Depressive Disorders in Older Adults Resource Review for Teaching Depressive Disorders in Older Adults Add text Zvi D. Gellis, PhD Stanley G. McCracken, PhD, LCSW Director, Center for Mental Health & Aging Senior Lecturer Hartford Geriatrics Faculty Scholar The University of Chicago State University of New York at Albany

Presentation Outline Significance of depression in older adults Epidemiology of depression in older adults Comorbidity of depression in older adults Depression and suicide in older adults Evidence-based treatment of depression in older adults Psychosocial interventions Pharmacological interventions Minor depression

Presentation-continued Depression screening Special settings Late life depression in primary care Late life depression in home health care Late life depression in assisted living Late life depression in long-term care/nursing homes

Depression Overview Leads to physical mental & social disability. Depression can be persistent, intermittent. Depression can increase levels of health services use and costs.

Commonly raised concerns about depression—as they present in seniors I can’t do anything for myself. But I’m too old to be depressed. I’m not depressed. I just do not feel that my life is worth anything. I’m in pain much of the time. I’m of no use to anyone. I don’t see my friends anymore. I’m not interested in anything.

Detection rates are poor Reluctance of elderly to seek MH care. Lack of knowledge and/or reluctance of PCP/Human Services to detect or refer. Disguised presentation of depression or anxiety related to medical conditions.

Inappropriate Care Fragmented mental health services. Financial constraints limit time spent with client. Mental health concerns compete with comorbid medical problems

Epidemiology of Depression in Older Adults Rates of depression vary by setting. Rate of depressive symptoms are higher than rates of depressive disorders.

Prevalence of Major Depression in Later Life More prevalent in women than men Depressed Mood risk factor-suicidal ideation

Prevalence of Clinically Significant Depressive Symptoms in Later Life More prevalent in women than men Anhedonia is a risk factor-suicidal ideation High rates of depressive symptoms

Disability and Depression in Later Life Downward Spiral Theory Depression is a risk factor for disability, and Disability increases the risk of depression. Result: A high prevalence of depressive symptoms and disorders among disabled older adults.

Prognosis of Depression in Older Adults Prognosis often poor. Predicts poor treatment adherence, may exacerbate medical conditions, slows recovery from other illnesses and surgery, and is associated with increased mortality.

Risk Factors Female gender Sleep disturbance Disability Prior history of depression Bereavement (recent loss or severe stress) Family history of mental illness/suicidal behavior Unexplained somatic symptoms History of self-medicating Chronic/major medical illness Stroke, heart disease, AIDS, cancer, diabetes, chronic pain

Comorbidity Comorbidity of depression and medical disorders is common. Adversely influences course of depression. Increases functional impairment, health costs, and use of health services.

Medical Conditions Associated with Depression Cancer Diabetes Osteoarthritis HIV/AIDS Hypothyroidism Stroke Epilepsy Heart disease and hypertension Parkinson’s disease Vitamin deficiency (Folate and/or B12) Alcohol/drug abuse or withdrawal

Late Life Depression Depressive Disorders are very real & one of the most common mental health problems among older adults. Depression is also common with vision impairment, other medical conditions, and alcohol abuse. Among older adults, suicide risk is high.

Depression and Suicide in Older Adults Suicide rate among older adults is twice that of the general population. Accounts for ~20% of all suicides (though older adults are only 13% of population). Males >85 have highest rate of any group. Males >80 take their lives at 2X rate of women.

Suicide Rates: Men >85 Compared To Adolescents

Suicide Risk Factors for Older Adults Demographic risk factors: Older age Male gender White race Unmarried status Clinical risk factors: Depression (esp. late-onset unipolar depression) Comorbid anxiety Substance abuse Isolation Loneliness Lack of social supports Declining physical health

Detection Rates are Poor Older suicide victims have had late onset undetected or untreated depressions. >70% have had contact with their primary care physician 3 months prior to their death, suggesting high rates of comorbid illness, and fears of pain or dependency on others.

Depression in Health Care Settings Attention to detecting and treating depression in healthcare settings reduces rates of depression. PROSPECT Project (Prevention of Suicide in Primary Care Elderly). Patients observed for 2 years. Patients offered medication or Interpersonal Therapy. Care mangers: monitor symptoms, adherence, treatment response, side effects. Participants had less severe symptoms, higher remission rates.

Interventions for Suicide Management LISTEN for clues in what they say: “I can’t go on What’s the use? I gave some things away,” ASK the client if (or how often) they are thinking about suicide. INFORM them that you are concerned for their wellbeing.

