Prevalence and Treatment of Diagnosed Depression amongElderly Nursing Home Residents in Ohio

Carrie A. Levin, PhD, Wenhui Wei, PhD, Ayse Akincigil, PhD, Judith A. Lucas, EdD, ScottBilder, MS, and Stephen Crystal, PhDFoundation for Informed Medical Decision Making, Boston, MA (C.A.L.); Institute for Health, HealthPolicy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, NJ(W.W., A.A., J.A.L., S.B., S.C.)

AbstractObjectives—To examine the prevalence and treatment of diagnosed depression among elderlynursing home residents and determine the resident and facility characteristics associated withdiagnosis and treatment.

Design, Setting, and Participants—Documented depression, pharmacotherapy,psychotherapy, sociodemographics, and medical characteristics were obtained from Ohio'sMinimum Data Set for 76 735 residents in 921 nursing homes. The data were merged with OnlineSurvey Certification and Reporting System data to study the impact of facility characteristics. Chi-squared statistics were used to test group differences in depression diagnosis and treatment. Multiplelogistic regressions were used to examine the prevalence of diagnosed depression, and among thosediagnosed, of receiving any treatment.

Results—There were 48% of residents who had an active depression diagnosis; among thosediagnosed, 23% received no treatment; 74% received antidepressants; 0.5% received psychotherapy;and 2% received both. African Americans, the severely cognitively impaired, and those ingovernment facilities were less likely to be diagnosed. Residents aged 85 and older, AfricanAmericans, individuals with severe mental illness, those with severe ADL or cognitive impairment,and individuals living in a facility with 4 or more deficiencies were less likely to receive treatment.

Conclusion—Significant disparities exist both in diagnosis and treatment of depression amongelderly residents. Disadvantaged groups such as African Americans and residents with physical andcognitive impairments are less likely to be diagnosed and treated. Our results indicate that work needsto be done in the nursing home environment to improve the quality of depression care for all residents.

KeywordsNursing homes; antidepressant; psychotherapy

Depression is the most burdensome and prevalent mental illness among nursing home (NH)residents.1–3 If untreated, inadequately treated, or unresponsive to treatment, depression canlead to a cascade of other adverse health outcomes such as malnutrition, poor hydration,weakening from physical inactivity, functional decline, decreased quality of life, andultimately, death.1–6 Among NH residents, prior studies have reported estimates of theprevalence rate for depression (variously defined to include major depressive disorder, otherdepression diagnoses and/or depressive symptoms) to range from 11% to 78%.7–13 Rates in

Address correspondence to Carrie A. Levin, PhD, Foundation for Informed Medical Decision Making, 40 Court Street, Suite 300, Boston,MA 02108. E-mail: clevin@fimdm.org.

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Published in final edited form as:J Am Med Dir Assoc. 2007 November ; 8(9): 585–594. doi:10.1016/j.jamda.2007.07.010.

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these NH studies were substantially higher than rates for community-dwelling elderlyindividuals.1,14–16 Despite this consistent evidence of high rates of underlying depressivesymptomatology, we lack sufficient understanding of the extent to which depression amongresidents is identified by facilities, the predictors of facility-identified depression, and theextent to which treatment is provided for identified depression. Generally, in prior studies,depression among NH residents has been reported to be substantially underdiagnosed8,11,15

and undertreated8,17–20 or inadequately treated.8,20–22 However, as there is rapid evolution ofdepression identification and treatment patterns among the community-dwelling near-elderlyand elderly,23,24 as well as disparities in such care, depression care in nursing homes may bea moving target. To inform efforts at quality improvement, it is important to examine recentpatterns of depression identification and treatment in routine care across the full spectrum ofnursing homes.

Improving care for depression among NH residents has been a widely acknowledged goaldating back to the 1987 Omnibus Budget Reconciliation Act (OBRA) nursing home reforms.25 In reviewing priorities for quality of care, improvement for vulnerable adults such as thosein nursing homes, an expert panel ranked improvement of depression care second only to theoverall issue of improved pharmacologic management among 78 conditions and problemsconsidered.26 Similar recommendations were highlighted in the first National HealthcareQuality Report, released by AHRQ in 200327 and in the 2003 American Geriatrics Society/American Association for Geriatric Psychiatry Consensus Statement on Improving the Qualityof Mental Health Care in US Nursing Homes.3 Yet many issues remain unresolved regardingadequacy of depression-related care in NHs such as unequal access to specialty care, length ofpersistent use of antidepressants and proper dosing of antidepressants,21,28 and information onmany topics is outdated.

