Treating Elderly Persons with Depression

1. Treating Elderly Persons with Depression Scott J. Adams, Psy.D. WICHE Mental Health Program

2. Objectives Discuss epidemiological and other relevant data regarding depression in geriatric populations. Discuss a clinical formulation of elderly persons regarding depression. Cover questions PCPs can ask of elderly patients to assess the presence of depression. Talking with elderly people about treatment options.

3. Prevalence Major depression among older adults in primary care settings is between 6.5% and 9% (Lyness et al., 2002). Estimates of overall depression vary widely based on patient�s context (in community, nursing home, etc.) and method of evaluation. Rates increase with need for home health care and hospitalization. 10%-25% of in primary care and community settings have subsyndromal depression with symptoms that do not meet diagnostic criteria but have a significant negative impact on their lives (Speer & Schneider, 2003) The prevalence of bipolar disorder among people aged 65 and over is reportedly less than 1 percent (Robins & Regier, 1991).

4. Epidemiology Gender 1. Depression may be 1.5- 2 times higher in older adult women (e.g., Kockler & Heur, 2002). This could be in part due to reporting bias and has been refuted in some studies that included post-mortem evaluations. B. Race 1. Studies disagree on prevalence of geriatric depression in ethnic group. Some say there is little difference between races , some studies show higher numbers in some groups, for example, African-Americans (Weissman et al., 1991). 2. Suicide is lower for people of color than in white older adults (CDC, 2005).

5. Risk Factors People who need home health care People who require hospitalization People who live in nursing homes Somatic illnesses Persistent insomnia Loss of their spouse Other losses (e.g., loved ones, loss in functioning) Poor social support Current acute or chronic stressors Heavy users of alcohol Educational attainment less than a high school degree

6. Clinical Case Formulation Here is a relatively simple formula one can use to assess elderly persons for depression: Place X Position = Problem Place: Where a person resides � own home, with family, in a facility. Position: One�s psychological place or status � connected vs. alone, independent vs. dependent, physically healthy vs. unhealthy, productive vs. nonproductive. Problem: The result of the interplay between one�s place and position.

7. Clinical Case Formulation Infant: Trust vs Mistrust - Needs maximum comfort with minimal uncertainty to trust himself/herself, others, and the environment Toddler: Autonomy vs Shame and Doubt - Works to master physical environment while maintaining self-esteem Preschooler: Initiative vs Guilt - Begins to initiate, not imitate, activities; develops conscience and sexual identity School-Age Child: Industry vs Inferiority - Tries to develop a sense of self-worth by refining skills Adolescent: Identity vs Role Confusion - Tries integrating many roles (child, sibling, student, athlete, worker) into a self-image under role model and peer pressure Young Adult: Intimacy vs Isolation - Learns to make personal commitment to another as spouse, parent or partner Middle-Age Adult: Generativity vs Stagnation - Seeks satisfaction through productivity in career, family, and civic interests Older Adult: Integrity vs Despair - Reviews life accomplishments, deals with loss and preparation for death

8. Clinical Case Formulation cont. Place Own Home With Family In a Facility Connected--------Alone Connected--------Alone Connected--------Alone Independent--------Dependent Independent--------Dependent Independent--------Dependent Healthy--------Unhealthy Healthy--------Unhealthy Healthy--------Unhealthy Productive--------Nonproductive Productive--------Nonproductive Productive--------Nonproductive By considering a given person�s position within a place, one can get a good idea of relevant issues. Generally speaking, the more a person falls on the left side of both the �place� and four �position� scales, the better off they will be psychologically. For example, a person in his/her own home who has connections with others, is mostly independent, is fairly healthy, and productive will be in a better position than someone at the opposite end of these scales. Additionally, this quick assessment tool can help identify potential interventions.

9. Assessment Interviewing Use the clinical case formula presented in previous slides. Geriatric Depression Scale (GDS) as a way to detect and talk about depression focusing less on dysphoric mood, which older adults are less likely to report.

10. Geriatric Depression Scale (short form)

11. Rule Outs 1. Medical causes 2. Bereavement 3. Bipolar Disorder (<1%) 4. Alzheimer�s, vascular dementia, other dementias

12. Dementia vs. Pseudo-dementia

13. Treatment Medication a. One study on antidepressant medication compliance found that 70% of older adults don�t take their meds as prescribed (NAMI, 2003) so address med compliance issues (e.g., fears about taking meds). b. Evidence suggests that medication may take longer to work. c. Residual symptoms appear to be common.

14. Treatment cont. 2. Psychotherapy Psychotherapeutic treatment are effective for geriatric patients. Meta-analytic studies show that effects are similar to those of younger adults (e.g., one meta-analysis showed an effect size of .72). 83% say they want to treat their depression (APA, 2003). Evidence is inconclusive regarding best kind of psychotherapy, but meta-analysis of psychotherapy studies have included a range of psychotherapy styles. Many types are probably effective. Older adults may require a longer course of psychotherapy than younger adults. 3. Combined Treatment The data indicate that medication or therapy alone can be effective, but combining them has the best outcome (Reynolds et al., 1999; Little et al., 1998; Thompson et al., 2001).

15. Other Interventions If you use the clinical case formula described earlier (Place x Position = Problem), interventions may become apparent. For instance, does a person have connections but feels unproductive, or is he/she physically healthy but alone? There are many combinations, but even simple things can help a great deal. A major theme is one of control and mastery. Even people who have significant physical illnesses and require significant care can do things to achieve greater control and mastery in their lives. Education is always helpful, particularly in terms of helping patients see that they do not have to accept depression as a necessary part of aging.

16. Discussing Treatment The primary treatments are psychotherapy or counseling and medication. As a general rule, the younger the child, the longer psychotherapy with the child will take. Instead, it�s better to work with parents. Family therapy may be the best option if there are multiple problems in the home. Sometimes a child becomes a focus of problems but is not the only one with problems. Many parents (understandably) do not want to put their kids on medications. One of the primary issues will be symptom severity. Brief explanations of how medications work go a long way in demystifying and destigmatizing them.

17. Parent Resource List Depression Education Websites: Mayo Clinic: www.mayoclinic.com National Institute of Mental Health: www.nimh.nih.gov Mental Health America:www.mentalhealthamerica.net Books on How to Help Depressed Children: The Depressed Child: A Parent�s Guide for Rescuing Kids - Dr. Douglas A. Riley, Ph.D. The Childhood Depression Sourcebook - Jeffrey A. Miller, Ph.D. Helping Your Depressed Child - Martha Underwood Barnard, Ph.D.

18. Pediatric Depression References Costello, E. J., Angold, A., Burns, B. J., Stangl, D. K., Tweed, D. L., Erkanli, A., & Worthman, C. M. (1996). The Great Smoky Mountains study of youth: Goals, design, methods, and the prevalence of DSM� III�R disorders. Archives of General Psychiatry, 53, 1129�1136. Kessler, R. C., Avenevoli, S., & Merikangas, K. R. (2001). Mood disorders in children and adolescents: an epidemiologic perspective.� Biological Psychiatry,�49,�1002-1014. Lewinson, P. M., Hops, H., Roberts, R. E., & Seeley, J. R., (1993). Adolescent Pychopathology I: Prevalence and incidence of depression and other DSM-III-R disorders in high school students. Journal of Abnormal Psychology, 102, 133-144. Rappaport, N., Bostic, J. Q., Prince, J. B., & Jellinek, M. (2006). Treating pediatric depression in primary care. Journal of Pediatrics, 148, 567-568.