Depression, Social Isolation and the Urban Elderly Conference on Geriatric Mental Health

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Depression, Social Isolation and the Urban
ElderlyConference on Geriatric Mental Health

• May 18, 2006
• Lloyd I. Sederer, MD
• Executive Deputy Commissioner
• Mental Hygiene Services
• NYC Department of Health and Mental Hygiene

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Presentation Outline

• Mental Hygiene in New York City
• Key Issues in Geriatric Mental Health
• Depression Prevalence, Burden, and Comorbidity
• The Epidemiology of Social Isolation
• Ongoing Initiatives
• Future Directions

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Mental Hygiene in NYC

• 1954 1st NYC Mental Health Board
• 1962 Deinstitutionalization begins
• 1972 Alcoholism services added
• 1977 Mental Retardation services added
• 1993 Early Intervention services added
• 2002 NYC Departments of Health and Mental
  Hygiene merged

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Division of Mental Hygiene

• Planning, Purchasing and Providing quality
  control over mental hygiene services for New
  Yorkers of all ages by contracting with CBOs
• Population-based mental hygiene interventions
• Depression Screening in Primary Care
• SBIRT, Buprenorphine and Naloxone reducing
  overdose deaths in NYC
• Advocacy
• Public Education and Collaborating with NYC
  Stakeholders

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Key Issues with Regard to Geriatric Mental Health

• Capacity sheer projected growth of pop. over 65
  (35 million nationwide nearly doubling by 2030)
• Increased co-morbidity of health and mental
  health
• Lack of specialized services
• Isolation of Seniors
• -Administration on Aging, 2002

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Older Adults and Mental Hygiene

• Approximately 366,000 adult aged 55 or older in
  NYC are affected by a psychiatric or a substance
  abuse disorder
• 1 in every 5 people 55 or older experiences a
  mental disorder which is not a normal part of
  aging and this figure is expected to double by
  2030
• In 2001, 124 adults in NYC age 55 or older
  committed suicide

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Depression and Rates of Suicide in Older Adults

• Serious depression is the leading risk factor for
  suicide in older adults
• Among older patients who committed suicide, 20
  visited their primary care physician on the same
  day as their suicide, 40 within the past week,
  and 70 within the past month

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Prevalence of Depression

• In any given year, about 21 million American
  adults suffer a depressive episode, about 400,000
  in NYC
• Lifetime Prevalence for a Major Depressive
  Disorder
• 10-25 of women
• 5-12 of men
• Major Depression affects 10-13 of medical
  outpatients

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Co-MorbidityDepression and Chronic Disease

• Depressive disorders are associated with
  increased prevalence of chronic diseases (e.g.,
  asthma, diabetes, heart disease and stroke)
• Chronic disease worsens symptoms of depression
• Seven out of 10 office visits to a primary care
  doctor concern chronic diseases

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Depressive Disorders Worsen Chronic Disease

• Increased somatic symptoms, eg, multiple pain
  complaints
• Greater functional disability
• Increased mortality
• Increased healthcare utilization and costs
• Poor self-management
• Decreased adherence to treatment regimens
• Greater drug interactions due to polypharmacy

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Disparities and Untreated Depression in NYC
(NYCHANES)

• Only 37 of New Yorkers with depression report
  receiving mental health treatment
• Of the NYers in treatment, only a quarter of
  African Americans and Hispanics (26 and 27
  respectively compared with nearly half 49 of
  Whites)
• Untreated depression causes suffering, disability
  and most tragically, suicide
• Of those with Major Depressive Disorder (MDD),
  close to 50 report feelings of wanting to die,
  33 consider suicide and 8.8 report a suicide
  attempt

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Social Isolation

• There is a high rate of isolation among the
  elderly which creates a further obstacle to
  identifying and treating mental illness in this
  population. The loss of a social support network
  which occurs among he isolated elderly creates
  stress that increases the likelihood of
  developing mental health issues.
• Seniors with high scores on social isolation
  scales are more likely to report depression than
  seniors with low scores

