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Update on Elderly Depression

and Suicide
Dr. E Cheung
Associate Consultant
Psychogeriatric Team
Castle Peak Hospital

Depression in the Elderly


Common
Treatable
Under-diagnosed & under-treated
> 60% treated inappropriately
Disease burden
Morbidity & mortality

Prevalence of elderly depression


in different care settings
Care setting

Prevalence of
depressive
symptoms

Prevalence of
major
depressive
disorder

Community

15%

1-3%

Primary care

20%

10-12%

Acute hospital

20-25%

10-15%

Long term care

30-40%

16%

Prevalence of Depression (2)

In Hong Kong
1034 elderly aged 70 and above living in
Shatin (Chiu et al, 1998):
Major depression 1.54%
Dysthymia 3.66%
Adjustment disorder with depressed
mood 1.54%

Global burden of diseases


(WHO)
1996

2020

Lower respiratory
diseases

Ischaemic heart disease

Diarrhoeal diseases

Unipolar depression

Perinatal conditions

Road traffic accidents

Unipolar major
depression

CVA

Ischaemic heart disease

COAD

Depression is associated with


increased mortality
Author

FU (months)

Mortality
(%)

Murphy,
1983

124

12

14

Rabins,
1986

100

12

Murphy,
1988

120

48

34

Baldwin,
1986

100

48

26

Risk factors of elderly depression


1. Female gender
2. Being widowed or divorced
3. Medical illness, e.g. stroke, neurological disorders
4. Functional disability
5. Family and personal history of depression
6. Social isolation
7. Life events
8. Medications, e.g. antihypertensives, steroids and
antiparkinsonian drugs
9. Caregiving, e.g. carers of people with dementia

Aetiology (1)
Social: reduced social networks, loneliness,
bereavement, poverty, physical ill health
Psychological: low self-esteem, lack of
capacity for intimacy, physical ill health
Biological: neuronal loss/neurotransmitter
loss, genetic risk, physical ill health

Aetiology (2)

Disease:
Direct: CVA, Parkinson's disease,
thyroid disease, Cushing's disease,
Hungtington's disease
Indirect: pain, disability, chronicity, poor
diet, decreased activity

Aetiology (3)

Drugs:
Digoxin, L-dopa, steroid
Beta-blockers, methyldopa
Chronic benzodiazepine use
Phenobarbitone
Neuroleptics in chronic use

Diagnosis
A syndromal diagnosis
Based on eliciting a specific cluster of
symptoms through careful history taking
and mental state examination, supplemented
by relevant physical examination
No confirmatory laboratory tests
ICD-10 or DSM-IV

International Classification of
Disease (ICD-10)

Cardinal symptoms: depressed mood, loss of


interest (anhedonia), loss of energy (anergia)
Additional symptoms: reduced concentration,
reduced self esteem (present), guilty feelings
(past), hopelessness and pessimism (future), self
harm or suicidal ideas, sleep disturbance,
decreased appetite, loss of libido, psychomotor
changes

Diagnostic and Statistical Manual


of Mental Disorders (DSM-IV)

Depressed mood most of the day


Marked diminished interest or pleasure in normal
activities
Significant weight loss or weight gain
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive guilt
Recurrent suicidal thoughts or attempts
Reduced ability to concentrate

Diagnostic difficulties
Primary care physicians could identify no
more than 50% of patients with a
diagnosable depressive syndrome (Mulsant
& Ganguli, 1999)
Presentation of depression in the elderly
may be modified by factors associated with
old age

Clinical presentation of elderly


depression

Compared with young depressives, older people


have (Weisman,1991):
Less disturbed sleep
(19% vs 25%)
Less appetite disturbance
(16% vs 27%)
Less disturbed energy
(11% vs 18%)
Less guilt
(5% vs 13%)
Less diminished concentration (8% vs 16%)
Fewer thought about death
(22% vs 31%)

Peculiar features of elderly


depression

Minimisation of sadness (Georgotas, 1983)


Somatisation or disproportionate complaints associated
with physical disorder (Sheehan et al, 2003)
"Neurotic" symptoms of recent onset
"Trivial" acts of deliberate self-harm
"Pseudodementia"
Depression superimposed on dementia
Accentuation of premorbid personality traits and recent
change in behaviour

Key questions to ask (1)


How is your mood?
Have you lost interest in anything?
Do you get less pleasure from things you
usually enjoy?
How long have you had these symptoms?
Have you been diagnosed before with a
depressive disorder?

