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HOW TO RECOGNIZE DEPRESSION
Presenter: Dr. David Greenspan
Introduction to your Home Study Program
This Home Study was developed from an audio recorded program that was recorded directly at a
live seminar/program. This type of home study format is ideal for participants who prefer reading
rather than listening to information. We hope you enjoy both the content and the presentation.
Presenter: Dr. David Greenspan, a geriatric-psychiatrist who is currently Medical Director of
Carrier Clinic, a psychiatric facility in New Jersey. His expertise includes clinical treatment of
the elderly and he has presented programs nationally for audiences for professional associations
and educational institutions for the last 20 years on a variety of mental health illnesses and
issues. Dr. David Greenspan is a published author and has written on depression and endocrine
disorders in Depression and Coexisting Disease
Editor: Lilly Mill, Executive Director, Center for Health Care Education
Editor: Genie Hamlett, RN, NHA, Medical Update
Sally Hughes, Medical Update
© 2009 CENTER FOR HEALTH CARE EDUCATION
2011 Medical Update, Inc
HOW TO RECOGNIZE DEPRESSION
Program Outline
Causes of Depression
Mental Health Issues in the Elderly
Risk Factors/Triggers for Depression
Symptoms and Behavior Associated with Depression
Administering and Use of Depression Scales and/or Assessments for Depression
Treatments for Depression
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Case Examples of Depressed Elderly
HOW TO RECOGNIZE DEPRESSION
Overview: This seminar is based on evaluation and treatment of clinical depression of
elderly in Mental Health Settings and other settings. Today we’ll discuss:
a. the origins of depression-the biological, social and physical explanations
b. helps to intervene with depression
c. types of depression
d. how to find resources i.e. find clinicians and staff to help residents
e. how to determine the appropriateness of admitting residents to your
facilities
I would like to hear from the audience what your definitions are of - Late-life?
*Who are we talking about?
*What is aging?
*Who is old? The elderly?
*What about getting old is bad?
*What are the images of being old?
Audience Responses:
*Physical Illness
*Self-value and roles lost
*Mental deterioration
*Pain
*Isolation
*Disabilities
*Wisdom-use of one’s life experience
*More time available
*Freedom from roles, obligations and responsibilities.
The surveys show in our country that the negative beliefs are not true. They showed that
we have images from our culture about aging and then we put these into our minds. There
is ageism, the belief that older adults can’t do things and don’t. That they can’t deal with
loss. They actually deal better with loss as they grow older. In fact, those who went through
the difficult economic Great Depression had less depression in later life.
Older adulthood is an opportunity to grow, cope, learn, and can respond well to
interventions. The process of aging is actually kinder to most of us than we expect it to be.
However, discussions and presentations at a National Institute for Health Conference stated
that when there is depression in late life it is more often missed and therefore not diagnosed
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and treated. This is because many primary care physicians think that the complaints are a
result of aging i.e. physical pain, losses etc. It was also reported that 1 in 6 elderly patients
meet the criteria for major depression and the primary care physician did not diagnose or
treat the depression.
The primary care physicians do not routinely assess for depression as a functional
disability or for suicidal tendencies. The patients are then at risk for more general medical
conditions.
Depression is a recurring condition and the treating physician needs to stay on top of it or it
will come back worse than before, if it is not diagnosed and followed by treatment...and
often neither of these occur. In Skilled Nursing Facilities 25% to 35% meet the criteria for
major depression and 60% have depressive symptoms. We don’t know why there is such a
high incident of major depression. There are no specific studies on this. In the general
community there is a rate of 2-3% of minor depressive symptoms and 10% with significant
symptoms of depression. This is still much lower than significant symptoms of depression in
younger persons.
There was an article in the “Atlantic Monthly” by Stanley Jacobson where he stated that
depression was a natural response to predicted losses of the elderly. I disagree with him and
the studies show just the opposite and that the elderly do not respond to losses in this way.
They’re overselling major depressive disorder to old folks. It’s less clinical depression but
there are going to be reactions to changes in life. In addition, the elderly have a tendency to
bounce back from loss and in fact they’ve developed amazing coping mechanisms to the
losses in their lives.
There is this common belief amongst doctors that “Wouldn’t you be depressed if ...certain
events or losses occur?” ... or Ageism-“What do you expect you’re old!” This belief keeps
those with major depression sick and untreated. Major Depression is a serious and
treatable illness but with this belief about the elderly, the primary care physicians can wash
their hands of the problem.
Audience Question: “My mother has depression. How can you make her or other elderly
depressed patients comply with treatment?
Your mother probably feels shame and guilt associated with her depression. This is a
terrible problem because there is a lot of stigma associated with mental iIllness and the
isolation that these people often feel. I often describe major depression in a way that people
can relate to it better...without the stigma...as a medical illness i.e. cancer, anemia or high
blood pressure. If there is an illness we need to treat it.
So for example, let’s take a scenario with 85 year-old Mrs. Jones who fell and broke her
hip.
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We would keep her pain free through pain management; or we’d give her surgery to fix
her broken hip. We need to treat Major Depression the same way, to treat the illness in
order to give patients a better quality of life. There is no reason someone has to be in pain
because of Depression. We treat it so they’re not in psychological pain.
There are certain types of strokes that cause Major Depression even if the physical
symptoms of the stroke are the same. Half of the patients had Major Depression and the
other half rarely became depressed.
Major Depression can present with physical symptoms. I have one patient who constantly
presents herself as having burning and pins and needle sensations every night at 3 in the
morning. She continues to blame her medicines, even her Tylenol. When suddenly major
depression occurs in a 77 year-old woman (or even with someone younger) there have to be
other explanations besides the fact that she is old and her husband died ten years ago.
There are physical changes, structural changes in the brain that occur with major
depression. Magnetic Resonate Imaging (MRI) was done on older adults with dementia and
also on adults with major depression. When the two MRIs were
compared they showed similar structural damage. Some of the symptoms in dementia and
major depression are also similar such as memory impairment, disturbance in executive
functioning (poor decision making or indecisiveness) to name a few. In the 1940’s
Alzheimer’s may have been diagnosed instead of major depression. Some other similarities
are as follows:
a. Aphasia- Loss or impairment of the power to use or comprehend words
usually resulting from brain damage.
b. Apraxia- Loss or impairment of the ability to execute complex coordinated
movements without muscular or sensory impairment. Many times with
major depression there is a retardation or slowing of movement.
c. Agnosia- Loss or diminution of the ability to recognize familiar objects or
stimuli usually resulting from brain damage.