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Social Isolation and the Elderly

• Social Isolation in the elderly is associated
  with
• Depression
• Re-hospitalization
• Delayed care-seeking
• Poor nutrition
• Premature mortality

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Challenges of Engaging Socially Isolated Seniors

• Socially isolated seniors represent a hidden
  population that is difficult to identify.
• The size and geographic distribution of the
  population of socially isolated seniors in New
  York City is unknown.
• There are no population-based reports on the
  health characteristics of socially isolated
  seniors in New York City.

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Community Partners

• Geriatric Mental Health Alliance
• Brookdale Center for the Aging
• United Neighborhood Houses Report Aging in the
  Shadows
• described the problem of social isolation among
  seniors,
• the particular vulnerability of NYC seniors
• gave examples of program types and
  recommendations for change

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DOHMH Epidemiology Report on Seniors at Risk for
Social Isolation

• Produced by Dr. Tina McVeigh in our Division of
  Epidemiology
• In response to a request from UNH to further
  analyze our Community Health Survey Data with
  respect to social isolation risk factors
• Data used were not specifically collected for
  this purpose, but were extrapolated from existing
  data generated by our annual Community Health
  Survey.

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Objective of the Analysis

• To identify and characterize seniors at risk for
  social isolation in New York City using existing
  data from the 2002 and 2003 New York City
  Community Health Survey.

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Risk Factors Used in Analysis of Social Isolation

• Living alone
• Neither working nor belonging to a religious or
  community group
• Interrupted phone service for 24 hours or more in
  last year
• Meeting criteria for nonspecific psychological
  distress
• Being unable to work or experiencing at least 10
  days of activity limitation in the past month
  attributable to health or mental health problems
• Feeling that ones neighborhood is quite unsafe
  
• Having no friends or relatives to rely on for
  emotional support

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Methods

• NYC Community Health Survey (CHS)
• Population-based
• Random digit-dialed telephone survey
• Approximately 10,000 respondents per year
• 1,601 respondents 65 in 2002
• 1,618 respondents 65 in 2003
• CHS was not designed to assess social isolation.

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Limitations of Self Reporting

• Our findings are limited by self report and proxy
  indicators of social isolation.
• We dont know
• Who we missed (false negatives)
• Who we incorrectly included (false positives)

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Geographical Distribution

• Spatial analyses of these data identify a number
  of neighborhoods with high concentrations of
  seniors at risk for social isolation.
• These findings can be used to inform the
  development of targeted interventions to improve
  the longevity and quality of life of some of New
  Yorks most fragile seniors.

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Mapping of Results

• Total Number of New Yorkers Aged 65 and Older by
  Neighborhood
• Absolute Numbers of Seniors at Risk for Social
  Isolation
• Prevalence of Seniors at Risk for Social
  Isolation
• Prevalence of Nonspecific Psychological Distress
  among NYC Seniors

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West Queens
Flushing - Clearview
Borough Park
Ridgewood Forest Hills
Coney Island
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Lower East Side
Ridgewood Forest Hills
Borough Park
Bedford Stuyvesant
Coney Island
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South Bronx
Lower East Side
Lower Manhattan
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Distribution of Risk Factors for Social Isolation
Among Seniors, by Nonspecific Psychological
Distress (NPD) Status
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Implications

• Using existing data from a population-based
  survey we were able to identify a subpopulation
  of seniors who appear to be at risk for social
  isolation.
• This group is more likely to be female, Hispanic,
  unmarried, poorly educated and poor.

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Rates of Insurance and PCPs in Socially Isolated
Seniors

• Despite poorer health, seniors at risk for social
  isolation had similar rates of health insurance
  and preventive care as seniors not at risk.
• They were, however, less likely to have a primary
  care provider and more likely to have deferred
  medical care because of cost.

