Scattergood Foundation

Advancing Innovative Strategies for Change in Behavioral Health

Center for Innovative Care in Aging, Johns Hopkins School of Nursing

Name of Innovative Program: 
Beat the Blues
Sponsoring Organization
Center for Innovative Care in Aging, Johns Hopkins School of Nursing
Name of Innovative Program Lead: 
Laura N. Gitlin, PhD
E-mail Address of Innovative Program Lead: 
lgitlin1@jhu.edu
Project Description: 
Beat the Blues (BTB) involves an academic-community partnership between a nationally accredited non-profit senior community center (Center in the Park), and a research center (Johns Hopkins University’s Center for Innovative Care in Aging), to address depression care in African Americans, age 55+.  Although an estimated 30% of older African Americans with chronic diseases report depressive symptoms, unequal access to depression care is consistently documented for this group. BTB involves in-home or telephone screening for depressive symptoms by senior center staff, and a home-based intervention delivered by licensed social workers that involves five components: depression education, care management, referral and linkage to health/mental health resources, instruction in stress reduction strategies, and behavioral activation.  Behavioral activation helps participants identify personal activity goals and specific steps for achieving them.  Activity goals may include but are not limited to managing chronic disease, addressing care management needs, and/or enhancing engagement in social or discretionary activities.  
Creativity and Innovation: 
BTB reflects a novel model for mental health care with potential to overcome stigma and barriers to access to depression care for older African Americans. Although primary care is the principal setting for depression care, older African Americans remain under-detected and undertreated.  This group may be more comfortable disclosing depressive symptoms to staff of community-based agencies with whom they have a trusted relationship and more frequent contact.  Also innovative is training senior center staff in depression care.  This builds agency capacity to respond to the mental health needs of disenfranchised older adults in a community setting.  Also innovative is its cultural relevance; its name reflects the language of the target population; the use of activity as a therapeutic modality to overcome negative mood cycles reflects the preferred coping mechanism of the targeted group; and use of a nonpharmacologic approach as first-line treatment reflects the preferences of this population.
Leadership: 
Senior centers routinely assess older adults for service needs and health status, serve as initial contact for a continuum of aging services, and provide a safety net offering meals, health checks, care management and referral services.  However, few staff are trained in depression care and senior centers typically do not provide depression care.  Through BTB, senior center staff received depression education to enhance recognition of depression symptoms and use of standardized screens for depressive symptoms such as the Patient Health Questionnaire (PHQ -9).  BTB created an infrastructure for screening participants in various programs delivered by the senior center and then referring those who screened positive to mental health treatments including the BTB in-home treatment approach.  The academic-community partnership continues with the development of standard, replicable manuals and approaches for interventionist training and agency preparation as part of the dissemination efforts to make BTB available to other community organizations. 
Sustainability: 
BTB is a standard, replicable program with a treatment manual to guide intervention implementation and an agency manual to guide infrastructure development for screening and service delivery.  As screening costs are minimal (<$3.00 per/person), this component can easily be replicated.  The intervention delivered in homes, may appear resource-intensive, yet cost compare favorably with leading depression treatments including antidepressant use.  There were no issues with recruitment/enrollment nor were there adverse events associated with treatment.  Over 700 participants were screened for depression over 2 years; 31% of those assessed as part of an in-home service for temporally medically compromised older adults had depressive symptoms; 97% assessed from the community at-large had depressive symptoms.  Although BTB was designed specifically for older African Americans, the model for building capacity in community organizations and intervention components can be used with and have high relevance for other minority, hard-to-reach and undertreated populations with minor changes required. 
Replicability: 
BTB is a standard, replicable program with a treatment manual to guide intervention implementation and an agency manual to guide infrastructure development for screening and service delivery.  As screening costs are minimal (<$3.00 per/person), this component can easily be replicated.  The intervention delivered in homes, may appear resource-intensive, yet cost compare favorably with leading depression treatments including antidepressant use.  There were no issues with recruitment/enrollment nor were there adverse events associated with treatment.  Over 700 participants were screened for depression over 2 years; 31% of those assessed as part of an in-home service for temporally medically compromised older adults had depressive symptoms; 97% assessed from the community at-large had depressive symptoms.  Although BTB was designed specifically for older African Americans, the model for building capacity in community organizations and intervention components can be used with and have high relevance for other minority, hard-to-reach and undertreated populations with minor changes required.
Results/Outcomes: 
BTB was tested in a randomized clinical trial with 208 participants. At 4-months, the BTB group showed statistically significant and clinically meaningful improvements in depressive symptoms on various depression scales (PHQ-9 and CES-D) compared to the wait-list control group.  Additionally, the BTB group had significant improvements in depression knowledge, well-being, quality of life, and behavioral activation levels.  The BTB group also showed decreased anxiety levels and functional difficulties compared to the control group.   Remission of symptoms was found in 43.8% of BTB participants at 4-months vs. 26.9% of controls and a reduction in symptom severity was found in 64.0% of BTB participants compared to 40.9% of controls.  At 8-months, the original BTB group continued to maintain gains in all areas except functional difficulty where there was a small decline in benefit.  Upon receipt of BTB following the 4-month follow-up, the control group showed similar benefits.
#1611