Diagnosing And Treating Depression In Older Adults
This information on depression is for health and mental health professionals including:
- psychologists
- psychiatrists
- psychotherapists
- physicians
- psychiatric nurses
- clinical social workers
This information is for reference only. Actual recommendations will depend on the needs of individual patients and resources available.
Prevelance
Risk Factors and Symptoms
Diagnosis
Management
Prevelance
- According to Mental Health: Report of the Surgeon General (1999), 3.8% of people over the age of 55 residing independently in the community suffer from major depression in any given year.
- Of the nearly 35 million Americans age 65 and older, an estimated 2 million have a depressive illness (major depressive disorder, dysthymic disorder, or bipolar disorder) and another 5 million may have ”subsyndromal depression,“ or depressive symptoms that fall short of meeting full diagnostic criteria for a disorder.
- Having a chronic medical illness increases a person’s risk of having a depressive disorder. In outpatient medical settings, the prevalence of major depression among seniors is about 12%; in nursing homes, it is about 25%.
Alexopoulos GS. Mood disorders. In: Sadock BJ, Sadock VA, eds. Comprehensive Textbook of Psychiatry, 7th Edition, Vol. 2. Baltimore: Williams and Wilkins, 2000.
Narrow WE. One-year prevalence of depressive disorders among adults 18 and over in the U.S.: NIMH ECA prospective data. Unpublished table.
U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.
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Risk Factors and Symptoms
Risk factors for depression
- Family history of:
- Recurrent depression
- Bipolar disorder
- Alcohol abuse or dependence
- Personal history of :
- Chronic medical illnesses, especially heart disease, Parkinson’s disease, Alzheimer’s disease, diabetes mellitus, stroke, and cancer.
- Chronic pain
- Loss of physical functioning
- Prior depressive disorders
- Recent significant loss
- Multiple recent stressors (within past 6 months)
- Social isolation
Symptoms of depression
Sadness does not always equal depression, and depression is not always marked by sadness. A person may be depressed if he or she experiences:
- Changes in:
- Sleep (increase or decrease), especially if he or she wakes up at 2 or 3 AM and can t get back to sleep
- Weight (gain or loss)
- Loss of interest in sex
- Interpersonal relationships (not wanting to be with or around other people)
- Feelings of:
- Apathy
- Anxiety
- Helplessness and hopelessness
- Irritability
- Problems with:
- Fatigue, low energy
- Anhedonia (lack of interest in usual activities or hobbies)
- In addition to these symptoms, depressed individuals may:
- Complain of multiple vague physical symptoms, such as headaches, joint aches, GI discomfort
- Visit a medical doctor 5 or more times in 1 year for somatic complaints (e.g., headaches, body aches, abdominal pain)
- Have difficulty adhering to treatment for a chronic health problem
- Begin to drink alcohol excessively
Other potential causes of symptoms
- Alcohol or substance abuse
- Cognitive impairment or dementia
- Medication
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Diagnosis
DSM-IV diagnostic criteria
A definitive diagnosis of depression is based on the following criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV):
- Increase or decrease in sleep
- Loss of interest in formerly pleasurable activities
- Guilt, low self-esteem
- Low energy
- Poor concentration
- Increase or decrease in appetite
- Psychomotor agitation or retardation
- Suicidal ideation
DSM-IV TR criteria: five axes
Evaluate depressed patients using all five axes in the DSM-IV TR criteria:
- Axis I: Clinical Disorders, other conditions that may be a focus of clinical attention
- Axis II: Personality Disorders, borderline intellectual functioning or mental retardation
- Axis III: General Medical Conditions
- Axis IV: Psychosocial and Environmental Problems and Stressors
- Axis V: Global Assessment of Functioning
Screening Instruments
More specialized assessments
Some patients also require evaluation for:
- Medical problems
Lab tests (for example, serum vitamin B12 and folate levels, fasting glucose and thyroid function tests)
- Psychological issues
Cognitive testing
- Substance abuse
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Management
Care for suicidal patients
- Refer patients who present safety risks to themselves or others to a hospital emergency department
Medication
Anti-depressant drugs
Commonly Prescribed Antidepressant Drugs:
| Type: |
Examples: |
| TSSRI: selective serotonin reuptake inhibitor |
Zoloft (sertraline), Prozac (fluoxetine), Paxil (paroxetine), Celexa (citalopram); Lexapro (Escitalopram)
|
| SNRI: serotonin and norepinephrine reuptake inhibitor |
Effexor (venlafaxine); Cymbalta (Duloxetine)
|
| NaSSA: noradrenaline and selective serotonin antidepressant |
Remeron (mirtazapine)
|
| NDM = norepinephrine and dopamine modulator |
Wellbutrin (bupropion)
|
| MAOI: Monoamine oxidase inhibitor |
Nardil (phenelzine)
|
| TCA: Tricyclic antidepressant |
Pamelor (nortriptyline); Norpamine (desipramine)
|
All antidepressants appear to be equally effective in large populations, so the choice of agent is usually based on: potential side effects that are either helpful (such as sedation for insomnia symptoms) or harmful (such as anticholinergic symptoms) to the patient; coexisting medical and psychiatric illnesses; prior response to antidepressants in either the patient or close relatives; and possible drug-drug interactions.
