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Impact Manual

Impact Manual

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  • 1. Making an IMPACT on Late Life Depression Working with Your Health Care Team
  • 2. IMPACT Patient Brochure What is Depression?Depression is a medical condition that affects a person’s mood, thoughts, behaviorand body. It is more than the temporary sadness people normally feel whenunpleasant or stressful things happen in their lives. Everyone sometimes feels sad,blue or edgy for awhile. But when a person has depression, these feelings are moreintense and long lasting. Things that used to be easy or enjoyable, like spendingtime with family or friends, take great effort. And there are often physicalproblems like appetite loss, sleeplessness and extra aches and pains.As many as 15% of older adults may suffer from depression. In later life, peopleface many losses and physical discomforts. They may mistakenly assume thatdepression is a normal part of aging and never realize they have an illness that canbe treated. Many people also fear that their depression is somehow their fault.They think it is due to weakness or a character flaw.The truth is depression is a medical problem. It has to do with an imbalance inbrain chemicals called neurotransmitters. Life stresses, hereditary factors andmedical problems can lead to a change in levels of these normal chemicals in thebrain. This chemical change leads to some of the common symptoms ofdepression, like depressed mood, sleep and appetite problems, loss of energy,trouble concentrating and pain. Physical symptoms and negative thoughts makepeople feel like withdrawing and deepen their depressed mood. All of thesefactors can worsen each other in an ever-deepening cycle of depression. The goodnews is depression is NOT a natural part of aging and you CAN get better. 2
  • 3. IMPACT Patient Brochure How Can my Doctor Help?At first it may seem odd to talk to a medical person, like your doctor or primarycare provider about depression symptoms. You may think that it doesn’t makesense to bring up emotional problems at a medical visit, where you need to focuson physical problems. But remember that depression is a medical condition relatedto brain chemistry.You should also know that many of the symptoms of depression are physical. Lowenergy, changes in appetite, sleep problems, and pain (such as headaches andstomach pain) are among the physical symptoms some people have. Problemswith memory and concentration can seem like “senility” or Alzheimer’s disease,but may be due to depression. Also, many of the chronic illnesses common inolder adults can cause depression. These include heart problems, stroke, diabetes,Alzheimer’s disease, arthritis, Parkinson’s disease and cancer. Medications used totreat illnesses common in older persons can also cause depression. Somemedicines for arthritis, high blood pressure, heart disease and menopause, forexample, can cause or worsen depression. For all of these reasons, it makes a lotof sense to talk to a medical professional about depression.Medical doctors are trained in depression diagnosis and treatment. But your doctorneeds to know about your symptoms in order to choose the best treatment for you.Tell your doctor how you are feeling. And ask questions. Keep a list of thequestions you want to ask, and bring it to your next visit.As a participant in Project IMPACT you also have access to another health careprofessional, your Depression Clinical Specialist. Your Depression ClinicalSpecialist and your doctor work together as a team to make sure you get the bestpossible care for your depression. They can also call on additional members of thehealth care team, including other mental health specialists, to help with anyproblems that may come up. We encourage you to contact your DepressionClinical Specialist any time you have questions about the project or about yourdepression.Depression Clinical Specialist: _______________________________________Phone Number: ____________________________________________________ 3
  • 4. IMPACT Patient Brochure What are the Symptoms of Depression?Many different symptoms can be part of depression, and they may be mild,moderate or severe. Different people are affected in different ways. While oneperson may sleep and eat more than usual, another may have trouble falling asleepand have no appetite at all. One person may feel constantly nervous and jumpy,while another feels like life is in slow motion. Some people have intensesymptoms for weeks or months, sometimes to the point where they cannot get outof bed. Others have less severe symptoms that last for months or even years.People with severe depression may think about dying, or even wish to die.Effective treatment helps people get their energy and hopefulness back.Depression symptoms and problems:• Sad or empty feelings• Loss of interest or pleasure in activities like outings, music, reading or sex• Poor concentration; difficulty thinking, remembering and making decisions• Poor energy• Feelings of worthlessness or guilt• Thoughts of suicide or self-harm• Sleep problems (sleep more OR less than usual)• Appetite/weight change (eat more OR less than usual)• Physical agitation or slowness• Anxiety• Somatic (bodily) symptoms, such as frequent aches and pains or stomach problemsWhen people are feeling depressed they may be more likely to turn to drugs oralcohol for relief. Thus drug and alcohol problems can be related to depression,but their use may actually make depression worse. Depressed people sometimesalso have severe anxiety or panic attacks. Some may have strange feelings, likehaving things seem unreal, or seeing or hearing things that others cannot see orhear. Some depressed people may suffer from a condition called bipolar disorderor manic depression. In this disorder, periods of depression alternate with periodsof being overly excited, high or irritable. 4
