Dr. Mellor is Associate Professor, Ms. Russo is a doctoral candidate, Dr. McCabe is Professor, and Dr. Davison is Lecturer, School of Psychology, Deakin University, Burwood, and Dr. George is Professor, Aged Persons’ Mental Health, Eastern Health, Peter James Centre, Forest Hill, Victoria, Australia.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. The research reported in this article was supported by a research grant from Beyondblue, the National Depression Initiative in Australia ( http://www.beyondblue.org.au).
Address correspondence to David Mellor, PhD, Associate Professor, School of Psychology, Deakin University, Burwood 3125, Victoria, Australia; e-mail: firstname.lastname@example.org.
© 2008/Getty Images/Stockbyte Platinum
The prevalence of depression among older adults receiving community-based care and those in residential facilities has been shown to be elevated to levels well above those of the general population (Davison et al., 2007; “NIH Consensus Conference,” 1992). In addition, treatment access rates for this disorder among older adults receiving care are low (George, Davison, McCabe, Mellor, & Moore, 2007). Given that depressed older adults have an increased need for care, an increased mortality rate, and decreased quality of life (Covinsky et al., 1999; Fries, Mehr, Schneider, Foley, & Burke, 1993; Gurland, 1992; McCrae et al., 2005; “NIH Consensus Conference,” 1992; Samuels & Katz, 1995), which may be compromised further by the numerous physical conditions that have been found to be associated with late-life depression (Huang et al., 2000; Katz, 1996; Lebowitz et al., 1997), it is imperative that strategies are implemented to both reduce the rate of depression and ensure those older care recipients who are depressed receive appropriate treatment.
Recent research has consistently suggested that the low treatment rate for depression among older adults who receive care in their own homes or in residential facilities is related to the lack of detection of the disorder and/or lack of referral to an appropriate medical or mental health practitioner. For example, studies with care staff (McCabe, Davison, Mellor, & George, 2008), care recipients (Mellor, Davison, McCabe, & George, in press), and families of care recipients (Mellor, Davison, McCabe, & George, 2008) have suggested that both care staff and general practitioners (GPs) are more focused on day-to-day management of physical concerns than on emotional well-being and mental health. In addition, care recipients themselves tend to avoid discussing their emotions with direct care staff (Alexopoulos et al., 2002; Mellor et al., in press) and are reticent to take up their GPs’ time on such matters (Mellor et al., 2006; O’Connor, Rosewarne, & Bruce, 2001).
Given this set of circumstances, one way to improve the situation is to encourage care staff, who have the most contact with these older adults, to place a greater focus on the emotional state of care recipients. However, research has found that care staff may lack knowledge of depression as well as self-efficacy in taking action if they do recognize it (Davison, McCabe, Mellor, & George, 2006; Mann et al., 2000; McCabe et al., 2008). In addition, organizational barriers, such as poor communication between professional caregivers and senior staff, often impede any action that an informed and confident caregiver may decide to take (McCabe et al., 2008). In light of these issues, it has been recommended that training programs be developed to increase the knowledge and self-efficacy of professional care providers in dealing with depression (e.g., “NIH Consensus Conference,” 1992) and to overcome some of the organizational barriers that restrict depressed older care recipients from accessing appropriate treatment (Davison et al., 2006; McCabe et al., 2008).
A few studies have reported on the effectiveness of geriatric mental health training programs for staff who work with older adults. Smith et al. (1994) evaluated an education and training program designed to improve the quality of psychosocial care provided by nursing personnel in rural long-term care settings. The 2-day program, which included lectures and group exercises, was found to improve staff knowledge and attitudes toward care recipients with mental health problems. Butler and Quayle (2007) implemented a 2-day late-life depression training program specifically designed to improve caregivers’ attitudes toward and knowledge of depression among elderly care recipients. The authors found that the training program was effective in producing both knowledge and attitude change among their primary care nurse participants.
Beyondblue Depression Training Program
To further meet the challenge of identifying and managing depression among elderly care recipients, we developed a modularized depression training program for professional caregivers and senior staff working in community and residential care. The Beyondblue Depression Training Program was designed to improve professional caregivers’ knowledge of depression, as well as enhance their skills and self-efficacy in detecting depression and monitoring treatment response. In addition, the program was designed to improve and facilitate communication with senior staff and appropriate referrals to medical professionals.