Key questions to ask (2)


Any important health changes within the
past year?
Any major changes in your life in the
preceding 3 months?
Any symptoms to suggest underlying
physical illness?
Have you ever thought you would be better
off dead?

Assessment
History
Mental state examination
Use of standardised instruments, e.g.
Geriatric depression scale (GDS)
Cognitive assessment
Physical examination
Investigation

Geriatric Depression Scale


(GDS)
Validated standardised scales available
locally for screening of depression: 15-item
Chinese Geriatric Depression Scale Short
Form (GDS) (Lee et al, 1993)
Cut-off point of 8/15
Can be applied by trained non-medical
personnel

1.
2.

3.
4.

5.

6.
7.
8.
9.

10.
11.
12.
13.
14.
15.

? ()

()

________

Principles of management
1.
2.
3.

4.

5.

Monitoring the risk of self-harm


Educating the patient (and care givers) about depression
and involving him or her in treatment decisions
Treating the whole person - coexisting physical disorder;
attention to sensory deficits and other handicaps; reviewing
medication with a view to withdrawing those unnecessary
Treating depressive symptoms with the aim of complete
remission (as residual symptoms are a risk factor for
chronic depression)
Prompt referral of patients requiring specialist mental
health services

When to refer for specialist


advice? (WPA, 1999)

When the diagnosis is in doubt (e.g. is this dementia?)


When depression is severe, as evidenced by:
Psychotic depression
Severe risk to health because of failure to eat or drink
Suicide risk
Complex therapy is indicated (e.g. in cases with medical
comorbidity)
When first-line therapy fails (although primary care
physicians may wish to pursue a second course of an
antidepressant from a different class)

Treatment
Physical treatment
Pharmacological treatment
Electroconvulsive therapy
Psychosocial treatment

The Monoamine Hypothesis


The 3 monoamines: noradrenaline,
serotonin and dopamine
Depression believed to be the result of a
deficiency of monoamine neurotransmitters
All known antidepressants act by increasing
the activity of these neurotransmitters in the
brain by various mechanisms

Special considerations in the


elderly
Pharmacokinetics (change in volume of
distribution , metabolism, elimination)
Co-morbid physical illnesses
Drug interactions
Dosing

Pharmacological treatment

Information for patients and carers:


Start low, go slow
Typical side effect
Delay in onset of therapeutic action
Lack of dependence potential
Need for continuation treatment
following initial response

The Five Rs of antidepressant


treatment
Response
Remission
Recovery
Relapse
Recurrence

Recovery

Remission

Mood

Response
Relapse

Acute
Continuation
treatment treatment
Time

Recurrence

Maintenance
treatment

Principles of antidepressant
treatment
1.
2.
3.
4.
5.

Ascertain diagnosis
The ultimate aim of treatment is remission
Treatment has to be adequate in dosage,
duration and compliance has to be ensured
If there is no response after an adequate trial,
switch to another class of antidepressant
If there is partial response, further increase
dosage and/or persist for a longer duration or
augmentation

Principles of antidepressant
treatment
6.
7.

8.

Address psychosocial issues and psychoeducation


Continuation treatment at least 6 to 9 months
after remission, longer for elderly (12 to 24 months)
at the same dose
Maintenance treatment prophylactic treatment
for patients with multiple past episodes, serious ill
health, chronic social difficulties and very severe
depressive symptoms. No consensus on length of
maintenance.

Risk factors for recurrence


(WHO, 1989)
1.
2.
3.
4.
5.
6.
7.
8.

