Managing Depressive Disorders In Older Adults

Practice Guideline for the Treatment of Patients with Major Depression

American Psychiatric Association. http://www.psych.org/psych_pract/treatg/pg/Depression2e.book.cfm

SUMMARY

This guideline, which was developed by an expert blue ribbon panel, includes the following topics:

Summary of treatment recommendations, for the psychiatric management of patients with major depressive disorder during the acute, continuation, and maintenance phases of treatment as well as discontinuation.
Formulation and implementation of a treatment plan during the various phases of the illness
Specific clinical features that influence the treatment plan, notably psychiatric features, demographic and psychosocial variables, and the natural history and course of the illness.
Background information on specific features of the diagnosis, epidemiology and natural history and course of the disease and review of the available evidence on acute phase somatic treatments, acute phase psychosocial interventions, psychotherapy combined with pharmacotherapy, continuation and maintenance treatments.
Future research needs in the areas of antidepressant medications, psychotherapy, ECT and other treatment modalities also are included.

Recommendations are grouped into three categories, depending on the level of clinical confidence regarding the recommendation.

Level I is recommended with substantial clinical confidence
Level II is recommended with moderate clinical confidence
Level III is recommended on the basis of individual circumstances

Includes excellent summary tables, (e.g., for commonly used antidepressants and treatments for side effects of medications) and extensive references.

TREATMENT RECOMMENDATIONS

Basic components of psychiatric management:

performing a diagnostic evaluation
evaluating safety of the patient and others
evaluating the level of functional impairments
determining a treatment setting
establishing and maintaining a therapeutic alliance
monitoring the patient's psychiatric status and safety
providing education to patients and families

Choice of an initial treatment modality:

In addition to basic psychiatric management, options for treatments in the acute phase include:

Pharmacotherapy for moderate to severe MDD unless ECT is planned. Patient preference should drive selection for mild MDD
Psychotherapy can be used alone for patients with mild to moderate MDD.

Patient preference should influence the decision.
Clinical features that may suggest the use of psychotherapeutic interventions include:

Presence of significant psychosocial stressors
Intrapsychic conflict
Interpersonal difficulties
Co-morbid axis II disorder

Combination of medication and psychotherapy may be useful for patients with moderate to severe MDD and

Psychosocial issues
Interpersonal problems
A co morbid axis II disorder
Poor adherence with treatment modalities
Partial response to adequate trials of single treatment modalities

ECT should be considered for patients with MDD with

A high degree of symptom severity and functional impairment
Presence of psychotic symptoms or catatonia

Combination of antipsychotic and antidepressant medications or ECT should be used for psychotic depression

Other Recommendations:

Brief recommendations for treatment after the initial phase are also included:

Management in the Continuation Phase (during 16-20 weeks following remission)
Management in the Maintenance Phase
Considerations in the Decision to Use Maintenance Treatment

The Expert Consensus Guideline Series: Pharmacotherapy of Depressive Disorders in Older Patients

A Postgraduate Medicine Special Report, October 2001 {http://www.psychguides.com/ecgs5.php}

The recommendations in this 80 plus page guideline reflect the aggregate opinions of 50 experts who were identified from the NIMH list of grant recipients for research in geriatric psychiatric disorders, and the membership of the American Association of Geriatric Psychiatry.

These guidelines address a number of key questions concerning the pharmacological treatment of depression in older adults, including:

Assessment of depression in older patients
Selection of acute treatment strategies and medications
Dosing and duration of treatment
Treatment resistance
Strategies for continuation and maintenance treatment
Special treatment issues
Treatment of depression in the presence of co morbid medical conditions
Management of depression that is associated with a medication
Combining medications in older patients

There is also a “Depression in Older Adults: A Guide for Patients and Families” {http://www.psychguides.com/Geriatric Depression LP Guide.pdf } that was prepared by George S. Alexopoulos, M.D., Ira R. Katz, M.D., Ph.D., Charles F. Reynolds, III, M.D., and Ruth Ross, M.A., with the assistance of the National Depressive and Manic-Depressive Association (NDMDA), the American Association of Geriatric Psychiatry and the Alzheimer’s Association.

