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Depression Deficiency

By Jessica Girdwain

It’s not unusual for older adults to suffer from depression, but research shows they aren’t receiving the mental health care they need.

Older adults need better mental health care, according to the John A. Hartford Foundation’s recent survey of more than 1,300 adults aged 65 and older, which found that this group is receiving treatment that doesn’t meet evidence-based standards.

“This has been a problem for quite some time,” says Christopher M. Callahan, MD, a professor of medicine and the director of the Indiana University Center for Aging Research. “There has always been a concern that depression was underreported and undertreated in primary care. When older adults get the right treatment, they do get better, but experts were beginning to wonder if that was really happening.”

And research indicates it’s not. “More than 20% of older adults have a diagnosable mental or substance abuse disorder, but less than half of those get treatment,” says Kimberly Williams, LMSW, director of The Center for Policy Advocacy and Education at the Mental Health Association of New York City.

However, the outlook really isn’t bright for those who do receive treatment. Fewer than 25% of older adults receive treatment from mental health professionals, who “provide minimally adequate treatment less than 50% of the time,” Williams says.

One reason for this disparity involves problems related to mental health care access, Williams explains. This includes service shortages, affordability issues, lack of services in home and community settings, restricted access to medications, and lack of knowledge about mental illness and the effectiveness of treatment.

Callahan says the presumption remains among providers that depression will improve simply by initiating a drug treatment. According to the Hartford survey, 46% of people receiving treatment said their providers didn’t follow up with them within a few weeks of starting treatment, and 38% did not have a discussion about possible side effects from their medications.

However, healthcare practitioners and older adults should be aware that treatment largely is a work in progress. “Once you start a patient on a drug, you have to monitor them frequently to see if they are getting better and then change their therapy if they’re not improving. This is just like what a primary care doctor would do when treating diabetes,” Callahan says.

When it comes to depression and anxiety medications, “There’s this expectation that it takes these medications one month to provide improvement in a patient’s mental health but after 10 days on an adequate dose, they should feel better. If they don’t, it’s time to make changes to their treatment,” according to Gary Kennedy, MD, director in the division of geriatric psychiatry at Montefiore Medical Center in the Bronx, New York.

The good news is that the stigma sometimes associated with depression has been reduced to some extent. In the Hartford survey, only 13% of survey participants said they wouldn’t tell anyone if they were depressed or anxious, and most older adults would tell their doctors on their own.

“There’s a distinct difference between the elderly and the boomers in terms of how they view depression,” says James Siberski, MS, CMC, coordinator of the Gerontology Education Center for Professional Development at Misericordia University in Dallas, Pennsylvania. “People in their 80s and 90s think being depressed is being crazy, so they don’t report it.”

On the other hand, Siberski notes that boomers are better educated about depression. “All of their friends have taken or are taking Prozac,” he says.

Regardless of elders’ age and degree of depression, Siberski stresses that physicians often are too quick to arrive at a diagnosis, failing to complete a comprehensive physical exam, including blood work and thyroid tests (since thyroid problems can trigger depression), and ruling out delirium, which also can cause depression. “More than anything, doctors have to treat the underlying cause,” Siberski says.

It’s also important for physicians to know that only 21% of older adults had heard that depression could double the risk of dementia and 34% knew that depression is associated with a twofold increase in the risk of heart disease, according to the Hartford survey. That creates an even greater incentive to identify older adults with mental health issues and start treatment.

Steps to Screening
Siberski suggests physicians should first look at a patient and ask the caregiver or spouse whether the patient looks sad. If so, physicians should ask whether the patient has looked that way for the last two weeks. If the answer is yes, that should raise the physician’s suspicion that the patient may be depressed, although the underlying cause remains unknown.

The next step is to use a questionnaire to screen the patient. Siberski uses the Montreal Cognitive Assessment, a 30-point test he prefers because it probes all four lobes of the brain and can help with detecting mild cognitive impairment. “Using this scale, I can get a better feel for whether there’s a cognitive issue at play,” he explains.

Williams uses the PRIME-MD for screening, which includes the PHQ-9 for depression and the GAD-7 for anxiety. In terms of alcohol abuse screening, the AUDIT-C is becoming the standard. “Ideally, older adults should be screened annually for mental and substance abuse conditions,” she advises.

Another red flag occurs when a patient is unable to give the date and month when asked. “People with depression don’t try. If there’s a cognitive impairment issue, the patient may try and fail,” Siberski says. 

Additionally, according to Williams, physicians should be alert for the following symptoms:

• loss of interest in people and activities that were previously a source of pleasure;

• inability to concentrate;

• irritability;

• agitation or moving slowly;

• sleeping or eating too much or too little;

• fear of social situations; and

• repetitive complaints about physical problems.

Who’s at Risk?
According to Siberski, an older adult who lives alone faces the highest risk of depression. “There is no one there to report potential depression,” he explains. “Elders are typically not good historians when it comes to their symptoms. They may say they have a lot of problems but won’t call it depression.”

Plus, he says about 9% of the elderly will have low-grade depression, which is harder for physicians to recognize without a support system watching for and reporting the signs.

Redesigning a Practice
Physicians can work with other healthcare providers, family members, and caregivers when trying to treat an elder patient’s depression. “The model of care should be collaborative. With a patient’s permission, it’s helpful to invite family into the room, in particular with complex conditions,” Kennedy says. He recommends talking to a third party, such as a family member or collaborative care nurse, to get additional perspective.

Callahan suggests a practice redesign which, he admits, is a big undertaking but one that improves care immensely. “Having a team work for the physician by enlisting a care manager, who’s already embedded in the primary care practice, who can take on the responsibility of monitoring patients’ treatment over time is important. This allows the physician to individualize care and would be considered state-of-the-art treatment,” he explains.

For primary care physicians, Callahan suggests looking at the IMPACT study (Improving Mood-Promoting Access to Collaborative Treatment), which funded the recent Hartford survey, as it offers resources about how to implement a new team-based model and provides older adults with the mental health care they need.

— Jessica Girdwain is a Chicago-based freelance writer who has contributed health-related articles to several national magazines.