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Depression and Older Adults

Depression and Older Adults. Mark Snowden, M.D., M.P.H. Associate Professor University of Washington Medical Director Geriatric Psychiatry Services Harborview Medical Center. OVERVIEW. Prevalence and heterogeneity Major Depression Treatment Minor Depression Treatment Bereavement

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Depression and Older Adults

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  1. Depression and Older Adults Mark Snowden, M.D., M.P.H. Associate Professor University of Washington Medical Director Geriatric Psychiatry Services Harborview Medical Center

  2. OVERVIEW • Prevalence and heterogeneity • Major Depression Treatment • Minor Depression Treatment • Bereavement • Depression in Dementia • Response to Drug Failure

  3. 1 YR PREVALENCE AFFECTIVE DISORDER Age (yrs) Odds Ratio 15-24 25-34 35-44 45-54 1.67* 1.32 1.35 1.0 * p<.05 (Kessler,RC et al. Arch Gen Psych Jan. ‘94)

  4. COHORT DEPRESSION RATES .14 Cumulative Depression Rate .07 1935-44 1945-54 1955-64 1925-34 1915-24 1905-14 0 14 24 34 44 54 64 74 Age (yrs)

  5. PREVALENCE OF DEPRESSION IN GERIATRIC POPULATIONS SettingMaj. Depr. Community Med. Clinics Nursing Homes 1 - 4% 5 - 10% 12 - 20%

  6. PREVALENCE OF DEPRESSION IN GERIATRIC POPULATIONS SettingMaj. Depr.Depr. Sxs. 8 - 16% 17 - 35% 30 - 45% Community Med. Clinics Nursing Homes 1 - 4% 5 - 10% 12 - 20%

  7. Differential Diagnosis Maj. Depression (Partial Remission) Dysthymia Minor Depression Adj. Disorder w/ depressed mood Mood Disorder due to Medical Condition Depression of Alzheimer’s Dementia Bereavement

  8. DSM IV MAJOR DEPRESSION CRITERIA 1) Depressed Mood and/or 2) Anhedonia

  9. DSM IV MAJOR DEPRESSION CRITERIA 3) Anorexia/wt loss 4) Insomnia or Hypersomnia 5) Psychomotor Agitation or Retardation 6) Fatigue 7) Feelings of Worthlessness/Guilt 8) Indecisiveness/Trouble Concentrating 9) Recurrent Thoughts of Death/Suicide

  10. Late Onset vs Early Onset Depression N=246 Symptom Odds Ratio Loss of Interest * 4.01 Motor Retardation 0.57 Guilt Feelings 1.16 Pessimism 1.87 Psychotic Sxs. 0.58 Gen. Anxiety 0.72 * P<.05 (Krishnan et al. Am J Psychiatry, 5/95)

  11. OVERVIEW • Prevalence and heterogeneity • Major Depression Treatment • Minor Depression • Bereavement • Depression in Dementia • Response to Drug Failure

  12. NEW GENERATION ANTIDEPRESSANTS • Selective Serotonin Re-uptake Inhibitors • Fluoxetine (Prozac) • Sertraline (Zoloft) • Paroxetine (Paxil) • Citalopram (Celexa) • Escitalopram (Lexapro)

  13. SSRIs • More Alike than Different • Half Life: Fluoxetine>>citalopram>sertraline=paroxetine • Anticholinergic: Paxil mild > fluoxetine, sertraline, citalopram • Drug Interactions: Fluoxetine > paroxetine > sertraline, citalopram

  14. NEW GENERATION ANTIDEPRESSANTS • Bupropion (Wellbutrin) • Venlafaxine (Effexor) • Duloxetine (Cymbalta) • Mirtazepine (Remeron)

  15. BUPROPION • Different, Unknown therapeutic mechanism • Stimulant-like structure • Seizure Risks/Contraindication

  16. VENLAFAXINE XR • Low Dose: Serotonergic> Noradrenergic • Higher Dose: More combination 5HT & NE • Fewer Drug-Drug Interactions than SSRIs • Hypertension Side Effect

  17. Duloxetine • Combined Serotonergic and Noradrenergic • Decreased Risk Hypertension • Some efficacy for neuropathic pain

  18. MIRTAZEPINE • Serotonergic and Noradrenergic mechanisms • Mild-moderate sedation • Associated with some weight gain

  19. TRICYCLIC ANTIDEPRESSANTS • Tertiary (amitriptyline, imipramine, doxepin) • Secondary(nortriptyline, desipramine) • Secondary have fewer side effects Anticholinergic: desipramine < nortriptyline Orthostatic Hypotension: nortriptyline < desipramine Sedation: nortriptyline > desipramine

