Influence of Cognitive Impairment, Illness, Gender, and African-American Status on Psychiatric Ratings and Staff Recognition of Depression

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Influence of Cognitive Impairment, Illness, Gender, and African-American Status on Psychiatric Ratings and Staff Recognition of Depression Jeanne A. Teresi, Ed.D., Ph.D., Robert Abrams, M.D. Douglas Holmes, Ph.D., Mildred Ramirez, Ph.D. Carol Shapiro, R.N., Joseph P. Eimicke, B.S.

Objective: The authors examined the multivariate relationships between depression recognition by staff members and characteristics of nursing home residents. Methods: Analyses used a simple random sample of 270 residents, drawn from six randomly selected nursing homes, who were evaluated by psychiatrists for depression and depressive symptomatology. Results: African Americans were generally seen by psychiatrists as having less depressive symptomatology than residents from other ethnic groups. The data suggest that nurse aides, perhaps because they see residents more often or because they are less influenced by demographic characteristics, may be the most valid source of information about residents’ depression. In contrast, after partialing out the degree of depression severity, nurses tended to overrecognize depression among African-American residents. Social workers underrecognized depression among residents with cognitive impairment and/or Parkinson disease and among women, and overrecognized depression among African Americans. Conclusion: The results underline the need for more training in depression recognition, particularly in distinguishing social from clinical phenomena and in distinguishing symptoms of dementia from those of depression. Equally important is further investigation of the potential biases associated with diagnosis and recognition of depression among African Americans. (Am J Geriatr Psychiatry 2002; 10:506–514)

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ailure to recognize and treat depression among nursing home residents is likely to have important consequences for their overall health and quality of life.1–3 For example, it is suspected that depression increases hospitalization,4 medical morbidity, and mortality.5–7

Depression is associated with disturbed sleep and appetite, unwanted weight loss, pessimistic outlook, loss of interest in activities, joylessness, and personality changes,8,9 any of which could have a negative impact on adjustment to a nursing home. Persons with depres-

Received December 14, 2000; revised April 4, 2001; accepted April 16, 2001. From the Hebrew Home for the Aged at Riverdale, Riverdale, NY (JAT,DH,MR,CS,JPE), Columbia University Stroud Center and New York State Psychiatric Institute, Department of Geriatrics (JAT), the Department of Psychiatry, Weill Medical College of Cornell University (RA), and Columbia University College of Physicians and Surgeons (DH). Address correspondence to Dr. Teresi, Research Division, Hebrew Home for the Aged at Riverdale, 5901 Palisade Ave., Riverdale, NY 10471. Copyright 䉷 2002 American Association for Geriatric Psychiatry

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Teresi et al. sion may experience symptoms of functional dependency that interfere with the activities of daily living and prevent participation in activity programs. Such persons may be less likely to comply with medical treatment regimens or to accept adequate nutrition and hydration. Eventually, they may be at greater risk for developing decubiti due to inactivity or for requiring tube-feeding. Disability stemming from depression has been found comparable to the disability associated with severe physical illness.10 However, some of the disability associated with depression may be avoidable because, unlike many chronic medical illnesses and unlike dementia, depression can be not only managed, but effectively treated, as well.11 A prerequisite to treatment of depression is its recognition; however, despite the prevalence of depression, it often is not recognized by nursing home staff. For example, the Survey of Institutionalized Persons12 asked both a staff member and next-of-kin whether the resident needed psychiatric services and, if they were thought to be needed, whether such services were being provided. Neither the staff nor the relatives reported more than a small (⬍10%) proportion of the residents as needing any psychiatric services, although both sources agreed that needed psychiatric services were, in many instances, not being provided. Not surprisingly, in view of these findings, Rovner et al.2 found that fewer than 25% of depressed residents were treated for depression by nursing home physicians. A possible interpretation of the failure to recognize depression is that staff members view states of unhappiness or demoralization as being troublesome conditions that do not, however, merit specific psychiatric intervention. This attitude, coupled with low reimbursement rates for mental health care, may contribute at least partially to the nonrecognition and/or nondiagnosis of psychiatric disorders. The focus of this article is an examination of the multivariate relationship between depression recognition by staff members and characteristics of nursing home residents.

