Tool on Depression: Assessment and Treatment For Older Adults CANADIAN COALITION FOR SENIORS MENTAL HEALTH To promote seniors mental health by connecting.

Tool on

Depression: Assessmentand TreatmentFor Older Adults

CANADIAN COALITION FORSENIORS’ MENTAL HEALTH

To promote seniors’ mental health by connecting people, ideas and resources

COALITION CANADIENNE POUR LA SANTÉ MENTALE DES PERSONNES ÂGÉES

Promouvoir la santé mentale des personnes agées enreliant les personnes, les idées et les ressource

Reality: Defining Seniors’ Reality: Defining Seniors’ Mental HealthMental Health

• Mood Disorders Mood Disorders • Anxiety Disorders Anxiety Disorders • Dementia – Alzheimer’s Dementia – Alzheimer’s

DiseaseDisease• Personality DisordersPersonality Disorders• Concurrent DisordersConcurrent Disorders• Schizophrenia; AutismSchizophrenia; Autism• Suicidal BehaviourSuicidal Behaviour

Mental Illness is NOT a normal consequence of aging!

• Depression: Depression: 14.7% – 20% in the 14.7% – 20% in the communitycommunity

• LTC: LTC: 80 - 90% of residents80 - 90% of residents• Alzheimer’s: Alzheimer’s: 1 in 3 over 85 1 in 3 over 85 • Delirium Delirium

up to 50% up to 50%

• Suicide: Suicide: Suicide rate for older Canadian men Suicide rate for older Canadian men

nearly 2x that of the nation as a whole nearly 2x that of the nation as a whole

Mental Illness is NOT a normal consequence of aging!

• Major Depression 2-4%Major Depression 2-4%• Depressive symptoms 14 – 20%Depressive symptoms 14 – 20%• Schizophrenia 0.5%Schizophrenia 0.5%• Dementia 8% (rising to 34% in Dementia 8% (rising to 34% in

those >85)those >85)• Paranoid thoughts: 10%Paranoid thoughts: 10%• Anxiety Disorders: 19%Anxiety Disorders: 19%• Alcohol dependence 1-3% Alcohol dependence 1-3% (problem drinking 4-23%)(problem drinking 4-23%)

Who should be screened for Who should be screened for depression?depression?

• Recently bereaved with symptoms 3-6 months Recently bereaved with symptoms 3-6 months after the loss after the loss

• Socially isolatedSocially isolated• Persistent complaints of memory difficultiesPersistent complaints of memory difficulties• Chronic disabilitiesChronic disabilities• Recent major illness (e.g., within 3 months)Recent major illness (e.g., within 3 months)• Persistent sleep difficultiesPersistent sleep difficulties• Somatic concerns or anxiety Somatic concerns or anxiety • Refusal to eat or neglect of personal careRefusal to eat or neglect of personal care• Recurrent or prolonged hospitalizationRecurrent or prolonged hospitalization• Diagnosis of dementia, Parkinson’sDiagnosis of dementia, Parkinson’s• Recent placement in a nursing/LTC homeRecent placement in a nursing/LTC home

Health care providers should have knowledge andHealth care providers should have knowledge andskills in the application of age-appropriate skills in the application of age-appropriate

screening and assessment tools for depression in screening and assessment tools for depression in older adults.older adults.

Recommended Screening Recommended Screening ToolsTools

for Depressionfor Depression

Screening Tools for DepressionScreening Tools for Depression

Without significant cognitive impairment in Without significant cognitive impairment in general general

medical or geriatric settings include: medical or geriatric settings include: • Geriatric Depression Scale (GDS)Geriatric Depression Scale (GDS)• SELFCARE SELFCARE • Brief Assessment Schedule Depression Brief Assessment Schedule Depression

Cards (BASDEC) for hospitalized Cards (BASDEC) for hospitalized patients. patients.

