Table 1 Resident Level Covariates & Justification

 Age

Calculated as difference between assessment reference date (A3) and birth date (AA3a)

 Sex

AA2

 Marital status

A5

Justification for Covariates

 Cardiovascular diseases

Either of arteriosclerotic heart disease (I1d), cardiac dysrhythmia (I1e), congestive heart failure (I1f), deep vein thrombosis (I1g), peripheral vascular disease (I1j), other cardiovascular disease (I1k)

Major depression effects 19% of patients post myocardial infarction¹. 14 to 60% of patients with heart failure experience depressive symptoms². In peripheral vascular disease between 12 and 24% have depression, however this increases with amputation³. A UK study found 18.1% of patients had depressive symptoms⁴. Deep vein thrombosis and post thrombotic syndrome are known to negatively effect health related quality of life^{5, 6}.Where DVT was associated with higher anxiety and depression compared to control on the EQ-5D⁶.

 Renal failure

I1uu

Across the 5 stages of chronic kidney disease the prevalence of depression 21.4%⁷

 Diabetes mellitus

I1a

The relative risk of depression in diabetes is RR 1.27⁸.

 Stroke or transient ischemic attack

I1u or I1dd

The prevalence of any depressive disorder in stroke is 33.5%⁹.

 Seizure disorder

I1cc

Epilepsy has 22.9% prevalence of depressive disorders¹⁰

 Neurodegenerative disease

Either of amyotrophic lateral sclerosis (I1q), Huntington’s chorea (I1x), multiple sclerosis (I1y), or Parkinson’s disease (I1aa)

In Parkinson’s disease, 35% experience clinically relevant depressive symptoms¹¹. For Multiple Sclerosis 30.5% have depression¹². Those with Amyotrophic Lateral Sclerosis have a OR of depression of 1.7¹³. Approximately 31.7% of those with Huntington’s disease experience major depression¹⁴.

 Traumatic brain injury

I1ee

Traumatic brain injury has a 43% prevalence of depressive disorders¹⁵

 Anxiety disorder

I1ff

Anxiety is common in LTC, with 29.7% of patients reporting anxiety symptoms¹⁶.

 Bipolar disorder

I1hh

Bipolar disorder¹⁷ includes depressive symptoms as part of the diagnosis

 Schizophrenia

I1ii

Depressive symptoms are common (~ 7–75%) patients with schizophrenia^{18, 19}, with depression also being part of the diagnostic criteria for schizoaffective disorders¹⁷.

 Cancer

I1rr

8–24% of Cancer patients experience depression²⁰.

 Respiratory disease

Asthma (I1jj) or emphysema/chronic obstructive pulmonary disease (I1kk)

Pulmonary diseases have been associated with depression^{21, 22} and depression in LTC²³.

 Gastrointestinal disease

I1ss

21.6% of Inflammatory bowel disease patients experience symptoms of depression²⁴.

 Liver disease

I1tt

Liver diseases, for e.g. non-alcoholic cirrhosis, has an incidence risk ratio for depression of 1.76.²⁵

 Physical dependency

Activities of Daily Living – Hierarchical²⁶ score > 3

Depression is associated with a decline in function (e.g. poor self sufficiency)²⁷

 Visual impairment

Either of cataracts (I1ll), diabetic retinopathy (I1mm), glaucoma (I1nn), or macular degeneration (I1oo)

Poor vision in seniors is associated with an 1.94 odds of depression (95% CI1.68, 2.25)²⁸

 Hearing impairment

C1 = 2 (hears in special situations only) or C1 = 3 (hearing highly impaired)

Loss of hearing is associated with depression, OR 1.71 (95%CI 1.28,2.27)²⁸.

 Pain

Either J2a = 2 (daily pain) or J2b = 3 (phases of excruciating pain regardless of frequency)

Pain and depression are highly correlated across multiple settings²⁹.

Outcome

TREC survey variable

Justification for covariates

Unit type

Care units are either general long term care, non secure dementia, secure dementia, secure mental health/ psychiatric, or other

Our research has demonstrated that quality issues within LTC facilities vary substantially among care units and that unit-level measurement in addition to facility0level measurement is crucial to account for this variance.³⁰

Unit staffing

For each care unit TREC collects information on care staffing by care provider group that allows to calculate the care hours per resident day for care aides, licensed practical nurses and registered nurses.³¹

Systematic reviews suggested a link between higher staffing levels and better quality of care (including detection and management of depressive symptoms).^32–34

Facility location

Facility is located in either the Edmonton or Calgary Health Zone, in the Fraser or Interior Health Authority, or in the Winnipeg Regional Health Authority

The Canadian Health Act requires public payment only for medical services provided in hospitals or by physicians.³⁵ Provinces/territories determine individually which services are paid publicly (and how much is paid) and which services clients must cover themselves. Policies regulating LTC differ substantially among Canadian provinces, and so do quality of care issues.³⁶ Therefore, and because this is one of the stratification variables to sample TREC facilities, we adjusted our models for facility location.

Facility size

Facility is small (<  80 beds), medium (80–120 beds) or large (>  120 beds)

Evidence suggests that an LTC facility’s size affects quality of care.³⁷ Therefore, we adjusted our models for facility location. Therefore, and because this is one of the stratification variables to sample TREC facilities, we adjusted our models for facility location.

Facility owner-operator model

Facility owner operator model is either public not-for-profit, voluntary not-for-profit (e.g., faith based) or private for-profit

Evidence suggests that an LTC facility’s ownership model affects quality of care.³⁷ Therefore, we adjusted our models for facility location. Therefore, and because this is one of the stratification variables to sample TREC facilities, we adjusted our models for facility location.

Mental health/geriatric services provided in facility

TREC collects data on whether or not mental health and geriatric services are available in each TREC facility. Services include geriatric mental health consulting, geriatrician, psychiatrist or geriatric psychiatrist, each coded as 1 (available) or 0 (not available)

Availability of mental health services is key to detection and appropriate management of depressive symptoms in older adults³⁸.