Treating Children with Depression by yaofenjin


									Treating Elderly Persons with
      Scott J. Adams, Psy.D.
   WICHE Mental Health Program
• Discuss epidemiological and other relevant
  data regarding depression in geriatric
• Discuss a clinical formulation of elderly
  persons regarding depression.
• Cover questions PCPs can ask of elderly
  patients to assess the presence of
• Talking with elderly people about treatment
• Major depression among older adults in primary care settings is
  between 6.5% and 9% (Lyness et al., 2002).

• Estimates of overall depression vary widely based on patient’s
  context (in community, nursing home, etc.) and method of

• Rates increase with need for home health care and

• 10%-25% of in primary care and community settings have
  subsyndromal depression with symptoms that do not meet
  diagnostic criteria but have a significant negative impact on
  their lives (Speer & Schneider, 2003)

• The prevalence of bipolar disorder among people aged 65 and
  over is reportedly less than 1 percent (Robins & Regier, 1991).
A. Gender

 1. Depression may be 1.5- 2 times higher in older adult women (e.g.,
    Kockler & Heur, 2002). This could be in part due to reporting bias
    and has been refuted in some studies that included post-mortem

B. Race

 1. Studies disagree on prevalence of geriatric depression in ethnic
    group. Some say there is little difference between races , some
    studies show higher numbers in some groups, for example, African-
    Americans (Weissman et al., 1991).

 2. Suicide is lower for people of color than in white older adults (CDC,
                   Risk Factors
•   People who need home health care
•   People who require hospitalization
•   People who live in nursing homes
•   Somatic illnesses
•   Persistent insomnia
•   Loss of their spouse
•   Other losses (e.g., loved ones, loss in functioning)
•   Poor social support
•   Current acute or chronic stressors
•   Heavy users of alcohol
•   Educational attainment less than a high school
          Clinical Case Formulation
Here is a relatively simple formula one can use to assess elderly
  persons for depression:

                Place X Position     = Problem

Place: Where a person resides – own home, with family, in a

Position: One’s psychological place or status – connected vs.
  alone, independent vs. dependent, physically healthy vs.
  unhealthy, productive vs. nonproductive.

Problem: The result of the interplay between one’s place and
           Clinical Case Formulation
Infant: Trust vs Mistrust - Needs maximum comfort with minimal uncertainty to trust
   himself/herself, others, and the environment

Toddler: Autonomy vs Shame and Doubt - Works to master physical environment
  while maintaining self-esteem

Preschooler: Initiative vs Guilt - Begins to initiate, not imitate, activities; develops
   conscience and sexual identity

School-Age Child: Industry vs Inferiority - Tries to develop a sense of self-worth by
  refining skills

Adolescent: Identity vs Role Confusion - Tries integrating many roles (child, sibling,
  student, athlete, worker) into a self-image under role model and peer pressure

Young Adult: Intimacy vs Isolation - Learns to make personal commitment to
  another as spouse, parent or partner

Middle-Age Adult: Generativity vs Stagnation - Seeks satisfaction through
   productivity in career, family, and civic interests

Older Adult: Integrity vs Despair - Reviews life accomplishments, deals with loss
   and preparation for death
          Clinical Case Formulation cont.
  Own Home                           With Family                      In a Facility
  Connected--------Alone             Connected--------Alone            Connected--------Alone
Independent--------Dependent      Independent--------Dependent      Independent--------Dependent
   Healthy--------Unhealthy           Healthy--------Unhealthy          Healthy--------Unhealthy
Productive--------Nonproductive   Productive--------Nonproductive   Productive--------Nonproductive

By considering a given person’s position within a place, one can get a good
   idea of relevant issues.

Generally speaking, the more a person falls on the left side of both the “place”
  and four “position” scales, the better off they will be psychologically.

For example, a person in his/her own home who has connections with others, is
   mostly independent, is fairly healthy, and productive will be in a better
   position than someone at the opposite end of these scales.
Additionally, this quick assessment tool can help identify potential interventions.

