Depression Clinical Practice Guideline

1. DepressionClinical Practice Guideline

2. Disclosures

3. Learning Objectives

4. Depression • Depression is a spectrum of mood disorders characterized by a sustained disturbance in emotional, cognitive, behavioral, or somatic regulation and associated with significant functional impairment and a reduction in the capacity for pleasure and enjoyment.

5. Introduction • Maintain a high index of suspicion for the presence of depression or depressive symptoms in long term care (LTC) patients • Late-life depression may be overlooked or inadequately treated

6. Introduction • The relationship between medical conditions and depression is complex • Depression may exacerbate coexisting medical illness • Some medications may cause or contribute to depression

7. Federal Regulations and Depression • F157-§483.10(b)(11) -- Notification of changes • (i) A facility must immediately inform the resident; consult with the resident’s physician; and if known, notify the resident’s legal representative or an interested family member when there is: • (B) A significant change in the resident’s physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) • For purposes of §483.10(b)(11)(i)(B), Clinical complications are such things as … or onset of depression

8. Federal Regulations and Depression • F250-§483.15(g)(1) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident • “Medically-related social services” means services provided by the facility’s staff to assist residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs • Types of conditions to which the facility should respond with social services by staff or referral include: • Depression

9. Federal Regulations and Depression • EATING-§483.25(a)(1)(iv) • If the resident’s eating abilities have declined, is there any evidence that the decline was unavoidable? 1. What risk factors for decline of eating skills did the facility identify? • d. Depression or confused mental state is responsible for 50% or eating problems or weight loss in Seniors

10. Federal Regulations and Depression • 42 CFR 483.25(f)(1)&(2), F319, F320, Mental and Psychosocial Functioning • Surveyors are instructed to review whether the facility had identified, evaluated, and responded to a change in behavior and/or psychosocial changes, including depression

11. Recognition • Recognition is the first stage of the care process • Recognition” means identifying the presence of a risk or condition • How: PHQ-2 shows that only 14-25% of residents in LTC have depression • Caregivers identify depression poorly • The PHQ-2 identifies 85% of patients with depression Reference: Practical Depression Screening in Residential Care. Am. J. Geriatrics Psychiatry. 17:7. July 2009. 556-564

12. Recognition • Does the patient have a history of depression or a positive depression screening test? • Review available transfer information, referral data and patient and family history • Look for history of depression, psychiatric disorder(s), treatment of hospitalization • Document the presence of these conditions in the medical record

13. Recognition • Depression is common among patients in the LTC setting • Treatment is effective • Adopt a policy encouraging formal screening of all patients for depression • Appropriate screening tools include: • Geriatric Depression Scale • Cornell Scale for Depression in Dementia • Center for Epidemiologic Studies of Depression Scale • Patient Health Questionnaire 9 • Clinical Interview • Do you feel life is worth living? • What makes you happy?

14. Recognition • Does the patient have signs or symptoms of depression? • Nursing staff are in a good position to recognize signs and symptoms (S&S) of depression (Behavior – not subjective) • Look for S&S in RAI. MDS, RAPs, progress notes, family interaction notes

15. Symptoms Of Depression 3

16. Recognition • Does the patient have risk factors for depression? • Evaluate for risk factors • If risk factors are present, develop an interdisciplinary (IDT) care plan • If no risk factors are found, monitor periodically (every 3 months)

17. Some Risk Factors for Depression • Alcohol or substance abuse • Current use of a medication associated with a high risk of depression • Hearing or vision impairment severe enough to affect function – 30% increase rate of depression • History of attempted suicide • History of psychiatric hospitalization • Medical diagnosis or diagnoses associated with a high risk of depression • New admission or change in environment • New stressful losses, including loss of autonomy, loss of privacy, loss of functional status, loss of body part, or loss of family member, friend or pet • Personal or family history of depression or mood disorder • Personality Anxiety Disorder – Sleep problem (day time)

18. Assessment • Assessment is the second stage of the care process • “Assessment” means clarifying the nature and causes of a condition or situation and identifying its impact on the individual

19. Assessment • Has the patient had a persistently depressed mood or loss of interest or pleasure for at least 2 weeks? • Has depressed mood (dysphoria) or loss of interest or pleasure (anhedonia) been present for at least 2 weeks; and • has dysphoria or anhedonia contributed to the patient’s functional or social impairment or decline • Is substance abuse or bereavement not present • Personality Disorder • Personality traits influence clinical outcomes in a day hospital Reference: Treatment of Elderly Depressed Patients. Am. J. Geriatric Psychiatry. 17. 335-344. April 2009.

