Received: 6 February 2019 Accepted: 6 August 2019

DOI: 10.1002/gps.5196

RESEARCH ARTICLE

Feasibility of a family‐centered intervention for depressed

older men in primary care

Ladson Hinton1 | Erika La Frano2 | Danielle Harvey6 | Eduardo Delgadillo Alfaro1 |

Richard Kravitz3 | Andrew Smith4 | Ester Carolina Apesoa‐Varano5 | Asma Jafri4 |

Jurgen Unutzer7

1
Department of Psychiatry and Behavioral
Sciences, University of California at Davis,
Objective: Families provide considerable support to many older adults with depres-
Sacramento, California, USA sion, yet few intervention studies have sought to include them. Family participation in
2
Community Health Centers Del Valle, Santa depression treatment aligns with the preferences of older men, a group at high risk
Maria, California, USA
3 for depression under treatment. This study examined the feasibility of a family‐
Department of Internal Medicine, University
of California at Davis, Sacramento, California, centered depression intervention for older men in a primary care setting.
USA
4
Methods: A clinical trial was conducted in a Federally Qualified Health Center
San Joaquin General Hospital, French Camp,
California, USA (FQHC) in California's Central Valley. Depressed older men (age 50 and older)
5
Betty Irene Moore School of Nursing, were allocated to usual care enhanced by depression psychoeducation or a family‐
University of California at Davis, Sacramento,
California, USA
centered depression intervention delivered by a licensed clinical social worker.
6
Department of Public Health Sciences, Intervention feasibility was assessed in terms of recruitment, retention, and extent
University of California at Davis, Sacramento, of family engagement. The PHQ‐9 was administered at baseline, 1, 3, and 6 months.
California, USA
7
Department of Psychiatry and Behavioral
Results: For more than 6 months, 45 men were referred to the study; 31 met the
Sciences, University of Washington, Seattle, inclusion criteria, 23 were successfully enrolled, and 20 (88%) participated in more
Washington, USA
than or equal to one treatment sessions. Overall, 85% (11 of 13) of men allocated
Correspondence to the intervention engaged a family member in more than or equal to one session
Ladson Hinton, Department of Psychiatry and
Behavioral Sciences, University of California at
and 54% (7 of 13) engaged the family member in more than or equal to three ses-
Davis, Sacramento, California, USA. sions. While men in both groups showed evidence of a significant decline in PHQ‐9
Email: lwhinton@ucdavis.edu
scores early on, which attenuated over time, there were no significant between group
Funding information differences.
National Institute of Mental Health, Grant/
Award Number: R34MH099296 Conclusions: Our family‐centered depression intervention showed acceptable fea-
sibility on the basis of a variety of parameters. Future research on family‐based
approaches may benefit from longer duration and more intensive treatment as well
as additional strategies to overcome recruitment barriers.

K E YW OR D S

depression, family, interventions, men, primary care

1 | I N T RO D U CT I O N depression in late‐life has many adverse consequences including sub-

stantial suffering and losses in quality of life,5 decreased ability to
Major depression is relatively uncommon (1%‐3%) in healthy, function,6 poor adherence to medical care, poor outcomes from co‐
community‐living older adults, yet 5% to 10% of older adults in pri- morbid medical disorders such as heart disease and diabetes,7
mary care settings meet criteria for major depression.1-4 Untreated increased health care costs,7,8 and increased mortality.9-12 Older men