staff (e.g., nurse, social worker, aide) might in part determine readiness and/or ability to recognize depression. Similarly, the likelihood of recognizing depression might vary according to resident factors such as communication difficulty, concomitant behavioral problems, physical illness, or the manifestation of various clinical features of depressive symptomatology. Accordingly, we tested the following hypotheses: 1. Recognition of depressive symptoms will be negatively associated with degree of cognitive impairment. We hypothesized that depressed individuals with more severe cognitive impairment would be less likely to have their depression recognized than would individuals with less severe impairment. 2. Women will have more unrecognized depression than will men. We hypothesized that a) the symptoms of men would be taken more seriously because whereas men might tend to report symptoms less frequently than women, they are more likely than women to take overt action, such as suicide; and b) women might be thought of as “complainers” and their symptoms, therefore, minimized or dismissed outright. 3. After we control for depression severity, the influence of demographic variables on recognition of depressive symptomatology will vary across professional levels of staff. We hypothesized that social workers would be least influenced by demographic factors in the recognition of depressive signs and symptoms. Because of their training as social workers, we posited that extraneous factors such as demographic characteristics of the resident would play less of a role in recognition of depression.

Conceptual Model and Hypotheses

A probability sample of six New York downstate (metropolitan area, including Westchester) nursing homes was developed. Selection of downstate institutions allowed variability with respect to institutional resources and inclusion of minority group members. The facility response rate was 100%. We drew a probability sample of 55 residents from each facility, yielding a total sample of 330 residents (among whom 11 refused to

The theoretical model used here is based on the assumption that recognition of depressive symptomatology and syndromes will be influenced by staff and resident factors. For example, because of differences in foci and scope of training and experience among different levels of staff, the level and disciplinary group of

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METHODS Design and Sample

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Recognition of Depression participate in the study). The resident-level response rate was 96.7%. However, an additional 6.3% later refused the psychiatric assessment, and an additional 9% could not be assessed by psychiatrists because of severe illness, communication difficulty, and/or impairment of consciousness. The resulting 270 residents were assessed by psychiatrists and also were evaluated for depression by staff members. Nurses provided information for 259 residents, nurse aides for 237, and social workers for 240, representing staff response rates ranging from 86% to 94%. Because scale scores were declared missing if 50% or more of the items were answered as unknown, the final ns were lower. For example, among the 259 nurses providing some information about residents’ depression, 21% were unable to provide information for 50% or more of the items contained in the Depression Recognition Scale outcome variable; among nurse aides and social workers, the comparable rates of missing data were 23% and 28%, respectively. Finally, because of missing data among one or more variables included in the multivariate analyses, the final ns upon which these analyses were based are the following: psychiatrists, 231; nurse aides, 149; nurses, 170; and social workers, 145. An analysis of the differences between those residents rated by both the psychiatrists and staff and of the subset rated only by psychiatrists indicates that the latter were significantly more cognitively impaired, communication-impaired, behavior-disordered, and impaired in ambulation. There were no significant demographic differences between the groups. The mean age for the sample, which was predominantly female (81.8%), was 84.5 years (standard deviation [SD]: 9.65). About 20% were African American, and 76% white, non-Latino. On average, participants had received 9.9 years of education (SD: 4.15). Most subjects were widowed (56.3%) or never married (20.6%). Data were collected from 1995 through 1997. The majority of staff (89% or more of all staff groups) were women; nurse aides had worked in their profession for a median of 108 months; nurses, for 204 months; and social workers, for 64 months. The majority (90%) of aides were black; one-third of nurses were Asian, and one-fourth were black; 85% of social workers were white, non-Latino. In terms of self-reported training in depression, 71% of nurse aides, 44% of nurses, and 52% of social workers reported having ever received formal in-service training

