REVIEW

A systematic review of the effectiveness of in-home community nurse led interventions for the mental health of older persons
Penelope Thompson
BEd, RN, BNurs (Hons)

Research Ofcer, School of Nursing and Midwifery, La Trobe University, Bundoora, Vict., Australia;

Lyn Lang

MEd, BEd, BHSc, RN

Director, Nursing Studies Unit, La Trobe University (Albury-Wodonga Campus), Wodonga, Vict., Australia;

Merilyn Annells

PhD, RN

Professor of Community Nursing, School of Nursing and Midwifery, La Trobe University, Bundoora, Vict., Australia

Submitted for publication: 3 February 2007 Accepted for publication: 14 November 2007

Correspondence: Merilyn Annells Professor of Community Nursing School of Nursing and Midwifery La Trobe University Bundoora Vict. 3086 Australia Telephone: +61 3 9893 4223. E-mail: drjones@bigpond.net.au

T H O M P S O N P , L A N G L , A N N E L L S M ( 2 0 0 8 ) Journal of Clinical Nursing 17, 14191427 A systematic review of the effectiveness of in-home community nurse led interventions for the mental health of older persons Aims and objectives. The aim was to systematically review evidence about the effectiveness of in-home community nurse-led interventions for older persons with, or at risk of, mental health disorders, to inform best practice nursing care with this focus. The primary review question was How effective are in-home community nurse-led interventions for older persons with or at risk of mental health disorders for improving mental health? The outcome indices of interest were nursing actions to determine incidence or prevalence of mental health disorders, any change in a patients attitude towards their mental health condition, any change in objective measurement of mental health, or a change in diagnostic status. Background. The rising incidence of mental health disorders in older persons is a major concern for community nurses in developed countries. Effectively facilitating improved mental health for older persons is necessary in this era of ageing populations with increased demands on health funding. Disseminating systematically reviewed evidence for in-home community nursing that positively impacts on the mental health of older persons is crucial to ensure effective care is provided to this vulnerable patient group. Results. This review reveals that there is evidence to support the superiority of applying validated screening tools for mental health disorders over relying on community nurses opinions and non-validated tools about this matter. Design. Systematic review. Methods. Search of electronic databases. Conclusion. A clear need for replication and multi-centre trials of reviewed pertinent studies is identied. Relevance to clinical practice. Community nurses should consider using validated screening tools for this focus. Until such time as higher quality evidence is available about other nursing interventions, the reviewers suggest that the prime nursing action

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should be the identication of whether older persons receiving community nursing care might have a mental health disorder and, if so, then collaborative referral is made to appropriate services. Key words: aged, community nursing, mental disorder, systematic review

Introduction
The de-institutionalisation of persons with mental health disorders (MHDs) since the 1960s (Morris 1996, Cohen 1999), combined with an ageing population (Jeste et al. 1999), has seen community nurses in many developed countries increasingly respond to the care needs of growing numbers of older persons with MHDs. The demand for community-based nursing care of older persons with, or at risk of, MHDs is set to increase. For instance, Jeste et al. (1999) estimate a prevalence of almost 20% of older persons with signicant symptoms of mental illness in the USA, and projects that the number will more than triple from four million in 1970 to 15 million by the year 2030. Nursing care in the home for persons with MHDs has been demonstrated to have a positive impact on rates of hospital readmission, quality of life and length of hospital stay (Cohen 1999). Community nurses are in a pivotal position to identify changes in mental health and for implementing strategies that might include screening, assistance with medications, monitoring for changes over time, referral and, perhaps, psychotherapies like counselling. Globally, it is usual that actual mental health assessment is conducted only by qualied mental health professionals, including perhaps community mental health nurses; however, community nurses may screen for the possibility of MHDs that may identify the need for mental health assessment by qualied others. There are economic, social and cultural imperatives to ensure the effectiveness of nursing interventions for older persons with MHDs and systematic reviews tangentially related to this topic have examined the effectiveness of interventions for home-based psychogeriatric patients (Van Citters & Bartels 2004, Bruce et al. 2005), but no review has focused on the specic role of the generalist community nurse who provides home-sited nursing care to older persons.