There is more major depression with some illnesses such as myocardial infarction (heart
attack), stroke, cancer, chronic obstructive pulmonary disease (COPD), Senile Dementia of
the Alzheimer’s Type (SDAT), and Parkinson’s Disease. There are statistics that within one
year in a Skilled Nursing Facility (SNF) that there is 2
to 3 times the chance of dying from a heart attack or stroke if it is accompanied by Major
Depression.
Major Depression can present with physical symptoms in and of itself i.e. pain, headache,
stomach upset, constipation, inability to swallow, dementia, fatigue, weight loss and vague
complaints. It can increase the chance of death with heart attack and stroke.
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Major Depression is more disabling than stroke or COPD, but less serious than a heart
disease. Major Depression increases the utilization of health care resources of all kinds
including primary care physician visits, hospitalizations, medical tests and emergency room
visits. It is the second most disabling illness in the country.
Major Depression causes significant caregiver/family burden because:
1) People with depression are not fun to be with.
2) They are sick, just the way someone has arthritis or pneumonia they’re
more work.
3) We don’t understand depression. We experience it as burden/nuisance to
us.
This can also be when abuse of an elderly person can take place due to the frustrations of
taking care of someone with depression.
Major Depression is treatable versus agitated dementia because with dementia you don’t
have a reversible condition. In some persons who exhibit Depression with cognitive
problems there is an increased risk factor for dementia...or put another way it can be a
harbinger of dementia. Depression can be seen as reversible dementia if it is treated and the
person keeps up with the treatment. So one can see that there may be a co-morbidity
between dementia and major depression. We also see in the early stages of dementia less
depression but later stages there can be signs/symptoms of major depression.
Alzheimer’s disease has symptoms of memory problems but without mood disorder
symptoms and is not treatable any longer with anti-depressants. In other words the
cognitive problems are not clearing up with the psychotropic medications.
Major Depression causes dysfunctional suffering and strongly affects the quality of life. I
tell people that you can remain miserable or get better. It can ruin people’s lives and some
report it as one of the worst experiences of their life. It also can amplify the physical
symptoms for a person. In the community the elderly spend more time in bed and their
visits to their primary care physician can increase to as many as nine times a year. Those
who are depressed are typically on 5 or more medications and complain more.
Major Depression increases healthcare costs (as per health insurance company
records)...often it doubles annual healthcare expenditures for the elder care.
Elderly suicide rates are on the rise and account for 25% of all completed suicides. White
males are at greater risk. If there is physical illness, or they are widowed or substance
abuse is involved, they are at higher risk of suicide. If there is major depression they are
more likely to use larger amounts of alcohol and sedatives because of difficulty with
sleeping.
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Major Depression can also cause barriers to recovery in other disorders due to poorer
cooperation with their rehabilitation plans i.e. self-care, medication regimes, won’t eat and
so this also takes up more time for staff in a residential setting like a Skilled Nursing
Facility (SNF). If your nursing staff is complaining about a particular patient and dementia
with agitation has been ruled out, then most likely you’re dealing with a major affective
disorder. There will be more conflict with residents with a major affective disorder.
Depression in late life is a brain disease. We’re not sure if it’s genetic in late life as it’s more
sporadic. There are psychosocial stressors in depression. There seems to be some protection
from depression in late life if someone has at least one good friend and/or a supportive
social network. Depression must be seen as a disability and we need to break the cycle of
suicide, drug dependence and medical mortality with sound treatment.
How do you tell the difference between a depressed mood versus Major Depression?
In diagnosing depression patients do not usually have same symptoms of Major Depression
and not for as long. In some studies state that depressive symptoms are minor forms... but
same disease. Major Depression affects more systems in one’s life i.e. work, personal
relationships. Twin studies showed that the twins had the same symptoms for Major
Depression and that there were also psychosocial symptoms… In other words a broader
impact on their lives.
In Major Depression a person will have five or more of the following symptoms and 1 or 2
for at least 2 weeks:
* Depressed mood
* Anhedonia (inability to experience pleasure or loss of interest from once
enjoyable activities)
* Anorexia/hyperphagia (usually less appetite than overeating)
* Insomnia/hypersomnia
* Psychomotor agitation/retardation
* Fatigue or loss of energy
* Feelings of worthlessness or guilt
* Reduced concentration/indecisiveness
* Thoughts of death/suicidal ideation
*Complaints that they “Feel Sick”- complaints of headache and stomach
aches.
There is a difference between bereavement and depression, though bereavement can look
like major depression.
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Freud wrote a book called “Mourning and Melancholia” he also pointed out how similar
the two syndromes are. If it’s grief the person will eventually be able to let it go. It serves a
purpose and then the individual is able to come into their own and begin to live life again.
It’s not a continuous condition. The symptoms of major
depression can be present for about two-months and then diminish. About one-third of
people who are grieving a death have hallucinations which are normal. They sometimes see
or feel their loved ones who have died in their presence. They usually find this very
comforting and they’re positive experiences.
“There was a study of 500 bereaved adults and they benefitted from treatment i.e. some
anti-depressants for short-term and some form of therapy if more of the symptoms were
Major Depression and they were having difficulty after a year resolving their loss.” Loss in
late life is common and as you remember older adults have a tendency to resolve grief well.
In this study about 8-13 percent of the adults met the criteria for Major Depression for oneyear.
In bereavement, people can feel the following but note some of the differences:
Sad, apathy but not Anhedonia, can have anorexia and overeat, disrupted sleep, restless
(only), anergia (lack of energy is rare), guilt over event only, poor concentration, thoughts
of suicide/death are fleeting at most, hallucinations or
feeling of a presence but in waves, and usually an improvement of symptoms in two
months.
So what/how do we detect the triggers that can lead to an accurate diagnosis? There is a
Minimum Data Set (MDS) that we can refer to and the detection triggers are as follows:
* Change in sleep or appetite
* Failure to thrive
* Apathy or irritability (many times that morning unpleasantness)
* Physical health complaint especially that don’t lead to a diagnosis
* Restlessness or agitation
* Negativism, refusals of care
*Avoidance and isolation, less social interaction i.e. won’t leave their rooms
for activities
* Suicidal ideation
There are many barriers to diagnosis. Around 17-37 percent in the private care sector
meets the criteria for major depression but only 32 percent get diagnosed. The Primary
Care Physicians don’t miss it in reality because they don’t know what to look for to
diagnose major depression. Again we see a bias against making a call because of ageism. ‘I
see it but don’t really see it’.