  20. OTHER CONSIDERATIONS • Sedation • more with mirtazepine • Sexual Dysfunction • less with bupropion • Hypertension Risk • venlafaxine • Seizure History • bupropion contraindicated

  21. GERIATRIC DOSING ___Initial (mg)__ 10 10 25 10 10 20 75 37.5 15 Est. therapeutic Dose 50-125 10-40 50-200 20-60 20-40 40-60 200-450 150-375 30-45 Nortriptyline Fluoxetine Sertraline Paroxetine Citalopram Duloxetine Bupropion Venlafaxine Mirtazepine

  22. Antidepressant Duration • Low Dose: 1-2 wks before change • Intermediate dosing: 2-4 wks • Maximum Dose: 4-6 wks

  23. Intervention Example:Depression Care Management (Clinic) • Identification of depressed persons with a screening instrument • Measurement-based care • Psychotherapy • Antidepressants • Depression care manager (DCM) (MSW,Ph D, RN) • Treatment monitoring • Follow-up • Coordinate care with PCP • Goals • Improve low rates of engagement • Enhanced adherence to depression treatment

  24. Intervention Example:Depression Care Management (Clinic) Core Elements • Active identification of depression • Evidence- and measurement-based treatment and outcomes • A person trained to support and deliver the treatment (“depression care manager”, DCM) • A consulting psychiatrist.

  25. Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) Unutzer J et al. JAMA 2002;288:2836-2845 • RCT: N=1801, 60 yrs and older • 18 primary care clinics/ 5 states • Intervention: Depression Care Manager (RN or Ph.D) w/ supervising psychiatrist • Education • Care management • Support of antidepressants from PCP • Problem Solving Treatment • Usual Care Control

  26. IMPACT OUTCOMES12 Months 45 % 25 19 8

  27. Prevalence and heterogeneity • Major Depression Treatment • Minor Depression Treatment • Bereavement • Depression in Dementia • Response to Drug Failure

  28. Minor DepressionResearch Criteria for Further Study • 2-4 of 9 criteria sxs for Maj. Depression • Depressed Mood or Anhedonia • No hx major depression, Mania • Not Dysthymic

  29. Minor Depression and Dysthymia in Primary Care Elderly • N= 415 pts>/=60yr • 11 wk, multi-center trial • 3-4 sxs at least 4wks AND Ham-D >9 • RCT paroxetine vs placebo+usual care vs PST Williams JW et al. JAMA 284:1519-1526, 2000

  30. Minor Depression and Dysthymia in Primary Care Elderly • Mean change HSCL-20(1-4 points) • Paroxetine 0.61 PST 0.52 placebo 0.40 • Statistically significant for paroxetine, not PST Williams JW et al. JAMA 284:1519-1526, 2000

  31. HSCL-D-20 Scores by Treatment Assignment Williams, J. W. et al. JAMA 2000;284:1519-1526.

  32. HSCL-D-20 Scores of Patients With Minor Depression Williams, J. W. et al. JAMA 2000;284:1519-1526.

  33. Remission Rate Williams, J. W. et al. JAMA 2000;284:1519-1526 • Minor Depression • Paroxetine 53% PST 44% Placebo 49% • Dysthymia • Paroxetine 46% PST 51% Placebo 40% No treatment statistically significant vs Placebo

  34. PROSPECTPrevention of Suicide in Primary Care Elderly: Collaborative Trial • N=598 elderly, 20 primary care clinics, 3 cities • CES-D > 20, depression dx (Maj and Minor) • Minor = 4 sxs, Ham-D >9, 4 wks duration • Intervention: Depression Care Managers • Antidepressant algorithm • Interpersonal Psychotherapy • Usual Care Bruce ML et al, JAMA 2004; 291(9): 1081-1091

  35. PROSPECTPrevention of Suicide in Primary Care Elderly: Collaborative Trial • Ham-D reduction -Minor Depression-Not statistically significant 38% reduction vs 34%, intervention vs usual care Bruce ML et al, JAMA 2004; 291(9): 1081-1091

  36. NURSING HOMEMINOR DEPRESSION • RCT: Paroxetine vs Placebo • N=24 without criteria Maj. Depression • Mean Age: 88yrs • Results:No differences(CGIC, Ham D, Cornell) • 45% placebo response rate • Paroxetine - Decreased MMSE Burrows A et al. Depress Anx 2002; 15(3):102-10

