Blackburn J.A., Dulmus C.N. (Editors). Handbook of gerontology: evidence-based approaches to theory, practice, and policy

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research. The life course perspective depicts how individual age-defined path-

ways interact with social roles and obligations (i.e., work and family) and with

life transitions, social conditions, and future options (Elder, 1994). Therefore,

when understanding the experience of late-life depression, the history of a per-

son’s development and expected transitions through social institutions and or-

ganizations is considered through detailing the cohort-specific influences,

contextual factors, and maturity processes of each individual (Knight, 2004). By

using this perspective, Mirowsky and Ross (1992) reported increasing levels of

depression for older adults in comparison to other age groups through their life

course analysis. They report that even though both young and old may be more

likely to be unemployed, have lower incomes, and be unmarried than those in

middle adulthood, these statuses (i.e., for older adults, retirement, widowhood,

etc.) have different meanings in the two groups, which leads to more feelings of

powerlessness, and subsequently more depression for older adults.

Recent qualitative research regarding depressed older adults’ beliefs about

causes of depression further highlights a social model of depression. This cross-

cultural comparison demonstrated that culture is associated with varying be-

liefs on the causes of depression. In particular, Lawrence and colleagues (2006,

p. 23) conclude that a majority of their participants considered depression “an

illness arising from the adverse personal and social circumstances that can ac-

crue in old age” and that “an acceptance of the social and aging precipitants of

depressees was not incompatible with the concept of depression as an illness.”

The participants listed causes such as aging and loss of independence; bereave-

ment; loneliness; relationship changes; biological factors; personality, social, and

financial causes; and past experiences. This review of the etiology of depression

in late life argues for a biopsychosocial approach that incorporates the knowl-

edge base of multiple disciplines to best guide the development and implementa-

tion of evidence-based treatments.

PROGNOSIS

Overall, depression has long been considered to be the most treatable psychiatric

disorder affecting older adults (Blazer, 1993; Gellis, 2006). Treatment by antide-

pressants and by psychotherapy have been well supported in the literature as de-

creasing the duration and severity of depression in this age group (Baldwin et al.,

2003; Blazer, 2003; Mackin & Areán, 2005; Shanmugham et al., 2005). In fact, it can

be expected that effective treatments will positively impact the depression out-

come after just 6 to 12 weeks for the majority of patients (Schulberg, Katon,

Simon, & Rush, 1999). With the basic premise that depression is amenable to

treatment, depression is often divided into three prognostic categories: single ep-

isode, recurrent, and chronic (Blazer, 1993). In single-episodic depression, a per-

son experiences only one episode of major depression that may have a natural

course of less than 1 year. If not presenting high-risk symptoms (such as suicidal-

ity) and if provided adequate treatment in primary care, persons with a single ep-

isode of depression may be sufficiently cared for in an outpatient primary care

setting and not require specialty mental health care (Schulberg et al., 1999).

The second prognostic category describes persons with recurrent depression.

Here the depression follows an episodic pattern, and a person experiences at least

Depression 277

two episodes of depression that are separated by at least one remission in symp-

toms. A remission could last for decades, or could just be 1 year without signifi-

cant depressive symptoms. Often the course runs through a full episode of major

depression, partial remission, and eventual remission. Mitchell and Subrama-

niam’s (2005) systematic review of the prognosis of late-life depression docu-

mented that older adults experience remission rates similar to that of

middle-aged adults, yet may be at higher risk for relapse. Their recommendation

to provide long-term treatment for maintenance and prevention of relapse

matches the suggestions of several other groups (Segal, Pearson, & Thase, 2003;

Shanmugham et al., 2005). For recurrent depression, treatment may be offered in

a collaborative approach, with the primary care physician providing maintenance

care and seeking specialty mental health consultation or referral for the reoccur-

rence of a major depressive episode (Alexopoulos et al., 2005).

The third category describes persons who experience a more chronic duration

of depression that does not appear to have episodic breaks in symptoms. This

form of depression describes people who persistently report symptoms sufficient

for major depression diagnostic criteria for 2 or more years (American Psychiatric

Association, 1994). A single episode of depression that does not receive adequate

depression treatment may fit this category, but so too would long-duration de-

pressive episodes that do not respond to adequate treatment. This unremitting

depression is sometimes referred to as “treatment-resistant” depression and

often requires specialty mental health care to manage the symptoms and multiple

treatment needs. Some factors associated with increased chronicity of depression

are perceived impaired social support, increased medical comorbidity, and im-

paired physical functioning (Hayes et al., 1997).