Antidepressants have been shown to be safe and efficacious in the treatment of geriatricdepression1,3,9,29 and have been widely used in the nursing home population.3,21,29–36

Psychotherapy constitutes an alternative modality, particularly when antidepressant treatmentis not acceptable to residents or their families, a situation that may be more frequent for AfricanAmerican elders.37

One critical issue in the care of NH residents with depression is the role of mental healthspecialists such as psychiatrists or psychologists. Psychiatric evaluation can be important indifferential diagnosis and optimizing use of psychotropic treatment, including adjustment ofregimens and dosages for initially unresponsive residents, and decisions on need for psychiatrichospitalization. In their 2003 consensus statement, the American Geriatrics Society andAmerican Association for Geriatric Psychiatry recommended that residents who havedepression with psychotic features who have not responded to 6 or more weeks of treatmentbe referred to mental health professionals.3

Surprisingly little information is available about the extent and predictors of mental healthservices use for depressed NH residents; disparities in such care; and variations across facilities.18,19 Greater prevalence of identified depression among nursing home residents has beenshown to be associated with younger age, being female, having ever been married, white non-Hispanic ethnicity, higher cognitive function, heart disease, and Parkinson's disease,7 usingdata from the 1996 Medical Expenditure Panel Survey-Nursing Home Component.

Although dated, the few prior studies on this topic indicate low overall rates of specialty careuse; sharp disparities by race/ethnicity, age, and other socioeconomic factors; and very limitedaccess to care in rural areas.18,24,38 Residents 85 and older, those with severe cognitiveimpairment, and black residents were less likely to receive antidepressants once depressionhas been identified.8 Residents who receive care from mental health specialists tend to be

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younger; live in the Northeast; and have schizophrenia, dementia, or other mental disorder.17 Other results report that residents with depression, schizophrenia, or psychosis are morelikely to receive specialist mental health services, while those with more ADL (activities ofdaily living) limitations, and older residents, as well as those residing in government NHs, orhomes run by chains, are less likely to receive specialist mental health services.18,19

While geriatric depression has traditionally been considered much underdiagnosed, Crystaland colleagues recently reported that the depression diagnosis rate more than doubled amongcommunity-dwelling elderly individuals between 1992 and 1998, increasing by 107%,23 withconcomitant increases in antidepressant use. Rapidly evolving patterns of depressionidentification and treatment in the NH setting create a critical need for more current analyses.In this study, we used a merged Minimum Data Set (MDS) and online Survey Certificationand Reporting (OSCAR) data set to assess the prevalence of diagnosed depression amongelderly nursing home residents, and subsequently, to examine the rate of treatments(pharmacotherapy and psychotherapy) they received. Additionally, we examined whetherdisparities in diagnosis and treatment exist and described how both resident-and facility-levelcharacteristics are associated with such differences.

Design And MethodsData

In this study, the 2000 Ohio Long-term Care MDS was used as the source of NH residentinformation. These data were merged with the OSCAR data to obtain nursing home facilitycharacteristics. The research protocol was approved by Rutgers, the State University of NewJersey's Institutional Review Board. The MDS is a nationally standardized 350-item summaryscreening and assessment tool designed to collect data on nursing home residents includingtheir physical, psychological, and psychosocial functioning, active clinical diagnoses, healthconditions, treatments and services received, demographics, payer source, and advancedirectives.39 All Medicare- and Medicaid-certified nursing facilities are required to use theMDS to assess each resident, first upon admission and then on a quarterly and annual basisand when there is “significant change” in the resident's health status and needs.40 OSCAR isa uniform computerized database maintained by the Centers for Medicaid and MedicareServices (CMS) containing information on all Medicare/Medicaid-certified NHs includingfacility characteristics and staffing data; aggregated resident characteristics; and surveydeficiencies. The information in OSCAR is collected by state licensure and certificationagencies as part of the yearly Medicare/Medicaid certification process.

In the current study, the sample includes all residents 65 or older who had been in an Ohio NHfor at least 3 months in 2000, but excluded those who were comatose or those living in ahospital-based NH, as research has suggested that hospital-based nursing homes might have adifferent case-mix than freestanding ones.41–43 When there was more than one assessment foreach resident within the year, we chose the assessment closest to the end of the year. Facilitycharacteristics were drawn from the OSCAR data closest to the MDS assessment date. Thefinal sample included 76 735 residents in 921 nursing homes.