  37. PEARLSProgram to Encourage Active and Rewarding Lives for Seniors • RCT N=138 pts, > 59 yrs old • Minor Depression (51%), Dysthymia (49%) • PEARLS • Problem Solving Treatment • Physical and Social Activation • Pleasant Events Planning • Antidepressant Consultation • Versus: Usual Care Ciechanowski P et al, JAMA 2004; 291:1569-1577

  38. PEARLSRESULTS • Decrease (50% or more) depression score • 43% intervention group vs 15% usual care • Remission • 36% intervention group vs 12% of usual care Ciechanowski P et al, JAMA 2004; 291:1569-1577

  39. Problem Solving Treatment • 7 Steps • Clarify and define the problem • Set realistic goals • Generate multiple solutions • Evaluate and compare solutions • Select a feasible solution • Implement the solution • Evaluate the outcome

  40. Explanations/Strategies • Placebo Response? • 40-50% in most, 12-15% in PEARLS • Watchful waiting, less specific support -If persistent, then specialty care • Setting? • In home vs primary care/NH • May not need to wait in home-bound elderly

  41. Prevalence and heterogeneity Major Depression Treatment Minor Depression Treatment Bereavement Depression in Dementia Response to Drug Failure

  42. Bereavement • Grief • Can be intense, severe sadness • ‘Complicated’ when involving • Frank psychosis • Persistent SI • Marked worthlessness • Guilt beyond events surrounding the death • Major Depression beyond 2 months of death

  43. Bereavement Related Major Depression • RCT, placebo controlled, N=80, • All subjects >/= 50yrs old. • Met DSM IV criteria for major depression • Median time from death = 32 wks. • 1) Nortrip. vs. 2)Nortrip + IPT vs. 3) IPT + placebo, vs. 4) placebo Reynolds CF et al. Am J Psychiatry 1999;156:202-208

  44. Bereavement Related Major Depression • Depression Remission: 1) Nortrip. = 56% 2)Nortrip + IPT =69% 3) IPT + placebo= 29% 4) placebo=45% *Statistically significant medication effect • No tx group difference in bereavement score Reynolds CF et al. Am J Psychiatry 1999;156:202-208

  45. Bereavement Summary • Major depression syndrome common • Responds to antidepressant therapy • No clear benefit in grief sxs. • Role for Interpersonal Psychotherapy less clear • No data re: tx minor depression in bereavement

  46. Prevalence and heterogeneity Major Depression Treatment Minor Depression Treatment Bereavement Depression in Dementia Response to Drug Failure

  47. Depression in Alzheimer’s DiseaseSertraline • 12 wk Randomized, placebo controlled trial • N=22 Outpatients with maj. depression • Avg Age = 77yrs • Avg MMSE = 17 • Sertraline avg dose (81mg) • 8-12 point decrease Cornell Scale for Depression • No significant change in Ham-D, Cogn, ADLs Lyketsos et al. Am J Psychiatry 2000; 157(10): 1686-1689

  48. Sertraline in Severely Demented Patients • RCT-DB, N=31 nursing home patients, 8wks • All stage 6 or 7 Global Deterioration Scale • 84% with minor depression • Sertraline vs. placebo • Cornell Scale for Depression in Dementia Sertraline: pre=6, post =3 Placebo: pre=6, post=4 • P=NS Magai C et al. Amer J Geriatr Psychiatry 2000;8:66-74.

  49. Nortriptyline in Depressed Nursing Home Residents • RCT-DB, N=69, 8 wks • Regular (50mg) vs low (10mg) Nortriptyline • Overall: 35% responders w/ regular dose vs 17% with low dose • Demented: 41% responders with low dose Streim JE et al. Am J Geriatr Psychiatry 2000;8:150-159.

  50. Depression of Alzheimer’s Disease (Provisional) Olin JT et al. Am J Geriatr Psychiatry 2002;10:125-128 1) Clinically significant depressed mood (sad, hopeless, discouraged, tearful) 2) Decreased positive affect or pleasure to social contact, usual activities 3) Social isolation or withdrawal 4) Disruption in appetite 5) Disruption in sleep 6) Psychomotor changes (e.g. agitation, retardation) 7) Irritability 8) Fatigue or loss of energy 9) Worthlessness, hopelessness, inappropriate guilt 10) Recurrent thoughts of death, suicidal ideation

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