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DEPRESSION IN THE ELDERLY
Module developed by James T. Birch, Jr., MD, MSPH Assistant Clinical Professor Dept. of Family Medicine, Division of Geriatric Medicine Landon Center on Aging University of Kansas Medical Center
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Objectives Review the diagnostic criteria for depression
Increase awareness of the prevalence and consequences of untreated depression in the older adult Discuss screening, treatment, and follow-up for those who have depression
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Content 1. Define depression
2. Review the epidemiology of depression in the elderly. 3. Risk Factors 4. Recognition of signs and symptoms 5. Differential Diagnosis 6. Screening Tools 7. Treatment 8. Review the consequences/complications of inadequately treated depression. 9. ACOVE – 3 Indicators
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Introduction Depression is under-recognized and undertreated in the older adult Many older adults who die by suicide (up to 75%) suffer with depression and most visited a physician within a month before death Untreated depression can delay recovery or worsen the outcome of other medical illnesses via increased morbidity or mortality Depression is NOT a part of normal aging
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What is Depression? DSM-IV-TR Definition
Five or more of the following must have been present during the same 2-week interval and represent a change from baseline functioning One(1) of the symptoms must be depressed mood or loss of interest or pleasure Geriatric Nursing (26)3;2005 The illustrated definition of depression is lifted from the DSM-IV-TR (Text Revision) published in 2000 containing updates on diagnostic categories and modified to reflect terminology that is consistent with ICD9 coding.
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What is Depression? DSM-IV-TR (a.k.a. “core symptoms”; occur most of the day nearly every day) Depressed mood Loss of interest in all or almost all activities or pleasure (anhedonia) Appetite change or weight loss Insomnia or hypersomnia Psychomotor agitation or retardation
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What is Depression? DSM-IV-TR (cont.) Loss of energy or fatigue
Feelings of worthlessness or excessive guilt Difficulty with thinking, concentration, or decision making Recurrent thoughts of death or suicide Preoccupation with somatic symptoms, health status, or physical limitations
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What is Depression? For Major Depression, these symptoms
Produce social impairment Are not related to substance abuse Are not related to bereavement
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What is Depression? Types of Depressive Disorders (DSM-IV)
Mild episode of major depression Moderate episode of major depression Severe episode of major depression Severe episode of major depression with psychotic features AMDA Clinical Practice Guideline Mild episode of major depression: minor impairment in social activities, relationships and overall function that persists for at least 2 weeks. Patient does NOT have more than five diagnostic symptoms Moderate episode of major depression: symptoms or functional impairment between mild and severe, persisting for at least 2 weeks. Severe episode of major depression: marked interference with and impairment of social activities, relationships, and overall functioning, persisting for at least 2 weeks. Patient has five or more diagnostic symptoms. Severe episode of major depression with psychotic features: symptoms include delusions and hallucinations
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What is Depression? Minor depression is common
15% of older persons Causes use of health services, excess disability, poor health outcomes, including mortality Major depression is not common 1%–2% of physically healthy community dwellers Elders less likely to recognize or endorse depressed mood
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What is Depression “Late-life” depression (a geriatric syndrome)
is a recurrence of depressive symptoms that initially occurred during early adulthood. there is no known or identifiable precipitating factor. patients usually have no family history of depression. Depressed mood is not required to meet criteria for major depressive disorder.
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Epidemiology (of major depression)
Community-Dwelling % Primary Care Settings 10 – 12 % Nursing Home 10-26% Permanent Placement Up to 43% Hospitalized 11 – 45 % These are estimated prevalence rates of depression across various settings
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Risk Factors Alcohol or substance abuse
Current use of a medication associated with a high risk of depression Hearing or vision impairment severe enough to affect function History of attempted suicide History of psychiatric hospitalization
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Risk factors Medical diagnosis or diagnoses associated with a high risk of depression New admission or change of environment New stressful losses (loss of autonomy, privacy, functional status, body part, family member or friend) Personal or family history of depression or mood disorder
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What medications do YOU prescribe for older adults that might place them at risk for
DEPRESSION ?
