Treating Elderly Persons with Depression

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Treating Elderly Persons with Depression

• Scott J. Adams, Psy.D.
• WICHE Mental Health Program

2
Objectives

• Discuss epidemiological and other relevant data
  regarding depression in geriatric populations.
• Discuss a clinical formulation of elderly persons
  regarding depression.
• Cover questions PCPs can ask of elderly patients
  to assess the presence of depression.
• Talking with elderly people about treatment
  options.

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Prevalence

• Major depression among older adults in primary
  care settings is between 6.5 and 9 (Lyness et
  al., 2002).
• Estimates of overall depression vary widely based
  on patients context (in community, nursing home,
  etc.) and method of evaluation.
• Rates increase with need for home health care and
  hospitalization.
• 10-25 of in primary care and community settings
  have subsyndromal depression with symptoms that
  do not meet diagnostic criteria but have a
  significant negative impact on their lives (Speer
  Schneider, 2003)
• The prevalence of bipolar disorder among people
  aged 65 and over is reportedly less than 1
  percent (Robins Regier, 1991).

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Epidemiology

• Gender
• 1. Depression may be 1.5- 2 times higher in
  older adult women (e.g., Kockler Heur, 2002).
  This could be in part due to reporting bias and
  has been refuted in some studies that included
  post-mortem evaluations.
• B. Race
• 1. Studies disagree on prevalence of geriatric
  depression in ethnic group. Some say there is
  little difference between races , some studies
  show higher numbers in some groups, for example,
  African-Americans (Weissman et al., 1991).
• 2. Suicide is lower for people of color than in
  white older adults (CDC, 2005).

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Risk Factors

• People who need home health care
• People who require hospitalization
• People who live in nursing homes
• Somatic illnesses
• Persistent insomnia
• Loss of their spouse
• Other losses (e.g., loved ones, loss in
  functioning)
• Poor social support
• Current acute or chronic stressors
• Heavy users of alcohol
• Educational attainment less than a high school
  degree

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Clinical Case Formulation

• Here is a relatively simple formula one can use
  to assess elderly persons for depression
• Place X Position Problem
• Place Where a person resides own home, with
  family, in a facility.
• Position Ones psychological place or status
  connected vs. alone, independent vs. dependent,
  physically healthy vs. unhealthy, productive vs.
  nonproductive.
• Problem The result of the interplay between
  ones place and position.

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Clinical Case Formulation

• Infant Trust vs Mistrust - Needs maximum comfort
  with minimal uncertainty to trust
  himself/herself, others, and the environment
• Toddler Autonomy vs Shame and Doubt - Works to
  master physical environment while maintaining
  self-esteem
• Preschooler Initiative vs Guilt - Begins to
  initiate, not imitate, activities develops
  conscience and sexual identity
• School-Age Child Industry vs Inferiority - Tries
  to develop a sense of self-worth by refining
  skills
• Adolescent Identity vs Role Confusion - Tries
  integrating many roles (child, sibling, student,
  athlete, worker) into a self-image under role
  model and peer pressure
• Young Adult Intimacy vs Isolation - Learns to
  make personal commitment to another as spouse,
  parent or partner
• Middle-Age Adult Generativity vs Stagnation -
  Seeks satisfaction through productivity in
  career, family, and civic interests
• Older Adult Integrity vs Despair - Reviews life
  accomplishments, deals with loss and preparation
  for death

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Clinical Case Formulation cont.

• Place
• Own Home With Family In a Facility
• Connected--------Alone
  Connected--------Alone
  Connected--------Alone
• Independent--------Dependent
  Independent--------Dependent
  Independent--------Dependent
• Healthy--------Unhealthy
  Healthy--------Unhealthy
  Healthy--------Unhealthy
• Productive--------Nonproductive
  Productive--------Nonproductive
  Productive--------Nonproductive
• By considering a given persons position within a
  place, one can get a good idea of relevant
  issues.
• Generally speaking, the more a person falls on
  the left side of both the place and four
  position scales, the better off they will be
  psychologically.
• For example, a person in his/her own home who has
  connections with others, is mostly independent,
  is fairly healthy, and productive will be in a
  better position than someone at the opposite end
  of these scales.
• Additionally, this quick assessment tool can help
  identify potential interventions.

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Assessment

• Interviewing
• Use the clinical case formula presented in
  previous slides.
• Geriatric Depression Scale (GDS) as a way to
  detect and talk about depression focusing less on
  dysphoric mood, which older adults are less
  likely to report.