MeasuresDepression Diagnosis and Treatment—A resident was considered to have diagnoseddepression on an MDS assessment (Section Iee. Disease Diagnoses: Depression) if there wasan “active” physician-documented depression diagnosis in the resident's clinical record usinga 7-day look-back period. An “active” diagnosis is defined as having “a relationship to currentADL status, cognitive status, mood and behavior status, medical treatments, nursingmonitoring, or risk of death.”40

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Our analysis showed that among residents without a depression diagnosis, 15% receivedantidepressant therapy and 1.3% received psychotherapy (data not shown). Some of theseindividuals may have unrecorded depression, but these treatments are also widely used forconditions or symptoms other than depression. Because the objective of the current study wasto examine the pattern of treatment among depressed residents, we focused on the treatment(antidepressant and/or psychotherapy) received by residents with diagnosed depression.Depression treatment was defined dichotomously as any antidepressant, psychosocial therapy,or group therapy received by the resident during the 7 days prior to the assessment. Our analysisshowed that among those who received depression treatment, less than 1% had psychotherapyas the sole mode of treatment. Given that such a small portion of the depressed elderly residentsreceived psychotherapy as their sole treatment, we determined that it is more meaningful tocombine antidepressant therapy and psychotherapy together to examine any treatment as ouroutcome of interest, rather than to conduct separate analyses of antidepressant therapy andpsychotherapy. Because of the low proportion of residents receiving psychotherapy only, ourfindings on predictors of treatment are dominated by variations in antidepressant use.

Resident Characteristics—Sociodemographic characteristics included resident's gender,age (categorized as 65 to 74, 75 to 84, and 85 or older to allow for nonlinear age effects), race/ethnicity (white, African American, and other), education level (less than high school, highschool graduate, and college graduate or above), and marital status at assessment (nevermarried, married, widowed, and separated/divorced).

Physical and mental comorbidities were extracted from the Disease Diagnoses section of theMDS. Individual physical comorbidities were summed to create a summary measure of burdenof physical comorbidity, which included arthritis, diabetes, hypertension, cancer, stroke,congestive heart failure, and chronic obstructive pulmonary disease (COPD). The number ofconditions was categorized into none, 1–2, 3–4, and 4+. Comorbid severe mental illness (SMI)was defined as having an active diagnosis of schizophrenia or bipolar disorder. Physicalfunction was measured using the hierarchical activities of daily living (ADL) scale developedand validated by Morris et al44 using 7 MDS ADL self-performance variables. Chroniccognitive impairment was constructed using the Cognitive Performance Scale, which assignsresidents into cognitive performance categories (from intact to severely impaired).

Facility Characteristics (from OSCAR)—Nursing home size was measured by numberof beds (categorized as less than 50, 50–99, 100–199, and 200+), occupancy rate (percentageof beds occupied on the day of the survey), and NH location (rural or urban). Ownership typewas classified into government, for profit, or not for profit, and Medicaid ratios represent theproportion of residents whose care was paid for by Medicaid. We also distinguished NHs thathad a multifacility chain affiliation from freestanding facilities. Another dichotomous controlvariable was provision of onsite mental health services. Staffing was measured as total nursinghours (RNs, LPNs, and NAs) per resident per day. Aggregate facility acuity level was measuredwith an acuity index that is a sum of an ADL index (proportion of residents dependent in eating,toileting, transferring, ambulation) and a special treatments index (proportion of residentsrequiring respiratory care, suctioning, IV therapy, tracheostomy care, or parenteral feeding).45–47 Since occupancy rates, total nursing hours, Medicaid ratios and the acuity index werenot distributed uniformly across their range, we categorized the rates into quartiles. Data onfacility deficiencies represent the number of deficiencies recorded in OSCAR across the 17major areas used in the survey process,48 categorized into 0–2, 3–4, and greater than 4deficiencies, to allow for nonlinear effects.

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AnalysesBivariate group differences in rates of outcomes (diagnosis of depression and any treatmentamong those diagnosed with depression) were tested across resident and facility characteristicsusing chi-square analyses. Robust multiple logistic regressions were then performed todetermine the adjusted effects of the covariates on a resident's probability of receiving adepression diagnosis, and if depressed, on the probability of receiving any treatment(antidepressant only, psychotherapy only, or both antidepressant therapy and psychotherapy).Both the bivariate analysis and logistic regressions adjusted for clustering of residents withinfacilities and were done using SAS-callable SUDAAN V8.0.49

ResultsThe characteristics of Ohio elderly nursing home residents in 2000 are presented in the first 2columns of Table 1. Most were female (75%), white (89%), and widowed (64%). Physicalcomorbidity was prevalent, with 90% having at least 1 chronic physical illness. Over 75% weredependent in ADL activities, and 81% had at least some cognitive impairment. The modelresident lived in a for-profit (74%) facility in an urban area (78%) with 100 to 199 (62%)residents.