Suggested guidelines for acute treatment
- Patients are typically started on the lowest effective dose of medication; the dosage may be increased based on tolerability of side effects and if there has been no response after 1-2 weeks of treatment.
- Most side effects to anti-depressant drugs occur in the first few weeks of treatment. Schedule follow-up visits at least 3 times in the first 3 months.
- It may take 2-4 weeks of treatment before a patient begins to feel better. Other patients may experience relief within 2-3 days.
- For patients who do not respond to an adequate trial of a particular anti-depressant, a change to a different medication may be helpful.
- Patients should continue to take anti-depressants even after they feel better because stopping the medicine too soon can result in a relapse.
- If this is the first depressive episode, patients should continue to take antidepressants for at least 12 months. Then they can gradually taper and try to discontinue the medication, always watching for a recurrence of their symptoms.
- If this is the second or more depressive episode in the patient s lifetime, he or she should take antidepressants indefinitely. The medication can treat the acute episode and it can prevent future episodes. Once someone has had 2 or more episodes of depression, the chance of another episode in the future is extremely high (80-90%).
Lack of a response to anti-depressant medication may be due to:
- Non-compliance
- Inadequate dosing
- Inadequate duration of therapy
- The wrong choice of medicine.
Psychotherapy
Immediately refer patients to a psychiatrist if they have depression plus any of the following conditions:
- Severe anxiety or anorexia
- Significant psychomotor agitation or retardation
- Psychosis or mania
- Suicidal or homicidal thinking
Consider referring patients to a psychiatrist if they have depression plus any of the following disorders:
- Substance abuse
- Eating disorders
- Post traumatic stress or other anxiety disorders
- Physical or emotional abuse issues
- Obsessive compulsive disorder
- Personality disorders
Combined pharmacotherapy and psychotherapy
For patients with depression who have been treated with psychotherapy alone:
Consider medication if symptoms do not improve after 6 weeks or if symptoms continue after 3 months. Medication should always be considered if the patient has suicidal thoughts, psychotic symptoms (e.g., if he or she is hearing derogatory or other types of voices or having delusions), severe vegetative symptoms (such as refusal to eat or large weight loss), or worsening of symptoms.
Continuation treatment
- Acute treatmentmost often refers to the first three months after the patient begins to take antidepressant drugs. The goal of this treatment is to achieve remission of the symptoms of depression.
- Remissionrefers to minimal residual symptoms (Hongtu: add links to more info. on these scales.}Hamilton Depression Scale score less than 7 or PHQ-9 score of 4 or less).
- To prevent a relapse, most patients should remain on continuation treatment (at the medication s full dosage) for 12 months following symptom resolution.
Maintenance treatment
- Some patients remain on maintenance therapyfollowing continuation treatment.
- The risk of recurrenceof depression increases with each episode of depression. Maintenance treatment is advised for patients who have had 2 or more previous episodes of depression.
Discontinuing active treatment
Few people like to take medication and patients often want to stop taking antidepressants. This is best done gradually. Patients should be reminded of the symptoms they had when they were first treated for depression. These symptoms are likely to recur and they should watch for them when they begin to lower the dosage of the antidepressant. If the symptoms do begin to reappear, the patient should go back to the previous dose of medication that kept the symptoms under control.
Abruptly ending treatment can cause short-term reactions in a discontinuation syndrome:
Physical symptoms of this syndrome include:
- Gastrointestinal problems (nausea, vomiting, cramping, diarrhea)
- Sleep disturbances
- Headaches, dizziness, and imbalance
- Sweating
Psychological symptoms of this syndrome include:
- Anxiety
- Agitation
- Low mood
Tapering dosages of anti-depressants, rather than stopping abruptly, can prevent discontinuation syndrome.
Adapted from:
- Brigham and Women's Hospital. Depression. A guide to diagnosis and treatment. Boston (MA): Brigham and Women's Hospital; 2001. 9 p. [6 references]
- Excellus/Identification and Treatment of Major Depression in Primary Care
