Depression in the Elderly Laura Moyer MD December 8, 2010 Objectives Review criteria for the diagnosis of depression and discuss several commonly used screening instruments Discuss risk factors for depression in the elderly Review treatment options for depression DSM IV Criteria for Major Depressive Episode Five or more of the following symptoms have been present during the same 2-wk period and represent a change from previous functioning. At least one of the symptoms is either depressed mood or loss of interest or pleasure Depressed mood most of the day, nearly every day Loss of interest or pleasure in activities Significant wt loss or gain or change in appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Decreased ability to think/concentrate or indecisiveness Recurrent thoughts of death; suicidal ideation Other common mood disorders 1. Mood disorder due to a general medical condition When depression appears to result directly from a specific medical condition (ie hypothyroidism or pancreatic cancer) In addition to treatment of the medical condition, treatment of the mood disorder is also often needed 2. Minor Depression Also called sub-syndromal depression, mild depression, and sub-clinical depression. Defined as having 2-4 depressive symptoms as described in DSM-IV criteria for MDD. Is more common than late-life MDD. 15-50% of patients with minor depression develop MDD within 2 years. Prevalence of depression Major depression Clinically significant depressive symptoms Acute care hospitals Approx 11% 25% Non-psychiatric outpatient clinics Approx 5% 10% Long-term care settings Approx 12% 30% Risk Factors for Late Life Depression Unlike depression in early life, genetic factors are less important in depression that starts later in life. Late onset depression is associated with a higher frequency of : Cognitive impairment Cerebral atrophy Deep white matter changes Patients at risk for cerebral vascular disease (ie HTN, DM) are at greater risk for developing late life mood disorders (including pts with small vessel vascular disease.) Other risk factors include hx of depression, chronic medical illness, female sex, being single or divorced, alcohol abuse, stressful life events. MEDICATIONS THAT MAY CAUSE DEPRESSION Birrer and Vemuri (2004) Cardiovascular drugs: Clonidine (Catapres) Digitalis Guanethidine (Ismelin) Hydralazine (Apresoline) Methyldopa (Aldomet) Procainamide (Pronestyl) Propranolol (Inderal) Reserpine (Serpasil) Thiazide diuretics Antiparkinsonian drugs: Amantadine (Symmetrel) Bromocriptine (Parlodel) Levodopa (Larodopa) Antipsychotic drugs: Fluphenazine (Prolixin) Haloperidol (Haldol) Sedatives and antianxiety drugs: Barbiturates Benzodiazepines Chloral hydrate Ethanol Anticonvulsants: Carbamazepine (Tegretol) Ethosuximide (Zarontin) Phenobarbital Phenytoin (Dilantin) Primidone (Mysoline) Chemotherapeutics: 6-Azauridine Asparaginase (Elspar) Azathioprine (Imuran) Bleomycin (Blenoxane) Cisplatin (Platinol) Cyclophosphamide (Cytoxan) Doxorubicin (Adriamycin) Mithramycin (Mithracin) Vinblastine (Velban) Hormones: Adrenocorticotropin Anabolic steroids Glucocorticoids Oral contraceptives Other drugs: Choline Cimetidine (Tagamet) Disulfiram (Antabuse) Lecithin Methysergide (Sansert) Phenylephrine (Neo-Synephrine) Physostigmine (Antilirium) Ranitidine (Zantac) Anti-inflammatory/anti-infective agents: Ampicillin Cycloserine (Seromycin) Dapsone Ethambutol (Myambutol) Griseofulvin (Grisactin) Isoniazid (INH) Metoclopramide (Reglan) Metronidazole (Flagyl) Nalidixic acid (NegGram) Nitrofurantoin (Furadantin) Nonsteroidal anti-inflammatory agents Penicillin G procaine Streptomycin Sulfonamides Tetracycline Stimulants: Amphetamines (withdrawal) Caffeine Cocaine (withdrawal) Methylphenidate (Ritalin) Major Depression in Neurologic Disorders Associated with Aging Stroke 40-60% Parkinson Disease 30-40% Alzheimer’s Disease 20-40% Birrer and Vemuri (2004) Suicide in the elderly 14.3 of every 100,000 people age 65 and older died by suicide in 2004, higher than the rate of about 11 per 100,000 in the general population. Non-Hispanic white men age 85 and older were most likely to die by suicide. They had a rate of 49.8 suicide deaths per 100,000 persons in that age group. Up to 75% of older adults who die by suicide visited a physician within a month before death. www.cdc.gov/ncipc/wisqars Mortality Late life depression has been associated with increased mortality apart from suicide Murphy et al (1987) – 16 year prospective study of a general population. Persons with reported depression experienced 1.5x number of deaths expected on the basis of rates for a large reference population. Challenges in diagnosing depression in late life Clinicians and family may incorrectly attribute depressive symptoms to aging process or result of life stresses/losses (such as physical illness, spousal death, financial stresses.) In older adults, patients may not report feeling depressed, but may have anxiety, somatic symptoms, irritability, and/or cognitive decline. Agitation in patients with dementia can be a symptom of depression. Patients may deny or under report symptoms due to stigma/shame of psychiatric symptoms. Undetected depression in older patients Licht-Strunk et al (2009) – Conducted a one year follow-up study of GP pts >55y/o who were diagnosed with depression using the GDS-15 and PRIME-MD. GPs and pts were not informed of the test results. 