‘‘Sad, Bad or MadSad, Bad or Mad’’a private psychiatrista private psychiatrist’’s experience on Elderly Depressions experience on Elderly Depression

從一位私人精神科醫生的角度看從一位私人精神科醫生的角度看

長者抑鬱症 長者抑鬱症

Dr. Ip Yan Ming Dr. Ip Yan Ming 叶恩明医生叶恩明医生Vice-PresidentVice-President

Hong Kong College of PsychiatristsHong Kong College of Psychiatrists

Sad, Bad or Mad ?Sad, Bad or Mad ?不開心不開心 ? ? 不好不好 ? ? 精神 正常精神 正常 ??

• People lives longer nowadaysPeople lives longer nowadays• Older & wiserOlder & wiser• But more likely to have losses (of health, But more likely to have losses (of health,

loved ones & social horizon)loved ones & social horizon)• When depressive disorder appears, When depressive disorder appears,

it may neither be sad, bad nor mad.it may neither be sad, bad nor mad.

Sad, Bad or Mad ?Sad, Bad or Mad ?不開心不開心 ? ? 不好不好 ? ? 精神 正常精神 正常 ??

But many people assume:But many people assume:• Depression equals to sadness and is a Depression equals to sadness and is a

normal part of ageing that will go normal part of ageing that will go away by itself.away by itself.• If nothing bad has happened to him/her, If nothing bad has happened to him/her,

one should not be sad. one should not be sad. • It’s bad to bother others with sadness.It’s bad to bother others with sadness.• Seeing psychiatrist is a sign of madness.Seeing psychiatrist is a sign of madness.

Depression in the ElderlyDepression in the Elderly長者抑鬱症 長者抑鬱症

Under-diagnosed & under-treatedUnder-diagnosed & under-treated

Not uncommon Not uncommon

TreatableTreatable

> 50% diagnosed or treated inappropriately> 50% diagnosed or treated inappropriately

Worsen quality of lifeWorsen quality of life

Increase morbidity & mortalityIncrease morbidity & mortality

15% suicide15% suicide

餘暉心態餘暉心態

老，不一定沉鬱消極老，不一定沉鬱消極

Prevalence Prevalence (( 發病率發病率 ) of elderly ) of elderly depression in different care settingsdepression in different care settings

Care settingCare setting Prevalence of Prevalence of depressive depressive symptomssymptoms

Prevalence of Prevalence of major major

depressive depressive disorderdisorder

CommunityCommunity 15%15% 1-3%1-3%

Primary carePrimary care 20%20% 10-12%10-12%

Acute hospitalAcute hospital 20-25%20-25% 10-15%10-15%

Residential careResidential care 30-40%30-40% 16%16%

Diagnosis ( Diagnosis ( 断症 断症 ))

A syndromal diagnosis (clinical) A syndromal diagnosis (clinical)

Based on eliciting specific symptom Based on eliciting specific symptom cluster through careful history taking and cluster through careful history taking and mental state examinationmental state examination

ICD-10 or DSM-IVICD-10 or DSM-IV

ICD-10ICD-10Cardinal symptomsCardinal symptoms: :

1. abnormal depressed mood for >2 weeks, 1. abnormal depressed mood for >2 weeks, 2. loss of interest / pleasure (anhedonia), 2. loss of interest / pleasure (anhedonia), 3. loss of energy (anergia)3. loss of energy (anergia)

Additional symptomsAdditional symptoms: : 1. loss of confidence / self esteem, 1. loss of confidence / self esteem,

2. inappropriate guilt, 2. inappropriate guilt, 3. suicidal thoughts / behaviour, 3. suicidal thoughts / behaviour, 4. diminished ability to think / concentrate, 4. diminished ability to think / concentrate, 5. psychomotor changes, 5. psychomotor changes, 6. sleep disturbance, 6. sleep disturbance, 7. appetite changes 7. appetite changes

DSM-IVDSM-IV1.1. Depressed mood most of the dayDepressed mood most of the day2.2. Marked diminished interest or pleasureMarked diminished interest or pleasure3.3. Significant weight or appetite changeSignificant weight or appetite change4.4. Insomnia or hypersomniaInsomnia or hypersomnia5.5. Psychomotor agitation or retardationPsychomotor agitation or retardation6.6. Fatigue or loss of energyFatigue or loss of energy7.7. Feelings of worthlessness or excessive guiltFeelings of worthlessness or excessive guilt8.8. Reduced ability to think or concentrate Reduced ability to think or concentrate 9.9. Recurrent suicidal thoughts or attemptsRecurrent suicidal thoughts or attempts-- 5 or more s/s for >2 weeks , must have (1) -- 5 or more s/s for >2 weeks , must have (1)

or (2)or (2)