20. Assessment • Is it appropriate to perform a medical work-up for factors contributing to signs and symptoms of possible depression? • Will depend upon: • patient’s condition • prognosis • advance care directives • expressed preferences of the patient or family

21. Laboratory Tests For Evaluating Possible Depression3

22. Assessment • Is the patient taking medications that might cause or contribute to depression? • Many medications can affect: • mood • affect • level of consciousness

23. Alpha-methyl dopa Anabolic steroids Anti-arrhythmic medications Anticonvulsant medications Antidementia Barbiturates Benzodiazepines (i.e., long acting) Carbidopa or levodopa Certain beta-adrenergic antagonists (propranolol) Clonidine Cytokines (specifically IL-2) Digitalis preparations Glucocorticoids H2 blockers Metoclopramide Opioids Medications That May Cause Symptoms of Depression References: D. Rogers et. al. General Drug Associated with Depression. Psychiatry. 5, Dec. 2008. 28-41. Sidhuk et. al. Watch for Psychotropics Causing Psychiatric Side Effects. Current Psychiatry. August 2009. 61-74.

24. Assessment • Does the patient have one or more conditions that may increase the likelihood of depression or that may cause depressive symptoms

25. Most important Alcohol dependency Cerebrovascular diseases Medications that can cause mood disorders Neurodegenerative disorders (e.g., Alzheimer’s disease, Parkinson’s disease, multiple sclerosis) Substance abuse Sleep apnea (40%-60% of patients with dementia) Important Cancer Chronic obstructive pulmonary disorder Chronic pain Congestive heart failure Coronary artery disease Diabetes Electrolyte imbalance Endocrine disorders (thyroid) Head trauma Metabolic problems Myocardial infarction Orthostatic hypotension Physical, verbal, emotional abuse Schizophrenia Anxiety Important Comorbid Conditions* *Reference: Is a Medical Illness Causing your Patients Depression. Current Psychiatry. 8. 2009. 43-54.

26. Assessment • Do the patient’s signs and symptoms resolve with treatment of comorbid condition(s)? • Take appropriate action if medical diagnoses or conditions are suspected of contributing to depressive symptoms • When depression and a medical condition coexist, both conditions are likely to require treatment • To the extent possible, address underlying causes and evaluate the impact of such measures

27. Assessment • Clarify the diagnosis • The DSM-IV defines the following types of depressive disorders: • Mild episode of major depression • Moderate episode of major depression • Severe episode of major depression • Severe episode of major depression with psychotic features • Minor depression disorder – 80% convert to MDD (Major Depression Disorder) • Bipolar type II • Dysthymic disorder • Adjustment disorder with depressed mood or with mixed anxiety and depressed mood

28. Major Depression • Weight loss or gain • Insomnia or hypersomnia • Psychomotor retardation • Agitation (irritability, anxiety, fatigue) • Decreased energy • Guilt feelings • Inability to concentrate • Thoughts of death or suicide (life not worth living) Loss ofinterest or pleasure + 4 symptoms x 2 weeks Depressed Mood + 4 symptoms x 2 weeks • AND these symptoms: • Produce social impairment • Are not related to substance abuse. • Are not related to bereavement Reference: Comorbid Depression in Psychogeriatric Nursing Homes Wards which Symptoms are Prominent. Am. J. Geriatric Psychiatry. 17:7. July 2009. 565-575.

