Primary Care Approach to Dealing with Psychological Problems in the Elderly

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Primary Care Approach to Dealing with
Psychological Problems in the Elderly

• Samuel Y.S. Wong MD
• School
• of
• Public Health Primary Care,
• Chinese University of Hong Kong

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Depression in late life

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

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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

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Burden of elderly suicide in HK
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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

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

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Providers 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

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Barriers for integrationvariability 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.

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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

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

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From GP in the UK

• ..i wonder whether actually weve got patients
  being treated for depressionas 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

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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 its probably loneliness, because they
  dont have much family around.and their
  partners goneand they dont have anywhere to
  go.

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From primary care nurses,

• sometimes I think people are depressed because
  thats where their life is at that timeso I
  think theres almost an acceptable sometimes that
  its justifiable depression, you know, there are
  reasons for it.

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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.

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Making the diagnosis

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

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Making the diagnosis

• patients described the potential value of an
  ongoing relationship in allowing the GP to be
  alert to patients feelings
• my doctor knew, he knows me inside out. He knew
  immediately, he is a lovely doctor.

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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.

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• I think you are probably reluctant to go looking
  for the diagnosisif its present the its a lot
  easier.if there isnt a huge amount of support
  for following it up, and often there isnt.
• it is unfair to start delving and then say,
  right fine. Weve found that out but nothing we
  can doyou do have a tendency not to think about
  it too much

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• 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

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

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• 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.

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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

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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.

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• 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!!

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Solutions

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

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Collaborative Care for Depression in late life
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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

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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)

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Collaborative Care Modelother 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

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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

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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 didnt
  feel like doing anything about it. I couldnt get
  into it at all. So I left it.

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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

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Description from coordinator

• Depression isnt loneliness. But, one of the
  themes that comes through people I see, its 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 theres
  no matter how depressed people are, its trying
  to re-humanisefind what may be weve got in
  common. so the more I know about them, not
  necessarily about their illness, about them as a
  person.

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• it is very flexibleif someone asked me what I
  was really doing Id say I use a very eclective
  common sense non-rocket-science approach, thats
  very , very individual to whatever the patients
  needs are

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Other examples
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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

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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?

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• 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

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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

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• Outcome measures
• Incidence of DSM depressive and/or anxiety
  disorders at 1 year
• Secondary depressive/anxiety symptoms, QOL,
  health service utilization over time
• At baseline, 3, 6, 9, 12 and 15 months

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Summary

• CARE that include interpersonal continuity of
  care by a care provider, easily accessible based
  on needs
• Importance of social care in addition to medical
  care
• Integration and collaborative use of various
  social, psychological and medical services
• From low intensity to high intensity

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Thank you!!