Depression in adult and in elderly. Suicide and its prevention. Bong wan tsien Dept. of Family Medicine PPUKM.

Depression in adult and in elderly. Suicide and its prevention.

Bong wan tsienDept. of Family Medicine

PPUKM

Goals and Objectives

• Identify the variation in presentation of depression in various age groups

• Overview of assessment of depression along with use of common rating scale

• Selection of antidepressants in management of depression

• Special considerations with antidepressant use in elderly

• Overview of risk factors for Suicide

Epidemiology

• Men: 5-12%• Women: 10-25%• Prevalence 1-2% in elderly

– 6-10% in Primary Care setting– 12-20% in Nursing home setting– 11-45% in Inpatient setting– >40% of outpt. Psychiatry clinic and inpt. psychiatry

• Peak age of onset 3rd decade• Late-life depression: secondary to vascular etiology

Patho-physiology

• Elevated stress levels• Decreased levels or activity of

nor-epinephrine and/or serotonin• Decreased latency to 1st rapid eye movement

sleep phase and hypoperfusion of the frontal lobes

• Cerebro-vascular disease• Deep white matter hyperintensity

Etiology

• Biological factors• Social factors• Psychological factors

Biological factors

• Genetic– High prevalence in first degree relatives– High concordance with monozygotic twins– Short allele of serotonin transported gene

• Medical Illness: – Parkinson's, Alzheimer's, cancer, diabetes or stroke

• Vascular changes in the brain • Chronic or severe pain• Previous history of depression• Substance abuse

Social factors

• Loneliness, isolation • Recent bereavement • Lack of a supportive social network • Decreased mobility

– Due to illness or loss of driving privileges

Psychological factors

• Traumatic experiences– Abuse

• Damage to body image • Fear of death • Frustration with memory loss • Role transitions

Common precipitants• Arguments with friends/relatives• Rejection or abandonment• Death or major illness of loved one• Loss of pet• Anniversary of a (-) event• Major medical illness or age-related deterioration• Stressful event at work • Medication Noncompliance• Substance use

Definition

A syndrome complex characterized by mood disturbance plus variety of cognitive, psychological, and vegetative disturbances

Clinical Features

• DSM IV-TR criteria– 5/9 should be present for at least two

weeks– Must be a change from previous

functioning – Presence of decreased interest or

low/depressed mood is must feature• SIGECAPS

SIG(M)ECAPS• Sleep disturbance: decreased or increased• Interest or pleasure*: decreased• Guilt or feeling worthless • Mood* : sustained low or depressed • Energy loss or fatigue • Concentration problems or problems with

memory • Appetite disturbance, weight loss or gain• Psychomotor agitation or retardation• Suicidal ideation, thoughts of death

MINOR Depression• Also known as

– subsyndromal depression

– subclinical depression– mild depression

• 2 - 4 times more common than major depression

• Associated with:– subsequent major

depression– greater use of health

services– reduced physical,

social functioning– loss of quality of life

• Responds to same treatments!

Atypical depression

• Somatic complaints• Hyperphagia, • Hypersomnia, • Hypersensitivity to rejection• “Heavy” feeling in upper or lower

extremities (leaden paralysis)

Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335.

Depression – the physical presentationIn primary care, physical symptoms are often

the chief complaint in depressed patients

N = 1146 Primary care patients with major depression

In a New England Journal of Medicine study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief compliant1

Dysthymia• More chronic, low intensity mood disorder• By definition, symp must be present > 2 yrs

consecutively• It is characterized by anhedonia, low self-esteem, &

low energy• It may have a more psychologic than biologic

etiology• It tends to respond to Rx & psychotherapy equally• Long-term psychotherapy is frequently able to bring

about lasting change in dysthymic individuals

Bipolar Disorder• People with this type of illness change back

and forth between periods of depression and periods of mania (an extreme high).