67% of pts were not detected by GP as being depressed – of these pts 33% had remitted after one year 33% of pts had depression detected by GP – of these pts 37% had remitted after one year Other studies suggest that primary care physicians may fail to recognize 30-50% of patients with major depressive episodes - Thibault and Steiner (2004) Screening for Depression The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. Grade: B recommendation What if any screening instrument do you use? Screening for Depression Patient Health Questionnaire (PHQ-9) This questionnaire consists of several statements. Read each statement carefully, then pick the number that best describes the way you have been feeling during the past two weeks, including today. Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several Days More than half the days 0 1 2 Nearly every day 3 1) Little interest or pleasure in doing things? 2) Feeling down, depressed, or hopeless? 3) Trouble falling or staying asleep, or sleeping too much? 4) Feeling tired or having little energy? 5) Poor appetite or overeating? 6) Feeling bad about yourself -- or that you are a failure or have let yourself or your family down? 7) Trouble concentrating on things, such as reading the newspaper or watching television? 8) Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual? 9)Thoughts that you would be better off dead or of hurting yourself? Screening for Depression PHQ-2 is comprised of the first 2 questions of the PHQ-9. Patients who score >= 3 on PHQ-2 should be assessed with the remaining 7 questions of the PHQ-9. PHQ-9 sensitivity 88%, specificity 88%. Positive predictive value when used as a standardized screening test is 56%, but when given to selected patients suspected of having depression it increases to 88% - Thibault and Steiner (2004) Indications to Start Antidepressant Therapy Based on PHQ-9 PHQ-9 Depression Score Severity 1-4 None Clinician Response None 5-9 Mild-moderate If not currently treated, rescreen in 2wks. If on treatment, optimize RX and rescreen in 2wks. 10-14 MDD Start antidepressant therapy >=15 MDD Start antidepressant therapy; obtain psych consult if suicidality or psychosis is suspected. Prescriber Response Guidelines at 4wks Based on PHQ-9 and STAR*D Studies PHQ-9 Score or Change No decrease or increase Decrease of 2-4 points Decrease of >=5 points Score <5 Outcome No response Partial response Response Remission Clinician Response Switch medication Add medication Maintain medication Maintain medication Geriatric Depression Scale (GDS, short form) Choose the best answer for how you have felt over the past week: 1. Are you basically satisfied with your life? YES / NO 2. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO 4. Do you often get bored? YES / NO 5. Are you in good spirits most of the time? YES / NO 6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO 8. Do you often feel helpless? YES / NO 9. Do you prefer to stay at home, rather than going out and doing new things? Y/ N 10. Do you feel you have more problems with memory than most? YES / NO 11. Do you think it is wonderful to be alive now? YES / NO 12. Do you feel pretty worthless the way you are now? YES / NO 13. Do you feel full of energy? YES / NO 14. Do you feel that your situation is hopeless? YES / NO 15. Do you think that most people are better off than you are? YES / NO http://www.stanford.edu/~yesavage/GDS.english.short.html Geriatric Depression Scale Although differing sensitivities and specificities have been obtained across studies, for clinical purposes a score > 5 points is suggestive of depression and should warrant a follow-up interview. Scores > 10 are almost always depression. Wancata et al (2006) – Systematic review looking at the screening accuracy of both versions of the GDS. GDS-30 sen 0.753, spec 0.770, GDS-15 sen 0.805, spec 0.750 Evaluating patients with dementia for depression Neither PHQ-9 or GDS are reliable when administered to pts with moderate/severe dementia (but are valid in pts with MMSE scores >=15) – Katz (1998) Issues with applying DSM- IV criteria (For example, cannot use “decreased ability to think/concentrate” as a criteria for diagnosis.) Ascertainment of symptoms requires recall of recent experiences. Evaluating patients with dementia for depression Hamilton Depression Rating Scale (HDRS) – 21 questions asking about symptoms such as insomnia, agitation, anxiety, and somatic symptoms. Has been used to demonstrate treatment responses for depression in randomized clinical trials in patients with dementia. Another similar scale is the Cornell Scale for Depression in Dementia (CS) Evaluating patients with dementia for depression There can be