Four versions of the manual have been developed for RNs and personal care assistants (PCAs), both of whom work in residential care settings, and care managers and direct caregivers, who work in community settings. Although the content for residential and community programs is similar, the manuals use examples and case studies that reflect characteristics specific to each setting. The details of the programs are described below.
Basic Training Program
The basic four-session packages for PCAs and direct caregivers provide instruction in the use of standardized procedures for the identification of depression and how to respond appropriately to signs of depression, particularly referring this information to senior staff.
Session 1 introduces caregivers to the nature and prevalence of depression, suicide rates among older adults, and the impact of depression on the physical health of this population. Caregivers are taught about the symptoms most likely to develop in depressed older care recipients. Emphasis is placed on deconstructing the myth that depression is “part of getting old” and on understanding that depression is common, yet treatable, among older adults.
Session 2 aims to improve caregivers’ skills in recognizing indications of depression in older adults. Care-givers are taught how to use a simple checklist to help in the routine detection and monitoring of these symptoms. Case studies are used to provide examples of symptom patterns and to provide the opportunity for participants to practice applying their new knowledge to detect depressive symptoms. These case studies also provide the opportunity for participants to discuss difficulties that may arise in recognizing depressive symptoms among older adults. A particular focus is on the ways older adults may mask symptoms of depression and on the use of appropriate communication with older care recipients to elicit signs of depression in its early phases.
Session 3 aims to teach caregivers how to respond appropriately to care recipients with symptoms of depression. The session also focuses on the issue of overlap between anxiety and depression and between dementia and depression. Case studies are presented to facilitate discussion of issues that may arise in such circumstances.
Session 4 focuses on referral procedures and day-to-day management of older adults with depression. Caregivers are taught a standardized procedure of referral to senior personnel to facilitate the early detection and treatment of older adults with depression. Case studies are presented and discussed, and any issues that arise are addressed. The ways caregivers can help clients with depression is outlined and discussed, with a focus on individualized activity scheduling.
Advanced Training Program
A six-session program was developed for RNs working in residential facilities, and a separate six-session program was developed for care managers working in community-based settings. These programs contain the above four sessions from the basic program, as well as two additional 2-hour sessions designed specifically for RNs and care managers. These additional advanced sessions focus on assessment skills and include training in the use of two validated screening tools, as well as skills in collecting a psychiatric history for new care recipients. In addition, these sessions teach participants skills in interfacing with health care providers and implementing strategies to help older adults with depression.
Session 5 aims to teach participants how to identify depression in care recipients with dementia. Case studies are discussed to address any issues that arise in working with this group. This session also aims to improve participants’ assessment skills, with training focused on the use of two validated screening tools: the short form of the Geriatric Depression Scale (Yesavage et al., 1983) and the Cornell Scale for Depression in Dementia (CSDD) (Alexopoulos, Abrams, Young, & Shamoian, 1988). Staff are trained in administering the CSDD through the use of a semi-structured interview with the care recipient and combining this with observations of the care recipient when calculating ratings.
Session 6 aims to teach participants skills in interfacing with health care professionals such as GPs and mental health specialists. Participants are trained in collecting a psychiatric history with new care recipients, which they practice using the validated screening tools introduced in session 5.
Within both the basic and advanced training programs, worksheets are included in the manual to record changes in older adults’ symptoms. These worksheets are designed to be used in routine practice by professional caregivers to facilitate early detection of depression, monitor treatment response, and facilitate communication with medical professionals.
In this study, we report on the implementation of the training program with professional caregivers in both residential and community services in Australia. In particular, we report on their perceptions of how the program increased their knowledge of depression among older adults, increased their self-efficacy in recognizing and taking action in response to depression in their care recipients, and reduced organizational barriers to provision of treatment for depression, as well as their overall evaluation of the training program.
The 52 participants in this study were professional caregivers (50 women and 2 men), who ranged in age from 24 to 65, with a mean age of 45 (SD = 11 years). Participants worked in various elder care settings: 4 community-based services (n = 26, 50%), and 5 residential nursing homes or hostels (n = 26, 50%). Among those working in residential care, 4 participants (15%) worked in nursing homes for older adults (high-level care facilities), and the remaining participants (n = 22, 85%) worked in hostels (low-level care facilities).
Among those working in community settings, 13 (50%) were care managers and 13 (50%) were direct caregivers. Of the participants working in residential nursing homes and hostels, 10 (38%) were RNs and 16 (62%) were PCAs. The length of time participants had worked in the elder care industry ranged from 4 months to 28 years, with a mean length of employment of 8 years (SD = 7 years, 3 months).
