Institute of Geriatric Psychiatry: Research

Weill Cornell Advanced Center for Intervention and Services Research (ACISR)
Director: GS Alexopoulos, M.D.
Co-Director: ML Bruce, Ph.D.

The mission of the Weill Cornell Advanced Center for Intervention and Services Research (ACISR) is to produce and disseminate comprehensive interventions that effectively target the complex clinical and social factors contributing to late-life depression, minimize the splintering of health care, and can be implemented under the current health reimbursement system. The rapid increase of older persons (73% increase is anticipated in the US by year 2020) and the diseases and disabilities complicating their care, make geriatric research a national priority.

The ACISR focuses on late-life depression because of its overwhelming consequences on the health of older persons. Late-life depression is the leading cause of disability, increases medical morbidity and mortality, causes suffering, family disruption, and increases the cost of care. The ACISR's investigators have worked to understand the biological, medical, cognitive, and psychosocial problems of depressed elders and use this knowledge to develop targeted interventions. The ACISR research program is focusing on three barriers to care:

  1. Access to health care and engagement;
  2. Clinical and psychosocial complexity; and
  3. Difficult to treat syndromes and patients.

The ACISR has become a national resource for studies of the largely neglected persons with late life depression. It relies on a harmoniously working team with complementary skills and a research organization that promotes synergy at the conceptual, methodological, and research implementation level. The ACISR has a strong record of peer-reviewed publications, federal grants, career development, training programs, and community outreach.

The ACISR conducts efficacy studies as well as effectiveness and implementation research so that it can increase the impact of evidence-based care. Its community partner is the Westchester Geriatric Mental Health Coalition, which consists of medical practices, community mental health clinics, home healthcare agencies, rehabilitation hospitals, and government organizations who share our concerns. This partnership brings the ACISR interventions where most depressed elders are served. Thus the Westchester County serves as an "incubator" of novel interventions. The ACISR further tests at a national level interventions developed in Westchester County. This strategy can establish the public health significance of locally developed interventions and health services advances.

The ACISR consists of three Cores, which constitute the research infrastructure supporting many independently-funded studies.

1. Operations Core (Director: GS Alexopoulos, M.D.)

The Operations Core (OC) has developed structures that maximize the potential for scientific discovery, the development of investigators, and the ethical and orderly conduct of research. To accomplish these goals the OC has relied on:

  1. A group of investigators with history of productive collaborative research;
  2. research training experience; and
  3. strong ties with the scientific and the non-scientific community.

The OC serves as the Center's hub creating synergy and guiding the methodological, scientific and community partnership activities of the ACISR investigators. These tasks are integrated in five Units:

  • Administrative Unit
  • Interventions Management Unit
  • Biostatistics & Data Management Unit
  • Career Development and Training Unit
  • Community Network Unit

2. Research Methods Core (Director: ML Bruce, PhD, MPH)

The mission of the Research Methods Core (RMC) is to advance the quality and impact of research in "real world settings" by addressing challenges posed by the clinical and service delivery complexities of depressed elders with limited access to good care.

Work on the Data Analysis Level: Recognizing the design restrictions imposed by community settings, the RMC has worked to understand the impact of cluster size on type I error, power, and bias and to balance type I error and statistical power in studies with multiple outcomes. Building on earlier studies, the RMC now works in two areas:

  1. Compensation introduced by comparisons of non-equivalent groups: As cluster randomization is often the design used in community randomized controlled trials, the RMC is adapting propensity methodology to adjust for imbalance in clusters.
  2. Attrition: The RMC is studying whether some easy to administer items help in fulfilling the ignorability assumption of mixed effects models and thereby reduce bias in estimating the treatment effect. Furthermore, the RMC is evaluating an alternative a non-parametric, multiple imputation procedure in analyzing "missing not at random" data.

Work on the Design Level: The RMC works to address two sets of challenges to the generalizability of community-based interventions. The first concerns the role of agency staff members in recruitment of participants. The second set of challenges originates from the local nature of interventions, i.e. the public health impact of a study at a local community partnership will be limited if the findings are not broadly relevant. The RMC addresses these challenges at the design level with:

  1. Procedures to reduce and identify sample bias introduced by the participation of community staff in participant recruitment;
  2. Strategies to identify and recruit community agencies to participate as intervention sites (maximizing heterogeneity and ensuring long-term commitment); and
  3. Structured implementation procedures guiding agencies and investigators in accommodating the intervention to the agencies context and in assimilating the intervention into the agencies' routine.

3. Principal Research Core (Director: GS Alexopoulos, MD)

1. The Principal Research Core's (PRC) mission is to serve as the conceptual architect of the ACISR's research program. To this end, the PRC promotes studies on clinical, psychosocial, and biological predictors of outcomes and moderators of treatment response of geriatric depression and use their findings as a stimulus for developing interventions personalizing care at the patient and the care setting level. A central function of the PRC is to promote designs that permit testing of interventions at community settings at the soonest possible time that evidence of efficacy permits. Accordingly, the PRC research focuses on three barriers to care:

  1. Access to health care and engagement;
  2. Clinical and psychosocial complexity; and
  3. Difficult to treat syndromes and patients.

The PRC relies on:

  1. A team of investigators with complementary expertise in clinical biology, sociology, primary care, home healthcare and rehabilitation studies, biostatistics, and economics;
  2. an organization that rapidly translates biological and psychosocial findings into intervention studies;
  3. a track record of independently supported projects;
  4. experience in career development of investigators;
  5. working research partnerships with the Westchester Geriatric Mental Health Coalition, which includes the County Department of Mental Health, the County Department of Senior Programs and Services, community based primary care practices, rehabilitation hospitals; and home healthcare agencies.

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