Diagnostic difficulties (Diagnostic difficulties ( 難處難處 ))

Presentation of depression in the elderly Presentation of depression in the elderly may be modified by factors associated may be modified by factors associated with old agewith old age

Primary care physicians could identify no Primary care physicians could identify no more than 50% of patients with a more than 50% of patients with a diagnosable depressive syndrome diagnosable depressive syndrome (Mulsant & Ganguli, 1999)(Mulsant & Ganguli, 1999)

Peculiar features of elderly depression Peculiar features of elderly depression (( 特点特点 ) )

Minimisation of sadness (Minimisation of sadness (GeorgotasGeorgotas, 1983), 1983)Somatisation or disproportionate Somatisation or disproportionate complaints associated with physical complaints associated with physical disorder (Sheehandisorder (Sheehan et alet al, 2003), 2003)"Neurotic" symptoms of recent onset"Neurotic" symptoms of recent onset "Trivial" acts of deliberate self-harm"Trivial" acts of deliberate self-harm "Pseudodementia""Pseudodementia" Recent change in behaviourRecent change in behaviour (‘out of (‘out of character’)character’)

Assessment (Assessment ( 評估評估 ))

History (both from patient & informant)History (both from patient & informant)

Mental state examinationMental state examination

Use of standardised instruments, e.g. Use of standardised instruments, e.g. Geriatric depression scale (GDS)Geriatric depression scale (GDS)

Cognitive assessmentCognitive assessment

Physical examinationPhysical examination

InvestigationInvestigation

Geriatric Depression Scale (GDS)Geriatric Depression Scale (GDS)老人憂鬱量表

Validated standardized scales for Validated standardized scales for screening of depression: 15-item Chinese screening of depression: 15-item Chinese Geriatric Depression Scale Short Form Geriatric Depression Scale Short Form (GDS) (Lee (GDS) (Lee et alet al, 1993), 1993)

Cut-off point of 8/15 Cut-off point of 8/15

Can be applied by trained non-medical Can be applied by trained non-medical personnelpersonnel

老人憂鬱量表 

以下列舉的問題是人們對一些事物的感受。在過去一星期內，你是否曾有以下的感受，如有的話，請圈「是」，若無的話，請圈「否」。

  1. 你基本上對自己的生活感到滿意嗎？ 是 /

否2. 你是否已放棄了很多以往的活動和嗜好？ 是 / 否3. 你是否覺得生活空虛？ 是 / 否4. 你是否常常感到煩悶？ 是 / 否5. 你是否很多時感到心情愉快呢？ 是 / 否6. 你是否害怕將會有不好的事情發生在你身上呢？ 是 /

否7. 你是否大部份時間感到快樂呢？ 是 / 否8. 你是否常常感到無助？ (即是沒有人能幫自己 ) 是 /

否9. 你是否寧願留在家裏，而不愛出外做些有新意的事情？ (譬 是 /

否如 : 和家人到一新開張酒樓吃飯 )

10. 你是否覺得你比大多數人有多些記憶的問題呢？ 是 / 否

11. 你認為現在活著是一件好事嗎？ 是 / 否12. 你是否覺得自己現在是一無是處呢？ 是 /

否13. 你是否感到精力充足？ 是 / 否14. 你是否覺得自己的處境無望？ 是 /

否15. 你覺得大部份人的境況比自己好嗎？ 是 /

否  第 2, 3, 4, 6, 8, 9, 10, 12, 14, 15 題，答案「是」得 1 分第 1, 5, 7, 11, 13 題，答案「否」得 1 分 8 分 ===> 憂鬱的徵狀

Principles of managementPrinciples of management(( 處理的原则處理的原则 ))

1.1. Watch out for catastrophic risksWatch out for catastrophic risks2.2. Educating patient (& caregivers) about Educating patient (& caregivers) about

depression and involving them in Rx decisionsdepression and involving them in Rx decisions 3.3. Treating the whole person - coexisting physical Treating the whole person - coexisting physical

disorder; attention to sensory deficits and other disorder; attention to sensory deficits and other handicaps; reviewing medication; psycho-handicaps; reviewing medication; psycho-social intervention social intervention

4.4. Treating depressive symptoms with aim of Treating depressive symptoms with aim of complete remissioncomplete remission, then continue & maintain, then continue & maintain

5.5. Prompt referral of patients requiring specialist Prompt referral of patients requiring specialist mental health servicesmental health services

Treatment (Treatment ( 治療治療 ))

Physical treatmentPhysical treatment– Pharmacological treatmentPharmacological treatment– Electroconvulsive therapyElectroconvulsive therapy