Comorbidity
Chronic medical conditions
Chronic affective symptoms
Older age of onset of first episode
Severe functional impairment during depression
Psychotic depression
Previous suicide attempt
Family history of suicide and bipolar disorder

Tricyclic antidepressants (TCA)


Nortriptyline (Nortrilen), dothiepine
(Prothiaden), amitriptyline
Anticholinergic S/E
Anti-histaminergic S/E
Anti-adrenergic S/E
Cardiotoxicity

Mechanism of action of TCAs

Shown here is an icon of a tricyclic antidepressant (TCA). These drugs are actually five drugs
in one: (1) a serotonin reuptake inhibitor (SRI); (2) a noradrenaline reuptake inhibitor (NRI);
(3) an anticholinergic/antimuscarinic drug (M1); (4) an alpha adrenergic antagonist (alpha); and
(5) an antihistamine (H1).

Stephen M. Stahl: Es

Therapeutic actions of TCAs

The serotonin reuptake inhibitor (SRI) portion of the TCA is


inserted into the serotonin reuptake pump, blocking it and
causing an antidepressant effect

Stephen M. Stahl, Es

Therapeutic actions of TCAs

The noradrenergic portion of the TCA is inserted into the noradrenaline reuptake
pump , blocking and causing an antidepressant effect

Stephen M. Stahl, Es

Side effects of TCAs

Side effects of the tricyclic antidepressants- part 1. In this diagram, the icon of the
TCA is shown with its H1 (antihistamine) portion inserted into histamine receptors,
causing the side effects of weight gain and drowsiness.

Stephen M. Stahl, Es

Side effects of TCAs

Side effects of the tricyclic antidepressants - part 2. In this diagram, the icon of
the TCA is shown with its M1 (anticholinergic/antimuscarinic) portion inserted
into acetylcholine receptors, causing the side effects of constipation, blurred
vision, dry mouth and drowsiness.

Stephen M. stahl, Es

Side effects of TCAs

Side effects of the tricyclic antidepressants - part 3. In this diagram, the icon
of the TCA is shown with its alpha (alpha adrenergic antagonist) portion
inserted into alpha adrenergic receptors, causing the side effects of dizziness,
decreased blood pressure and drowsiness.

Stephen M. Stahl, Es

Dose titration of TCA

Most commonly used TCA: dothiepine


(Prothiaden)
Starting dose: 50mg nocte
Then increase in increments of 25 to
50mg depending on side effects every
few days aiming at an initial target dose
of 150mg
Maximum dose of 225mg nocte

Selective Serotonin Reuptake


Inhibitors (SSRIs)

Citalopram (Cipram), sertraline (Zoloft),


paroxetine (Seroxat), fluoxetine (Prozac),
escitalopram (Lexapro)
GI upset
Anorexia
Headache
Insomnia, anxiety, tremour
Sexual dysfunction
SIADH

Selective Serotonin Reuptake Inhibitor


(SSRI)
Shown here is the icon of a
selective serotonin reuptake
inhibitor (SSRI). In this case, 4
out of the 5 pharmacological
properties of the TCAs (tricyclic
antidepressants; Figure 6-13) are
removed. Only the serotonin
reuptake inhibitor (SRI) portion
remains; thus the SRI action is
selective, which is why these
agents are called selective SRIs.
Includes fluoxetine, fluvoxamine,
citalopram, paroxetine, sertraline and
escitalopram

Stephen M. Stahl, Es

Mechanism of Action of SSRIs

In this diagram, the SRI


(serotonin reuptake
inhibitor) portion of the
SSRI molecule is shown
inserted in the serotonin
reuptake pump, blocking it
and causing an
antidepressant effect. This
is analogous to one of the
dimensions of the TCAs.