  • 5. IMPACT Patient Brochure How Bad is My Depression?Doctors and researchers look at the signs and symptoms of depression listed on theprevious page. Sometimes they will also use a questionnaire that gives a numericscore to figure out how bad your symptoms are. Changes in this score over timecan help show if your treatment is helping, or if changes in your treatment planmay be needed. One questionnaire that can be used to give a score is called thePRIME MD Depression Scale (PHQ-9). Your doctor or Depression ClinicalSpecialist may have you fill out this short questionniare periodically to check onyour depression symptoms.Other “indicators” of depression include how much your social, personal, familyand work activities are affected, how long it’s been since you really felt good, thenumber of days you spent in bed recently (say, over the last month), and thenumber of days you had to cut back on your activities in the last month. Changes inthese indicators over time help tell if your depression is improving, and will helpguide adjustments to your treatment. 5
  • 6. IMPACT Patient Brochure How can Pleasant Activities and Relationships Help Improve Depression?Stresses in your social and work life are often part of the cycle of depression. Themore stress you are dealing with, the more your depression may be triggered. Asthe depression sets in, you may not feel like being around others. You may be lesslikely to take advantage of, or even notice the support you can get fromrelationships with friends and family. As the cycle continues, you may startcutting out pleasant activities and finding yourself more and more depressed.Breaking the cycle is not easy. It can help to notice the stresses in your life, and tomake a list of the relationships and pleasant passtimes you might be able to getback to. For many depressed people, getting better involves purposely planningpleasant activities into their daily routine. Perhaps you can visit yourgrandchildren more often, plan more outings or phone calls with friends, or join asenior center. There may also be pleasant activities you used to enjoy doing byyourself that you can put back into your life. Maybe you enjoy gardening, takingwalks or listening to music. Putting pleasure and support back into your life can bea big help in breaking the cycle of depression.Plans for pleasant activities: 6
  • 7. IMPACT Patient Brochure How Will My Depression Be Treated?Most older adults can benefit greatly from the depression treatments availabletoday. The most common treatments for depression are prescription medicationscalled antidepressants, psychotherapy, or a combination of both. The type oftreatment most appropriate for you depends on the type and severity of yoursymptoms, your experience with any previous treatment for depression, and yourpersonal preferences. Together with your Depression Clinical Specialist and yourdoctor you can choose the treatment that best fits your symptoms and lifestyle. Itusually takes a few weeks to begin to feel better, and full recovery may take a fewmonths of treatment. Though this gradual improvement may cause you to doubtthat treatment is working in the short-run, rest assured that treatment usually leadsto full recovery with a little more time. Once depression has been successfullytreated, it can come back. It is therefore important not to stop your antidepressantmedication or psychotherapy prematurely. It is also important to notice whetheryour symptoms seem to be returning and let your doctor or Depression ClinicalSpecialist know. 7
  • 8. IMPACT Patient Brochure What Will Treatment Be Like?Anti-depressant medications are thought to work by bringing the chemical balancein the brain back to normal. They are especially necessary for treating severedepression, but can also help with milder depression. There are many differentmedications to choose from. These medications are not tranquilizers and theydon’t make you “high.” They are not addictive. They may, however, have somephysical side effects. These can include one or more of the following: dizziness,drowsiness, dry mouth, constipation, weight gain, changes in sexual function,diarrhea, headaches, agitation or nervousness. For most patients side effects aremild. Your body will usually adjust to the medication in a week or two, andsymptoms will pass. It is important not to stop taking the medicine withoutspeaking to your doctor. If the side effects bother you too much, your doctor canusually find another medication for you to try. It may take several tries to find justthe right medicine for you, but it is very likely that you will find it with help fromyour Depression Clinical Specialist and your doctor. Common questions andanswers about antidepressant medications are listed in Appendix A at the end ofthis booklet.Many forms of psychotherapy have been shown to work for treating mild andmoderate depression, and can be used together with medications to treat severedepression. One one these is called Problem Solving Treatment – in Primary Care(PST-PC). This treatment involves six to eight sessions with your DepressionClinical Specialist. During the sessions you identify problems that may be causingor worsening your depression, and plan ways to solve them. As you solveproblems that are creating pain, stress, or negative thoughts in your life, you canbegin to break the cycle of depression. PST-PC is NOT an “insight oriented”therapy in which you spend many months talking about your childhood. It is atreatment focused on practical problem solving. While some people may startfeeling better right away, it can take a few weeks to start noticing improvements.Questions and answers about PST-PC are given in Appendix A at the end of thisbooklet. 8
