1 / 63

Integrating depression detection and treatment into work with older adults

Integrating depression detection and treatment into work with older adults. Peter A. Lichtenberg, Ph.D., ABPP Director, Institute of Gerontology & Professor of Psychology Wayne State University. Perspectives on Old Age. To me old age is always 15 years older than I am …

diane
Download Presentation

Integrating depression detection and treatment into work with older adults

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Integrating depression detection and treatment into work with older adults Peter A. Lichtenberg, Ph.D., ABPP Director, Institute of Gerontology & Professor of Psychology Wayne State University

  2. Perspectives on Old Age To me old age is always 15 years older than I am… Bernard Baruch, age 84 How old would you be if you didn’t know what age you were? Satchel Paige

  3. DSM-IV Major Depressive Disorder • At least 5 of the following 9 symptoms have been present for a 2 week period: (either a or b must be one of the 5 symptoms) • a. Depressed mood consistently - not transient • b. Loss of pleasure and interest in normally pleasurable activities (anhedonia) • c. Significant weight loss or gain (>5% body weight) • d. Insomnia or hypersomnia • e. Psychomotor agitation or retardation • f. Loss of energy, fatigue (even following a good night’s sleep) • g. Feelings of worthlessness, self-reproach, inappropriate guilt • h. Decreased ability to think or concentrate • i. Suicidal thoughts or attempt

  4. MAJOR Depressed mood or loss of pleasure 4 additional symptoms Interfere with social or occupational function At least 2 week duration MINOR Same 1 additional symptom Same Same There is nothing Minor about Minor Depression

  5. Prevalence:Depression at Late Life • ECA data: 1-month point prevalence is 10.0% • 2.3% MDD • 2.3% Dysthymia • 1.5% Minor Depression • 3.9% symptoms • 20-30% subsyndromal or minor • depression symptoms • 17-37% in PCCs • Gatz and Smyer (1992) 1-year prevalence of all mental disorders (>64) at 20%-22%. • Comorbidity of anxiety disorder for an MDD presentation is 35%-45%

  6. Prevalence of Major Depression in Older Adults By Setting 0 5 10 15 20 Nursing home Primary Care General hospital Assisted Living Home Health Care Community

  7. Depression Detectionin Primary Care • Major issue in geriatric primary care • 24 mos. study of HMO enrollees2:Mean age 75, 62% women • 16% prevalence of depression • 48% undetected • Least detected: Men 64-75 and all > 85

  8. ABCs of Depression J Fam Prac 03; S13

  9. Major negative impacts of depression • Pre-mature mortality • Increased physical disability—one of leading causes in world • Link btwn depression and subsequent cognitive decline • Lower quality of life • Poorer relations with others/social network/support

  10. Depression Etiology • Biological

  11. Depression Etiology: Biological • Neurotransmitters • Serotonin • Norepinephrine • Dopamine

  12. Neurotransmitters and Mood, Cognition, & Behavior

  13. Neurotransmitter Function

  14. Pathophysiology • Neurochemical imbalance • Serotonin • Norepineprine • Dopamine

  15. Results of SSRI Clinical Trials • Effective in older adultsbut not that much more than placebo • SSRI limitations • Use of physically healthy elders • Major differences are side effects, not efficacy • Liver side effects a concern—especiallyin elders

  16. SSRIs Prozac 20 mg Zoloft 50 mg Paxil 20 mg Paxil CR 25 mg Celexa 20 mg www.drugs.com

  17. SNRI Cymbalta 20 mg Effexor 25 mg Effexor XR 75 mg www.drugs.com

  18. SARI Serzone 50 mg Trazodone 50 mg Serzone 100 mg

  19. NDRI and NaSSA Wellbutrin 75 mg Remeron 30 mg Wellbutrin SR 100 mg

  20. Antidepressant Side Effects

  21. Increasing reliance on meds with little evidence to support it • Response yes, remit no… • Antidepressant use doubled from 1996 (5%) to 10.4% in 2006; switch from 2 or > meds increased from 42% in 1997 to 60% in 2006; 3 meds from 16% to 33% (Olfason et al., 2006)

  22. Placebo and You:2nd Generation Antidepressants • Acute phase, parallel group, double blinded, placebo controlled with random assignment, for 2nd generation antidepressants not associated with a med disorder and 60 or >. Cochrane and Medline • 10 unique trials with 13 contrasts (N=2377 active drug and 1788 placebo) • Response rates for Drug = 44.4% • Response rate for Placebo=34.7% • 10-12 weeks > 6-8 weeks • Discontinuation rates highest for Drug. • 2nd generation meds work but effects are modest and vary. • For every 100 treated, 8 show a response and 5 remission in excess of placebo • TCAs perform about the same as 2nd generation meds • Placebo rates vary 19-47%. Lots of heterogeneity: Nonspecific effects • Nelson et al., 2009

  23. Vascular Depression Hypothesis Vascular diseases “can predispose, precipitate, or perpetuate a depressive syndrome in many elderly patients”Alexopoulos9

  24. Vascular disease can cause microvascular brain tissue damage in frontal/subcortical areas of brain • Diabetes • Atrial Fibrillation • Hypertension • Smoking • Obesity • High cholesterol

  25. Development of Depressive Disorders Hypertension, Diabetes, CAD, StrokeGenetics, Neurological Disease, Stroke, Etc. Frontal Striatal Lesions Vulnerability To Depression Life Events Social Support Depressive Disorders Model of Risk Factors That Lead to Depressive Disorders Adapted from Krishnan KRR. Biol Psychiatry. 2002; 52: 185-192

  26. Vascular Burden Study(Mast, MacNeill & Lichtenberg, Amer J Geriat Psychiatry, 2004) Sample 680 consecutively admitted geriatric rehab patients (age 60+) Separated into 3 groups: Stroke: Pts with evidence of stroke, n=205 CVRF: Pts with CVRFs but no stroke, n=353 Non-vascular: Pts with no stroke or CVRFs, n=122

  27. Hypotheses Prevalence of depression will be greater among patients with vascular disease (stroke and CVRFs) than among non-vascular medical patients. Prevalence will not differ between stroke and CVRF groups.