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I was at a teaching a seminar a little while ago and I presented this example to a group of
physicians and a few nurses:
Mr. Jones was brought into his primary care physician after he was diagnosed with
terminal cancer and it was predicted he would have about six months to one year to live. He
won’t get out of bed. He says he has pain, is weak and tired ...too much pain. What did the
doctors say- Tell the wife that’s it’s terrible for him to have terminal cancer and it’s really
sad. The nurse said the same thing. I had a drug company representative in the audience
and she was the only one to say- “He has 5 of the 9 symptoms of Major Depression and
maybe he should be treated with some medication.”
Again here is the bias of the medical profession that it is to be expected in later life and also
with a major illness; and actually this is not necessarily true.
What are the causes of depression? There can be multiple heterogeneous, multiple
contributors that cause Major Depression.
There is “essential” Major Depression that is from a biological cause. We have different
brain chemicals or neurotransmitters that we believe contribute to Major Depression. We
haven’t been able to actually see them but there is serotonin, norepinephrine which assists
us with sleep, mood stabilization, appetite control. Serotonin is produced in the brain but a
great deal of it is also produced in our digestive system. Norepinephrine also has a similar
role for our brains. If there is a lack of one or both of these brain chemicals then “essential”
major depression can develop.
Major Depression can be drug induced, because they can contribute the same symptoms.
Some of the anti-hypertensive (blood pressure medicines) or antacids are some of the
medications that can create mood problems, lethargy or side effects
that cause physical symptoms.
Chronic medical conditions can cause the person to have Major Depression. The beginning
of dementia can cause similar symptoms as it pertains to Major Depression. Bereavement
and/or loss as we said previously can mimic the same conditions as Major Depression.
There may be patient barriers that can interfere with a proper diagnosis for evaluation of
major depression. The patient may hide the illness, so they amplify somatic symptoms i.e.
constipation, stomach and chest pains and constant headaches. There may be different
presentations to hide the illness due to cultural teachings regarding complaining about
what’s happening to us. Some cultures emphasize being stoic and others are more vocal
with their emotions.
As a result of these barriers it’s important to use collaborators such as family members or
friends. For example, a patient may say that she’s sleeping too much but her daughter is
saying that her mother is up at night and restless and not sleeping well. It’s important to
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look for the “masked” or atypical presentations that I discussed just a short while ago. The
evaluator should rule out “real” medical problems and get a complete physical exam, blood
work and urinalysis. It is critical to make a thorough review of all the medications that the
patient is taking. Sometimes medications can interact or contribute to major depression.
I want to take a look at “Screening Tools” for diagnosing depression. Remember if they
have 5 out of 9 symptoms for 2 weeks or more as per the Diagnostics and Statistics Manual
(DSM) it is considered depression. The DSM is updated periodically...(When the American
Psychiatric Association needs more money they’ll come out with a new version...laughter).
White males who are older than 62 years old are at greatest risk. The elderly suicide rate is
on the rise and accounts for 25% of all completed suicides. If there is physical illness,
widowed or substance abuse (alcohol, prescription drugs) all increase risk of major
depression or it was there before and they may be self-medicating with alcohol.
What treatment strategies are there for major depression?
Question from audience: “When someone is in a residential facility do we have leverage to
force care on those residents who don’t want to take medicine or go to therapy?”
So your question is when we’re in a position to recommend treatment and for those that
don’t want to participate do we have some leverage? That’s a very good question.
We need to remember that most people with depression don’t recognize that they have a
problem and resist what we have to offer. They lose hope in everything! I say to my families
and patients- “Try this medication and come to therapy for at least six-months”. “If it
doesn’t work we’ll work together to see if there is anything that has to be adjusted or
changed.” “Give me one shot.” We need to appeal to hope in our patients.
There are laws in New Jersey (and in some other states) that can force a person to comply
with treatment.
1. Go to court for guardianship if someone is deemed incompetent by a physician or
psychiatrist...if the person does not have the the cognitive capabilities to take care of him
or herself.
2. There are mental health laws for treatable mental illness and when someone is a danger
to self or others. Then a judge can order an individual into a hospital. The person would be
evaluated within 30 days again while still on the unit in the hospital. A patient does have
constitutional rights to say no to treatment. If a patient is committed to a psychiatric
hospital then they can give them medication as prescribed by the treating psychiatrist.
How many of you have heard of Dr. Kevorkian? Well he’s in jail! It was bad practice and
the courts stopped him from his practices. There was an assumption that people wanted to
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be helped to die. We now know that depression is normal in terminal illness but it can be
treated. It’s very complicated. I’m not against advance directives but euthanasia is a
different concept. We must be careful again to not base our policy decisions on what we
assume it’s like to be an older adult. It’s based on fundamental misconceived assumptions
that there are no alternatives and no treatments for Major Depression.
I’ve had cases where the family says to me, “Don’t force happiness onto my parent”...and
I’ve threatened lawsuits because you can’t abandon and neglect older adults. They can
have a decent quality of life even if they’re sick.
There’s treatment available for major depression. When they have 5 symptoms of the 9
then we are obligated to treat them. There are ethics in medicine. Major depression does
not get better by itself. It is extremely rare for that to happen and if it does, I question if it
really was major depression.
Treatment for major depression greatly enhances an elderly person’s level of functioning
and there is usually rapid progress. If it’s a physical illness then it will not respond to antidepressants. You’ll actually have adverse medical outcomes, the physical illness will
worsen. For example, if it’s arthritis, hypertension (high blood
pressure) or Chronic Obstructive Pulmonary Disease (COPD) also called Emphysema for a
more familiar medical term. The other common COPD is chronic bronchitis.
The goals of treatment for major depression are as follows:
* Decrease and alleviate symptoms of major depression
*The alleviating of symptoms will in turn improve the person’s coping skills.
*Give them a better perspective,
more focused, better problem solving and overall deal with life better.
* Improved psycho-social functioning
*Prevent recurrences of major depression because each time they fall back
into major depression the more difficult it is to pull themselves out of it again.
A moment ago I spoke about COPD. There is some data from a study that I’d like to tell
you about. There were a group of patients who had a fear of suffocation that often occurs
when COPD is present. So half of the people were given a placebo and the other half was
given a tricyclic antidepressant called Nortriptyline (the brand names are Pamelor or
Aventyl Hydrochloride). At the end of the six-week study 25% of the patients who took the
placebo still had fears of suffocation and for those who took the antidepressant it went
down to 15%, which is a significant drop.
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So again we have an example of how major depression can mimic physical illnesses. If the
patients without true major depressive syndrome take an antidepressant, typically nothing
will happen.