  • 9. IMPACT Patient Brochure What About Drug Interactions?Older adults often take several different medications regularly for chronicconditions common in later life. These medicines can interact with each other, orwith antidepressant medications that might be added. For this reason it isimportant to make sure your doctor knows about all of the medications you arecurrently taking, both prescription and over-the-counter. This information willhelp your doctor decide which medications can be safely prescribed for you.It is also useful for your doctor to know about herbal remedies you may be trying,such as St. John’s Wort, ginko biloba, and any other homeopathic medicines. 9
  • 10. IMPACT Patient Brochure Why Get Help?Although some people get better from depression naturally, many suffer for weeks,months or even years. Research shows that the right treatment can help you getbetter quickly. But the idea of getting help for depression may be hard to thinkabout, especially if you are feeling hopeless. And family and friends may believeyou should just “snap out of it,” or that anti-depressant medications are “nervepills” that will cover up your problems. It may be hard to overcome these barriersand ask for help. You can share this booklet with family members to help themunderstand what a diagnosis of depression really means, and that effectivetreatment is available. Friends and family members can be helpful partners duringthe process of getting better. They are often the ones who notice that yourdpression is getting better or possibly coming back before you do. There is asection on what family members need to know in Appendix B at the end of thisbooklet that may be very useful to share.Treatment can help free you from the sadness, despair and isolation of depression.No matter how bad you may feel, there is hope. Depression is a treatable medicalillness. Treatment can help you feel better, and return you to a happier morefulfilling life. 10
  • 11. IMPACT Patient Brochure Appendix A:COMMON QUESTIONS ABOUT TREATMENTS FOR DEPRESSIONQuestions about antidepressant medications:1. How do antidepressants work? • Antidepressants help restore the correct balance of certain chemicals called neurotransmitters in critical regions of the brain.2. My problem is inability to sleep. How can an antidepressant help with this? • In many cases, poor sleep is a by-product of a major depression. Once the depression lifts, the sleep improves as well. • Antidepressants can help restore normal sleep, even in people who do not have major depression. They are advantageous over other sleeping pills in that they are not habit-forming, and they usually do not impair concentration or coordination. • Chronic lack of sleep can sometimes lead to certain kinds of pain, and the pain makes it even harder to sleep. Antidepressants help restore sleep and thereby improve pain.3. I have a problem with pain. How can an antidepressant help with this? • Antidepressants have been shown to be successful (even in the absence of major depression) in a number of pain conditions such as diabetic neuropathy, postherpetic neuralgia, and phantom limb pain. • Antidepressants may also help restore normal sleep and ‘reverse’ a vicious cycle of pain and poor sleep.4. I have low energy and feel tired a lot of the time. How can anantidepressant help with this? • Low energy and fatigue commonly occur in people with major depression. Once the depression improves, their energy starts to return as well. • Antidepressants can help restore energy in patients who are depressed. With treatment, patients will feel less tired and more able to do their usual activities.5. I have a lot of stress in my life. How can an antidepressant help with this? • Life stress can cause or worsen the symptoms of depression. The depression can then worsen the impact of such stressors (such as work stress, family problems, physical disabilities or financial worries) and your ability to cope 11
  • 12. IMPACT Patient Brochure with them. Treating the depression can help some patients break out of this vicious circle.6. Are antidepressants addictive? • No. Antidepressants are not habit-forming or addictive. They do not produce a ‘high’ feeling, but slowly alter the amount of certain chemicals called neurotransmitters in the brain over a number of weeks. Restoring the levels to a more normal balance usually brings the depression under control. • Some people have been taking antidepressants continually for up to 30 years without any significant (physical or psychological) adverse effects.7. My problem is anxiety or panic attacks, not depression. How can antidepressants help? • In many cases, anxiety is a by-product of depression. Once the depression lifts, the anxiety improves as well. • Antidepressant medications are