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in depression. The median hours of training among all groups during the past 6 months was 0; 48% of aides, 25% of nurses, and 27% of social workers reported having attended an in-service presentation on depression during the past 6 months. Procedures Before data were collected, we obtained informed consent from either the resident (if cognitively intact) or from the family member (if the resident was cognitively impaired). Because some nursing home residents are incapable of arousal or, if alert, incapable of response, it was necessary to prescreen them in order to ascertain ability to respond. The measure used for screening was taken from the National Institute on Aging (NIA) Research Version13 of the Mattis Dementia Rating Scale (RMDRS),14 of which Section A prescreens individuals for ability to respond. All subjects received the Cornell Scale for Depression in Dementia (CSDD),9 the Feeling Tone Questionnaire (FTQ),15 the Minimum Data Set (MDS) chart review,16 and the Institutional Comprehensive Assessment and Referral Evaluation (INCARE) screen.17–19 A small proportion of respondents were sufficiently cognitively capable to complete the Hamilton Rating Scale for Depression (Ham-D)20 and the Structured Clinical Interview (SCID).21 Depression recognition measures were obtained from the nursing and the social work staff most familiar with each resident. After we established interrater reliability on study measures with respect to 44 subjects, one of three research psychiatrists was assigned to evaluate each resident. Other data were collected by research staff at the master’s-degree level. Measures Resident characteristics. Measures of ambulation, behavior disorder, paralysis, and Parkinson disease (PD) were obtained using the INCARE. The Mini-Mental State Exam22 was used to determine cognitive status, and the FTQ constituted a measure of depression severity. Psychometric properties for the depression protocol are presented elsewhere.23 Means and SDs and reliability coefficients for the independent variable scales used in these analyses appear in Table 1. The Cronbach alphas (used to estimate internal consistency) for the current project are generally adequate, ranging from 0.64 for behavior disorder to 0.92 for ambulation.

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Teresi et al. TABLE 1.

Summary statistics for the scales used in the analyses INCARE

Scale Name

Mean

Standard Deviation

Cognitive disorder: MMSE (n⳱267) Ambulation disorder: INCARE (n⳱205) Behavior: INCARE Observed Behavior Disorder Scale (n⳱287) Paralysis (n⳱286) Parkinson disease (n⳱283) Depression severity: Feeling Tone Questionnaire (n⳱212) Age, years (n⳱308) Female (n⳱314) African-American (n⳱286)

13.89 3.66 2.11 0.09 0.74 7.83 84.53 0.82 0.20

12.86 2.69 2.54 0.29 1.39 5.87 9.65 0.39 0.40

# of Items

Alpha

20 4 17

0.82 0.92 0.64

16

0.91

Note: All scales were scored in the deviant direction, including the Mini-Mental State Exam.

Psychiatrist and resident depression measures. The Depression Diagnostic Scale (DDS)23 contains a Diagnostic Impression Worksheet consisting of 26 items measuring (DSM-III-R)24 major depression and (Research Diagnostic Criteria) minor depression. This worksheet documents the decision-making process in the diagnosis of every subject. Each DSM-III-R criterion or symptom area is coded as Present, Absent, or No Information across six possible sources of information: resident, nurse, nurse notes, social worker notes, medical doctor notes, or occupational/physical therapy notes. A final psychiatric opinion is then recorded for each diagnostic criterion or symptom, and a final diagnosis is made. Thus, for example, it is possible to document the sources involved in determining whether “there is a markedly diminished interest or pleasure in all or almost all activities, most of the day, nearly all day.” The DDS score comprises the sum of the 26 final symptom ratings, prorated, when necessary, for missing data. The estimate of internal consistency for this sample was 0.89. The Feeling Tone Questionnaire (Depression Severity; FTQ),15 used as the measure of depression severity in the analyses, contains 16 questions asked of the resident; typical items: “Are you feeling well?”; “Are you feeling happy today?”; “Do you feel lonely?”; “Do you have a good appetite?”; “Do you sleep well?” Each item is asked of the respondent and rated “non-deviant,” “deviant,” or “equivocal” (“sometimes; it depends”). The response to each item is rated for affect using a 5-point continuum, from 1: “laughs, praises, enthusiastic, emphatically positive” to 5: “extreme negative: cries, groans, curses, is emphatically negative.” In this application, the alpha was 0.91.