Objectives and methods

The objectives of this review were: 1 To present the best available information on the range and efcacy of in-home community nurse-led interventions for older persons with, or at risk of, MHDs; 2 To ascertain gaps in knowledge about community nurseled interventions for older persons with, or at risk of, MHDs; 3 To suggest foci for further research regarding this topic. The primary question addressed by this review was: How effective are in-home community nurse-led interventions for older persons with or at risk of MHDs for improving mental health?

Inclusion criteria
Types of studies This review considered any randomised controlled trials, quasi-experimental studies or studies with a qualitative research design that addressed in-home community nurse-led interventions intended to facilitate the mental health of patients who are older persons. Publications that consisted solely of narrative or opinion were not considered for this review. Only studies published in English between 1995 2006 were considered. Types of participants The activities of community nurses were the principal focus. The term community nurse was, for the purpose of this review, conned to registered nurses who were generalists (non-specialist) and employed by an organisation providing home-based health care. Nurses with a designated mental health nursing function or based in community health clinics were outside the scope of this review. Studies that included community nurses patients who were aged 60 years or older, male or female, living at home (that is, not in a managed care facility) and had, or were at risk of, a MHD were examined. Types of interventions Interventions of interest were those carried out by a community nurse in the patients home, and which specically intended to facilitate the mental health of the patient.

Aim
This review aimed to identify the effects of nurse-led interventions for home-based patients who are older persons (60 + years of age) with or at risk of MHDs.
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Consequently, interventions sought for review were wideranging and included screening, education, referral, consultation, counselling, medicine administration, complementary therapy or any psychological intervention that could be instigated within the scope of a community nurses role. Types of outcome measure The outcome measures of interest were those that measured: Nursing actions to determine incidence or prevalence of MHDs; Any change in a patients attitude towards their MHD; Any objective measurement of mental health; A change in diagnostic status regarding a MHD.

independently evaluated the retained studies to ensure their inclusion was appropriate.

Critical appraisal
The methodological quality of each included study was assessed independently by the two reviewer units prior to nal inclusion. The reviewer units were not blinded to the names of the authors, institutions, journal or results of the studies during the assessment process. Studies were assessed and rated for the validity of their design and conduct, specically focusing on: The quality of randomisation; Whether or not participants were blinded to treatment; Whether or not allocation to treatment groups was concealed from the allocator; Whether attrition was adequately accounted for; Whether or not those assessing outcomes were blind to the treatment allocation; Whether the control and treatment groups were comparable at entry; Whether groups were treated identically other than for the stated interventions; Whether outcomes were measured reliably and in the same way for all groups; Whether appropriate statistical analyses were used. The protocol for disputations was arbitration by a third party.

Search methods
Identication of studies
Using a three-tiered strategy, studies were initially identied in CINAHL and MEDLINE using the terms nurse and mental disorder and aged in the title or abstract, or indexed as key words. An in-depth search followed using all identied index terms and key words, and nally a handsearch of the bibliographies of all relevant studies was undertaken. Data bases searched included: CINAHL, MEDLINE, PsycINFO, Proquest Health and Medical Complete (including Dissertation and Theses), Excerpta Medica Database (Embase), Australian Public Affairs Information Service (APAIS) Health, The Cochrane Library, Joanna Briggs Institute of Nursing and Midwifery, DARE and World Health Organisation Health Evidence Network. The search was limited to studies published between 1995 and 2006 in the English language. Publication bias was addressed to a limited extent through the searching of Dissertation and Theses in the Proquest Database. Time constraints restricted the search strategy and did not allow for hand-searching of topic-specic journals, comprehensive searching of the Internet, contacting of relevant organisations or topic experts for further references, or replication of the search by an independent person.