Moderate to severe cognitive impairment: Moderate to severe cognitive impairment: • Cornell Scale for Depression in DementiaCornell Scale for Depression in Dementia

Are my older patients at higher

risk of depression? (laminate)Risk factors: Risk factors: • socially isolated socially isolated • persistent complaints of memory difficulties persistent complaints of memory difficulties • chronic disabling illness chronic disabling illness • major physical illness within the last 3 months major physical illness within the last 3 months • persistent sleep difficulties persistent sleep difficulties • somatic concerns or recent-onset anxiety somatic concerns or recent-onset anxiety • refusal to eat or neglect of personal care refusal to eat or neglect of personal care • recurrent or prolonged hospitalization recurrent or prolonged hospitalization • diagnosis of dementia, Parkinson’s disease, or diagnosis of dementia, Parkinson’s disease, or

stroke stroke • recent placement in a nursing/LTC homerecent placement in a nursing/LTC home

If your patient is recently If your patient is recently bereaved: bereaved:

• active suicidal ideation active suicidal ideation • guilt not related to the deceased guilt not related to the deceased • psychomotor retardation psychomotor retardation • mood congruent delusions mood congruent delusions • marked functional impairment (2 months marked functional impairment (2 months

after loss) after loss) • reaction that seems out of proportion to reaction that seems out of proportion to

the lossthe loss

ContinuedContinued

Tool development onTool development on

DepressionDepressionAssessmentAssessmentFor Older AdultsFor Older Adults Developed by NICE Mental Health TeamDeveloped by NICE Mental Health Team

Part 1: RISK, SCREENING

1 IS MY PATIENT AT RISK FOR DEPRESSION?

National Guidelines for Seniors Mental Health: Part 2: 2.1.1

PREDISPOSING FACTORS• Female• Widowed or divorced• Previous depression history• Brain changes due to vascular problems• Major physical and chronic disabling illnesses• Medications or Polypharmacy• Excessive alcohol use• Social disadvantage & low social support• Caregiver for person with a major disease (e.g.,dementia)• Personality type (e.g., relationship or dependence

problems)

PRECIPITATING FACTORS• Recent bereavement• Move from home to other places (e.g., nursing home)• Adverse life events (e.g., losses, separation, financial

crisis)• Chronic stress with declining health, family or marital

problems• Social isolation• Persistent sleep difficulties

Part 1: Risk Screening

2 RECOMMENDED ASSESSMENT OPTIONS

National Guidelines for Seniors Mental Health: Part 2: 2.1.2

A structured interview using one of the following tools:

TOOLS DEVELOPED TO REFLECT DEPRESSION OLDER ADULTS WITH AVAILABLE

WEBSITES

In general medical practice, nursing/residential homes or inpatient settings

• SIG E CAPS- (http://webmedia.unmc.edu/intmed/geriatics/reynolds/pearlcards/depression/

depressionindex.htm)• The Geriatric Depression Scale (http://www.stanford.edu/~yesavage/GDS.html)• Brief Assessment Schedule for the Elderly (BASDEC) (http://www.medalreg.com/www/sheets/ch18/depression%20Koenig

%20scale.xls)

In community surveys• Center for Epidemiological Studies – Depression Scale• The Geriatric Mental State Schedule (GMSS)

For depression in the presence of dementia or significant cognitive difficulties

• The Cornell Scale for Depression in Dementia (http://www.emoryhealthcare.org/departments/fuqua/CornellScale.pdf )

3 DIAGNOSTIC CRITERIA

National Guidelines for Seniors Mental Health: Part 2: 2.2

DIAGNOSTIC CRITERIA FOR DEPRESSION - DSM 1+V )

A cluster of symptoms present on most days, most of thetime, for at least 2 weeks• Depressed mood• Loss of interest or pleasure in normal, previously enjoyed

activities• Decreased energy and increased fatigue• Sleep disturbance• Inappropriate feelings of guilt• Diminished ability to think or concentrate• Appetite change (i.e., usually loss of appetite in the elderly)• Psychomotor agitation or retardation• Suicidal ideation or recurrent thoughts of death

DSM IV-TR CLASSIFICATION (APA, 2000)

