The illustrated definition of depression is lifted from the DSM-IV-TR (Text Revision) published in 2000 containing updates on diagnostic categories and modified to reflect terminology that is consistent with ICD9 coding.
Mild episode of major depression: minor impairment in social activities, relationships and overall function that persists for at least 2 weeks. Patient does NOT have more than five diagnostic symptoms Moderate episode of major depression: symptoms or functional impairment between mild and severe, persisting for at least 2 weeks. Severe episode of major depression: marked interference with and impairment of social activities, relationships, and overall functioning, persisting for at least 2 weeks. Patient has five or more diagnostic symptoms. Severe episode of major depression with psychotic features: symptoms include delusions and hallucinations
These are estimated prevalence rates of depression across various settings
We strongly encourage the use of one of the scales for diagnosis and management, but if you need to do a real quick screen, you can use the two-item scale illustrated here. This 2-item scale is also known as the Patient Health Questionnaire 2 (PHQ-2), which asks about depressed mood and anhedonia. It is easily administered by an office staff member or a physician during a primary care visit.
Depression in the geriatric
DEPRESSION IN GERIATRICS SHYAM SUNDAR
Introduction Depression is under-recognized and undertreated in the older people. Many older adults who die by suicide (up to 75%) suffer with depression and most visited a physician within a month before death Untreated depression can delay recovery or worsen the outcome of other medical illnesses via increased morbidity or mortality Depression is NOT a part of normal aging
What is Depression? DSM-IV-TR Definition Five or more of the following must have been present during the same 2-week interval and represent a change from baseline functioning One of the symptoms must be depressed mood or loss of interest or pleasure
What is Depression?(a.k.a. “core symptoms”; occur most of the day nearly every day) Depressed mood Loss of interest in all or almost all activities or pleasure Appetite change or weight loss Insomnia or hypersomnia Psychomotor agitation or retardation
Loss of energy or fatigue Feelings of worthlessness or excessive guilt Difficulty with thinking, concentration, or decision making Recurrent thoughts of death or suicide Preoccupation with somatic symptoms, health status, or physical limitations Feelings of guilt or worthlessness Thoughts of wishing you were dead
For Major Depression, these symptoms Produce social impairment Are not related to substance abuse Are not related to bereavement [the loss of a loved one by death]
Types of Depressive Disorders Mild episode of major depression Moderate episode of major depression Severe episode of major depression Severe episode of major depression with psychotic features
Minor depression is common 15% of older persons Causes ↑ use of health services, excess disability, poor health outcomes, including ↑ mortality Major depression is not common 1%–2% of physically healthy community dwellers Elders less likely to recognize or endorse depressed mood
“Late-life” depression (a geriatric syndrome) is a recurrence of depressive symptoms that initially occurred during early adulthood. there is no known or identifiable precipitating factor. patients usually have no family history of depression. Depressed mood is not required to meet criteria for major depressive disorder.
Epidemiology (of major depression) Community- Primary Care Dwelling 1 - 9 % Settings 10 – 12 % Nursing Home Hospitalized 10-26% 11 – 45 % Permanent Placement Up to 43%
Risk Factors Alcohol or substance abuse Current use of a medication associated with a high risk of depression Hearing or vision impairment severe enough to affect function History of attempted suicide History of psychiatric hospitalization
Causes As you grow older, you face significant life changes that can put you at risk for depression. Health problems – Illness and disability; chronic or severe pain; cognitive decline; damage to body image due to disease. Loneliness and isolation – Living alone; a dwindling social circle due to deaths or relocation; Reduced sense of purpose – Feelings of purposelessness or loss of identity due to retirement or physical limitations on activities. Fears – Fear of death or dying; anxiety over financial problems or health issues. Recent bereavement – The death of friends, family members, and pets; the loss of a spouse or partner.
What medications do YOUprescribe for older adults that might place them at risk for DEPRESSION ?
Medications that may cause symptomsof Depression Anabolic steroids Anti-arrhythmic medications (amiodarone, mexilitine) Anticonvulsant medications Carbidopa or levodopa Certain beta-adrenergic antagonists (i.e. propranol)
What is the most commonly used and validated screening tool for diagnosis of Depression in the geriatrics patient?The Geriatric Depression Scale
Screening Tools Two – item scale During the previous 2 weeks…….. 1. Have you often been bothered by feeling down, depressed or hopeless? 2. Have you often been bothered by having little interest or pleasure in doing things? (“Yes” answer to either is considered positive)is highly sensitive for detecting major depression in persons over age 65.
TREATMENT Ttreatment is effective in about 80% of identified cases, when treatment is provided. Effective management requires a biopsychosocial approach, combining pharmacotherapy and psychotherapy. Therapy generally results in improved quality of life, enhanced functional capacity, possible improvement in medical health status, increased longevity, and lower health care costs.
Pharmacotherapy Selective Serotonin Reuptake Inhibitors : fluoxetine Tricyclic Antidepressants : imipramine and amitriptyline Monoamine Oxidase Inhibitors Other Antidepressants: mirtazapine and trazo
Consequences and Complications ofInadequately Treated Depression Recurrence, partial recovery, and chronicity . . . ↑ disability ↑ use of health care resources ↑ morbidity and mortality Suicide (one fourth of all suicides occur in persons ≥ 65)
Consequences and Complications ofInadequately Treated Depression Which demographic in the elderly population has the highest risk and incidence of suicide?Highest: white males age 80 & olderNext highest: white males between 65 and 80
Consequences and Complications ofInadequately Treated Depression Suicide: Ask the patients about thoughts of hurting themselves; if YES, ask whether they have a plan; if YES, ask what it is; then ask about stockpiled medications or weapons in the home. Patients with a plan require emergent psychiatric evaluation in ER or local crisis unit.
Consequences and Complications ofInadequately Treated Depression Risk factors for suicide: depression older age physical illness living alone (single, divorced, or separated and without children) male gender drug abuse or alcoholism having a personal or family history of suicide attempt severe anxiety or stress specific plan with access to firearms or other means.
Consequences and Complications ofInadequately Treated Depression Violent suicides (e.g. firearms, hanging) are more common than non-violent methods among older adults, despite the potential for drug overdosing
Summary All health care workers should maintain a high index of suspicion for the presence of depression or depressive symptoms in their patients. Screen older adults for depression at the initial visit
Summary Suicide is a serious concern in depressed older patients, particularly older white males Treatment (acute & preventive) should be individualized and may include: Pharmacotherapy Psychotherapy ECT Choice of antidepressant should be based on comorbidities, side-effect profiles, patient sensitivity, potential drug interactions