~1808 © 2019 John Wiley & Sons, Ltd. wileyonlinelibrary.com/journal/gps Int J Geriatr Psychiatry. 2019;34:1808–1814.
HINTON ET AL.
have the highest rates of completed suicide,13 and depression has
been identified as the most important and arguably the most modifi-
able risk factor for completed suicide.14 Depression undertreatment
is more common in older men, particularly ethnic minority older
15-17
men. Improving depression treatment for minority and nonminor-
ity men is vital to reduce health disparities and close gaps in care.18,19
One possible approach to strengthen depression care for older
men is to engage those in their social network to encourage help‐
seeking and to support treatment. Men often rely on family members,
particularly wives and daughters, for assistance with chronic illness
management, including medication management, health care decision
making, transportation to doctor's appointments, and participating in
health care visits. 20-24
More than one third of older adults who pres-
ent for treatment in primary care settings are accompanied by family
members, usually a spouse or adult child.25,26 A national survey found
that respondents were more willing to provide chronic disease self‐
management support for chronically ill family members/friends who
were also depressed but also found providing help to depressed
relatives/friends more difficult.27 Spouses, adult children, and friends
assist men with their help‐seeking for and disclosure of symptoms
related to medical problems.28,29 Families often play a very influential
role in getting depressed or suicidal men into formal treatment.15,30-32
Primary care providers also view family members as potential allies in
depression treatment.33 There is evidence of a preference for family
involvement in depression treatment from research with Latino and
white non‐Hispanic older men34 and nonelderly mixed‐sex samples,
which included large numbers of minorities.35 In the IMPACT trial,
the topic of family was a prominent theme in analysis of notes from
problem‐solving therapy.36
Despite the potential positive impact of family members on
depression treatment in primary care, surprisingly, little intervention
work has been done to include them. A recent review of depression
interventions on the basis of the chronic care model, for example,
did not cite a single example of family‐centered intervention.37 This
is surprising considering that recent reviews have noted significant
but modest positive health and mental health effects of chronic illness
interventions that involve spouses or other family members.17,38-40
One possible explanation for this gap is that challenges in including
family in men's depression care exist. Depression may threaten core
masculine norms and values, triggering feelings of shame and hinder-
ing help‐seeking and disclosure of symptoms to family mem-
bers.15,41,42 Prior qualitative studies, on the basis of the perspectives
of depressed older men as well as their family members and primary
care providers, have described possible challenges to family involve-
ment in depression interventions, including concerns about privacy,
confidentiality, and stigma.43 In addition, many older men may not
have a family member who is available or who wishes to participate.
Finally, involving family members might be difficult or even contraindi-
cated when family relationships are a significant source of stress or
relationships are so strained that family involvement may do more
harm than good.43,44 While family involvement in treatment is promis-
ing, interventions need to address these potential challenges if they
are to be successful.44
1809
Key points
1. A family‐centered depression intervention demonstrated
acceptable feasibility in primary care. 2. Recruitment
challenges were encountered that may reflect both patient
and provider barriers.
To advance our knowledge gap, the goal of this study was testing
the feasibility of a family‐enhanced depression treatment in a primary
care setting. We assessed the feasibility of the intervention and study
methods using accepted guidelines45 with respect to recruitment, ran-
domization, retention, treatment adherence, treatment fidelity, and
assessment processes. To our knowledge, this is the first feasibility
study of a family‐centered depression intervention in a primary care
setting.
2 | METHODS
2.1 | Study setting
The clinical trial was conducted in a Federally Qualified Health Center
in California's Central Valley, serving an ethnically diverse, lower
income population. During 2011, the two clinics had more than
33,000 patient visits with a high proportion of ethnic/racial minorities.
The study was conducted from December of 2015 through October of
2016. The study was approved by the IRBs at San Joaquin General
Hospital and the University of California, Davis.
2.2 | Subject recruitment and allocation to study
arms