Stephen M. Stahl, Es

Serotonergic-Noradrenergic
Reuptake Inhibitor (SNRI)
Venlafaxine (Efexor/Efexor XR)
Side effects similar to SSRI
May cause hypertension at high doses

Serotonergic-noradrenergic Reuptake
Inhibitors (SNRI)
Shown here is the icon of a dual reuptake
inhibitor which combines the actions of both a
serotonin reuptake inhibitor (SRI) and a
noradrenaline reuptake inhibitor (NRI). In this
case, 3 out of the 5 pharmacological properties
of the TCAs (tricyclic antidepressants) were
removed. Both the SRI portion and the NRI
portion of the TCA remain; however the alpha,
antihistamine and anticholinergic portions are
removed. These serotonin/noradrenaline
reuptake inhibitors are called SNRIs or dual
inhibitors. A small amount of dopamine
reuptake inhibition (DRI) is also present in
some of these agents, especially at high doses.

e.g. Venlafaxine
Stephen M. Stahl, Es

Reversible inhibitors of
monoamine oxidase A (RIMA)
Moclobemide (Aurorix)
Nausea
Headache
Insomnia
Restlessness
Agitation

Other antidepressants
SARI nefazodone (Serzone)
Sedation, lack of 5HT2 stimulation S/E
NaSSA mirtazapine (Remeron)
Sedation, dry mouth, increased appetite,
weight gain
NDRI bupropion (Wellbutrin)
Headache, dry mouth, agitation, nausea,
insomnia

Serotonin-2 Antagonist/reuptake Inhibitors


(SARI)
Shown here are icons for two of the
serotonin 2 antagonist/reuptake inhibitors
(SARIs). These agents also have a dual
action, but the two mechanisms are
different from the dual actions of the
SNRIs (serotonin noradrenaline reuptake
inhibitors). The SARIs act by potent
blockade both of serotonin 2 (5HT2)
receptors, combined with SRI (serotonin
reuptake inhibitor) actions. Nefazodone
also has weak NRI (noradrenaline reuptake
inhibition) as well as weak alpha
adrenergic blocking properties. Trazodone
also contains antihistamine properties and
alpha antagonist properties, but lacks NRI
properties.

Stephen M. Stahl, Es

Noradrenergic and Specific Serotonergic


Antidepressant (NaSSA)

e.g. Mirtazapine
Stephen M. Stahl, Es

Other antidepressants
Mianserin (Tolvon):
Sedation, aplastic anaemia,
agranulocytosis
Trazodone:
Sedation, orthostatic hypotension,
priapism

Commonly used antidepressant drugs


Drug
group

Member
commonly used
in the elderly

Starting dose

Therapeuti
c dose

Common side effects

SSRI

Sertraline

50 mg OM

50 mg BD

Nausea, headache,
weight loss

Citalopram

10 -20 mg OM

TCA

Nortriptyline

10 -25 mg
nocte

40 mg
OM
75 - 100
mg nocte

SNRI

Venlafaxine XR

75 mg daily

150 - 225
mg daily

Hypertension

NaSSA

Mirtazapine

15 mg nocte

30 - 45
mg nocte

Weight gain,
sedation, dizziness

RIMA

Moclobemide

150 mg BD

300 mg
BD

Agitation, insomnia
and headache

Dizziness, sedation, dry


mouth, urinary retention,
postural hypotension,
cardiotoxicity

Other pharmacological treatment

Others:
Antipsychotics
Lithium augmentation
Tri-iodothyronine (T3) augmentation
Antidepressant combination
Anticonvulsant augmentation
Buspirone augmentation
Pindolol augmentation

Electroconvulsive therapy (ECT)


Safe and effective
Indication in food refusal, suicidal risk,
severe retardation and poor response to
drug treatment
71-88% with good outcome
Post ECT confusion 18-52%
Twice or three times weekly for 6 to 12
sessions

Psychosocial interventions

Basic psychotherapeutic processes:


Listening and talking
Release of emotion
Giving information
Providing a rationale
Restoration of morale
Suggestion
Guidance and advice
The therapeutic relationship

Psychoeducation
Nature and pathogenesis of depression
Use of a Stress-diathesis model
Proposed treatment, expected side effects,
delay in onset of therapeutic response
Expected duration of continuation and
maintenance treatment

Evidence-based psychosocial
treatments
Interpersonal therapy
Cognitive behavioural therapy
For moderate to severe depression, the
combination of pharmacotherapy and
psychological treatment has been found to
be superior to either treatment given alone
(Reynolds et al, 1999)