1. Use the clinical case formula presented in
   previous slides.
2. Geriatric Depression Scale (GDS) as a way
   to detect and talk about depression
   focusing less on dysphoric mood, which
   older adults are less likely to report.
        Geriatric Depression Scale (short form)
Choose the best answer for how you have felt over the past week:
1. Are you basically satisfied with your life?                                  YES / NO
2. Have you dropped many of your activities and interests?                      YES / NO
3. Do you feel that your life is empty?                                         YES / NO
4. Do you often get bored?                                                      YES / NO
5. Are you in good spirits most of the time?                                    YES / NO
6. Are you afraid that something bad is going to happen to you?                 YES / NO
7. Do you feel happy most of the time?                                          YES / NO
8. Do you often feel helpless?                                                  YES / NO
9. Do you prefer to stay at home, rather than going out and doing new things?   YES / NO
10. Do you feel you have more problems with memory than most?                   YES / NO
11. Do you think it is wonderful to be alive now?                               YES / NO
12. Do you feel pretty worthless the way you are now?                           YES / NO
13. Do you feel full of energy?                                                 YES / NO
14. Do you feel that your situation is hopeless?                                YES / NO
15. Do you think that most people are better off than you are?                  YES / NO

Generally, a score > 5 points is suggestive of depression and should warrant a follow-
up interview. Scores > 10 are almost always depression.
                Rule Outs
1. Medical causes
2. Bereavement
3. Bipolar Disorder (<1%)
4. Alzheimer’s, vascular dementia, other
Dementia vs. Pseudo-dementia
1. Medication
  a. One study on antidepressant medication
  compliance found that 70% of older adults
  don’t take their meds as prescribed (NAMI,
  2003) so address med compliance issues
  (e.g., fears about taking meds).
  b. Evidence suggests that medication may
  take longer to work.
  c. Residual symptoms appear to be
                           Treatment cont.
2. Psychotherapy

•   Psychotherapeutic treatment are effective for geriatric patients. Meta-analytic
    studies show that effects are similar to those of younger adults (e.g., one meta-
    analysis showed an effect size of .72).
•   83% say they want to treat their depression (APA, 2003).

•   Evidence is inconclusive regarding best kind of psychotherapy, but meta-
    analysis of psychotherapy studies have included a range of psychotherapy
    styles. Many types are probably effective.

•   Older adults may require a longer course of psychotherapy than younger adults.

3. Combined Treatment

•   The data indicate that medication or therapy alone can be effective, but combining them
    has the best outcome (Reynolds et al., 1999; Little et al., 1998; Thompson et al., 2001).
                Other Interventions
If you use the clinical case formula described earlier (Place x
    Position = Problem), interventions may become apparent.

For instance, does a person have connections but feels
  unproductive, or is he/she physically healthy but alone? There
  are many combinations, but even simple things can help a
  great deal.

A major theme is one of control and mastery. Even people who
  have significant physical illnesses and require significant care
  can do things to achieve greater control and mastery in their
Education is always helpful, particularly in terms of helping
  patients see that they do not have to accept depression as a
  necessary part of aging.
            Discussing Treatment
The primary treatments are psychotherapy or counseling and
As a general rule, the younger the child, the longer
  psychotherapy with the child will take. Instead, it’s better to
  work with parents.
Family therapy may be the best option if there are multiple
  problems in the home. Sometimes a child becomes a focus
  of problems but is not the only one with problems.
Many parents (understandably) do not want to put their kids on
  medications. One of the primary issues will be symptom
Brief explanations of how medications work go a long way in
   demystifying and destigmatizing them.
          Parent Resource List
Depression Education Websites:
• Mayo Clinic:
• National Institute of Mental Health:
• Mental Health

Books on How to Help Depressed Children:
• The Depressed Child: A Parent’s Guide for Rescuing
  Kids - Dr. Douglas A. Riley, Ph.D.
• The Childhood Depression Sourcebook - Jeffrey A.
  Miller, Ph.D.
• Helping Your Depressed Child - Martha Underwood
  Barnard, Ph.D.
    Pediatric Depression References
• Costello, E. J., Angold, A., Burns, B. J., Stangl, D. K., Tweed, D. L.,
  Erkanli, A., & Worthman, C. M. (1996). The Great Smoky Mountains
  study of youth: Goals, design, methods, and the prevalence of DSM–
  III–R disorders. Archives of General Psychiatry, 53, 1129–1136.

• Kessler, R. C., Avenevoli, S., & Merikangas, K. R. (2001). Mood
  disorders in children and adolescents: an epidemiologic
  perspective. Biological Psychiatry, 49, 1002-1014.

• Lewinson, P. M., Hops, H., Roberts, R. E., & Seeley, J. R., (1993).
  Adolescent Pychopathology I: Prevalence and incidence of depression
  and other DSM-III-R disorders in high school students. Journal of
  Abnormal Psychology, 102, 133-144.

• Rappaport, N., Bostic, J. Q., Prince, J. B., & Jellinek, M. (2006).
  Treating pediatric depression in primary care. Journal of Pediatrics,
  148, 567-568.

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