Men were referred to the study by primary care providers or affiliated
staff at the time of their primary care visit. To be eligible for the
study, men needed to be age 50 or older, Spanish or English speaking,
PHQ‐9 depression score greater than or equal to 10, nondemented,
and not actively psychotic or acutely suicidal. In addition, men needed
to be willing to have a family member, broadly defined to include
nuclear and extended family, participate in the study. Eligible patients
who consented to the study were allocated to either the family‐
centered depression intervention or the enhanced usual care group
(2:1 allocation). Because of staffing constraints, all Spanish‐speaking
patients were allocated to the intervention and English‐speaking
patients were randomly assigned to either the family‐centered
depression intervention or the enhanced usual care group. Subjects
were informed of their allocation after consenting to participation.
Two social workers consented subjects, one of whom was bilingual
(Spanish and English).
1810
2.3 | Family‐enhanced intervention and enhanced
usual care condition
A manual was developed for the family‐enhanced depression interven-
tion. The manualized intervention was delivered by the bilingual
licensed clinical social worker (LCSW) in the primary care clinic and
consisted of up to 12 sessions delivered in the primary care clinic over
3 to 6 months. As part of the intervention, men were given the opportu-
nity to have a family member involved in some or all sessions. The inter-
vention included psychoeducation about depression and treatment,
support in self‐management (eg, medication adherence and problems
with medications), behavioral activation, coaching on primary care phy-
sician visits, and relapse and prevention planning. As part of the inter-
vention, men were given the opportunity to have a family member
participate in treatment sessions to support one or more of these
aspects of depression care. In addition to working with depressed older
men and their families, the LCSW communicated with the primary care
physician regarding symptom levels and any side effects or other prob-
lems with antidepressant medication. To promote the capacity of pri-
mary care physicians to treat older depressed men, a 1‐hour in‐service
training was held to provide guidance on working with family members
of depressed men and to review guidelines for depression management
in primary care. The enhanced usual care consisted of psychoeducation
about depression and provision of a list of community resources and
was delivered in a single session by a social worker.
2.4 | Clinical outcome assessment
After their baseline assessment at the time of enrollment, a research
assistant, blind to allocation, administered the PHQ‐9 to participants
at 1, 3, and 6 months. Clinical outcome assessment was conducted
in the home or by phone.
2.5 | Feasibility outcomes
Recruitment feasibility was assessed on the basis of the proportion of
men referred to the study who enrolled (ie, participated in at least one
outcome assessment). Subject retention in both arms of the study was
recorded on the basis of the number in each group who completed the
study, including the final assessment of outcomes. To assess feasibility
of the family‐centered treatment model, for the intervention group,
we tracked the extent of family engagement in treatment (ie, percent-
age with family members participating in at least one session, percent-
age with a family member participating in three or more sessions, and
the percentage of men who had family involved in at least 50% of
their treatment sessions). To assess treatment fidelity, intervention
notes written by the LCSW were coded to determine whether family
was engaged in core aspects of the manualized intervention, including
psychoeducation, behavioral activation, coaching related to physician
visits, and relapse and prevention planning. We also assessed the fea-
sibility of the administration of study measures in terms of percent of
baseline, 3‐ and 6‐month assessments completed.
HINTON ET AL.
2.6 | Statistical analyses
Feasibility and adherence outcomes were summarized as frequencies
and percentages. The primary clinical outcome, PHQ‐9, was summa-
rized both in terms of the percentage whose score at 6 months fell
below a clinical threshold of 10 as well as the percentage whose score
dropped by at least 5 points over the course of the study. Average tra-
jectories over time of PHQ‐9 scores were compared between the two
groups using mixed effects regression models, which utilized the
repeated assessments of the PHQ‐9 across individuals. This model
included person‐specific random intercepts and slopes to account for
variability in starting place and change. The model further included a
term for time in study (measured in months) squared to account for
nonlinearity in the trajectories. All model assumptions were met by
