Johns Hopkins research may improve early detection of dementia

Using scores obtained from cognitive tests, Johns Hopkins researchers think they have developed a model that could help determine whether memory loss in older adults is benign or a stop on the way to Alzheimer's disease. The risk of developing dementia increases markedly when a person is diagnosed with mild cognitive impairment, a noticeable and measurable decline in intellectual abilities that does not seriously interfere with daily life. But physicians have no reliable way to predict which people with mild cognitive impairment are likely to be in the 5 to 10 percent a year who progress to dementia. In a proof-of-concept study, the Johns Hopkins investigators analyzed records of 528 people age 60 and over, who were referred to the Johns Hopkins Medical Psychology Clinic for cognitive testing as part of a dementia work-up between 1996 and 2004. The results were compared to those of 135 healthy older adults who participated in a study of normal aging. Both groups completed tests of memory, language, attention, processing speed and drawing abilities from which 13 scores were recorded Nursing CEUs Since each person is naturally more skillful in some areas than in others, the scores of healthy adults showed a symmetrical, bell-shaped range: Most of their scores were high, a few were a bit lower, and a few were even lower. By grouping the patients into cohorts based on the severity of their dementia, the researchers found a trend in the test scores that is likely to mimic the deterioration of an individual's scores over time. At the outset, he says, Alzheimer's disease subtly disrupts some mental abilities, while leaving others intact. Thus, well before a person develops clear cognitive impairment, his or her performance declines slightly on a few measures. When shown on a graph, these changes cause the healthy symmetric, bell-shaped curve to shift and become asymmetrical. Regardless of how low a person's test scores were, the researchers determined that lopsidedness in their score distribution correlated with dementia. They predicted that people with low scores that were evenly distributed were not likely to develop dementia. But those with clearly lopsided test score distributions on the 13 measures administered were already experiencing varying levels of dementia. "Departures from the normal bell-shaped pattern of variability on cognitive tests might determine which people with low scores develop dementia," says David J. Schretlen, Ph.D., a professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine and leader of a study published online Nov. 12 in the journal Neuropsychology. Since these declines can be subtle, the researchers also increased the precision of cognitive testing by accounting for the effects of age, sex, race and education on test performance. The challenge for doctors, Schretlen explains, is that most normal, healthy people will produce a few low scores on cognitive testing. That makes it nearly impossible to know at the outset whether a patient who reports forgetfulness and produces one or two low scores has a benign form of mild cognitive impairment, or is in the earliest stage of dementia. As a result, doctors often tell such patients to return for follow-up testing in a year or two. But if future research confirms it, this new statistical model could help doctors get the prognosis right earlier in the disease, at the first visit, and start treating patients accordingly. Mostly, Schretlen says, doctors could use the new model to reassure patients who are not at risk of dementia, while fast-tracking interventions for those who are. Because there currently are no effective treatments for Alzheimer's disease, those likely headed that way could be counseled to take the good time they have to organize their affairs, and do things they have always wanted to do. They also could be fast-tracked into clinical trials of medications to slow the progression of dementia. "If we are going to have any hope of helping patients with Alzheimer's disease, we need to do it as early as possible," Schretlen says. "Once the brain deteriorates, there's no coming back." Recent failures of drugs in late-stage clinical trials for Alzheimer's disease have been a real blow, he adds, but new treatments are being developed. The new way of reading existing test scores follows a 2008 study by the same researchers showing that one of every six healthy adults scored poorly on two or more of 10 tests in a brief cognitive battery — even though there was nothing wrong with them. The main reason it is difficult to tell whether older people have benign mild cognitive impairment or not is because they are not routinely screened for cognitive impairment, he says. A visit to a specialist comes only after someone has noticed symptoms, and then cognitive testing is interpreted without the benefit of a baseline assessment. What would solve this problem, he says, would be for everyone over the age of 55 to get routine neurocognitive testing every five years. ### The study was supported by the Therapeutic Cognitive Neuroscience Fund; the Benjamin and Adith Miller Family Endowment on Aging, Alzheimer's and Autism; the William and Mary Ann Wockenfuss Research Fund Endowment; and the National Institutes of Health's National Institute of Mental Health (MH60504). Under an agreement with Psychological Assessment Resources, Inc., Schretlen is entitled to a share of royalties on sales of a test and software used in the study. The terms of this arrangement are being managed by The Johns Hopkins University in accordance with its conflict-of-interest policies. Other Johns Hopkins researchers involved in the study include Gila Z. Reckess, Ph.D.; Mark Varvaris, B.A.; and Barry Gordon, M.D., Ph.D. For more information about Schretlen, click here. Johns Hopkins Medicine (JHM), headquartered in Baltimore, Maryland, is a $6.7 billion integrated global health enterprise and one of the leading health care systems in the United States. JHM unites physicians and scientists of the Johns Hopkins University School of Medicine with the organizations, health professionals and facilities of The Johns Hopkins Hospital and Health System. JHM's vision, "Together, we will deliver the promise of medicine," is supported by its mission to improve the health of the community and the world by setting the standard of excellence in medical education, research and clinical care. Diverse and inclusive, JHM educates medical students, scientists, health care professionals and the public; conducts biomedical research; and provides patient-centered medicine to prevent, diagnose and treat human illness. JHM operates six academic and community hospitals, four suburban health care and surgery centers, and more than 30 primary health care outpatient sites. The Johns Hopkins Hospital, opened in 1889, was ranked number one in the nation for 21 years in a row by U.S. News & World Report. For more information about Johns Hopkins Medicine, its research, education and clinical programs, and for the latest health, science and research news, visit http://www.hopkinsmedicine.org Aging and Long Term Care CE Course Johns Hopkins Medicine Media Relations and Public Affairs