In another study for patients diagnosed with terminal breast cancer and all seeing
Oncologists, were divided into two groups. One group only saw their Oncologists and
received their normal treatments. The second group continued to see their Oncologists and
also received psychotherapy but no antidepressants. At the end of eight weeks those who
had psychotherapy had less symptoms of major depression, less pain, required less pain
medication and less doctor’s visits and appeared to be enjoying a higher quality of life.
So even with just psychotherapy major depression can improve. Though, psychotherapy
and antidepressants combined are even more effective in treating major depression.
There is a small group of people who complain about having depressive symptoms but they
don’t have major depression.
There was a book that was published entitled “Listening to Prozac”. Those who took
Prozac had better results. If you see depressive symptoms it could explain a person’s lower
functioning. You may see depression in a less aggressive form and medication may not help
this type of syndrome. However, we must also guard against not giving a diagnosis of
major depression and for if we do not give that diagnosis, the patient will not get proper
treatment. Remember when the elderly are depressed and also sick they are less likely to be
diagnosed with major depression. Those who are 61 years old to 69 years of age and
healthy are more likely to be seen as having a good reason to be diagnosed for major
depression...the older and sicker they become, the less likely they are be diagnosed with
major depression.
You can have a person who is diagnosed with cancer and you tell them that with a new
treatment they have a one in a million chance of being cured and maybe they’ll have an
extra year of a quality of life, they’ll try it. However, if you tell them that if their major
depression will be treated they’ll have a better quality of life they
become reluctant. People can be resistant to treatment with this illness.
So now you’ve done your evaluation and this elderly adult has major depression. What
interventions are safe and effective?
One – you can’t just rely on the information you receive from the patient when you are
conducting the evaluation. You need information from collaborators i.e. the nurse, a family
member. The patient and the family member can both be right.
The patient’s self-observation as important as the daughter who describes her mother’s
behaviors and they can in fact disagree.
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Another reminder, you have the results of the patient's physical exam and you’ve already
looked at all the risk factors then you also need to look at medication interactions. Have
you looked at whether hypothyroidism is a cause or does it look like major depression?
Philosophically this can be good- but once you have a diagnosis of major depression who
cares?
The DSM tries to get us away from causes- One, we don’t know because there could be a lot
of factors and two, treatment doesn’t care. Major depression is aggressive and persistent
and treatment will make a difference.
So here are some treatment strategies that can be used.
We have psychotherapy; we have social approaches where we help them remain connected
to the facility they are at and the people; medications; partial hospitalization where they
can go during the day and get psycho-social therapy and medication management; and
hospitalization where they can get a thorough treatment and a good crack at finding the
right medicine.
We need to educate the patient and their family about major depression.
*What is it?
*Is it treatable?
*What can the family and patient expect with treatment?
*How do we treat depression?
We tell them that major depression is persistent and let them know that treatment takes
time. An instant cure never happens! I tell them that if the patient adheres to treatment it
will take a minimum time of four to twelve weeks to see some results from medication and
psychotherapy, and additional treatments.
We need to educate them about common side-effects of medication. It is the top reason that
people stop taking their medications.
We need to keep the patient and their family focused and engaged in the treatment, because
it takes time.
Psychotherapy has been shown to help patients be more compliant with their medicine too.
We have to keep them engaged by telling them not to lose faith. Be clear about what you’re
trying to accomplish with treatment.
Use good eye contact to express your concern.
I often use the medical model as an example of why they need to take their medicine. For
example- If you had hypertension, would you stop taking your blood pressure medicine?
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No you wouldn’t stop taking your anti-hypertensive medicine! Stick with it! Trust me!
You’ll get better! Step in and say that you do care! I want to help you understand major
depression. I want you to get better and make good decisions for yourself.
Maintain weekly contact with the patient. Individualize your approach to the patient's
major depression, so each treatment needs to be unique. People have different lifestyles,
different levels of support and encouragement. Be open to their
questions.
Ask them questions. For example:
*How are you sleeping?
*Are you eating?
*What’s your activity level like?
*Are you socializing at all?
Psychotherapy alone has not yielded many studies in terms of its effects with major
depression. It does help to alter cognitive patterns and build emotional/coping skills for
those with major depression. Also there is research being conducted on mild to moderate
forms of depression.
Remember that the physiology of major depression is similar to the brain changes that we
see in dementia. In moderate to severe depression research has shown that if you combine
psychotherapy with medication, keep them in treatment and not just pop pills the drop-out
rate is cut in half.
Milieu therapy in a day center is good at treating mild to moderate depression. Group
therapy with older adults has been shown to be effective. They can solve psychosocial issues
and come up with solutions. Part of it can be reminiscence therapy.
*Remember when?
*What was your experience of ______?
*What did you do back then to solve your problem? In the past what helped?
This is good stuff.
Enhancing their physical health with aggressive physical training and weight lifting helps
with major depression. Good nutrition is important.
Question from audience: How hard do you push them to get them out of their rooms to
activities programs?
Dr. G: When NO becomes, emphatic the relationship will suffer because they really don’t
want to do anything. Depression is an illness; so respect it as you would any other illness.
Don’t push someone to the point where it becomes degrading or you’re abusing them.
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Other issues to consider include:
*Pharmacotherapy along with therapy works!
*Which antidepressants do we choose to use?
*Are they in the formulary of their insurance? This needs to be looked at.
More importantly will it help?
*What are the risks of the medications prescribed?
Antidepressants are effective but remember the side effects are tolerated half as well in
older adults than in younger adults. So with older adults you want to look at the
medication’s safety. Can it be tolerated by the older adult? Efficacy of dosing- Extended
release tablets can be better so that they only have to take it once or twice a day, rather
than four times a day. You want to keep the medication regimen uncomplicated.
They’ve done six-week studies of tricyclic (TCA) antidepressants and they were taken once
a day and their effects were predictable and they’re less expensive. They have limitations
though- they can cause:
*fainting from orthostatic hypotension,
*constipation,
*tachycardia (high heart rate),
*urinary retention,
*dry mouth,
*cognitive impairment
*sedation.
So for older adults this should not be your first line of treatment. Only if they’ve failed to
get better with other types of antidepressants. Unless they have medical problems that
would be exacerbated by the TCA’s. If you absolutely have to prescribe TCA’s the two with
the lowest side effects are Nortriptyline (Pamelor) or
Desipramine (Norpramin). Amitryptiline (Elavil) has been shown to be very effective for
pain management.
