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25 July 2000

Trial Targets Depression, Alcohol Abuse in Elderly

UCSF is enrolling patients in a large, multi-centered clinical trial that will study methods of treating the common but often under-diagnosed problems of depression, anxiety and alcohol abuse among the elderly.

Generally, older Americans are treated for mental disorders in the primary care setting, where a physician treats the problem by prescribing an antidepressant, says Patricia Arean, PhD, UCSF assistant professor of psychiatry and study co-principal investigator. Health care providers treat such problems in the primary care setting because they believe it's hard to encourage older people to accept a referral to go somewhere else for mental health care services, she adds. Even if the patients agree to talk to someone outside the primary care setting, they often have to endure long waiting lists that make getting an appointment difficult. As a result, they may give up, Arean says.

"You can't just give someone a prescription. They need to be followed for a period of time, educated about their disorder and on how to manage it," she says. "Providers don't have the time to do that. So the question is 'do we make mental health services in primary care better or do a better job getting older people into specialty care?'"

Carroll Estes, PhD, UCSF professor in the Institute for Health & Aging, is the principal investigator of the five -year study that will examine two models of service delivery for older patients. The first will integrate mental health services into the medical practice, having a social worker and psychiatrist present in the clinic working side by side with the primary care physician. If a physician recognizes signs of depression in a patient, he or she would probably prescribe antidepressants and then have the patient see the in-house psychiatrist, who would manage mental health services for that patient.

The second model will have a social worker present in the primary care practice to help the patient find outside mental health services. "So rather than saying here is list of names of people, the social worker would ask them what services they need and help them find the services," Arean says.

The patients will be followed for a year, randomized to either arm. Outcomes investigators will look at whether the patients receive the mental health services they need and whether they improve.

"In terms of getting better, we will look at whether their mental illness goes away, does the quality of their life improve, do they feel like their health has improved and are they satisfied with the services," Arean says.

About 15 percent of elderly people experience depression at some point and the condition is more chronic in the elderly than in younger people, according to the National Institute of Mental Health. Abuse of alcohol and legal drugs - both prescribed and over the counter -- affects up to 17 percent of adults over 60 years old in the United States, according to the Center for Substance Abuse Treatment.

The American Medical Association called elderly alcoholics a "hidden group" and the National Institute of Mental Health called depression in the elderly widespread and a serious public health concern in recent reports. "Clinical depression is very disabling to older people and suicide rates are higher for older men than in any other age group," Arean says.

Older people who abuse alcohol often use it to cope with mental problems.

"There tends to be a downplaying of how much people drink, but we suspect rates of heavy drinking to be fairly high in older patients who use alcohol as a means to cope with depression and anxiety," Arean says. "When you drink to steady your nerves and you do it consistently, you create another problem."

UCSF is one of 12 centers participating in the study and will enroll 300 patients. The emphasis will be on elderly African-Americans, who may suffer from some of these disorders even more so than other groups, according to Arean. "If you look at recent data on younger people, it shows that rates of alcohol abuse and depression tend to be higher for African-Americans," she said. "The same may hold true for older African-Americans."

Patients enrolled in the study will be seen at the Over 60 Health Center in Berkeley, a public health medical clinic geared toward older people. Participants must be at least 65 years old.

For more information, call study coordinator Rowena Nery, MA, UCSF research associate in the department of psychiatry at 415/476-7439.

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