the data. The model was fit using SAS software, version 9.4.
3 | RESULTS
3.1 | Recruitment feasibility
Overall, 45 men were referred for the study, 41 were assessed for eli-
gibility (two refused, including one that reported not having family
available, and two were lost to follow‐up) (see Figure 1). Of the 41
men who were assessed, 31 (76%) met inclusion criteria, and 23
(56%) consented and were allocated to one of the two treatment
arms, including 15 who were allocated to the family‐centered inter-
vention and eight to the enhanced usual care group. Two men in the
intervention group and one man in the enhanced usual care group
dropped out after randomization and did not complete the baseline
assessment or any follow‐up sessions, leaving a total of 20 success-
fully enrolled men with complete baseline data who participated in
one or more sessions after the initial baseline assessment, including
13 in the intervention group and seven in the enhanced usual care.
3.2 | Participant characteristics
The sociodemographic characteristics of the participants who received
the enhanced usual care (n = 7) and intervention (n = 13) are shown in
Table 1. Because of the allocation scheme (see Section 2), a higher
proportion of the men in the intervention arm were Latino and
Spanish‐speaking. Less than half the sample reported more than a high
school education, and more than half reported an annual income of
less than or equal to $10,000/year.
3.3 | Intervention adherence and retention
For the family‐enhanced intervention group, the mean duration of
treatment was 12.5 weeks (range 2‐24 weeks) and the mean number
of sessions completed was 6.1 (range 2‐12). In terms of intervention
adherence, 92% (12/13) completed at least three sessions. A total of
six sessions were missed, canceled, or rescheduled. One man in the
intervention group was lost to follow‐up after the second session.
HINTON ET AL.
FIGURE 1 CONSORT flow diagram [Colour figure can be viewed at wileyonlinelibrary.com]
3.4 | Feasibility of engaging family in the
intervention
Overall, 85% (11 of 13) of the men successfully engaged a family
member in at least one session, 54% (7 of 13) engaged the family
member in three or more sessions, and 62% (8 of 13) engaged a
family member in more than or equal to 50% of their treatment ses-
sions. Overall, family members participated in 67% (55 of 82) of the
total number of treatment sessions. There were no instances where
family involvement in the intervention was discontinued due to
conflict or because the LCSW viewed family involvement as
counter‐therapeutic. To assess treatment fidelity of the family‐
centered intervention, intervention notes written by the LCSW were
independently reviewed by a research assistant for the 12 of the 13
men who were allocated to the intervention and completed at least
one session (intervention notes were missing for one man). Interven-
tion notes from sessions in which a family member participated were
coded for presence of documentation of key elements of treatment,
including psychoeducation, self‐management (eg, medication adher-
ence), behavioral activation, coaching to interact with PCP, and
relapse and prevention planning. Overall, 83% (10 of 12) of the men
in the intervention group participated in at least one session with a
family member, which included psychoeducation; 75% (9 of 12) in
depression self‐management; 75% (9 of 12) in behavioral activation;
67% (8 of 12) in PCP coaching; and 50% (6 of 12) in relapse and pre-
vention planning.
1811
3.5 | Feasibility of assessments and clinical
outcomes
Among the 20 participants who were allocated and received either the
enhanced usual care or the family‐centered intervention, 93% (74 of
80) of the scheduled outcome assessments were completed across
the time points (ie, baseline, 1, 3, and 6 months). There were no signif-
icant between group differences in either the percent of men with
PHQ‐9 scores below 10 at 6 months or the percent of men with a
drop of 5 points or more in their PHQ‐9 scores at 6 months. A com-
parison of the trajectories of depressive symptoms using mixed effects
models (repeated measures, random effects models) is shown in
Figure 2. There were no statistically significant differences between
the intervention and enhanced usual care groups (P = .8), although
both groups showed evidence of initial decline (P = .02), which atten-
uated over time (P = .01) (Figure 2).
3.6 | Case example
The following case example illustrates family participation in the inter-
vention and their involvement in several aspects of depression care.
Mr. M is an 83‐year‐old, Spanish‐speaking patient with a history of
high blood pressure and a recent diagnosis of prostate cancer. His
PHQ‐9 at baseline was a 16. He attended eight sessions with his
daughter E who does not live with him. He has a conflictual relation-
ship with his wife. Mr. M presented to treatment with multiple
1812 HINTON ET AL.