MFT Intern Continuing Education

The California Board of Behavioral Sciences (CA BBS) has approved Aspira Continuing Education as a CE provider for MFT Interns (provider #PCE4374). Only certain courses are approved to be taken from an approved online CE provider like Aspira. The following Aspira courses are approved to be taken online by California MFT Interns. Click on the link below to go to the corresponding CEU Course Description page: •Child Abuse Assessment and Reporting CEU Course (7 hours) •Human Sexuality CEU Course (10 hours) •Spousal and Partner Abuse CEU Course (15 hours) •Aging and Long Term Care CEU Course (10 hours) Click here: BBS Website – Additional Coursework Requirements for verification. The following extra coursework is required as well but must be taken at an approved university: •Alcoholism and Chemical Dependency (1 semester unit; must be in your degree program if your school is in California) •Psychological Testing (2 semester units or 3 quarter units) •Psychopharmacology (2 semester units or 3 quarter units) •California Law and Professional Ethics (2 semester units or 3 quarter units) View Aspira's CEU Pricing page to see how to pay for Aspira's CE courses. View Aspira's CEU Offers page to see the latest offers and discounts available. Also, see how to earn free CEUs.

New study identifies signs of autism in the first months of life

Scientists at Marcus Autism Center, Children's Healthcare of Atlanta and Emory University School of Medicine identify markers of social disability present in 2 to 6-month-old infants later diagnosed with autism Researchers at Marcus Autism Center, Children's Healthcare of Atlanta and Emory University School of Medicine have identified signs of autism present in the first months of life. The researchers followed babies from birth until 3 years of age, using eye-tracking technology, to measure the way infants look at and respond to social cues. Infants later diagnosed with autism showed declining attention to the eyes of other people, from the age of 2 months onwards. The results are reported in the Nov. 6, 2013 advanced online publication of the journal Nature. The study followed two groups of infants, one at low and one at high risk for having autism spectrum disorders. High-risk infants had an older sibling already diagnosed with autism, increasing the infant's risk of also having the condition by 20 fold. In contrast, low-risk infants had no first, second, or third degree relatives with autism. "By following these babies from birth, and intensively within the first six months, we were able to collect large amounts of data long before overt symptoms are typically seen," said Warren Jones, Ph.D., the lead author on the study. Teams of clinicians assessed the children longitudinally and confirmed their diagnostic outcomes at age 3. Then the researchers analyzed data from the infants' first months to identify what factors separated those who received an autism diagnosis from those who did not. What they found was surprising MFT Intern Continuing Education "We found a steady decline in attention to other people's eyes, from 2 until 24 months, in infants later diagnosed with autism," said co-investigator Ami Klin, Ph.D., director of Marcus Autism Center. Differences were apparent even within the first 6 months, which has profound implications. "First, these results reveal that there are measurable and identifiable differences present already before 6 months. And second, we observed declining eye fixation over time, rather than an outright absence. Both these factors have the potential to dramatically shift the possibilities for future strategies of early intervention." Jones is director of research at Marcus Autism Center and assistant professor in the Department of Pediatrics at Emory University School of Medicine. Klin is director of Marcus Autism Center, chief of the Division of Autism & Related Disorders in the Department of Pediatrics at Emory University School of Medicine and a Georgia Research Alliance Eminent Scholar. The researchers caution that what they observed would not be visible to the naked eye, but requires specialized technology and repeated measurements of a child's development over the course of months. "To be sure, parents should not expect that this is something they could see without the aid of technology," said Jones, "and they shouldn't be concerned if an infant doesn't happen to look at their eyes at every moment. We used very specialized technology to measure developmental differences, accruing over time, in the way that infants watched very specific scenes of social interaction." Before they can crawl or walk, babies explore the world intensively by looking at it, and they look at faces, bodies, and objects, as well as other people's eyes. This exploration is a natural and necessary part of infant development, and it sets the stage for brain growth. The critical implications of the study relate to what it reveals about the early development of social disability. Although the results indicate that attention to others' eyes is already declining by 2 to 6 months in infants later diagnosed with autism, attention to others' eyes does not appear to be entirely absent. If infants were identified at this early age, interventions could more successfully build on the levels of eye contact that are present. Eye contact plays a key role in social interaction and development, and in the study, those infants whose levels of eye contact diminished most rapidly were also those who were most disabled later in life. This early developmental difference also gives researchers a key insight for future studies. "The genetics of autism have proven to be quite complex. Many hundreds of genes are likely to be involved, with each one playing a role in just a small fraction of cases, and contributing to risk in different ways in different individuals," said Jones. "The current results reveal one way in which that genetic diversity may be converted into disability very early in life. Our next step will be to expand these studies with more children, and to combine our eye-tracking measures with measures of gene expression and brain growth." ### The study, Attention to Eyes is Present But In Decline in 2-6 Month-Olds Later Diagnosed with Autism was funded by the Simons Foundation, the National Institute of Mental Health, the Marcus Foundation and the Whitehead Foundation. More information can be found at http://www.marcus.org/infants. Marcus Autism Center Marcus Autism Center is a not-for-profit organization and an affiliate of Children's Healthcare of Atlanta that treats more than 5,500 children with autism and related disorders a year. As one of the largest autism centers in the U.S. and one of only three National Institutes of Health Autism Centers of Excellence, Marcus Autism Center offers families access to the latest research, comprehensive evaluations and intensive behavior treatments. With the help of research grants, community support and government funding, Marcus Autism Center aims to maximize the potential of children with autism today and transform the very nature of autism for future generations. Visit marcus.org for more information.

OHSU Vollum Institute research gives new insight into how antidepressants work in the brain