As mentioned earlier, some of the dangers of not treating depression are in-

creased risk of suicide and mortality, increased physical disability, and increased

risk for complications of other medical conditions. Late-life depression not only

impacts the individual’s quality of life, but also leads to increased social costs

through the association with general health care dollars and loss of productivity

(Katon, Lin, Russo, & Unützer, 2003; Wells, 1997). As it is clear that the prognosis

of clinically significant depression can be positively impacted by effective inter-

ventions, it is therefore necessary to clearly understand how these evidence-

based interventions can be implemented in a variety of aging, social, and health

care settings.

EVIDENCE-BASED INTERVENTIONS

CREENING

Using standardized questionnaires in a systematic manner to increase detection

of depression is the basic premise of screening protocols. The screens may be self-

administered, in written or computerized formats, or administered by staff or cli-

nicians to older adults. The screens result in a score that indicates probable

depression and then flag the case for further evaluation by either the primary care

physician or other clinicians. Yet screening is a debatable solution because screen-

ing alone does not equate to positive health outcomes (Palmer & Coyne, 2003). One

study demonstrated that just handing the completed screener to the primary care

physician may not ensure that the screening occurs or that the information is

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utilized in treatment planning (Dobscha, Gerrity, & Ward, 2001). In fact, the U.S.

Preventive Services Task Force (2002) concluded that there is currently insuffi-

cient evidence to recommend for or against routine use of standardized question-

naires to screen for depression in primary care patients, and that if screening is

implemented, the settings must ensure that procedures conducive to accurate di-

agnosis, effective treatment, and careful follow-up are also implemented (Pignone

et al., 2002).

The failed attempts to improve the adequacy of depression treatment by solely

promoting the use of screening highlighted the need for sustainable, multifaceted

supports to the structure and organization of care (Gilbody, Whitty, Grimshaw, &

Thomas, 2003). Even though screening alone has not been associated with im-

proved depression rates of treatment and detection, screening is still a pivotal

component of evidence-based care. Clear evaluation of how the numerous depres-

sion screeners are appropriately or inappropriately used across settings and ser-

vice populations remains important.

The literature demonstrates that numerous screening options are available for

detecting depression. These scales vary in length, administration style, scoring

complexity, and underlying assumptions. Some of these scales were designed for

specific use in medical settings; others were designed specifically for older

adults. When selecting a screen for use, practitioners should compare the possible

depression screeners on four domains, as described by Corcoran (1991): (1) sam-

ple characteristics, (2) reliability, (3) validity, and (4) practicality.

In the first domain, sample characteristics, the focus was on identifying mea-

sures that were validated for older adult populations or specific clinic popula-

tions (e.g., primary care settings), diversity in populations, and languages

available. Examples of depression screens tested on older adults are listed in Table

11.1. The second domain for consideration in selecting a screening instrument is

the methodological concern for reliability—the ability of the measure to yield the

same value of a construct over time, situation, or other influences of error (Ker-

linger, 1986). Likewise, the third domain is the validity of the screening instru-

ment—the accuracy of the measure. Often, validity is measured by two factors:

specificity and sensitivity. Sensitivity refers to the instrument’s ability to cor-

rectly identify participants with depression (i.e., true positives). Specificity is the

ability to correctly identify those who do not have depression (true negatives; Ro-

bison, Gruman, Gaztambide, & Blank, 2002). In clinical practice, the focus has

been on ensuring high sensitivity because clinicians do not want to risk unrecog-

nized depression. However, low specificity also becomes a concern for resource

allocation because referring false-positive clients for full mental health evalua-

tion leads to resources being spent unnecessarily. This is especially problematic

in settings were competing demands and limited resources already confine the

reach of mental health service use (Nease, Klinkman, & Volk, 2002).

