Training Nursing Staff to Recognize Depression in Home Healthcare

Depression remains a significant public health problem for older adults in all service sectors (hospitals, primary care, long-term care).1,2 The failure to detect and adequately treat depression is associated with higher costs,3 morbidity, risk of suicide, and mortality from other causes,1,2 but depression is a treatable condition.4–6 Guidelines based on evidence from pharmacotherapy, psychotherapy,7 and care models for the primary care setting have been established,8 but there has been little research on practical approaches to operationalizing depression detection or treatment for the homecare setting.9 There is a substantial need for depression research in homecare, with major depression twice as common in older adults receiving homecare services10 as in those receiving primary care.11 A previous study found that 13.5% of subjects newly admitted to homecare suffered from major depression,10 that depression often remained unrecognized,12,13 and that few (12%) received adequate treatment. 10 The aim of the TRaining In the Assessment of Depression (TRIAD) intervention14 is to address inadequacies and improve routine depression case finding in older adult patients by homecare nurses. The U.S. Preventive Task Force15 recommends that all individuals aged 60 and older should be screened for depression periodically, and evidence-based nursing practice guidelines call for nurse depression screening.16,17 A few investigators have focused on the homecare nurse’s ability to implement such screening.14,18–20 The rationale for leveraging the role of homecare nurses includes their frequent and regular contact with patients. In Medicare-certified agencies, homecare nurses provide the vast majority (85%) of skilled care21 and are mandated to perform patient assessments periodically, including assessment for depression symptoms, yet homecare nurses do not feel adequately prepared22 and often fail to identify depression.12,13 Homecare nurses have expressed concerns about “asking direct questions about depression,” “invasion of patient privacy,” “precipitating patient distress (e.g., suicide ideation),” and the added paperwork burden required for screening activities.20 In addition, agencies may lack the supportive infrastructure to improve depression case finding. In a randomized trial,14 TRIAD was found to be a successful intervention. Specifically, it was found that nurses who received the TRIAD were 2.5 times as likely to correctly identify depressed patients and refer them for further evaluation, following agency protocols, and that referrals led to better clinical outcomes. There was no effect on unnecessary referrals for research-confirmed patients without depression (i.e., the intervention did not promote false-positive referrals). To promote dissemination of a proven effective intervention, this article describes in more detail the rationale, development, and use of TRIAD as it was implemented in a randomized controlled trial.14 It describes partnership activities with participating homecare agencies, needs assessment surveys, shadowing activities, and the content of the training curriculum and reports on nurses’ acceptance of the TRIAD intervention to develop their confidence in conducting depression detection, before and after the intervention.