Reducing Disparities in Late Life Depression and Metabolic Syndrome
Condition: Depressive Symptoms; Metabolic Syndrome X; Overweight; Obesity; Hypertension; Hyperglycemia; Dyslipidemias
MeSH terms: Hypertension; Microvascular Angina; Overweight; Metabolic Syndrome; Dyslipidemias; Hyperglycemia; Syndrome; Depression
Study type: Interventional

Summary: 
      Linkages between depression and cardiovascular disease have been well documented. These
      appear to be more than associations, and may reflect causal relationships through a number of
      proposed pathways, including decreased physical activity, poor dietary habits, medication
      non-adherence, and a direct impact on inflammatory mediators. Older adults are affected by
      both depression and heart disease, with increased risk in African American and Latino
      elderly.

      The BRIGHTEN-Heart trial tests the hypothesis that an enhanced primary care delivery system
      intervention which provides evidence-based, patient-centered mental health services targeting
      depression and cardiovascular risk factors can reduce the risk of development of
      cardiovascular disease in low-income elderly blacks and Hispanics. BRIGHTEN stands for
      Bridging Resources of a Geriatric Health Team via Electronic Networking, and in this
      intervention, specialty providers including geropsychologists, social workers, pharmacists,
      nutritionists, chaplains, occupational therapists, and others collaborate via the internet as
      a virtual team. The study will determine if such a virtual interdisciplinary clinical team
      collaboration can reduce depression in older (age ≥ 65) minority adults with comorbid
      depression and metabolic syndrome.
    

Detailed description: 
      Chicago has been characterized as one of America's most segregated cities, with many
      neighborhoods characterized by black and Hispanic populations living in concentrated pockets
      of poverty. In addition to lowered socioeconomic status, these neighborhoods are also
      characterized by remarkable health disparities relative to wealthier, predominantly white
      neighborhoods only a few miles away. Disparities in access to health services contribute to
      these poorer health outcomes, but are not wholly explanatory.

      For cardiovascular disease, the leading cause of death in the US, both black and Hispanic
      adults have elevated rates of many major risk factors including physical inactivity, obesity,
      elevated levels of Fasting Blood Glucose, and dyslipidemia. Blacks also have elevated rates
      of hypertension, and experience well-documented excess mortality rates. Experts are
      anticipating that, given high prevalence of risk factors, most importantly the metabolic
      syndrome, similar disparities in cardiovascular mortality may soon emerge for Hispanics as
      well.

      Beyond cardiovascular disease, these populations face psychosocial challenges such as
      poverty, unemployment, societal racism, and high rates of major and traumatic life stress,
      all of which can contribute to high rates of depression and anxiety symptoms. Even the
      physical environment adds to the levels of stress: empty buildings that can become criminal
      and drug havens, boarded up storefronts, lack of groceries providing access to fresh fruits
      and vegetables (so-called "food deserts"). Disparities in access to health services, and
      these environmental conditions, as well as personal and familial factors associated with
      poverty are related to health disparity outcomes in complex ways that are only beginning to
      be understood.

      Linkages between depression and cardiovascular disease have been well documented. These
      appear to be more than associations, but may reflect causal relationships through a number of
      proposed pathways, including decreased physical activity, poor dietary habits, medication
      non-adherence, and a direct impact on inflammatory mediators.

      Aging is often associated with worsening of health disparities. The most vulnerable
      subpopulation among the urban poor are the elderly, as they are naturally vulnerable due to
      old age, compounded by lifetime exposure to poverty, and diminished defenses against violence
      in their homes or neighborhoods, including routes to health service providers.

      To date, health care interventions targeting specific individual risk factors in the elderly
      have had only limited success in reducing health disparities in cardiovascular disease. The
      investigators hypothesize that this is due to two reasons. First, changes in the healthcare
      system are needed that feature multidisciplinary teams rather than individual practitioners.
      Second, treatment of cardiovascular risk factors requires attention to the patient's
      emotional state to guard against the possibility that providers and patients are working at
      cross-purposes; that is, the provider wants the patient to take action to improve long-term
      survival, while the patient is experiencing low self-esteem, hopelessness, helplessness, or
      even a passive or active wish to die. Reducing the risk of heart disease in this complex
      bio-psychosocial context requires more than prescribing the right medication or recommending
      that individuals modify their diet and exercise. The investigators hypothesize that a
      multi-level intervention targeting both the healthcare system and the individual's
      psychosocial and behavioral risk factors may succeed where past interventions have failed.