The sources provided for each screening instrument in Table 11.1 describe the

respective evidence for the validity and reliability of each measure identified for

use with older adults. Both Mulrow et al. (1995) and Williams, Pignone, Ramirez,

and Perez Stellato (2002) concluded that multiple instruments with reasonable

operating characteristics are available for depression screening. Williams et al.

concluded that because operating characteristics among the instruments are

equivalent, selecting a depression screener should depend on factors of feasibil-

ity, administration, and scoring ease.

279

Table 11.1

Overview of Select Depression Screens for Older Adults

Instrument Source

Sample

Settings

Number

of items Scope

Item

Response

Time

Frame

Score

Range

Usual

Cutoff

Point

Literacy

Level

Beck Depres-

sion Inventory

(BDI)

Steer, Cava-

lieri,

Leonard, &

Beck (1999)

Older adults

in academic

and VA

21, 13, 7 Depression-

specific,

includes

somatic

symptoms

Four statements

of symptom

severity per item

Today 0–63 10–19 mild,

20–29 mod-

erate, 30+

severe

Easy

Center for

Epidemiologic

Studies

Depression

Screen

(CES-D)

Radloff &

Teri (1986)

Older adults

in academic

and

community

20, 10 Depression-

specific

Four frequency

ratings: “less

than 1 day” to

“most to all” (5–7

days)

Past week 0–60 16+ Easy

Duke Anxiety

and Depres-

sion Scale

(DADS)

Parkerson &

Broadhead

(1997)

Primary

care

7, 10 Anxiety and

depression

Three frequency

ratings: “yes,

somewhat, no” for

three items;

“none, some, a

lot” for four items

Past week 0–100 31+ Average

Geriatric

Depression

Scale (GDS)

Arthur et al.

(1999)

Functionally

impaired

older

adults in

community

30, 15 Depression-

specific, omits

most somatic

symptoms

Yes or no Past week 0–30 11+ Easy

General

Health

Questionnaire

(GHQ)

Bashir,

Blizard,

Jenkins, &

Mann (1996)

Primary

care

30, 28, 12 Psychiatric

illness

Four frequency

ratings: “not at

all” to “much

more than usual”

Past few

weeks

0–28 4+ Easy

Hospital Anxi-

ety Depression

Scale (HADS)

Hermann

(1997)

Primary

care and

hospital

14 Depression

and anxiety

Four statements

of symptom

severity per item

Past week 0–21 11+ Difficult

(continued)

280

Table 11.1

Continued

Instrument Source

Sample

Settings

Number

of items Scope

Item

Response

Time

Frame

Score

Range

Usual

Cutoff

Point

Literacy

Level

Hopkins

Symptom

Checklist

(HSCL)

Nettelbladt,

Hansson,

Stefansson,

Borgquist, &

Nordstrom

(1993)

Older adults

in primary

care

25, 13 Multiple ver-

sions and com-

ponents

Four frequency

ratings: “not at

all” to “much

more than usual”

Past week 25–100 43+ Average

Inventory for

Depression

(ID)

Rush (1999) Older adults

in VA

15 Depression-

specific

Two items, yes or

no; Three items of

normal, overt, or

covert symptoms

Recently 0–15 10+ Easy

Medical Out-

comes Study

Depression

Scale (MOS-D)

Nagel,

Lynch, &

Tamburrino

(1998)

Primary

care

8 Depression-

specific

Frequency rat-

ings: “less than 1

day” to “most or

all” (5–7 days)

Past week 0–1 0.06+ Average

Primary Care

Evaluation

of Mental

Disorders

(PRIME-MD)

Spitzer et

al. (1994)

Primary

care adults

and older

adults

2 Multiple com-

ponents with

depression

Yes or no Past month 0–2 1+ Average

Patient Health

Questionnaire

(PHQ-9)

Kroenke,

Spitzer, &

Williams

(2001)

Primary

care adults

and older

adults

9 Multiple com-

ponents with

depression

Four frequency

ratings: “not at

all” to “nearly

every day ”

Past 2

weeks

0–27

0–4 none,

5–9 mild,

10–14 mod-

erate, 15–19

major, 20–27

severe

Average

(continued)

281

Zung Self-

Assessment

Depression

Scale (SDS)

Zung (1965) Primary

care

20 Depression-

specific

Four frequency

ratings: “little of

the time” to “most

of the time”

Recently 25–100 50–59 mild,

60–69 mod-

erate, 70+

severe

Easy

SELFCARE Bird,

MacDonald,

Mann, &

Philpot

(1987)

Older

adults in

community

12 Depression-

specific

Four to nine

frequency ratings

that vary by

question

Varying

times

0–12 6+ Average

Single-

question

Williams et

al. (1999)

Academic

primary care

1 Depression-

specific

Yes or no Past year 0–1 1 Easy

VA = Veterans Affairs.