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Medications that may cause symptoms of Depression
Anabolic steroids Anti-arrhythmic medications (amiodarone, mexilitine) Anticonvulsant medications Barbiturates Benzodiazepines Carbidopa or levodopa Certain beta-adrenergic antagonists (i.e. propranol)
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Medications that may cause symptoms of Depression
Clonidine Cytokines (specifically IL-2) Digitalis preparations Glucocorticoids (prednisone) H2 blockers Metoclopramide Opioids When new or worsening symptoms of depression are recognized, medication should be considered as a potential cause and withdrawn, then replaced with a drug less likely to cause depression. When this is not possible or withdrawal does not result in resolution of symptoms, consider pharmacotherapy for the depression.
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Laboratory Tests for Evaluation
CMP (lytes, BUN, creat, Ca++, glucose) CBC Serum levels of anticonvulsant drugs, TCAs, digoxin, theophylline Thyroid function (T3, T4, TSH) EKG Folate level UA Vitamin B12 The purpose of doing laboratory tests, is to identify medical conditions and diseases that produce depressive symptoms or carry an independent risk for causing depression. These conditions need to be taken into account when a patient is assessed for depression.
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Differential Diagnosis
Thyroid disorders (hypo- and hyper-thyroidism) Dementia (or mild cognitive impairment) Bereavement Anxiety Disorder Substance Abuse Disorder Personality Disorder Diabetes mellitus Underlying malignancy Anemia Medication side effects
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Differential Diagnosis
DEPRESSION Subacute onset Family recognition early Rapid progression Impairment inconsistent over time Pt admits deficits Appears depressed Anhedonia Abstract thought usually normal “I don’t know” response to questions Pt often unconcerned DEMENTIA Insidious onset Delayed family recognition Slow progression Impairment consistent; slow, gradual decline Pt denies/unaware of deficits Not depressed Can experience pleasure Abstract thought impaired Near miss answers Pt tries to cover up This slide illustrates the differences between depression and dementia.
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The Geriatric Depression Scale
What is the most commonly used and validated screening tool for diagnosis of Depression in the elderly patient? The Geriatric Depression Scale
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Screening Tools Geriatric Depression Scale (GDS; validated) 15 item scale ( > 5 points or positive responses is diagnostic) Cornell Scale for Depression in Dementia (scoring system: >12 means probable depression) Center for Epidemiologic Studies of Depression Scale (CES-D) Patient Health Questionnaire 9 (9 item self-rating scale) AMDA Clinical Practice Guideline There are many tools for diagnosing depression. They are often referred to as depression rating scales. Use of these tools at the beginning of treatment is the only reliable way to obtain an objective measure of the severity of a patient’s depression. This information is essential to monitor the effectiveness of treatment and to aid in decisions about whether or continue, change or terminate treatment. The Geriatric Depression Scale (GDS) is the most common of them all. We use it in our Geriatric Assessment clinics. It has been validated in many research studies. It is a 15-item scale where 5 or more positive responses is considered diagnostic of depression. It is limited in detecting depression in patients with moderate or severe dementia, learning disabilities, or low education level. In addition to the GDS, we have the Cornell Scale for Depression in Dementia (scoring system: >12 means probable depression), The Center for Epidemiologic Studies of Depression Scale (CES-D) can be especially useful for evaluating depression in African Americans and Native Americans…. and the Patient Health Questionnaire 9.
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Screening Tools Two – item scale (PHQ-2):
During the previous 2 weeks…….. 1. Have you often been bothered by feeling down, depressed or hopeless? 2. Have you often been bothered by having little interest or pleasure in doing things? (“Yes” answer to either is considered positive) Sensitivity: 100%; Specificity:77%; PPV: 14% NEJM: 357:22; 11/29/07 We strongly encourage the use of one of the scales for diagnosis and management, but if you need to do a real quick screen, you can use the two-item scale illustrated here. This 2-item scale is also known as the Patient Health Questionnaire 2 (PHQ-2), which asks about depressed mood and anhedonia. It is easily administered by an office staff member or a physician during a primary care visit.
