Integrating depression detection and treatment into work with older adults

1
Integrating depression detection and treatment
into work with older adults

• Peter A. Lichtenberg, Ph.D., ABPP
• Director, Institute of Gerontology
• Professor of Psychology
• Wayne State University

2
Perspectives on Old Age

• To me old age is always 15 years older than I am
• Bernard Baruch, age 84
• How old would you be if you didnt know what age
  you were?
• Satchel Paige

3
DSM-IV Major Depressive Disorder

• At least 5 of the following 9 symptoms have been
  present for a 2 week period (either a or b must
  be one of the 5 symptoms)
• a. Depressed mood consistently - not transient
• b. Loss of pleasure and interest in normally
  pleasurable activities (anhedonia)
• c. Significant weight loss or gain (gt5 body
  weight)
• d. Insomnia or hypersomnia
• e. Psychomotor agitation or retardation
• f. Loss of energy, fatigue (even following a
  good nights sleep)
• g. Feelings of worthlessness, self-reproach,
  inappropriate guilt
• h. Decreased ability to think or concentrate
• i. Suicidal thoughts or attempt

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There is nothing Minor about Minor Depression

• MAJOR
• Depressed mood or loss of pleasure
• 4 additional symptoms
• Interfere with social or occupational function
• At least 2 week duration

• MINOR
• Same
• 1 additional symptom
• Same
• Same

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PrevalenceDepression at Late Life

• ECA data 1-month point prevalence is 10.0
• 2.3 MDD
• 2.3 Dysthymia
• 1.5 Minor Depression
• 3.9 symptoms
• 20-30 subsyndromal or minor
• depression symptoms
• 17-37 in PCCs
• Gatz and Smyer (1992) 1-year prevalence of all
  mental disorders (gt64) at 20-22.
• Comorbidity of anxiety disorder for an MDD
  presentation is 35-45

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Prevalence of Major Depression in Older Adults By
Setting





0 5 10 15 20
Primary Care
Nursing home
General hospital
Assisted Living
Home Health Care
Community
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Depression Detectionin Primary Care

• Major issue in geriatric primary care
• 24 mos. study of HMO enrollees2Mean age 75, 62
  women
• 16 prevalence of depression
• 48 undetected
• Least detected Men 64-75 and all gt 85

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ABCs of Depression
A Affect Apathy Feelings of worthlessness Sadness, anger
B Behavior Sleep, appetite Social functioning Fatigue, agitation
C Cognition Negative thoughts Lack of concentration
J Fam Prac 03 S13
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Major negative impacts of depression

• Pre-mature mortality
• Increased physical disabilityone of leading
  causes in world
• Link btwn depression and subsequent cognitive
  decline
• Lower quality of life
• Poorer relations with others/social
  network/support

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Depression Etiology

• Biological

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Depression Etiology Biological

• Neurotransmitters
• Serotonin
• Norepinephrine
• Dopamine

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Neurotransmitters and Mood, Cognition, Behavior
Serotonin Norepinephrine Dopamine
Mood Mood Mood
Anxiety Anxiety Attention
Obsessions Alertness Pleasure
Compulsions Energy Reward
Panic Pain Motivation
Worry Apathy
Energy
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Neurotransmitter Function
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Pathophysiology

• Neurochemical
  imbalance
• Serotonin
• Norepineprine
• Dopamine

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Results of SSRI Clinical Trials

• Effective in older adultsbut not that much more
  than placebo
• SSRI limitations
• Use of physically healthy elders
• Major differences are side effects, not efficacy
• Liver side effects a concernespeciallyin elders

