Download Depression - Geriatrics Care Online

DEPRESSION AND
OTHER MOOD
DISORDERS
OBJECTIVES
Know and understand:
• Incidence and morbidity of depressive disorders
among older adults
• Diagnostic criteria for depression and mania
• Treatment options for older adults with
depression or mania
• Actions and side effects of drugs for depression
and mania in older adults
Slide 2
TOPICS COVERED
• Epidemiology
• Diagnosis
• Clinical Course
• Suicide
• Treatment: Psychotherapy, Drugs, ECT
• Managing Non-response
• Treating Bipolar Disorder
Slide 3
EPIDEMIOLOGY AMONG OLDER ADULTS
Minor depression
• 15% of older people
• Causes  use of health services, excess disability,
and poor health outcomes, including  mortality
Major depression
• 6%–10% of older adults in primary care clinics
• 12%–20% of nursing home residents
• 11%–45% of hospitalized older adults
Bipolar disorder
• Common diagnosis among aged psychiatric patients
• Does not “burn out” in old age
Slide 4
DSM-IV DIAGNOSTIC CRITERIA
FOR MAJOR DEPRESSION
Gateway symptoms (must have 1)
• Depressed mood
• Loss of interest or pleasure (anhedonia)
Other symptoms
•
•
•
•
•
•
•
Appetite change or weight loss
Insomnia or hypersomnia
Psychomotor agitation or retardation
Loss of energy
Feelings of worthlessness or guilt
Difficulty concentrating, making decisions
Recurrent thoughts of suicide or death
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SCREENING: PHQ-9
9-item Patient Health Questionnaire (PHQ-9)
• 9 items cover diagnostic criteria for major
depression
• Initial 2 questions can be used for screening
• Serial administrations can be used to reliably
assess response to treatment
• Not reliable in patients with moderate to severe
dementia
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INDICATIONS TO START
ANTIDEPRESSANT THERAPY
PHQ-9
Score
1–4
None
None
5–9
Mild to moderate
If not currently treated, rescreen in
2 weeks. If currently treated,
optimize antidepressant and
rescreen in 2 weeks.
10–14
Major depressive
disorder
Major depressive
disorder
Start antidepressant therapy.
>15
Depression Severity
Clinician Response
Start antidepressant therapy;
obtain psychiatric consultation if
suicidality or psychosis suspected.
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SCREENING:
GERIATRIC DEPRESSION SCALE (GDS)
• Yes/No format
• Lacks suicidal ideation query
• Not useful for assessing treatment response
Slide 8
DIAGNOSIS IN OLDER PATIENTS IS
DIFFICULT BECAUSE THEY . . .
• More often report somatic symptoms
• Less often report depressed mood, guilt
• May present with “masked” depression
cloaked in preoccupation with physical
concerns and complicated by overlap of
physical and emotional symptoms
Slide 9
DIAGNOSTIC CHALLENGES IN
MEDICAL SETTINGS
• Symptoms of depressive and physical disorders
often overlap, eg:
 Disturbed sleep
 Fatigue
 Diminished appetite
• Seriously ill or disabled people may focus on
thoughts of death or worthlessness, but not suicide
• Side effects of drugs for other illnesses may be
confused with depressive symptoms
Slide 10
HALLMARKS OF
PSYCHOTIC DEPRESSION
• Patients have sustained paranoid, guilty, or
somatic delusions (plausible but inexplicably
irrational beliefs)
• Among older patients, most commonly seen in
those needing inpatient psychiatric care
• In primary care, may be seen when patients
exhibit unwarranted suspicions, somatic
symptoms, or physical preoccupations
Slide 11
DIFFERENTIAL DIAGNOSIS
Medical illness can mimic depression
• Thyroid disease, conditions that promote apathy
Dementia has overlapping symptoms
• Impaired concentration
• Lack of motivation, loss of interest, apathy
• Psychomotor retardation
• Sleep disturbance
Bereavement is different because:
• Most disturbing symptoms resolve in 2 months
• Not associated with marked functional impairment
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CLINICAL COURSE IN
MAJOR DEPRESSION
Recurrence, partial recovery, and chronicity . . .