also among the most effective medical treatments for many anxiety disorders, including panic disorder and generalized anxiety disorder.8. How long will it take the medications to work? • It usually takes from one to six weeks for patients to start feeling better. In many cases, sleep and appetite improve first. It may take a little longer for your mood, energy, and negative thinking to improve. • If the depression has not improved after 4 to 6 weeks, you may need an increase in the dose or a change to another antidepressant.9. How long will I have to take the medication? • Once you are completely recovered from your depressive episode, you should stay on the medication for another 6 months to prevent a relapse. • Some patients who have had previous depressive episodes or are otherwise at high risk for a recurrence should be kept on a ‘maintenance’ dose of antidepressants for longer periods of time.10. Are there any dangerous side effects? • Side effects from antidepressants are usually mild. You should ask your doctor or Depression Clinical Specialist (who will coordinate with your doctor) what to expect and what to do if you have a problem. • In many cases, your body will get used to the medication and you won’t be bothered with the side effect for long. In other cases, your doctor may suggest that you lower the dose, add another medication, or change to another 12
  • 13. IMPACT Patient Brochure antidepressant. If used properly, there are no dangerous or life-threatening side effects.11. Is it safe to take antidepressants together with alcohol or othermedications? • In general, antidepressants can safely be taken with other medications. You should let your doctor or Depression Clinical Specialist know exactly which other medications (including over the counter medications) you are taking so that he/she can make sure that there are no problems. • Antidepressants can increase the sedating effects of alcohol. Be careful to avoid excessive alcohol intake while on these medications.12. What should I do if I miss the medication one day? • Don’t ‘double up’ and take the dose you forgot. Just keep taking your medication as prescribed each day.13. Can I stop the medication once I am feeling better? • No. You would be at high risk for having the depression come back, and may experience some temporary withdrawal symptoms. After one episode of depression, there is a 50 % risk that the depression will return. After two episodes, the risk goes to 70%; and after three episodes, the chances are 90 % that you will have a recurrence if you stop using the medication. In most cases, you should continue the medication for at least 6 months after you and your doctor agree that your recovery is complete. • DON’T STOP THE MEDICATION BEFORE DISCUSSING IT WITH YOUR PHYSICIAN OR DEPRESSION CLINICAL SPECIALIST.14. Will I get better? • With adequate treatment, between 50 and 80 % of patients will have a complete recovery. • Should you not respond to the first antidepressant treatment you try, there is an excellent chance that you will respond favorably to another medication or to psychotherapy.Questions about Problem Solving Treatment (PST-PC):1. What is PST-PC?Problem-solving treatment – primary care (PST-PC) is a brief form ofpsychotherapy that teaches people how to solve the problems that are making themdepressed. You will meet with your depression clinical specialist for 4-8 weeks, 13
  • 14. IMPACT Patient Brochureand during that time you will learn seven steps to fix the problems that arebothering you.2. Four to eight weeks seems awfully short. How can I solve all my problemsin so few meetings?The goal of PST is to teach you how to solve problems on your own. You will notbe expected to solve all your problems during this time. But, you will get to solvea few problems. By working on some of your problems in the 4-8 weeks you havewith your DCS, you will learn to solve all the other problems in your life on yourown.3. Four to eight weeks seems awfully long to learn how to solve problems. DoI have to go to every one of those meetings?Learning how to solve problems is not easy. You will want to practice the skillsyou are being taught. Although you do not have to use all 8 meetings, you willwant to work with your DCS at least 4 times to learn PST.4. Do I have to tell my DCS everything?Most people have a hard time talking about their problems to people they don’tknow. While it is important to talk about all the major problems that you think arerelated to your depression, you don’t have to talk about every problem you have.Because the goal of PST-PC is to TEACH you how to solve problems on yourown, you can learn PST by focusing on any problem you feel comfortablediscussing.5. Do I have to talk about my mother?Not unless she is currently one of your problems. PST-PC focuses on problemsyou are having now, not your childhood.6. Homework? What if I don’t do my homework?We encourage you to practice you new skills outside of the meetings. Try and doyour homework! You will not be graded. But , even if you don’t finish yourhomework, plan on coming anyway, we want to see you. 14