• Symptoms of mania may include:– Less need for sleep– Overconfidence– Racing thoughts– Reckless behavior– Increased energy– Mood changes are usually gradual, but can be

sudden

Pseudo-dementia

• A syndrome of cognitive impairment that mimics dementia but is actually depression

• Poor attention and concentration• Symptoms resolve as the depression is treated

effectively• If considerable cognitive impairment remains, an

underlying dementia is suspected• Even “completely recovered” patients have

higher rates of dementia (20% /year of f/u)• This is 2.5 to 6 times higher than population risk

Psychotic depression• Abnormal thought process – psychotic

thinking • Frank hallucinations and delusions

Depression in Elderly• NOT a normal part of aging• 2 million Americans over age 65

have depressive illness• Sub-syndromal depression

increases the risk of developing depression– Leads to early relapse and

chronicity• Often co-occurs with other serious

illnesses• Under-diagnosed and under-

treated• Suicide rates in the elderly are the

highest of any age group.

Facts in Elderly

• Only 11 percent : in community receive adequate antidepressant treatment

• The direct and indirect costs – $43 billion each year

• Late life depression is particularly costly because of the excess disability that it causes and its deleterious interaction with physical health

Depression in Elderly• Difficult to diagnose

• Low/depressed mood need not be present

• Persistent loss of pleasure and interest in previously enjoyable activities (anhedonia) must be present

• Reject diagnosis of depression

• Masked depression or depression without sadness- mainly somatic complaints

Depression in Elderly• Symptoms of minor depression • Somatic complaints: Persistent, vague,

unexplained physical complaints• Agitation, anxiety• Memory problems, difficulty concentrating• Social withdrawal• A high degree of suspicion and specific inquiry

is necessary for its detection and treatment

Differential diagnosis in Elderly

• Differentiation from medical illness:– Hyperthyroidism– Parkinson’s disease– Carcinoma of the pancreas– Dementia

• Bereavement:– Time limited resolves within few months– 14% develop depression within 2 yrs of loss– Look for functional impairment

Depression associated with Structural Brain Disease

• Alzheimers disease:– 20% of subjects with early AD have depression

• CerebroVascular disease: Vascular depression:– Anhedonia, executive dysfunction and absence of guilt

preoccupations – Late age of onset– Risk factors for vascular disease– Prefrontal or subcortical white matter hyperintensities on

T2 weighted MRI– Non-amnestic neuropsychologic deficits in tasks req’

initiation, persistence and self monitoring

Assessment

DASS-21

• The Depression scale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia, and inertia.

• The Anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect.

• The Stress scale is sensitive to levels of chronic non-specific arousal. It assesses difficulty relaxing, nervous arousal, and being easily upset/agitated, irritable/over-reactive and impatient.

Geriatric Depression ScaleChoose the best answer for how you have felt over the past week:1. Are you basically satisfied with your life? YES / NO2. Have you dropped many of your activities and interests? YES / NO3. Do you feel that your life is empty? YES / NO4. Do you often get bored? YES / NO5. Are you in good spirits most of the time? YES / NO6. Are you afraid that something bad is going to happen to you? YES / NO7. Do you feel happy most of the time? YES / NO8. Do you often feel helpless? YES / NO9. Do you prefer to stay home, rather than going out, doing new things? YES / NO10. Do you feel you have more problems with memory than most?

YES / NO11. Do you think it is wonderful to be alive now? YES / NO12. Do you feel pretty worthless the way you are now? YES / NO13. Do you feel full of energy? YES / NO14. Do you feel that your situation is hopeless? YES / NO15. Do you think that most people are better off than you are? YES / NO*Underlined items constitute the four item scale

Labs:

• FBC• TSH• Dementia workup• Cognitive testing• ECG

Why treat

• Substantially the likelihood of death from physical illnesses

• impairment from a medical disorder and impedes its improvement

• When untreated - interferes with a patient's ability to follow the necessary treatment regimen

• Healthcare costs of elderly people: 50% higher than those of non-depressed seniors.