Vollum Institute scientist publishes two papers on neurotransmission in today’s edition of Nature Research from Oregon Health & Science University's Vollum Institute, published in the current issue of Nature, is giving scientists a never-before-seen view of how nerve cells communicate with each other. That new view can give scientists a better understanding of how antidepressants work in the human brain — and could lead to the development of better antidepressants with few or no side effects. The article in today’s edition of Nature came from the lab of Eric Gouaux, Ph.D., a senior scientist at OHSU's Vollum Institute and a Howard Hughes Medical Institute Investigator. The article describes research that gives a better view of the structural biology of a protein that controls communication between nerve cells. The view is obtained through special structural and biochemical methods Gouaux uses to investigate these neural proteins. The Nature article focuses on the structure of the dopamine transporter, which helps regulate dopamine levels in the brain. Dopamine is an essential neurotransmitter for the human body's central nervous system; abnormal levels of dopamine are present in a range of neurological disorders, including Parkinson's disease, drug addiction, depression and schizophrenia. Along with dopamine, the neurotransmitters noradrenaline and serotonin are transported by related transporters, which can be studied with greater accuracy based on the dopamine transporter structure. The Gouaux lab's more detailed view of the dopamine transporter structure better reveals how antidepressants act on the transporters and thus do their work Alcoholism and Drug Abuse Counselors Continuing Education The more detailed view could help scientists and pharmaceutical companies develop drugs that do a much better job of targeting what they're trying to target — and not create side effects caused by a broader blast at the brain proteins. "By learning as much as possible about the structure of the transporter and its complexes with antidepressants, we have laid the foundation for the design of new molecules with better therapeutic profiles and, hopefully, with fewer deleterious side effects," said Gouaux. Gouaux's latest dopamine transporter research is also important because it was done using the molecule from fruit flies, a dopamine transporter that is much more similar to those in humans than the bacteria models that previous studies had used. The dopamine transporter article was one of two articles Gouaux had published in today’s edition of Nature. The other article also dealt with a modified amino acid transporter that mimics the mammalian neurotransmitter transporter proteins targeted by antidepressants. It gives new insights into the pharmacology of four different classes of widely used antidepressants that act on certain transporter proteins, including transporters for dopamine, serotonin and noradrenaline. The second paper in part was validated by findings of the first paper — in how an antidepressant bound itself to a specific transporter. "What we ended up finding with this research was complementary and mutually reinforcing with the other work — so that was really important," Gouaux said. "And it told us a great deal about how these transporters work and how they interact with the antidepressant molecules." Gouaux's discoveries over the years in neurotransmission have established him as one of the top investigators in his field. His research has important implications for understanding the mechanisms of not just antidepressants, but also drugs used for the treatment of a wide range of psychiatric and neurological diseases. Gouaux's co-authors on the dopamine