Late Life Depression & Suicide Potential
A Physicians Guide to Identification and Treatment
By: AARP
Major Depression: Identification and Treatability
Epidemiology
• Approximately 3 percent of elderly individuals living in the community meet
research criteria
for major depression; moreover, between 10 and 14 percent have sustained
depressive syndromes.
• Depression is common in primary practice settings; approximately half of
elderly patients
seen for medical care of physical ailments have significant depressive symptoms
and 15 percent
meet criteria for severe clinical depression.
• Depression in later life is not necessarily associated with excessive stress
or adverse life
events; in a significant proportion of cases, depression occurs in the absence
of a clearly
identifiable precipitant.
Criteria for Major Depression
The criteria for major depression are:
• Depressed mood
OR
• Loss of interest or pleasure in most or all usual activities plus at least
four of these
symptoms, all of this occurring for at least two weeks:
1. Changes in appetite or weight
2. Disturbed sleep
3. Motor agitation or retardation
4. Fatigue or loss of energy
5. Feelings of worthlessness, self-reproach, or excessive guilt
6. Suicidal thinking or attempts
7. Difficulty with thinking or concentration
Although most of these symptoms may be caused or contributed to by physical
illness, depression
must be considered in the differential diagnosis of such patients. Depression
alone can cause
all of these symptoms.
Diagnosis of Major Depression
Making an accurate diagnosis in older patients is complicated because
physical illnesses that
accompany aging and the medications used to treat them can also produce
alterations in mental
state. The identification of sadness, self-recrimination and/or undue pessimism
can help the
clinician distinguish clinical depression from the apathy and lassitude
associated with occult
physical illness. However, many older persons are reluctant to discuss mental
health concerns
with their physicians so identification may require careful, sensitive and
persistent questioning
by the physician.
Older individuals with major depression usually have signs and symptoms that are
quite similar
to those found in depressed younger adults; however, there are some differences.
How Depression Symptoms Differ in the Older Patient
1. Sadness of mood is usually present but is often masked by other symptoms.
2. Impairment in cognition may be marked and dominate the clinical picture, even
appearing like
dementia.
3. A psychosomatic tendency often dominates, and the patient complains of aches
and pains or
other physical symptoms. Older depressives are more likely to demonstrate
exaggerated and
ruminative fears about their physical well-being than young counterparts.
Treatment of Depression in Older Persons
Psychotherapy: Studies have shown that psychotherapy can alleviate depressive
disorders in some
older adults.
Antidepressant Medication: Many older individuals with clinical depression have
a robust response
to antidepressant medication. This is true in both the physically well elderly
seen in outpatient
settings and in frail individuals residing in long-term care facilities.
However, physical frailty
is associated with reduced tolerance of antidepressant medications. It should be
noted that
antidepressants are not used routinely for grieving individuals whose grief
remains within the
"normal bounds" of intensity and duration.
Clinical features that increase the likelihood of a good response to
antidepressants are:
1. Decreased appetite or weight loss
2. Early morning waking
3. Decreased reactivity to environment
4. Psychomotor retardation or agitation
5. A clear onset of depressive symptoms
6. History of previous episodes of depression
7. A history of prior response to an antidepressant drug
8. A sense of hopelessness
9. Anhedonia (inability to experience pleasure in any circumstance)
10. Decreased functionality in conjunction with the depression
11. A family history of depression
Response to pharmacotherapy in major depressed older people generally requires
plasma concentration of secondary amine tricyclic antidepressants that are
comparable to those used m young adults.
Recover generally occurs in 3-6 weeks of treatment, but a small proportion of
patients only respond after 2-3 months of treatment.
Older depressed persons have been successfully treated with the newer classes of
antidepressants.
These newer agents have different side effect profiles than the traditionally
used secondary
amine tricyclic antidepressants, Buproprion, trazodone, and, of especially
current interest, the
selective serotonin reuptake inhibitors (SSRIs: fluoxetine) sertraline,
paroxetine) hold considerable promise in the elderly. Dose/response
relationships and aging· effects on vulnerability to side effects with newer
antidepressants continue to be studied.
Depression is a recurrent illness. Systematic studies demonstrate that
continuing antidepressant
medication for at least six months after recover significantly reduces rates of
relapse. Recent
data indicates that patients with frequent episodes may require years of
prophylactic pharmacotherapy.
Electroconvulsive Treatment; Using modern techniques, electroconvulsive
treatment is a safe and very effective treatment for severe major depression in
individuals who cannot tolerate or do not respond to standard antidepressant
treatments.
Suicide Prevention in the Elderly
Epidemiology
* On average, in America, 1 older person commits suicide every 82 minutes; there
are 17 elder suicides daily.
* The suicide rate for individuals aged 80 to 84 is almost twice that of the
general population.
* Elderly white males are at the highest risk.
* More than 80% of such suicides had visited their primary care physician within
a month of their
death: 20% had done so within 24 hours.
Diagnosis of Potential for Suicide
It is necessary to ask direct questions related to suicide risk, once it is
established that the person
is suffering from depression. The following questions address the relevant
factors;
* Does the patient volunteer suicidal thoughts?
* Has the patient thought through plans for suicide?
* Does the patient have access to the means of suicide?
* Does the patient have an exaggerated concern about a real or imagined physical
illness?
* Is there evidence of a sense of hopelessness?
* Is the patient extremely depressed and withdrawn?
* Is this an elderly white male?
* Is there alcohol involved?
* Are there social contacts with whom to share emotional thoughts?
* Does the patient's cognitive status vary from day to day?
* Do you have reason to suspect the patient might not be taking his/her
prescribed medications?
* Is someone available at home for companionship until the depressed mood is
controlled or resolved?
Treatment for Suicidal Ideation
If such factors are found, the primary care physician must consider suicidal
risk in the subsequent
management. Companionship and surveillance must be arranged, and
hospitalization) for safety, must be seriously considered. Reduction of access
to the means of suicide, including prescription and/or over-the-counter drugs
and especially guns, must be implemented. Follow-up must be aggressive and
proactive, not waiting for the patient or even a family member to initiate or
sustain it. Referral to a psychiatrist is indicated.
Conclusion
Since it is clear that depression in the elderly is often missed or not
considered in the differential
diagnosis, primary care physicians are encouraged to think of depression more
frequently in the
differential diagnosis of an older person who is unwell or failing. They should
ask specific questions to identify whether the clinical features for depression
or the criteria listed for major depression are present. Then they must consider
referral for psychotherapy and/or mounting a trial of antidepressant therapy,
starring low, following closely, and increasing the dose to an adequate level,
for long enough to ensure that the depression could respond (6-12 weeks at a
therapeutically adequate dose, possibly with confirmation by blood level). Once
controlled, the patient should be maintained on the same dose for at least six
months, and often longer, to prevent relapse. When the risk for suicide is
identified, treatment must be aggressive and proactive.
Written by;
Richard J. Ham, M.D.
SUNY Distinguished Chair in Geriatric Medicine
Professor of Medicine, Professor of Family Medicine
Past President, American Geriatrics Society
Barnett S. Meyers, M.D.
Associate Professor of Clinical Psychiatry
Cornell University Medical College
Past President, American Association of Geriatric Psychiatry
Wilmes-Reitz Psychological
23632 Calabasas Rd., Suite 202
Calabasas, California 91302
(818) 591-8270
wrpsych@aol.com
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