Psychosocial treatmentPsychosocial treatment

The Monoamine HypothesisThe Monoamine Hypothesis

The 3 monoamines:The 3 monoamines:

serotonin, noradrenaline and dopamineserotonin, noradrenaline and dopamine

Depression believed to be a result of Depression believed to be a result of dysfunctiondysfunction of monoamine neurotransmitters of monoamine neurotransmitters

All effective antidepressants act by increasing All effective antidepressants act by increasing the synaptic concentration of these the synaptic concentration of these neurotransmitters in the brain by various neurotransmitters in the brain by various mechanismsmechanisms

NorepinephrineAnxiety

IrritabilitySerotonin

Mood, Emotion,Cognitive function

SexAppetite

Aggression

Drive

Dopamine

Motivation

Energy Interest

Impulse

Biogenic Amine ImbalanceBiogenic Amine Imbalance

Pharmacological treatmentPharmacological treatment(( 藥物治療藥物治療 ))

Information for patients and carers:Information for patients and carers:– Start low, go slowStart low, go slow– Typical side effectsTypical side effects– Delay in onset of therapeutic actionDelay in onset of therapeutic action– Need for continuation treatment following Need for continuation treatment following

initial responseinitial response

Tricyclic antidepressants (TCA)Tricyclic antidepressants (TCA)

Nortriptyline, dothiepin, imipramine, Nortriptyline, dothiepin, imipramine, amitriptyline, clomipramine, trimipramineamitriptyline, clomipramine, trimipramine

- Anticholinergic S/E (urinary retention & - Anticholinergic S/E (urinary retention & constipation may be troublesome)constipation may be troublesome)

- Anti-histaminergic S/E- Anti-histaminergic S/E

- Anti-adrenergic S/E- Anti-adrenergic S/E

- Cardiotoxicity - dangerous if overdose- Cardiotoxicity - dangerous if overdose

Stephen M. Stahl: Essential PsychophaStephen M. Stahl: Essential Psychopharmacology 1996 rmacology 1996

Mechanism of action of TCAsMechanism 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).

Selective Serotonin Reuptake Inhibitors Selective Serotonin Reuptake Inhibitors (SSRIs)(SSRIs)

Citalopram (Cipram), sertraline (Zoloft), Citalopram (Cipram), sertraline (Zoloft), paroxetine (Seroxat), fluoxetine (Prozac), paroxetine (Seroxat), fluoxetine (Prozac), escitalopram (Lexapro), fluvoxamine (Faverin)escitalopram (Lexapro), fluvoxamine (Faverin)

- GI upset- GI upset

- Headache- Headache

- Insomnia, anxiety, tremor- Insomnia, anxiety, tremor

- Sexual dysfunction- Sexual dysfunction

(better tolerated than TCA but increase the risk (better tolerated than TCA but increase the risk of GI bleeding in the very old)of GI bleeding in the very old)

Serotonergic-Noradrenergic Serotonergic-Noradrenergic Reuptake Inhibitor (SNRI)Reuptake Inhibitor (SNRI)

Venlafaxine (Efexor/Efexor XR)Venlafaxine (Efexor/Efexor XR)

Duloxetine (Cymbalta)Duloxetine (Cymbalta)

Milnacipran (Ixel)Milnacipran (Ixel)

- Side effects similar to SSRI- Side effects similar to SSRI

- Dizziness, increase heart rate- Dizziness, increase heart rate

- May cause hypertension at high doses- May cause hypertension at high doses

Serotonin-2 Antagonist / Reuptake Serotonin-2 Antagonist / Reuptake Inhibitors (SARI)Inhibitors (SARI)

trazodone (Trittico)trazodone (Trittico)

- Very sedating- Very sedating

- Dizziness, nausea, postural hypotension, - Dizziness, nausea, postural hypotension, rarely priapism, no anticholinergic S/Erarely priapism, no anticholinergic S/E

nefazodone (Serzone)nefazodone (Serzone)

- Less sedating, - Less sedating,

Other Other AntidepressantsAntidepressants

NaSSA – NaSSA – mirtazapine (Remeron)mirtazapine (Remeron)– Sedation, increased appetite, weight gain, Sedation, increased appetite, weight gain,

oedema, (nausea & sexual S/E uncommon)oedema, (nausea & sexual S/E uncommon)

NDRI – NDRI – bupropion (Wellbutrin)bupropion (Wellbutrin)– Headache, agitation, nausea, insomnia, Headache, agitation, nausea, insomnia,

(no sexual S/E)(no sexual S/E)