The participants reported varied professional training in elder care. Of the 13 care managers, 2 had completed a Certificate III course, 1 reported receiving “other” formal training, and the remaining care managers had a university education, either in social work, health promotion, nursing, or sociology. Most direct caregivers (n = 8) reported previous training in elder care at the Certificate III level, and 1 reported no formal training. In addition, 2 direct caregivers reported previous completion of a university degree in community development, and 2 reported receiving “other” formal training.
Among the participants working in residential settings, all of the RNs were Division I (n = 10), with 6 reporting they had completed a university degree. Four RNs reported having received “other” formal training, such as training in hospitals. The training most common among PCAs working in nursing homes and hostels was a Certificate qualification from technical and further education colleges. Two PCAs reported receiving no formal training.
Approval to conduct this study was obtained from the University Ethics Committee and the boards of management of each participating elder care service. Managers from these agencies were contacted initially and agreed to allow elder care staff members to be approached for participation in this study. Caregivers from each of these agencies were invited to participate in this study. The participants, who received paid leave to attend the training program, completed the program in their work-places in groups of 10 to 20 over 4 weeks (PCAs and direct caregivers) or 6 weeks (case managers and RNs). The training program was implemented by a psychologist (S.R.) who had been trained for the purposes of the study.
Post-Training Focus Group Interview
At the completion of the training program, four focus groups were conducted to obtain feedback from participants about the program and their experiences in completing it. Participation in the focus groups was determined by availability, and 24 (46%) of those who participated in the training programs were represented. The two focus groups for the basic training program included 5 PCAs, and 7 direct caregivers. The other two focus groups, which related to the advanced training program, included 8 care managers and 4 RNs. With the informed consent of participants, discussions were audiorecorded to allow for transcription of data.
A semi-structured interview guide was used in the focus groups. The focus group interview for the basic program included questions such as:
- How do you feel about detecting depression among older adults after completing the program?
- Did the program increase your knowledge?
- Did the program increase your skills in recognizing depression and in knowing what to do?
- Do you think you will use the simple checklist in practice?
- How did you find the level of complexity of the program? Did it come in at your current knowledge/ skill level?
- Do you feel better able to communicate with older adults with depression?
- Do you feel better able to discuss your concerns with your manager?
The interview guide for the advanced program included additional items:
- Do you feel better able to discuss your concerns with GPs and take these concerns to the next level?
- Do you think GPs will respond to your information?
- Do you feel better able to detect depressive symptoms in older adults?
- Do you feel better able to encourage caregivers to express their concerns about depression among their clients?
Three aspects of professional care-givers’ perceived abilities, as well as their perceptions of the effectiveness of the program, emerged from the focus group discussions following the training program:
- Perceived knowledge and awareness of depression.
- Self-efficacy in working with depressed older adults.
- Perceived barriers to best management of depression in older adults.
- Effectiveness and evaluation of the training program.
Perceived Knowledge and Awareness of Depression
Caregivers unanimously reported that the program had increased their knowledge of depression, and they generally believed the program extended, refreshed, and reinforced their existing knowledge and skills base. They also felt more confident detecting depression among older adults following completion of the program. Some caregivers mentioned specific aspects they found most useful, including the screening tools; the topics on differences between depression, anxiety, and dementia; and the forum to discuss these specific areas and share experiences. Caregivers indicated that they found the program to be both interesting and useful, particularly as it related to their work. Participants’ feedback included:
- “It [the program] is useful because you can take this knowledge out there with you and use it in the workplace” (direct caregiver, community setting).
- “It sort of crystallized it [information on depression] in my mind; this is what I look for” (care manager, community setting).
- “[The program] is easy enough for every level of staff to be able to take it on board and do something” (RN, residential nursing home).
Caregivers identified a new awareness of the high levels of depression within the client groups with whom they were working. They all expressed positive feelings of increased knowledge and skills and felt better able to communicate with older adults. Open-ended questions were identified as a useful tool when conversing with care recipients; one PCA in a residential nursing home who had already tested the newly acquired skill found it to be useful, saying, “I used them with one of our gentlemen, and it sort of helped actually.”