transporter paper were both members of his lab; Aravind Penmatsa, Ph.D., and Kevin Wang, Ph.D. Gouaux's co-authors on the second Nature paper were also members or former members of his lab: Hui Wang, Ph.D.; April Goehring, Ph.D.; Kevin Wang, Aravind Penmatsa and Ryan Ressler, Ph.D. Both papers were funded by the American Heart Association, the National Institute of Mental Health, (1F32MH093120 and 5R37MH070039) and the Howard Hughes Medical Institute. About the OHSU Vollum Institute The Vollum Institute is a privately endowed research institute at OHSU and is dedicated to basic research that will lead to new treatments for neurological and psychiatric diseases. Vollum scientists have transformed the field of neuroscience and, in particular, have been pioneers in the study of cellular signaling, neuronal development, gene regulation and the neurobiology of disease. About OHSU Oregon Health & Science University is a nationally prominent research university and Oregon’s only public academic health center. It serves patients throughout the region with a Level 1 trauma center and nationally recognized Doernbecher Children’s Hospital. OHSU operates dental, medical, nursing and pharmacy schools that rank high both in research funding and in meeting the university’s social mission. OHSU’s Knight Cancer Institute helped pioneer personalized medicine through a discovery that identified how to shut down cells that enable cancer to grow without harming healthy ones. OHSU Brain Institute scientists are nationally recognized for discoveries that have led to a better understanding of Alzheimer’s disease and new treatments for Parkinson’s disease, multiple sclerosis and stroke. OHSU’s Casey Eye Institute is a global leader in ophthalmic imaging, and in clinical trials related to eye disease.

Depression Therapy Effective for Poor, Minority Moms

Faced with the dual demands of motherhood and poverty, as many as one fourth of low-income minority mothers struggle with major depression. But the stigma associated with mental illness coupled with limited access to quality treatment prevent the majority of these struggling women from receiving help. Now a new study shows that screening for the disorder and providing short-term, relationship-focused therapy through weekly home visits can relieve depression among minority mothers, even in the face of poverty and personal histories of abuse or violence. Such help can have far reaching benefits not only for mothers, but also for their children, say the authors. "It's amazing, really," says psychologist Sheree Toth, lead author and executive director of the University of Rochester's Mt. Hope Family Center. "This research tracked a 14-week intervention for mothers who are terribly overwhelmed, surrounded by high-crime neighborhoods, lacking social support, and often traumatized—my fear was, 'this is never going to work.'" But to the surprise of Toth and her Rochester team, the series of convenient, one-hour therapy sessions relieved depression in participants much better than standard clinic-based care. The study participants also continued to improve eight-months after the treatment ended, regaining a sense of hope and control over their lives and reporting feeling more connected to and supported by others. For example, on the Beck Depression Inventory (BDI), a widely used questionnaire in which a score of 19 or above indicates major depression, women in the study group saw their depressive symptoms decline from an average of 27 at the beginning of therapy to 9.6 eight months after the program concluded. By contrast, women who received community care remained clinically depressed, with an average BDI score of 21 at the follow-up.

