Chapter 56: Depression in Diverse Populations & Older Adults

Anxiety symptoms are often common among depressed individuals. Among older adults, cognitive impairment may be associated with depression. Within various cultures, depression can manifest with more somatic symptoms rather than mood symptoms.

Mental health is an essential part of overall health. Unfortunately, some demographic groups are at increased risk for having unmet mental health needs, including children and youth, older adults, and members of medically underserved racial and ethnic groups. Because these groups are most likely to seek treatment for their mental health problems in primary care settings, it is essential that primary care physicians and other allied health practitioners be skilled in providing high-quality mental health services.

Depression is one of the leading causes of disability worldwide. It is a highly prevalent condition, affecting 35% of patients seen in primary care settings, and its prevalence in all age groups has been increasing in recent years. The most common age of onset is between 25 and 35 years of age, and an earlier age of onset of depression is associated with worse prognosis and functional impairment over time. Depression is twice as common among women as men, and African American and Hispanic individuals with a diagnosis of depression are less likely to receive mental health services compared to their white counterparts, as older adults are less likely to receive mental health services compared to younger adults.

Depression is a highly comorbid condition, particularly in later life. Medical illness and disability–more common in the elderly–are risk factors for depression. Depression diminishes quality of life, leads to nonadherence with self-care and treatment recommendations, increases the use of medical services, and is associated with cognitive impairment in adults. Furthermore, depression is often associated with medical and social complexity–patients with depression often have multiple chronic conditions, poor socioeconomic status, and poor social support, which, in turn, increase the risk of developing depression. Major psychosocial risk factors for depression include bereavement, caregiver strain, social isolation, disability, chronic medical illness, and role transitions.

Preventive interventions that target individuals at higher risk for depression (or the adverse effects of depression) can allow primary care providers to focus their efforts on promoting whole-person health. Effective primary prevention efforts that decrease the incidence of depression often require a multifactorial, interdisciplinary approach that targets multiple risk factors across various sectors. Interventions may include education about stress-coping techniques; facilitating healthy relationships with friends, family, and support groups; and protecting sleep quality through better sleep hygiene. Secondary prevention strategies include screening tools to enhance detection and treatment of depression. Universal screening in primary care settings, when coupled with effective treatment, can be an important tool in the prevention of depression. Finally, tertiary prevention efforts, which include antidepressant treatment and psychotherapy, have been shown to reduce relapse rates and morbidity associated with depression. Universal, selective, and indicated preventive interventions target the general public or specific individuals at highest risk for developing depression in the future.

The type and level of severity of depression run along a spectrum, ranging from subclinical varieties to major depression. Major depression typically occurs in discrete episodes, each with a clear beginning and end. After an initial episode, >50% of individuals will have additional episodes in their lifetime. Among older adults with depression, approximately 50% had experienced depression earlier in their life, and the other half experienced their first depressive episode after the age of 60.

A. Initial Assessment

Many individuals are reluctant to seek care for mental health problems. In a national sample of people who reported experiencing major depression, >33.3% of individuals did not seek treatment. In addition, many adults are reluctant to report their depressive symptoms to their primary care physicians. Recent data suggest discordance between patients presenting with symptoms of depression and physicians’ appraisal of depression symptoms during primary care visits. Even so, primary care physicians prescribe the majority of antidepressant medication in the United States, and have a major responsibility to detect and effectively treat depression in these settings.

Initial assessment should include a focused psychiatric history and examination, and, for older adults, a brief clinical cognitive examination. In addition, a medical history, physical examination, focused neurologic examination, and laboratory studies to rule out physical conditions with similar symptoms are preferred as part of the assessment. It is also important to assess other domains, particularly for older adults, including level of functioning or disability, loss or grief concerns, the physical environment, and psychosocial stressors.