Diagnosis of DepressionTable 1 shows the prevalence of diagnosed depression among residents by sociodemographiccharacteristics as well as the characteristics of the facility in which they lived. Forty-eightpercent of the elderly residents (N = 36 888) were documented as having a depression diagnosis.Bivariate analyses showed that rates of depression diagnosis varied significantly by most ofthe resident characteristics including gender, age, race/ethnicity, education, marital status,presence of physical comorbid conditions, ADL status, and cognitive impairment status.However, only 2 facility characteristics (percentage of residents in the facility with Medicaidas the primary payer, and number of facility deficiencies) showed significant differences in thebivariate analyses. Results from the multiple logistic regression on diagnosis of depressionconfirmed the results from the bivariate analysis. When controlling for other factors, beingfemale, having higher education achievement, and ever being married were associated withsignificantly higher likelihood of being diagnosed with depression. African Americans wereabout half as likely as whites to have a depression diagnosis (OR = 0.52, 95% CI = [0.48,0.57]). Older age was also associated with lower likelihood of having a depression diagnosis(aged 75–84: OR = 0.91, 95% CI = [0.87, 0.95]; aged 85 and older: OR = 0.66, 95% CI = [0.63,0.70]). While physical comorbidity was associated with higher odds of being diagnosed withdepression, comorbid SMI did not have a significant impact. Compared to elderly residentsindependent in ADLs, those who were dependent, but not totally dependent, were more likelyto be diagnosed with depression (OR = 1.32, 95% CI = [1.21,1.44]). The impact of cognitiveimpairment on the odds of receiving a depression diagnosis was not monotonic, with odds ofdiagnosis highest among those with some impairment, lowest among those with severeimpairment, and intermediate among those with no impairment.

Similar to the results from the bivariate analyses, few facility characteristics had impact on theresident's likelihood of being diagnosed with depression. Residents in facilities with the highestquartile of total nursing hours per resident per day were more likely to have a depressiondiagnosis than those in the lowest quartile (OR = 1.09, 95% CI = [1.01, 1.18]). Residents livingin government-owned facilities were significantly less likely to be diagnosed with depressionthan those in for-profit facilities (OR = 0.88, 95% CI = [0.78, 0.99]). Residents in facilitieswith a high number of deficiencies (8+) were less likely to be diagnosed with depression thanthose in facilities with a very low number of deficiencies (0–2) (OR=0.92, 95% CI = [0.86,0.99]).

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Treatment of DepressionTable 2 presents results on the rates of any depression treatment (antidepressant and/orpsychotherapy or group therapy) received by elderly residents diagnosed with depression. Ingeneral, 77% received either an antidepressant or psychotherapy within the 7 days prior to theassessment. The bivariate analyses of any treatment showed that significant subgroupdifferences exist for all of the resident variables. Older age, minority race/ethnicity, comorbidSMI, total ADL dependence, and severe cognitive impairment were associated withsignificantly lower rates of depression treatment, while higher educational achievement, everbeing married, and physical comorbidities were associated with significantly higher treatmentrates. Similar to the findings on the depression diagnosis, few facility characteristics, exceptfor percentage of residents with Medicaid as primary payer and number of deficiencies, hadsignificant impact on treatment rates.

Multiple logistic regression results on any use were consistent with these findings. Whencontrolling for other factors, compared to their counterparts, older residents (aged 75–84: OR= 0.90, 95% CI = [0.82, 0.97]; aged 85 and oldr: OR = 0.71, 95%CI = [0.65, 0.77]), AfricanAmericans (OR = 0.80, 95% CI = [0.72, 0.89]), residents with SMI (OR = 0.75, 95% CI =[0.68, 0.93]), residents with total ADL dependence (OR = 0.50, 95% CI = [0.42, 0.60]), andresidents with severe cognitive impairment (OR = 0.60, 95% CI = [0.54, 0.66]) weresignificantly less likely to receive depression treatment, while residents with higher education(high school: OR = 1.07, 95% CI = [1.01, 1.14]; college and above: OR = 1.12, 95% CI = [1.03,1.22]), married or widowed residents (OR = 1.22, 95% CI = [1.09, 1.36], and OR = 1.16, 95%CI = [1.05, 1.29]), and more comorbid physical conditions were associated with significantlyhigher odds of receiving any treatment. The only facility characteristic that was significant inthe regression was the number of deficiencies. Compared with residents living in facilities with0 to 2 deficiencies, those living in facilities with 5 or more deficiencies were significantly lesslikely to be treated.