Women who received home-based interpersonal therapy saw their depression subside by the end of treatment and continue to improve eight months later. Women who received standard care experienced much less relief. The results, says Toth, point to the need for screening high-risk populations. None of these women were seeking treatment, but were identified instead through a questionnaire and an interview at physicians' offices and clinics for the Women, Infants, and Children (WIC) subsidized nutrition program. Says Toth: "When I go to the doctor, they ask me if I use my seatbelt. Why would we not be asking questions about depression when we know the chances of being hit by a car are way less than the chances of being hit by depression? People are suffering needlessly." Published online November 8 in Development and Psychopathology, the findings are good news for mothers and their children alike. "Extensive research has shown that young children whose primary caregivers are depressed often begin life on the wrong foot," explains Toth. "They may fail to develop secure attachments, setting them up for a cascade of difficulties, from behavior problems during childhood and failure in school to involvement in the juvenile justice system and major psychiatric problems down the road." Despite the widespread prevalence of depression among minority mothers, researchers have largely overlooked this vulnerable population. "In fact, studies that formed the empirical base for the American Psychiatric Association guidelines for depression treatment included 3,860 participants, with only 27 identified as African American and none as being of Latina descent," the authors write. To address the imbalance, the researchers tracked 128 low-income mothers of one-year-olds, 60 percent of whom were Black, 20 percent Hispanic, and 20 percent Caucasian. In addition to poverty, the vast majority of these mothers faced extensive life challenges. All but 6 percent had been depressed for more than a year, 87 percent reported histories of child abuse, 30 percent had been raped or sexually assaulted by a relative, and 27 percent suffered from posttraumatic stress disorder. The study tested the effectiveness of interpersonal psychotherapy, a short-term depression treatment that has worked with more advantaged populations. "A big part of this approach is instilling hope," says Robin Sturm, a co-author and one of the family therapists who worked on the study. She and other therapists first help clients recognize that feelings, such as a lack of energy or motivation, are symptoms of depression not signs of laziness or other character flaws. "If they can separate themselves from the symptoms, it helps them see that they can get better," says Sturm. The bulk of the intervention then focuses on identifying and easing one or two key relationship problems in clients' lives. This could be overcoming the loss of a loved one, reconnecting with a family member, or learning how to resolve conflicts with a partner. Using a variety of tools, from role-playing to analyzing arguments, participants practice more effective ways to interact. "The aha moment is when these women realize, 'I have a sense of control,'" says Sturm. "Perhaps there is domestic violence. They can't control what the other person does, but they can control what they do. That stuck feeling is the hallmark of depression." A critical element of the study model was to offer therapy in clients' homes, an option chosen by 85 percent of participants. "It sends a powerful message that I am willing to come to you," explains Sturm, who, if needed, also met with clients in her car or drove them to the clinic for their appointment. "When people are depressed, it may be too hard to have the energy to make it to appointments," she says. The program's flexibility also reduced the need for childcare and transportation, resulting in a compliance rate of 100 percent, the authors report. Therapists were also sensitive to the stigma of mental illness in minority communities. If clients appeared uncomfortable with a diagnosis like depression, therapists used terms like overwhelmed or moody instead and stressed that such feelings were common for parents faced with the demands of childrearing. Instead of therapy, they sometimes describe their appointments as "spending some time talking about how you are feeling." The program involved no anti-depressants or other medication, further distancing the intervention from psychiatric care, says Sturm. To assess the effectiveness of this flexible, problem-solving approach, the study randomly assigned a second group of mothers to standard community care, matched by race, education, age, and other factors. The control group received clinic-based counseling or cognitive behavior therapy, a common short-term treatment for depression, along with a variety of other interventions, including medication, support groups, and marital and family counseling. The comparison was clear: home-based, interpersonal psychotherapy lifted depression much more effectively than standard care. The findings underscore the importance of actively screening and offering culturally sensitive, convenient care for our most vulnerable populations, says co-author Fred Rogosch, associate professor of psychology at the University of Rochester and director of research for Mt. Hope Family Center. In one clinical trial, 83 percent of low-income young minority women referred for treatment for depression did not attend even one session. "Most of these women don't even like to talk about depression. Most of these women would never have asked for treatment," says Rogosch. "When I go to the doctor, they ask me if I use my seatbelt," says Sheree Toth. "Why would we not be asking questions about depression when we know the chances of being hit by a car are way less than the chances of being hit by depression? People are suffering needlessly." "We also are concerned about the children of mothers who feel isolated, helpless, and angry. That is not the ideal emotional environment for infants and toddlers to grow up in. Reaching out to these mothers is critical for their children," says Rogosch. Even with the creative accommodations offered in this study, Rogosch notes that 40 percent of mothers identified as depressed declined all care. The authors suggest that future research should explore ways to make the interview process even more welcoming. Assaf Oshri and Julie Gravener from the University of Rochester and Antonio Alexander Morgan-López from the University of North Carolina at Chapel Hill also contributed to the paper. The research was supported by the National Institutes of Mental Health, grant MH091070 LPC Continuing Education About the University of Rochester The University of Rochester (www.rochester.edu) is one of the nation's leading private universities. Located in Rochester, N.Y., the University gives students exceptional opportunities for interdisciplinary study and close collaboration with faculty through its unique cluster-based curriculum. Its College, School of Arts and Sciences, and Hajim School of Engineering and Applied Sciences are complemented by its Eastman School of Music, Simon School of Business, Warner School of Education, Laboratory for Laser Energetics, School of Medicine and Dentistry, School of Nursing, Eastman Institute for Oral Health, and the Memorial Art Gallery.