Literacy level: Easy = Third- to fifth-grade reading level; Average = Sixth- to ninth-grade reading level; Difficult = Ninth-grade reading level or higher.

Adapted from “Identifying Depression in Primary Care: A Literature Synthesis of Case-Finding Instruments,” by J. W. Williams, M. Pignone, G. Ramirez, and C. Perez Stellato,

2002,

General Hospital Psychiatry, 24,

pp. 225–237; and

Assessment of Depression in Older Adults,

by E. L. Woodhead and S. Stoner, paper presented at the Gerontological

Society of America, Orlando, FL, November 2005. Adapted with permission.

Symptom Dri-

ven Diagnostic

System—Pri-

mary Care

(SDDS-PC)

Broadhead

et al. (1995)

Primary

care

5 Multiple com-

ponents with

depression

Yes or no Past month 0–5 2+ Easy

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Other issues of practicality are the instrument’s length, the time it takes to

complete, whether or not it requires someone to administer it, its social accept-

ability and utility, its purpose, and its method of scoring (Corcoran, 1991). Some

depression screens, such as the Primary Care Evaluation of Mental Disorders

(PRIME-MD) 2-item screener (Löwe, Kroenke, & Grafe, 2005), conclude only

whether or not the older adult may be experiencing probable depression. Such

measures tend to be short and easy to administer but are limited in the informa-

tion they provide. A longer scale, such as the 15-item Geriatric Depression Scale,

may require more time for administration and scoring, but it has an added in-

formative value because it provides a measure of the depression severity (Arthur,

Jagger, Lindesay, Graham, & Clarke, 1999). The Patient Health Questionnaire 9

(PHQ-9) not only provides a measure of severity, but also provides information

on DSM-IV symptoms of depression, including a question about suicide risk

(Kroenke, Spitzer, & Williams, 2001). Therefore, choosing between these two in-

struments depends on specific purpose and needs. Areán and Ayalon (2005) use

similar criteria—psychometric quality, ease of administration, and clinical char-

acteristics—in reviewing depression screening tools; they conclude that for older

primary care patients, the PHQ-9 or Center for Epidemiological Studies Depres-

sion Scalre-Revised (CES-D-R) may be most appropriate due to ease of adminis-

tration, uniformity and universality for use with various age groups, and ability

to effectively detect depression.

In summary, when selecting a depression screen to implement it is necessary

to plan for the follow-up procedures for initiating depression treatment and how

one will monitor the effectiveness of the care provided. Here are several ques-

tions to consider when reviewing the evidence for which screener to use:

• Do the testing samples for the depression screen represent the target

population?

• Is the literature on the depression screen up to date?

• Does the literature provide information on reliability and validity of the

screen?

• Is the sensitivity (true positives) and specificity (true negatives) for the

screen acceptable for the resources and needs of the target setting?

• Is the depression screen of appropriate length and social acceptability?

• Does the depression screen provide information about severity?

• Is the depression screen feasible to administer, score, and incorporate into

routine practice?

• Is the depression screen available in the languages needed by the target

population?

• Does the depression screen detail specific symptoms of concern (e.g., suici-

dality)?

The following recommendations are provided to improve the likelihood that

the depression screen will not only be practical for transfer to new settings, but

also will have beneficial impact on the depression care provided to older adults:

• Ensure that older adults have extended time, space, and assistance when

needed to complete self-administered forms.

Depression 283

• Use process evaluation to verify the consumer friendliness, cultural compe-

tency, and provider satisfaction of the measure with each new population.

• Monitor response rate through the percentage of participants completing it,

the rate of the screener outcome’s being incorporated into the treatment

plan (e.g., through diagnosis, referral, or other relevant interventions), and

the impact on participant outcomes on depression severity, quality of life,

and disability days.