Data collection
To minimise the risk of error during data transcription, data were extracted independently by two reviewer units using a quantitative data extraction tool requiring identication of the number of participants, description of intervention, outcome measures, the results for dichotomous data for all groups and of continuous data for all groups, a checklist for assessing validity of the study and space for recording both the authors conclusions and the reviewers comments. Data were compared for differences.

Data synthesis
The review topic was deliberately broad and the identied studies investigated many different nurse-led interventions for a variety of MHDs. Statistical pooling of results was not appropriate; therefore, results were summarised in narrative form. Consequently, where multiple assessments were used on a single group of subjects, all outcomes were reported typically this would not occur in a meta-synthesis to avoid over-estimation of the data.
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Selection of studies
Identied studies were assessed for relevance based on the title, abstract and body text; those identied from the handsearch were assessed for relevance on title alone. A full report of each relevant study was then retrieved and read in detail to assess whether it met inclusion criteria. Two reviewer units (a unit of one researcher and a unit of two researchers)

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P Thompson et al. Community nurse implementation of multidisciplinary developed management plans of older patients with depression Community nurse implementation of multidisciplinary developed management plans of older patients with depression Community nurse recognition of older patients depressive symptoms Outcome and Assessment Information Set (OASIS) 15-item Geriatric Depression Scale (GDS-15) 15-item Geriatric Depression Scale (GDS-15) Total quality management (TQM) Primary Care Evaluation of Mental Disorders (PRIME-MD), Psychological Distress Index ((PDI-29), Case managers a priori judgement of older clients mental health status Psychogeriatric Assessment & Treatment in City Housing (PATCH)

Results
Description of studies
The search identied 204 studies of interest, of which only fourteen met inclusion criteria. Critical appraisal resulted in ve eliminations leaving nine studies that met all inclusion criteria (see Table 1). Of the nine included studies, only one was a randomised controlled trial (see Table 1). The variation in study design and purpose made it inappropriate to combine results in a meta-analysis. Investigation of depressive symptomatology was the sole focus of seven of the nine included studies: two studies investigated any mental health disorder as dened by the Diagnostic and Statistical Manual of Depressive Disorders (DSM), version III onwards, including depression, anxiety, schizophrenia and substance abuse disorders. Given that the range of mental health disorders affecting older persons is broad, and the variety of nursing activities related to mental health care for persons living at home is extensive, the paucity of rigorously designed studies is noteworthy. All included studies used nurses to screen patients for MHDs, either as a component or the primary focus of the study, reecting the signicant role nurses play in the early identication of at-risk older persons. The results are presented as two clusters based on the focus of their interventions: screening and comprehensive nursing interventions.

Country

Intervention/focus

USA USA USA USA USA Canada

UK

UK

USA

Randomised controlled trial

Screening
Nurse practitioners used the 15-item Geriatric Depression Scale (GDS-15) to ascertain the prevalence of depressive symptomatology in a large convenience sample of 345 homebound older persons (Engberg et al. 2001). Participants were sourced from a larger study on homebound older persons living with self-reported incontinence. Data were collected during the rst 12 visits of an in-home face-to-face admission assessment. Clinical recognition of depression was also sought from in-home chart review and medication review. Brown et al. (2003) sought to determine the ability of community nurses to identify depressive symptoms correctly in older patients living at home (n = 403). The survey responses of 42 nurses regarding presence of depressive symptoms were compared with the results of patient interviews by research assistants using the Structured Clinical Interview for DSM-IV disorders (SCID). The professional status of the research assistants was not disclosed; therefore, the quality of the interviews is questionable. Diagnostic status was conrmed using multiple methods. Nurses opinions about whether or not, and to what extent, the patient was depressed were surveyed verbally and compared with the DSM-IV diagnosis of

Case-controlled cohort

Table 1 Included studies author/s, design, country and intervention/focus

Case-controlled cohort Blanchard et al. (1999)

Brown et al. (2003) Brown et al. (2004) Dalton and Busch (1995) Engberg et al. (2001) Flaherty et al. (1998) Preville et al. (2004)

Blanchard et al. (1995)

Descriptive correlational Descriptive correlational Descriptive correlational Descriptive correlational Case-control Descriptive correlational

Study design

No.