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Staff depression rating scales. The SHORT-CARE Direct Resident Assessment Depression/Demoralization Scale,26 developed using cross-national samples,27,28 contains items such as: “Feeling sad or depressed during the past month,” “Poor appetite in the absence of obvious medical cause and without nausea,” “Less interest or enjoyment in activities,” “Lies awake with anxious or depressed feelings and thoughts,” and “Has cried during the past month.” The SHORT-CARE Direct Resident Assessment Depression Scale was modified for use as a staff depression recognition measure by altering the stem of the question; for example, “Has s/he felt sad and depressed during the past month?”; The measure contains 29 items asked of the resident or of three groups of staff members: social workers, nurses, and nurse aides. The nurse aide, nurse, and social worker most involved with each resident’s care were each asked the SHORT-CARE Depression Scale items that reflected the presence of possible symptoms of depression. Respondents were asked to rate the symptoms according to whether each was Present, Absent, or Not Ratable (usually because of severe communication disorder). The research psychiatrists rated the same symptoms as described above. The Direct Resident Assessment had an internal consistency of 0.86 for the current sample. The Staff Assessments had internal consistencies of 0.96 for social workers, 0.91 for nurses, and 0.93 for nurse aides. Depression recognition. Congruence refers to the amount of agreement between staff and diagnostic evaluation of individual depression symptomatology. Depression recognition congruence was measured by calculating congruence deviations based on a symptom scale. The SHORT-CARE scales, described above, were

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510

Note: The test of the full model with Depression Severity included is represented by the first number; numbers in parentheses are the results of the reduced model, without Depression Severity. *p⬍0.05; **p⬍0.01.

0.05 (0.05) 0 (0) 0.03 (0.03) 0.01 (0.01) 0.03 (0.03) 0.01 0 (0) 0.02 (0.02) 0.03 (0.03) 0.19 (0.18) 0 (0) 0.22 0.23* (0.22*) 0 (0) 0.06 ⳮ0.10 (ⳮ0.09) 0.02 (0.02) 0.23 0.15 (0.16) 0 (0) 0.10 0.09 (0.09) 0.01 (0.01) 0.18 0.16* (0.17*) 0.09 0.15 0.09 0 (0.01) 0.15 ⳮ0.04 (ⳮ0.04) 0.01 (0.01) 0.18 0.18* (0.18*) 0.02 (0.03) ⳮ0.19 ⳮ0.18* (ⳮ0.19*) 0.16 (0.08) 0.43 0.13 (0.13) 0 (0) ⳮ0.04 ⳮ0.07 (ⳮ0.09) 0 (0) 0.05 0.02 (ⳮ0.01) 0 (0) 0.03 0.06 (0.06) 0 (0) 0.02 0 (0.01) 0.01 (0.01) 0.10 0.05 (0.09) 0.01 (0.01) 0.16 0.12 (0.15) 0 (0) 0.08 0.07 (0.07) 0 (0) 0 ⳮ0.01 (ⳮ0.01) 0.01 (0.01) 0.05 0 (0.04) 0 (0) 0.08 0.09 (0.10) 0.20 0.38 0.36** 0.13 0.32 0.30** 0.01 (0.02) 0.05 0.01 (0) 0 (0) 0.13 0 (0.02) 0 (0.01) 0.10 0.04 (0.09) 0 (0.01) 0.14 0.11 (0.14) 0.02 (0.03) ⳮ0.06 ⳮ0.06 (ⳮ0.10) 0 (0.01) ⳮ0.16 ⳮ0.16* (ⳮ0.18*) 0.26 (0.08) 0.40 0.10 (ⳮ0.01) 0.16 (0.04) 0.40 0.11 (0.04) Cognitive impairment 0.02 0.04 (ⳮ0.03) Behavior disorder 0.02 0.03 (0.03) Ambulation disorder 0.10 0.02 (0.06) Paralysis 0.04 0.05 (0.06) Parkinson disease 0.10 0.08 (0.10) Depression severity 0.45 0.43** Age 0.17 0.07 (0.09) Female 0.13 0.07 (0.13) African American ⳮ0.18 ⳮ0.16** (ⳮ0.18**) Multiple regression 0.51 0.23 (0.05) Adj. R2; R2

