ProfJohnSnodons LATE LIFE DEPRESSION

OLD AGE PSYCHIATRY IN VIETNAM LATE-LIFE DEPRESSION by John Snowdon Old age psychiatrist October, 2012 Late life depression  Prevalence of different types of depression  Subthreshold depression  Factors associated with late life depression: Life events Disability Medical problems Dementia with depression  Vascular depression Environment Social Psychotherapy Medication  Management  GP prevention of suicide (Gotland study) Depression Disorders in which the central feature is a lowering of mood, usually accompanied by a reduced capacity to enjoy or take interest in one’s usual activities Depression in old age Prevalence 13% - but this includes:  adjustment disorder with depressed mood  ‘subthreshold’ depressions (often as disabling & significant as ‘major’ depressions)  depressions associated with physical illness (e.g Parkinson’s, stroke, cancer, etc.) or with dementia Blazer and Williams 1980: 14.7% of 997 were depressed, 6.5% being medically related, 4.5% “simply dysphoric”, 3.7% major Older person commonly denies depression May be ‘masked’ and present as a physical problem, or with apathy, irritability or being demanding Prevalence of depression in association with physical/organic illnesses GENERAL MEDICAL PATIENTS 10 to 20% major CANCER 25% major/adjustment STROKE 23% to 34% major PARKINSON’S 45% depressed (most major or dysthymia) DEMENTIA 23% depressive disorder 11% major DISABLED 35% significantly depressed NON-DISABLED 12% significantly depressed THE PREVALENCE OF PSYCHIATRIC DISORDERS IN NURSING HOMES compare with Vietnam) (to US Australia Dementia (25% depressed) >80% 80% Behavioural disturbance >67% 68% 6% to 25% 9.7% Major depression Depressive symptoms 30% to 50% ICD-10 depressive episode 19.5% Anxiety disorders 3.5% 4% Schizophrenia 2.4% 5.4% of new admissions schiz, paranoid Source: US: Streim et al, 1997; Rovner & Katz, 1993; Rovner et al, 1990 AUSTRALIA: Snowdon; Henderson; Rosewarne et al 1997; Ames SOME CAUSES OF DISTRESS IN LATE LIFE Noxious stimuli Pain Aggravation Feeling unwell Worry or concern Yearning Not being able to understand Being misunderstood Loss(es) Etc Neurobiochemical changes? The quality of life of a person who is in distress will be improved if the cause of distress is removed or can be countered Aetiology matters! Cause matters! Are diagnostic labels helpful? What is the clinical utility of the DSM-IV or ICD-10 labels when discussing treatment and prognosis of mental disorders in late life? DSM-IV LABELS THAT DIFFERENTIATE TYPES OF DEPRESSION IN LATE LIFE 296.xx Bipolar 296.xx Major (Psychotic, Melancholic, Non-melancholic) 300.4 Dysthymic Disorder 309.xx Adjustment disorder with depressed mood 293.83 Mood disorder due to a general medical condition 29x.xx Substance-induced mood disorder 290.xx Dementia (Alzheimer’s) with depressed mood 290.43 Dementia (vascular) with depressed mood 311 Depressive disorder n.o.s (?minor, subthreshold, subsyndromal) ( v62.82 Bereavement) (295.70 Schizoaffective disorder – depressed) ‘Vascular depression’ hypothesis: Alexopoulos et al, Arch Gen Psychiatry, 1997, 54, 915-922 Late-onset depressive disorder A preventable variant of cerebrovascular disease? Hickie I & Scott E, Psychol Med 1998, 28, 1007-1013 Ischemic basis for deep white matter hyperintensities in major depression A neuropathological study Thomas AJ et al, WMH and depression Herrmann LL, Le Mesurier M, Ebmeier KP (2008) White matter hyperintensities in late life depression: a systematic review Journal of Neurology, neurosurgery and Psychiatry 79, 619-624 Colloby SJ et al (2011) Relationship of orthostatic blood pressure to white matter hyperintensities and subcortical volumes in late-life depression British Journal of Psychiatry 199, 404-410 Late onset depression  Alexopoulos et al (1997) Arch.Gen Psych postulated that cerebrovascular disease predisposes to, precipitates and perpetuates late-life depression by damaging specific brain circuits or through inflammation Damage to vascular epithelium is followed by release of proinflammatory cytokines and tissue necrosis factor alpha (Alexopoulos & Kelly, World Psychiatry 2009)  Association of late-life depression with executive dysfunction, with decreased interest in activities and psychomotor retardation Poor response to antidepressants  More deep white matter hyperintensities on MRI (especially frontal and temporal) in depressed than non-depressed elderly Associated with CV disease, reduced cerebral bloodflow, etc  CV disease, rather than glucocorticoid-mediated brain damage, is responsible for the persistence of cognitive deficits associated with late-life depression TREATMENT OF DEPRESSION Age-related differences in suitability and dosage of medications Therapy depends on formulation re aetiology Reverse reversible physical or environmental causes Psychosocial treatments may be most important, often combined with medication How we deal with demoralisation? Antidepressants: SSRIs, venlafaxine, mirtazapine, reboxetine Usually avoid amitriptyline If psychotic, add neuroleptic, but may need ECT ECT usually effective for ‘biological’ depressions unless there is associated physical illness Let’s discuss treatment resistance Prognosis How does it differ between age-groups? ECT in old age Why hasn’t anyone yet looked at differences in outcome after ECT given to age-matched EOD and LOD patients? Or looked at prediction of outcome in relation to MRI changes? (There is a poor response to antidepressants if there are WMH ++) Van Schaik AM et al (2012) Efficacy and safety of continuation and maintenance electroconvulsive therapy in depressed elderly patients: a systematic review American Journal of Geriatric Psychiatry 20, 5-17 Vascular depression: treatment – or prevention?  