3 4 5 6 7 8

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Rabins et al. (2000)

Author/s

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major or minor depression. Both the nurses and the interviewers were blinded to the results of the initial patient interview. In a subsequent study, Brown et al. (2004) compared the accuracy of 64 community nurses start-of-care Outcome and Assessment Information Set (OASIS) ratings of depressive symptom items (depressed mood and diminished interest in most activities) against the clinical ratings obtained during SCID interview of 220 randomly-selected, medical-surgical home care older people. Unlike Brown et al. (2003), quality control was attempted with the study psychologist reviewing the interviews and rating the patients for major or minor depression. The interviewers and study psychologist were blinded to the outcomes of the OASIS assessments. Similarly, Dalton and Busch (1995) investigated whether nurses were making depression-related nursing diagnoses for a convenience sample of 40 patients who were clinically depressed according to the 30 item GDS (GDS-30). Patient histories were examined for the presence of relevant North American Nursing Diagnosis Association (NANDA) diagnoses, and opinion reports were sought from nurses regarding their patients mental health status. Evaluation of this study was constrained by the report not indicating whether there was blinding during data collection, the number of nurses involved or how their verbal reports were ascertained. In a large study (n = 177) comparing accuracy of three different tools to the SCID (Preville et al. 2004), the necessity of effective screening by nurses for psychiatric disorders was demonstrated. Of interest to this review was the study component whereby the nurse case manager was asked whether or not there was a probable case of mental health disorder (yes/no). Within the following four weeks, a psychologist, blinded to the initial interview results, conducted the SCID interview for DSM-IV disorders and diagnosed the patient. Psychologists administering the SCID were trained to do so, providing some quality control.

sion scale (DPDS); secondly, detailed assessment through the Geriatric Mental State (GMS-AGECAT) History and Aetiology Schedule (HAS) that combines a semi-structured interview with a computer program to generate symptom proles and diagnoses according to psychiatric protocols; thirdly, study nurses kept a diary of their activities. Research workers blinded to the subject status collected the three month data and analysed the nurses diaries. In a follow-on study, Blanchard et al. (1999) sought evidence of the longer term benets by repeating Short-CARE and GMS-AGECAT on 64 subjects over 623 months: 35 out of 47 of the original intervention group and 29 out of 49 of the original control group. Variation in interview time was accounted for. A ve-part total quality management (TQM) plan intervention group was compared with a historical control group for rates of hospitalisation in the study by Flaherty et al. (1998). Additional analyses included effectiveness of nurses psychosocial assessment in detecting depression compared with the GDS-30. Patients were not randomised and data collections were unblinded. Rabins et al. (2000) tested the impact of a nurse-based mobile outreach programme on levels of depression, psychiatric symptoms and undesirable moves (e.g., to a nursing home). This tiered study identied psychiatric disorder screen-positive residents 60 years of age (n = 310), and a random sample of 10% of screen-negative residents (n = 61) from a cluster of urban public housing buildings. Participants underwent a SCID for DSM-III disorders and cognition assessment as administered by trained mental health professionals at baseline and repeated at 26 months. Outcome measures of interest were a change in the Brief Psychiatric Rating Scale-18 item (BPRS-18) and the Montgomery-Asberg Depression Rating Scale (MADRS).

Methodological quality of included studies

Study designs were appropriate for the phenomena being investigated. No studies reported power calculations to estimate adequate sample size, with only two studies having sufcient participants to be considered moderately sized that is, greater than 200 participants (Brown et al. 2003, 2004), and the remainder, bar one, had numbers too small to be considered representative. Rabins et al. (2000) sampled their entire population. Limitations to the signicance on generalisability of ndings were generally well reported: for example small numbers, the recruiting of nurses from only one agency and non-random sampling. Random sampling for subjects is an important means of ascertaining a representative sample and controlling for selection bias. Two studies did report random sampling (Brown et al.
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Comprehensive nursing interventions

