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

2. 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

3. 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

4. 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

5. Etiology
Biological factors
Social factors
Psychological factors

6. Biological factors Genetic Medical Illness:
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

7. Social factors Loneliness, isolation Recent bereavement
Lack of a supportive social network
Decreased mobility
Due to illness or loss of driving privileges

8. Psychological factors
Traumatic experiences
Abuse
Damage to body image
Fear of death
Frustration with memory loss
Role transitions

9. 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

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

11. 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

12. 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

13. MINOR Depression Also known as
subsyndromal depression
subclinical depression
mild depression
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!
We also want to watch for MINOR DEPRESSION, which is also called “subclinical” or “subsydromal” depression because it does not meet the full “criteria” for MAJOR depression. For example, “Sally” complains that “nothing is enjoyable anymore” and doesn’t want to participate in any activities, including coming to meals (e.g., has lost the ability to experience pleasure in nearly all activities). She wakes up early every morning and cannot return to sleep (e.g., sleep disturbance). She has lost 5 pounds in a month because she is not eating right (e.g., appetite change, weight loss), and complains of being tired all the time (e.g., fatigue) – which is another reason she doesn’t want to attend activities. These are all changes for Sally; all occur nearly every day; and all have persisted for 2 weeks. But Sally has four, but not five of the targeted signs and symptoms, so does have “major depression.”
Is Sally’s quality of life compromised by these changes? YES! Will supportive therapy, talking therapy (e.g., individual or group psychotherapy) or even antidepressant medication therapy help relieve Sally’s symptoms? YES!! In short, identifying ALL people with significant symptoms of depression is important to restoring quality of life!

14. Atypical depression Somatic complaints Hyperphagia, Hypersomnia,
Hypersensitivity to rejection
“Heavy” feeling in upper or lower extremities (leaden paralysis)

15. Depression – the physical presentation
In primary care, physical symptoms are often
the chief complaint in depressed patients
In a New England Journal of Medicine study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief compliant1
N = 1146 Primary care patients with major depression
Simon GE, et al. N Engl J Med. 1999;341(18):

16. 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

17. 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

18. 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

19. Psychotic depression Frank hallucinations and delusions
Abnormal thought process – psychotic thinking
Frank hallucinations and delusions

20. 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.

21. 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

22. 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

23. 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

24. 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

25. 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

26. Assessment

27. 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. 

28. Geriatric Depression Scale
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 home, rather than going out, doing new things? YES / NO 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 *Underlined items constitute the four item scale

29. Labs:
FBC
TSH
Dementia workup
Cognitive testing
ECG

30. 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.

31. Treatment
Non-medical
Medical

32. 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
Inform about depression
Avoid stressors

33. Medical Interventions
Medications
Psychotherapy
Electro-convulsive therapy
Vagal Nerve stimulation
Combination therapy

34. Medications Serotonergic Noradrenergic Dopaminergic Dual mechanism
SSRIs: Citalopram, Escitalopram, Sertraline, Paroxetine, Fluoxetine
Noradrenergic
TCAs
Dopaminergic
Bupropion
Dual mechanism
Venlafaxine, Mirtazapine, Duloxetine, SSRIs + Buproprion

35. Medication
Starting Dose (mg/day)
Therapeutic Dose (mg/day)
TCAs
Amitryptyline
Nortriptyline
Imipramine
25-50 25
50-200
SSRIs
Citalopram
Fluoxetine
Sertraline
Paroxetine
Escitalopram
10-20 10
20-60
20-80
20-50 20
MAOIs
Phenelzine
Tranylcypromine 45
180
30-60
Mixed antidepressants
Mirtazapine
Venlafaxine XR
Bupropion SR
Duloxetine
7.5-15
37.5
20-30
15-45
75-225
300 60

36. 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

37. 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

38. Psychotherapy Very helpful in mild to moderate depression
Response time slower
Relapse less frequent
CBT
As effective as antidepressants
IPT
more effective than antidepressants
in treating mood suicidal ideations,
and lack of interest, whereas
antidepressants are more
effective for appetite and
sleep disturbances

39. 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

40. 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

41. Vagal Nerve Stimulator (VNS)

42. SUICIDE: DON’T FORGET
Ask about
suicidal ideation
intent

43. 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

44. 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

45. Assessment tool for suicide risk:
S- Male Sex A- Age (young/elderly) D- Depression P- Previous attempts E- ETOH R- Reality testing (Impaired) S- Social support (lack of) O- Organized plan N- No spouse S- Sickness

46. 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

47. 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.

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

49. 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

50. 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.

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

52. 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

53. 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

54. 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.

55. What is the most likely diagnosis?
Bereavement

56. 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”

57. 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

58. 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”.

59. 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.

60. 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”.

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

62. 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

63. 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.

64. 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?

65. 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

66. 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.

67. 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

68. 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

69. 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. 

70. Depression is not normal in seniors
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

71. Questions