Mental+Health



**FACILITATORS: Sara Haberlein, Kaylan Stoner**
 * < **Contents** * Learner Objectives
 * Required Readings and Websites
 * Healthy People 2020 Objective
 * Related Epidemiological Data
 * Screening Guidelines and Assessment Parameters
 * Behavioral Intervention Recommendations
 * Discussion of Intervention Efficacy ||

**Introduction **
In this wiki seminar you will be introduced to various required and recommended readings and websites related to mental health promotion and prevention, specifically depression and suicide. Each will expand on the information already provided within the contents of the wiki. Please be sure to thoroughly read all the information provided so you are better able to participate in the discussion prompt provided at the end. Enjoy!

**Learner Objectives **

 * The learner will analyze how mental health and suicide impacts Healthy People 2020 goals.
 * The learner will identify physical and psychological risk factors associated with depression and suicide.
 * The learner will identify strategies a heath care provider can use to address depression and suicide risk factors.
 * The learner will identify the different family levels of care and appropriate interventions for each.
 * The learner will use appropriated USPSTF screening and immunization recommendations for people at risk due to mental health and suicide.

<span style="font-family: Verdana,Geneva,sans-serif;"> **<span style="color: #000099; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Required Readings and Websites **
<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">McDaniel, S. H., Campbell, T., Hepworth, J., & Lorenz, L. //Family oriented primary care (2nd ed).// New York, NY: Springer.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Chapter 1.** Basic premises of family-oriented primary care
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Chapter 20.** Mobilizing resources: The assessment and treatment of depression in primary care
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Chapter 25.** Working together: Collaboration and referral to family-oriented mental health professionals
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Website: Healthy People 2020
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Website: AMA Promoting Adolescent Health
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Website: USPSTF used to identify appropriate prevention interventions
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Vannoy, S. D., Fancher, T., Meltvedt, C., Unutzer, J., Duberstein, P., & Kravitz, R. L. (2010). Suicide inquiry in primary care: creating context, inquiring, and following up. [Randomized Controlled Trial Research Support, N.I.H., Extramural]. //Annals of Family Medicine, 8//(1), 33-39. [ARES]

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Friedman, R. A., & Leon, A. C. (2007). Expanding the black box - depression, antidepressants, and the risk of suicide. //New England Journal of Medicine, 356//(23), 2343-2346. [ARES]

==**<span style="color: #000099; font-family: Arial,Helvetica,sans-serif; font-size: 90%;"> <span style="color: #000099; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Recommended Readings and Websites **== <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Centers for Disease Control and Prevention <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">National Institute of Mental Health <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Helpguide.org <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The Living Memoir

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==<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">**<span style="color: #000099; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Healthy People 2020 Objective ** ==

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">There are many Healthy People 2020 objectives related to mental health. Two are identified as leading health indicators (LHI):


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">MHMD-1: Reduce the suicide rate
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">MHMD-4: Reduce the proportion of persons who experience major depressive episode (MDE)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">MHMD-4.1 Adolescents aged 12 to 17 years

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Another important objective is MHMD-11: Increase depression screening by primary care providers

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">There is a link below to take you to the complete list of objectives formulated regarding mental health.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">

==<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">**<span style="color: #000099; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Related Epidemiological Data ** == In the United States, 25% of adults are diagnosed with a mental illness, accounting for $300 billion in health care costs in 2005 (Center for Disease Control and Prevention [CDC], 2011). Two of the most well known topics within the mental health category are depression and suicide. According to the CDC (2011), "More than 1 out of 20 Americans 12 years of age and older reported current depression in 2005-2006" (para. 3); and "every 15 minutes, someone dies by suicide in this country" (para.1).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Map of Regional Rates (Depression & Suicide)**

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">From the map you can see the highest rates of depression are in the western and southern states.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Now let's compare this to the regional rates of suicide in the US.



<span style="color: #000000; font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The highest rates of suicide are in the western and northwestern states.

<span style="color: #000000; font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The overlap of high rates of both depression and suicide occur in the western states demostrating a link beween depression and suicide.