There are antidepressants that work on Serotonin which is also a neurotransmitter which
helps the brain communicate. Citalopram (Celexa) is one of Selective Serotonin Reuptake
Inhibitors (SSRI). Some of the SSRI’s can also assist with the sleep disturbances that are
common with major depression and sleeping pills and
anti-anxiety medications don’t help with sleep. For example Desyrel (Trazadone) can be
used to assist with sleep.
Luvox (Fluvoxamine) is good for Obsessive Compulsive Disorder. Serzone (Nefazadone)
has improved tolerance, low anticholinergic (dry mouth) side effects and can be taken once
a day. There is more safety because it’s hard to overdose on. It can produce fatigue, nausea
and some anorexia.
15
Prozac, when it first came on the market, Newsweek magazine said it was a miracle. With
the elderly within 48 hours they were in the hospital. With older adults, start at smaller
doses such as 20 mg and see how they tolerate it. Prozac can cause sexual dysfunction in
younger adults and lower the heart rate.
What other drugs can SSRI’s interact with. SSRI’s create what’s called the P450 liver
enzyme which can get rid of other drugs and can lower other drugs effectiveness in older
adults. Celexa is 5th safer for low drug interaction. Zoloft is second best.
Serzone and Trazadone can assist with sleep but may create cognitive problems and
Serzone can cause liver damage with long-term use. So there is a need to do liver tests if the
patient is taking Serzone. These two drugs need titration and are typically taken twice a
day.
Monoamine oxidase inhibitor (MAOI’s) are particularly effective in treating atypical
depression. They’re the last line of defense when other medications won’t work. They have
also been shown to be effective with agitated major depression. Though the patient has to
be very careful with their diet because aged cheese,
chocolate, aged wines can cause a hypertensive reaction. So food interactions are a primary
concern and therefore they have to follow a very strict diet. This class of drugs was
originally marketed as an anti-hypertensive.
Wellbutrin (Buproprion) is an antidepressant in which scientists are not quite sure what
brain chemicals it works on. It is also marketed as Zyban which assists people in stopping
cigarette smoking. Some people can get agitated and get headaches from Wellbutrin. It
does come in Extended Release which can assist in reducing these side effects.
There are some medications that act on both serotonin and norepinephrine. Effexor
(Venlafaxine) can sometimes cause headache and agitation just like Wellbutrin. Remeron
(Mirtazepine) has difficult side effects profile. Some people can feel sick though not
generally. It can also cause sedation. With older adults who are
not eating because of major depression, Remeron can increase appetite and help them gain
weight.
This can be a big problem for younger adults who want to stay thin. There is an average
weight gain of 12-15 pounds. If you do prescribe it to an older adult you need an adequate
trial period and go slowly to full course of treatment. They may not need maximum dosage.
Higher doses depends on antidepressant but also be careful not to undercut older adults.
Start dosing slowly and monitor the side effects, suicidality and drug interactions.
You need to assess completely for TCA’s and can do blood levels to make sure they’re not
too high. Review the treatment with the family. If you are using antianxiety and TCA’s and
16
you fail to monitor and educate everyone, they may discontinue too soon or decide not to
take enough of the medication.
Six out of ten times with the first antidepressant you will need to adjust the dose and
probably times it’s taken. You may also have to try a different agent. You may also need to
try an augmentation combination therapy to the antidepressant. You may add ativan,
xanax, buspar, an antipsychotic such as resperidol, Haldol, Zyprexa or
Mellaril. Especially if they have psychotic symptoms.
Lithium is used for bipolar disorders. Anticonvulsants such as Depakote and Tegritol can
be combined with two antidepressants such as a TCA, SSRI or Wellbutrin.
All treatment modalities come with their risks and benefits. Some patients say, "No, I’ll be
worse". This is where education comes in again. What are the alternatives? There are
natural plant substances such as St. John’s Wart-which by the way is dangerous if mixed
with a MAOI. There is kava-kava and acupuncture. I also agree with the assertion to
include a bio-psychosocial approach.
How do we measure quality care of those residents? Do we have to flounder when we face
major depression?
Does the primary care physician have insight into major depression and do they quickly
give an immediate fix rather than work through the problem? There are some clients who
can grapple with a problem and others who can’t.
You need a strategy for getting a program going at your facility?
How do you screen potential providers at your facility?
How do you structure your relationship with providers?
Do you develop a multi-discipline team?
How do you define the team?
Facilities need to set up systems to assist a psychiatrist.
Facilities can set up a chart for medical illness but not for mental health.
Who pays for treatment?
Is there a consultation fee for the service and do they then bill patient
through Medicaid?
Does the facility contract for time?
When the facility can define terms of work/salary set it can control situation better.
There can be quality control, documenting codes and facility could be more satisfied with
the relationship.
17
I sometimes get cooperation from nursing homes. The administrative nursing and their
follow-through can vary. I train people in mental health and still resistance can come from
anywhere. The training needs to be global and comprehensive. Remember the residents
need to be on a dose of medication that works to prevent recurrence and
Once they are better, they need to stay on same dose.
Now I want to talk about Electro Convulsive Therapy (ECT) and why it works. It is
spectacular how it works.
The physiology of electrical currents is analogous to how electrical currents work in the
cardio version. The process is identical- neurons all off/all on after electrical current. We’re
not sure why a seizure works better than medications for those that don’t respond to any
medications. The side effects are nominal and it is safe and side effects are rarely
permanent. There are initially some problems with short-term memory and some
disorientation.
Often, it appears terrifying but it is safe. During the procedure, there is an anesthetist
present. In addition there are two nurses and the psychiatrist standing by. It is effective
with psychosis that accompanies major depression. The bottom line is finding and
administering the dose that gets the patient well, keeps the patient well.
What do you do to keep the patient well for one year?
A study showed that if you give a medication (Pamelor), a placebo, psychotherapy or
nothing for one-year the results showed:
* 75% to 85% with just medication did fine.
* Psychotherapy free, 4 out of 5 do well
* With psycho therapy, 50% do well or 1 out of 2.
*Nothing done, 4 out of 5 times remain sick with major depressive
symptoms.
Medication needs to be given for at least one year and if they are well after one year they
are less likely to get sick again. If you cut back on the dose at the beginning of the second
year and the major depressive symptoms return, you need to begin the full treatment again.
So if you started with Zoloft and it continues to work, stick with it.
