Depression Clinical Practice Guideline

Depression Clinical Practice Guideline For Medical Directors, Attending Physicians and Advanced Practitioners Depression • Depression is a spectrum of mood disorders characterized by a sustained disturbance in emotional, cognitive, behavioral, or somatic regulation and associated with significant functional impairment and a reduction in the capacity for pleasure and enjoyment. Introduction • Maintain a high index of suspicion for the presence of depression or depressive symptoms in long term care (LTC) patients • Late-life depression may be overlooked or inadequately treated Introduction • The relationship between medical conditions and depression is complex • Depression may exacerbate coexisting medical illness • Some medications may cause or contribute to depression Recognition • Step 1: – Does the patient have a history of depression or a positive depression screening test? • Review available transfer information, referral data and patient and family history • Look for history of depression, psychiatric disorder(s), treatment of hospitalization • Document the presence of these conditions in the medical record Recognition-Step 1 Continued • Depression is common among patients in the LTC setting • Treatment is effective • Adopt a policy encouraging formal screening of all patients for depression • Appropriate screening tools include: – – – – Geriatric Depression Scale Cornell Scale for Depression in Dementia Center for Epidemiologic Studies of Depression Scale Patient Health Questionnaire 9 Recognition • Step 2 – Does the patient have signs or symptoms of depression? • Nursing staff are in a good position to recognize signs and symptoms (S&S) of depression • Look for S&S in RAI. MDS, RAPs, progress notes, family interaction notes Symptoms Of Depression 3 Most important •Depressed mood most of the day, almost every day (by either subjective report or observation made by others , Diminished interest or pleasure in most activities, most of the time, Thoughts of death or suicide. •Difficulty making decisions, Feelings of helplessness, Feelings of worthlessness or hopelessness, Inappropriate feelings of guilt, Psychomotor agitation or retardation not attributable to other causes, Social withdrawal, avoidance of social interactions or going out. Sometimes •Appetite change, Change in ability to think or concentrate, helpful Change in activities of daily living (ADLs), Family history of mood disorders, Fatigue or loss of energy, worse than baseline, Insomnia or hypersomnia nearly every day. Increased complaints of pain, Preoccupation with poor health or physical limitations, Weight loss or gain. Important Recognition • Step 3 – Does the patient have risk factors for depression? • Evaluate for risk factors – If risk factors are present, develop an interdisciplinary (IDT) care plan – If no risk factors are found, monitor periodically Some Risk Factors for Depression • Alcohol or substance abuse • Current use of a medication associated with a high risk of depression • Hearing or vision impairment severe enough to affect function • History of attempted suicide • History of psychiatric hospitalization • Medical diagnosis or diagnoses associated with a high risk of depression • New admission or change in environment • New stressful losses, including loss of autonomy, loss of privacy, loss of functional status, loss of body part, or loss of family member, friend or pet • Personal or family history of depression or mood disorder Assessment • Step 4 – Has the patient had a persistently depressed mood or loss of interest or pleasure for at least 2 weeks? • Has depressed mood (dysphoria) or loss of interest or pleasure (anhedonia) been present for at least 2 weeks; and • has dysphoria or anhedonia contributed to the patient’s functional or social impairment or decline • Is substance abuse or bereavement not present Assessment • Step 5 – Is it appropriate to perform a medical workup for factors contributing to signs and symptoms of possible depression? • Will depend upon: – patient’s condition – prognosis – advance care directives – expressed preferences of the patient or family Laboratory Tests For Evaluating Possible Depression3 Preferred Tests •Chemistry profile (electrolytes, blood urea nitrogen, creatinine, glucose) •Complete blood count •Serum levels of anticonvulsant or tricyclic antidepressant, if taking either type of medication •Thyroid function (T3, T4, TSH) Other Tests That May Be Considered •Electrocardiogram •Folate level •Serum calcium level •Serum level of digoxin or theophylline, if taking either medication •Urinalysis •Vitamin B12 level Assessment • Step 6 – Is the patient taking medications that might cause or contribute to depression? • Many medications can affect: – mood – affect – level of consciousness Medications That May Cause Symptoms of Depression • Alpha-methyl dopa • Anabolic steroids • Anti-arrhythmic medications • Anticonvulsant medications • Barbiturates • Benzodiazepines (i.e., long acting) • Carbidopa or levodopa • Certain beta-adrenergic antagonists (propranolol) • Clonidine • Cytokines (specifically IL-2) • Digitalis preparations • Glucocorticoids • H2 blockers • Metoclopramide • Opioids Assessment • Step 7 – Does the patient have one or more conditions that may increase the likelihood of depression or that may cause depressive symptoms Important Comorbid Conditions • Important • Most important – Cancer – Alcohol dependency – Chronic obstructive pulmonary disorder – Cerebrovascular – Chronic pain diseases – Congestive heart failure – Medications that can – Coronary artery disease cause mood – Diabetes disorders – Electrolyte imbalance – Neurodegenerative – Endocrine disorders (thyroid) disorders (e.g., – Head trauma Alzheimer’s disease, – Metabolic problems Parkinson’s disease, – Myocardial infarction multiple sclerosis) – Orthostatic hypotension – Physical, verbal, emotional abuse – Substance abuse – Schizophrenia Assessment • Step 8 – Do the patient’s signs and symptoms resolve with treatment of comorbid condition(s)? • Take appropriate action if medical diagnoses or conditions are suspected of contributing to depressive symptoms • When depression and a medical condition coexist, both conditions are likely to require treatment • To the extent possible, address underlying causes and evaluate the impact of such measures • Step 8 – Clarify the diagnosis Assessment • The DSM-IV defines the following types of depressive disorders: – Mild episode of major depression – Moderate episode of major depression – Severe episode of major depression – Severe episode of major depression with psychotic features – Minor depression disorder – Bipolar type II – Dysthymic disorder – Adjustment disorder with depressed mood or with mixed anxiety and depressed mood Major Depression Depressed Mood + 4 symptoms x 2 weeks •Weight loss or gain •Insomnia or hypersomnia •Psychomotor retardation (agitation) •Decreased energy •Guilt feelings •Inability to concentrate •Thoughts of death or suicide (life not worth living) AND these symptoms: Produce social impairment Are not related to substance abuse. Are not related to bereavement Loss of interest or pleasure + 4 symptoms x 2 weeks Rating Scales • Use at the beginning of treatment • Only reliable way to obtain an objective measure • Essential to monitoring the effectiveness of treatment – Geriatric Depression Scale (GDS) – Cornell Scale for Depression in Dementia (CSDD) – Center for Epidemiologic Studies of Depression Scale (CES-D) – Patient Health Questionnaire 9 (PHQ-9) Assessment • Step 10 – Does the situation warrant additional psychiatric support? • Depression is often managed readily by primary care practitioners • Effective psychiatric support may not be readily available in the LTC setting • In some cases, however, psychiatric support is helpful Assessment • Step 11 – Does the patient’s depression exhibit complications that may pose a risk to the patient or to others? • determine if the patient is psychotic, severely agitated, aggressive, neurovegetative, or suicidal • Suicide risk increases with the severity of depression. Treatment • Depression usually responds to treatment with psychotherapy, medications, or a combination of the two • An effective individualized care plan includes both nonpharmacologic and pharmacologic interventions Phases of Depression Phase Acute 3 Treatment Duration Approx. 