Depression

1. Depression Martin Forsberg, MD Assistant Professor UMDNJ –SOM NJISA

2. Depression This medical student presentation is offered by the New Jersey Institute for Successful Aging. This lecture series is supported by an educational grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

3. Learning Objectives • Distinguish clinical features of characteristic of depression in the elderly • Recognize geriatric appropriate pharmacologic and non-pharmacologic treatment of depression • Differentiate pseudodementia and dementia with depression

4. Dorothea Lange's “Migrant Mother” 1936 Source: Library of Congress, Farm Security Administration/Office of War Information Photograph Collection

5. Erikson’s Integrity vs. Despair Begins when the individual experiences a sense of mortality Manifests as a review of life and career to determine if it was a success or failure Ego integrity (wisdom) is an informed and detached concern with life itself in the face of death itself Despair manifests itself as a fear of death, a sense that life is too short, and depression

6. Why this is Important Depression is associated with increased morbidity and mortality i.e. DM, post MI, post CVA, dementia Depression can lead to suicide Depression can impact quality of life Depression is a biological as well as psychological phenomenon Inappropriate treatment can have risks

7. Recognizing Depression Differentiate Depression Major depression Clinical depression depression Adjustment disorder/Situational depression Uncomplicated grieving Dysthymia

8. Late-onset Depression More rapid response to treatment More likely to have cognitive component More likely to have neurological findings More likely to have abnormal brain imaging Less likely to have family history Less likely to stay in remission

9. Whatfactor best predicts MI #2? Multiple choice: • Blood pressure • Hemoglobin A1c • Waist circumference • Depression symptoms • Homocysteine level

10. Diagnostic Criteria DSM IV TR (validated for adults) Know criteria for Major Depressive Episode (MDE) Adjustment Disorder Dysthymia Know SIG E CAPS Know howdepression can present atypically (i.e. in some geriatric patients) Screen for mania/bipolar disorder

11. Course of Illness (MDE) Depressive episode acute phase continuation phase maintenance phase Relapse Remission Recurrence Thase ME, Kupfer DJ. Recent developments in the pharmacotherapy of mood disorders. J Consult Clin Psychol 1996;64(4):647. Figure 1.

12. Case Vignette A 75 year old man has first onset of depression at 70. He was not sure what was wrong with him but he felt that he should kill himself. He bought a shotgun and had just put it in his mouth when his daughter called because his grandson wanted to tell him he scored 2 runs in little league that day. Patient realized that suicide was not an option and got treatment. His doctor did not know that he had been so close to killing himself. Now he is on maintenance therapy with citalopram and can talk about his depression objectively. No recurrence and no residual symptoms.

13. Depression Screening Tests • GDS commonly used screen not valid in dementia • PHQ-9 good screen and diagnostic tool and gives you the ability to track severity • Research diagnostic instruments (HDRS, Cornell Depression scale) not routinely used clinically and can be cumbersome

14. Atypical Presentation Fewer than 5 of DSM criteria Unexplained somatic complaints Imprecise description or denial by patient Anorexia/failure to thrive Somnolence/fatigue/insomnia Low motivation/anhedonia Poor cognitive performance

15. When is it not Depression Clearly situational (often loss) Minor symptoms Short duration No neurovegetative symptoms No thoughts of suicide Better accounted for by Other illness Dementia Substance abuse

16. Role of Alcohol • Alcohol doesn't cause clinical depression though in intoxication it is a CNS depressant. • Alcohol dependence or abuse often comorbid with subclinical or clinical depression. • Your patients are unlikely to volunteer that they have a problem and may even deny it if confronted. • Educate about association with depression, urge patient to examine use, quit, and/or offer help. • If anxiety or depression did not precede alcoholism, treatment with antidepressants not likely to help.

17. How do I know if it is grief? • Grief reaction or bereavement is a normal reaction to a loss • Normal to feel numbness, sorrow, even guilt • Leads to accepting and moving forward • Normal to feel presence of, see, or hear deceased • Complicated grief reaction • Symptom severity same as clinical depression including thoughts of hurting self or weight loss • Often requires antidepressant treatment • Benzodiazepines can prolong normal or complicated grief

18. How to Treat Depression Psychotherapy (alone or in combination) Availability Acceptance of patient Cognitive ability Pharmacotherapy Can use same meds as in younger adults Start low, go slow, but go Monitor for side effects Iatrogenic causes are common ECT

19. Psychotherapy • Individual and group psychotherapy can be used effectively in non-demented elderly • Cognitive behavioral therapy has most evidence for efficacy • Interpersonal and supportive therapy can be helpful • Efficacy of treatment often equals medical treatments and combination is most effective

20. Pharmacotherapy • First line treatment of unipolar depression is SSRI or SNRI • Alternatives include bupropion and mirtazepine • All SSRI and SNRI are equally effective • Medication choice is based on side effect profile • Use generic when possible • Augmentation can get complicated • Psychiatric meds are not “Happy Pills”

21. Hospitalization Geropsychiatric inpatient units Active suicidal ideation Severe depression with psychotic features Initiating ECT Refractory severe symptoms Rehab for substance abuse

22. Suicide Loneliness and hopelessness are most common 75-90% suffer from depression and/or substance abuse Death wishes are more common (5%) Beliefs and family are important Highest risk in elderly white males Overdose most common method

23. Prevalence of Depression Multiple choice: 1% 2% 10% 15% 30%

24. Case Vignette A 70 year old patient is brought in by family for memory assessment. Chief complaint is forgetfulness and loss of interest. Neuropsychological assessment reveals no consistent global deficits. Report states patient often responded with "I don't know" and she declined to finish other sections. Scales of depressive symptoms were high. Patient referred to geropsychiatry and diagnosed with depression. Treated with SSRI for two months. Patient and family report improvement in mood and memory.

25. Pseudodementia Also called cognitive impairment of depression Often affects recall (but not once cued) Often inconsistent deficits “I don’t know” more common than incorrect response Less language and global impairment Depression, especially with cognitive impairment is a risk factor for later development of dementia

26. Depression in Dementia • Can mimic • Apathy • Emotional flattening • Pathological crying • Catastrophic reaction • Often symptoms are treated but evidence suggests meds work as well as usual care • Unless MDD is pre-existing meds may not be necessary