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SSRIs
Prozac 20 mg
Zoloft 50 mg
Paxil 20 mg Paxil CR 25 mg
Celexa 20 mg
www.drugs.com
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SNRI
Cymbalta 20 mg
Effexor 25 mg
Effexor XR 75 mg
www.drugs.com
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SARI
Serzone 50 mg
Trazodone 50 mg
Serzone 100 mg
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NDRI and NaSSA
Wellbutrin 75 mg
Remeron 30 mg
Wellbutrin SR 100 mg
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Antidepressant Side Effects
Tricyclics SSRI SNRI NDRI SARI/NaSSA MAOI
Dry mouth Nervousness Nausea Agitation Nervousness Drowsiness Weakness
Blurred vision Agitation Loss of appetite Weight loss Nausea Dry mouth Dizziness
Constipation Insomnia Anxiety Nervousness Headache Nausea Headache
Difficulty urinating Headache Headache Blurred vision Loss of appetite Weight loss Dizziness Trembling
Worsening glaucoma Nausea Insomnia, bad dreams, tiredness Insomnia Liver problems (serzone)
Impaired thinking Dry mouth Dry mouth Constipation Inc blood pressure Orthostasis Food interactions
Tiredness Diarrhea Sexual dysfunction Dry mouth Constipation Muscle pain
Inc blood pressure Sexual dysfunction Inc heart rate Inc blood pressure Seizures Weight gain
Orthostasis Inc heart rate Platelet dysfunction Inc cholesterol Constipation
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Increasing reliance on meds with little evidence
to support it

• Response yes, remit no
• Antidepressant use doubled from 1996 (5) to
  10.4 in 2006 switch from 2 or gt meds increased
  from 42 in 1997 to 60 in 2006 3 meds from 16
  to 33 (Olfason et al., 2006)

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Placebo and You2nd Generation Antidepressants

• Acute phase, parallel group, double blinded,
  placebo controlled with random assignment, for
  2nd generation antidepressants not associated
  with a med disorder and 60 or gt. Cochrane and
  Medline
• 10 unique trials with 13 contrasts (N2377 active
  drug and 1788 placebo)
• Response rates for Drug 44.4
• Response rate for Placebo34.7
• 10-12 weeks gt 6-8 weeks
• Discontinuation rates highest for Drug.
• 2nd generation meds work but effects are modest
  and vary.
• For every 100 treated, 8 show a response and 5
  remission in excess of placebo
• TCAs perform about the same as 2nd generation
  meds
• Placebo rates vary 19-47. Lots of
  heterogeneity Nonspecific effects
• 
  Nelson et al., 2009

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Vascular Depression Hypothesis

• Vascular diseases can predispose, precipitate,
  or perpetuate a depressive syndrome in many
  elderly patients Alexopoulos9

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Vascular disease can cause microvascular brain
tissue damage in frontal/subcortical areas of
brain

• Diabetes
• Atrial Fibrillation
• Hypertension
• Smoking
• Obesity
• High cholesterol

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Development of Depressive Disorders

• Hypertension, Diabetes, CAD, Stroke
  Genetics, Neurological Disease, Stroke, Etc.

Frontal Striatal Lesions
Vulnerability To Depression
Life Events
Social Support
Depressive Disorders
Model of Risk Factors That Lead to Depressive
Disorders Adapted from Krishnan KRR. Biol
Psychiatry. 2002 52 185-192
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Vascular Burden Study(Mast, MacNeill
Lichtenberg, Amer J Geriat Psychiatry, 2004)

• Sample
• 680 consecutively admitted geriatric rehab
  patients (age 60)
• Separated into 3 groups
• Stroke Pts with evidence of stroke, n205
• CVRF Pts with CVRFs but no stroke, n353
• Non-vascular Pts with no stroke or CVRFs, n122

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Hypotheses

• Prevalence of depression will be greater among
  patients with vascular disease (stroke and CVRFs)
  than among non-vascular medical patients.
• Prevalence will not differ between stroke and
  CVRF groups.

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Results H1

• Prevalence and severity of depression did not
  differ significantly among the 3 patient groups.

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Results H1Vascular Burden

• Presence of 2 CVRFs was associated with
  increased prevalence of depression in the
  non-stroke group.