Make a clear DSM-IV diagnosis & document

Different types of depressive disorders

• Major depressive episodes (i.e., part of unipolar, bipolar mood disorder or

secondary to a medical condition)• Dysthymic disorder• Depressive disorders not otherwise

specified: A group of disorders including minor

depressivedisorder, post psychotic depressive disorder ofschizophrenia and depressive disorders of

unclearetiology (e.g., may be primary or secondary to

amedical condition or substance induced)

4 SUICIDE RISKNational Guidelines for Seniors Mental

Health: Part 2: 2.1Non-modifiable risk factors• Old age• Male gender• Being widowed or divorced• Previous attempt at self-harm• Losses (e.g., health status, role, independence, significant relations)Potentially modifiable risk factors• Social isolation• Presence of chronic pain• Abuse/misuse of alcohol or other medications• Presence & severity of depression• Presence of hopelessness and suicidal ideation• Access to means, especially firearmsBehaviors to alert clinicians to potential

suicide• Agitation• Giving personal possessions away• Reviewing one’s will• Increase in alcohol use• Non-compliance with medical treatment• Taking unnecessary risk• Preoccupation with death

Part 2: WHEN TO TREAT, REFER, & MONITORING & LONG

TERM TREATMENT

Commonly-used Antidepressant Medications-Commonly-used Antidepressant Medications-

National Guidelines for Seniors Mental Health: Part National Guidelines for Seniors Mental Health: Part 55

Generic Generic NameName

Trade Trade NameName

Starting Starting dosedose

mg/daymg/day

AverageAverage

DoseDose

Maximum Maximum recommenrecommended dose ded dose

(CPS)(CPS)

Comments/CautionComments/Caution

SSRISSRI CitalopramCitalopram CelexaCelexa 1010 20-4020-40 40 mg40 mg EscitalopraEscitalopramm

CipralexCipralex 55 10-2010-20 20 mg20 mg

SertralineSertraline ZoloftZoloft 2525 50-15050-150 200 mg200 mg Other AgentsOther Agents BuproprionBuproprion

WellbutriWellbutrinn

100100 100 mg 100 mg BIDBID

150 mg BID150 mg BID May cause seizuresMay cause seizures

MirtazapinMirtazapinee

RemeronRemeron

1515 30-4530-45 45 mg45 mg

MoclobemiMoclobemidede

ManerixManerix 150150 150-300 150-300 BIDBID

300 mg BID300 mg BID Do not combine with Do not combine with MAO-BMAO-B inhibitors or Tricyclicsinhibitors or Tricyclics

VenlafaxineVenlafaxine

EffexorEffexor 37.537.5 75-22575-225 *375 mg*375 mg **For severe For severe depression; Maydepression; May increase blood increase blood pressurepressure

Tricyclic AntidepressantsTricyclic Antidepressants DesipraminDesipraminee

NorpramNorpraminin

10-25 10-25 50-15050-150 300 mg300 mg

Anticholinergic Anticholinergic propertiesproperties cardiovascular side-cardiovascular side-effects; effects; Monitor blood levelsMonitor blood levels

NortriptylinNortriptylinee

AventylAventyl 10-2510-25 40-10040-100 200 mg200 mg

Anticholinergic Anticholinergic properties;properties; cardiovascular side-cardiovascular side-effects;effects; Monitor blood levelsMonitor blood levels

5 WHEN TO TREAT

National Guidelines for Seniors Mental Health: Part 2: 2.1.1

Following a positive screen for depression a complete bio-psycho-social

assessment should be conducted including:• A review of diagnostic criteria in the DSM 1V-TR or ICD 10 manuals• An estimate of severity, including presence of psychotic or catatonic

symptoms• Risk of suicide, by directly asking patients about suicidal ideation, intent

and plan• Personal or family history of mood disorder• Medication use and substance abuse• Review of current stressors and life situation• Level of functioning/disability• Family situation, social integration/support• Mental status exam, plus assessment of cognitive function• Physical exam and lab tests to determine if medical issues contribute or

