افسردگی عمده و افسردگی زیر آستانه ای بین دریافت مراقبت در خانه بزرگسالان سالمند Major Depression and Subthreshold Depression among Older Adults Receiving Home Care

Introduction Home- and community-based care services or HCBS is an umbrella term encompassing a wide range of services, such as transportation, Meals on Wheels, and senior centers, designed to help older adults remain safely in their homes. HCBS have received increased attention as a venue for improving late-life depression in response to the persistent shortage of geriatric mental health providers, the clinical complexity of late-life depression, and the challenges of scaling up evidence-based depression care in the primary care setting.1,2 A good understanding of the burden of depression and gaps in treatment in HCBS is a critical first step toward developing effective strategies to integrating depression care into these settings. Studies on depression in HCBS settings have focused on Medicare home health.3–7 Estimates of major depression have ranged from 8.5%4 to 13.5%3 in regional, non-probability samples whereas in a nationally representative sample of Medicare home health recipients, 6.4% had a diagnosis of major depression.6 Another set of studies assessed subsyndromal depression in recipients of non-specified HCBS, and found that 24% to 42% of HCBS recipients had significant depressive symptoms.8–15 Some of the variation in estimates might be due to the fact that HCBS cover a wide range of services delivered by different types of providers. This study expands previous research by focusing on home care, a specific type of HCBS provider. Relatively more research on depression has been performed in the home health care setting3–7 as compared to home care. Home care and home health care are distinct. Home care as defined in this study refers to non-skilled personal care and companionship services, such as assistance with activities of daily living (ADLs), light housekeeping, medication management, escort to appointments, and general companionship. Home care is a booming industry due to the rising aging population in the United States, consumer preferences for aging in place, and public policy favoring community-based alternatives to institutional long-term care.16 Home care is provided full-time, part-time, intermittently, or even around the clock based on care recipients’ long-term care needs, whereas home health care provides intermittent skilled nursing care and rehabilitation services after an acute illness. Home care is paid for by a variety of sources including out-of-pocket payment, Medicaid, veterans’ benefits, and long-term care insurance, whereas home health care is primarily paid by Medicare. Home care is often provided without a physician’s order or supervision, whereas home health benefits require physician’s orders. Relevant to the present investigation, the burden and clinical manifestations of depression, as well as treatment, may differ between the home care and home health care settings. Older adults who receive home care tend to be homebound and experience multiple chronic illnesses, functional impairment, and social isolation.17 In addition, recipients of paid home care often experience a loss of physical and social independence. Not being able to fully care for one’s self and reduced ability to move about in the community conflicts with people’s desire for freedom, control and self-sufficiency.18 For these reasons, we expected a high burden of depression in older home care recipients.