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Conclusions from Study

• Concept of vascular burden
• Replication in sample of 600 community dwelling
  elders (Yochim, Mast Lichtenberg 2003)

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Case StudyVascular Depression

• 78 YO WM recently retired Diabetes, heart
  disease
• Depression evident but physical limitations keep
  him from travelling the way he wants to
• At age 80 begins falling, exhaustion, lower
  energy expenditure (frailty)
• Falls and dies at age 82

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Activity Limitation TheoryChange in activities
mediates relationship between medical condition
and depression.
Activity Restriction
Depression
Illness, Pain
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Depression FunctionExercise Interventions

• Interventions
• Weight-lifting 20 wks v lectures 10 wks20
• 13 major 17 minor depressives, mean age 71
• Follow-up at 20 weeks and 26 months
• Aerobics v resistance v education, 3 mos21
• 439 knee osteoarthritics, mean age 69 22 scored
  above BDI cutoff
• Follow-up at 3 months and 18 months

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Depression FunctionExercise Interventions

• Results
• Both aerobic and resistance exercise reduced
  depression, disability, pain
• Exercise more effective than education
• Compliance best for low depression groups
• Adherence to exercise declined over time

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Case Study

• 81 year old womanhealthy until enters hospital
  for acute kidney failure
• Dx. Multiple Myeloma
• Chemotherapy
• Depression evident
• Treatment works and allows her to return to
  gardening and hiking
• Depression disappears

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Lewinsohnian Model of Depression

• Feelings and behavior are linked
• Three decades of research support the behavioral
  model for persons including
• Young, middle-aged, older adults
• Caregivers
• Demented elders

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Behavioral Treatment of Depression

• Rationale
• Goal
• Techniques

• What the person does is related to how s/he
  feels
• To increase positive events and decrease negative
  ones
• Relaxation, mood monitoring graphing

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The Retirement Research Foundation-Institute of
Gerontology Project

• Integrating Mental Health in Occupational Therapy
  Practice with Older Adults
• Cathy Lysack Peter Lichtenberg (PIs), plus team
  of WSU experts in aging, and community partners.

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The DVD Box Set

• 1. Introduction, Aging and Mental Health
• 2. Understanding and Treating Depression
• 3. Medications for Treatment of Depression
• 4. Family Caregiving
• 5. Falls, Balance and Exercise
• 6. Driving Rehabilitation and Community Mobility
• Plus
• - A CD with assessments, powerpoint slides, and
  references/resources in pdf format.
• - A DVD with video of full patient assessments.

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Behavioral Activation

• Combines meaningful activity and pleasant events
• Teaches patients that mood is related to what
  they are doing
• Does not require a big time investment to
  integrate into treatment

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Elements of Behavioral Activation

• Mood ratings
• Rationale
• Pleasant event Brainstorming
• Identify barriers to implementation
• Commit to making a change

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Attitudes about talking with older adult clients
about mood

• Older adults are resistant to talking about their
  mood or sadness?
• Pre Post (True response)
• 53 16 (30 OTs in training group)
• 45 (112 OTs in one day conference
• Combined data (144 OTs)
• 40 did not know diagnostic criteria for
  depression
• 33 overestimated amount of depression in
  population they work with
• These were statistically significant changes
  plt.05

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Performance Indicator Descriptive Data
 Table 1 Demographic information N All Patients
Age (years) 384 80.1
Gender (female) 384 69.2
Heart Disease 384 49.2
Diabetes Mellitus 384 29.2
Dementia 384 19.0
CVA 384 11.8
Depression 384 10.5
Medications for depression or anxiety 384  19.2
High levels of comorbidity
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 Table 2 Performance Indicators Pre-training (n 199) Post-training (n 184)
Mention of mood or depression 66.3 77.7
Depression screening 3.0 25.3
Reporting mood to treatment team 25.5 31.5
Referral to other health professional 7.5 13.7
Mention of pleasant events or behavioral activation 9.0 16.1
Report mood ratings of patient 6.0 11.8
Identify pleasant events 5.6 15.0
Get commitment from patient to attempt events 4.1 8.6
Mention of cognitive functioning 70.0 88.8
Cognitive screening 11.1 39.0
Report cognitive functioning to treatment team 24.5 34.3
Referral to other health professional because of cognitive functioning 5.6 6.1
Mention of caregiver 46.7 38.8
Report on coping/stress of caregiver 2.6 5.9
Referral of caregiver to sources of help  7.3 12.0 
plt.05 plt.01
Performance Indicator Change Data
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Case Study