<span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Health disparity and influence of culture, gender, sexual orientation, developmental level, age, and access to care on depression and suicide**

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">According to the NIMH (2012), "women are 70% more likely than men to experience depression during their lifetime" (para. 1). As of 2008, women and adults age 50+ were most likely to use available treatment for their depression. (NIMH, 2012). Looking at the difference in lifetime percentages of depression between ethnicities "6.52% among whites and 4.57% among blacks and 5.17% among Hispanics" (CDC, 2011).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The population most affected by suicide is males. From 2002-2006, the highest rates of suicide (ages 10+) were in American Indian/ Alaskan Native males followed next by non-Hispanic whites, then non-Hispanic Black males, Hispanic males, Asian males, American Indian/Alakan females, non-Hispanic white females, Asian females, Hispanic females, and non-Hispanic Black females (CDC, 2011). Although more males die from suicide than females, females are more likely to attempt suicide. The difference is death rates comes from the fact that males tend to use more lethal methods in suicide attempts. (NIMH, 2012).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">From 1991 until 2003, the age with the highest suicide rates was those age 65 and older. As of recently, the rates in people age 25-64 has risen and surpassed the rate in people age 65+.

<span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Potential impact of depression and suicide on individuals and society.**

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Depression pays a large toll on individuals and families. Not only does depression alter a person's personal life (eating, sleeping, activity level), but it can alter the professional life of the individual, as well as increase their risk for suicidal behavior. Depression is treatable through lifestyle modifications, medications, and therapy.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">If depression is not effectively treated in an individual, it can descend into a chronic disease. According to the CDC, "in addition to being a chronic disease in its own right, the burden of depression is further increased as depression appears to be associated with behaviors linked to other chronic diseases" (2011, para. 6).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Suicide is 100% preventable. It can leave family and loved ones of the individual devestated and shocked. Below is an image explaining some of the various impacts that suicide has on a society.



<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Here is an interesting article to read specifically regarding a public health action plan to promote and prevent mental health in relation to chronic disease prevention. It is provided through the CDC and spans 2011 to 2015. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">

==<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">**<span style="color: #000099; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Screening Guidelines and Assessment Parameters ** ==

<span style="color: #000000; font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Screening guidelines and assessment parameters and methods.

<span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians


 * 1) <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 110%;"><span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Screen all adults (age 18 and older) for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and followup : Grade B; however, do not screen all adults (age 18 and older) for suicide: Grade I
 * 2) <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Screen all adolescents (age 12-18 years old) for major depressive disorder (MDD) in clinical practices that have systems in splace to assure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and followup: Grade B; however, do not screen all adolescents (age 12-18 years old) for suicide: Grade I
 * 3) <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Do not screen children (age 7-11 yeard old) because evidence is insufficient to determine the balance of benfits and harms of screening these individuals for major depressive disorder: Grade I; in addition, do not screen children (age 7-11 years old) for suicide: Grade I

<span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">All of the recommendations

<span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">__**Risk** **factors**__ **to assess are:** __<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Protective Factors** __<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**:**
 * 1) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;"> Depression (Smith, Saisan, & Segal, 2011)
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Lonliness
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Lack of social support
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Recent stressful life experiences
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Family history
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Marrital/relationship problems
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Financial strain
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Early childhood trauma or abuse
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Alcohol or drug abuse
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Unemploywment or underemployment
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Health prolems or chronic pain
 * 1) <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Suicide (CDC, 2011)
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Family history of suicide
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">History of child maltreatment
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Previous suicide attempts
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">History of mental disorder, particularly clinical depression
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">History of alcohol and substance abuse
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Feelings of hopelessness
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Impulsive or aggressive tendencies
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma)
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Local epidemics of suicide
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Isolation
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Barriers to accessing mental health treatment
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Loss (relational, social, work, or financial)
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Physical illness
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Easy access to lethal methods
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts
 * 1) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Depression
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">A sense of attachment and belonging
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Supportive social networks (friends and family)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Good relationships with at least one parent
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Sound psychological development
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Life skills such as conflict resolution, anger management and problem solving
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Parents modelling effective problem solving skills
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Family cohesion and harmony
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Good social skills
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Positive coping skills
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Opportunities for control
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Access to appropriate levels of income
 * 1) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Suicide (US Public Health Service, 1999)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Effective clinical care for mental, physical, and substance abuse disorders
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Easy access to a variety of clinical interventions and support for help seeking
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Family and community support (connectedness)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Support from ongoing medical and mental health care relationships
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Cultural and religious beliefs that discourage suicide and support instincts for self-preservation


 * <span style="color: #000000; font-family: Verdana,Geneva,sans-serif; font-size: 110%;">USPSTF Screening recommendations for adults (18+) **



<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Depression screening tools recommended by the USPSTF** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">To screen patients for depression use the PRIME-MD PHD (2 Question Screen): if patient responds "yes" to either question, this is considered a positive result. A full diagnosic interview must then be completed.