CHG R2 Beta r

Beta

CHG R2

r

Beta

CHG R2

r

Beta

CHG R2

r

Social Worker (nⴔ145) Nurse (nⴔ170)

Variable

As shown in Table 2 (column 2), depression severity (r⳱0.45; p⬍0.01) and resident age (r⳱0.17; p⬍0.01) were significantly related to the DDS at the zero-order level. African Americans were significantly less likely than were white, non-Latinos (r⳱ –0.18; p⬍0.01) to be evaluated as having depressive symptomatology. The first analyses involved examination of the correlates of depression recognition. The hypothesis that depression among women would be underrecognized was supported for nurses’ and social workers’ ratings; both groups identified significantly fewer (p⬍0.05) symptoms of depression than did the psychiatrist. Age was significantly related to depression underrecognition by nurses (r⳱0.13; p⬍0.05) and social workers (r⳱0.15; p⬍0.05). As hypothesized, most other relationships between demographic variables and recognition variables were not significant. The exception was that nurses and social workers tended to overrecognize depression among African Americans (r⳱ –0.16; r⳱ –0.19, respectively; p⬍0.05). Recognizing that some of those with severe (endstage) dementia could not be assessed for depression, it had been hypothesized that, among those who could be assessed, those with more cognitive impairment would be more likely to have underrecognized depression. This was borne out only among social workers, for whom level of residents’ cognitive impairment was significantly related (r⳱0.22; p⬍0.01) to underrecognition of depression.

Nurse Aide (nⴔ147)

Bivariate Correlates of the Depression Diagnostic Scale and Depression Recognition

Psychiatrist (nⴔ231)

RESULTS

TABLE 2.

scored and prorated for missing data; each score was converted to a standard (z)-score so that all sources were on the same metric. Then the aide z-score, the nurse z-score, and the social worker z-score were each individually subtracted from the psychiatrist’s z-score. Consequently, a positive z-score on the resulting measure indicated that the psychiatrist had rated more symptoms as present (staff underrecognition) than had the staff member, and a negative z-score indicated that the staff member had rated more symptoms as present (overrecognition) than had the psychiatrist.

Multiple-regression analysis relating Depression Diagnostic or Depression Recognition scales to covariates and demographic characteristics of the sample

Recognition of Depression

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Teresi et al. Multivariate Analysis Multivariate analyses were conducted predicting the DDS scores given by psychiatrists or the Depression Recognition Scale scores given by nurse aides, nurses, and social workers. Two multiple-regression models were tested: a full model, which included depression severity, and a reduced model, which did not (see Table 2). The full model was applied in order to determine whether or not demographic variables might be correlated with depression severity; if so, they might not be significant in relation to recognition of depression after partialing out the effect of severity. It was hypothesized that, after controlling for depression severity, extraneous factors such as demographic characteristics of residents should not remain significant in relation to depression recognition. Although intercorrelations were generally low, formal collinearity diagnostics were performed to confirm the absence of multicollinearity. Examination of both the reduced and the full model for the Depression Diagnostic Scale shows that only status as an African American was significant as a predictor of depression. African Americans, as contrasted with whites and other ethnic groups, were more likely to be rated by psychiatrists as having less depressive symptomatology. An examination of characteristics of African Americans showed them not to differ significantly from whites in terms of cognitive impairment, behavior disorder, depression severity, or gender. Blacks were significantly younger than their white counterparts and tended to have more paralysis, possibly due to stroke. The reduced model predicting staff recognition showed that no demographic variables were related to nurse aide recognition; in the full model, only depression severity was significant. Examination of the full model showed that, after partialing out depression severity, nurses tended to overrecognize depression among patients who were African-American. This was similar to the relationships found with the reduced model. Among social workers, the underrecognition of depressive symptomatology was significantly associated with several resident characteristics: PD, cognitive impairment, and female gender. Social workers also were significantly more likely to overrecognize depression among African Americans, as contrasted with non-African Americans. The full model showed that,

