A RESEARCH OF DEPRESSION IN GERIATIC PATIENT AND THE USE OF PHQ TOOLS TO IDENTIFY PATIENT WITH DEPRESSION TO INITIATE TREATMENT ON TIME

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A RESEARCH OF DEPRESSION IN GERIATIC PATIENT AND THE USE OF PHQ TOOLS TO IDENTIFY PATIENT WITH DEPRESSION TO INITIATE TREATMENT ON TIME

CHAPTER ONE

INTRODUCTION

Background of the study

The public health burden of affective illnesses is great. Depression is expected to be the second leading cause of disability adjusted life years (DALY’s) worldwide by 2020 (1), and in the United States its associated direct and indirect costs have been estimated at over $83 billion per year.

Depression in later life is common and disproportionately affects those with high medical burden and disability. Studies show that from 8% to 16% of community-dwelling older adults have clinically significant depressive symptoms, with higher rates among elderly women, the oldest old, and those with physical disability and cognitive impairment (3). In primary care, medical/surgical inpatient and long term care settings, up to a 35% of elderly patients have major, minor, or subsyndromal depression. Depression is associated with decreased quality of life (7), is a risk factor for suicide (8), and is independently associated with non-suicide mortality (9). Because subthreshold depression also results in many of the same untoward outcomes as major depression, it too is a target for prevention efforts.

Accurate and timely detection of major and subsyndromal depression is critical to reducing this burden, but depression among older adults is particularly challenging to identify and manage. Barriers to recognizing and effectively treating late life depression have been identified at the system (e.g., cost, continuity of care), provider (e.g., lack of training in geriatric care, competing demands on time), and patient levels (e.g., stigma, clinical complexity of resulting from comorbid conditions). Despite the US Preventive Services Task Force recommending routine depression screening in primary care, these barriers limit the number of older adults who are identified and adequately treated for affective illness. Thus, depression screening in other venues where high-risk populations exist is warranted. One setting that may offer a unique and important opportunity for elders at risk for affective illness and its sequelae is the Aging Services Network.

The Older Americans Act of 1965 established the ASN as a system now comprising 56 State Units on Aging, 629 Area Agencies on Aging, 246 Tribal organizations, and nearly 20,000 community services provider organizations. Its mission is to help older adults maintain their independence at home by providing a range of services from information and referral programs to comprehensive care management, both in the seniors’ homes and in community centers. The ASN serves over 7 million older adults and 300,000 caregivers each year, a high proportion of whom are at risk for depression due to social stressors, medical illness, and functional impairments. Studies that have examined the prevalence of mental disorders among ASN agency clients indicate that rates of clinically significant depression are high, but systematic efforts to detect and treat affective illness in community-based social service settings are rare. Broader dissemination of a depression screening tool well suited for use in the ASN would help address this disparity.

The effectiveness of a screening tool for depression requires that it be brief, easy to administer and interpret by a variety of providers in a variety of settings, and have good predictive properties. Several instruments have been developed to assist in the task. Perhaps the most widely disseminated in primary care settings is the Patient Heath Questionnaire, a valid and reliable screening tool for depressive syndromes among adults, including the elderly. Its nine questions correspond to the criteria set for major depression designated by the Diagnostic and Statistical Manual of Mental Disorders, allowing application of a DSM-IV-TR diagnostic algorithm for depressive disorders or a continuous measure of depressive symptom severity. The Patient Health Questionnaire-2, an abbreviated version of the PHQ-9, has also been found to have similar properties among older adults and among Veterans. While not establishing a diagnosis of affective disorder, the PHQ-2 and the PHQ-9 are accurate in identifying persons who may benefit from a clinical assessment to determine if the illness is present. The utility of these instruments has been assessed primarily in medical practice. The objective of this study was to examine their performance when administered to aging services care management clients, with the goal of providing guidance to social service agencies on what strategy for depression screening may be best suited to their particular service delivery system. Our specific aims were to examine the criterion validity (sensitivity, specificity, negative and positive predictive values and receiver operating curves) of the (a) PHQ-2, (b) the PHQ-9, and (c) the sequential administration of the PHQ-2 followed by the PHQ-9, in a sample of older community dwelling adults who received an in-home social work assessment for non-medical care management services.

Statement of the problem

There may have been previous researches in this subject. This work gives further explanations and analysis in awareness of professions in business education among secondary schools

Objectives of the study
To understand the impact of students awareness and their choice of profession in business education
To understand the relationship between students’ orientation levels and their choice of profession in business education

Research questions
What is the impact of students awareness and their choice of profession in business education
What is the relationship between students’ orientation levels and their choice of profession in business education