      The investigators therefore propose testing the hypothesis that an enhanced primary care
      delivery system intervention which provides evidence-based, patient-centered mental health
      services targeting depression and cardiovascular risk factors can reduce the risk of
      development of cardiovascular disease in low-income elderly blacks and Hispanics. Researchers
      at Rush University Medical Center have developed and tested several "virtual"
      interdisciplinary team interventions, in which healthcare providers communicate as a team via
      e-mail, telephone, fax, or video conferencing. The first of these, the Virtual Integrated
      Practice project demonstrated that primary care practices could partner with community-based
      teams to improve care of older adults with chronic illness. A subsequent program called
      BRIGHTEN (Bridging Resources of a Geriatric Health Team via Electronic Networking) enhanced
      the assessment and treatment of late life depression and anxiety in primary care. The
      proposed "BRIGHTEN Heart study" will determine if a virtual interdisciplinary clinical team
      (BRIGHTEN Heart) can reduce depression in older (age ≥ 65) minority adults with comorbid
      depression and metabolic syndrome. The overall purpose of this study is to reduce racial
      disparities in cardiovascular morbidity and mortality in black and Hispanic elderly by
      effectively controlling behavioral and psychosocial risk factors.

      A second, exploratory purpose of the study is to better understand the impact of current
      major stressors and lifetime and current traumatic stressors, as these may be "hidden"
      factors that impact emotional state, individual behavior, access to care, and intervention
      adherence. It is our goal to them incorporate what the investigators learn about the impact
      of major and traumatic stressors into later intervention as part of our overall Center
      efforts.

      Study Hypothesis:

      Compared to an educational group, older minority patients with symptoms of depression and
      comorbid metabolic syndrome receiving the BRIGHTEN Heart virtual team intervention will
      demonstrate

        1. Significant reductions in symptoms of depression [Primary trial outcome]

        2. Significant reductions in metabolic syndrome

        3. Improved adherence with medications prescribed for medical illnesses

      Primary Aim

        1. To determine whether BRIGHTEN Heart can reduce depression symptoms in older adults with
           the metabolic syndrome

           Secondary Aims

        2. To determine whether the BRIGHTEN Heart intervention can result in reduced prevalence of
           metabolic syndrome as compared to a control population

        3. To test the mediating hypothesis that the BRIGHTEN Heart intervention results in
           improvements in adherence with medications

           Exploratory Aim

        4. To explore the impact of trauma and major life stressors on the results of the
           intervention
    

Intervention name(s): Generations older adult membership program; BRIGHTEN Heart Virtual Team intervention
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Rush Generations is a membership program for older adults emphasizing chronic disease prevention and management through a wide range of health and aging-related programs. Participants assigned to the Generations intervention are actively encouraged to participate in activities, including:
• RUSH-based lectures by experts in the fields of health and aging providing practical information and resources on physical and mental health, functional status, and social support. • Individual and family consultations with social work staff. • Health fairs with a variety of assessment services and information about community-based social service and health agencies. • Assistance with referral to community programs such as physical activity, driver safety events, and mind-body connection workshops.; BRIGHTEN Heart provides an interdisciplinary team evaluation of physical and mental health and on-going support for mental health & health behavior change for 6 - 12 months, including:
• Comprehensive health risk assessment by a licensed social worker, including physical, mental, and functional status. • Virtual team case review and recommendations by interdisciplinary team including psychologist, social worker, occupational therapist, pharmacist, chaplain, dietitian, geriatric psychiatrist, and patient's primary care physician. • Development of Patient Centered Action Plan, in which the social worker assists the patient in prioritizing recommendations. • Monthly telephone calls by the social worker to support implementation of Action Plan and Case Management. • Evidence Based Psychotherapy, as needed, delivered by supervised geriatric psychology and social work fellows.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Geriatrics; Older adults; Health Disparities; Health Services for the Aged; Interdisciplinary Health Team; Depressive symptoms; Metabolic Syndrome X; Overweight; Obesity; Hypertension; Hyperglycemia; Dyslipidemias