• Lasts longer in the elderly.

Treatment

• Non-medical • Medical

• Inform about depression• Avoid stressors

Non-Medical interventions• Balanced diet• Fluids• Exercise• Avoid alcohol• Family support/social support• Focus on positives• Promote autonomy• Promote creativity• Alternate therapy: Pet therapy,

horticulture therapy• Pace appropriately

Medical Interventions

• Medications• Psychotherapy• Electro-convulsive therapy• Vagal Nerve stimulation• Combination therapy

Medications

• Serotonergic– SSRIs: Citalopram, Escitalopram, Sertraline,

Paroxetine, Fluoxetine• Noradrenergic

– TCAs• Dopaminergic

– Bupropion• Dual mechanism

– Venlafaxine, Mirtazapine, Duloxetine, SSRIs + Buproprion

Medication Starting Dose (mg/day) Therapeutic Dose (mg/day)

TCAsAmitryptylineNortriptylineImipramine

25-502525-50

100-30050-200100-300

SSRIsCitalopramFluoxetineSertralineParoxetineEscitalopram

10-2010-2025-5010-2010

20-6020-80100-20020-5020

MAOIsPhenelzineTranylcypromine

4520

18030-60

Mixed antidepressantsMirtazapineVenlafaxine XRBupropion SRDuloxetine

7.5-1537.5100-15020-30

15-4575-22530060

Special considerations in elderly

• Start low and go slow• Dose adjustment based on renal clearance: 30%

reduction of mirtazapine clearance with creatinine clearance : 11-15

• SSRIs are used at the same dose as adults• Response time is longer in elderly >6-12 weeks• Because of higher risk of relapse in elderly, continue

antidepressants for > 2 years after remission of major depressive disorder

Special considerations in elderly

• All antidepressants are equally efficacious• SSRIs are better tolerated than TCAs• Escitalopram, citalopram, sertraline, venlafaxine and

mirtazapine may have fewer drug interactions• SSRI related side effects seen in elderly

– Extrapyramidal side effects– Apathy– Anorexia– SIADH– Upper GI bleeding

Psychotherapy

• Very helpful in mild to moderate depression• Response time slower• Relapse less frequent• CBT

– As effective as antidepressants• IPT

more effective than antidepressantsin treating mood suicidal ideations,and lack of interest, whereas antidepressants are more effective for appetite and sleep disturbances

Electro-convulsive Therapy• Indications:

– Failure of antidepressant trials– Severe depression with catatonic or psychotic features– High risk of suicide– Poor tolerability of oral meds

• Response rates from 70-90%• Most efficacious antidepressant• Contraindication: ICP, intracranial tumors• 3x/wk with avg number of treatments 8-12, may need maintenance therapy• Side effects: Short term memory loss

Vagal Nerve Stimulation

• Electrical pulses applied to the left vagus nerve in the neck for transmission to the brain

• Intermittent stimulation– 30 sec on/5 min off

• Implanted in over 11,500 patients • Battery life of 8-12years, weighs 38 gms, 10.3 mm

thick• Side effects:

– hoarse voice, pain or tingling in the throat or neck, cough, headache and ear pain, difficulty sleeping, shortness of breath, vomiting

Vagal Nerve Stimulator (VNS)

SUICIDE: DON’T FORGET

• Ask about

–suicidal ideation –intent

Suicide risk in elderly

• Very Important, Easy to miss• Always ask • Firearms at home• Many older adults who commit suicide have

visited a primary care physician very close to the time of the suicide– 20 percent on the same day– 40 percent within one week – of the suicide

Suicide risk in elderly

• Suicides twice as common as homicides• 12% of the population is elderly, they account

for 20% of the 30,000 suicides/yr• Older patients make 2 to 4 attempts per

completed suicide, younger patients make 100 to 200 attempts per completion

• When they decide - they are serious

Assessment tool for suicide risk:S- Male SexA- Age (young/elderly)D- DepressionP- Previous attemptsE- ETOHR- Reality testing