There are several treatment options available depending on the severity of the diagnosis. Psychotherapy and antidepressant medications are two of the most common treatments for depression.
<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Antidepressant medications used include (NIMH, 2012):**

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Selective serotonin reuptake inhibitors(SSRI) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Serotonin and norepinephrine reuptake inhibitors(SNRI) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Tricyclics <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Tetracyclics <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Monoamine Oxidase Inhibitors (MAOIs)

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">While it is suggested to collaborate with mental health specialists, Primary Care Practitioners are able to prescribe and manage "uncomplicated depression" (McDaniel, Campbell, Hepworth, and Lorenz, 2005). Please see pages 355-357 fin McDaniel et al. for more information on how to implement antidepressent medications in primary care.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The USPSTF (2009) makes the following recommendations for treatment based on the patient's age:

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">"In treating patients aged 18 to 29 years, clinicians may want to select a psychotherapeutic approach or medications other than SSRIs because of the increased risk for suicidal behavior associated with the use of SSRIs. Similarly, for adults 65 years or older, clinicians may want to select a psychotherapeutic approach or medications other than SSRIs because of the increased risk for UGI bleeding associated with the use of SSRIs. In addition, the concurrent use of SSRIs with a nonsteroidal anti-inflammatory drug (NSAID) or low-dose aspirin increases the risk for UGI bleeding in adults (aged 40 to 79 years), although the increase in risk is less with aspirin. The risk for UGI bleeding is greater for medications that feature a moderate to high degree of serotonin reuptake inhibition" (para. 11)


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%; line-height: 0px; overflow: hidden;">Suicide Screening **

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;"> If the individual has a history of depression or a positive result after screening for depression, suicide screening should be done. The following are questions that should be asked to assess for suicide risk. ( McDaniel, Campbell, Hepworth, and Lorenz, 2005, p. 360).
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Have you thought that life is not worth living or that you wished you were dead? (passive)
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Have you thought about hurting yourself?.... killing yourself? (active)
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Have you thought about the manner in which you might end your life? (plans)
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Do you possess what it would take (e.g. pills, firearms) to carry out your plan to end your life? (means)

==<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">**<span style="color: #000099; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Behavioral Intervention Recommendations ** == <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The following evidence based practice interventions are recommeded by the CDC for the screening and prevention of depression and suicide specifically related to the older adult population:


 * **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">//IMPACT// (Improving Mood-Promoting Access to Collaborative Treatment) ** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Originally based on a study conducted from 1998-2003 by Dr. Jürgen Unützer across the United States comparing specific interventions to identify and prevent depression with conventional and regularly practiced interventions provided by primary care physicians for depression in older adults. Since the success of the study, IMPACT has been adopted by many facilities and practicing physicians throughout the United States and abroad. It has also been shown to be productive in multiple ethnic groups and throughout a wide variety of socioeconomic populations. Currently there are studies being conducted to show the efficacy of the program in other patient populations such as adolescents, cancer patients, diabetic patients, and adults of all ages.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Suggests screening older adults using the PHQ-9 screening tool for depression.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">5 essential elements of IMPACT:
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Collaborative care is the cornerstone of the IMPACT model.** More specifically the primary care physician works with the care manager to develop a plan and implement treatment.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Depression care manager is involved.** May be a nurse, social worker or psychologist that works directly with the primary care physician. They specifically:
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Educate the patient about depression
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Support antidepressant therapy prescribed by the patient's primary care provider if appropriate
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Coach patients in behavioral activation and pleasant events scheduling
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Offer a brief (six-eight session) course of counseling, such as Problem-Solving Treatment in Primary Care
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Monitor depression symptoms for treatment response
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Complete a relapse prevention plan with each patient who has improved
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Designated psychiatrist is involved.** There role is to consult to the care manager and primary care physician for patients that need more involved treatment because they don't respond to the initial treatment provided.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Outcome measurement takes place.** The care managers regularly assesses depressive symptoms to determine progress from treatment.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Stepped care is provided:**
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Treatment adjusted based on clinical outcomes and according to an evidence-based algorithm
 * <span class="style1" style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Aim for a 50 percent reduction in symptoms within 10-12 weeks
 * <span class="style1" style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">If patient is not significantly improved at 10-12 weeks after the start of a treatment plan, change the plan. The change can be an increase in medication dosage, a change to a different medication, addition of psychotherapy, a combination of medication and psychotherapy, or other treatments suggested by the team psychiatrist.