Elderly suicide

Elderly suicide in Hong Kong


Extent of the problem

High rate of elderly suicide:


Two to three times higher in the elderly (2535 per
100,000) than the general population (10-13 per
100,000)
30% of all suicide deaths were aged 60 or above
High rate of success
Ageing population
Population aged 65 or above increased from 0.63
million in 1996 to 0.76 million in 2000 (21%
increase)

Suicide rates by age group in


Hong Kong

Country

Number of
suicides

Rate per
100 000

Ranking by
suicide rate

China

195 000

16.1

24

India

87 000

9.7

45

Russia

52 500

41.5

USA

31 000

11.9

38

Japan

20 000

16.8

23

Germany

12 500

15.8

25

WHO, 1999 Ranking by number of suicides

Country

Lithuania

Number of Rate per


suicides
100 000

Ranking by
number of
suicides

1600

41.9

22

600

40.1

25

Russia

52 500

37.6

Latvia

850

33.9

23

Hungary

3000

32.9

16

Sri Lanka

5400

31.0

Estonia

WHO, 1999 Ranking by rates of suicide

What do we know about elderly


suicide in Hong Kong?

Characteristics of elderly suicide


completers
Low attempt to completion ratio 4:1
Greater determination as evidenced by:
Lethal methods: 52% by jumping from
height, 36% by hanging (Chi & Yu, 1997)
Fewer warning signs
Greater planning and resolve
Prevention after onset of a suicidal crisis
may be less successful for the elderly

Characteristics of elderly suicide


completers

Evidence from psychological autopsy studies:


71-95% of suicide victims aged 65 or above
had a major psychiatric disorder (Conwell et al,
2002)
86% of HK Chinese elderly suicide victims had
a diagnosable psychiatric disorder compared
with 9% in controls, with depression being the
most common diagnosis (Chiu et al, 2004)

Characteristics of elderly suicide


completers

Elderly suicide completion is also associated with:


Past history of suicide attempt
Physical illness and functional impairment
Social isolation
Recent life event
Rigid, anxious and obsessional personality style

Risk factors
Psychiatric disorder

Social milieu

Personality

Genetics
Family Hx

Service utilisation of elderly


suicide completers

Locally, 77% of suicide completers had consulted a


doctor one month before death, compared to 39% in
controls (Chiu et al, 2004)
Most were because of non-psychiatric problems
Only 37% of the suicide completers had a life time
history of consulting a psychiatrist although 86% of
them suffered from a psychiatric problem (Chiu et al,
2004)
The rate of consulting a psychiatrist is 65% in a Swedish
psychological autopsy study (Waern et al, 2002)

Studies on suicidal ideations

Among 516 elderly aged 70 or above in


Berlin (Linden & Barnow, 1997):
14.7% said that life is not worth living
(77.5% had depression)
5.4% wished to be dead or thought about
suicide (95.7% had depression)
1.0% showed suicidal ideas or gestures
(100% had depression)

Completer- 30/100,000
Attempter 100/100,000

Suicidal Intentions 1-5%

Life not worth living 15-19%


Normal 80%

Normal

Slightly
depressed

Life
Not
Worth
Living

Suicidal
Intentions

Attempters

Completers

TIME-LINE

Evidence-based means and tools

Gotland study (Rihmer et al, 1995):


depression-related suicide rates decreased with
training programme for general practitioners on
the diagnosis and treatment of depression
TeleHelp-TeleCheck service (De Leo et al, 2002):
reduction in elderly suicide rates after
introduction of tele-help service

What do we know about elderly


suicide?
1.

2.

3.
4.

Elderly suicides are characterised by a higher rate than the


general population, higher lethality, greater determination
and fewer warning signs
They are consistently associated with a number of risk
factors, e.g. past history of suicide, physical illness,
psychiatric illness and certain personality traits (Conwell et
al, 2002)
Some of these factors are modifiable, e.g. depressive illness
The majority of elderly who eventually commit suicide
would make contact with a primary care physician one
month before their suicide (but not necessarily for a mood
problem) and most remain undetected (Chiu et al, 2004)

What do we know about elderly


suicide?
5.