Mianserin (Tolvon)Mianserin (Tolvon)::– Sedation, rash, rarely: blood dyscrasia, no Sedation, rash, rarely: blood dyscrasia, no

anticholinergic S/E, sexual S/E uncommonanticholinergic S/E, sexual S/E uncommon

Reversible inhibitors of monoamine Reversible inhibitors of monoamine oxidase A (RIMA)oxidase A (RIMA)

Moclobemide (Aurorix)Moclobemide (Aurorix)

- Nausea- Nausea

- Headache- Headache

- Insomnia- Insomnia

- Restlessness- Restlessness

- Agitation- Agitation

Other pharmacological treatmentOther pharmacological treatment

AntipsychoticsAntipsychotics

Lithium augmentationLithium augmentation

Tri-iodothyronine (T3) augmentationTri-iodothyronine (T3) augmentation

Antidepressant combinationAntidepressant combination

Anticonvulsant augmentationAnticonvulsant augmentation

Buspirone augmentationBuspirone augmentation

Electroconvulsive therapy (ECT)Electroconvulsive therapy (ECT)

Safe and effectiveSafe and effectiveIndicated if prompt effect is needed (in Indicated if prompt effect is needed (in food refusal, suicidal risk, severe food refusal, suicidal risk, severe retardation) or refractory to drug treatmentretardation) or refractory to drug treatment71-88% with good outcome71-88% with good outcomePost ECT confusion 18-52%Post ECT confusion 18-52%Memory impairment is temporaryMemory impairment is temporaryTwice or three times weekly for 6 to 12 Twice or three times weekly for 6 to 12 sessionssessions

Psychosocial interventionsPsychosocial interventions

Basic psychotherapeutic processes:Basic psychotherapeutic processes:– *Establish Rapport*Establish Rapport– Listening and talkingListening and talking – Release of emotionRelease of emotion – Giving informationGiving information – Restoration of moraleRestoration of morale – SuggestionSuggestion – Guidance and adviceGuidance and advice – The therapeutic relationshipThe therapeutic relationship

PsychoeducationPsychoeducation

Nature and pathogenesis of depressionNature and pathogenesis of depression

Use of a “Stress-diathesis” modelUse of a “Stress-diathesis” model

Proposed treatment, expected side Proposed treatment, expected side effects, delay in onset of therapeutic effects, delay in onset of therapeutic responseresponse

Expected duration of continuation and Expected duration of continuation and maintenance treatmentmaintenance treatment

Evidence-based psychosocial Evidence-based psychosocial treatmentstreatments

Interpersonal therapyInterpersonal therapy

Cognitive behavioural therapyCognitive behavioural therapy

For moderate to severe depression, the For moderate to severe depression, the combination of pharmacotherapy and combination of pharmacotherapy and psychological treatment has been found to psychological treatment has been found to be superior to either treatment given alonebe superior to either treatment given alone (Reynolds (Reynolds et alet al, 1999), 1999)

When to refer for specialist When to refer for specialist advice? (WPA, 1999)advice? (WPA, 1999)

When diagnosis is in doubt (e.g. dementia?)When diagnosis is in doubt (e.g. dementia?) When depression is severe, as evidenced by: When depression is severe, as evidenced by: – Psychotic depressionPsychotic depression – Severe risk to health because of failure to eat or drinkSevere risk to health because of failure to eat or drink – Suicide riskSuicide risk

Complex therapy is indicated (e.g. in cases with Complex therapy is indicated (e.g. in cases with medical comorbidity)medical comorbidity) When first-line therapy fails (although primary When first-line therapy fails (although primary care physicians may wish to pursue a second care physicians may wish to pursue a second course of antidepressant from a different class)course of antidepressant from a different class) & & beyond the GP’s therapeutic limitationbeyond the GP’s therapeutic limitation

Referral to Psychiatric ServiceReferral to Psychiatric Service

GP GP usuallyusually referrefer when: when:

1.1. their treatment has failed – commonest their treatment has failed – commonest reason reason

2.2. pressure from patient or relativespressure from patient or relatives3.3. suicidal riskssuicidal risks4.4. social or behavioural (e.g. violent) crisissocial or behavioural (e.g. violent) crisis

Tendency for non-referral or late referralTendency for non-referral or late referral

Sad, Bad or Mad ?Sad, Bad or Mad ?不開心不開心 ? ? 不好不好 ? ? 精神 正常精神 正常 ??

In Summary:In Summary:• Elderly Depression are not rare but Elderly Depression are not rare but often not detected or treated properlyoften not detected or treated properly• It need not be sad, bad or mad.It need not be sad, bad or mad.• Highly treatable & quality of life Highly treatable & quality of life improves.improves.• Treat with care, start low & go slow.Treat with care, start low & go slow.• When in doubt, ready to refer or consult.When in doubt, ready to refer or consult.

The EndThe End