1. ‘ Sad, Bad or Mad ’ a private psychiatrist ’ s experience on Elderly Depression 從一位私人精神科醫生的角度看 長者抑鬱症 Dr. Ip Yan Ming 叶恩明医生 Vice-President Hong Kong College of Psychiatrists

2. Sad, Bad or Mad ? 不開心 ? 不好 ? 精神正常 ? People lives longer nowadays People lives longer nowadays Older & wiser Older & wiser But more likely to have losses (of health, loved ones & social horizon) But more likely to have losses (of health, loved ones & social horizon) When depressive disorder appears, When depressive disorder appears, it may neither be sad, bad nor mad.

3. Sad, Bad or Mad ? 不開心 ? 不好 ? 精神正常 ? But many people assume: But many people assume: Depression equals to sadness and is a normal part of ageing that will go away by itself. Depression equals to sadness and is a normal part of ageing that will go away by itself. If nothing bad has happened to him/her, one should not be sad. If nothing bad has happened to him/her, one should not be sad. It’s bad to bother others with sadness. It’s bad to bother others with sadness. Seeing psychiatrist is a sign of madness. Seeing psychiatrist is a sign of madness.

4. Depression in the Elderly 長者抑鬱症 Under-diagnosed & under-treated Not uncommon Treatable > 50% diagnosed or treated inappropriately Worsen quality of life Increase morbidity & mortality 15% suicide

5. 餘暉心態

6. 老，不一定沉鬱消極

7. Prevalence ( 發病率 ) of elderly depression in different care settings Care setting Prevalence of depressive symptoms Prevalence of major depressive disorder Community15%1-3% Primary care 20%10-12% Acute hospital 20-25%10-15% Residential care 30-40%16%

8. Diagnosis ( 断症 ) A syndromal diagnosis (clinical) Based on eliciting specific symptom cluster through careful history taking and mental state examination ICD-10 or DSM-IV

9. ICD-10 Cardinal symptoms: 1. abnormal depressed mood for >2 weeks, 1. abnormal depressed mood for >2 weeks, 2. loss of interest / pleasure (anhedonia), 2. loss of interest / pleasure (anhedonia), 3. loss of energy (anergia) 3. loss of energy (anergia) Additional symptoms: 1. loss of confidence / self esteem, 1. loss of confidence / self esteem, 2. inappropriate guilt, 3. suicidal thoughts / behaviour, 4. diminished ability to think / concentrate, 5. psychomotor changes, 6. sleep disturbance, 7. appetite changes

10. DSM-IV 1.Depressed mood most of the day 2.Marked diminished interest or pleasure 3.Significant weight or appetite change 4.Insomnia or hypersomnia 5.Psychomotor agitation or retardation 6.Fatigue or loss of energy 7.Feelings of worthlessness or excessive guilt 8.Reduced ability to think or concentrate 9.Recurrent suicidal thoughts or attempts -- 5 or more s/s for >2 weeks, must have (1) or (2)

11. Diagnostic difficulties ( 難處 ) Presentation of depression in the elderly may be modified by factors associated with old age Primary care physicians could identify no more than 50% of patients with a diagnosable depressive syndrome (Mulsant & Ganguli, 1999)

12. Peculiar features of elderly depression ( 特点 ) Minimisation of sadness (Georgotas, 1983) Somatisation or disproportionate complaints associated with physical disorder (Sheehan et al, 2003) "Neurotic" symptoms of recent onset "Trivial" acts of deliberate self-harm "Pseudodementia" Recent change in behaviour (‘out of character’)

13. Assessment ( 評估 ) History (both from patient & informant) Mental state examination Use of standardised instruments, e.g. Geriatric depression scale (GDS) Cognitive assessment Physical examination Investigation

14. Geriatric Depression Scale (GDS) Geriatric Depression Scale (GDS) 老人憂鬱量表 Validated standardized scales for screening of depression: 15-item Chinese Geriatric Depression Scale Short Form (GDS) (Lee et al, 1993) Cut-off point of 8/15 Can be applied by trained non-medical personnel