TABLE 1 Characteristics of intervention and enhanced control stressors including marital discord, financial limitations, and a new can-
groups cer diagnosis. His mood was depressed and his affect congruent with

Intervention Enhanced usual content; he was tangential and needed frequent redirection to the
N = 13 care N = 7 topic at hand. The patient had been taking antidepressants for a few
months when he was enrolled in the study but could not recall the
Age, mean (SD) 60.2 (9.6) 57.4 (4.8)
name of the medication. The daughter reported that while on this
Married/living with partner, n (%) 10 (77) 3 (43)
medication, the patient was “sleepy all the time and unable to do any-
≥High school education, n (%) 5 (38) 4 (57)
thing.” As a result, the daughter requested a new medication and he
Income ≤$10,000/year, n (%) 6 (46) 6 (86)
was prescribed Lexapro 5 mg. During behavioral activation, the patient
Retired, n (%) 7 (54) 6 (86) indicated that he enjoyed making piñatas because doing so made him
Latino 10 (77) 2 (29) “forget about my problems.” His daughter supported the behavioral
Family participants in intervention plan by placing daily calls to provide encouragement and ensure that
Spouses 7 (54) N/A he had materials. Over the course of the treatment, his PHQ‐9

Sibling 3(23) N/A remained unchanged. After receiving psychoeducation about depres-
sion treatment and coaching about how to better communicate with
Daughter 1 (8) N/A
the PCP, the daughter requested an increase in dosage. As a result,
Nonea 2 (15) N/A
Mr. M's dosage increased to 20 mg and he began to show significant
PHQ‐9 mean score at time of 14.8 (13, 2.9) 15.3 (6, 4.1)
improvement as evidenced by a score of 5 to 7 in the PHQ‐9. Mr. M
consent (n, SD)
became more active and able to employ adaptive coping strategies
PHQ‐9 mean score at 3 months 10.1 (11, 6.6) 13.0 (7, 7.5)
such as positive self‐talk and distraction during stressful times. Follow-
(n, SD)
ing a period of stability, he was engaged in relapse prevention. His
PHQ‐9 mean score at 6 months 11.8 (12, 7.1) 13.3 (7, 6.3)
(n, SD) daughter supported him in this phase by helping identify specific
depressive symptoms previously experienced as well as by validating
Mean weeks of treatment (SD) 12.5 (5.8)2-24 N/A
[range] the patient's engagement in treatment and noticeable improvement.

Mean number of treatment 6.1 (2.7) N/A

As illustrated in this case, the patient's daughter participated
sessions (SD) in several different aspects of depression care, including
a
psychoeducation about depression (nature of the condition, treat-
Did not have a family member participate in treatment
ments), depression self‐management (monitoring and reports medica-
tion side effects), participation in his visits with the patient's primary
care physician, supporting behavioral activation, and participating in
relapse and prevention planning. A notable aspect of this case is the
patient's preference that because the patient and his wife had a con-
flictual relationship, he preferred to include his daughter rather than
his wife in the intervention.