• 80 YO live alone woman, falls fractures hip
• OT administers MLDTmild cognition problems,
  mild-moderate depressive sx.
• Interviews woman about enjoyable activities
• Discovers woman loves to be read to and discuss
  poetry
• Depression recedes and woman makes gains and can
  return home

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Wordens Four Tasks of Grief

• Accept the reality of the loss
• Work through the pain of grief
• Adjust to the environment in which the deceased
  is missing
• Emotionally relocate the deceasedand move on
  with life

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Bereavement

• Bereavement 800,000 people/year bereavement (20
  MDD) Key What is depression what is abnormal
  grief and what is OK?
• Complicated Bereavement V Code
• Yearning for, preoccupation for, searching
  for, excessive crying, disbelief regarding death
  and non-acceptance of death, as well as social
  isolation. Global functioning suffers.
• Must generally return to pre-loss activities
• Assess for depression and the above
  variables
• Texas Revised Inventory of Grief (26 items,
  0-65)
• Inventory of Complicated Grief (18 items
  and score 25 or gt)

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Grief and Depression

• Depression as a typical complication of grief29
• 13.9 of newly bereaved had depressive symptoms
  after 2 years v 4 of married persons
• Percent of newly bereaved with depressive
  symptoms by month (no gender difference)

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Early Loss and Late Life Expression in Poor Elders

• 109 older-old African Americans
• 51 of respondents lost parentto death or
  desertion by age 16
• Those with parental loss had
• Decreased education, social resources, and family
  satisfaction
• Increased depressive symptoms

• Subjects
• Findings

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Case Study

• 78YO woman loses husband and leg (below knee) in
  same month (diabetes)
• Enters psychotherapy
• Excessive guilt, searching, waiting for husband
  to returnfor months
• Works through issues surrounding fathers death
• Begins to get active and convinces adult children
  to get jobs and help care for her

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Assessment, referral and how to

• Screening for depression is important
• Communicating with the clinical team is key
• Understanding basic approaches to intervention is
  helpful

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MLDT Emotional Status Measure GDS-3

• Do you feel pretty worthless the way you are now?
• Do you feel that your life is empty?
• Do you often feel downhearted and blue?

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MLDT GDS-3 Decision Making

• If just one GDS-3 item is answered
• YES,
• A complete evaluation for
• depression is recommended

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Items from the Geriatric Depression Scale Items
1-5

1. Are you basically satisfied with your life?
2. Have you dropped many of your activities and
   interests?
3. Do you feel that your life is empty?
4. Do you often get bored?
5. Are you in good spirits most of the time?

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Items from the Geriatric Depression Scale Items
6-10

1. Are you afraid that something bad is going to
   happen to you?
2. Do you feel happy most of the time?
3. Do you often feel helpless?
4. Do you prefer to stay home rather than going out
   and doing something?
5. Do you feel you have more problems with memory
   than most?

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Items from the Geriatric Depression Scale Items
11-15

• Do you think it is wonderful to be alive?
• Do you feel pretty worthless the way you are now?
• Do you feel full of energy?
• Do you feel your situation is hopeless?
• Do you think most people are better off than you
  are?
• GDS score greater than or equal to 5 raises
  suspicion as to depression

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Communicating results of screening

• Integrated Care and its role in treating older
  adults

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Integrated Care

• Interdisciplinary Health Care that emphasizes a
  high degree of collaboration in
• Patient evaluation
• Treatment planning
• Outcome evaluation

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2007 American Psychological Association
Presidential Task Force
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Individual Assessments
Shared information Team goals Intervention plan
strategies
Individual Delivery of Care
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Practice Models

• Fully Integrated Care - part of treatment team
  coordinated behavioral and medical care (i.e.
  response to illness, Rx develop/ situational
  issues, management chronic)
• Consultant Model evaluation physician
  consultation, brief interventions
• Co-Location Model- essentially specialty mental
  health care in same location as primary care

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Case for Integrated Care

• Supported research evaluations- integrated care
  more sessions, than enhanced referral (Bartels et
  al, 2004)
• Evidence studies of reduced symptoms, improved
  life quality (see Aredin, 2003 Skultety Zeiss,
  2006)
• Reduced stigma and increased knowledge re
  behavioral health