Clinical Practice Guideline: Pharmacotherapy Companion to Depression

American Medical Directors Association {http://www.amda.com/info/cpg/depressiontherapy.htm}

This guideline consists of a series of questions that should be addressed when selecting an antidepressant drug along with comments based on literature review and consensus. In addition, the guideline addresses pharmacoeconomic considerations and the role of the consultant psychiatrist. The treatment questions that the clinician should ask fall into three broad areas:

Confirming the diagnosis and determining the need for pharmacotherapy

Does the patient meet DSM-IV criteria?
Is the patient on any medication that may be contributing to the depressive symptoms?
Does the patient have an underlying medical condition which may be contributing to depressive symptoms? If so, has it been addressed?
Does the patient need drug therapy I addition to environmental, spiritual, cultural and ethnic approaches to the treatment of depression?

Selecting, initiating and titrating the drug

Has the patient (or a family member) been treated with an antidepressant in the past? If so, what was it and how effective was it
Does the patient have absolute or relative contraindications to specific antidepressants?
Have the patient’s current medications been reviewed to determine the potential for drug interactions with an antidepressant?
Has an appropriate starting dose been selected and has the initial titration schedule been written?
What are the consequences of the drug selection for the facility?

Monitoring outcomes

How and when will the clinician measure response to the antidepressant drug?
Has there been a noticeable improvement in the target symptoms after 4-6 weeks on the current dose?
Has there been a noticeable improvement in target symptoms after 4-6 weeks on the optimal tolerated dose?
How long should the patient who has no intolerable side effects remain on an antidepressant once treatment goals are met?

A clinical algorithm is provided that summarizes the steps involved in addressing and pharmacologically treating depression in long-term care patients.

The guideline was developed by an interdisciplinary work group using a process that combined evidence and consensus based thinking. Scientific research in the long-term care setting is scarce and the majority of recommendations are based on the expert opinion of practitioners in the field.

Treatment of Depression – Newer Pharmacotherapies

Evidence Report/Technology Assessment Number 7, by Agency for Health Care Policy and Research (AHCPR) http://www.ahcpr.gov/clinic/epcsums/deprsumm.htm

The ultimate purpose of this report is to help clinicians make informed choices about newer antidepressant drugs and herbal therapies, and to aid organizations developing clinical guidelines for the treatment of depression. It provides a comprehensive evaluation of the newer pharmacotherapies and herbal treatments for depressive disorders in adults and children and focuses on 29 newer antidepressant drugs and 3 herbal remedies. Older antidepressants and psychosocial therapies are considered only when they are compared directly to a newer antidepressant.

An expert multidisciplinary panel formulated 24 specific questions, guided by 2 key principles: the potential to summarize new information not addressed in previous literature synthesis and relevance to clinicians making treatment decisions and policymakers developing guidelines.

Questions address

The efficacy of newer pharmacotherapies for the most prevalent forms of depression and for individuals with recurrent or refractory depression
Relative efficacy of newer agents compared to psychosocial therapies and the efficacy of herbal remedies
Major depression and other depressive disorders

Primary outcomes of interest

Depressive symptoms as assessed by a rating scale or clinical diagnosis
Total dropouts and dropouts due to adverse effects

Secondary outcomes

Health-related quality of life
Functional status
Suicides

The report also focuses on

specific patient populations (e.g., children and adolescents)
specific settings (e.g., primary care or post-partum care)
issues involving combination treatments with other psychotropics, psychosocial therapies, and augmenting agents
long term efficacy
questions related to adherence
common adverse effects
but serious adverse effects
gaps in knowledge which could not be answered by the available evidence

Depression: A Guide to Diagnosis and Treatment

Brigham and Women’s Hospital {http://www.brighamandwomens.org/medical/handbookarticles/
depression/depression_frame.asp

Major Recommendations:

Diagnostic strategy
Treatment
Major risk factors for recurrent depression
Depressive disorders unique to women

Premenstrual dysphoric disorder (PMDD)
Postpartum depression
Depression during perimenopause

Guideline recommendations are based on a comprehensive assessment of research on depression and the American Psychiatric Association’s Practice Guideline for Major Depressive Disorder in Adults.

