Download 私人精神科醫生分享處理長者抑鬱的經驗Sad, Bad or Mad

‘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
Sad, Bad or Mad ?
不開心? 不好?
?
• People lives longer nowadays
• Older & wiser
• But more likely to have losses (of health,
loved ones & social horizon)
• When depressive disorder appears,
it may neither be sad, bad nor mad.
Sad, Bad or Mad ?
不開心? 不好?
?
But many people assume:
• 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.
• It’s bad to bother others with sadness.
• Seeing psychiatrist is a sign of madness.
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
餘暉心態
老，不一定沉鬱消極
Prevalence (發病率) of elderly
depression in different care settings
Care setting
Prevalence of
depressive
symptoms
Community
15%
Prevalence of
major
depressive
disorder
1-3%
Primary care
20%
10-12%
Acute hospital
20-25%
10-15%
Residential care
30-40%
16%
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
ICD-10
Cardinal symptoms:
1. abnormal depressed mood for >2 weeks,
2. loss of interest / pleasure (anhedonia),
3. loss of energy (anergia)
Additional symptoms:
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
DSM-IV
1.
2.
3.
4.
5.
6.
7.
8.
9.
--
Depressed mood most of the day
Marked diminished interest or pleasure
Significant weight or appetite change
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive guilt
Reduced ability to think or concentrate
Recurrent suicidal thoughts or attempts
5 or more s/s for >2 weeks , must have (1)
or (2)
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)
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’)
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
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
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.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
你基本上對自己的生活感到滿意嗎？
你是否已放棄了很多以往的活動和嗜好？
你是否覺得生活空虛？
你是否常常感到煩悶？
你是否很多時感到心情愉快呢？
你是否害怕將會有不好的事情發生在你身上呢？
你是否大部份時間感到快樂呢？
你是否常常感到無助？(即是沒有人能幫自己)
你是否寧願留在家裏，而不愛出外做些有新意的事情？(譬
如 : 和家人到一新開張酒樓吃飯)
你是否覺得你比大多數人有多些記憶的問題呢？
你認為現在活著是一件好事嗎？
你是否覺得自己現在是一無是處呢？
你是否感到精力充足？
你是否覺得自己的處境無望？
你覺得大部份人的境況比自己好嗎？
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
是/否
是/否
是/否
是/否
是/否
是/否
是/否
是/否
是/否
是/否
是/否
是/否
是/否
是/否
是/否
Principles of management
(處理的原则)
Watch out for catastrophic risks
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; psychosocial intervention
4. Treating depressive symptoms with aim of
complete remission, then continue & maintain
5. Prompt referral of patients requiring specialist
mental health services
1.
2.
Treatment (治療)
Physical treatment
– Pharmacological treatment
– Electroconvulsive therapy
Psychosocial treatment
The Monoamine Hypothesis
The 3 monoamines:
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
Biogenic Amine Imbalance
Norepinephrine
Energy
Interest
Anxiety
Irritability
Serotonin
Mood,
Impulse
Emotion,
Cognitive Sex
function Appetite
Motivation
Aggression
Drive
Dopamine
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
Tricyclic antidepressants (TCA)
Nortriptyline, dothiepin, imipramine,
amitriptyline, clomipramine, trimipramine
- Anticholinergic S/E (urinary retention &
constipation may be troublesome)
- Anti-histaminergic S/E
- Anti-adrenergic S/E
- Cardiotoxicity - dangerous if overdose
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).
Stephen M. Stahl: Essential
Psychopharmacology 1996
Selective Serotonin Reuptake Inhibitors
(SSRIs)
Citalopram (Cipram), sertraline (Zoloft),
paroxetine (Seroxat), fluoxetine (Prozac),
escitalopram (Lexapro), fluvoxamine (Faverin)
- GI upset
- Headache
- Insomnia, anxiety, tremor
- Sexual dysfunction
(better tolerated than TCA but increase the risk
of GI bleeding in the very old)
Serotonergic-Noradrenergic
Reuptake Inhibitor (SNRI)
Venlafaxine (Efexor/Efexor XR)
Duloxetine (Cymbalta)
Milnacipran (Ixel)
- Side effects similar to SSRI
- Dizziness, increase heart rate
- May cause hypertension at high doses
Serotonin-2 Antagonist / Reuptake
Inhibitors (SARI)
trazodone (Trittico)
- Very sedating
- Dizziness, nausea, postural hypotension,
rarely priapism, no anticholinergic S/E
nefazodone (Serzone)
- Less sedating,
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
Reversible inhibitors of monoamine
oxidase A (RIMA)
Moclobemide (Aurorix)
- Nausea
- Headache
- Insomnia
- Restlessness
- Agitation
Other pharmacological treatment
Antipsychotics
Lithium augmentation
Tri-iodothyronine (T3) augmentation
Antidepressant combination
Anticonvulsant augmentation
Buspirone augmentation
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
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
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
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)
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
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
Sad, Bad or Mad ?
不開心? 不好?
?
In Summary:
• Elderly Depression are not rare but
often not detected or treated properly
• It need not be sad, bad or mad.
• Highly treatable & quality of life improves.
• Treat with care, start low & go slow.
• When in doubt, ready to refer or consult.
The End