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Treatment The consequences of depression in the elderly require serious attention because of the disproportionately high risk of suicide For the year 2000, 13% of the U.S. population was 65 and older, and the suicide rate accounted for 18% of all suicides Geriatric Nursing (26)3: 2005
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Treatment Goals of therapy: improve mood, function, and quality of life Goals of treatment of an acute depressive episode are to achieve recovery and prevent future episodes of depression The intended outcome should be complete resolution of symptoms, not simply a reduction in depressive symptoms. Three phases of treatment are generally required to achieve these goals.
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Treatment Acute Phase (reverse current episode)
Duration: about 3 months: Goal is complete recovery from signs and sx of acute episode Continuation Phase (prevent a relapse) Duration: 4-6 months: Goal is to prevent relapse as sx continue to decline and functionality improves Maintenance Phase (prevent future recurrence) Duration: 3 months or longer: Goal is to prevent recurrence of a new depressive episode
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Treatment Pharmacotherapy Psychotherapy
Electroconvulsive therapy (ECT)
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Treatment Patients should be monitored for response to treatment by:
Observation for resolution of signs and symptoms of depression Documenting improvement in scores on screening tools Improvement in attendance at and participation in usual activities Improvement in sleep pattern Also monitor patients carefully for side effects and interactions with other medications Before discussing details of pharmacotherapy, it is important to remember the importance of monitoring patients during treatment.
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Treatment : Pharmacotherapy
Antidepressants SSRI’s Celexa (citalopram) 20-40mg/day Lexapro (ecitalopram) 10-20mg/day Prozac (fluoxetine) 20-40mg q am Paxil (paroxetine) 10-40mg q am or q hs Zoloft (sertraline) mg q am Better tolerated than tricyclics SIADH at high doses and sexual side effects Interact with CYP-450 isoenzymes by inhibition Can increase the anticoagulant effect of warfarin Do not discontinue abruptly; taper the dose Note to faculty: I do not recommend stressing dosage recommendations on the above slide or the following slides. Focus on drug classes and their effects.
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Treatment : Pharmacotherapy
Antidepressants (SSRIs continued) Nausea and diarrhea might occur Fluoxetine is not a preferred drug for use in the elderly due to a prolonged half life (4-6 days; metabolite 9.3 days) and potential for many drug interactions. It might also induce anxiety, sleep disturbance, and/or agitation Paroxetine is also not favored due to anti-cholinergic properties and other effects noted with fluoxetine
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Treatment : Pharmacotherapy
Antidepressants Tricyclics (secondary amines) Norpramin (desipramine) qd / q hs Pamelor, Aventyl (nortriptyline) 20 – 100 mg q hs Potential for anticholinergic and sedative effects Avoid in pts. who are prone to constipation, orthostatic hypotension, glaucoma, or who have BPH May cause ventricular conduction delays and heart block May be fatal in overdose
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Treatment : Pharmacotherapy
Antidepressants Bicyclics Effexor (venlafaxine) 75 mg BID Effexor XR – 100mg qd Fewer drug interactions Can cause or aggravate hypertension Pts. are at risk for withdrawal syndrome
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Treatment : Pharmacotherapy
Antidepressants SNRI and SSRI Cymbalta (duloxetine) mg/day Norepinephrine, 5HT2 and 5HT3 antagonist Remeron (mirtazapine) mg q hs Can cause serotonin syndrome when given with other SSRI’s
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Treatment : Pharmacotherapy
Antidepressants Norepinephrine-dopamine reuptake inhibitor Wellbutrin (bupropion) 100 mg TID Wellbutrin SR mg BID Serotonin antagonist and reuptake inhibitor Serzone (nefazodone) 150mg BID Desyrel (trazodone) 50 – 200mg q hs
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Treatment : Pharmacotherapy
Antidepressants Stimulants Ritalin (methylphenidate) 20mg BID Provigil (modafinil) 400mg q am Dexedrine (dextroamphetamine) 2.5-5mg 7am and noon
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Treatment : Pharmacotherapy
Antidepressants Monoamine Oxidase Inhibitors (MAOIs) Marplan (isocarboxazid) 30 mg/day Nardil (phenelzine) 30–45 mg/day Parnate (tranylcypromine) 30–40 mg/day Orthostatic hypotension, falls Life-threatening hypertensive crisis if taken with tyramine-rich foods, cold remedies (pressor amine) Fatal serotonin syndrome possible if taken with SSRI, meperidine