We also see that if we stop ECT after one year sometimes the patient becomes sick again
with major depression. So after the completion of ECT, try medication and psychotherapy
again. However, if the patient still doesn’t respond then you need to do maintenance one,
two, three or once a month (according to your evaluation of the patient's needs). Women
18
needed ECT every two weeks for best results and we don’t know why. The electrical
currents are measured in Jewels and the maximum in ECT is 400 Jewels a bit less than
cardiac shock. It’s not enough to get electrocuted and the duration is two seconds.
So this is the end of my time today. I hope you come away having learned something
(applause).
General considerations in the use of medication in older adults*
*Source: Home Study 031 (P), Author: Dr. David Greenspan
Older adults have unique considerations whenever medications are prescribed. Many
younger patients can be treated, more or less, alike. For older adults, however,
individualized considerations of medication choice, dosing and side effect profile is
substantial. This is due to the fact that older adults start with their genetic differences that
are greatly magnified by their life history of habit, exposure and illness. So the first ‘rule of
thumb’ when treating older adults for any condition is to be more careful and thorough in
the initial evaluation.
The second ‘rule of thumb’ is to recognize that the aged are more vulnerable to the impact
of side effects. Perhaps the most useful definition of ‘aging’ is the ‘reduced ability to adapt
to stress’. The ‘older’ a person is (other than chronologically), the more difficult to
successfully cope with an untoward event. So, if a 28 year old has a loss of blood pressure
due to a medication side effect and falls over, they are most likely to get back up with a few
scrapes or bruises. The 78 year old with the same loss of blood pressure causing the same
fall may not get up at all and surgery for a hip fracture may be necessary. Same side effect,
but the coping with that stress is quite different and age dependent.
The third ‘rule of thumb’ is that the bodies of older adults cause them to collect medication
in their tissue, excreting and deactivating them at a slower rate than younger patients.
Therefore, any dose of medication is more likely to be ‘felt’ more vigorously, especially
when it comes to having side effects.
The fourth ‘rule of thumb’ is that older adults tend to be on many medications at the same
time. Drug/Drug interactions will be more common. Moreover, the interaction of multiple
medications in a single patient will not have been studied. It is not reasonable to assume
that what is known about any two medications will hold true if 5-10 are used at the same
time. Thus, special caution is in order.
Taken together, considering a medication approach should always be considered carefully.
A complete evaluation must always precede the use of any new medication. Careful
tracking for efficacy is required so that ineffective medication can be tapered and
discontinued. Moreover, the general approach of “Start low and go slow” should be
applied. Start low implies selecting a low dose to initiate any psychopharmacologic
19
treatment. Go slow means to take ones time with the gradual titration of the medication up
to an effective treatment dose or down when discontinuing medication unless it is urgent to
do so. Rapid changes of medication should best be done in a hospital setting. Finally, if at
all possible, stop medication as often as new ones are started. Polypharmacy, the ordering
of multiple medications, cannot be avoided, but it can and should be minimized.
Major Depression* *Source: Home Study:031(P). Author: Dr. David Greenspan
Major Depression is, perhaps, the most important psychiatric disorder in the long term
care setting. It is not the most common…but it is the most frequent, highly treatable
condition that is associated with high degrees of morbidity, mortality, individual suffering
and therefore diminished quality of life. Moreover, depression is easily overlooked as being
an expected if not acceptable part of life in a long term care facility. This prejudice
contributes to an inadequacy of detection and treatment of the disorder
.
Research has demonstrated that major depression causes as great a degree of disability as
stroke, diabetes or COPD. Moreover, major depression is associated with a significant
increase in mortality due to 3 causes the least of which is suicide, a catastrophic event in
any setting. The 2 most common causes of increased death among patients with depression
are cardiovascular and cerebral vascular where both heart attacks and strokes are known
to occur with greater likelihood in patients with depression compared to those without
depression. This increased likelihood of death or disability due to heart attack and stroke
can go as much as 5 times higher in some circumstances. Moreover, the use of medical
resources for all other causes is enhanced with patients who have major depression. The
cause of the general malaise, discomfort, the pessimism and perplexity that is often
associated with an increased demand for medical attention is frequently due to depression
complicating another illness. Moreover, depression impairs patient’s attention to their
nutrition, hygiene, activity level and socialization all of which are protective of many other
physical health problems. Their pessimism and irritability often contribute to both reduced
patient compliance and staff attention as well. Thus the impact of major depression goes
well beyond the individual who suffers with the primary disorder but will impact on the
costs of their general maintenance, the quality of life for their peers, and most importantly
for family and staff that are making efforts to care for them.
Major Depression Diagnosis* Source: Home Study:031(P). Author: Dr. David Greenspan
The hallmark of major depression is either sadness or a loss of interest with associated
pleasure most of the day nearly every day that goes on for at least two weeks. Many older
adults, perhaps as many as 1/3 who suffer from major depression will not report sad mood.
Thus a reliance on the constellation of signs and symptoms as identified in the DSM is
critical for making this diagnosis.
20
DSM IV Major Depressive Episode
5 or more including 1 or 2 for at least 2 weeks

1) Depressed mood

2) Loss of pleasure or interest

Anorexia/hyperphagia

Insomnia/hypersomnia

Psychomotor agitation/retardation

Fatigue or loss of energy

Feelings of worthlessness or guilt

Reduced concentration/indecisiveness

Thoughts of death/suicidal ideation
Not bereavement
Other significant signs and symptoms include difficulties with sleep and appetite, motor
restlessness or slowing, confusion, inattention and memory complaints, a lack of energy or
a weakness, feelings of guilt, or perception of being a significant burden. Major depression
is often associated with a wish to die or the desire to commit suicide.
Many older adults will not or can not describe some of the many features associated with
depression as noted above. Additionally, there are numerous illnesses both chronic and
acute seen frequently with older adults which can contribute too many of the signs and
symptoms as described here. These include dementia, cancer, coronary artery disease,
stroke, diabetes, COPD to name just a few. Efforts have been made to better understand
the relationship of these varied co-morbid disorders and how they impact on the diagnosis
depression. For instance, it is known that patients with cancer often complain of being
weak, sad about the future and lose their appetite, all associated with Major depression as
well. Can these concerns be relied upon to help with a depression diagnosis or should they
be ‘ignored’ or ‘only counted if out of proportion to the expectation from the cancer alone’?
Despite the possibility for confusion, the general rule of thumb, is that if the constellation of
signs and symptoms are identified irrespective of other possible contributors then major
depression can and should be diagnosed and treated for benefit from such treatment will
justify the intervention. So, for example, a patient with cancer, who has the symptoms of
depression with sadness, poor appetite and energy along with two other characteristic signs
or symptoms for at least two weeks should receive treatment for depression. Studies show
over and over again that treatment of this depression with cancer will contribute
significantly to an improved mood and outlook, enhanced energy, diminished discomfort,
improved sleep and appetite and overall improved quality of life. These treated cancer
patients have a greater success in dealing with all aspects of the cancer, its treatment and
the inevitable terminal phase of life.