29. Rating Scales • Use at the beginning of treatment • Only reliable way to obtain an objective measure • Essential to monitoring the effectiveness of treatment • Geriatric Depression Scale (GDS) • Cornell Scale for Depression in Dementia (CSDD) • Center for Epidemiologic Studies of Depression Scale (CES-D) • Patient Health Questionnaire 9 (PHQ-9) • Most reliable and efficient

30. Assessment • Does the situation warrant additional psychiatric support? • Depression is often managed readily by primary care practitioners (80/20) • Effective psychiatric support may not be readily available in the LTC setting • In some cases, however, psychiatric support is helpful • 25% improve with medication, while 58% improve with counseling and medication • Post-stroke depression resolves in 6 months regardless of treatment (20-40% have behavioral symptoms)

31. Assessment • Does the patient’s depression exhibit complications that may pose a risk to the patient or to others? • Determine if the patient is psychotic, severely agitated, aggressive, neurovegetative, or suicidal • Suicide risk increases with the severity of depression

32. Treatment • Treatment is the third stage of the care process • “Treatment” means selecting and providing appropriate interventions for that individual

33. Treatment • Depression usually responds to treatment with psychotherapy, medications, or a combination of the two • An effective individualized care plan includes both nonpharmacologic and pharmacologic interventions • Pharmacologic: • Antianxiety, antipsychotic, antidepressive and antidementia • Non-Pharmacologic (other psychotherapies): • Emotion-oriented, interpersonal therapy, sensory stimulation therapy • Cognitive Behavioral Therapy (CBT) – (art, music, massage) only in early stage, Problem Solving Therapy, Environmental Activity – (exercise) • Supportive Therapies

34. Phases of Depression Treatment3

35. Treatment • Implement appropriate treatment for the patient’s depression • Minimize institutional aspects of the environment • Facilitate interaction with family members and friends • Provide opportunities for spiritual activity (50% of LTC residents have an interest) • Provide socialization interventions

36. Psychotherapy • Considerable advances have occurred • Both cognitive-behavioral therapy and learning-based therapy have a significant impact on depression symptoms in older adults

37. Pharmacologic Treatment • All antidepressants approved by the U.S. Food and Drug Administration have been shown to be relatively safe in most populations • However, they are effective in some, but not all, populations

38. Electroconvulsive Therapy (ECT) • (ECT) should be considered if: • The patient’s condition is rapidly deteriorating or, • If antidepressant medication is not tolerated or has failed • Mild depression – failure of 4-6 antidepressants • Moderate depression – failure of 2-4 antidepressants • Sever depression – failure of 1-2 antidepressants or suicidal risks • 50% effective • Transitional Stimulation (limited studies in seniors)

39. Assessing Treatment Response • Treatment response can vary widely among depressed elderly patients • Patient response is generally not predictable before the initiation of treatment • Beliefs that older patients in general respond more slowly to antidepressant treatment are unsubstantiated12-15

40. Most Common Psychosocial Interventions for Depression References: L. Volicer. Effects of Continuous Activity Program on Behavior Symptoms of Dementia. AMDA. Sept. 2006. 7: 426-431. M. Smith et. al. Beyond Bingo: Meaningful Activities for Persons with Dementia. Annals of Long-Term Care. July 2009.

41. Federal Regulations and Depression • F329 - §483.25(l) Unnecessary Drugs • 1. General. Each resident’s drug regimen must be free from unnecessary drugs. • An unnecessary drug is any drug when used: • (i) In excessive dose (including duplicate therapy); or • (ii) For excessive duration; or • (iii) Without adequate monitoring; or • (iv) Without adequate indications for its use; or • (v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or • (vi) Any combinations of the reasons above.