 disability
 use of health care resources
 morbidity and mortality
suicide
Slide 13
OLDER ADULTS AND SUICIDE
• Older age associated with increasing risk of suicide
• One fourth of all suicides occur in people  65 years
• Risk factors: depression, physical illness, living alone,
white male, alcoholism
• Violent suicides (eg, firearms, hanging) are more
common than non-violent methods among older
adults, despite the potential for drug overdosing
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STEPS IN TREATING DEPRESSION
•
Acute — reverse current episode
•
Continuation — prevent a relapse
 Continue for 6 months
•
Maintenance — prevent recurrence
 Continue for 12–18 months or
indefinitely if hospitalization was
required or suicidality or psychosis
was present
Slide 15
TYPES OF THERAPY
FOR DEPRESSION
• Psychotherapy
• Pharmacotherapy
• Electroconvulsive therapy (ECT)
Slide 16
PSYCHOTHERAPY
• Individualize standard approaches
 Cognitive-behavioral therapy
 Interpersonal psychotherapy
 Problem-solving therapy
• Combine with an antidepressant (has been
shown to extend remission after recovery)
• Watch for depressive syndromes in caregivers,
who might benefit from therapy
• Supportive psychotherapy
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PHARMACOTHERAPY
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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ANTIDEPRESSANTS
• Tricyclic antidepressants
• Selective serotonin-reuptake inhibitors
• Selective serotonergic and noradrenergic
reuptake inhibitors (SSRI/SNRIs)
• Others: bupropion, nefazodone, mirtazapine,
monoamine oxidase inhibitors, methylphenidate
Slide 19
TRICYCLIC ANTIDEPRESSANTS (TCAs)
• Secondary amine TCAs most appropriate for
older patients are nortriptyline and desipramine
• For severe depression with melancholic
features
• Avoid in the presence of conduction
disturbance, heart disease, intolerance to
anticholinergic side effects
Slide 20
SELECTIVE SEROTONIN-REUPTAKE
INHIBITORS (SSRIs)
• Citalopram, escitalopram, fluoxetine,
paroxetine, sertraline
• For mild to moderately severe depression
• Side effects:
 Anxiety, agitation, nausea & diarrhea, sexual
effects, pseudoparkinsonism,  warfarin effect,
other drug interactions, hyponatremia/SIADH
 Falls and fractures in nursing-home residents
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BUPROPION
• Generally safe & well tolerated
•  activity of dopamine & norepinephrine
• Side effects:
 Insomnia, anxiety, tremor, myoclonus
 Associated with 0.4% risk of seizures
• Dose range: 150–300 mg/day
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SSRI/SNRIs: VENLAFAXINE
• Acts as SSRI at low doses; at higher doses,
as SNRI
• Effective for major depression & generalized
anxiety
• Side effects:
 Nausea
 Hypertension
 Sexual dysfunction
• Dose range: 75–300 mg/day
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SSRI/SNRIs: DESVENLAFAXINE
•
Active metabolite of venlafaxine
•
Side effects:
 Nausea
 Headache
 Hypertension
•
Dose range 25–50 mg/day
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SSRI/SNRIs: DULOXETINE
• Equally SSRI and SNRI
• Effective for major depression and FDAapproved for neuropathic pain
• Precautions: drug interactions (CYP450 1A2,
2D6 substrate), chronic liver disease,
alcoholism, serum transaminase elevation
• Dose range: 20–60 mg/day
Slide 25
MIRTAZAPINE
• Norepinephrine, 5-HT2 , and 5-HT3 antagonist
• Associated with weight gain, increased appetite
• May be used for nursing-home residents with
depression & dementia, nighttime agitation,
weight loss
• Dose range: 15–45 mg/day
• Soluble tablet that dissolves in the mouth (not
sublingual)
• May be given as single bedtime dose (sedative
side effects)
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MONOAMINE OXIDASE INHIBITORS
(MAOIs)
• Use if patient is resistant to other antidepressants
• Side effects:
 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
Slide 27
METHYLPHENIDATE
• No controlled data demonstrating efficacy
for depression
• Has been used for decades to treat major
depression
• May have role in reversing apathy, lack of
energy in patients with dementia or
disabling medical conditions
Slide 28
RESPONSE TO
ANTIDEPRESSANTS
• Only 50% of patients with major depressive
disorder fully respond to initial antidepressant
treatment
• An additional one third recover when the
antidepressant is switched, or augmented with a
second antidepressant or psychotherapy
• Of patients who do recover, 40%–60% experience
recurrence, depending on the severity of the initial
episode and persistence of symptoms
Slide 29
MANAGEMENT OF PARTIAL
RESPONSE OR NON-RESPONSE
• The most common prescribing error is failure
to increase the dose to the recommended
level within the first 2 weeks of treatment
• For non-response or intolerance, switch to
another SSRI or another drug class
• For partial response to an SSRI, add
bupropion or buspirone
Slide 30
REASONS TO USE ECT
• Effective for treatment of major depression &