B. Symptoms and Signs

Specific features associated with depressive disorders are described as follows:

• Depressed mood: feeling sad, “low,” empty, hopeless, gloomy, or “down in the dumps,” different from a normal sense of sadness or grief

• Anhedonia: inability to enjoy usually pleasurable activities (eg, sex, hobbies, daily routines)

• Changes in appetite or weight: a decrease in appetite (most patients) or an increase in appetite associated with craving specific foods

• Changes in sleep patterns: insomnia (difficulty falling asleep, staying asleep, or early-morning awakening) in most patients; hypersomnia in some patients

• Changes in activity: psychomotor retardation (speech, thinking, movement) or psychomotor agitation (inability to sit still, pacing, hand wringing)

• Loss of energy: decreased energy, tiredness, fatigue

• Cognitive changes: inability to think, concentrate, or make decisions

• Sense of worthlessness or guilt: excessive feelings of low self-esteem, self-blame, and lack of self-worth

• Suicidal ideation: thoughts of death or suicide, with and without a plan, or suicide attempts

A total of five of the nine features, including either depressed mood or anhedonia, must be present during the same 2-week period for the patient to be diagnosed with major depressive disorder. Symptoms of depression can present with varying degrees of severity, and may be accompanied by symptoms of anxiety or mania. In addition, symptoms can occur in the context of discrete episodes of depression, or, in cases of more chronic, unremitting symptoms, can be considered a persistent depressive disorder. Among older adults, a key factor is symptom presentation, which may differ considerably from that of younger adults. Older adults are less likely to present with affective symptoms than younger adults. Primary care providers should focus on assessing symptoms of cognitive difficulty, sleep disturbance, psychomotor retardation, and feelings of hopelessness in older adults.

C. Screening Measures

Many validated screening instruments exist for screening depression in diverse populations. Screening for depression in the primary care setting can be initiated using a two-question initial screening test to detect the presence of depressed mood and anhedonia: “Over the past 2 weeks, have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?”). This short screening test is often referred to as the Patient Health Questionnaire-2 (PHQ-2). PHQ-2 scores ≥ 3 are 83% sensitive and 92% specific for diagnosing major depression when used in primary care settings. Patients who screen positive on the PHQ-2 can be further evaluated with the PHQ-9, which has been validated in multiple culturally diverse populations, including African Americans, Africans, Chinese Americans, Hispanics, and others, as well as in older adults. In primary care settings where the quality of depression care is high, patients received universal screening for depression with the PHQ-9.

Among older adults, the Geriatric Depression Scale (GDS) has several versions, including an original 30-item version, as well as 20-, 15-, 12-, 10-, 5-, 4-, and 1-item versions of the scale. The GDS-15 and GDS-5 have been shown to be as effective as the GDS-30 in diagnosing depression in older adults.

The PHQ-9 and GDS-15 has been proven effective in detecting suicidal ideations. Risk factors for attempting suicide include mood disorders and other mental disorders, substance use disorders, history of deliberate self-harm, becoming disabled, and a history of suicide attempts. A majority of individuals who have completed suicide will have seen their primary care physician in the month before their death, which signals an opportunity for primary care providers to provide lifesaving interventions. Once a patient has been deemed to be at higher risk of suicide; immediate referral to specialty mental health services is indicated.

All screening tools should be seen as the initial phase of the assessment, and should be followed by a more detailed assessment to confirm the diagnosis of depression, which includes evaluating for concomitant psychiatric problems (including substance use disorders, manic episodes, or anxiety disorders) and determining the severity of depression. Table 56-1 lists several screening instruments for depression.

The most critical comorbid health conditions to consider in a person with depression include alcohol and substance use disorders and medications that can cause mood disorders (eg, prednisone). Late-life depression often coexists with cognitive impairment and other illnesses of the central nervous system (CNS), and the concomitance increases the risk of developing symptoms of Alzheimer’s disease compared with those with cognitive impairment without depression. Bipolar depression must also be ruled out in patients presenting with depressive symptoms. All patients with depressive symptoms should be screened for a history of manic or hypomanic symptoms. Depending on the clinical presentation, physicians should also assess the patient for a variety of general medical problems that could be contributing to mood symptoms, including cardiac disease, diabetes, and certain types of cancer. Among older adults, accidental misuse of medications and physical, verbal, or emotional abuse by caregivers or relatives should also be evaluated.

If untreated, depression can lead to multiple complications, including more serious, treatment-resistant forms of the illness, worsening physical condition, and suicide. Individuals with untreated depression are at greater risk for complications from general medical problems, alcohol and substance use disorders, and relationship problems. Impairment in social and occupational functioning can lead to increased disability.