 * **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">//PEARLS// (Program to Encourage Active Rewarding Lives for Seniors) ** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The PEARLS Program was developed at the University of Washington in the late 1990s by a team led by Dr. Ed Wagner. Over the past decade, two ramdomized controlled trials (RCTs) have demonstrated that the program is effective in reducing depressive symptoms and improving quality of life in older adults and adults of all ages with epilepsy. It has been used successfully in communities throughout the United States. PEARLS, specifically for older adults, was designed to treat minor depression and dysthymic disorder in adults over the age of 60. The RCT related to older adults, found that the program participants were three times as likely to experience a reducation in their depressive symptoms as those who were not treated with the PEARLS program. The people enrolled in the study were mainly housebound and had an average of five chronic medical conditions.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Suggests screening older adults using the PHQ-9 screening tool for depression.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Three unique features of the PEARLS program:
 * **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">In-home delivery method. **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Allows the care provider to overcome limitations to ambulation or transportation that are common in this patient population. Counselors can also ensure more regular contact with their clients than would often be possible in outpatient settings.
 * **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Designed to be part of an existing community-based program. **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">This increases the likelihood of providing safety net resources and comprehensive care to individuals that may have few resources available and otherwise might "fall through the cracks".
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**The program incorporates current approaches to chronic illness care.** Including:
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The Chronic Care Model: Advocates the use of educational materials, patient registries, tracking tools and system integration in order to empower individuals and ensure the most comprehensive care possible.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Collaborative Care: This includes developing a collaborative/shared definition of an individual's problems; targeting, goal-setting and planning a course of action; creating a continuun of self-management training and support; and ensuring active, sustained follow-up.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Three key components of PEARLS:
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Problem solving treatment.** Participants learn to recognize symptoms of depression, understand the link between unsolved problems and depression, and apply a highly effective 7‐step approach to solving their problems.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Social and physical activation.** Participants develop a plan to engage in activities that interest them, since involvement in social and physical activities improves quality of life and mood of people with depression.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Pleasant activity scheduling.** Very often, depressed individuals find it difficult to initiate activities that are enjoyable. PEARLS participants work with the PEARLS counselor to identify and participate in activities they find pleasurable, which helps them manage their depression.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The PEARLS depression intervention is typically conducted over six to eight sessions in a six-month period and consists of problem solving treatment (PST), behavioral activation, and pleasant activities scheduling.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Problem solving treatment:** Used to help the patient develop a sense of control over their lives. This allows the patient and counselor to clarify and define the problem, set realistic goals, generate multiple solutions, evaluate and compare solutions, select a feasible solution, implement the solution, and evaluate the outcome.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Behavioral activation:** This helps the patient to re-establish healthy routines, increase positive experiences, and overcome avoidance patterns. In the end, the patient will experience improved mood and better functioning.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Pleasant activities scheduling:** The counselor encourages the patient to choose activities they enjoy. This allows the patient to concentrate on pleasant activities rather than their depressive symptoms.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Before regular counseling sessions can begin, a process of recruiting and screening prospective clients for depressive disorders must first take place. During the course of the PEARLS treatment, the counselor must pay attention to different ways of conducting sessions depending whether it is a first, middle or last session.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Throughout the period during which sessions are conducted, there is ongoing clinical supervision on a weekly or biweekly basis. Medical and psychiatric supervision consists of:
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Each PEARLS case is reviewed regularly by a team that includes a psychiatrist.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The psychiatrist and the patient's primary care provider may need to begin medication treatmet for depression.