Despite the simplicity of the DSM approach to diagnosis, many older adults will not have
the words as the DSM provides for them to identify the signs and symptoms of major
21
depression. Moreover, they may not have either the ability nor the willingness to
acknowledge the symptoms. Thus the diagnosis of depression can be more difficult in the
context of patients with dementia or aphasia which interferes with communication. Or,
they may not want to acknowledge changes fearing that they ‘complain’ too much or are
already too much the burden. Or they may expect depressive symptoms such as feeling
weak, anxious, worried, or sleepless as an expected part of being ill in the nursing home
and so not describe them as ‘a problem’. Cultural differences and expectations can also
play a significant role in altering the communication that we so desperately rely on for
making a diagnosis. There is no biologically objective test for major depression, a diagnosis
which is made strictly on observation and patient reports.
Grief and Depression* Source: Home Study:031(P). Author: Dr. David Greenspan
Perhaps the most confusing aspect of the diagnosis of Major depression is its confusion
with grief or mourning. Being in a long term care facility is always associated with
significant loss. This may be the loss of a loved one, health and vigor, financial
independence and security, a home of many years, autonomous choice, privacy, connection
with friends and family, and the ability to determine one’s own future. Grief is usually
associated with many of the symptoms of depression. The disruption of moving into a
nursing home is so commonly associated with a grief reaction that it is typically expected
during the first few weeks after admission. Research is attempting to clarify the
relationship between grief and depression. However, a few things are very clear. 1) major
depression and grief differ to the extent that patients with depression are much more likely
to commit suicide. 2) Though grief can go on for many months, it is not usually thought of
as debilitating enough to require regular assistance as Major depression can. 3) The
circumstances of grieving can often trigger a Major depressive episode and so should be
addressed proactively. And finally 4) the treatments for depression may be effective at
diminishing the pain of the grieving process without interfering with it.
Major depression usually occurs in the context of one of two primary disorders of mood
either bipolar affective disorder which usually has its onset in early life or major depressive
disorder. Both of these are considered chronic conditions with symptomatic exacerbations
i.e. major depressive episodes. Thus, major depressive disorder and/or bipolar disorder are
more like asthma or diabetes. The illness can be controlled but is never fully ‘cured’. And
like asthma or diabetes, without constant attention exacerbations will occur. Sometimes,
these will need hospitalization. Research has demonstrated that the likelihood of recurrence
of major depression episodes after remission of a previous episode is extremely likely in the
first 6 to 12 months if treatment is discontinued prematurely. Moreover, for patients who
have had multiple episodes of depression, maintenance treatment should be considered life
long. Thus appropriate standards for the ongoing use of antidepressant medication after
symptoms of depression have resolved suggests a minimum of 6 to 12 months of full dose
active treatment following complete remission i.e. when symptoms of depression are no
longer evident and the patient appears well. For patients who have had multiple episodes
22
in their past, full dose treatment with antidepressant medication should continue
indefinitely without dose reduction trials.
Commonly Prescribed Antidepressants* Source: Home Study:031(P). Author: Dr.
David Greenspan
Medication
Anticholinergic Sedation Hypotension Stimulating GI
Fluoxetine/ Prozac 0
(*)
Paroxetine/ Paxil 0
(a) (*)
Sertraline/ Zoloft 0
Citalopram/ Celexa 0
Escitalopram/
0
Lexapro
Nortriptyline/
++
Pamelor (b)
Desipramine/
++
Norpramine (b)
Venlafaxine/
0
Effexor (c)
Buproprion/
0
Wellbutrin (d)
Mirtazepine/
0
Remeron (e)
Phenelzine/ Nardil 0
(f)(*)
Tranylcypromine/ 0
Parnate (f)(*)
0
0
+
+
Daily
Dose
Range
5-80mg
0
0
0
+
10-50mg
0
0
0
0
0
0
0
0
0
+
+
+
25-200mg
10-40mg
10-20mg
++
+
0
0
25-100mg
+
+
+
0
25-300mg
0
0
+
+
75-375mg
0
0
++
0
++
0
0
(e)
100-400m
g
7.5-45mg
0
++
0
0
15-90mg
0
0
++
0
10-50mg
0 Rare, + Uncommon or mild, ++ sometimes or moderate, +++ frequent or severe.
a) Significant withdrawal syndrome in some individuals
b) Need to monitor blood levels and EKG for possible heart block.
c) Increase in systolic blood pressure reported
d) Seizures at higher doses. Insomnia due to its stimulating side effects.
e) Increased appetite and weight gain.
f) Requires MAOi diet to prevent malignant hypertension. Restrictions on other
medications.
(*) Special caution with drug/drug interactions
Depression* Source: Home Study:031(P). Author: Dr. David Greenspan
23
The pharmacotherapy of major depression has already been reviewed previously.
Diagnosis of depression can be difficult but sleep and appetite changes, motor restlessness,
gloomy and fixed or hostile/irritable mood, and withdrawal from self care and activity
should all raise the suspicion of the disorder. It should be said here that the treatment of
depression in the context of Alzheimer’s disease or multi-infarct dementia is no different
than idiopathic depressive illness. Response rates are probably not as high. Side effect of
worsening cognitive function is to be monitored carefully. The dosing should not be
different and the role of ECT is as important here as it is in major depression at any time.
Concerns about cognition in ECT or brain damage and ECT have been studied carefully.
ECT has been shown to be safe and effective usually improving cognitive function as it
diminishes the agitation and depression.
GUIDANCE TO SURVEYORS* Source: Home Study:031(P). Author: Dr. David
Greenspan
TAG F-329
(l) Unnecessary drugs.
(1) General. Each resident's drug regimen must be free from unnecessary drugs. An
unnecessary drug is any drug when used:
G. Antidepressant Drugs
The under diagnosis and under treatment of depression in nursing homes has been
documented in a Journal of the American Medical Association paper entitled "Depression
and Mortality in the Nursing Home" (JAMA, February 27, l991-vol. 265, No. 8). HCFA
continues to support the accurate identification and treatment of depression in nursing
homes.