Treatment of mental disorders has increased substantially over the past decades, yet a majority of adults with mental disorders do not receive treatment at all, or do not receive treatment in accordance with accepted standards of care. For minority populations, rates of high-quality mental health treatment are even lower.

Selection of an initial treatment modality should be influenced by both clinical factors (eg, severity of symptoms) and patient preference. In general, evidence-based recommendations for treatment of moderate to severe depression in the primary care setting involves a combination of pharmacotherapy and psychotherapy, and for the treatment of mild to moderate depression, psychotherapy or pharmacotherapy alone.

Although the majority of depressed patients are treated in primary care settings, some cases are especially difficult to manage in general medical clinics without specialized services. Specialized psychiatric care is strongly indicated if clinical findings support a diagnosis of psychotic depression, bipolar disorder, active suicidal ideation, depression with comorbid substance abuse, depression with comorbid dementia, treatment-resistant depression, and other needs for a more specialized assessment.

A. Psychotherapeutic Interventions

For patients with mild to moderate major depressive disorder, psychotherapy alone may be appropriate. Cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) are evidence-based psychotherapeutic approaches used in the treatment of patients with major depressive disorder. Factors to consider when determining how often to see an individual patient include the goals of the psychotherapy, the frequency necessary to create and maintain a therapeutic alliance, the frequency required to ensure treatment adherence, and the frequency necessary to monitor and address suicidality. Often, if a skilled therapist is not available in the primary care setting, referral to a mental health specialist may be indicated (eg, psychiatric nurses, licensed clinical social workers, psychologists, or psychiatrists). Primary care providers should ensure that patients are made aware of psychotherapy as an option and that they are assisted in accessing psychotherapeutic interventions.

B. Pharmacotherapy

Antidepressant medications may be initiated for treatment of patients with mild symptoms of major depressive disorder, and should be initiated for all patients with moderate to severe symptoms. Improvement should be noted within 6–8 weeks of initiating therapy, and the goal of antidepressant therapy is to achieve full remission of depressive symptoms. Studies have shown that maintenance antidepressant therapy is effective in preserving improvements and preventing recurrent depression.

The most commonly used antidepressant mediations are listed in Table 56-2. Selective serotonin reuptake inhibitors (SSRIs) are usually first-line therapy, due to greater tolerability and equal efficacy compared to other antidepressants. Other medications likely to be optimal for most patients include nortriptyline, bupropion, venlafaxine, and duloxetine. Because of their potential to cause serious side effects and the need for dietary restrictions, monoamine oxidase inhibitors (MAOIs) are typically reserved for patients with treatment-resistant depression.

Patients prescribed antidepressant medication should be monitored to assess their response to pharmacotherapy as well as side effects and adverse reactions. After dosing antidepressant medication at the recommended starting dose, it is important to increase the medication over time to an efficacious dose. Few patients treated for depression in primary care reach the recommended therapeutic dosage of the medicine. Screening tests can be used to objectively monitor a patient’s progress throughout treatment. To maintain consistency with clinical practice guidelines, patients should be seen for follow-up after initiating pharmacological treatment within 2–4 weeks. If no response is seen within the initial 6-8-week period of pharmacological therapy, referral for specialty mental healthcare may be considered.

Stepped-care models have been used in primary care settings to manage diverse conditions such as hypertension, and have been shown to be effective in improving the quality of depression care for patients in primary care settings. Stepped-care models are systematic procedures based on using the most effective, but least intensive, treatment for patients, which includes detailed monitoring and tracking of patients’ response to interventions. An example of a stepped-care model for depression treatment is shown in Table 56-3.

C. Complementary/Alternative Therapies

Some studies show a beneficial effect of exercise programs in treatment of depression in comparison to antidepressant medication alone. Meditation-based cognitive therapy has been shown to be effective for treatment of and decreasing recurrence of major depressive disorder. A variety of coping and self-management strategies can also be helpful, such as peer support, exercise, good nutrition, progressive muscle relaxation, setting aside time for pleasurable activities, and setting small, achievable goals. Furthermore, increasing evidence in the medical literature supports the beneficial role of spirituality in the health of patients.