DiscussionIn this paper, we described patterns of identification of depression (diagnosis) and its treatmentamong long-stay nursing home residents aged 65 and older. We also determined characteristicsof residents and facilities that predict whether a resident received a depression diagnosis andsubsequent treatment.

Our results indicate that the oldest-old are approximately a third less likely than those age 65to 75 to be diagnosed; those with very severe cognitive impairment are a third less likely to bediagnosed than cognitively intact residents; and African Americans are half as likely as whitesto be diagnosed with depression. It is beyond the scope of this paper to determine the relativecontribution to these differences of differential underdiagnosis (or overdiagnosis), versusactual variations in rates of depression. Results also indicate that residents in facilities withmore than 4 deficiencies were less likely to be diagnosed with depression.

There are also significant disparities in the likelihood of treatment for identified depression,with those who are cognitively impaired, non-white, and those with more ADL dependencybeing less likely to receive treatment among persons diagnosed with depression. There is apressing need to better understand why those who are more physically and psychologicallydependent are less likely to receive treatment, and to address these disparities. What, forexample, are the roles of resident and family preferences; residents' physicians; nursing staff;consultant pharmacists; and other actors in decisions on treatment? What are the mostappropriate measures of depression care quality for use as benchmarks for qualityimprovement? Does depression manifest itself in different ways among African American

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residents, and what other factors are involved in the lower rates of identified depression and,once identified, of depression treatment among these residents?

Much more research is needed on the identification and treatment of depression among nursinghome residents. Ideally, such research would use data that combine independent, structuredresearcher assessments of underlying depression symptoms with detailed information onfacility recognition and treatment; however, few such data are available on large, recent,generalizable populations of facilities. Existing data such as the MDS provide important clues,but are subject to significant limitations. One limitation of using the MDS as a data source isthat treatments (antidepressant and/or psychotherapy) received by the resident were examinedonly during the seven days prior to the assessment, and no detailed pharmaceutical data werereported, such as medication name and dosage. Among NH residents generally, both for thosediagnosed with depression and those who are not, psychotherapy was received ratherinfrequently. A possible explanation may be that antidepressant therapy is cheaper and easierto administer than psychotherapy. The low frequency of psychotherapy is not unexpected inthis population because many nursing homes do not directly employ or contract withpsychiatrists or other mental health professionals. Also, as psychotherapy was not likely to beprovided on a daily basis, the 7-day look-back period using MDS data limited our ability toidentify psychotherapy users.

Additionally, more information about the types of treatment that residents receive wouldimprove the study. The antidepressants as a class are recorded on the MDS, but we did nothave access to particular drug names and also did not know much about the type of or reasonsfor pharmacotherapy offered (whether it was to treat depression; whether a resident receivesan antidepressant because of sleep problems; whether a resident is prescribed a stimulant fordepressive symptoms; whether the resident is on hospice; whether a resident has been offeredtherapies other than antidepressants; and whether a resident has a strong social network). Weare able to identify the total number of medications that a resident is taking, but do not knowthe type of concomitant medications.

Depression is often underrecognized or undertreated because it occurs in the context of otherphysical and social problems9,29 especially when age is often accompanied by social isolation,withdrawal, prolonged bereavement, and economic problems.51 It is well established thatpsychiatric disorders such as depression tend to co-occur with chronic general medicalillnesses. Functional impairment and comorbidity, both physical and mental, are likely to havean effect on treatment and diagnosis of depression, although through opposing mechanisms.On the one hand, it is likely that patients with many comorbidities may have stronger ties tothe health care system and may be more likely to view psychological distress as a medicalproblem. They may be more likely to receive a depression diagnosis because of their morefrequent interaction with health care professionals. Conversely, depression may beundertreated because providers may be concerned about the side effects or interaction of theantidepressants with one or more other pharmacological treatments the patient is receiving forhis or her comorbid conditions.23

Another limitation of our study is the lack of specificity in the diagnosis and treatment ofdepression as indicated on the MDS. Our results indicate the prevalence of depression amongNH residents as documented in the MDS as 48%, which is fairly high, compared to a studythat found fewer than 20% of residents to have major depression (as measured through directresident interview via the Geriatric Depression Scale) or symptoms of depression.11 Ourrelatively high prevalence rate may be due to the way in which depression is measured in theMDS as our study relies on a documented depression diagnosis in the MDS assessment, butproviders may enter a diagnosis of depression on a resident's chart for a range of depressivedisorders from mild depression that may accompany other comorbid conditions afflicting

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elderly nursing home residents to more serious cases of major depression. More detail on thetype and severity of the depression as well as the type of pharmacotherapy offered would beuseful, but since the MDS is our sole data source for resident variables and we did not haveaccess to MDS Section U (specific medication name and dose), our specification of bothdiagnosis and treatment is limited to that information that is captured in routine MDSassessments.