The following is a list of commonly used antidepressant drugs:
Antidepressant Drugs
Generic Name Brand Name
Amitriptyline* (Elavil)
Amoxapine (Asendin)
Desipramine (Norpramin, Pertofrane)
Doxepin* (Sinequan)
Imipramine* (Tofranil)
Maprotiline (Ludiomil)
Nortriptyline (Aventyl, Pamelor)
Protriptyline (Vivactil)
Trimipramine* (Surmontil)
Fluoxetine (Prozac)
Sertraline (Zoloft)
Trazodone (Desyrel)
Clomipramine* (Anafranil)
Paroxetine (Paxil)
Bupropion (Wellbutrin)
24
Isocarboxazid* (Marplan)
Phenelzine* (Nardil)
Tranylcypromine* (Parnate)
Venlafaxine (Effexor)
Nefazodone (Serzone)
Fluvoxamine (Luvox)
* These are not necessarily drugs of choice for depression in the elderly. They are listed
here only in the event of their potential use.
Consider drug therapy "unnecessary" only after determining that the facility's use of the
drug is:
o In excessive dose (including duplicate drug therapy);
o For excessive duration;
o Without adequate monitoring;
o Without adequate indications of use;
o In the presence of adverse consequences which indicate the dose should be reduced or
discontinued; or
o Any combination of the reasons above.
Allow the facility the opportunity to provide a rationale for the use of drugs prescribed
outside the preceding Guidelines. The facility may not justify the use of a drug prescribed
outside the proceeding Guidelines solely on the basis of "the doctor ordered it." This
justification would render the regulation meaningless. The rationale must be based on
sound risk-benefit analysis of the resident's symptoms and potential adverse effects of the
drug.
Examples of evidence that would support a justification of why a drug is being used outside
these Guidelines but in the best interests of the resident may include, but are not limited to:
o A physician’s note indicating for example, that the dosage, duration, indication, and
monitoring are clinically appropriate, and the reasons why they are clinically appropriate;
this note should demonstrate that the physician has carefully considered the risk/benefit to
the resident in using drugs outside the Guidelines.
o A medical or psychiatric consultation or evaluation (e.g., Geriatric Depression Scale) that
confirms the physician’s judgment that use of a drug outside the Guidelines is in the best
interest of the resident.
o Physician, nursing, or other health professional documentation indicating that the
resident is being monitored for adverse consequences or complications of the drug therapy;
o Documentation confirming that previous attempts at dosage reduction have been
unsuccessful;
o Documentation (including MDS documentation) showing resident's subjective or
objective improvement, or maintenance of function while taking the medication;
o Documentation showing that a resident's decline or deterioration is evaluated by the
interdisciplinary team to determine whether a particular drug, or a particular dose, or
duration of therapy, may be the cause;
o Documentation showing why the resident's age, weight, or other factors would require a
25
unique drug dose or drug duration, indication, monitoring; and
o Other evidence the survey team may deem appropriate.
If the survey team determines that there is a deficiency in the use of anti-psychotics, cite the
facility under either the "unnecessary drug" regulation or the "anti-psychotic drug"
regulation, but not both.
NOTE: The unnecessary drug criterion of "adequate indications for use" does not simply
mean that the physician's order must include a reason for using the drug (although such
order writing is encouraged). It means that the resident lacks a valid clinical reason for use
of the drug as evidenced by the survey team's evaluation of some, but not necessarily all, of
the following: resident assessment, plan of care, reports of significant change, progress
notes, laboratory reports, professional consults, drug orders, observation and interview of
the resident, and other information.
GERIATRIC DEPRESSION: * Source Clinical Practice Guidelines No. 5
Depression in Primary Care: Volume 2 Treatment Of Major Depression;
US Department of Health and Human Services, April 1993
Guideline: Depression in the elderly should not routinely be ascribed to demoralzation or
“normal sadness” over financial barriers, medical problems or other concerns. The
general principles for treatment of adults with major depressive disorder apply as ell to
elderly patients.
CONFOUNDS IN THE DIAGNOSIS AND TREATMENT OF DEPRESSION IN THE
ELDERLY
A. Concurrent non-psychotropic medications may
Cause depression
Change antidepressant blood levels
Increase antidepressant side effects
Biochemically block antidepressant effects
Call for modifying the oral dosage
B. Concurrent medical illnesses may:
Cause depression biologically
Reduce the efficacy of antidepressant medications or psychotherapy
Change antidepressant drug metabolism
Impair the ability to participate in psychotherapy
Create disability contributing to both chronicity and reduced treatment
efficacy
Increase the need for simplified medication dosing schedules (e. g. once daily)
C. Concurrent nonmood psychiatric conditions may:
Cause depression (e.g. early Alzheimer’s)
26
Call for different medications
Impair participation in psychotherapy
Reduce response to antidepressant medications (e. g. personality disorders)
Worsen prognosis of depression (e. g. alcoholism)
D. Other Issues
Slower metabolism with age often requires lower dosages
Transportation difficulties may restrict access to care
Increased interview time needed
Fix income may availability of therapy and nongeneric antidepressant
medications due to cost
Editor’s note: insurance coverage also may limit options for treatment, medications and
psychotherapy availability of psychiatrists in facilities may also limit diagnosis and
treatment of depression in the elderly who are institutionalized
For additional readings on Depression in the Elderly, we have listed other sources:
Geriatric Depression, Jason Guthrie, Geriatric depression is a serious concern facing many
communities in both the outpatient and nursing home settings.
www.ncrhp.uic.edu/copcprojects/2003
Yesavage Geriatric Depression Scale www.fbhc.org/Patients/Interactive/gDepression.cfm
Depression 101 Now www.JustAnswer.com/Health
Lumetra- Geriatric Scale (GDS) 2 page tool helps determine depression in a resident. The
tool contains a short questionnaire and a scoring system. www.lumetra.com/resourcecenter/index.aspx?id=844
Clinical Toolbox: Geriatric Depression Scale; Instrument for evaluating depression in the
elderly when there is a clinical suspicion of depression in elderly when there is a clinical
suspicion of depression or positive response to a screening question.
www.hospitalmedicine.org/geriresource/toolbox/geriatric_depression_scal.htm
3/5/08
Geriatric Depression Treatment: Recent research on depression of older adults
www.torontodrugtreatmentcourt.ca/geriatric-depression-treatment.php
Geriatric Depression Treatment in Nonresponders to Selective Serotonin
www.psychiatrist.com/abstracts/200412/120406.htm 3/5/2008
Diagnosis and Treatment of Depression in Late Life, NIH Consensus Statement Online
1991 No 4-4 (1991 11 4-6); 9(3): 1-27…although it is an old article it is very comprehensive
and still relevant.
27