15. 老人憂鬱量表 以下列舉的問題是人們對一些事物的感受。在過去一星期內，你是否曾有以下 的感受，如有的話，請圈「是」，若無的話，請圈「否」。 1. 你基本上對自己的生活感到滿意嗎？是 / 否 2. 你是否已放棄了很多以往的活動和嗜好？是 / 否 3. 你是否覺得生活空虛？是 / 否 4. 你是否常常感到煩悶？是 / 否 5. 你是否很多時感到心情愉快呢？是 / 否 6. 你是否害怕將會有不好的事情發生在你身上呢？是 / 否 7. 你是否大部份時間感到快樂呢？是 / 否 8. 你是否常常感到無助？ ( 即是沒有人能幫自己 ) 是 / 否 9. 你是否寧願留在家裏，而不愛出外做些有新意的事情？ ( 譬 是 / 否 如 : 和家人到一新開張酒樓吃飯 ) 10. 你是否覺得你比大多數人有多些記憶的問題呢？是 / 否 11. 你認為現在活著是一件好事嗎？是 / 否 12. 你是否覺得自己現在是一無是處呢？是 / 否 13. 你是否感到精力充足？是 / 否 14. 你是否覺得自己的處境無望？是 / 否 15. 你覺得大部份人的境況比自己好嗎？是 / 否 第 2, 3, 4, 6, 8, 9, 10, 12, 14, 15 題，答案「是」得 1 分 第 1, 5, 7, 11, 13 題，答案「否」得 1 分  8 分 ===> 憂鬱的徵狀

16. Principles of management ( 處理的原则 ) 1. Watch out for catastrophic risks 2. Educating patient (& caregivers) about depression and involving them in Rx decisions 3. Treating the whole person - coexisting physical disorder; attention to sensory deficits and other handicaps; reviewing medication; psycho- social intervention 4. Treating depressive symptoms with aim of complete remission, then continue & maintain 5. Prompt referral of patients requiring specialist mental health services

17. Treatment ( 治療 ) Physical treatment –Pharmacological treatment –Electroconvulsive therapy Psychosocial treatment

18. The Monoamine Hypothesis The 3 monoamines: serotonin, noradrenaline and dopamine serotonin, noradrenaline and dopamine Depression believed to be a result of dysfunction of monoamine neurotransmitters All effective antidepressants act by increasing the synaptic concentration of these neurotransmitters in the brain by various mechanisms

19. Norepinephrine Anxiety Irritability Serotonin Mood, Emotion, Cognitive function Sex Appetite Aggression Drive Dopamine Motivation Energy Interest Impulse Biogenic Amine Imbalance Biogenic Amine Imbalance

20. Pharmacological treatment ( 藥物治療 ) Information for patients and carers: –Start low, go slow –Typical side effects –Delay in onset of therapeutic action –Need for continuation treatment following initial response

21. Tricyclic antidepressants (TCA) Nortriptyline, dothiepin, imipramine, amitriptyline, clomipramine, trimipramine - Anticholinergic S/E (urinary retention & constipation may be troublesome) - Anticholinergic S/E (urinary retention & constipation may be troublesome) - Anti-histaminergic S/E - Anti-histaminergic S/E - Anti-adrenergic S/E - Anti-adrenergic S/E - Cardiotoxicity - dangerous if overdose - Cardiotoxicity - dangerous if overdose

22. Stephen M. Stahl: Essential Psychopharmacology 1996 Mechanism of action of TCAs Shown here is an icon of a tricyclic antidepressant (TCA). These drugs are actually five drugs in one: (1) a serotonin reuptake inhibitor (SRI); (2) a noradrenaline reuptake inhibitor (NRI); (3) an anticholinergic/antimuscarinic drug (M1); (4) an alpha adrenergic antagonist (alpha); and (5) an antihistamine (H1).

