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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.

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Update on elderly depression and suicide l.jpg

Update on Elderly Depression and Suicide

Dr. E Cheung

Associate Consultant

Psychogeriatric Team

Castle Peak Hospital


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Depression in the Elderly

  • Common

  • Treatable

  • Under-diagnosed & under-treated

  • > 60% treated inappropriately

  • Disease burden

  • Morbidity & mortality


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Prevalence of elderly depression in different care settings


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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%


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Global burden of diseases (WHO)


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Depression is associated with increased mortality


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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


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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


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Aetiology (2)

  • Disease:

    • Direct: CVA, Parkinson's disease, thyroid disease, Cushing's disease, Hungtington's disease

    • Indirect: pain, disability, chronicity, poor diet, decreased activity


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Aetiology (3)

  • Drugs:

    • Digoxin, L-dopa, steroid

    • Beta-blockers, methyldopa

    • Chronic benzodiazepine use

    • Phenobarbitone

    • Neuroleptics in chronic use


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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


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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


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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


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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


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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%)


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Peculiar features of elderly depression

  • Minimisation of sadness (Georgotas, 1983)

  • Somatisation or disproportionate complaints associated with physical disorder (Sheehanet 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


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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?


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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?


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Assessment

  • History

  • Mental state examination

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

  • Cognitive assessment

  • Physical examination

  • Investigation


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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


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Principles of management

  • 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


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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)


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Treatment

  • Physical treatment

    • Pharmacological treatment

    • Electroconvulsive therapy

  • Psychosocial treatment


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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


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Special considerations in the elderly

  • Pharmacokinetics (change in volume of distribution , metabolism, elimination)

  • Co-morbid physical illnesses

  • Drug interactions

  • Dosing


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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


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The Five “R”s of antidepressant treatment

  • Response

  • Remission

  • Recovery

  • Relapse

  • Recurrence


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Recovery

Remission

Mood

Response

Recurrence

Relapse

Acute

treatment

Continuation

treatment

Maintenance

treatment

Time


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Principles of antidepressant treatment

  • 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


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Principles of antidepressant treatment

  • 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.


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Risk factors for recurrence (WHO, 1989)

  • 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


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Tricyclic antidepressants (TCA)

  • Nortriptyline (Nortrilen), dothiepine (Prothiaden), amitriptyline

  • Anticholinergic S/E

  • Anti-histaminergic S/E

  • Anti-adrenergic S/E

  • Cardiotoxicity


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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: Essential Psychopharmacology 1996


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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, Essential Psychopharmacology, 1996


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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, Essential Psychopharmacology, 1996


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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, Essential Psychopharmacology, 1996


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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, Essential Psychopharmacology, 1996


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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, Essential Psychopharmacology, 1996


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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


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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 l.jpg

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, Essential Psychopharmacology,1996


Mechanism of action of ssris l.jpg

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, Essential Psychopharmacology, 1996


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Serotonergic-Noradrenergic Reuptake Inhibitor (SNRI)

  • Venlafaxine (Efexor/Efexor XR)

  • Side effects similar to SSRI

  • May cause hypertension at high doses


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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, Essential Psychopharmacology, 1996


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Reversible inhibitors of monoamine oxidase A (RIMA)

  • Moclobemide (Aurorix)

  • Nausea

  • Headache

  • Insomnia

  • Restlessness

  • Agitation


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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


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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, Essential Psychopharmacology, 1996


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Noradrenergic and Specific Serotonergic Antidepressant (NaSSA)

e.g. Mirtazapine

Stephen M. Stahl, Essential Psychopharmacology, 1996


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Other antidepressants

  • Mianserin (Tolvon):

    • Sedation, aplastic anaemia, agranulocytosis

  • Trazodone:

    • Sedation, orthostatic hypotension, priapism


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Commonly used antidepressant drugs

Drug group

Member commonly used in the elderly

Starting dose

Therapeutic dose

Common side effects

SSRI

Sertraline

50 mg OM

50 mg BD

Nausea, headache, weight loss

Citalopram

10 -20 mg OM

40 mg OM

TCA

Nortriptyline

10 -25 mg nocte

75 - 100 mg nocte

Dizziness, sedation, dry mouth, urinary retention, postural hypotension, cardiotoxicity

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


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Other pharmacological treatment

  • Others:

    • Antipsychotics

    • Lithium augmentation

    • Tri-iodothyronine (T3) augmentation

    • Antidepressant combination

    • Anticonvulsant augmentation

    • Buspirone augmentation

    • Pindolol augmentation


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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


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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


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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


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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)


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Elderly suicide


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Elderly suicide in Hong Kong Extent of the problem

  • High rate of elderly suicide:

    • Two to three times higher in the elderly (25–35 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)


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Suicide rates by age group in Hong Kong


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WHO, 1999 Ranking by number of suicides


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WHO, 1999 Ranking by rates of suicide


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What do we know about elderly suicide in Hong Kong?


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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


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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)


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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


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Risk factors

Psychiatric disorder

Social milieu

Personality

Genetics

Family Hx


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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)


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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)


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Completer- 30/100,000

Attempter – 100/100,000

Suicidal Intentions – 1-5%

Life not worth living – 15-19%

Normal – 80%


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Life

Not

Worth

Living

Slightly

depressed

Suicidal

Intentions

Normal

Attempters

Completers

TIME-LINE


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Evidence-based means and tools

  • Gotland study (Rihmer et al, 1995):

    • depression-related suicide rates decreased withtraining programme for general practitioners on the diagnosis and treatment of depression

  • TeleHelp-TeleCheck service (De Leo et al, 2002):

    • reduction in elderly suicide rates afterintroduction of tele-help service


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What do we know about elderly suicide?

  • 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)


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What do we know about elderly suicide?

  • 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


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Strategies in suicide prevention

  • Universal prevention

  • Selective prevention

  • Indicated/targeted prevention


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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


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Important features of the two-tiered 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


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Aims of ESPP

  • Early detection of elderly at risk of suicide

  • Effective and adequate management


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Early detection

  • Raising the awareness of target referrers and general public:

    • Promotional and bibliographic material

    • Liaison with target medical referrers

    • Liaison with non-medical target referrers

    • Organise training sessions, lectures, publicity activities

    • Setting up of regional committee with local NGOs


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Early detection

  • Improving access to service

    • Setting-up of Fast Track Clinic (FTC) with an aim of providing medical assessment in a timely manner

    • Early intervention service by CPNs within 7 days of referral with medical outreach in exceptional cases

    • Non-medical referral accepted, including screening using the GDS and referrals from listed NGOs


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Effective and adequate management

  • 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


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Service boundary

  • Age 65 or above

  • Residing in the relevant catchment areas

  • Inclusion criteria

    • Suicidal ideation/thoughts/talk/plan

    • Previous attempt of suicide

    • Suspected moderate to severe depression (either by medical assessment or by screening using the GDS)


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Workflow of ESPP

NGO/hotlines

(Screening)

TMH/POH

A&E, in-patient

GP/DH/GOPD

Mood problem

Suicidal idea

Suicide attempt

Consultation

Early

Intervention

(CPN)

FTC

Multidisciplinary

team

In-patient service

Home visits/telecheck


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Clinical assessment and management

  • Full psychiatric assessment

  • Clear documentation

  • Indicate rationale for decisions


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Assessment of suicidal risk

  • Asking about suicidal inclinations does not make suicidal behaviour more likely

  • Willingness to make tactful but direct enquiries about a patient’s intention

  • Be alert to factors that signify an increased risk of suicide


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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


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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


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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


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The End


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