A 12-page patient resource document, Depression: Taking care of your emotional health (2002) is available at the Brigham and Women’s Hospital Web site, www.brighamandwomens.org

Screening for Depression: Recommendations and Rationale

Third US Preventive Services Task Force (USPSTF) {http://www.gideline.gov/summary/summary.aspx?ss=15&doc_id=3176&nbr=2042}

SUMMARY

Intended users: Advance practice nurses, nurses, physician assistants and physicians in primary care specialties (dermatology, family practice, internal medicine, pediatrics, psychiatry and psychology)

Interventions and practices considered:

Screening

Instruments

Zung self-assessment depression scale
Beck Depression Inventory
General Health Questionnaire
Center for Epidemiologic Study Depression Scale
Other screening instruments

Asking questions about mood and anhedionia
Full diagnostic interviews using standard diagnostic criteria
Recurrent screening

Treatment

Antidepressants, such as tricyclics, SSRI’s, heterocyclic agents, MAOIs
Psychotherapeutic approaches (cognitive-behavioral therapy or brief psychosocial counseling)
Combined medication and psychotherapy
Education/quality improvement interventions

Major outcomes considered

Accuracy (sensitivity, specificity and positive or negative predictive values)
Effects of screening and feedback on rates of diagnosis, treatment and patient outcomes
Clinical outcomes after treatment, including severity of depression, functional status and health care utilization.

The USPSTF grades its recommendations according to one of five classifications reflecting the strength of the evidence and magnitude of net benefit (benefits minus harms).

A: strongly recommend routinely providing to eligible patients
B: Recommend routine provision to eligible patients
C: Makes no recommendation for or against
D: Recommends against providing the service to eligible patients
I: Evidence is insufficient to recommend for or against routinely providing the service.

Recommendations

The USPSTF recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment and follow-up. Grade B recommendation.

The UDPDTF concludes the evidence is insufficient to recommend for or against routine screening of children or adolescents for depression. Grade I recommendation

Major Depression in Adults for Mental Health Care Providers

Institute for Clinical Systems Improvement {http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=179}

SUMMARY

Scope and Target Population: major depressive episodes in outpatient setting for adults

Clinical Highlights for Physicians:

How to evaluate whether a system is successfully functioning in its diagnosis, treatment plan and follow up of major depression
What the presentations for depression are
Evaluate depressed patients using all five axes in the DSM-IV TR criteria and provide documentation for this evaluation
Assess patients who present with the following and consider emergency treatment or hospitalization

safety risks to themselves or others
are unable to care for themselves
experience psychotic thinking

Treatment decisions should involve agreement between the patient and his or her provider
Phases of treatment
- Acute refers to treating with antidepressant medication in order to achieve remission of depressive symptoms
- Continuation is the phase where one continues to treat with antidepressants in order to keep the patient free of symptoms for the duration of the current episode
Medication guidelines are given

Priority Aims and Suggested Measures for Health Care Systems

Improve the comprehensive evaluation of patients with major depression
Improve the efficacy of treatment through diagnosis of major depression
Improve the assessment of patients of treatment and its effectiveness for patients diagnosed with major depression by using a reliable scale at follow-up visits to show symptom reduction
Improve the adherence and maintenance of appropriate treatments for patients diagnosed with major depression by having follow up contacts with a health care professional

Intended Users: all primary care and mental health professionals treating patients with major depressive disorders

Recommendations

Recommendations are provided in the form of an algorithm with 14 components, accompanied by detailed annotations. Components of the algorithm are:

Patient presents with depressive symptoms
Evaluate psychiatric symptoms and co-morbidities
Does patient fit DSM-IV criteria for major depressive episode
Does patient need emergency treatment?
Is active chemical abuse/dependency present?
Treat for current or most recent episode using medication and/or psychotherapy/educate about depression
Is patient responding adequately?
Evaluate dose, duration and compliance
Continuation and maintenance treatment for major depressive episode
Consider other strategies

The Pharmacologic Management of Major Depression in the Primary Care Setting

Medical Advisory Panel for the Pharmacy Benefits Management Strategic Health Group, Department of Veterans Affairs {http://www.vapbm.org/guidelines/depressionguidelines_1.pdf}

SUMMARY

This guideline is the work of the Medical Advisory Panel for Pharmacy Benefits Management of the Department of Veterans Affairs. It is comprised of practicing physicians from the VA and the Department of Defense. Whenever possible, this group relies upon evidence-based, multidisciplinary, nationally recognized consensus statements for the basis of VA guidelines. Relevant literature is reviewed and assessed with consideration given to the VA population. The literature was critically analyzed with evidence grading. The rating scale used for this document was based on the evidence rating used by the US Preventive Services Task Force, adapted from the Canadian Task Force on the Periodic Health Examination.