With systemwide automated reporting of MDS data now in place, new opportunities exist touse these data to address important research needs as well as for regulation and qualityimprovement of nursing facilities. The Center for Health Systems Research and Analysis(CHSRA) originally developed quality indicators for use by individual facilities for qualityimprovement efforts including 2 depression measures: the prevalence of symptoms ofdepression and the prevalence of depression without antidepressant therapy. These indicatorsare used in connection with the survey process and for internal quality improvement.Prevalence of symptoms of depression and prevalence of depression with no antidepressanttherapy have been used as 1 of 24 MDS quality indicators that individual facilities can havebeen using for quality improvement efforts since the late 1990s50; however, depressionmeasures were not included among the original publicly reported quality measures for nursinghome residents on the Centers for Medicare and Medicaid (CMS) Web page: Nursing HomeCompare (www.cms.gov). Following the National Quality Forum recommendations in 2003,percent of residents who have become more depressed or anxious was added to Nursing HomeCompare beginning in January 2004. The data used in this study are from 2000–2001 OhioMDS data when MDS data were newly automated and depression was not yet publicly reportedon the CMS Nursing Home Compare web site. Future research should address longitudinalchanges in documentation of depression throughout this period to assess whether changes inpublic reporting has an impact on the reliability and validity of the documentation of depressiondiagnoses and symptoms on individual resident MDS assessments.

Our finding that elderly depressed residents with some cognitive impairment were as likely toreceive psychotherapy as those with intact cognitive ability was consistent with findings fromAbraham et al,51 who reported that residents with mild to moderate cognitive impairment werelikely to benefit from psychotherapy. Nevertheless, further analyses linking the MDS toMedicaid or Medicare claims would certainly allow for more detailed exploration ofinitialization and persistence in pharmacotherapy and psychotherapy among nursing homeresidents.

The cross-sectional design is another limitation of this study. Data used in this analysis are asnapshot of long-stay residents and do not support analysis of longitudinal results. We do notknow whether a resident's depression is chronic, or if his or her depression diagnosis representsa new episode. Our analyses were limited to long-stay residents who had been in the facilityfor at least 3 months; short-stay residents were excluded. We made no attempt to compareresults between residents who were long versus short-stay. These are topics for future research.Finally, our results represent nursing home residents in only one state and therefore may notbe generalizable to the whole nation.

ConclusionDespite these limitations, our findings tend to dispel the longstanding belief that depression issubstantially underdiagnosed and undertreated among NH residents. Our findings indicate avery substantial rate both of depression identification and of antidepressant treatment fordepression among NH residents, perhaps as a result of general increases in awareness ofdepression among the elderly, and of the positive potential of available treatments. However,many questions are left unanswered. Do lower treatment rates for cognitively impaired

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individuals signify appropriate treatment, or that this subpopulation of NH residents is beingundertreated? Is depression care quality related to other measures of quality, as suggested bythe association between number of deficiencies and lower treatment rates? And with relativelyhigh rates of depression, treatment now common in nursing home settings, how successful arethese treatments in improving outcomes for residents? Further work needs to be done to assessthe quality of depression care in nursing homes to determine the optimal treatment for all NHresidents.

AcknowledgmentsFunded by National Institute of Mental Health Grant 1-RO1 MH076206 and AHRQ Grant R24-HS011825.

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27. National Healthcare Quality Report. Agency for Healthcare Research and Quality. Rockville, MD:2003 [September 15, 2007]. Available at: http://www.ahrq.gov/qual/nhqr03/nhqr03.htm

28. Streim JE, Oslin D, Katz IR, Parmelee PA. Lessons from geriatric psychiatry in the long-term caresetting. Psychiatr Q 1997;68(3):281–307. [PubMed: 9237321]

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32. Friedrich MJ. Recognizing and treating depression in the elderly. JAMA 1999;282(13):1215.[PubMed: 10517408]

33. Katona C. Managing depression and anxiety in the elderly patient. Eur Neuropsychopharmacol2000;10 4:S427–432. [PubMed: 11114487]