4 | DISCUSSION

To our knowledge, this is the first study to report the feasibility of a

FIGURE 2 PHQ‐9 score trajectories in family‐centered intervention
(n = 13) and enhanced usual care (n = 7) groups
family‐centered depression intervention in a primary care setting.
One of the main findings from this study is that the intervention
appears feasible on the basis of several different measures, including
adherence, retention, and the extent of family participation. As
illustrated in the case study, we found that it is feasible to engage
family members in multiple aspects of depression care, including
psychoeducation, supporting depression self‐management, and
relapse prevention planning.
Recruitment for this study proved to be challenging and resource‐
intensive. It took more than 6 months to recruit a relatively small sample
of depressed older men in a clinic with a relatively high volume of
patient care. Multiple factors may have contributed to the low volume
of referrals to the study. One factor that may have been important is
that many men either did not wish to include family in their depression
HINTON ET AL.
treatment or did not have a family member who was available to
participate. Other factors that may have contributed include clinic pro-
viders being reluctant to refer to the study. Prior work has shown that
primary care providers express several concerns about including family
in depression care.43 Together, these factors suggest that this type of
intervention may not be feasible for a significant number of men in a
typical primary care setting and might be used selectively for those
men who find this approach acceptable and have a family member
who can be engaged in treatment. Education and training of primary
care providers may also be needed to address barriers to referral and
better equip providers to discuss the role of family in depression care
with men.
Our findings are consistent with our preliminary work, demonstrat-
ing that family involvement in depression care is viewed positively by
older men46 but also has potential challenges.43,44 The men who were
randomized to the family‐centered intervention were successfully
engaged and, in most cases, we succeeded in having family members
participate in depression treatment. However, our findings also indi-
cate that barriers to recruitment many be substantial in this setting,
including men not having family members who are available to
participate.
There are several important limitations to this pilot study. First,
this is a small pilot study conducted in an FQHC serving a safety‐
net population with a high proportion of Latinos and caution should
be used in generalizing to other populations. In addition, our study
sample is not elderly, but includes men in the their 50s and 60s. Sec-
ond, we did not quantify or study the men who were approached but
refused to be referred to the study (or their reasons) which would
have been very useful in better understanding recruitment and
engagement challenges. Third, we had to modify our RCT design
because of staffing constraints, resulting in a disproportionate number
of Latinos in our intervention group. While there was some improve-
ment in the PHQ‐9 depression scores in both groups, the overall
change was modest when compared with earlier trials of collaborative
care interventions for late‐life depression.47 It is important to note
that this pilot study was not sufficiently powered to examine
between group differences.
We found that men's depression scores improved significantly but
this effect attenuated over time. One interpretation of this finding is
that the relatively low intensity (mean of only 6.1 contacts with the
LCSW) and short duration of the intervention (mean number of weeks
in treatment was 12.5) may not have been sufficient for this “safety
net” population at a federally qualified health center. Because most of
the treatment occurred during the first 3 months of the intervention,
the increase in depression scores from 3 to 6 months may suggest the
need to modify our treatment approach by increasing the number of
sessions and duration of treatment. Another possible modification is
to engage family members later in treatment as an enhancement when
initial treatment has not been effective. Working with men individually
during the first phase of treatment may allow time to assess the family
support network, help men understand the nature of their depression,
and reduce depression‐related stigma, all of which may help men be
more receptive to involving family members.
1813
5 | CO NC LUSIO N
Looking forward, there are important next steps for family‐centered