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Treatment Should the elderly patient experiencing bereavement be treated for Depression? NO! However, if symptoms of MAJOR DEPRESSION persist for more than 2 months after the loss, treatment for depression should be strongly considered. Unutzer, J. NEJM, Nov. 29, 2007
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Treatment : Psychotherapy
Cognitive-behavioral Interpersonal Short-term psychodynamic Life review, reminisce Problem solving Supportive Bereavement therapy Behavioral Dialectical-behavioral therapy
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Treatment : Psychotherapy
Individualize standard approaches Cognitive-behavioral therapy Interpersonal psychotherapy Problem-solving therapy Combination with an antidepressant has been shown to extend remission after recovery Watch for depressive syndromes in caregivers, who might benefit from therapy
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Treatment : Psychotherapy
Individualize choice of drug on basis of: Patient’s comorbidities Drug’s side-effect profile Patient’s sensitivity to these effects Drug’s potential for interacting with other medications
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Treatment : ECT For depression with pronounced psychotic features and resistance to standard medical therapy Effective for treatment of major depression & mania; response rates exceed 70% in older adults
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Treatment : ECT First-line treatment for patients at serious risk for suicide, life-threatening poor intake Standard for psychotic depression in older adults; response rates 80%
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Treatment : ECT Side Effects
Anterograde amnesia improves rapidly after treatment Retrograde amnesia is more persistent; recall of events just before treatment may be lost permanently Lasting effects not shown in longitudinal studies Right unilateral treatment: fewer side effects but less effective than bilateral
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Treatment : ECT Contraindications
Increased intracranial pressure Recent MI or CVA and unstable CAD increase risk of complications Continue pharmacotherapy following completion of ECT treatment May use maintenance ECT to prevent relapse
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Treatment Response Responsive to initial pharmacotherapy 40% 40% of cases of major depression respond to initial pharmacotherapy within 6 weeks Additional 15% to 25% achieve remission with continued treatment for 6 weeks GRS, 2006 Monotherapy fails 35-45% Responsive to continued treatment 15-25%
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Treatment Response The most common prescribing error is failure to increase the dose to the recommended level within the first 2 weeks of treatment When monotherapy fails: Consider switch to another drug class Combine lithium carbonate, methylphenidate, or triiodothyronine with secondary amine TCA Add psychotherapy Consult a geriatric psychiatrist The elderly are prone to treatment failures and recurrences. This is frequently due to lack of adequate follow-up and monitoring.
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Treatment Response Reasons for partial response or treatment failure
Dementia that is confused with or accompanied by late life depression Concurrent psychosis (interferes with diagnosis and treatment of depression) Compliance is difficult when patients are depressed
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Consequences and Complications of Inadequately Treated Depression
Recurrence, partial recovery, and chronicity . . . disability use of health care resources morbidity and mortality Suicide (one fourth of all suicides occur in persons 65)
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Consequences and Complications of Inadequately Treated Depression
Which demographic in the elderly population has the highest risk and incidence of suicide? Highest: white males age 80 & older Next highest: white males between 65 and 80 AMDA Guidelines
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Consequences and Complications of Inadequately Treated Depression
Suicide: Ask the patients about thoughts of hurting themselves; if YES, ask whether they have a plan; if YES, ask what it is; then ask about stockpiled medications or weapons in the home. Patients with a plan require emergent psychiatric evaluation in ER or local crisis unit.
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Consequences and Complications of Inadequately Treated Depression
Risk factors for suicide: depression older age physical illness living alone (single, divorced, or separated and without children) male gender drug abuse or alcoholism having a personal or family history of suicide attempt severe anxiety or stress specific plan with access to firearms or other means.