CWRU study finds mending ruptures in client-therapist relationship during PTSD treatment has positive benefits

In order for prolonged exposure therapy, an evidence-based psychotherapy for PTSD, to reach its full potential, any misperceptions or ruptures in trust and communication between therapist and client need fixing, according to a new Case Western Reserve University study. The study, reported in the Journal of Consulting and Clinical Psychology online article, “Patterns of Therapeutic Alliance: Rupture-Repair Episodes in Prolonged Exposure for PTSD,” is among the first to examine how ruptures in the relationship between the therapist and client can damage a patient’s treatment outcome. An alliance rupture may occur when there is a break in the therapist-client bond. For example, ruptures in the therapeutic relationship may occur when therapeutic progress stalls, negative feelings arise between the therapist and client, or when the work in therapy becomes challenging PTSD - Clinical Practice Guideline for Management of Post Traumatic Stress “We want therapists to know that a rupture in the therapeutic relationship isn’t a bad thing, as long as the therapist tends to it,” said Stephanie Keller, one of the study’s researchers and a Case Western Reserve doctoral student in clinical psychology. “However, if the rupture is not repaired, then your patient may not do as well in treatment.” The research study included 116 people who experienced a traumatic event such as childhood sexual or physical abuse, physical assault, or combat exposure, and had a primary diagnosis of PTSD. Participants engaged in a 10-session treatment program called prolonged exposure (PE) therapy. To help therapists chart progress and examine the therapeutic relationship, each client assessed his or her own PTSD symptoms and perception of their relationship with the therapist during treatment. This helped researchers to identify those clients who experience no ruptures in the therapeutic relationship (a stable relationship), clients who experienced a rupture that was subsequently repaired, and those with ruptures that went unrepaired LCSW Continuing Education The first PE session outlined what would happen over the course of treatment to set specific goals. Exposure-based exercises began in the second session, which included exposure to anxiety-provoking situations that served as trauma-reminders and talking about their traumatic experiences. In this sample, 28 percent of patients experiences a repaired rupture and 18 percent experienced a rupture, or dip in the therapeutic relationship, that was never repaired. An unresolved rupture in the therapist-client relationship became a predictor for a poorer outcome in treatment, Keller said. She also said more research is needed to figure out why these alliance ruptures occur and how to best repair them. The research was funded through a National Institute of Mental Health PTSD research project, directed by Norah Feeny, Ph. D. from Case Western Reserve University and Lori A. Zoellner, Ph. D. from the University of Washington. Other researchers contributing to the project were lead investigator and Case Western Reserve alumna AnnaMaria Aguirre McLauglin, and Eric A. Youngstrom, of the University of North Carolina at Chapel Hill.

Interactive computer program helps patients talk with their physician about depression