  • 15. IMPACT Patient Brochure Appendix B: WHAT SHOULD FAMILY AND FRIENDS KNOW ABOUT DEPRESSION?Family and friends may be helpful to you now. Showing them this section mayanswer some of their questions about depression and help them to help you getbetter.I am a family member or friend. I worry…1) Is this my fault?Because the causes of depression often are not clear, it’s easy for family membersor close friends to feel guilty about their loved one’s illness. Instead of worryingabout the past, think of specific things you can do from now on. Focus on theprospects for a brighter future. Someone who is depressed will frequently beirritable or be less interested in your relationship. Don’t take it personally.2) What if I just make things worse?Self-blame is a big part of depression; try not to fall into that trap yourself. Youwon’t always know the right thing to say, but don’t let that stop you from talking.It’s more important that you let your loved one know you care and that you areavailable to help. Persistence and good intentions will go a long way.3) What should I avoid doing or saying?Even if you mean well and try hard, there may still be difficult times. Here aresome common “don’ts” to keep in mind: • Don’t say, “Can’t you just get a grip on yourself?” Depression is not laziness, but if your depressed friend or family member can’t do the things he or she normally does, you may feel burdened. It helps to remember the times when you felt especially frustrated or discouraged. • Don’t use the silent treatment. Sometimes you may say nothing for fear of saying something wrong. Silence can leave lots of room for a depressed person’s negative or self-critical interpretations. If you don’t know what to say or do, try asking. Or just tell the truth: “I’d like to help, but I don’t know what to say.” • Don’t say, “You’re acting like you didn’t take that pill today.” Try not to associate taking antidepressant medication with negative events. 15
  • 16. IMPACT Patient BrochureI am a family member or friend. I’d like to know…4) How can I help? • Encourage pleasurable regular activities. Physical and social activities are effective natural antidepressants. They help people with depression regain the energy and motivation that depression drains away. People in treatment are encouraged to purposely schedule pleasant activities in their daily routines even though it may be difficult. You can help by being a partner. Try to schedule a walk, a movie, or some other pleasurable physical, entertaining or social activity everyday with your depressed family member or friend. You may meet with some resistance, but do not take “no” for an answer. Start slowly, offer lots of encouragement, and keep at it. • Encourage hope. Hold the belief that your depressed family member or friend will recover. Remember past successes, accomplishments, and good times. Encourage them to be hopeful and believe that they will recover. One of the hardest things for depressed people to cope with is having their family and friends treat them differently. Non-judgmental love from family and friends is especially important to someone who is depressed. • Help turn mountains back into molehills. Daily problems seem so overwhelming to someone who feels depressed, it’s hard for them to even start to solve them. You can help make the problems manageable by helping your family member or friend to: 1) Break the problem into small pieces 2) Decide what to take on first 3) Identify one or two small steps to start with 4) Set a specific time and place to get started 5) Recognize and praise their successes • Get involved in the depression treatment. Depressed people feel terribly alone. Offer to help in a way that works for you. The two of you can read about depression and talk about what you have learned together. Or, you might go along on visits to the doctor, nurse, or counselor. Sometimes there are problems in a relationship that can cause depression. Also, depression can sometimes cause serious problems in a relationship. If difficulties in the relationship are stressful, you might consider joint counseling. • Recognize improvements. Tell your family member or friend when you see improvements in their mood, attitude, and behavior, especially if treatments seem to be working. This is important as you may notice positive changes before the depressed person does.5) How can I help keep depression from coming back? 16
  • 17. IMPACT Patient Brochure Most depressed people feel significantly better after 1 or 2 months oftreatment. Unfortunately, depression sometimes returns, especially if treatment isstopped too early. Once things are better, you can help by watching out for early warning signs.If depression starts to creep back into someone’s life, you may be the first tonotice. Sleep problems, irritability or withdrawal from social situations are clues. When things are going well, it may be a good idea to sit down together tomake a list of early warning signs or clues that depression is returning. See if youcan make a plan in advance about how you can bring up your concerns in the mosthelpful way. Then you can mention warning signs of depression without seemingcritical. 17
  • 18. IMPACT Patient Brochure Notes: 18
  • 19. IMPACT Patient Brochure AcknowledgementsThis brochure was developed at the IMPACT study coordinating center by Sabine Oishi, MSPHand Jürgen Unützer, MD, MPH with help from Rebecca Shoai and Christine Smith andcontributions from :John Williams, MD, MHSLinda Harpole, MD, MPHChristopher Callahan, MDEnid Hunkeler, MAWayne Katon, MDMarc Hoffing, MD, MPHMark Hegel, PhDPatricia Arean, PhDProject IMPACT is funded by the John A. Hartford Foundation, New York, NY and the CaliforniaHealthCare Foundation, Oakland, CA. Project IMPACT © 1999 – Center for Health Services Research, UCLA Neuropsychiatric Institute 19