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Consequences and Complications of Inadequately Treated Depression
Violent suicides (e.g. firearms, hanging) are more common than non-violent methods among older adults, despite the potential for drug overdosing
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ACOVE – 3 Quality Indicators
Total of #20 IF-THEN-BECAUSE directives for care of Depression; they include: Screening for and Recognizing Depression Documenting Depression Symptoms Suicidal Ideation Evaluate for Comorbid condition Initiating Depression Treatment Antidepressant Choice
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ACOVE – 3 Quality Indicators
Psychotic Depression Electrocardiogram for Tricyclic Use Interactions with MAOIs Depression Follow-Up The First 12 Weeks of Depression Treatment Continuing Depression Therapy
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ACOVE – 3 Quality Indicators
Indicators #4 thru #7 were selected for review
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ACOVE – 3 Quality Indicators
Indicator #4 : IF a VE receives a diagnosis of a new depression episode, THEN the medical record should document at least three of the nine DSM-IV target symptoms for major depression within 2 weeks of diagnosis, BECAUSE monitoring depression treatment requires identification and reevalution of the presenting depression symptoms.
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ACOVE – 3 Quality Indicators
Indicator #5: IF a VE receives a diagnosis of a new depression episode, THEN the medical record should document on the day of diagnosis the presence or absence of suicidal ideation and psychosis, BECAUSE suicidal patients may require hospitalization, and patients with psychotic depression may need antipsychotic medication or ECT and referral to a psychiatrist.
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ACOVE – 3 Quality Indicators
Indicator #6: IF a VE has thoughts of suicide, THEN the medical record should document, on the same date, that the patient has no immediate plan for suicide or was referred for evaluation for psychiatric hospitalization AND…..
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ACOVE – 3 Quality Indicators
Indicator #7: IF a VE has thoughts of suicide, THEN the medical record should document on the same date, that the patient was asked about access to firearms, BECAUSE the likelihood of suicide increases if the patient has a specific plan to commit suicide and access to firearms, and it decreases if the patient is hospitalized to receive psychiatric care.
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Summary All health care workers should maintain a high index of suspicion for the presence of depression or depressive symptoms in their patients. Screen older adults for depression at the initial visit
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Summary In older adults, depression is:
Common (especially “minor” depression) Associated with morbidity Difficult to diagnose because of atypical presentation, more somatic concerns, overlap with symptoms of other illnesses Differential diagnoses include other medical illnesses, dementia, bereavement
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Summary Suicide is a serious concern in depressed older patients, particularly older white males Treatment (acute & preventive) should be individualized and may include: Pharmacotherapy Psychotherapy ECT Choice of antidepressant should be based on comorbidities, side-effect profiles, patient sensitivity, potential drug interactions
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Final thought: On the Threshold of Eternity. In 1890, Vincent van Gogh painted this picture seen by some as symbolizing the despair and hopelessness felt in depression. Van Gogh himself suffered from depression and committed suicide later that same year.
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References Geriatrics Review Syllabus, 6th Edition; American Geriatrics Society, 2006, Chap. 35, pp Nakajima, G.A., Wenger, N.S. Quality Indicators for the Care of Depression in Vulnerable Elders; JAGS: (55)S2:S302-11; Oct. 2007 Current Geriatric Diagnosis and Treatment; Landefeld, C.S., et al; McGraw-Hill Co., Chap. 14, pp Depression: Clinical Practice Guideline; American Medical Directors Association Buffum, M.D., et al; Treating Depression in the Elderly: An Update on Antidepressants; Geriatric Nursing 26(3): Kotylar, M. Update on Drug-Induced Depression in the Elderly; Am J of Geriatric Pharmacotherapy 3(4):Dec. 2005; Update on Depression in the Elderly Retrieved 02/19/2009 National Institute of Mental Health; Older Adults: Depression and Suicide Facts; Unutzer, J. Late-Life Depression; NEJM 357(22): Nov. 29, 2007; pp
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