HARMACOTHERAPY

The use of medications to effectively treat depression is not unique to older

adults; however, because older adults take more drugs than younger adults in

general and because the number of drugs taken tends to increase with age, the

issue of pharmacotherapy to treat late-life depression does require a specific

knowledge base in geriatrics (American Medical Association [AMA], 2002). Sur-

vey data suggest that older adults take an average of three prescription and non-

prescription drugs daily (Hanlon, Schmader, Ruby, & Weinberger, 2001). Further

complicating the use of pharmacotherapy to treat late-life depression is the

knowledge that taking a greater number of drugs is associated with an in-

creased risk for adverse drug reactions (AMA, 2002), which puts older adults at

disproportionate risk. Not only are drug-drug interactions a concern, but so too

are drug-disease interactions that may put older adults at risk (McLeod, Huang,

Tanblyn, & Gayton, 1997). Also, pharmacokinetic changes that coincide with

aging may alter the absorption, distribution, hepatic metabolism, and renal ex-

cretion processes that influence the impact of any one prescription medication

(AMA, 2002). Therefore, it is necessary to review evidence-based pharmacother-

apy interventions for depression that are specific to the needs and characteris-

tics of older adults.

General guidelines for geriatric pharmacotherapy focus on the principles of ef-

ficacy, safety, appropriateness of drug and dose (i.e., “Start low and go slow”), the

complexity of the treatment regimen, cost, and patient compliance (AMA, 2002).

Table 11.2 lists appropriate drug recommendations for older adults with depres-

sion. Although guidelines identify selective serotonin reuptake inhibitors

(SSRIs) as the first-line treatment of choice due to their receiving the highest rat-

ings for efficacy and tolerability, even though evidence-based reviews report that

tricyclic antidepressants (TCAs) had similar tolerability (Alexopoulos et al., 2001;

Baldwin et al., 2003; Colenda et al., 2003; Raj, 2004; Segal, Pearson, & Thase, 2003;

Shanmugham et al., 2005). The expert guidelines provide the caveat that the con-

sequences of the TCAs’ side effects are more serious than those of SSRIs (Shan-

mugham et al., 2005). In deciding which SSRI should be used, it is important to

note that not only do the pharmacokinetic profiles of the SSRIs vary, but also that

each SSRI is associated with its own specific risks for side effects and drug-drug

interactions (Trivedi, 2003). Thus, choice of which antidepressant to prescribe

should be guided by each individual patient’s potential for drug interactions,

simplicity of dosing, and side effect profile (Baldwin et al., 2003; Shanmugham

et al., 2005). It is also important to note inappropriate prescribing practices that

may lead to depression in certain disease groups or that identify specific consid-

erations for not prescribing antidepressants due to the risks to the older patients,

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Table 11.2

Guidelines for Common Antidepressants to Treat Late-Life Depression

Dose (mg)*

Antidepressant Medication

(Generic Name) Range Usual Comments

SSRIs

Fluoxetine HCl (Prozac) 10–60 20 Has a long half-life.

Sertraline HCl (Zoloft) 25–150 75 Potential for diarrhea; do not give

with pimozide (Orap).

Paroxetine HCl (Paxil)

Paroxetine HCl, controlled-release

(Paxil CR)

10–40 20 Side effects may include dry

mouth, constipation, weakness/

fatigue, nausea, weight gain.

Citralopram hydrobromide

(Celexa)

10–40 20 Activating, morning dosing. Rela-

tively few drug interactions. Side

effects may include dry mouth.

Escitalopram oxalate (Lexapro) 10–20 10 Activating, morning dosing. Few

drug interactions.

TCAs

Nortriptyline HCl (Aventyl,

Pamelor)

10–125 50

Anticholinergic effects, weight gain,

weakness/fatigue.

Desipramine 75–200 100–200 Tachycardia, insomnia/agitation.

Others

Bupropion HCl (Wellbutrin) 100–300 150 Potential for weight loss. Also mar-

keted as Zyban for use as smoking

deterrent.

Venlafaxine extended-release

(Effexor XR)

37.5–225 112.5 Potential nausea, agitation/insom-

nia; 1% to 3% risk of elevated

blood pressure.