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Geriatric Depression Scale (short form)
Choose the best answer for how you have felt over
the past week 1. Are you basically satisfied
with your life? YES / NO 2. Have you dropped
many of your activities and interests? YES /
NO 3. Do you feel that your life is empty?
YES / NO 4. Do you often get bored? YES
/ NO 5. Are you in good spirits most of the time?
YES / NO 6. Are you afraid that something bad
is going to happen to you? YES / NO 7. Do you
feel happy most of the time? YES / NO 8. Do
you often feel helpless? YES / NO 9. Do you
prefer to stay at home, rather than going out and
doing new things? YES / NO 10. Do you feel you
have more problems with memory than most? YES /
NO 11. Do you think it is wonderful to be alive
now? YES / NO 12. Do you feel pretty worthless
the way you are now? YES / NO 13. Do you feel
full of energy? YES / NO 14. Do you feel
that your situation is hopeless? YES / NO 15.
Do you think that most people are better off than
you are? YES / NO Generally, a score gt 5
points is suggestive of depression and should
warrant a follow-up interview. Scores gt 10 are
almost always depression.
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Rule Outs

• 1. Medical causes
• 2. Bereavement
• 3. Bipolar Disorder (lt1)
• 4. Alzheimers, vascular dementia, other
  dementias

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Dementia vs. Pseudo-dementia
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Treatment

• Medication
• a. One study on antidepressant medication
  compliance found that 70 of older adults dont
  take their meds as prescribed (NAMI, 2003) so
  address med compliance issues (e.g., fears about
  taking meds).
• b. Evidence suggests that medication may take
  longer to work.
• c. Residual symptoms appear to be common.

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Treatment cont.

• 2. Psychotherapy
• Psychotherapeutic treatment are effective for
  geriatric patients. Meta-analytic studies show
  that effects are similar to those of younger
  adults (e.g., one meta-analysis showed an effect
  size of .72).
• 83 say they want to treat their depression (APA,
  2003).
• Evidence is inconclusive regarding best kind of
  psychotherapy, but meta-analysis of psychotherapy
  studies have included a range of psychotherapy
  styles. Many types are probably effective.
• Older adults may require a longer course of
  psychotherapy than younger adults.
• 3. Combined Treatment
• The data indicate that medication or therapy
  alone can be effective, but combining them has
  the best outcome (Reynolds et al., 1999 Little
  et al., 1998 Thompson et al., 2001).

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Other Interventions

• If you use the clinical case formula described
  earlier (Place x Position Problem),
  interventions may become apparent.
• For instance, does a person have connections but
  feels unproductive, or is he/she physically
  healthy but alone? There are many combinations,
  but even simple things can help a great deal.
• A major theme is one of control and mastery. Even
  people who have significant physical illnesses
  and require significant care can do things to
  achieve greater control and mastery in their
  lives.
• Education is always helpful, particularly in
  terms of helping patients see that they do not
  have to accept depression as a necessary part of
  aging.

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Discussing Treatment

• The primary treatments are psychotherapy or
  counseling and medication.
• As a general rule, the younger the child, the
  longer psychotherapy with the child will take.
  Instead, its better to work with parents.
• Family therapy may be the best option if there
  are multiple problems in the home. Sometimes a
  child becomes a focus of problems but is not the
  only one with problems.
• Many parents (understandably) do not want to put
  their kids on medications. One of the primary
  issues will be symptom severity.
• Brief explanations of how medications work go a
  long way in demystifying and destigmatizing them.

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Parent Resource List

• Depression Education Websites
• Mayo Clinic www.mayoclinic.com
• National Institute of Mental Health
  www.nimh.nih.gov
• Mental Health Americawww.mentalhealthamerica.net
• Books on How to Help Depressed Children
• The Depressed Child A Parents Guide for
  Rescuing Kids - Dr. Douglas A. Riley, Ph.D.
• The Childhood Depression Sourcebook - Jeffrey A.
  Miller, Ph.D.
• Helping Your Depressed Child - Martha Underwood
  Barnard, Ph.D.

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Pediatric Depression References

• Costello, E. J., Angold, A., Burns, B. J.,
  Stangl, D. K., Tweed, D. L., Erkanli, A.,
  Worthman, C. M. (1996). The Great Smoky Mountains
  study of youth Goals, design, methods, and the
  prevalence of DSM IIIR disorders. Archives of
  General Psychiatry, 53, 11291136.
• Kessler, R. C., Avenevoli, S., Merikangas, K.
  R. (2001). Mood disorders in children and
  adolescents an epidemiologic perspective. 
  Biological Psychiatry, 49, 1002-1014.
• Lewinson, P. M., Hops, H., Roberts, R. E.,
  Seeley, J. R., (1993). Adolescent Pychopathology
  I Prevalence and incidence of depression and
  other DSM-III-R disorders in high school
  students. Journal of Abnormal Psychology, 102,
  133-144.
• Rappaport, N., Bostic, J. Q., Prince, J. B.,
  Jellinek, M. (2006). Treating pediatric
  depression in primary care. Journal of
  Pediatrics, 148, 567-568.