3 months 4-6 months Goal To achieve complete recovery from signs and symptoms of acute depressive episode (i.e., remission) To prevent relapse as patient’s depressive symptoms continue to decline and his or her functionality improves To prevent recurrence of a new depressive episode Continuation Maintenance 3 months or longer, depending on patient’s needs Treatment • Step 12 – Implement appropriate treatment for the patient’s depression • • • • Minimize institutional aspects of the environment Facilitate interaction with family members and friends Provide opportunities for spiritual activity Provide socialization interventions Psychotherapy • Considerable advances have occurred • Both cognitive-behavioral therapy and learningbased therapy have a significant impact on depression symptoms in older adults Pharmacologic Treatment • All antidepressants approved by the U.S. Food and Drug Administration have been shown to be relatively safe in most populations • However, they are fective in some, but not all, populations Electroconvulsive Therapy (ECT) • (ECT) should be considered if: – the patient’s condition is rapidly deteriorating or, – if antidepressant medication is not tolerated or has failed • Mild depression – failure of 4-6 antidepressants • Moderate depression – failure of 2-4 antidepressants • Sever depression – failure of 1-2 antidepressants or suicidal risks Assessing Treatment Response • Treatment response can vary widely among depressed elderly patients • Patient response is generally not predictable before the initiation of treatment • Beliefs that older patients in general respond more slowly to antidepressant treatment are unsubstantiated12-15 Most Common Psychosocial Interventions for Depression Intervention Preferred Techniques Psychotherapy Psychosocial intervention –Cognitive-behavioral therapy –Interpersonal therapy –Problem-solving therapy – Supportive therapy –Bereavement groups –Family counseling –Participation in social events –Psychoeducation Monitoring • Step 13 – Monitor the patient’s response to treatment for depression • Goals of treatment may include, but need not be limited to, the following: – Resolution of signs and symptoms of depression. – Improvement of scores on the GDS, CSDD, or CESD. – Improvement in attendance at and participation in usual activities. – Improvement in sleep pattern. Pharmacotherapy Considerations • Pharmacokinetics and Drug Interactions – Pharmacokinetic differences among older patients produce differing drug concentrations than in younger and healthier groups – Patients taking multiple drugs are at risk for drugdrug interactions and subsequent adverse events. – Most antidepressants are susceptible to drug interactions, – May be necessary to adjust doses of a patient’s other medications Pharmacotherapy Considerations • Treatment Strategies – No single class of antidepressant has been found to be more effective than another in the acute treatment of late-life depression. – Therapeutic drug-level monitoring maybe useful initially depending on the agent used (tricyclic) – Routine drug monitoring is not necessary except when: • depressive symptoms do not respond to treatment or when adverse side effects of treatment are apparent Pharmacotherapy Considerations • Tricyclic tertiary amines at therapeutic doses frequently are not tolerated in the LTC population • Monoamine oxidase inhibitors are not acceptable first-line drugs in the LTC setting CHOICE OF ANTIDEPRESSANT 3 Drug Preferred Agents Class SSRIs Citalopram Escitalopram Mirtazapine Paroxetine Sertraline Venlafaxine XR TCAs Desipramine Nortriptyline Alternate Agents Bupropion Fluoxetine Not Recommended Nefazodone Trazodone Amitriptyline Amoxapine Doxepin Imipramine Isocarboxazid Maprotiline Tranylcypromine Doses of Antidepressants That Are Likely to be Adequate3 Antidepressant Bupropion SR Citalopram Desipramine Escitalopram Fluoxetine Fluvoxamine Mirtazapine Nortriptyline Paroxetine Sertraline Venlafaxine XR Average Starting Dose (mg/day) 100 10 – 20 10 – 40 10 10 25 – 50 7.5 – 15 10 – 30 10 – 20 25 – 50 25 – 75 Average Target Dose After 6 Weeks (mg/day) 150 – 300 20 – 30 50 – 100 10 20 50 – 200 15 – 30 40 – 100 20 – 30 50 – 100 75 – 200 Usual Final Acute Dose (mg/day) 300 – 400 30 – 40 100 – 150 10 – 20 20 – 40 100 – 300 30 – 45 75 – 125 30 – 40 100 – 200 150 – 300 Treatment of Depression That Coexists With Mild to Moderate Dementia Preferred Treatment Option Other Options That May Be Considered Psychosocial interventions Caregiver-focused treatment Supportive psychotherapy Bupropion SR Mirtazapine Paroxetine Pharmacologic Medication alone treatment (citalopram, escitalopram, sertraline, venlafaxine XR) Medication plus psychosocial intervention Cholinesterase inhibitor Summary • Depressive symptoms are: – common among older adults – can have a major effect on their quality of life • Accurate diagnosis of depression is important • Depression usually responds to treatment with psychotherapy, medications, or a combination of the two • Treatment options should be consistent with the patient’s and family’s wishes and advanced directives