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35. Koenig HG. Late-life depression: How to treat patients with comorbid chronic illness. Interview byAlice V. Luddington. Geriatrics 1999;54(5):56–61. quiz 62. [PubMed: 10365186]

36. Menting JE, Honig A, Verhey FR, et al. Selective serotonin reuptake inhibitors (SSRIs) in thetreatment of elderly depressed patients: A qualitative analysis of the literature on their efficacy andside-effects. Int Clin Psychopharmacol 1996;11(3):165–175. [PubMed: 8923095]

37. Cooper LA, Gonzales JJ, Gallo JJ, et al. The acceptability of treatment for depression among African-American, Hispanic, and white primary care patients. Med Care 2003;41(4):479–489. [PubMed:12665712]

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40. Centers for Medicare and Medicaid Services (CMS). RAI: Minimum Data Set (MDS). Version 2.0Manual. 2004 [September 15, 2007]. Available at:http://www.cms.hhs.gov/NursingHomeQualityInits/20_NHQIMDS20.asp

41. Burns, BJ.; Taube, CA. Mental health services in general medical care in nursing homes. In: Fogel,B.; Furino, A.; Gottieb, G., editors. Mental Health Policy for Older Americans: Protecting Minds atRisk. Washington, DC: American Psychiatric Press; 1984. p. 63-84.

42. Harrington C, Carrillo H, Mullan J, Swan JH. Nursing facility staffing in the states: The 1991 to 1995period. Med Care Res Rev 1998;55(3):334–363. [PubMed: 9727302]

43. Singh DA, Schwab RC. Retention of administrators in nursing homes: What can management do?Gerontologist 1998;38(3):362–369. [PubMed: 9640856]

44. Morris JN, Fries BE, Mehr DR, et al. MDS Cognitive Performance Scale. J Gerontol 1994;49(4):M174–182. [PubMed: 8014392]

45. Cowles, CME. 2002 Nursing Home Statistical Yearbook. Montgomery Village, MD: CowlesResearch Group; 2003.

46. Fries BE, Schneider DP, Foley WJ, Gavazzi M, Burke R, Cornelius E. Refining a case-mix measurefor nursing homes: Resource Utilization Groups (RUG-III). Med Care 1994;32(7):668–685.[PubMed: 8028403]

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48. Harrington, C.; Carrillo, H.; Wellin, V. Nursing Facilities, Staffing, Residents, and FacilityDeficiencies, 1994 through 2000. San Francisco: Department of Social and Behavioral Science,University of California; 2001.

49. Research Triangle Institute. Sudaan User's Manual. 8.0. Research Triangle Park, NC: ResearchTriangle Institute; 2001.

50. Zimmerman DR, Karon SL, Arling G, et al. Development and testing of nursing home qualityindicators. Health Care Financ Rev 1995;16:107–127. [PubMed: 10151883]

51. Abraham IL, Neundorfer MM, Currie LJ. Effects of group interventions on cognition and depressionin nursing home residents. Nurs Res 1992;41(4):196–202. [PubMed: 1383947]

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Tabl

e 1

Prev

alen

ce o

f Dep

ress

ion

amon

g O

hio

Nur

sing

Hom

e R

esid

ents

The

Sam

ple

Dia

gnos

ed w

ith D

epre

ssio

nL

ogis

tic R

egre

ssio

n on

Dia

gnos

is o

f Dep

ress

ion

Tot

al N

Col

%N

Row

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% C

I

Tota

l76

735

100.

036

888

48.1

——

Res

iden

t Cha

ract

eris

tics

Gen

der*

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ale

19 1

0824

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7444

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—

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mal

e57

627

75.1

2831

449

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25†

[1.2

0,1.

30]

Age

*—

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ge 6

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10 7

1114

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9351

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—

 A

ge 7

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28 5

1137

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570

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]

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ge 8

5 an

d ov

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513

48.9

16 8

2544

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66†

[0.6

3,0.

70]

Rac

e/Et

hnic

ity*

 W

hite

68 0

3588

.733

771

49.6

——

 A

fric

an A

mer

ican

8117

10.6

2859

35.2

0.52

†[0

.48,

0.5

7]

 O

ther

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724

644

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83‡

[0.7

0, 0

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Educ

atio

n Le

vel*

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ss th

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12 6

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igh

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9123

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48.4

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1.16

]

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5372

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.06,

1.24

]

Mar

ital s

tatu

s at a

sses

smen

t *

 N

ever

mar

ried

7272

9.5

2936

40.4

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arrie

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16.5

6081

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1.38

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1.48

]

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ed49

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64.4

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4748

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42†

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4,1.