Blanchard et al. (1995) sought to ascertain whether depressed older adults (n = 96) gained mental health benet from a threemonth intervention of individualised care plans implemented by a nurse when compared with usual primary care management. Each case was randomly allocated to either the study nurse intervention (n = 47) or usual primary care management (n = 49). The intervention was implementation of the care plan through ten weekly nurse visits of 45 minutes duration with additional liaison with the local general practitioner and the multidisciplinary team. Data were obtained in three forms at entry and at three months: rstly, the Short-CARE tool screened for depression using the imbedded diagnostic depres-

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2003, 2004) but did not specify their process beyond designed to recruit a representative sample of agency patients (Bruce et al. 2002). The remainder used convenience or purposive sampling (Blanchard et al. 1995, 1999, Dalton & Busch 1995, Flaherty et al. 1998, Rabins et al. 2000, Engberg et al. 2001, Preville et al. 2004). The reviewers suggest this lack of randomised sampling may be in part explained by an attempt to avoid the problem of who misses out in treatment studies, but also the design and populations for the majority of the included studies did not readily lend themselves to randomisation. Of the three studies reporting randomisation to intervention/control groups (Blanchard et al. 1995, 1999, Rabins et al. 2000), none reported their randomisation processes or whether selection bias was controlled for using allocation concealment. Two studies deliberately matched participants for duration of diagnosis of depression (Blanchard et al. 1995, 1999). Post-hoc analysis for matching of group demographics was reported in four studies and generally found to be well-matched. Notable group differences were reported as rates of marriage (higher in intervention group) (Rabins et al. 2000) and duration of weeks of home care service (longer in control group) (Flaherty et al. 1998). Enumeration of attrition rates is important for the detection of attrition bias and generally the studies in this review made some attempt to report these gures. Drop out rates were relevant for ve studies and were enumerated in three (Blanchard et al. 1995, 1999, Preville et al. 2004), included in the analyses in two (Blanchard et al. 1995, 1999), but not reported or not considered in the outcome in two (Flaherty et al. 1998, Rabins et al. 2000). Attrition rates were relevant for four studies and were enumerated in three (Flaherty et al. 1998, Blanchard et al. 1999, Rabins et al. 2000), included in the analysis of one (Blanchard et al. 1999), and not reported in one (Blanchard et al. 1995). In addition, intention-to-treat analysis was reported in one study (Blanchard et al. 1999), although how this was conducted was unclear that is, were
Table 2 Frequency of use of validated screening or assessment tools Tool Diagnostic Depression Scale (DPDS) Structured Clinical Interview for DSM III or IV Disorders (SCID)

participants analysed in the groups to which they were randomised regardless of which (or how much) treatment they actually received, and regardless of other protocol irregularities, such as ineligibility, and were all participants included regardless of whether their outcomes were actually collected (Deeks, Higgins & Altman 2005). Detection bias was controlled for by blinding of outcome assessors in six studies (Blanchard et al. 1995, 1999, Rabins et al. 2000, Brown et al. 2003, 2004, Preville et al. 2004). Only one study declared their assessors unblinded (Flaherty et al. 1998). Tools used to measure outcomes or used as criterion standards were all reported as well-validated (see Table 2). Reported data were largely in raw form and accompanied by analyses and estimates of signicance, such as p values and condence intervals. Despite the use of the gold standard SCID for the detection of MHDs, the quality of data collected is questionable when not conducted by a psychiatrist. Some attempt at quality control was made: Preville et al. (2004) used trained psychologists; Rabins et al. (2000) used trained mental health professionals; and Brown et al. (2004) used research associates who tested highly on inter-rater reliability with a second associate (intraclass r = 091, 95% CI 086095) and then used a psychologist to review the interviews and assign the diagnosis. By contrast, the research assistants used by Brown et al. (2003) are only reported as having training in reliability, which in no way confers expertise. The quality of the data in two studies using the GDS is also called into question as they did not screen out participants with high level cognitive impairment (Dalton & Busch 1995, Flaherty et al. 1998), despite the fact that the GDS fails to identify depression in persons with mild to moderate dementia (Montorio & Izal 1996).