The purpose of the guidelines is to assist practitioners in clinical decision-making, to standardize and improve the quality of patient care, and to promote cost-effective drug prescribing

They are attuned to the needs of primary care practice but are directed to providers at all levels
They also serve as a basis for monitoring local, regional and national patterns of pharmacological care geared to VA-type populations

The guideline is divided into four sections:

Executive summary:
- As many as one in 8 individuals may require treatment for depression during their lifetimes.
- Given the high prevalence of depressive symptoms and major depressive episodes in patients of all ages, depression should be routinely considered and treated by PCPs and other non-psychiatric practitioners.
- Diagnosis of depression is based on assessment of the patient’s mood, behavior and physical symptoms. Some clinicians use structured interviews or questionnaires to assist in screening and/or diagnosis of depression. Choice of screening instrument should be left to the discretion of the practitioner.
No one antidepressant medication is clearly more effective than another. No single medication results in remission for all patients. Patient-specific factors and drug side effect profiles may favor one class over another, but there are no clear differences in efficacy among or within classes.
Selective Serotonin Reuptake Inhibitors (SSRIs) should be considered first line antidepressants for most patients in the primary care setting because of their low toxicity relative to other available antidepressants.

There is insufficient evidence to recommend one specific SSRI over another.

Patients who present with depression and suicidal thoughts and/or symptoms of psychosis should be immediately evaluated by a psychiatrist.
Algorithm – The algorithm is intended to provide a systematic approach to the management of patients with major depression. The letters within the boxes refer to the corresponding annotations.
Annotations are the further discussion of the evidence for making each recommendation . Details on drug therapy are provided to encourage the safe and effective implementation of the pharmacotherapy recommendations made in this guideline. Recommendations discussed in the annotation are referenced and graded according to the grading system noted above.
Appendices provide additional information for the clinician when considering treatment options.
Contains many helpful tables and diagrams

Guidelines for the Treatment and Management of Depression by Primary Healthcare Professionals

National Health Committee { http://www.nzgg.org.nz/guidelines/0039/depression_guideline.pdf }

SUMMARY

This monograph of guidelines from New Zealand was published in 1996 to help primary care workers recognize and manage depression. One of its strong features is the culture specific information on the Maori and Pacific Islanders. In addition to the topics listed below there are 12 appendices covering topics that range from DSM-IV criteria for the diagnosis of depression to medical conditions that commonly have associated depression, various interview guides and scales to guides for antidepressants prescribed in New Zealand, guidelines for the care of people in the community who are at risk for suicide, lists of consumer and support groups and references. There are a number of useful tables and diagrams throughout the narrative.

Definition of depression and description of various depressive disorders
Prevalence of depression
Etiology and risk factors
The clinical course of major depressive episode and dysthymic disorder
Recognition and diagnosis

Maintain a high index of suspicion and evaluate risk factors
Consider the differential diagnosis

Substance abuse
Other psychiatric disorders
Dementia in older people
General medical conditions and medications
Grief reaction or periods of sadness

Diagnosis of depressive disorders

Deciding whether there is a depressive disorder
Additional factors to be considered for older people
Additional issues for interviewing children and adolescents

Assessment

Assessing the nature and severity of the depressive disorder

Assessing the risk of suicide and likelihood of harm to others
Outpatient treatment of people who are suicidal

Development of a therapeutic relationship-working together
Assessment of severity
Assessment of melancholic features
Assessment of duration of the depressive disorder
Assessment of cultural issues
Maori
- Signs of depressive disorders
Pacific Island cultures
Assessment of other issues

Gender issues
Postnatal depression
Violence issues
Sexual orientation

Initial treatment options

Involvement of others
Monitoring

Frequency of monitoring

Initial treatments

Education
Lifestyle
Problem solving

Use of antidepressants and psychological interventions

Antidepressants
Specialist treatment
Factors in selecting a specific antidepressant
Risks of suicide using antidepressants
Combining antidepressants with psychological therapies
Psychological therapies
Cognitive behavioral therapy
Interpersonal therapy
When to use psychological therapy
How to use psychological therapy (alone or with medication)
The psychological therapies referral

Treatment issues for special populations

Older people
Children and adolescents
Women
Sexual orientation

Cultural issues

Maori
Pacific Islands people

Monitoring and review of treatments

Monitoring
Continuation of treatment

Effective treatment for the continuation phase

Changing treatments

Maintenance

How to maintain outcomes and prevent relapse

Self help groups
Psychological therapies
Discontinuation of medication

Specialist treatment

When to refer to mental health services or a psychiatrist
Valuable information when referring.