42. Federal Regulations and Depression (F 329) • INTENT: §483.25(l) Unnecessary drugs • The intent of this requirement is that each resident’s entire drug/medication regimen be managed and monitored to achieve the following goals: • The medication regimen helps promote or maintain the resident’s highest practicable mental, physical, and psychosocial well-being, as identified by the resident and/or representative(s) in collaboration with the attending physician and facility staff • Risk/Benefit (Just document in progress note); • Pharmacists must notify • MD can ignore • Non-pharmacological interventions (such as behavioral interventions) are considered and used when indicated, instead of, or in addition to, medication; • Clinically significant adverse consequences are minimized; and

43. Federal Regulations and Depression (F 329) • Determining the frequency of monitoring. The frequency and duration of monitoring needed to identify therapeutic effectiveness and adverse consequences will depend on factors such as clinical standards of practice, facility policies and procedures, manufacturer’s specifications, and the resident’s clinical condition • Monitoring involves three aspects: • Periodic planned evaluation of progress toward the therapeutic goals; • Continued vigilance for adverse consequences; and • Evaluation of identified adverse consequence

44. Federal Regulations and Depression (F 329) • Tapering of a Medication Dose/Gradual Dose Reduction (GDR) • There are various opportunities during the care process to evaluate the effects of medications on a resident’s function and behavior, and to consider whether the medications should be continued, reduced, discontinued, or otherwise modified

45. Federal Regulations and Depression (F 329) • For any individual who is receiving an antipsychotic medication to treat a psychiatric disorder other than behavioral symptoms related to dementia (for example, depression with psychotic features), the GDR may be considered contraindicated, if: • The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying psychiatric disorder; or • The resident’s target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder

46. Antidepressants All antidepressants classes, e.g., Alpha - adrenoceptor antagonist, e.g., mirtazapine Dopamine-reuptake blocking compounds, e.g., bupropion Monoamine oxidase inhibitors (MAOIs) Serotonin (5-HT 2) antagonists, e.g., nefazodone, trazodone Selective serotoninnorepinephrine reuptake inhibitors (SNRIs), e.g., duloxetine, venlafaxine Indications Agents usually classified as “antidepressants” are prescribed for conditions other than depression including anxiety disorders, post-traumatic stress disorder, obsessive compulsive disorder, insomnia, neuropathic pain (e.g., diabetic peripheral neuropathy), migraine headaches, urinary incontinence, and others F 329

47. Antidepressants Selective serotonin reuptake inhibitors (SSRIs), e.g., citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline Tricyclic (TCA) and related compounds Dosage Use of two or more antidepressants simultaneously may increase risk of side effects; in such cases, there should be documentation of expected benefits that outweigh the associated risks and monitoring for any increase in side effects F 329

48. F 329 Duration • Duration should be in accordance with pertinent literature, including clinical practice guidelines • Prior to discontinuation, many antidepressants may need a gradual dose reduction or tapering to avoid a withdrawal syndrome (e.g., SSRIs, TCAs) • If used to manage behavior, stabilize mood, or treat a psychiatric disorder, refer to Section V –Tapering of a Medication Dose/Gradual Dose Reduction (GDR) in the guidance Monitoring • All residents being treated for depression with any antidepressant should be monitored closely for worsening of depression and/or suicidal behavior or thinking, especially during initiation of therapy and during any change in dosage • Weekly for 1-3 months and quarterly thereafter (Do Not give 3 month prescription if requested by PBM - Pharmacy Benefit Manager)

49. F 329 Interactions/Adverse Consequences/Positive Benefits • May cause dizziness, nausea, diarrhea, anxiety, nervousness, insomnia, somnolence, weight gain, anorexia, or increased appetite. Many of these effects can increase the risk for falls • Bupropion may increase seizure risk and be associated with seizures in susceptible individuals • SSRIs in combination with other medications affecting serotonin (e.g., tramadol, St. John’s Wort, linezolid, other SSRI’s) may increase the risk for serotonin syndrome and seizures • Augmentation with Buspirone, Aripiprazole, or Lithium – limited benefits in 4-6 weeks

50. Antidepressants Monoamine oxidase inhibitors (MAOIs), e.g., isocarboxazid, phenelzine, tranylcypromine Indications/Contraindications Should not be administered to anyone with a confirmed or suspected cerebrovascular defect or to anyone with confirmed cardiovascular disease or hypertension Should not be used in the presence of pheochromocytoma MAO Inhibitors are rarely utilized due to their potential interactions with tyramine or tryptophancontaining foods, other medications, and their profound effect on blood pressure F 329