discrepancies between patient and caregiver-derived information regarding presence of depression. Based on patient interviews,14% of a sample of pts with AD met DSM criteria for major depression, but 50% did on the basis of info from caregivers. Motivational disturbances increase with severity of dementia (symptoms such as apathy, passivity, and decreased initiative.) It has been suggested that most apathy observed in AD is unrelated to depression and that emphasizing motivational/vegetative symptoms is likely to lead to overdiagnosis. Katz (1998) Evaluation and Treatment Evaluate medical status/thyroid/substance abuse (ie sedatives and alcohol) Consider time course of medication use to symptom onset When picking an antidepressant, ask about prior antidepressant use and family hx of antidepressant use Select antidepressant based on side effect profile and ease of dosing Only 10-40% of depressed elderly are given medication More than 1/3 of pts rely solely on their primary care physician for treatment of psychiatric conditions Birrer and Vemuri (2004); amednews.com (11/2010) Treatment If patient has depression with psychotic features, than treatment with combo of antidepressant and antipsychotic or ECT or referral to psychiatrist should be initiated. (Psychotic symptoms are present in 20-45% of hospitalized elderly pts with depression and 3.6% of community-dwelling pts with depression.) Compared with nonpsychotic depression, patients with psychotic depression have recovery rates that are reduced by ½ and relapse and disability rates 2x greater. Treatment Only 50% of pts with MDD fully respond to an initial antidepressant treatment. An additional 1/3 recover when the antidepressant is switched to another agent or augmented with a 2nd antidepressant or psychotherapy. Outcome studies indicate the recovery rate for elderly depressed pts is similar to younger depressed patients. Causes for poorer outcomes include clinicians prescribing too low doses for too short of time Treatment Data indicates that 4 wks is adequate to identify pts who will be non-responders or partial-responders at 12 wks. At 4 wks on treatment: 1/3 non-responders 1/3 partial-responders 1/3 full-responders ACOVE Guidelines In an older adult, newly treated for depression, document within 4 wks of treatment initiation: Degree of response to >= 2 of 9 DSM IV criteria Any medication adverse events If no meaningful response after 6 wks of Rx, then by the 8th week: Rx dose should be optimized or changed or refer to psychiatrist If pt has only partial response after 12 wks of Rx, then by the 16th week: Switch to a different med class or add 2nd med or add psychotherapy or refer to psychiatrist PROSPECT (Prevention of Suicide in Primary Care Elderly- Collaborative Trial) – published guidelines for pharmacological treatment of late-life depression. Augmentation vs Substitution STAR *D (Sequenced Treatment Alternatives to Relieve Depression)- When pts did not achieve remission with citalopram, augmentation with bupropion or buspirone achieved remission in 1/3 of pts and was superior to switching to another agent (remission achieved in ¼ of pts who switched to venlafaxine, bupropion, or sertraline.) PROSPECT: In partial responders, the algorithm favors first a dosage increase up to the maximum recommended dosage followed by augmentation of current treatment. Augmentation vs Substitution Factors favoring substitution: Avoids potential drug-drug interactions Simpler medication regimen and lower costs Easier attribution and management of side effects Factors favoring augmentation: Preserves improvement produced by current antidepressant (in partial responders) Prevents delay associated with discontinuation of current med and titration of a new one Combo of two different antidepressants affecting different neurotransmitter systems may have synergistic effect ACOVE Guidelines If patient has responded to Rx, then continue on same dose for >= 6 mo If patient has had >=3 episodes of depression, than pt should receive maintenance therapy with same dose for >= 24 mo. Recurrence risk after 1st episode of major depression – 50%, after 2nd episode 70%, after 3rd episode 90% SSRIs SSRIs are recommended 1st line antidepressant. – often initiate doses at half usual adult dosage and then titrate slowly for a few weeks to optimal dose. More favorable safety and side effect profiles compared with other antidepressants. Common side effects include GI symptoms– other potential side effects include hyponatremia, sweating, sexual dysfunction, insomnia, somnolence, tremor. SSRIs are weak inhibitors of cytochrome P450 system – can affect pts taking drugs with dosage-dependent enzyme inhibition interactions and a narrow therapeutic index (ie TCAs, neuroleptics, anticonvulsants, warfarin.) SSRIs Sertraline (Zoloft) – begin 25mg, move to 50mg as indicated. Rarely need greater than 100mg in elderly but can increase to 200mg Citalopram (Celexa) – begin 10mg; final dosage 20-40mg Escitalopram (Lexapro) – begin 5-10mg ; final dosage 10-20mg Fluoxetine (Prozac) – long half life a disadvantage – begin 5-10mg; final dosage 2040mg Paroxetine (Paxil) – May be sedating/cause fatigue, withdrawal occurs – begin 10mg; final dosage 20-40mg Other Antidepressants Bupropion (Wellbutrin)– may be as effective as SSRIs and TCAs in treatment of MDD – begin 75mg bid - lowers seizure threshold, insomnia, no anxiolytic properties; final dosage 150-300mg Trazodone – begin 25-50mg –sedation; final dosage 100400mg Mirtazapine (Remeron) – begin 7.5mg - sedation, increased appetite; final dosage 15-45mg SNRIs Venlafaxine (Effexor) – option for treatment resistant depression, rapid onset - begin 37.5 -75mg - HTN, anxiety, GI symptoms; final dosage 75-300mg Duloxetine (Cymbalta) – begin 20mg – increased lfts – approved for neuropathic pain treatment; final dosage 3060mg Other Antidepressants ACOVE guidelines – If starting an antidepressant, then the following medications should not be used as 1st or 2nd line therapy: tertiary amine tricyclics (amitriptyline, doxepin,imipramine, clomipramine, trimipramine), MAOIs; unless atypical depression is present, benzos, or stimulants (except methylphenidate.) TCAs with fewer anticholinergic side effects include nortriptyline (secondary tricyclics.) TCAs can cause sedation, cardiac effects, orthostatic hypotension, and lower seizure threshold. Hypo/hypertension and food-drug interactions are most likely problems with MAOI use. Augmentation strategies Buproprion to SSRIs or Venlafaxine Mirtazapine ECT Patients intolerant to treatment Depressed elderly with somatic symptoms may mistake somatic symptoms early in treatment for side effects, leading to premature discontinuation of antidepressant medication. In PROSPECT, somatic symptoms are assessed at baseline and at f/u. If side effects occur, dosage or time of administration can be adjusted, or symptomatic treatment instituted (ie stool softeners). Pts unable to tolerate citalopram 10mg/day are treated with bupropion SR. If unable to tolerate it, they are switched to nefazodone. “Citalopram, bupriopion, and nefazodone affect different neurotransmitter systems and have distinct side effect profiles. Thus, it is unlikely that a patient would not be able to take any of these medications.” Psychotherapeutic interventions Can include cognitive-behavior therapy, supportive psychotherapy, problem-solving therapy, and interpersonal therapy. Can be beneficial alone, or in conjunction with medication therapy. A combo of psychotherapeutic interventions and medication therapy has better results than either form of treatment alone for mod/severe depression. Older adults often have better treatment compliance, lower dropout rates, and more positive responses to psychotherapy than younger patients. ECT (Electroconvulsive therapy) Effective for depression complicated by psychosis or poor response to medication therapy First-line treatment for patients at serious risk of suicide Remission Better rates of remission – pts with good social support, better medical health, early and aggressive treatment with antidepressants, and use of ECT when indicated. References Birrer RB, Vemuri SP. Depression in later life: A diagnostic and therapeutic challenge. Am Fam Physician. 2004;69(10):2375-82. Center for Disease Control and Prevention. Accessed online November, 2010 at: www.cdc.gov/ncipc/wisqars. Geriatric Depression Scale. Acessed online November, 2010 at: http://www.stanford.edu/~yesavage/GDS.english.short.html. Katz IR. Diagnosis and treatment of depression in patients with Alzheimer’s disease and other dementias. J Clin Psychiatry. 1998;59 Suppl 9:38-44. Lapid MI, Rummans TA. Evaluation and management of geriatric depression in primary care. Mayo Clin Proc. 2003;78(11):1423-9. Licht-Strunk E et al. The prognosis of undetected depression in older general practice patients. A one year follow-up study. J Affect Disord. 2009;114(1-3):3105. Moyer, CS. Primary care doctors carrying heavier mental health load. Accessed online November, 2010 at: http://www.amaassn.org/amednews/2010/10/25/prl21025.htm. Mulsant BH et al. Pharmacological treatment of depression in older primary care patients: the PROSPECT algorithm. Int J Geriatr Psychiatry. 2001;16(6):585-92. References Murphy et al. Affective disorders and mortality. A general population study. Arch Gen Psychiatry. 1987;44(5):473-80. Pacala JT, Sullivan GM, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine. 7th ed. New York: American Geriatrics Society; 2010. Sinyor M, Schaffer A, Levitt A. The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Trial: A review. Can J Psychiatry. 2010;55(3):126-35. Thibault JM, Steiner RW. Efficient identification of adults with depression and dementia. Am Fam Physician. 2004;70(6):1101-10. U.S. Preventative Services Task Force. Screening for depression in adults. Acessed online November, 2010 at: http:///www.uspreventiveservicestaskforce.org/uspstf/uspsaddepr.htm. Wancata J et al. The criterion validity of the Geriatric Depression Scale: a systematic review. Acta Psychiatr Scand. 2006;114(6):398-410.