Primary Care Resources - Depression

Depression is a medical disorder— just like diabetes, high blood pressure, or heart disease — that requires attention.  Day after day depression affects thoughts, feelings, physical health, and behaviors. Depression is not just “feeling blue” or “down in the dumps.”  It is not just being sad after a loss.  It is not an ordinary part of aging.

Why is it important?

  • Major depression affects up to 15% to 20% of people older than 65 years of age.
  • 10% to 20% of patients develop chronic depressive symptoms despite treatment
  • 25% to 30% of patients fail to respond to initial therapy. (1)
  • 90% will NOT seek out the help or their depression will be missed or ignored, denying them beneficial  treatment for mental health problems.(1)

Common Causes

  • Health problems:  frailty, illness and disability; chronic or severe pain; cognitive decline; damage to body image due to surgery or disease.
  • Loneliness and isolation: Living alone; a dwindling social circle due to deaths or relocation; decreased mobility due to illness or loss of driving privileges.
  • Reduced sense of purpose: Feelings of purposelessness or loss of identity due to retirement or physical limitations on activities.
  • Fears – Fear of death or dying; anxiety over financial problems or health issues.
  • Recent bereavements –death of friends, family members, and pets; the loss of a spouse or partner. (3)

Key Considerations

Depression red flags include:

  • sadness
  • fatigue
  • abandoning or losing interest in hobbies or other pleasurable pastimes,
  • social withdrawal and isolation (reluctance to be with friends, engage in activities, or leave home)
  • weight loss or loss of appetite
  • sleep disturbances (difficulty falling asleep or staying asleep, oversleeping, or daytime sleepiness)
  • loss of self-worth (worries about being a burden, feelings of worthlessness, self-loathing)
  • increased use of alcohol or other drugs
  • fixation on death; suicidal thoughts or attempts

Often presents atypically which may include:

  • cognitive impairment
  • physical symptoms,
  • non-specific features of irritability
  • calling out and restlessness
  • may co-exist with dementia

Factors suggestive of higher risk of suicide include: 

  • Older Males
  • Somatic complaints
  • Agitated
  • Sleeplessness
  • Evidence of Plan/intent
  • Significant loss of support
  • Goal of treatment is remission: assess treatment using Patient Health Questionnaire–9 (2)
  • Treatment can be pharmaceutical (antidepressants) or non-pharmaceutical.  Factors to guideantidepressant choice can include previous response, concurrent conditions, type of depression, other medications, and risk of overdose.(1)  ECT can be particularly effective in treating depression in elderly.

References

1.   Frank, C.  (2014) Pharmacologic treatment of depression in the elderly.  Canadian Family Physician
      (CFP) vol. 60 no. 2, 121-126, February 2014.  Retrieved Feb.  2014 from:  
      http://www.cfp.ca/content/60/2/121.full    

2.   Mood Disorders Society of Canada.  Retrieved Feb. 2014 from: 
      http://www.mooddisorderscanada.ca/

3.   Robinson, L., Segal, J. & Smith, M. (2014) Depression in Older Adults & the Elderly
      Retrieved Feb. 2014 from:
      http://www.helpguide.org/mental/depression_elderly.htm

Recommended Readings / Guidelines

1.   Canadian Coalition for Seniors’ Mental Health. (2006). National Guidelines for Seniors’ Mental Health:
      The
assessment and treatment of Depression.  Canadian Journal of Geriatrics,  2006 volume 9, supple-
      ment 2. Retrieved March 2014 from:
      http://ccsmh.ca/national-guidelines-for-seniors-mental-health-project/

2.   Dickinson, J., Gorber, S.C., Jaramillo, A.,  Joffres, M.,  Lewin, G., Pottie, K., Shaw, E. and Tonelli, M. 
      Canadian Task Force on Preventive Health Care, Recommendations on screening for depression in adults
      CMAJ  June 11, 2013  vol. 185 no. 9.  Retrieved March 2014 from:
      http://www.cmaj.ca/content/185/9/775.full.pdf+html

3.   National Institute for Health and Clinical Excellence.  (2009).  The treatment and management of depression
      in adults
.  Retrieved March 2014 from:  
      http://www.nice.org.uk/nicemedia/pdf/CG90NICEguideline.pdf

4.   Registered Nurses’ Association of Ontario.  (2004). Caregiving Strategies for Older Adults with Delirium,
      Dementia and Depression
.  Retrieved March 2014 from: 
      http://rnao.ca/bpg/guidelines/caregiving-strategies-older-adults-delirium-dementia-and-depression

5.   Registered Nurses’ Association of Ontario.  (2003).  Screening for Delirium, Dementia and Depression in the
      Older Adult
. Retrieved March 2014 from: 
      http://rnao.ca/bpg/guidelines/screening-delirium-dementia-and-depression-older-adult