51]

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para

ted/

Div

orce

d73

599.

637

1750

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47†

[1.3

7,1.

58]

No.

of p

hysi

cal c

omor

bid

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ases

*

J Am Med Dir Assoc. Author manuscript; available in PMC 2010 June 18.

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Levin et al. Page 13

The

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ple

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gnos

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ith D

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ssio

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tic R

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ssio

n on

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f Dep

ress

ion

Tot

al N

Col

%N

Row

%O

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% C

I

 N

one

7777

10.1

3041

39.1

——

 1–

241

119

53.6

18 9

8046

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32†

[1.2

5,1.

39]

 3–

425

001

32.6

13 1

5052

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66†

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76]

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26†

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6,2.

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Seve

re m

enta

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724

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 N

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93.3

34 4

0848

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nden

t23

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6245

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 Li

mite

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8645

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[0.9

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 D

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dent

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8957

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503

51.3

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1.44

]

 To

tal d

epen

denc

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15.5

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Cog

nitiv

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7256

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†[0

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0.83

]

Faci

lity

char

acte

ristic

s

Urb

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es59

749

77.9

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6747

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Size

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697

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14 8

9519

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3448

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]

 10

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947

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5748

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99[0

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]

 20

0 an

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over

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J Am Med Dir Assoc. Author manuscript; available in PMC 2010 June 18.

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Levin et al. Page 14

The

Sam

ple

Dia

gnos

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ssio

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tic R

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Dia

gnos

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f Dep

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Tot

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Col

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Aff

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ion

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43 9

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Occ

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9548

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qua

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9341

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9239

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% o

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aid

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yer*

 Lo

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19 1

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1948

.7—

—

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qua

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19,1

3624

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48.6

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[0.9

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 Th

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Num

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819

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Acu

ity in

dex

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wes

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2248

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1.05

]

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 H

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R, o

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J Am Med Dir Assoc. Author manuscript; available in PMC 2010 June 18.

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Levin et al. Page 15* Si

gnifi

cant

gro

up d

iffer

ence

(P <

.05)

in p

reva

lenc

e of

dep

ress

ion

diag

nosi

s by

chi-s

quar

e st

atis

tics.

†, ‡

, and

§ d

enot

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gnifi

cant

eff

ect i

n th

e lo

gist

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gres

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, at 1

%, 5

%, a

nd 1

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resp

ectiv

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Bot

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are

test

s and

logi

stic

regr

essi

ons a

djus

ted

for c

lust

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resi

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s with

in fa

cilit

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Levin et al. Page 16

Tabl

e 2

Tre

atm

ent a

mon

g O

hio

Nur

sing

Hom

e R

esid

ents

Dia

gnos

ed w

ith D

epre

ssio

n

The

Sam

ple

Any

Tre

atm

ent

Log

istic

Reg

ress

ion

on A

ny T

reat

men

t of D

epre

ssio

n

NC

ol %

NR

ow %

OR

95%

CI

Tota

l36

888

100.

028

378

76.9

Resi

dent

Cha

ract

eris

tics

Gen

der*

 M

ale

8574

23.2

6732

78.5

 Fe

mal

e28

314

76.8

21 6

4676

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98[0

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1.05

]

Age

*

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ge 6

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5493

14.9

4399

80.1

 A

ge 7

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14 5

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d ov

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77]

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]

Educ

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ss th

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Mar

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para

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No.

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*

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one

3041

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2196

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J Am Med Dir Assoc. Author manuscript; available in PMC 2010 June 18.

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Levin et al. Page 17

The

Sam

ple

Any

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atm

ent

Log

istic

Reg

ress

ion

on A

ny T

reat

men

t of D

epre

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n

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OR

95%

CI

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980

51.5

14 5

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20†

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35.6

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Seve

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Cog

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Faci

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Size

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J Am Med Dir Assoc. Author manuscript; available in PMC 2010 June 18.

NIH

-PA Author Manuscript

NIH

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NIH

-PA Author Manuscript

Levin et al. Page 18

The

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J Am Med Dir Assoc. Author manuscript; available in PMC 2010 June 18.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

Levin et al. Page 19

The

Sam

ple

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Reg

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CI,

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R, o

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* Sign

ifica

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roup

diff

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ce (P

< .0

5) in

the

type

s of t

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chi

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are

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hi-s

quar

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s with

in fa

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† an

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deno

te si

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n th

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% a

nd 5

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Bot

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ted

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lust

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s with

in fa

cilit

ies.

J Am Med Dir Assoc. Author manuscript; available in PMC 2010 June 18.