  28. Results H1 Prevalence and severity of depression did not differ significantly among the 3 patient groups. Non-vascular CVRF Stroke Depression GDS>10 30.3% 35.1% 36.4% Mild depression GDS 11-15 18.0% 23.2% 24.1% Severe (GDS 16+) depression 12.3% 11.9% 12.3%

  29. Results H1:Vascular Burden Presence of 2+ CVRFs was associated with increased prevalence of depression in the non-stroke group. No CVRFs One CVRF Two or moreCVRFs Prevalence of depression CVRF group 0/0 78/254 (30.7%) 46/99 (46.9%) Prevalence of depression Stroke group 8/28 (28.6%) 39/97 (40.2%) 24/70 (34.3%)

  30. Conclusions from Study Concept of vascular burden Replication in sample of 600 community dwelling elders (Yochim, Mast & Lichtenberg 2003)

  31. Case Study—Vascular Depression 78 YO WM recently retired; Diabetes, heart disease Depression evident but physical limitations keep him from travelling the way he wants to At age 80 begins falling, exhaustion, lower energy expenditure (frailty) Falls and dies at age 82

  32. Activity Limitation TheoryChange in activities mediates relationship between medical condition and depression. Activity Restriction Depression Illness, Pain

  33. Depression & Function:Exercise Interventions Interventions Weight-lifting 20 wks v lectures 10 wks20 13 major & 17 minor depressives, mean age 71 Follow-up at 20 weeks and 26 months Aerobics v resistance v education, 3 mos21 439 knee osteoarthritics, mean age 69; 22% scored above BDI cutoff Follow-up at 3 months and 18 months

  34. Depression & Function:Exercise Interventions Results Both aerobic and resistance exercise reduced depression, disability, pain Exercise more effective than education Compliance best for low depression groups Adherence to exercise declined over time

  35. Case Study 81 year old woman—healthy until enters hospital for acute kidney failure Dx. Multiple Myeloma Chemotherapy Depression evident Treatment works and allows her to return to gardening and hiking Depression disappears

  36. Lewinsohnian Model of Depression • Feelings and behavior are linked • Three decades of research support the behavioral model for persons including: • Young, middle-aged, & older adults • Caregivers • Demented elders

  37. Rationale Goal Techniques What the person does is related to how s/he feels To increase positive events and decrease negative ones Relaxation, mood monitoring & graphing Behavioral Treatment of Depression

  38. The Retirement Research Foundation-Institute of Gerontology Project • Integrating Mental Health in Occupational Therapy Practice with Older Adults • Cathy Lysack & Peter Lichtenberg (PIs), plus team of WSU experts in aging, and community partners.

  39. The “DVD Box Set” 1. Introduction, Aging and Mental Health 2. Understanding and Treating Depression 3. Medications for Treatment of Depression 4. Family Caregiving 5. Falls, Balance and Exercise 6. Driving Rehabilitation and Community Mobility Plus: - A CD with assessments, powerpoint slides, and references/resources in pdf format. - A DVD with video of full patient assessments.

  40. Behavioral Activation • Combines meaningful activity and pleasant events • Teaches patients that mood is related to what they are doing • Does not require a big time investment to integrate into treatment

  41. Elements of Behavioral Activation • Mood ratings • Rationale • Pleasant event Brainstorming • Identify barriers to implementation • Commit to making a change

  42. Attitudes about talking with older adult clients about mood • Older adults are resistant to talking about their mood or sadness? • Pre Post (True response) • 53% 16%* (30 OTs in training group) • 45% (112 OTs in one day conference Combined data: (144 OTs) • 40% did not know diagnostic criteria for depression • 33% overestimated amount of depression in population they work with *These were statistically significant changes p<.05

  43. Performance Indicator Descriptive Data High levels of comorbidity

  44. Performance Indicator Change Data

  45. Case Study 80 YO live alone woman, falls fractures hip OT administers MLDT—mild cognition problems, mild-moderate depressive sx. Interviews woman about enjoyable activities Discovers woman loves to be read to and discuss poetry Depression recedes and woman makes gains and can return home

  46. Worden’s Four Tasks of Grief • Accept the reality of the loss • Work through the pain of grief • Adjust to the environment in which the deceased is missing • Emotionally relocate the deceasedand move on with life

  47. Bereavement • Bereavement: 800,000 people/year bereavement (20% MDD) Key: What is depression; what is abnormal grief; and what is OK? • Complicated Bereavement: V Code • Yearning for, preoccupation for, searching for, excessive crying, disbelief regarding death and non-acceptance of death, as well as social isolation. Global functioning suffers. • Must generally return to pre-loss activities • Assess for depression and the above variables • Texas Revised Inventory of Grief (26 items, 0-65) • Inventory of Complicated Grief (18 items and score 25 or >)

  48. Grief and Depression • Depression as a typical complication of grief29 • 13.9% of newly bereaved had depressive symptoms after 2 years v 4% of married persons • Percent of newly bereaved with depressive symptoms by month (no gender difference):

  49. Subjects Findings 109 older-old African Americans 51% of respondents lost parentto death or desertion by age 16 Those with parental loss had: Decreased education, social resources, and family satisfaction Increased depressive symptoms Early Loss and Late Life Expression in Poor Elders

More Related