Self-Effcacy in Working with Depressed Older Adults
Participants felt an increased sense of confidence in their abilities to detect depression following completion of the program, with most of them specifically identifying their increased understanding in distinguishing dementia and depression. Caregivers all agreed they felt better equipped to communicate with older adults with depression, reporting, “We have a couple of tools now to work with” (PCA, residential nursing home) and “I think that it does improve confidence and experience” (care manager, community setting).
Perceived Barriers to Best Management of Depression in Older Adults
PCAs and direct caregivers all agreed they were better able to discuss their concerns with their manager after completing the program, feeling that it gave them, as one community-based direct caregiver stated, “more ammunition, and that little bit [of] extra confidence behind your arguments.”
They also believed their managers would be responsive to their concerns, with one community-based direct care-giver already having received positive feedback following the implementation of her newly acquired referral skills and the use of the simple checklist, stating, “I have had positive feedback this week with one of my clients…. He has become very depressed. So I just put a feedback form in, and there has been some action taken.”
Most RNs and care managers agreed that after completing the program, care-givers would be more likely to speak to them about their concerns, and several indicated that this had already occurred in their workplace. For example, a community care manager said, “Well, I’ve had one e-mail already,” and a residential RN stated, “I am encouraging the girls. The checklists have been coming in to me, and this process is starting to filter down to the other caregivers, which is really good.”
Despite these remarks, other RNs and care managers believed many barriers would still prevent caregivers from approaching them, including RN and care manager perceptions of staff laziness, difficulty implementing change in workplace practices, and lack of skill and knowledge among staff who did not take part in the program and who may feel that monitoring depression is outside their role.
Most RNs and care managers felt better able to discuss their concerns with GPs, as the screening tools they used to help the process of referral gave them more credibility. However, some remained skeptical that GPs would be responsive, with one community-based care manager expressing that “it depends on the GP,” and one residential nursing home RN stating that “[they] still need a little push.”
Effectiveness and Evaluation of the Training Program
Participants appreciated that the program was presented in “layman’s terms,” making it simple to understand and stay involved. Group members did not believe anything had been left out and thought the level of the program was appropriately targeted, stating:
- “Yeah, [I am now] better able to recognize signs and feed it back through the case manager” (direct caregiver, community setting).
- “I think you covered it very well; it was very thorough” (RN, residential nursing home).
- “I like the fact that you could understand it and it was in layman’s terms and it wasn’t trying to make it too complex and out of other people’s league. It’s very user friendly” (RN, residential nursing home).
- “It was such a great opportunity” (direct caregiver, community setting).
RNs voiced a consensus that it would have been beneficial for more PCAs and team leaders to have participated in the program. They thought it would be good to do all of the training together. As one residential nursing home RN stated, “I thought that it was very educational. And what I liked about it was when the PCAs were here that they learnt [sic] a lot and took a lot on board, and I think for registered nurses it was well worth doing.”
Many participants enjoyed the level of interaction and believed the small group size worked well, as expressed by one residential PCA: “It was good, because you are relaxed and happy and jolly. It wasn’t like listening to some stale drone.” Yet another stated that “sometimes the discussions are much better than a whole heap of overheads. We’ve had training in the past where people have come out, and it’s been just overhead upon overhead, and you think ‘oh.’”
All participants agreed a couple of full-day or half-day annual refresher sessions would be useful. The specific sessions seen to be most useful to repeat were detection, distinguishing between depression and dementia, and distinguishing between anxiety and depression. One residential nursing home PCA stated, “It made you think, and when you started thinking about it, you thought, ‘Hang on a minute, maybe I don’t know that much about anxiety and the difference between it and depression and how they overlap.’”
Caregivers voiced the importance of the information conveyed and the difficulty in trying to help other staff members who did not participate in the training to broaden their perspectives. For example, as one residential nursing home PCA said, “Perhaps it is their tunnel vision…. If they were educated on it, they may change their views. So that’s [education] the thing that I think they need.”
Some caregivers believed all staff would benefit from the training program. One residential PCA suggested that it would be good if employers “could introduce it a little more, into the rest of the workplace, rather than just a few of us.”
It was generally believed that the role-playing activities were the least beneficial and enjoyable element of the program. In contrast, caregivers found other aspects to be valuable. One residential nursing home PCA expressed that “the group discussions were good…. They [group discussions] open up to more ideas and share existing knowledge between each other.” A community care manager shared that “instead of role-plays…it may be good to talk through a written scenario or watch a DVD of different case studies…[which] may achieve the same endpoint.”
