Primary Care Approach to Dealing with Psychological Problems in the Elderly

1. Samuel Y.S. Wong MD School of Public Health & Primary Care, Chinese University of Hong Kong Primary Care Approach to Dealing with Psychological Problems in the Elderly

2. Depression in late life • Tremendous suffering • Functional impairment • Reduced health related quality of life • Reduced adherence to medical treatments • Increased mortality from physical conditions

3. Magnitude of Depression • Most common illness associated with negative impact and disease burden by 2020 • 1 in 10 people over 65 • Most common mental health disorder of later life • Can affect 5 – 15% of older adults who visit primary care provider

7. Burden of elderly suicide in HK

8. Primary care role in late life depression • Primary care providers e.g. GP is the responsible person for most of the cases • Exists effective medical, psychological and psychosocial interventions • Although often not adopted widely in primary care • Low levels of detection and treatment

9. Late life depression: Conceptual framework High prevalence but low detection and management of late life depression in primary care

10. Patient factors • Somatic presentation of complaints • Physical co-morbidities make recognition difficult • Beliefs: fear of stigmatization or anti-depressant is addictive • Misattribution of symptoms for “old age”, “ill health” or “grief” • Under-detection especially in men

11. Provider’s factors • Lack necessary consultation skills or confidence • Time limited consultation • Therapeutic nihilism : normal response to difficult circumstances, illnesses or life events • Dissatisfaction with the type of treatments that can be offered i.e. psychological interventions

12. Barriers for integration:variability in care • Issues for primary care doctors (GPs) in HK • Skills • Training & Continuing education for primary mental health • Time • Resources SYS Wong, K Lee, K Chan, A Lee. What are the barriers faced by general practitioners in treating depression and anxiety in Hong Kong? International Journal of Clinical Practice 2006 Apr; 60(4): 437-4.

13. Societal factors • Age discrimination? • Longer life expectancy means longer years with morbidity? • Loneliness? Low birth rate & smaller households means fewer children and families for support in later years • Lack of support for elderly? • Adverse life events: death of loved ones

14. But, how do these elderly & their providers view depression in late life?

17. Primary care providers • Late life depression as a problem of their everyday work, rather than objective diagnostic category • GPs described it as part of a spectrum including loneliness, lack of social network, reduction in function and saw depression as “understandable” and “justifiable”

18. From GP in the UK: • “…..i wonder whether actually we’ve got patients being treated for depression…as a way of medicalising their discontent.” • “our local population often have quite good reasons to be dissatisfied with life, so it is a normal response to a situation rather than a sign of pathology…”

19. From nurses from the UK • Tension between nurses’ knowledge of depression as a clinical conditions and their perception as a social or existential problem: • “I think it’s probably loneliness, because they don’t have much family around….and their partner’s gone…and they don’t have anywhere to go”.

20. From primary care nurses, • “sometimes I think people are depressed because that’s where their life is at that time…so I think there’s almost an acceptable sometimes that it’s justifiable depression, you know, there are reasons for it….”

21. Making the diagnosis • GPs think making diagnosis in the elderly is different from that in the younger population • “not something they do or admit to themselves….20s generation, they are geared up to being depressed and being treated for it…..actually they are no more depressed than I am, that are being treated for depression as a way of medicalising their discontent”.

22. Making the diagnosis • GPs reported diagnosing depression by placing symptoms in the context of what they knew about that particular patient’s life. Diagnostic scales were said to exclude these contextual clues.

23. Making the diagnosis • patients described the potential value of an ongoing relationship in allowing the GP to be alert to patient’s feelings: • “…my doctor knew, he knows me inside out. He knew immediately, he is a lovely doctor”.

24. Management of late life depression in primary care • Barriers that make it difficult to provide care for patients with depression • The majority reluctant to make the diagnosis of depression in an elderly person because of a feeling that they had nothing to offer the patient.

25. “I think you are probably reluctant to go looking for the diagnosis…if it’s present the it’s a lot easier….if there isn’t a huge amount of support for following it up, and often there isn’t.” • “it is unfair to start delving and then say, “right fine. We’ve found that out but nothing we can do…you do have a tendency not to think about it too much”

26. Reluctance to give antidepressants because of poly-pharmacy • “I have used fluoxetine, but again they get very agitated and it can be a bit disturbing to elderly people”

27. GP described uncertainty over the effectiveness of antidepressants, not from evidence but from their experiences • “what actually happens is there’s a sort of general inaction, people just stay on them forever, without getting better. And don’t change and nothing happens except they are on more treatment and the system is paying for more drugs”.