mania
• First-line treatment for patients at serious risk
for suicide, life-threatening refusal of food,
fluids, medications
• Standard for psychotic depression in older
adults; response rates 80%
Slide 31
COGNITIVE SIDE EFFECTS OF ECT
• 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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USING ECT
• Contraindications are few:
 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
Slide 33
DIAGNOSING BIPOLAR DISORDER
(1 of 2)
• Elevated, irritable, or expansive mood persisting
for at least 1 week, plus
• Three of the following:







Inflated self-esteem, grandiosity
Hypersexuality
Marked increase in activity
Marked decreased need for sleep
Pressured speech
Racing thoughts, flight of ideas
Distractibility
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DIAGNOSING BIPOLAR DISORDER
(2 of 2)
• Grandiose or paranoid delusions may be
present
• Older patients are more likely to have an
admixture of depression that presents as
irritability
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TREATMENT OF BIPOLAR DISORDER
• Most primary providers refer suspected cases to a
psychiatrist due to the frequency of recurrence, psychosis,
and suicidality
• Family-focused treatment prevents recurrent episodes of
illness and delays hospitalization when accompanied by
pharmacotherapy
• Pharmacotherapy prevents recurrent episodes but is less
effective without family-focused treatment
• Paradoxically, a depressive episode in any form of bipolar
disorder should rarely be treated with an antidepressant
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TREATMENT OF BIPOLAR DEPRESSION &
MIXED MANIA WITH DEPRESSION
•
•
Primary mood stabilizer: lamotrigine or lithium
Attain adequate dose or therapeutic level
For inadequate response add:
 Mixed mania
and
depression
•
•
•
•
•
Lithium
Aripiprazole
Valproate
Risperidone
Olanzapine
Depressive episode
 Mania frequent
 Rapid cycling
 Hx of antidepressant-induced
mania
•
•
•
•
Lithium
Valproate
Lamotrigine
Olanzapine
 Mania rare
 Not rapid cycling
 No hx of
antidepressantinduced mania
•
•
Bupropion or SSRI
Not TCA, not SNRI
Slide 37
TREATMENT OF MANIA AND BIPOLAR
DEPRESSION: LITHIUM CARBONATE
• Target plasma levels for older patients: 0.6–1.0 mEq/L
• Use cautiously with renal insufficiency
• Delay of up to 2 weeks to achieve steady state
• The following may increase lithium levels:
 NSAIDs, thiazide- and K+-sparing diuretics,
furosemide
 Dehydration, salt depletion
• Side effects: fine resting tremor, myoclonus, intention
tremor
Slide 38
TREATMENT OF MANIA AND BIPOLAR
DEPRESSION: VALPROIC ACID
• Target concentrations of 50–100 g/mL
• Efficacy comparable to lithium
• Delay of up to 2 weeks to achieve steady state
• Side effects:
 Sedation, rashes,  platelet counts & functioning
 Liver toxicity may develop in patients with hepatic
disease
 Reduce dosage in renal insufficiency
 Lab monitoring of CBC, liver enzymes, and
chemistries required
Slide 39
TREATMENT OF MANIA & BIPOLAR
DEPRESSION: ANTIEPILEPTICS
Carbamazepine
• FDA-approved for bipolar disorder
• Side effects:
 Mild bone marrow suppression with leukopenia &
thrombocytopenia in 5%–10% within first 2 weeks
 Rare: life-threatening agranulocytosis, aplastic anemia
• Lab monitoring required
Lamotrigine
•
•
•
•
FDA-approved for bipolar depression
Little data on use in late life
Associated with Stevens-Johnson syndrome
Reduce dose in liver dysfunction
Slide 40
TREATMENT OF MANIA AND BIPOLAR
DEPRESSION: ANTIPSYCHOTICS
Risperidone (0.25–6 mg; risk of movement disorder)
• FDA-approved for acute mania and mixed bipolar I episodes
Olanzapine (2.5–15 mg; may cause weight gain)
• FDA-approved for acute mania and mixed bipolar I episodes
Quetiapine (25–750 mg; may cause sedation)
• FDA-approved for acute mania and bipolar I and II
depression
Aripiprazole (5–15 mg; little used in older adults)
• FDA-approved for acute mania and mixed bipolar I episodes
Slide 41
SUMMARY (1 of 3)
• 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 diagnosis: medical illnesses,
dementia, bereavement
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SUMMARY (2 of 3)
• Suicide is a serious concern in depressed older
patients, particularly older white males
• Treatment (acute & preventive) should be
individualized and may include:
 Psychotherapy
 Pharmacotherapy
 ECT
• Choice of antidepressant should be based on
comorbidities, side-effect profiles, patient
sensitivity, potential drug interactions
Slide 43
SUMMARY (3 of 3)
• Bipolar disorder is common in older psychiatric
patients and may be treated with lithium, or
antiepileptic or antipsychotic agents
• Family-focused treatment improves the results
of pharmacotherapy
• Patients who do not respond to usual treatment
for depression or mania should be referred to a
geriatric psychiatrist
Slide 44
QUESTION 1 (1 of 2)
Which of the following statements regarding treatment for
major depressive disorder is true?