Calcium channel blockers are potentially useful in treatment: a controlled double-blind trial of nimodipine showed that 45% of those on nimodipine plus antidepressant improved, versus 25% on antidepressant plus placebo Taragano et al, IJGP 2001, 16, 254-260 54% on nimodipine + fluoxetine versus 27% fluoxetine + placebo Taragano et al, International Psychogeriatrics 2005, 17, 487-498 These studies haven’t yet been replicated! Nimodipine too expensive?  Lower risk of vascular depression by controlling hypertension, hyperlipidaemia and homocysteine Aspirin? PSYCHOTHERAPY IN OLD AGE Interpersonal therapy Problem-solving therapy Cognitive behaviour therapy Reminiscence / life review Therapies in cognitively impaired patients Family therapy Adapting therapies to suit older What can be done for someone who is adjusting to losses ? Or adjusting to having a progressively disabling physical or cognitive disability ? Non-pharmacological interventions ? Medication ? What works best in cases of demoralisation ? Risk factors for depression in nursing homes 1) 2) 3) 4) Medical illness & disability Rates of depression increase with functional dependency and level of care and the nature and personal significance of the disability But not just psychological! What about neurobiological? Other losses or depressing events Institutional factors (including morale of staff) Different types – differing management ? Is the range of depressive disorders encountered in nursing homes different to that seen in other settings ? Are some types of depression responsive to antidepressants (& other treatments), while others are not ? How much co-morbid medical conditions obstruct or prevent appropriate treatment ? Can we devise strategies to prevent development of depression ? Psychotherapy for depression in nursing homes When a depression is related to a loss (of health, home, self-esteem, mastery, loved ones, etc) it is understandable that antidepressants may not relieve feelings of depression – even if we believe that stress and steroid output can lead to hippocampal damage and thus depression Adjusting to a loss, ventilating feelings, finding new ways of looking at things, will help those with sufficient cognitive ability to be involved Communicating feelings may still be important for those with severe dementia Psychotherapy for depression Mastery is the extent to which a person feels they have control over their life and environment – and MASTERY provides PSYCHOLOGICAL RESILIENCE and FACILITATES ADAPTATION in stressful life situations, including after medical events Enhancement of sense of control may EMPOWER functionally challenged older people and help them manage the adversity of disability 42, 807-813 Jang et al, The Gerontologist, 2002, Good news! Payne et al (IJGP 2002, 17, 247-253) looked at depression levels among newly admitted residents of Copper Ridge, an ACF in Maryland MEAN AGE 79.7 years, 71.6% WOMEN ALL RESIDENTS HAD DEMENTIA  On admission, 40 (19.9%) of 201 were depressed (>12 on CSDD)  months after admission, of the 40, + new cases (total 6%) were depressed  12 months after admission, of the 40, + new cases (total 4.5%) were depressed No mention of death rate among the 201 illnesses or physical disabilities No discussion of physical THE GOTLAND STUDY During the early 1980s this study showed that it was possible to reduce the incidence of suicide through introduction of a comprehensive education programme aimed at GPs The rate fell from 20 to per 100,000 (Rutz et al, Acta, 1989) Two additional one-day seminars for GPs in 1993 and 1995 1990-1994 and 100% increase in antidepressant prescription 15% reduction in suicide (especially women) Conclusion Late life depression is common Functional impairment is commonly a precipitant and ongoing factor Assessment of relevant factors will provide guidance re interventions PREVENTION: be alert to the relevant factors (including vascular risk factors and stress) .. .Late life depression  Prevalence of different types of depression  Subthreshold depression  Factors associated with late life depression: Life events Disability Medical... hyperintensities and subcortical volumes in late- life depression British Journal of Psychiatry 199, 404-410 Late onset depression  Alexopoulos et al (1997) Arch.Gen Psych postulated that cerebrovascular disease... hyperintensities in major depression A neuropathological study Thomas AJ et al, WMH and depression Herrmann LL, Le Mesurier M, Ebmeier KP (2008) White matter hyperintensities in late life depression: a