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What DOHMH Can Do

• Continuously improve measures for identifying and
  quantifying both seniors at risk for social
  isolation and individuals with mental health
  concerns
• Collaboration with DFTA, the Geriatric Mental
  Health Alliance, educational institutions, and
  partners in both primary care and mental health
  settings can lead to innovative solutions

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OngoingPublic Mental Hygiene Solutions

• Increased Access to Buprenorphine Treatment for
  New Yorkers Addicted to Opioids including
  Prescription Painkillers
• Increased Depression Screening and Management in
  Primary Care

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Buprenorphine

• Older adults can be at risk for addiction to pain
  killers as a result of surgery or chronic pain
• DOHMH has a five point plan to implement
  buprenorphine throughout NYC
• Buprenophine is a medication used to treat opioid
  addiction that can be prescribed by a physician
  in the privacy of an office visit and does not
  carry many of the obstacles or stigma of
  methadone maintenance

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DOHMH Depression Initiative

• Screening seniors for depression in the Bronx
• Educate the public, reduce stigma Public
  Education Campaign
• Subways, buses, check cashing sites
• Increase access to care
• Working with insurance providers and employers
• Implement depression screening and management in
  primary care practices throughout the City
• Outreach to Primary Care Providers including HHC,
  Voluntary Hospitals, FQHCs, and University
  Student Health Centers
• HHCs Electronic Health Record
• Depression detailers visiting 800 PCPs in Citys
  areas of highest need
• DOHMH Office of Care Management

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Depression Screening for Seniors Pilot Program

• DOHMH, DFTA, MHA of NYC collaborated
• Funding for one full-time social worker to staff
  initiative
• Goal screen seniors in senior centers and in
  their homes in the Bronx (CDs 1-6)
• Ultimate goal is to expand citywide

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Why Screen and Manage Depression in Primary Care?

• Among older patients who committed suicide, 20
  visited their primary care physician on the same
  day as their suicide, 40 within the past week,
  and 70 within the past month
• Patient preference and first line of defense
• Screening for depression in the primary care
  setting improves detection rates
• US Preventative Service Task Force (USPSTF)
  recommends screening adults for depression
• Only 50 of those referred to specialty mental
  health practitioners complete more than one visit

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Depression in Primary Care
In primary care, physical symptoms are often the
chief complaint in depressed patients.
In a New England Journal of Medicine study, 69
of diagnosed depressed patients reported
unexplained physical symptoms as their chief
complaint
N 1146 Primary care patients with major
depression
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Depression Management

• Patient Education
• Foster provider-patient relationships, reduce
  stigma, enhance treatment adherence
• Treatment (Medication and/or psychotherapy)
• Combined treatment with antidepressants and
  psychotherapy is recommended as first line
  treatment for patients with severe major
  depressive disorder
• Depression is treatable in 65 to 75 of elderly
  patients
• Ongoing Monitoring
• Care management, follow-up PHQ9

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Depression Campaign Long term Goals

• Depression screening and management as a standard
  of care in all primary care practices
• Improve the number of people receiving treatment
  for depression
• Improve the quality of care and outcomes for
  individuals with depression

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Need for Additional Linkages

• Communication of potential increased demand to
  local MH providers
• Continued efforts to increase capacity in mental
  health system
• Ongoing support for doctors and primary care
  settings with care managers
• Need to increase and improve workforce and its
  expertise in services to older adults

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More Needs to Be Done

• Increased training for people entering the
  medical, mental health and service fields
  (Emphasis in our Hunter College Scholarship
  program for individuals who are focusing on
  geriatric services)
• Exploration of new models like integrated
  health/mental health teams (Diabetes/Depression
  Collaboratives as an example)
• Continued advocacy and support for additional
  resources

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Conclusions

• Older individuals in urban areas are at high risk
  for both social isolation and depression and
  require new and creative solutions to reach and
  serve them.