Depression in Older Adults University at Albany, SUNY Gero Innovations Grant

Today’s presentation Overview of late life depression Identify who is at risk Recognize depressive symptoms TOOLS: How to Screen / Assess Manage suicidal behavior When to refer older clients to a mental health professional Information on antidepressant medications Recognize EBP psychosocial treatments  

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

Who’s at Risk? Generally Women If you experienced a recent loss or severe stress Fam. History of mental illness/suicidal behavior Unexplained somatic symptoms History of self-medicating Chronic/major illness Strokes heart disease, AIDS, cancer, diabetes, chronic pain

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

Suicide Rate Of Older Adults Higher Than Young Adults (15-24) Source: Mortality Reports. National Center for Injury Prevention and Control. Centers for Disease Control and Prevention. http://webappa.cdc.gov/sasweb/ncipc/mortrate10_sy.html

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 Why are older adults hesitant to seek MH care? Cohort grew up when MH diagnosis meant really crazy/institutionalized Tend to feel it is personal failing to not “pull self up by your bootstraps” Re Disguised presentation of depression or anxiety – or pain, sleep disorder, GI issues, etc.

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

Prevalence of Subthreshold Depression in Later Life High rates of depressive symptoms More prevalent in women than men Anhedonia is a risk factor-suicidal ideation

Disability & 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 & disorders among disabled older adults.

Answers to commonly asked questions 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

Major Depression Episode 5 or more of the following symptoms during past two weeks: Depressed mood most of the day, nearly every day (subjective/other report) Decreased interest/pleasure in all activities Significant weight loss (e.g. 5% body wght/1 month) or overeating Insomnia or hypersomnia

Major Depressive Episode cont’d Psychomotor agitation/retardation fatigue or loss of energy feelings of worthlessness excessive guilt unable to concentrate, indecisiveness recurrent thoughts of death, recurrent suicidal ideation without a plan or a suicide attempt or a specific plan

Major Depression Criteria Presence of a single Major Depressive Episode absence of psychosis, hallucinations, delusions no manic, episode hx

Minor Depression Older adult reports 2 to 4 symptoms for at least 2 weeks One of the symptoms has to be: Depressed mood or lack of pleasurable activities

Depressive Symptoms vs Clinical Depression Many elderly may not be clinically depressed Medical conditions, meds, family, financial or bereavement problems are some factors associated with symptoms of depression Older person may be experiencing the “blues” of depressed mood

Why screen for late life depression? Screening improve the accurate identification of depressed clients Treatment of identified depressed adults decreases clinical morbidity. Reduce potential suicidality Also – they look better. Depressed people can appear demented or those with mild cognitive decline can look very impaired. When depression treated, they can follow up on other health maintenance strategies (such as med compliance, exercise, socialization) better.

Assessment of late life depression Ask about family history Assess for risk factors Complete the screening with the client Discern the type of depression Most prevalent forms of depression Major depression Minor depression Subthreshold depression

Assessment of late life depression Ask about family history Assess for risk factors Complete the screening with the client Discern the type of depression Most prevalent forms of depression Major depression Minor depression Subthreshold depression

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

Physical appetite weight sleep change psychomotor changes fatigue Depressive Symptoms Psychological depressed mood feelings of worthlessness/guilt loss of interest decreased concentration/memory suicidal ideation Physical appetite weight sleep change psychomotor changes fatigue

Elderly may show signs and symptoms D Dysphoria E Eating behavior 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 of pleasurable activities N Negativity in relation to self, others, future

Depression Screening Tools Rapid Rating Scales PHQ-9 Geriatric Depression Scale CES-D Scale BDI HAM-D Give students one of the above tools to try out with one another. How is this screening different than with younger adults? (greater variety of ways to ask about depressive symptoms without using the word depression)

Case: Mrs. D 76 yr old female Frequently contacts primary care physician about her health When seen, she expresses numerous worries about other areas of her life She relates that she has always been a “worry wart” and this has made her life difficult She has difficulty concentrating, making decisions She reports feeling restless, difficulty going to sleep because of excessive rumination She worries that others avoid her because she is no fun to be around She lives alone She states that she doesn’t feel like doing anything Ask students for differential diagnosis Criteria for Major Depression – 5 symptoms Decreased pleasure (9) Insomnia (6) or psychomotor agitation Unable to concentrate (5) Excessive guilt (4) Consider how long? Risk of suicide? Other anxiety disorder?

Suicidality Components Thoughts of death Intent Plan Means Prior suicidal history or behavior

Interventions for Suicidal Management Listen for clues in what they say: ‘No one left”, “I can’t go on”, What’s the use?, I gave some things away” ASK the client INFORM them that you are concerned for their wellbeing

Interventions for Suicidal 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

Interventions for Approaching the Topic of late Life Depression How are things at home? Have you had any stress lately? How are you handling it? How have you been coping?

Interventions for Approaching the Topic of Late Life Depression Discuss your concerns with client You can say: “It is very common…” “It is a medical condition” “It is treatable”

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

Evidence-Based Interventions (1) Cognitive Behavioral Therapy has been well-validated in controlled efficacy trials in community & primary care settings Sessions range (8-20)

Evidence-Based Interventions (2) Problem Solving Therapy has been well- validated in controlled efficacy trials in community & primary care settings Sessions (range 6 – 12) RCT of brief PST intervention with homebound older adults (Gellis, 2007)

Evidence-Based Interventions (3) Interpersonal Therapy has been validated in controlled efficacy trials in mental health, outpatient, & primary care settings IPT focuses on interpersonal events such as interpersonal disputes / conflicts, interpersonal role transitions, complicated grief related to onset and / or maintenance of depression.

Evidence-Based Interventions (4) Relaxation training has shown effects for depression & generalized anxiety (5) Adjunct written educational materials for clients & family members have been shown to improve medication adherence & clinical outcomes (6) Pharmacologic Treatments 70-80% of depressed pts will respond to meds alone -most pts respond within 4-6 weeks -”Start Low and Go Slow” Related interventions not specifically for depression: Caregiver interventions

Antidepressants SSRIs – 1st line of treatment SNRIs TCA - e.g. imipramine MAOI - Restriction in diet (no cheese or smoked food) and no antihistamines

Serotonin Selective Reuptake Inhibitors Fluoxetine (Prozac), 20-80 mg/d Initiate with 5-10 mg/d Sertraline (Zoloft), 50-200 mg/d Initiate with 25-50 mg/d Paroxetine (Paxil), 20-50 mg/d Initiate with 10mg/d Fluvoxamine (Luvox), 50-300 mg/d Initiate with 25 mg/d Citalopram (Celexa) - Initiate with 10-20 mg/d Start low- -Go Slow

Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) Venlafaxine-XR (Effexor-XR) 75-300 mg/d Cymbalta Typical side effects GI distress, jitteriness, headaches, sexual disturbance

And Remember…. Depression in older adults is real if the symptoms are: excessive, uncontrollable, create distress, and interfere with daily living

Summary Depression is prevalent in aging but is not a part of aging Comorbid with other medical illnesses Most forms of depression are easily diagnosed and treatable Depression requires training for careful screening and follow-up Early screening and intervention is critical Appropriate asmt. And tx can improve the QoL for depressed older persons

Depression in Older Adults 2007 University at Albany, SUNY