Interventions for Suicide Management Most people who are thinking about suicide will communicate their intent through clues. Myth: asking someone about suicide will encourage it. Refer to mental health/psychiatry.

Psychosocial Interventions Evidence-based approaches such as structured problem-solving therapy (PST), cognitive behavioral therapy (CBT), and interpersonal therapy (IPT) are effective adjuncts or alternatives to medication. CBT and PST are particularly promising among older adults from diverse ethnic backgrounds. Majority of primary care patients prefer counseling over medication. Important since client attitudes and preferences affect acceptance and adherence to treatment for depression.

Evidence-Based Psychosocial Interventions Problem Solving Therapy has been well-validated in controlled efficacy trials in community & primary care settings, including with frail, homebound, medically ill older adults. Sessions (range 6 – 12)

Evidence-Based Psychosocial Interventions Cognitive Behavioral Therapy has been well-validated in controlled efficacy trials in community and primary care settings. At least as effective as medication and other forms of psychotherapy. Sessions range (8-20) Combined case management and CBT may be more effective for low-income and certain minority elders.

Evidence-Based Psychosocial Interventions Interpersonal Therapy (IPT) has been validated in controlled efficacy trials in mental health, outpatient, and primary care settings. IPT focuses on interpersonal events (such as relationships, interpersonal disputes/ conflicts), interpersonal role transitions, and complicated grief related to onset and/or maintenance of depression. Purpose is to improved communication, develop/enhance social support network.

Evidence-Based Psychosocial Interventions Relaxation training has shown beneficial effects for depression and generalized anxiety. Adjunct written educational materials for clients and family members have been shown to improve medication adherence & clinical outcomes

Psychosocial Treatment of Late Life Depression Treatment protocols typically time-limited (6-20 sessions). Goal of brief interventions: treat the problem; specifically, change behavior of individuals experiencing mental health problems. Interventions include assessment and direct feedback, contracting, goal setting, cognitive and behavioral techniques, use of written and educational materials. Insufficient evidence on culturally appropriate treatments.

Interventions for Approaching the Topic of Late Life Depression Ask questions. How are things at home? How have you been coping? Have you had any stress lately? How are you handling it? Discuss your concerns with client. You can say: It is a very common It is a medical condition It is very treatable

What Can You Do Prior to Referral for Mental Health Services? Be supportive; Be patient. Allow individual to express his/her concerns/fears. Listen without being judgmental. Don’t take things personally if he/she is irritated or angry. Provide choices and be complimentary. Attempt to provide daily activities.

Guidelines for Making a Referral to Mental Health Services If the older client has a psychiatric history. If there is suicidal ideation. Client safety, risk of suicide. Hospitalization. Client needs medication evaluation. Client needs ongoing therapy.

Evidence-Based Pharmacologic Interventions Pharmacologic Treatments Antidepressants: widely used, safe, and effective for moderate-severe depression in older adults. All classes about equally effective, though older adults have fewer adverse effects with newer meds. 70-80% of depressed patients will respond to meds alone. Most individuals respond within 4-6 weeks. ”Start Low and Go Slow.” (Start with low dose and increase slowly.)

Antidepressants SSRIs – 1st line of treatment SNRIs TCA: Cardiac effects, dizziness, constipation, urinary hesitance MAOI: Restriction in diet (avoid foods/drinks produced by process of aging [cheese, smoked meat, pickled fish, fermented beverages-alcohol]) and numerous drug interactions.

Medication Interactions Antidepressants and other meds can have interactions through the liver and liver enzymes, which breakdown the meds. Changes can   plasma levels and interfere with the metabolism of other meds.

Medications that Can Mimic Depression Sedatives, sleeping pills, antianxiety medications Beta blockers and other antihypertensives Steroids Tagamet

Minor Depression Minor depression is more common than major depression among older adults. Associated with increased risk of mortality. Symptoms may remit over time. However, for many minor depression is a precursor to major depression. CBT, IPT, PST appear promising, though evidenced- based studies are few.

Minor Depression in Older Adults

Depression Screening Criteria to justify MH screening: Incidence high enough to justify cost? (Depression prevalent among older adults in many settings.) Does problem have significant effect on QOL? (Depression among older adults causes serious health and social consequences.) Is effective treatment available? (There are effective psychosocial and pharmacological treatments.) Are there valid, cost-effective screening tools? (There are.) Are adverse effects acceptable to client and worker? (In our experience-yes.)