depression interventions. Our study did not have sufficient statistical
power to examine the efficacy of the family‐centered intervention
and this would be an important next step. In addition, it may be impor-
tant to consider where in the stepped care model of depression treat-
ment a family‐centered approach is best considered. Our study
recruited men and attempted to engage family at the beginning of
treatment. Another approach would be to consider family engagement
as an augmentation strategy to treatment in men who have not
responded to initial treatment in primary care.
ACKNOWLEDGEMENTS
Edward Elizarraras assisted with recruitment and data collection.
Funding for this study was supported by the National Institute of
Mental Health of the National Institutes of Health under award num-
ber R34MH099296.
DATA AVAILABILITY
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
ORCID
Ladson Hinton https://orcid.org/0000-0001-6198-8540
RE FE RE NC ES
1. Barrett JE, Barrett JA, Oxman TE, et al. The prevalence of psychiatric
disorders in a primary care practice. Arch Gen Psychiatry.
1988;45(12):1100‐1106.
2. Koenig HG, Blazer DG. Epidemiology of geriatric affective disorders.
Clin Geriatr Med. 1992;8(2):235‐251.
3. Lyness JM, Caine ED, King DA, Cox C, Yoediono Z. Psychiatric disor-
ders in older primary care patients. J Gen Intern Med.
1999;14(4):249‐254.
4. Schulberg HC, Mulsant B, Schulz R, Rollman BL, Houck PR, Reynolds
CF III. Characteristics and course of major depression in older primary
care patients. Int J Psychiatry Med. 1998;28(4):421‐436.
5. Unutzer J, Katon W, Williams JWJ, et al. Improving primary care for
depression in late life: the design of a multicenter randomized trial.
Med Care. 2001;39(8):785‐799.
6. Alexopoulos GS, Vrontou C, Kakuma T, et al. Disability in geriatric
depression. Am J Psychiatry. 1996;153(7):877‐885.
7. Katon WJ. The institute of medicine “Chasm” report: implications for
depression collaborative care models. Gen Hosp Psychiatry.
2003;25(4):222‐229.
8. Unützer J, Patrick DL, Simon G, et al. Depressive symptoms and the
cost of health services in HMO patients aged 65 years and older: a
4‐year prospective study. JAMA. 1997;277(20):1618‐1623.
9. Blazer DG, Hybels CF, Pieper CF. The association of depression and
mortality in elderly persons: a case for multiple, independent pathways.
J Gerontol A Biol Sci Med Sci. 2001;56(8):M505‐M509.
1814
10. Ganguli M, Dodge HH, Mulsant BH. Rates and predictors of mortality
in an aging, rural, community‐based cohort: the role of depression.
Arch Gen Psychiatry. 2002;59(11):1046‐1052.
11. Unutzer J, Bruce ML. The elderly. Ment Health Serv Res. 2002;
4(4):245‐247.
12. Yaffe K, Edwards ER, Covinsky KE, Lui LY, Eng C. Depressive symp-
toms and risk of mortality in frail, community‐living elderly persons.
Am J Geriatr Psychiatry. 2003;11(5):561‐567.
13. Arias E, Anderson RN, Kung HC, et al. Deaths: final data for 2001:
national vital statistics resports. National Center for Health Statistics:
Hyattsville, MD; 2003.
14. Conwell Y, Duberstein PR, Caine ED. Risk factors for suicide in later
life. Biol Psychiatry. 2002;52(3):193‐204.
15. Hinton L, Zweifach M, Oishi S, et al. Gender disparities in the treat-
ment of late‐life depresion: qualitative and quantitative findings from
the IMPACT trial. Am J Geriatr Psychiatry. 2006;14(10):884‐892.
16. Crystal S, Sambamoorthi U, Walkup JT, Akıncıgil A. Diagnosis and
treatment of depression in the elderly medicare population:
predictors, disparities, and trends. J Am Geriatr Soc. 2003;
51(12):1718‐1728.
17. Unutzer J, Katon W, Callaha CM, et al. Depression treatment in a sam-
ple of 1,801 depressed older adults in primary care. J Am Geriatr Soc.
2003;51(4):505‐514.
18. Angel JL, Hogan DP. Population aging and diversity in a new era. In:
Whitfield KE, ed. Closing the Gap: Improving the Health of Minority
Elders in the New Millennium. Washington DC: Gerontological Society
of America; 2004.
19. Gonzalez HM, Vega WA, Williams DR, et al. Depression care in the
United States: too little for too few. Arch Gen Psychiatry.
2010;67(1):37‐46.
20. Compton MT, Esterberg ML. Treatment delay in first‐episode
nonaffective psychosis: a pilot study with African American family
members and the theory of planned behavior. Compr Psychiatry.
2005;46(4):291‐295.
21. Maly RC, Umezawa Y, Ratliff CT, Leake B. Racial/ethnic group differ-
ences in treatment decision‐making and treatment received among
older breast carcinoma patients. Cancer. 2006;106(4):957‐965.
22. Aging U‐Ao. America's families care: a report on the needs of America's
family caregivers. 2000.