(Impaired)S- Social support

(lack of)O- Organized planN- No spouseS- Sickness

Suicide Risk

• Paradoxically ↑ as patient begins to respond to treatment

• Somatic or “vegetative” symptoms (sleep, appetite, energy) are usually the first symptoms to improve

• “Cognitive” symptoms of depression (low self-esteem, guilt, suicidal thoughts) tend to improve more slowly

• CASE: REFERRAL• You have been asked to see Mrs. D. Pressed. She is a

78 year old woman whose husband died suddenly of a heart attack one month ago.

• Her family doctor reports that since the death, she has appeared sad-looking, with low energy and trouble falling asleep. She has spoken of “feeling his presence” and hearing his voice call her name. She is accompanied by one of her daughters.

•

• What else would you like to know?• 1. Past psychiatric history• Past medical history• Medications and substances• Family history• Personal history

• CASE: PAST PSYCHIATRIC HISTORY• She had a postpartum depression after the birth

of her youngest child. She was treated successfully for two years with Amitriptyline 150 mg OD.

• CASE: PAST MEDICAL HISTORY• Hypertension on Hydrochlorthiazide 25 mg OD• Osteoarthritis on Tramadol 50mg tds/prn• 2003 – fracture right wrist from fall

• CASE: FAMILY HISTORY• Mrs. Pressed is the middle child of a sibship of 7. Her mother had

“bad nerves”. Two of her brothers had alcohol problems.•

CASE: PERSONAL HISTORY• Mrs. Pressed was born in Kuching. Her childhood was

unremarkable. She finished Form 5 and then worked as a waitress. She married at age 18 and moved to Klang with her husband. She stayed at home to raise their three daughters, and then worked as the church secretary for 15 years until she retired at age 60. Her husband retired from his job at the bank at age 65. They moved into a seniors’ apartment five years ago.

•

• What do you think is going on?• 1. Bereavement• Adjustment Disorder with depressed mood• Major Depression (?with psychotic features)

• What else would you like to know?• Estimate of severity: presence of catatonic or

psychotic symptoms• Suicide risk assessment• Level of functioning or disability• Review DSM Criteria for depression

• CRITERIA FOR DEPRESSION• SIGECAPS• Sleep disturbance• Loss of Interest• Inappropriate or excessive feelings of Guilt• Decreased Energy and increased fatigue• Diminished ability to think or Concentrate• Appetite change• Psychomotor agitation or retardation• Suicidal ideation

• CASE: HISTORY OF PRESENT ILLNESS• Mrs. Pressed reports the following information:• She feels “down” with poor sleep and energy, and

hasn’t been enjoying usual activities like knitting or playing bridge with friends. Her appetite and concentration are normal, and she denies hopelessness or suicidal ideation.

• She sometimes hears her husband’s voice calling her name, but knows he has died. She does not report symptoms of anxiety or psychosis. She has not been drinking alcohol. There is no impairment in cognition or functioning.

• What is the most likely diagnosis?• Bereavement

• BEREAVEMENT• What is bereavement?• Reaction to the death/loss of a loved one• May present with symptoms characteristic of

major depression• Typically seen as “normal”

• BEREAVEMENT• What symptoms suggest “abnormal” grief?• Guilt about things other than actions taken or not

taken at the time of the death• Thoughts of death other than feeling that he/she

should have died with the deceased• Intense worthlessness• Marked psychomotor retardation• Marked and prolonged functional impairment• Hallucinatory experiences other than transiently

hearing or seeing the deceased person

• What is your management plan?• You agree to see her in one month for a follow

up appointment. You refer her to an upcoming grief group. You ask her daughter to “keep an eye on her”.