Caregivers particularly liked the handouts, which they thought were useful resources for future reference. All participants confirmed their intentions in using the checklist, as expressed by a residential nursing home PCA, who stated, “I’ve photocopied 20 of them, that’s how keen I am,” and a community-based direct caregiver, who said the checklists were “very simple to use.”
Overall, RNs and care managers found the additional two sessions, which focused on training in the use of two validated screening tools and communicating with GPs, to be particularly useful. They were all positive about using both of the screening tools in the future. As one community-based care manager stated, “It’s good to have, and now we know what to do. Instead of trying to think and ask questions, we can look at the tools. I think it was very helpful.” A residential nursing home RN called the tools “practically useful.”
In this study, we obtained feedback from caregivers of older adults on the usefulness of a newly developed training program designed to assist them in recognizing, monitoring, and taking appropriate action when one of their care recipients shows symptoms of depression. The program was delivered to both direct care and senior staff, with the latter group receiving additional modules.
Post-training focus group interviews with participants demonstrated that the professional caregivers believed they had an increased awareness of the symptoms of depression and recognized that they were in the best position to detect depression among older adults in their care. They all indicated an increased sense of confidence in their abilities to detect depression in their older care recipients and specifically identified their better understanding of the distinction between dementia and depression and their greater confidence in communicating with depressed older adults as benefits.
The focus group interviews also indicated that caregivers believed communication between staff members was no longer a barrier to care for their older clients. PCAs and direct caregivers all indicated that after the program, they were better able to discuss their concerns with senior staff, whom they believed would be responsive to their concerns. Another encouraging finding was that senior staff (RNs and care managers) believed that training in the use of validated screening tools was particularly useful and would benefit them in communicating with GPs and mental health professionals. Although previous research by McCabe et al. (2008) indicated that community care managers were reluctant to consider the use of screening tools among their care recipients because they believed it would compromise their professional relationship with care recipients, no such concerns were apparent after this program.
Limitations and Future Research
Despite this optimism, the findings need to be considered with caution. Our qualitative methods, which were based on semi-structured interviews, may have limited the range of data collected and thereby produced results that are an artifact of the procedure. Therefore, the results may not be generalizable to other settings, and they need to be supported with further empirical evidence. In other words, this preliminary and qualitative pilot study lays the foundation for a more systematic and rigorous controlled study of the benefits of the program. A future study would use quantitative measures of the variables investigated in this study, with a particular focus on the persistence of changes in work practices and the impact of the program on care recipients’ well-being. This would necessitate a longitudinal design and randomized allocation of caregivers or facilities to training and control conditions.
Overall, the training program examined in this study proved to be highly acceptable to the participants and had, from their perspective, positive effects on their knowledge, efficacy, and work practices. These enhancements to their skill repertoire were reported to be associated with improved communication within their services and with GPs. These findings suggest that the training program may be a useful strategy to address the significant problem of detection and treatment of depression among older care recipients.
- Alexopoulos, GS, Abrams, RC, Young, RC & Shamoian, CA1988. Cornell Scale for Depression in Dementia. Biological Psychiatry, 23, 271–284. doi:10.1016/0006-3223(88)90038-8 [CrossRef]
- Alexopoulos, GS, Buckwalter, K, Olin, J, Martinez, R, Wainscott, C & Krishnan, KR2002. Comorbidity of late life depression: An opportunity for research on mechanisms and treatment. Biological Psychiatry, 52, 543–558. doi:10.1016/S0006-3223(02)01468-3 [CrossRef]
- Butler, MP & Quayle, E2007. Training primary care nurses in late-life depression: Knowledge, attitude and practice changes. International Journal of Older People Nursing, 2, 25–35. doi:10.1111/j.1748-3743.2007.00054.x [CrossRef]
- Covinsky, KE, Kahana, E, Chin, MH, Palmer, RM, Fortinsky, RH & Lande-feld, CS1999. Depressive symptoms and 3-year mortality in older hospitalized medical patients. Annals of Internal Medicine, 130, 536–569.
- Davison, T, McCabe, M, Mellor, D & George, K2006. Detection of depression among aged persons with depression: The role of care staff. In Katsikitis, M (Ed.), Proceedings of the Joint Conference of the Australian Psychological Society and the New Zealand Psychological Society (pp. 85–89). Auckland, New Zealand: The Australian Psychological Society, Inc.