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after controlling for level of depression severity, the same results still obtained among social workers. Contrary to the third hypothesis, examination of the adjusted R2s showed that, for social workers, the demographic and other variables in the reduced model accounted for about 13% of the variance in depression recognition scores, contrasted with nurse aides (0%), and nurses (4%). For the full model, depression severity related most strongly to diagnosis and recognition except among social workers, where the strongest predictors were the demographic variables. In fact, depression severity was not significantly related to recognition at the multivariate level for social workers. Recognition, expressed as agreement with psychiatric ratings, was not related to actual symptoms; residents with greater symptom scores were as likely to be overrecognized as underrecognized by social workers. In order to more fully investigate the relationship of staff membership to depression ratings, an additional analysis (not shown here) was performed, examining the multivariate relationship between SHORT-CARE staff scales of depression and psychiatric Depression Diagnostic Scale scores, controlling for demographic variables. Both the reduced model (without depression severity) and the full model showed that nurse aide scores were more highly related to psychiatrist scores than were the scores for other staff groups; b⳱0.33; (p⬍0.001) for aides, 0.09 (NS) for nurses, and 0.01 (NS) for social workers, for the full model, and b⳱0.37 (p⬍0.001) for aides, 0.13 (NS) for nurses, and 0.18 (NS) for social workers for the reduced model. This implies that nurse aides were more congruent with psychiatric ratings than were the other staff groups.

DISCUSSION Examining first the multivariate relationship with the psychiatric evaluation, the Depression Diagnostic Scale showed that, for both the reduced and the full model, African Americans had lower depression diagnostic scores. Women tended to have higher depression diagnostic scores. This is similar to the findings of others29 and may reflect reporting bias, but the relationship was only a nonsignificant trend. Depression was unrelated at the multivariate level to ambulation disorder or to the two chronic diseases studied. This is in contrast to findings among community-resident elderly subjects (see

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Recognition of Depression Jorm for a review of studies),30 although, in the current sample, there may have been a restricted range of ambulation scores, given the high degree of impairment characteristic of elderly nursing home residents. Although there were nonsignificant zero-order and multivariate correlations with cognitive status, this finding might be explained by the lack of linear association between depression symptomatology and cognitive impairment. For example, analyses not presented here showed that the rates of depression were lower among those with normal and mild impairment and again among those with very severe, end-stage disease. In the multivariate analyses of the recognition of depression, nurse aide ratings were least influenced, and social worker ratings most influenced, by demographic variables. Social workers significantly overrecognized depression among African Americans, but underrecognized depression among women, those with cognitive impairment, and those with PD. In fact, the relatively greater proportion of variance accounted for by demographic variables (18%) is surprising. The fact that the adjusted R2s for the reduced and full models were the same for social workers (coupled with the finding that depression severity was not significantly related to recognition among social workers) suggests that social workers are more likely to be influenced by extraneous demographic or social factors than by clinical symptomatology in evaluating depression. The correlation of the Depression Diagnostic scale with the staff-rated SHORT-CARE Depression scales were also variable: 0.50 for nurse aides, 0.37 for nurses, and 0.37 for social workers.23 The results of the regression analysis relating psychiatric scale scores and staff scale scores showed that nurse aides were most congruent; this result is consistent with other findings from these data reported elsewhere, showing that among the three groups, aides were most sensitive and social workers least sensitive with respect to diagnoses. The lower correlation of nurse ratings with diagnostic ratings is also consistent with a study of long-term care residents,31 which found no significant differences in nurserated Cornell Scale scores across groups characterized as meeting criteria for DSM-III-R diagnosis versus those without mood disorder. Also, relatively low (0.27) correlations were observed in that study between nurse and informant versions of the Cornell Scale and with nurse-informant Cornell Scale scores and the Geriatric Depression Rating Scale (0.17). Two interpretations advanced by the study authors were that nurses are an