• CASE: MRS. PRESSED• Mrs. Pressed does not attend her follow-up

appointment. Two months later you see her in the emergency department after she has taken an overdose of Tramadol. She has significantly deteriorated and rarely gets out of bed. She stopped eating and drinking one week ago and has lost 10kg. She rarely bathes, and doesn’t clean the house. She is very quiet, but often speaks of having headaches. She believes this is from “brain cancer”, and that she is dying. She wishes she had died from the overdose.

• CASE: MENTAL STATUS EXAMINATION• The previous information is confirmed by MSE

including assessment for cognitive function.• Mrs. Pressed does not appear to have insight

into her condition. On MMSE she scores 18/30, often answering “I don’t know”.

• What is your diagnosis?• Major depression,• Severe,• With psychotic features

• Does depression look different in the elderly?• “Depressed mood” may be less prominent• More anxiety• More likely to express somatic complaints

– 65% have hypochondriacal symptoms• Less likely to report guilt feelings• Cognitive impairment more common• Psychosis more common

– Typical delusions – more common• Somatic, persecution, nihilism, poverty

• CASE: MRS. PRESSED• You start Mrs. Pressed on Citalopram 5 mg, in one week

increasing the dose to 10 mg. By one month she is taking 20 mg OD and starting to feel better. Her daughter calls 2 weeks later to say her mother seems very confused and disoriented. You suggest she sees the family doctor to check for hyponatremia, which is found on blood work.

• Citalopram is reduced to 10 mg, the hyponatremia resolves, but her mood deteriorates on the lower dose. After 6 weeks with normal blood work, you suggest she increase the dose back to 20 mg, and you monitor electrolytes closely.

• CASE: MRS. PRESSED• In 2 months she is feeling 70% better, but is

still not enjoying her previous hobbies, such as knitting or playing bridge. She still misses her husband terribly. She is also worried about taking any more medication.

• WHAT SHOULD YOU DO NOW?

• ANTIDEPRESSANT CONSIDERATIONS IN THE ELDERLY• Guidelines for Switching Antidepressants:• Change if:• No improvement in symptoms after at least 4 weeks at maximum

tolerated or recommended dose• Insufficient improvement after 8 weeks at maximum tolerated or

recommended dose• When recovery is incomplete after an adequate trial, consider:• Further 4 weeks of treatment, with or without augmentation (meds

or psychotherapy)• Switching to another antidepressant

– When switching, it is safe to reduce the first medication while starting the alternate (cross-over titration)

– Consider specific interaction profiles

• CASE: MRS. PRESSED• Given Mrs. Pressed’s concern about increasing

the dose of medication, you decide together to pursue a non-pharmacological augmentation treatment. She attends a grief group at the hospital day program for 10 weeks. When seen three months later, she is doing well.

• ANTIDEPRESSANT CONSIDERATIONS IN THE ELDERLY

• Guidelines for Starting Antidepressants:• “Start low, go slow”• Start at half the dose of younger people• Aim to reach an average dose at one month

• LENGTH OF TREATMENT• Long-term Treatment Guidelines:• After 1st episode continue to treat for at least a year• Monitor for recurrence up to 2 years• Medication discontinuation should be slow (over months)• Patients with partial resolution of symptoms, more than 2 episodes,

severe or difficult to treat depression, or treatment requiring ECT, should receive indefinite treatment

• Treatment response in nursing home patients should be evaluated monthly after initial improvement, and at quarterly care conferences and annual assessment once remission is achieved

• Consider tolerance of treatment versus risks of discontinuation

• CONCLUSION• You continue to follow up with Mrs. Pressed

for another 2 years and she does very well. With your expert skills (and some luck) she does not have a relapse.

• KEYPOINTS FOR SENIORS• Depression is not normal in seniors• Seniors are at higher risk for depression

– Especially after bereavement– Seniors are more vulnerable

• Monitoring needs to be more aggressive so that seniors don’t fall through the cracks

• Consider Anticholinergic reactions

Questions