Elderly May Show Signs/Symptoms of: D Dysphoria E Eating behavior changes P Physical complaints R Rumination E Energy loss S Suicidal thoughts and plans S Poor sleep or too much sleep I Isolation (lack of social support) O Omission/reduction of pleasurable activities N Negativity in relation to self, others, future

Depression Screening Tools Rapid Rating Scales Self-report instruments Geriatric Depression Scale (GDS) Center for Epidemiological Studies Depression Scale (CES-D) Beck Depression Inventory (BDI) Patient Health Questionnaire-9 (PHQ-9) Zung Depression Scale Clinician-administered instruments Hamilton Rating Scale for Depression (HAM-D) Cornell Scale for Depression in Dementia (CSDD)

Structured Interviews for DSM-IV-TR Diagnosis Structured Clinical Interview for DSM-IV (SCID) Mini-International Neuropsychiatric Interview (MINI) Register and download paper and pencil versions free (available in several languages) at: https://www.medical-outcomes.com/indexSSL.htm

Screening Steps Obtain the person’s agreement to be screened. Explain the purpose for the screening. Administer and score the screening tool as instructions direct. If the screen is positive, make initial treatment referrals for further diagnostic assessment to the older person’s primary care physician for possible psychotherapy and antidepressant medication.

Screening The social worker is in a unique position to: Identify resources if financial barriers exist. Address stigma through psychoeducation. Encourage client follow through with the referral.

Special Settings: Late life Depression in Primary Care Integrating MH care within primary care is more effective than improving skills of the PCP. Collaborative care involves: nurses, social workers, or depression care managers, and vary in content and intensity. Interventions: increase knowledge about depression (psychoeducation), improve adherence to antidepressant medications, improve communication between physician and patient, decrease depressive symptoms.

Special Settings: Late life Depression in Primary Care Effective components of educational and organizational interventions: Enhanced nurse depression care manager role. Improvement in communication between primary care and psychiatry liaison. Practice guideline documentation and educational strategies generally ineffective.

Special Settings: Late life Depression in Primary Care PST alone and combined with medication and other components are effective. Added components: enhanced education and support, social and physical activation, self-care management, information and decision-making, counseling and support, communication with PCP. Collaborative management home care is another promising approach in older adults.

Special Settings: Late life Depression in Home Health Care HHC reduces hospitalization and nursing home use. Compared with general elderly population, HHC recipients are older, more socially isolated, more likely women, and have high rates of physical illness, disability, and depression. Many with depression do not receive treatment.

Special Settings: Late life Depression in Home Health Care Barriers to detection and treatment of depression: Heterogeneity of depression plus physical and cognitive impairment, social vulnerabilities, and medical conditions prevalent in HHC make it more difficult for accurate assessment, diagnosis, and treatment. Older adults less likely to voluntarily report affective symptoms of depression, more likely to ascribe symptoms to physical illness, less likely to use specialty MH care. PST is promising approach to treatment of depression in HHC.

Special Settings: Late life Depression in Assisted Living As in other settings, there is a significant rate of depression and depressive symptoms but they are undetected and untreated. Depression may be associated with cognitive impairment, agitation, recent hospitalization, dependence on others for >3 ADLs, psychosis, and social withdrawal. Multifaceted shared care is a promising approach to treatment.

Special Settings: Depression in Long-Term Care/Nursing Homes ~5% of older adults live in LTC. Significant proportion of LTC elderly with cognitive impairment and dementia have depression. Rapid screening, accurate diagnosis, and early treatment likely to reduce symptoms of depression. Undetected, untreated, or inadequately treated depression may result in higher rates of NH placement in patients with dementia, because of increased functional disability.

Special Settings: Depression in Long-Term Care/Nursing Homes Many LTC residents present with signs and symptoms that overlap with depression: anhedonia, irritability, flat affect. Comorbid anxiety and depression most prevalent in more severely depressed and anxious NH residents.

Special Settings: Depression in Long-Term Care/Nursing Homes Research on interventions for depression in older adult LTC/NH residents is sparse and deficient. Researchers recommend combined approach to treatment, including behavioral interventions and antidepressants. Psychosocial intervention is an initial first step with introduction of medication in more severe depression. A few psychosocial interventions, such as group and individual behavioral therapies, show potential but require further investigation.

Summary Depression is prevalent in aging but is not a part of aging. Rates of depression vary in different settings. Depression is often comorbid with other medical illnesses. Most forms of depression are easily diagnosed and treatable.

Summary Depression requires training for careful screening and follow-up. Suicide is prevalent among older adults, especially men. Early assessment and appropriate treatment is critical and can improve the quality of life for depressed older persons. CBT, PST, IPT, and antidepressant medications are safe, effective, and acceptable treatments for depression.