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**//Healthy IDEAS// (Identifying Depression, Empowering Activities for Seniors)**
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Healthy IDEAS was developed by Baylor College of Medicine's Huffington Center on Aging as part of the Model Progrmas Project sponsored by the National Council on Aging (NCOA) and funded by the John A. Hartford Foundation. The developement was further made possible by the U.S. Administration on Aging. It has been studied extensively and is recommended for replication based on the evidenced shown. The program has been designed for use with older adults (60+ years old) that live in the community and targets the underserved and chronically ill. It addresses commonly reconginzed barriers to mental health: detecting depression, helping clients understand depression as treatable helping them to gain knowledge and skills to self-manage it; and linking primary care, mental health care and social-service providers.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Healthy IDEAS is a 3 to 6 month program that takes place in the patient's home and utlizes telephone contact as well. The program requires at least three face-to-face contacts and three telephone contacts with the patient.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The program empowers the patients to manage their depression through a behavioral-activation (BA) approach that encourages involvement in meaningful, positive activities.
 * <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 110%; text-align: left;">**Behavioral-activation (BA):** Helps to promote the patient to overcome the inactivity associated with depression. The care provider uses knowledge of the patient's overall abilities and needs to mutually develop goals that the patient finds as positive and rewarding activities and that can improve the patient's mood. The care provider also helps to identify the steps it will take for the patient to successfully reach these goals.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Key elements of Healthy IDEAS:
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Screening:** for symptoms of depression and assessing their severity
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Educating:** older adults and caregivers about depression
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Linking:** older adults to primary care and mental health providers
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Empowering:** older adults to manage their depression through a behavioral activation approach that encourages involvement in meaningful activities

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">** Mass Media Interventions **

> SAMHSA's NREPP
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">World Suicide Prevention Day: September 10th annually
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">May is national mental health month
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">This link will take you to the SAMHSA'S National Registry of Evidence-based Programs and Practices (NREPP) website. From here you are able to conduct an advanced search to find specific programs related to mental health promotion.

==<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">**<span style="color: #000099; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Discussion of Intervention Efficacy ** ==

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Each of these programs (IMPACT, PEARLS, Healthy IDEAS) have been found to be successful through multiple studies. They each provide strong evidence for practice implications and can be found through the CDC as recommended preventions programs for older adults. Below is the link to the CDC article on the efficacy and further details of these programs.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The state of mental health and aging in America

**<span style="color: #000099; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">D2L Discussion Prompt **
<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">I am Leon, I am 68-yeard-old Latino, and was forced to leave my job and go on disability 5 months ago, soon after I was diagnosed with Parkinson disease. I worked for the same company my entire adult life. I am currently "under water" with my mortgage and at risk of losing my home to foreclosure.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">I have 2 grown children, both married and both nearby, and I lost my wife of 39 years to breast cancer 3 years earlier. My only pastime has been hunting; I now own 2 rifles after I was forced to sell 3 other guns to help pay my mortgage. I called you yesterday to ask for a prescription for antidepressants, I don't really need to be seen in the office. The office staff explains that I must be seen in the office before I can obtain a prescription.I made an appointment to meet with you today. I came to your office without shaving or showering, and I am telling you now that I really have no reason to continue living.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Discussion prompt:** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">In one paragraph summarize, <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">(a) Physical and psychological risk factors Leon exhibits. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">(b) Identify 2-3 strategies you as a health care provider can use to address Leon's risk factors, <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">(c) What routine screenings should be used with Leon? Review the family levels of care (e.g., minimal, information & collaboration, feeling & support, primary care family assessment & counseling, and medical family therapy) in McDaniel, et al. (2005) Chapter 1. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">(d) Select one of the family levels of care that you will use to guide your interventions with Leon in order to mobilize his 2 children in Leon's care <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">(e) Identify 2 corresponding interventions based on the level of care you selected.

=**<span style="color: #000080; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">References **=

<span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Care for Elders (2010). Healthy ideas: Addressing depression in older adults. Retrieved from <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">[]

<span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Centers for Disease Control and Prevention (2011). Retrieved from []

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Healthy People 2020 (2012). Improving the health of Americans. Retrieved from [|www.healthypeople.gov/2020]

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Impact (2011). Retrieved from []

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">McDaniel, S., Campbell, T., Hepworth, J., & Lorenz, A. (2005). //Family-oriented primary care// (2nd ed.). New York, NY: Springer.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Mental Health Foundation of Austrailia (2012). Protective factors. Retrieved from []

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">National Institute of Mental Health (2012). Transforming the understanding and treatment of mental illness through research. Retrieved from []

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Pearls (2011). Retrieved from []

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Smith, M., Saisan, J., Segal, J. (2011). Understanding depression: Signs, symptoms, causes, and help. Retrieved from [|www.helpguide.org]

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">United States Preventive Services Task Force (2009). Retrieved from []

<span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">U.S. Public Health Service (1999). The surgeon general’s call to action to prevent suicide. Washington (DC): US <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Department of Health and Human Services. Retrieved from __[]__

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