Outcomes
The breadth of the review questions has captured a diverse range of nursing activities related to older persons with, or at

The studies using the tool Blanchard et al. (1995) Blanchard et al. (1999) Brown et al. (2003) Brown et al. (2004) Preville et al. (2004) Flaherty et al. (1998) Dalton and Busch (1995) Engberg et al. (2001) Preville et al. (2004) Preville et al. (2004) Rabins et al. (2000) Rabins et al. (2000)

Geriatric Depression Scale-30 item (GDS-30) Geriatric Depression Scale-15 item (GDS-15) Primary Care Evaluation of Mental Disorders (PRIME-MD) Psychological Distress Index-29 (PDI-29) Brief Psychiatric Rating Scale-18 item (BPRS-18) Montgomery-Asberg Depression Rating Scale (MADRS)

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risk of, MHDs. The most frequent nursing action uncovered by this review was screening, with the remaining studies reporting multi-faceted nursing interventions. Results are, therefore, presented as two clusters: screening and comprehensive nursing interventions. Screening Screening for mental health disorders, most often depression, was the most frequent nursing activity investigated by the studies. Screening alone was the focus of ve studies (Dalton & Busch 1995, Engberg et al. 1999, Brown et al. 2003, 2004, Preville et al. 2004) and screening as a component of a more indepth intervention, a minor component of four studies (Blanchard et al. 1995, 1999, Flaherty et al. 1998, Rabins et al. 2000). In studies where screening alone was the focus, nurse judgements or usual admission assessments were compared with validated tools and in each case the tool was superior for detecting an actionable level of psychiatric symptoms. Nurses opinion about the mental health status of patients was consistently found to be inferior to validated screening tools. Dalton and Busch (1995) found that when the GDS-30 was used as the criterion standard, nurses recognised less than half (5 out of 11) (sensitivity 455%) of depressed patients, but correctly identied absence of depression in 25 out of 29 (specicity 862%). Brown et al. (2003) likewise demonstrated that nurses correctly identied depression in less than half of SCID positive patients (44 out of 97, sensitivity 454%), and correctly identied no depression in only threequarters of SCID negative patients (230 out of 306, specicity 752%). Higher levels of nursing experience correlated positively with recognition of depression (20 out of 36 = 56%, OR 437, 95% CI 0712679), as did certain patient characteristics, such as disability in Activities of Daily Living (18 out of 31 = 58%, OR 232, 95% CI 105500) and living with another person (30 out of 54 = 56%, OR 256, 95% CI 105625). Three patient characteristics predicted incorrect identication of depression- living alone (34 out of 117 = 29%, OR 1), use of antidepressants (14 out of 25 = 56%, OR 022, 95% CI 011047) and reporting a great deal of pain (26 out of 68 = 38%, OR 042, 95% CI 026068). Additionally, Preville et al. (2004) report data suggesting nurses a priori judgement identied only a third of SCID positive patients (22 out of 76, sensitivity 306%). General nursing assessment tools were also found to underdetect psychiatric symptoms in older patients. Flaherty et al. (1998) determined that organisation-specic psychosocial assessments were ineffective for screening for depression, with only 46 out of 81 (sensitivity 57%) of GDS-30 positive cases identied. Similarly, a study of admission OASIS data (Brown et al. 2004) reported that nurses identied only one third (12