A. Most older adults with the diagnosis are treated by a
psychiatrist.
B. In older adults on an effective dosage of antidepressants,
the response rate is close to 80% after 8 weeks.
C. Risk of recurrence or relapse is higher in patients who did
not reach full remission.
D. Augmentation with a second agent is not appropriate
after a partial response to one antidepressant.
E. Psychosocial interventions have little impact on rate of
remission or risk of recurrence.
Slide 45
QUESTION 1 (2 of 2)
Which of the following statements regarding treatment for
major depressive disorder is true?
A. Most older adults with the diagnosis are treated by a
psychiatrist.
B. In older adults on an effective dosage of antidepressants,
the response rate is close to 80% after 8 weeks.
C. Risk of recurrence or relapse is higher in patients who did
not reach full remission.
D. Augmentation with a second agent is not appropriate
after a partial response to one antidepressant.
E. Psychosocial interventions have little impact on rate of
remission or risk of recurrence.
Slide 46
CASE 1 (1 of 4)
• An 82-year-old woman comes to the office because she
is fatigued and worried that she is terminally ill.
• She is recently widowed and lives alone.
• History includes dyslipidemia, hypertension, and obesity;
she has no psychiatric history.
• Medications are furosemide, simvastatin, propranolol,
and aspirin.
• At her last visit 2 months ago, she was concerned that
she had cancer; extensive evaluation was negative.
• Since then, she has lost 6.8 kg (15 lb).
Slide 47
CASE 1 (2 of 4)
• Another set of tests are negative.
• The patient reluctantly agrees to try citalopram 40 mg,
even though she insists that she is not depressed and is
instead worried about her health.
• After 8 weeks, she is not sleeping, has lost an additional
8.2 kg (18 lb), and rarely leaves her house.
• She denies any desire to die—on the contrary, she fears
death—yet, more and more often, she wishes for “this
torture to be over.”
Slide 48
CASE 1 (3 of 4)
Which of the following is the most appropriate
next step?
A. Add mirtazapine 15 mg at bedtime.
B. Switch to another antidepressant.
C. Increase citalopram to 60 mg.
D. Admit to psychiatric inpatient unit for
electroconvulsive therapy.
E. Add risperidone 0.5 mg at bedtime.
Slide 49
CASE 1 (4 of 4)
Which of the following is the most appropriate
next step?
A. Add mirtazapine 15 mg at bedtime.
B. Switch to another antidepressant.
C. Increase citalopram to 60 mg.
D. Admit to psychiatric inpatient unit for
electroconvulsive therapy.
E. Add risperidone 0.5 mg at bedtime.
Slide 50
CASE 2 (1 of 4)
• A 75-year-old man comes to the office with several
vague complaints and concerns.
• He is retired and has been married for 50 years.
• Over the past 6 months, he has come to the office
repeatedly and has become increasingly homebound.
• He describes leg weakness, fatigue, and overall
malaise that prevent him from engaging in oncepleasurable activities.
• He has become fearful of driving and of being alone.
Slide 51
CASE 2 (2 of 4)
• The patient’s sleep and appetite are poor: he has lost
approximately 4.5 kg (10 lb).
• His history includes hypertension and spinal stenosis.
• Major depressive disorder is diagnosed, and a trial of
an antidepressant is begun.
Slide 52
CASE 2 (3 of 4)
Which of the following is characteristic of late-life
major depressive disorder?
A. Strong family history of mood disorder
B. Sudden onset of symptoms
C. Preferential response to treatment with firstgeneration antidepressants
D. Higher prevalence of somatic symptoms
Slide 53
CASE 2 (4 of 4)
Which of the following is characteristic of late-life
major depressive disorder?
A. Strong family history of mood disorder
B. Sudden onset of symptoms
C. Preferential response to treatment with firstgeneration antidepressants
D. Higher prevalence of somatic symptoms
Slide 54
ACKNOWLEDGMENTS
Editor:
Annette Medina-Walpole, MD
GRS7 Chapter Author:
Gary Kennedy, MD
GRS7 Question Writer:
Benoit H. Mulsant, MD
Pharmacotherapy Editor: Judith L. Beizer, PharmD
Medical Writers:
Beverly A. Caley
Faith Reidenbach
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2010 American Geriatrics Society
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