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important source of additional information about depression that may not be reflected in patient or physician ratings and/or that mood disorder in frail nursing home residents with dementia may be different from that commonly characterized as major depression. However, an alternative explanation is that staff recognition of depressive symptomatology among long-term care patients is low and in need of remediation. A possible limitation of the study is that the psychiatrists had access to medical records, so that, although ratings were independent, the psychiatrist ratings could have been influenced by staff reports; this could have produced an overestimate of agreement between staff and psychiatrist ratings. Thus, the results can be viewed as a conservative estimate of congruence. Both nurses and social workers overrecognize (relative to the psychiatric ratings) depression among African Americans. Although psychiatric ratings were used as the “gold standard” in this study, the negative association of these ratings with African-American status may nevertheless reflect a societal bias in the psychiatric ratings. Alternatively, the findings could reflect a lower prevalence of depression among African Americans. The prevalence ratio for major depression among African Americans was 3.6%, as contrasted with 16.5% for whites. These results showing lower rates of depression among African Americans are consistent with studies of primary care elderly patients,32 where rates for whites, estimated using a screening measure, were twice those of African Americans. Similarly, another study of elderly medical inpatients33 found lower rates of depression on the basis of self-reported symptoms among African Americans than among whites. Finally, the findings reported here are consistent with those from the Epidemiologic Catchment Area study,34 which showed that African Americans were less likely to report dysphoria than were whites. On the other hand, a study in England,35 using a diagnostic interview and algorithm, found higher rates of depression (13% to 19%) among groups of black Africans and Caribbeans than among a sample of whites (9%); however, in that study, the confidence intervals for the whites were overlapping with the black groups except for one comparison. Although some North American research, for example, that of Krause and Liang,36 has found that African Americans have higher depression scores than do other ethnic/racial groups, other research37 has found that after controlling for factors such as disability, education, and

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Teresi et al. health status, only small differences were observed between community-resident, elderly African Americans and non-African Americans in terms of frequencies of depressive symptoms. Because of the limited data available on rates of depression among African Americans in general,38 and particularly among African-American nursing home residents, it is difficult to speculate on the reasons for the overrecognition or on the generally lower estimated prevalence. As previously stated, the African-American and non-Latino, white sample did not differ significantly on most study variables, although they were significantly younger and more likely to have paralysis, possibly due to stroke. Although the results must be interpreted cautiously because of the small number (n⳱56) of African-American respondents, they do provide impetus for further study, particularly because African-American elderly subjects have been underrepresented in studies of institutional and communitybased long-term care. Studies of family caregivers’ perceptions have shown that informal caregivers of individuals with dementia tend to report more depressive symptoms in comparison with patient self-report39,40 and physician ratings.41 The data presented in this paper, based on research psychiatrist ratings, suggest that among formal caregivers, nurse aides provide the best source of information on depression. Social workers, either because they do not see the resident on a daily basis or because they are more influenced by demographic characteristics, may constitute a less valid source of information than do nursing staff. It is of interest in this context that nurses and social workers reported less in-service training with respect to depression than nurse aides. The finding that the median level of in-service training for depression reported was 0 for all staff, but that nurse

aides, who received disproportionately more training were more convergent with psychiatric ratings, underscores both the paucity of training provided for staff and the possible benefits of staff training in depression recognition. The results underline the need for more training in depression recognition, particularly in distinguishing social from clinical phenomena and in distinguishing symptoms of dementia from those of depression. Equally important is further investigation of the potential biases associated with diagnosis and recognition of depression among elderly African Americans. This is important because depression negatively affects quality of life and can be effectively treated even in patients with significant comorbid dementia. A recent consensus statement42 concludes that “Even when it appears to be an understandable response to illness, the onset of depression should be viewed as a sentinel event that increases the risk for subsequent declines in health status and functional ability.”

This paper is dedicated to the memory of Jacqueline Savinon-Sun, who was the field coordinator of the study and who died of cancer in April 1998 at the age of 27. An earlier version of this paper was presented as part of Aging 2000, a meeting of the International Psychogeriatric Association, held in Munich, Germany, September 13–18, 1998. An abstract was published in European Archives of Psychiatry and Clinical Neuroscience, 248, S53. Funding for this study was provided by the National Institute of Nursing Research (NR 030508) and the New York State Department of Health.

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