6.

7.

8.
9.

Low utilisation rate of psychiatric service among elderly suicide


completers may reflect lack of awareness and stigmatisation in the
community (Chiu et al, 2004)
Suicidal ideations and intentions are highly correlated with
depressive disorder and are useful key markers for identification of
at-risk individuals (Linden & Barnow, 1997)
Programme aimed at educating primary care physicians about
depression has been shown to reduce suicide rate, e.g. Gotland
study (Rihmer et al, 1995)
Telecheck shown to be a useful tool in providing care for elderly at
risk of suicide and reduce suicide rate (De Leo et al, 2002)
Relevant and locally validated instruments are available, e.g. GDS

Strategies in suicide prevention


Universal prevention
Selective prevention
Indicated/targeted prevention

Elderly Suicide Prevention


Programme (ESPP)

A early detection and targeted intervention


programme
Two-tiered model:
First tier comprises primary health care
practitioners, various listed NGOs and hotlines
coordinated by a regional committee
Second tier comprises specialist psychogeriatric
service in the form of a Fast Track Clinic and
multidisciplinary treatment team

Important features of the twotiered model


Improved access: one-stop service for the
client
Increased capacity for detection through the
use of standardised instruments and training
of non-medical personnel
Free-flow of patients between the two tiers
according to needs assessment

Aims of ESPP
1.
2.

Early detection of elderly at risk of suicide


Effective and adequate management

Early detection
1.

Raising the awareness of target referrers and


general public:
a.
Promotional and bibliographic material
b.
Liaison with target medical referrers
c.
Liaison with non-medical target referrers
d.
Organise training sessions, lectures, publicity
activities
e.
Setting up of regional committee with local
NGOs

Early detection
2.

Improving access to service


a.
Setting-up of Fast Track Clinic (FTC) with an
aim of providing medical assessment in a
timely manner
b.
Early intervention service by CPNs within 7
days of referral with medical outreach in
exceptional cases
c.
Non-medical referral accepted, including
screening using the GDS and referrals from
listed NGOs

Effective and adequate


management
1.
2.
3.
4.
5.
6.
7.

Individual biopsychosocial assessment with early


intervention service
Multidisciplinary approach including involvement of
referrer
Regular case conference
Adequate biological and psychosocial treatment
Coordination of psychosocial support and mobilising
resources from the community
Intensive follow-up by home visits and/or telecheck
In-patient facility

Service boundary
1.
2.
3.

Age 65 or above
Residing in the relevant catchment areas
Inclusion criteria
a.
Suicidal ideation/thoughts/talk/plan
b.
Previous attempt of suicide
c.
Suspected moderate to severe depression
(either by medical assessment or by screening
using the GDS)

Workflow of ESPP
NGO/hotlines
(Screening)

GP/DH/GOPD

TMH/POH
A&E, in-patient

Mood problem
Suicidal idea
Early
Intervention
(CPN)

Home visits/telecheck

Consultation
FTC

Suicide
attempt

Multidisciplinary
team

In-patient service

Clinical assessment and


management
Full psychiatric assessment
Clear documentation
Indicate rationale for decisions

Assessment of suicidal risk


Asking about suicidal inclinations does not
make suicidal behaviour more likely
Willingness to make tactful but direct
enquiries about a patients intention
Be alert to factors that signify an increased
risk of suicide

Assessment of suicidal risk


Consider known risk factors
Assess current suicidal risk
Assess suicidal intent planning,
preparation, precaution against discovery,
final rite, verbal cues, suicide note
Collateral information

Suggested questioning sequence

Whether the patient:


hopes things turn out well
gets pleasure out of life
feels hopeful from day to day
feels able to face each day
ever despairs about things
feels life to be a burden
wishes it would all end

Suggested questioning sequence

Whether the patient:


knows why he/she feels this way
has thought of ending life
has thought about the possible methods
has ever acted on any suicidal thoughts or
intentions
feels able to resist any suicidal thoughts

The End