mimic depressive symptomsTreatment can be divided into 3 main phases• Acute treatment phase: to achieve remission of symptoms• Continuation phase: to prevent recurrence or relapse of same episode of

illness• Maintenance or prophylaxis phase: to prevent future episodes or

recurrence

6 GUIDELINES FOR TREATMENT

National Guidelines for Seniors Mental Health: Part 4 & 5

Psychotherapies & Psychosocial Interventions• Supportive care should be offered to all patients who are depressed• Psychotherapy is a first line of treatment or in combination with antidepressant medication• Based on type of depression, coping style, level of cognitive functioning• Psychotherapy – provided by trained mental health professionals

Pharmacological Treatment• Medications are used in combination with psychosocial or psychotherapy treatments• Part of overall treatment of depressed older adults• See table for commonly used antidepressants• See full guideline for details of prescribing and monitoring

7 WHEN TO REFER

National Guidelines for Seniors Mental Health: Part 3: 3.5

Recommendations for clinicians to refer for Psychiatric Care at Time of Diagnosis• Psychotic depression• Bipolar disorder• Depression with suicidal ideation

8 MONITORING AND LONG TERM TREATEMENT

National Guidelines for Seniors Mental Health: Part 6: 3

Health care providers should monitor the older adult for re-occurrence of depression for the first 2 years after

treatment

• Ongoing monitoring should focus on depressive symptoms present

during initial episode• Older adults in remission of their first episode should be treated

for a minimum of one year and up to 2 years from time of

improvement• Older adults with recurrent episodes should receive indefinite maintenance therapy• In LTC homes, response to therapy should be evaluated monthly after initial improvement and then every three months, as well as annual assessment after remission of symptoms

NICE – Mental Health NICE – Mental Health TeamTeam

Depression Assessment Depression Assessment Tool, EvaluationTool, Evaluation

Evaluation OutlineEvaluation Outline1.1. Case Description (stakeholder consultation and tool Case Description (stakeholder consultation and tool

development process)development process) How many stakeholders were consulted?How many stakeholders were consulted? What disciplines / health care sectors / organizations were represented?What disciplines / health care sectors / organizations were represented? What is the geographical representation of stakeholders?What is the geographical representation of stakeholders? How were stakeholders recruited?How were stakeholders recruited? Describe process of consultation (i.e., teleconference calls, material Describe process of consultation (i.e., teleconference calls, material

distribution, survey monkey etc.).distribution, survey monkey etc.). Describe limitations.Describe limitations.

2.2. Knowledge Transfer SurveyKnowledge Transfer Survey To be collected at 3 weeks and 3 months post workshop sessionTo be collected at 3 weeks and 3 months post workshop session Offered in both paper and survey monkey formOffered in both paper and survey monkey form Phone call remindersPhone call reminders Consent formConsent form

3.3. In-depth Qualitative InterviewsIn-depth Qualitative Interviews Conducted 3 months after workshop – focus group or individual interviews Conducted 3 months after workshop – focus group or individual interviews

depending on scenario (tape recorded / transcribed)depending on scenario (tape recorded / transcribed) Consent formConsent form

4.4. Evaluation of Workshop SessionsEvaluation of Workshop Sessions To be distributed and collected at end of each sessionTo be distributed and collected at end of each session 5.5. Analysis –Analysis – mid April – mid-May mid April – mid-May

• Report- Report- June 2008 NICE ConferenceJune 2008 NICE Conference

CANADIAN COALITION FORSENIORS’ MENTAL HEALTH

To promote seniors’ mental health by connecting people, ideas and resources

COALITION CANADIENNE POUR LA SANTÉ MENTALE DES PERSONNES ÂGÉES

Promouvoir la santé mentale des personnes agées enreliant les personnes, les idées et les ressource

www.nicenet.caDisclaimer: This tool is intended for information purposes only and is

not intended

to be interpreted or used as a standard of medical/health practice.

www.ccsmh.ca