out of 36, sensitivity 333%) of SCID positive patients with depressive mood (36 out of 220) and only one out of 22 (sensitivity 45%) SCID positive patients for anhedonia (22 out of 220). Of all the demographic variables, only living alone demonstrated a negative correlation for the identication of depression by nurses (n = 87; 195%, PPV 429%). The necessity for effective screening is underpinned by the prevalence of MHDs in community-residing older persons. In the small sub-population of the home-bound incontinent older persons, nurses administering the GDS-15 detected depressive symptoms (GDS Score 5) in 501% (173 out of 345). Comprehensive nursing interventions Given the nature of the work of nurses, it is not surprising that several studies included in this review investigated comprehensive nursing interventions that dealt with the patients from admission through to discharge. The benets of individualised management plans developed during multi-disciplinary consultation were found to be signicant in the study by Blanchard et al. (1995). Patients receiving the nurse-implemented plan showed more improvement in their mean DPDS score over three months (845 SD 247 to 588 SD 26) than the patients receiving usual care (841 SD 233 to 715 SD 33, p = 005). Although the results have a larger than desirable level of signicance, given the small sample size, it does suggest a significant effect by the nursing intervention. Benets, however, were not generally sustained over the longer term: at follow up at 623 months an intention-to-treat analysis demonstrated that the mean DPDS scores of the intervention group as a whole deteriorated from 61 SD 27, p = 005 (n = 47) to 63 SD 33 (n = 43) (Blanchard et al. 1999). There was a demonstrable benet to the mental health of the older persons participating in the TQM intervention study (Flaherty et al. 1998). The TQM intervention group showed a reduction in their mean GDS-30 score (171 SD 46 to 154 SD 68, two-tailed t-test p = 0063) trending towards signicance. The magnitude of this nding is debatable as no comparable data were collected on the control group. The authors deduced that while no one specic part of the intervention could be said to have made a difference to hospitalisation rates, the entire package of education, planning and implementing the plan was effective. Similarly, the PATCH Model intervention was more effective for reducing psychiatric symptoms for older patients with a psychiatric diagnosis (BPRS 297 SD 84 down to 274 SD 72, p = 0002; MADRS. 137 SD 95 down to 91 SD 62) than usual care (BPRS 301 SD 112 up to 339 SD 136; MADRS 117 SD 58 up to 152 SD 95) (Rabins et al. 2000). In addition, 11% of all Stage 2 (case identication) subjects had undesirable moves to either a nursing home or to a
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board-and-care home, although no difference was detected between intervention and control (relative risk 097; 95% CI 044-217). The authors concluded that the PATCH Model is effective for reducing psychiatric symptoms.

Discussion
The objective of this review was to identify evidence of the effectiveness of community nurse-led interventions for older persons with or at risk of MHDs. In excess of 200 related studies were identied by the literature search, suggesting a high level of interest for improving nursing care to the affected older people. Only one randomised controlled trial was eligible for inclusion in this review. Bearing in mind that the inclusion of non-randomised studies in a review increases the risk for bias, we justify the inclusion of quasi-experimental studies as the nature of the nurse activities of interest in this review were unlikely to lend themselves to study designs using true randomisation. The dearth of studies on the role of generalist community nurses caring for older persons with, or at risk of, MHDs is a concern, given the rising numbers of older persons using community services. Moreover, whilst the emphasis on depression-related research is encouraging, the absence of research into generalist community nurse interventions for other mental health disorders in older persons is noteworthy. Of equal note, given the chronic nature of most MHDs, was the scarcity of studies measuring the outcomes of treatment interventions long-term. It was also of interest to the reviewers that, although this review is reporting globally, the site for the review was in Australia and no Australian studies met inclusion criteria for this review. Overall, given a lack of comparable gold standard studies, and considering the small subject numbers, study designs used, and the lack of multi-site trials, the ndings of this review constitute suggested trends rather than high level evidence. The single, unambiguous theme to emerge from this review is that validated screening tools are consistently and signicantly more accurate for detecting symptoms of MHDs than either the nurses opinions or a non-validated or non-MHDspecic tool. This nding is suggestive of the need for sensitive, pragmatic screening tools to be readily available for community nurses to detect actionable levels of MHD symptomatology. It is quite possible that without the use of validated screening tools, community nurses may well be contributing to the under-detection and hence under-treatment of mental health disorders in the older population. Engberg et al. (2001, p. 136) comments that studies that have measured depressive symptoms among older adults have generally reported higher levels of depression than those using clinical diagnostic criteria
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such as the DSM-IV criteria, and questions whether standardised screening measures overestimate the prevalence of depression or whether current clinical diagnostic criteria fail to recognise forms of depression that are common among older adults. Despite this concern, detection of symptoms as in screening and diagnosis of disorders are two different activities, and the presence of MHD symptomatology may have a clinically signicant impact on an individual even in the absence of a DSM-IV diagnosis. Beyond screening alone, three nurse-led interventions were reported as having some benet: individualised management plans, TQM approach and the PATCH Model Intervention, with each intervention embedded in inter-disciplinary collaboration. While the ndings of these studies were not in themselves generalisable, the fact that there is research of this nature tacitly acknowledges that nurse-led interventions are relevant and potentially benecial. Screening and comprehensive interventions for older persons with, or at risk of, MHDs are intrinsically linked as, without effective screening, it is certain that at least some patients would inevitably miss out on comprehensive intervention with potentially detrimental consequences for them, their families and the health budget in general. Nurses must have condence in the screening strategy they use in order to refer appropriately to other services and to maximise the effectiveness of an interdisciplinary teams collaboration. The importance of such condence is underscored by the nding that more experienced nurses performed better than less experienced counterparts, emphasising the importance of exposure to, and education regarding, older persons with MHDs, and the need for reliable screening tools in practice. The lack of high quality evidence is concerning, but must be seen in context with the fact that, in most areas of nursing care, large decits in the evidence-base for practice persist.