- Davison, TE, McCabe, MP, Mellor, D, Ski, C, George, K & Moore, K2007. The prevalence and recognition of depression among low-level aged care residents with and without cognitive impairment. Aging & Mental Health, 11, 82–88. doi:10.1080/13607860600736109 [CrossRef]
- Fries, BE, Mehr, DR, Schneider, D, Foley, WJ & Burke, R1993. Mental dysfunction and resource use in nursing homes. Medical Care, 31, 898–920. doi:10.1097/00005650-199310000-00004 [CrossRef]
- George, K, Davison, TE, McCabe, MP, Mellor, D & Moore, K2007. Treatment of depression for low-level care residential facilities for the elderly. International Psychogeriatrics, 19, 1153–1160. doi:10.1017/S1041610207005364 [CrossRef]
- Gurland, B1992. The impact of depression on quality of life of the elderly. Clinics in Geriatric Medicine, 8, 377–386.
- Huang, BY, Cornoni-Huntley, J, Hays, JC, Huntley, RR, Galanos, AN & Blazer, DG2000. Impact of depressive symptoms on hospitalization risk in community-dwelling older persons. Journal of the American Geriatrics Society, 48, 1279–1284.
- Katz, IR1996. On the inseparability of mental and physical health in aged persons: Lessons from depression and medical comorbidity. American Journal of Geriatric Psychiatry, 4, 1–16.
- Lebowitz, BD, Pearson, JL, Schneider, LS, Reynolds, CF 3rd. , Alexopoulos, GS & Bruce, ML et al. 1997. Diagnosis and treatment of depression in late life: Consensus update. Journal of the American Medical Association, 278, 1186–1190. doi:10.1001/jama.278.14.1186 [CrossRef]
- Mann, AH, Schneider, J, Mozley, CG, Levin, E, Blizard, R & Netten, A et al. 2000. Depression and the response of residential homes to physical health needs. International Journal of Geriatric Psychiatry, 15, 1105–1112. doi:10.1002/1099-1166(200012)15:12<1105::AID-GPS252>3.0.CO;2-W [CrossRef]
- McCabe, MP, Davison, T, Mellor, D & George, K2008. Knowledge and skills of professional carers working with older people with depression. Aging & Mental Health, 12, 228–235. doi:10.1080/13607860701797166 [CrossRef]
- McCrae, N, Murray, J, Banerjee, S, Huxley, P, Bhugra, A & Tylee, A et al. 2005. “They’re all depressed, aren’t they?” A qualitative study of social care workers and depression in older adults”. Aging & Mental Health, 9, 508–516. doi:10.1080/13607860500193765 [CrossRef]
- Mellor, D, Davison, T, McCabe, M & George, K2008. The management of depressed elderly care recipients: Family perspectives on the skills of professional carers. Journal of Community Health Nursing, 25, 44–61. doi:10.1080/07370010701836401 [CrossRef]
- Mellor, D, Davison, T, McCabe, M & George, K (in press). Professional carers’ knowledge and response to depression among their aged-care clients: The care recipients’ perspective. Aging and Mental Health
- Mellor, D, Davidson, T, McCabe, M, George, K, Moore, K & Ski, C2006. Satisfaction with general practitioner treatment of depression among residents of aged care facilities. Journal of Aging and Health, 18, 435–457. doi:10.1177/0898264306286199 [CrossRef]
- NIH consensus conference: Diagnosis and treatment of depression in late life. 1992. Journal of the American Medical Association, 268, 1018–1024.
- O’Connor, DW, Rosewarne, R & Bruce, A2001. Depression in primary care. 1: Elderly patients’ disclosure of depressive symptoms to their doctors. International Psychogeriatrics, 13, 359–365. doi:10.1017/S1041610201007748 [CrossRef]
- Samuels, SC & Katz, IB1995. Depression in the nursing home. Psychiatric Annals, 25, 419–424.
- Smith, M, Buckwalter, KC, Garand, L, Mitchell, S, Albanese, M & Kreiter, C1994. Evaluation of a geriatric mental health training program for nursing personnel in rural long-term care facilities. Issues in Mental Health Nursing, 15, 149–168. doi:10.3109/01612849409006910 [CrossRef]
- Yesavage, JA, Brink, TL, Rose, TL, Lum, O, Huang, V & Adey, M et al. 1983. Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37–49. doi:10.1016/0022-3956(82)90033-4 [CrossRef]