28. Patients viewed the treatment of depression in much broader terms than taking tablets, often suggesting that improved symptom control of physical illness or a change in their social situation (moving house) would solve their problem of feeling sad.

29. Providers’ main problems • Primary care professionals viewed their own skills to be limited, their time is limited, the resources in primary care is limited, and limited referral options to secondary care were also bemoaned…

30. Depression in late life in primary care • A move away from the biomedical view on the causation of depression to • A social view as the result of wider social and economic problems • NICE guidelines on depression acknowledge that the concept of depression has limitations and “is too broad and heterogenous as a category, and has limited validity as a basis for effective treatment plans”.

31. Depression is “understandable? A product of social and contextual issues?” • Issues to address in primary care: provision of psychological therapies in primary care • Lack of social care or voluntary services (integration of care) • Improved knowledge of services • Importance of interpersonal continuity of primary care!!

32. Solutions • Collaborative care approach (in the US & UK) across primary and secondary care • Stepped care approach (in the UK and Europe)

33. Collaborative Care for Depression in late life

34. Collaborative Care Model • Main components: • Deployment of care manager • Timely access to specialist mental health professionals when needed • Multi-model approaches with efficacies in the elderly • Problem solving, interpersonal therapy, CBT

35. Collaborative Care Model • Community psychiatric nurse based in primary care • Liaised closely with primary care professionals • Acts as care coordinator • Regular monitoring and review (monthly) with psychiatrist • With GP (email, telephone, face to face)

36. Collaborative Care Model:other components • Complex intervention • Education about depression, advice on antidepressant, manualised facilitated self-help intervention • Sign-posting to other services i.e. NGOs, voluntary agencies • Delivered through face to face interventions at patients’ home & telephone

37. Evaluation • Patients in the intervention group had significantly fewer symptoms at follow up that GP usual care alone • Similar effect size as in other studies

39. Evaluation & feedback from patients • Regarding the nurse: • “I could talk about anything, anything that was worrying me and the way I felt. I found that connection; whatever I said I was getting a comeback and good advice and helpfulness” • Regarding the manualised self help book: • Well, he left me this great book thing. I didn’t feel like doing anything about it. I couldn’t get into it at all. So I left it.”

40. Most valuable to elderly • From the nurse who carried out the intervention: • PERSONAL CONTACT with SOMEONE who was EMPATHIC and SHOWED INTEREST in the patient as an INDIVIDUAL

41. Description from coordinator • “Depression isn’t loneliness. But, one of the themes that comes through people I see, it’s a very high percentage of the people when I start looking through the records, the word loneliness comes up or at least isolation…….you know there’s no matter how depressed people are, it’s trying to re-humanise…find what may be we’ve got in common. …so the more I know about them, not necessarily about their illness, about them as a person.”

42. “it is very flexible…if someone asked me what I was really doing I’d say I use a very eclective common sense non-rocket-science approach, that’s very , very individual to whatever the patient’s needs are”

43. Other examples

46. Prevention of anxiety and depression: a generic stepped care program in primary care • Primary care: sub-threshold depressive and anxiety disorders common in primary care • High risk for developing depression and anxiety disorder • Most cost effective to identify a population at sufficiently high risk to justify the expense of intervention

47. Situation in Hong Kong • Long waiting list for referral to non-urgent psychiatric care • Gaps between the demand for psychological therapy and available supply • Stepped care model may be most cost-effective?

48. All patients start with intervention of low intensity with progress monitored • Those not responded well will “step up” to a subsequent treatment of higher intensity

50. Planned study at CUHK • Objective: to compare the effectiveness of a stepped care model in preventing full blown anxiety and depressive disorder in patients with sub-threshold symptoms with usual care • Prospective RCT • Stepped care component: 1) watchful waiting 2) social, medical & psychological support 3) individual face to face problem solving 4) consultation by primary care doctors with possible referral