Abstract/Project Summary – PROJECT 3 Depression and anxiety are common but undertreated in older adults undergoing cardiac surgical procedures. Approximately 400,000 older adults undergo cardiac surgery annually in the United States, and between a quarter and a half of these individuals have symptoms of preoperative anxiety or depression. Each of these individuals are at greater risk for depression/anxiety than the general older population. The perioperative period is a particularly vulnerable time, as the patient is concurrently confronted with social, functional and physical changes that accompany a major surgery. Most older adults with heart disease and depression or anxiety do not receive appropriate mental health treatment, and if they do, it is typically limited to pharmacologic interventions, further exacerbating already rampant polypharmacy. In this proposal, we will optimize and test a pharmacological and behavioral intervention bundle for older patients undergoing cardiac surgery, with clinically significant depressive and anxiety symptoms. We will institute a perioperative mental healthcare intervention bundle including: (1) applying a proven behavioral intervention, behavioral activation (BA), with strategies based on patient preferences and needs; and (2) medication optimization and deprescribing (MOD), targeting to optimize dosages of anti-depressant medications, and stopping harmful or ineffective medications. Aim 1 (Adaptation): Informed by a collaborative planning approach, we will adapt, develop and implement an optimal perioperative mental health intervention bundle for older adults undergoing major invasive cardiac procedures. Through stakeholder input, we will develop and iteratively adapt a behavioral and medication optimization intervention bundle for implementation in this population. Following initial protocol development, through treatment development trials, we will iteratively optimize the intervention through interactive feedback from patients over the age of 65 undergoing major cardiac intervention, and other stakeholders, noting barriers and facilitators to program completion. Aim 2 (Testing): Using a hybrid Type 1 randomized controlled trial design, we will compare the effectiveness of the intervention bundle with usual care in reducing symptoms of depression and anxiety in older patients undergoing cardiac surgery. For this aim, 100 patients with symptoms of depression and anxiety will be randomly assigned to the pharmacological and behavioral intervention bundle or usual care. Pre-operative depression and anxiety are associated with a host of adverse outcomes after surgery, including medical complications, falls, delirium, and mortality. Thus, medication optimization and deprescribing, in an intervention bundle with behavioral activation treatment of depression and anxiety in older adults undergoing cardiac surgery, is expected to improve not only symptoms of depression and anxiety but also other important post-o...