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

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

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

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

Etiology Biological factors Social factors Psychological factors

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

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

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

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

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

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

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

MINOR Depression Also known as subsyndromal depression subclinical depression mild depression 2 - 4 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!

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

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):1329-1335.

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

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

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

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

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.

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

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

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

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

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

Assessment

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. 

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

Labs: FBC TSH Dementia workup Cognitive testing ECG

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.

Treatment Non-medical Medical

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

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

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

Medication Starting Dose (mg/day) Therapeutic Dose (mg/day) TCAs Amitryptyline Nortriptyline Imipramine 25-50 25 100-300 50-200 SSRIs Citalopram Fluoxetine Sertraline Paroxetine Escitalopram 10-20 10 20-60 20-80 100-200 20-50 20 MAOIs Phenelzine Tranylcypromine 45 180 30-60 Mixed antidepressants Mirtazapine Venlafaxine XR Bupropion SR Duloxetine 7.5-15 37.5 100-150 20-30 15-45 75-225 300 60

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

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

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

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

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

Vagal Nerve Stimulator (VNS)

SUICIDE: DON’T FORGET Ask about suicidal ideation intent

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

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

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

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

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.

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

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

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.

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

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

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

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.

What is the most likely diagnosis? Bereavement

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”

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

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”.

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.

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”.

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

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

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.

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?

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

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.

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

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

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. 

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

Questions