Conclusions
Implications for practice
On the present evidence, the key recommendation for clinical practice is that home healthcare providers consider making available validated screening tools for MHDs for use by nurses during admission assessments or when an older patient is identiably at risk. At rst glance, this may seem simple but in reality there are many considerations for implementing such a change. The tool needs to not only be sensitive but quick to complete, as the burden of documentation and assessment is already considerable for most community nurses providing care in homes (Trossman 2002). Within Table 2, a number of screening tools for MHDs are listed for the consideration of community nurses, with the Geriatric Depression Scale (either

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15 or 30 item) being that most commonly applied in the reviewed studies, and probably so in clinical situations as well. Moreover, such a change in practice would require funding support for any additional work burden during and after the change, and enough time for nurses to undertake education before and during operationalisation. Meanwhile, until higher quality evidence is available, raising nurses awareness of MHDs in older home healthcare patients would be advantageous. Agencies could benet from conducting a basic educational needs analysis of their nurses to determine their level of knowledge about MHDs in older persons, and then implementing an ongoing, focussed education programme to enhance ability to recognise and manage MHDs.

Acknowledgements
The authors gratefully acknowledge the assistance from Jacqui Allen for her assistance with data analysis. This review was funded by a La Trobe University Faculty of Health Sciences Research Grant, Melbourne, Australia.

References
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Implications for research

Further research is clearly indicated from the ndings of this review. The trend in the literature suggests a role for effective routine screening for MHDs, particularly depression. Research efforts should now build on this understanding and the known accuracy of validated screening tools to discover sensitive, pragmatic and cost-effective processes to implement such screening of all older recipients of home health care. The focus of further, in-depth investigations should include controlled trials examining mental health outcomes from care provided by community nurses who have undertaken extra mental health education. Additionally, research to describe specic actions nurses currently use when identifying and managing older persons with MHDs should be undertaken, for which qualitative methods may initially be best used. Having established a broad baseline for comparison, wellstructured randomised controlled trials should be the preferred research design for the testing of interventions. Given the varied composition of nursing workforces across the globe and the possible small numbers of patients and nurses at many agencies, replication and multi-centre trials should be considered to enhance generalisability of ndings. Also, allowing for the chronic nature of many MHDs, measurement of outcomes over several months would better determine effectiveness of an intervention rather than shortterm studies. Finally, but crucially, more studies analysing the cost benet ratio of nursing interventions are needed to support scally sound spending of healthcare budgets.

Contributions
Study design: PT, MA, LL; data collection and analysis: PT, MA LL and manuscript preparation: PT, MA, LL

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd

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