Vintage Voices: Depression in Nursing Homes
Admission to a nursing home is one of the most significant challenges an individual can face. Coming to terms with the circumstances that created the need for long term care while simultaneously creating the best possible adjustment to one's next chapter, a new resident must be fully engaged and resilient to achieve a successful outcome. Unfortunately, many are burdened by depression at exactly this moment. Ideally, depression would be quickly identified and treated so that the resident has a "fighting chance" to create an optimal adjustment, but unfortunately, that is often not the case. Untreated depression may be the single most deleterious shortfall in skilled nursing facility (SNF) care, causing countless residents to decline when they otherwise could thrive.
The Centers for Medicare & Medicaid Services now requires SNFs to help residents achieve their "whole emotional and mental well-being." This is a part of a more general shift toward person-centered care, which takes into account every individual resident's needs and moves away from a symptom-focused approach that can lead to overmedication. Despite this trend, the vast majority of care remains devoted to treating residents' medical illnesses, even though psychiatric issues, particularly depression, are extremely prevalent. And since depression interferes with the successful treatment of most medical disorders, even well-intended medical interventions are likely to be less effective and much costlier.
The World Health Organization recently declared depression as the leading cause of illness and disability in the world. Those who work in the postacute arena will not be surprised to hear that the majority of SNF residents grapple with some form of depression. The rate of depression in SNFs is much higher than in the general population because these residents are simultaneously experiencing so many "slings and arrows of outrageous fortune," including medical problems, disability, disconnection from home and community, and uncertainty about their futures.
So why is depression missed so frequently in nursing facilities? The current method of identifying depression in SNFs, the Patient Health Questionnaire-9 (PHQ-9), part of MDS 3.0 (the Long Term Care Minimum Data Set), is an evidence-based screening tool. Facilities receive additional reimbursement for caring for residents identified as suffering from depression. While it sounds like a good start, the PHQ-9 relies on self-report data that can be distorted by the respondent's perception of the situation. And it is often administered by overburdened staff members who may not be adept in the administration of psychometric measures. Beyond that, many facilities don't establish a cut-off score at which a resident will be referred for further evaluation.
Looking past the PHQ-9, the entire process may fall victim to a pervasive tendency to underdiagnose depression in the geriatric population, a collective "Who wouldn't be depressed if they were in this person's shoes?" Since there is no lab test for depression, far too many people with significant and treatable depression fall through the cracks in the assessment process and eventually slip inexorably into a slow decline.
A full-court press is required to aggressively seek out and treat depression quickly so that residents don't carry this burden as they try to adjust to their new life situation and environment. The PHQ-9 is a good start, but it should be administered by the staff members with the most training in mental health—typically the social workers. All staff members, especially the nurses and nurses' aides, need education and training about depression and how to recognize it. And licensed clinicians—psychiatrists, psychiatric nurse practitioners, and psychologists—must be involved in every episode of care in which depression is suspected.
We are charged with understanding and caring for each resident's individual emotional and psychiatric needs in order to help them achieve their highest levels of functioning. The robust identification and treatment of depression is a great place to begin.
— Richard Juman, PsyD, is national director of psychology for TeamHealth.
— Robert Figlerski, PhD, is director of behavioral health in the New York region for TeamHealth.