(SACRAMENTO, Calif.) – Patients who used an interactive computer program about depression while waiting to see their primary-care doctor were nearly twice as likely to ask about the condition and significantly more likely to receive a recommendation for antidepressant drugs or a mental-health referral from their physician, according to a new study by researchers at UC Davis. The study, published online today in the Journal of the American Medical Association, was conducted to evaluate the effectiveness of a waiting-room intervention that encourages primary- care patients to discuss depression symptoms and care with their physician. While patients who received treatment or a referral for depression did not report improved mental health 12 weeks later, the study did show that providing information to patients about depression is an effective way to start the conversation in a primary-care setting about mental health. "We have developed an easy-to-use tool to help people with depression identify the symptoms, feel more comfortable discussing it with a primary-care provider and accept treatment if it is needed," said Anthony Jerant, professor of family and community medicine at UC Davis and senior author of the study. "This brief and relatively inexpensive intervention could be easily and widely implemented in a variety of health-care settings." Depression is an underrecognized and undertreated condition that can easily be overlooked during a typical primary-care visit. While calculating the number of people suffering from untreated depression is difficult, the Centers for Disease Control estimates that nationally 1-in-10 adults has reported symptoms of depression. The National Institute of Mental Health has said that major depressive disorders affect approximately 14.8 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year. When left untreated, depression poses high costs to society, jeopardizing relationships and employment, decreasing quality of life, prompting alcohol and drug abuse and, in some cases, leading to the higher risk of suicide Core Elements in Responding to Mental Health Crises CE Course Three waiting-room interventions tested The new study involved nearly 900 patients and 135 primary-care clinicians at seven Northern California health-care sites. Prior to their medical appointments, patients were screened for depression. All patients were then randomized to view one of three interventions: •A video – similar to a public-service announcement – focused on recognizing depression and talking with doctors about symptoms •An interactive multimedia computer program that provided patients with instant feedback and information tailored to different levels of depressive symptoms and treatment preferences •A non-depression-related video on healthy sleep The clinicians did not know which intervention their patients viewed. Immediately after the patients' appointments, the researchers determined if the patients discussed depression with their clinicians and whether they left with prescriptions for medications to treat depression and if they received a referral for mental-health services. Help for the most depressed The results showed that patients with baseline depression who either watched the informational video or used the computer program were nearly twice as likely as control subjects to request information about depression during their appointment. Those who used the interactive computer program were significantly more likely to receive a prescription or referral for depression (26 percent) than were those who viewed either the depression video (17.5 percent) or the video on sleep (16.3 percent). The computer program had the greatest impact on patients who were most depressed, according to the baseline screening. The investigators also studied the effects of the interventions on people who were not likely to be depressed according to the baseline screening. Among these patients, rates of prescribing and referral were low (about 5 percent) and did not differ by intervention group. According to Richard Kravitz, UC Davis professor of internal medicine and lead author of the study, it is important for public-health interventions to avoid inadvertently expanding unnecessary treatments that can do more harm than good and waste health-care resources. "We were concerned that the interventions could lead to treatment for depression for those who do not actually have it," said Kravitz. "Our interactive computer program, however, increased help for those who needed it the most without increasing treatment for those who didn't." According to Jerant, this study is the largest to compare "targeted" versus "tailored" interventions for stimulating people with depression to seek and accept treatment. Targeted interventions, such as the informational video used in the study, use terms and images most likely to resonate with the target audience, based on specific demographic factors. Four different versions were used in this study, targeted toward gender and income levels. The video took about three minutes to watch. Tailored interventions, such as the study's interactive computer program, integrate patient-specific answers to deliver information and guidance. The program used in the study, developed by the study investigators, prompted users to answer questions about symptoms of depression, informed users as to whether or not they were likely to be depressed, and provided guidance depending on the users' specific needs and interests. Patients assigned to the computer program spent about two to 15 minutes on it, with a median of five minutes. Kravitz speculated that the informational video did not work as well because, like a television commercial advertising a medication, it may require multiple repetitions to be effective. In contrast, the interactive computer program quickly provided a high level of personalization, which may account for its higher degree of effectiveness with a single use. The UC Davis investigators intend to further refine and study the interactive computer model to identify patients who need to receive more extensive treatment for their depression Professional Counselor Continuing Education ### Other UC Davis investigators on the study were Peter Franks, Daniel Tancredi, Christina Slee, Robert Bell, Debora Paterniti, Camille Cipri, Ana-Maria Iosif, Andrew Hudnut, Simon Dvorak and Charles Turner. Additional authors were Maga Jackson-Triche of the Northern California VA Health Care System, Steven Kelly-Reif of Kaiser Permanente Medical Group in Sacramento, Mitchell Feldman and Sarah Olson of UC San Francisco, and Ronald Epstein and Paul Duberstein of University of Rochester in New York. The study, titled "Patient Engagement Programs for Recognition and Initial Treatment of Depression in Primary Care," was supported by grants from the National Institute of Mental Health (1R01MH079387, K24MH072756 and K24MH02712).