23. Selective Serotonin Reuptake Inhibitors (SSRIs) Citalopram (Cipram), sertraline (Zoloft), paroxetine (Seroxat), fluoxetine (Prozac), escitalopram (Lexapro), fluvoxamine (Faverin) - GI upset - GI upset - Headache - Headache - Insomnia, anxiety, tremor - Insomnia, anxiety, tremor - Sexual dysfunction - Sexual dysfunction (better tolerated than TCA but increase the risk of GI bleeding in the very old) (better tolerated than TCA but increase the risk of GI bleeding in the very old)

24. Serotonergic-Noradrenergic Reuptake Inhibitor (SNRI) Venlafaxine (Efexor/Efexor XR) Duloxetine (Cymbalta) Milnacipran (Ixel) - Side effects similar to SSRI - Side effects similar to SSRI - Dizziness, increase heart rate - Dizziness, increase heart rate - May cause hypertension at high doses - May cause hypertension at high doses

25. Serotonin-2 Antagonist / Reuptake Inhibitors (SARI) trazodone (Trittico) - Very sedating - Very sedating - Dizziness, nausea, postural hypotension, rarely priapism, no anticholinergic S/E - Dizziness, nausea, postural hypotension, rarely priapism, no anticholinergic S/E nefazodone (Serzone) - Less sedating, - Less sedating,

26. Other Antidepressants NaSSA – mirtazapine (Remeron) –Sedation, increased appetite, weight gain, oedema, (nausea & sexual S/E uncommon) NDRI – bupropion (Wellbutrin) –Headache, agitation, nausea, insomnia, (no sexual S/E) Mianserin (Tolvon): –Sedation, rash, rarely: blood dyscrasia, no anticholinergic S/E, sexual S/E uncommon

27. Reversible inhibitors of monoamine oxidase A (RIMA) Moclobemide (Aurorix) - Nausea - Nausea - Headache - Headache - Insomnia - Insomnia - Restlessness - Restlessness - Agitation - Agitation

28. Other pharmacological treatment Antipsychotics Lithium augmentation Tri-iodothyronine (T3) augmentation Antidepressant combination Anticonvulsant augmentation Buspirone augmentation

29. Electroconvulsive therapy (ECT) Safe and effective Indicated if prompt effect is needed (in food refusal, suicidal risk, severe retardation) or refractory to drug treatment 71-88% with good outcome Post ECT confusion 18-52% Memory impairment is temporary Twice or three times weekly for 6 to 12 sessions

30. Psychosocial interventions Basic psychotherapeutic processes: –*Establish Rapport –Listening and talking –Release of emotion –Giving information –Restoration of morale –Suggestion –Guidance and advice –The therapeutic relationship

32. Psychoeducation Nature and pathogenesis of depression Use of a “Stress-diathesis” model Proposed treatment, expected side effects, delay in onset of therapeutic response Expected duration of continuation and maintenance treatment

33. Evidence-based psychosocial treatments Interpersonal therapy Cognitive behavioural therapy For moderate to severe depression, the combination of pharmacotherapy and psychological treatment has been found to be superior to either treatment given alone (Reynolds et al, 1999)

34. When to refer for specialist advice? (WPA, 1999) When diagnosis is in doubt (e.g. dementia?) When depression is severe, as evidenced by: –Psychotic depression –Severe risk to health because of failure to eat or drink –Suicide risk Complex therapy is indicated (e.g. in cases with medical comorbidity) When first-line therapy fails (although primary care physicians may wish to pursue a second course of antidepressant from a different class) & beyond the GP’s therapeutic limitation

35. Referral to Psychiatric Service GP usually refer when: 1. their treatment has failed – commonest reason 2. pressure from patient or relatives 3. suicidal risks 4. social or behavioural (e.g. violent) crisis Tendency for non-referral or late referral

36. Sad, Bad or Mad ? 不開心 ? 不好 ? 精神正常 ? In Summary: Elderly Depression are not rare but often not detected or treated properly Elderly Depression are not rare but often not detected or treated properly It need not be sad, bad or mad. It need not be sad, bad or mad. Highly treatable & quality of life improves. Highly treatable & quality of life improves. Treat with care, start low & go slow. Treat with care, start low & go slow. When in doubt, ready to refer or consult. When in doubt, ready to refer or consult.

37. The End