Mirtazapine (Remeron) 7.5–45 22.5 Potential sedation, weight gain.

*Start at lower end of range and adjust dose upward every 2 to 3 weeks, depending on response.

Adapted from “Depression in the Elderly: Tailoring Medical Therapy to Their Special Needs,” by A. Raj, 2004,

Post-

grad Medicine Special Report, 115,

retrieved March 20, 2006, from http://www.postgradmed.com/issues/2004

/06_04/raj.htm; and “Pharmacological Treatment of Depression in Older Primary Care Patients: The PROSPECT

Algorithm,” by B. H. Mulsant et al., 2001,

International Journal of Geriatric Psychiatry, 16,

pp. 585–592. Adapted

with permission.

as is described in Table 11.3. McLeod et al. (1997) provide alternative pharmaco-

logical therapy recommendations in these recognized inappropriate practices.

Evidence-based pharmacotherapy for the treatment of depression not only in-

corporates knowing which medications to use at what levels, but also a structured

treatment algorithm that describes how and when a physician should change the

treatment strategies of patients who experience partial or no response to the first

course of antidepressant treatment. Critical decision points are specified to en-

sure that proper and timely evaluation of the patient’s response is addressed. If

the patient has not reached remission, second- or third-line treatment options in-

clude a provider’s choice of augmentation with a second medication, combination

of two medications, or an antidepressant plus psychotherapy, and switching to a

Depression 285

different medication (Trivedi, 2003). Examples of treatment algorithms for de-

pression in general include the Texas Medication Algorithm Project and the Se-

quenced Treatment Alternatives to Relieve Depression. Large multisite

randomized clinical trials of depression interventions for older adults have also

developed their own treatment algorithms, such as the Improving Mood and Pro-

moting Access and Collaborative Treatment (IMPACT; Unützer, Katon, et al.,

2002) and the Prevention of Suicide in Primary Care Elderly Collaborative Trial

(PROSPECT; Bruce et al., 2004).

With the majority of older adults being responsible for taking their own med-

ications, achieving optimal compliance involves the provider’s medication selec-

tion; routine assessment of the outcome, including information about medication

use from the patient and family or other caretaker; and increasing the patient’s

health literacy. Unintentional noncompliance may be due to cognitive problems

with memory or confusion and impaired physical functioning (AMA, 2002).

Strategies to increase compliance include the following:

Table 11.3

Identification of Contraindicated Medications for Late Life Depression

Risk to Patient Alternative Therapy

Medications that May Cause Depression

•

Prescription of reserpine to treat hypertension

Another antihypertensive drug.

• Beta-blockers to treat hypertension Monitor for possible depression and pursue

treatment as needed.

• Many anticancer drugs Monitor for possible depression and pursue

treatment as needed.

• Interferon alfa medication Monitor for possible depression and pursue

treatment as needed.

Medical Conditions That May Cause Depression

• Hypothyroidism Check TSH level on diagnosis of depression.

Inappropriate Prescription of Antidepressants

•

TCA antidepressant for patients with a history

of glaucoma, benign prostatic hyperplasia, or

heart block

Use SSRI antidepressant.

•

SSRI for patients already receiving an

monamine oxidase (MAO) inhibitor to treat

depression

Avoid combing, ensure a wash-out period of at

least 7 days if switching an MAO inhibitor to an

SSRI.

• TCA to treat depression for patients with a

history of postural hypotension

Use SSRI, with monitoring of blood pressure.

•

TCA with active metabolites (e.g., imipramine

or amitriptyline) to treat depression

Use TCA without active metabolites or SSRI.

• Prescription of methylphenidate to treat

depression

Use SSRI or short half-life TCA without active

metabolites.

Adapted from “Defining Inappropriate Practices in Prescribing for Elderly People: A National Consensus Panel,”

by P. J. McLeod, A. R. Huang, R. M. Tamblyn, and D.C. Gayton, 1997,

Canadian Medication Association Jour-

nal, 156

(3), pp. 385–391; and “Depression in the Elderly: Tailoring Medical Therapy to Their Special Needs,” by

A. Raj, 2004,

Postgrad Medicine Special Report, 115,

retrieved March 20, 2006, from http://www.postgradmed

.com/issues/2004/06_04/raj.htm. Adapted with permission.