St. John’s wort has been used to treat depression for many years, and multiple randomized clinical trials have demonstrated its effectiveness in the treatment of mild to moderate depression. However, St. John’s wort has increased medication interactions, particularly in older adults, and is generally not recommended for treatment of depression in most populations. Interactions between St. John’s wort and antidepressants are concerning, especially considering that patients are often less likely to share information about herbal supplements that they are taking when discussing their current medications.

Other alternative medication therapies have conflicting reports about efficacy, but include S-adenosyl methionine (SAM-e), omega-3 fatty acids, and folic acid supplementation; however, further research is needed to determine their efficacy in the treatment of depression.

D. Combination Therapy

The combination of psychotherapy and medication is recommended for patients with moderate to severe depression. Patients who have a history of only partial response to adequate trials of either treatment modality alone may benefit from combined treatment. Sequential treatment of psychotherapy and pharmacotherapy may also be beneficial. Patients with poor adherence to individual treatments may also benefit from combined treatment of any form.

E. Electroconvulsive Therapy

Electroconvulsive therapy (ECT) remains a highly stigmatized treatment modality, but it is an evidence-based, effective therapy for depression, particularly among older adults and patients with psychotic or treatment-resistant depression. Patients often have rapid improvement of symptoms of depression, and usually receive two to three treatments per week for 3–6 weeks. Primary care providers should consider a referral to a mental health specialist for evaluation for ECT in patients who have not responded to multiple trials of medication and psychotherapy.

F. Integrated/Collaborative Care Models

Integrated care and collaborative care models have effectively improved the treatment of depression in primary care settings. An extremely well-studied model of using integrated care to treat depression in older adults is the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression. The IMPACT model has shown significantly better outcomes for treatment of depression in older adults compared to the usual care. The model embeds a depression care manager (supervised by a psychiatrist and primary care expert) in a primary care setting to provide comprehensive services to older adults with depression.

Integrated care models have shown particular efficacy among older adults, who are more likely to accept treatment for depression in primary care settings rather than in specialty mental health settings. Within diverse populations, integrated care/collaborative care models have also shown efficacy in African American and Hispanic populations, but further research on additional racially/ethnically diverse populations is needed.

G. Addressing Disparities and Cultural Differences in Depression Care

Studies have shown that different racial and ethnic groups, as well as different age and gender groups, experience and communicate symptoms of depression differently and prefer different forms of treatment. If the provider does not speak the patient’s native language, a well-trained healthcare interpreter should be used to ensure that accurate information is exchanged. Some minority populations are more receptive to psychotherapy than pharmacotherapy, and patient preferences should be explored in order to practice cultural competence. Because stigma continues to be a pervasive barrier to seeking appropriate mental health treatment, primary care providers should encourage open dialog and help correct any false assumptions about the origins of mental health problems and judgments about individuals with mental health problems.

Patient-provider communication is critical to diagnosis and treatment. The physician should elicit patients’ explanatory models (what patients believe is causing their illness) and agendas (what patients seek from treatment), the role of family members in their lives, how those family members will react to the patient being treated, and how patients perceive treatment. For some people, experiences of racism and prejudice may leave people suspicious of diagnoses that do not require radiologic or laboratory examinations. The provider must use excellent communication skills to convey humility, empathy, respect, and compassion, as these are important factors in securing an accurate diagnosis and effective treatment of depression in racially, ethnically, and culturally diverse populations (See Table 56-4).

Spirituality is often an important determinant of mental health. The mere presence of a religious affiliation and the saliency of a person’s religion have been shown to provide a strong defense against depression and suicide, particularly in older adults with medical illnesses or disability. This is important for providers not only because it may largely influence how patients cope with their illnesses, but also because studies have shown that validating this aspect of a patient’s life and incorporating it into treatment plans can positively affect the patient’s adherence to treatment and even accelerate rates of remission.

Primary care practitioners are the sole contacts for more than half of patients with mental illness, and therefore are important in ensuring recognition and treatment of depression. The good news is that most patients can be treated to remission, especially if medication and psychotherapy are combined. Depression is generally a chronic, relapsing illness; however, treatment works not only to make patients well but also to keep them well. Treatment provides symptomatic relief, facilitates functional improvements, and prevents relapse and recurrence.