead or had thoughts of hurting themselves at least several days in the past two weeks.
VA Author Manuscript
The most commonly endorsed symptoms were trouble falling asleep and feeling tired or having little energy. But such endorsement was not always associated with depressed mood or low interest/pleasure. Of those complaining of insomnia, only 24% also complained of associated mood or lost interest/pleasure; of those complaining of fatigue or anergy, only 30% also complained of the associated symptoms. Overall, 9% of patients endorsed 5 or more symptoms on the PRIME-MD (including lost interest or depressed mood) over at least several days, and 1% endorsed 5 or more symptoms nearly every day. Grief One hundred and thirty-six (43%) participants lost a close friend or family member in the past year; 51 (39% of those who lost someone; 16% of the total sample) report still being affected by the loss. Anxiety and Post Traumatic Stress Disorder
VA Author Manuscript
Many participants reported mild anxiety symptoms. About one-fourth described feeling nervous, on edge, or worrying (21.4% several days in the past month, 7.5% more than half the days). About one-third reported feeling easily annoyed or irritable (28.5% several days, 6.3% more than half the days). About two-fifths of the participants were either in combat or involved in some way with injured or dying servicemen (see Table 2). Fourteen percent of the total sample acknowledged having distressing memories of the war; 13% reported having distressing memories about other unusually scary or difficult life experiences; 10% reported distressing dreams related to the war or other traumatic experiences. Fewer reported experiencing a recapitulation of traumatic events or feeling physically or emotionally distressed when reminded of such events.
J Ment Health Aging. Author manuscript; available in PMC 2016 May 24.
Davis et al.
Page 6
Alcohol Use Most participants were not currently drinking alcohol (see Table 3). However, about 17% reported drinking more than 5 days per week, and about 5% reported drinking more than five drinks per sitting. For some, health care professionals (12.2% of the sample) or others (5.5%) had suggested cutting down or have expressed concern.
VA Author Manuscript
Relationship Between Mental Health Symptoms General anxiety symptoms were correlated with depressive symptoms (r = .47, p < .001). Endorsement of general anxiety and specific PTSD symptoms (having had distressing dreams, memories, recapitulation, and/or reactivity) were also correlated (r = .21; p < .001), but not depressive symptoms and PTSD. An ongoing grief reaction, (i.e., being “still affected” by a loss) was associated with more anxiety (t = 2.24, p < .05) and depression (t = 3.58, p than 1/2 the days*
Lost interest or pleasure in doing things
87.2%
6.7%
6.1%
Felt down, depressed, or hopeless
73.8%
17.3%
9.0%
Trouble falling or staying asleep
66.6%
12.2%
21.2%
Tired or had little energy
66.8%
13.7%
19.5%
Poor appetite or overeating
89.5%
4.8%
5.7%
Felt bad about self or a failure or had let self/family down
89.2%
8.0%
Trouble concentrating on things, such as reading the newspaper or watching TV
87.8%
7.4%
Moving or speaking so slowly that other people noticed
88.5%
6.7%
Thoughts that would be better off dead or of hurting self in some way
92.7%
5.7%
2.9% 4.8% 4.4% 1.2%
*
In this table the response categories “more than 1/2 the days” and “nearly every day” are collapsed in column three to “more than 1/2 the days.”
VA Author Manuscript J Ment Health Aging. Author manuscript; available in PMC 2016 May 24.
Davis et al.
Page 13
TABLE 2
VA Author Manuscript
PTSD Symptoms. When in the military, ever in combat?
42.5%
Ever in some way involved with injured or dying servicemen?
41.6%
Ever have distressing memories about the war?
14.2%
Ever have distressing memories about other unusually scary or difficult experiences in your life?
13.3%
Have distressing dreams?
10.0%
Ever feel like it (the war or other scary and difficult experience) is recurring or happening again?
3.3%
Feel physically or emotionally distressed or reactive when something reminds you of it?
2.6%
VA Author Manuscript VA Author Manuscript J Ment Health Aging. Author manuscript; available in PMC 2016 May 24.
Davis et al.
Page 14
TABLE 3
VA Author Manuscript
Alcohol Use. Item
Distribution
When was last drink of beer, wine, whiskey, or other liquor?
< 1 week
39.2
< 1 month
8.0
> 1 month
52.8
> 5 days
17.4
How many days a week drink?
How many drinks in one sitting?
Percent
3–4 days
5.7
1–2 days
16.7
None/less often
60.4
> 5 drinks
4.7
3–4 drinks
8.0
1–2 drinks
40.7
None/fewer
46.7
VA Author Manuscript VA Author Manuscript J Ment Health Aging. Author manuscript; available in PMC 2016 May 24.