23. Dettinger E, Clarkberg M. Informal caregiving and retirement timing
among men and women: gender and caregiving relationships in late
midlife. J Fam Issues. 2002;23(7):857‐879.
24. Lima JC, Allen SM, Goldscheider F, et al. Spousal caregiving in late
midlife versus older ages: implications of work and family obligations.
J Gerontol B Psychol Sci Soc Sci. 2008;63(4):229‐238.
25. Sayers SL, White T, Zubritsky C, Oslin DW. Family involvement in the
care of healthy medical outpatients. Fam Pract. 2006;23(3):317‐324.
26. Wolff JL, Roter D. Hidden in plain sight: medical visit companions as
a resource for vulnerable older adults. Arch Intern Med. 2008;
168(13):1409‐1415.
27. Janevic MR, Rosland AM, Wiitala W, Connell CM, Piette JD. Providing
support to relatives and friends managing both chronic physical illness
and depression: the views of a national sample of U.S. adults. Patient
Educ Couns. 2012;89(1):191‐198.
28. Norcross WA, Ramirez C, Palinkas LA. The influence of women on the
health care‐seeking behavior of men. J Fam Pract. 1996;43(5):475‐480.
29. Tudiver F, Talbot Y. Why don't men seek help? Family physicians' per-
spectives on help‐seeking behavior in men. J Fam Pract.
1999;48(1):47‐52.
HINTON ET AL.
30. Cabassa LJ. Latino immigrant men's perceptions of depression and atti-
tudes toward help seeking. Hispanic J Behav Sci. 2007;29(4):492‐509.
31. Murray J, Banerjee S, Byng R, Tylee A, Bhugra D, Macdonald A. Pri-
mary care professionals' perceptions of depression in older people: a
qualitative study. Soc Sci Med. 2006;63(5):1363‐1373.
32. Owens C, Lambert H, Donovan J, et al. A qualitative study of help
seeking and primary care consultation prior to suicide. Br J Gen Pract.
2005;55(516):503‐509.
33. Apesoa‐Varano EC, Hinton L, Barker JC, Unützer J. Clinician
approaches and strategies for engaging older men in depression care.
Am J Geriatr Psychiatry. 2010;18(7):586‐595.
34. Unutzer J, Dwight‐Johnson M, Apesoa‐Varano C, et al. Older men's
preferences for depression care: preliminary comparison of conjoint
survey and qualitative interviews. Am J Geriatr Psychiatry. 2011;19(3):
S9‐S57.
35. Dwight‐Johnson M, Lagomasino IT, Hay J, et al. Effectiveness of col-
laborative care in addressing depression treatment preferences
among low‐income Latinos. Psychiatr Serv. 2010;61(11):1112‐1118.
36. Riebe G, Fan MY, Unutzer J, et al. Activity scheduling as a core compo-
nent of effective care management for late‐life depression. Int J Geriatr
Psychiatry. 2012;27(12):1298‐1304.
37. Williams JWJ, Gerrity M, Holsinger T, et al. Systematic review of mul-
tifaceted interventions to improve depression care. Gen Hosp
Psychiatry. 2007;29(2):91‐116.
38. Rosland AM, Heisler M, Piette JD. The impact of family behaviors and
communication patterns on chronic illness outcomes: a systematic
review. J Behav Med. 2012;35(2):221‐239.
39. Martire LM, Schulz R. Involving family in psychosocial: interventions
for chronic illness. Curr Dir Psychol Sci. 2007;16(2):90‐94.
40. Wolff JL, Roter DL, Given B, Gitlin LN. Optimizing patient and family
involvement in geriatric home care. J Healthc Qual. 2009;31(2):24‐33.
41. Apesoa‐Varano EC, Barker JC, Hinton L. Shards of sorrow: older men's
accounts of their depression experience. Soc Sci Med. 2015;124:1‐8.
42. Seidler ZE, Dawes AJ, Rice SM, Oliffe JL, Dhillon HM. The role of mas-
culinity in men's help‐seeking for depression: a systematic review. Clin
Psychol Rev. 2016;49:106‐118.
43. Hinton L, Apesoa‐Varano EC, Unutzer J, et al. A descriptive qualitative
study of the roles of family members in older men's depression treat-
ment from the perspectives of older men and primary care providers.
Int J Geriatr Psychiatry. 2015;30(5):514‐522.
44. Hinton L, Sciolla AF, Unützer J, Elizarraras E, Kravitz RL, Apesoa‐
Varano EC. Family‐centered depression treatment for older man in pri-
mary care: a qualitative study of stakeholder perspectives. BMC Fam
Pract. 2017;18(1):88.
45. Leon AC, Davis LL, Kraemer HC. The role and interpretation of pilot
studies in clinical research. J Psychiatr Res. 2011;45(5):626‐629.
46. Dwight‐Johnson M, Apesoa‐Varano C, Hay J, et al. Depression treat-
ment preferences of older white and Mexican origin men. Gen Hosp
Psychiatry. 2013;35(1):59‐65.
47. Unutzer J, Katon W, Callahan C, et al. Collaborative care management
of late‐life depression in the primary care setting: a randomized con-
trolled trial. JAMA. 2002;288(22):2836‐2845.
How to cite this article: Hinton L, La Frano E, Harvey D, et al.
Feasibility of a family‐centered intervention for depressed older
men in primary care. Int J Geriatr Psychiatry. 2019;34:1808–1814.
https://doi.org/10.1002/gps.5196