An overview for the late-life depression in the setting of primary health care

1. DEPRESSION IN OLD AGE
(FOR PRIMARY HEALTHCARE ENCOUNTER)
AHMED EID ELAGHOURY, MD
EGYPTIAN AND ARAB BOARD-CERTIFIED IN PSYCHIATRY

2. Old Man in Sorrow (On the Threshold of
Eternity)
is an oil painting by Vincent van Gogh, 1890
Feb 2017 2Taif, SA

3. BACKGROUND
• DEPRESSION IS NOT A NORMAL CONSEQUENCE OF AGING
• DEPRESSION OFTEN GOES UNDIAGNOSED IN PRIMARY CARE
• DEPRESSION AMONG MEDICAL OUTPATIENTS ABOVE AGE 65 YRS: 7% - 36%
• FHX OF DEPRESSION: 2X ↑ RISK, LONGER EPISODE, MORE FREQUENT, MORE
SUICIDAL
• LATE LIFE DEPRESSION MAY BE: A PRODROMAL STAGE OF DEMENTIA OR AN
INDEPENDENT RISK FACTOR FOR DEMENTIA.
• THERAPEUTIC NIHILISM: PATIENT, FAMILY, OR PROVIDER ARE NOT ENCOURAGED
TO START RX
UpToDate: Jul, 2016
BMJ Best Practice: Dec,2016
Feb 2017 3Taif, SA

4. RISK FACTORS FOR LATE-LIFE DEPRESSION
• FEMALE SEX
• SOCIAL ISOLATION
• WIDOWED, DIVORCED, OR SEPARATED MARITAL STATUS
• LOWER SOCIOECONOMIC STATUS
• COMORBID GENERAL MEDICAL CONDITIONS
• UNCONTROLLED PAIN
• INSOMNIA
• FUNCTIONAL IMPAIRMENT
• COGNITIVE IMPAIRMENT
UpToDate: Jul, 2016
Feb 2017 4Taif, SA

5. MAJOR DEPRESSIVE EPISODE, MDE
• COURSE: SINGLE EPISODE/RECURRENT EPISODE [2-M APART]
• REMISSION: IN PARTIAL REMISSION/IN FULL REMISSION
• LATE ONSET PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA): CHRONIC
EPISODE FOR AT LEAST 2 YRS
DSM5, 2013
Feb 2017 5Taif, SA

6. OTHER DIFFERENT PRESENTATIONS
1. MDE WITH ANXIOUS DISTRESS: ANXIETY, FEARFULNESS. RISK FOR: SUICIDE,
RX NON-RESPONSE, LONGER EPISODES
2. MDE WITH MIXED FEATURES: SUBSYNDROMAL HYPOMANIA; IRRITABLE
DEPRESSION. RISK FOR: BIPOLAR DS, SRI NON-RESPONSE OR SRI
WORSENING
3. MDE WITH MELANCHOLIC FEATURES: SOMATIC/BIOLOGIC SYNDROME. RISK
FOR: SRI NON-RESPONSE, PSYCHOTIC SX
4. MDE WITH PSYCHOTIC FEATURES: MOOD-CONGRUENT/MOOD-
INCONGRUENT. E.G. COTARD SYNDROME
5. MDE WITH CATATONIA: DEPRESSIVE STUPOR
DSM5, 2013
Feb 2017 6Taif, SA

7. DEPRESSIVE DS DUE TO ANOTHER MEDICAL
CONDITION, AMC
• DUE TO THE DIRECT PATHOPHYSIOLOGICAL CONSEQUENCE OF AMC
• THERE IS AN EVIDENCE FROM HX, PE / LAB, IMAGING
• W/O DELIRIUM
• CAN BE: WITH DEPRESSIVE FEATURES, WITH MDE-LIKE FEATURES / WITH
MIXED FEATURES
• COMMON EXAMPLES: HYPOTHYROIDISM,OBESITY, DM, IHD, VIT D ↓, CANCER
• POST-STROKE (VASCULAR) DEPRESSION: FIRST 2 YRS AFTER A STROKE, ESP
LT BRAIN (COMMON IN 3-6 MS AFTER), RISK FACTOR FOR VASCULAR DEMENTIA
DSM5, 2013
Feb 2017 7Taif, SA

8. MEDICATION-INDUCED DEPRESSIVE DS
• AFTER EXPOSURE TO A MEDICATION
• DURING/SOON AFTER SUBSTANCE INTOXICATION/WITHDRAWAL
• NO EVIDENCE OF AN INDEPENDENT DEPRESSIVE DS: E.G. PRIOR HX,
PROTRACTED SX
• COMMON WITH: STEROIDS, INF, PROPRANOLOL
DSM5, 2013
UpToDate: Jul, 2016
Feb 2017 8Taif, SA

9. SCREENING THROUGH PHQ-2: TWO QS
• Q1: 'OVER THE PAST 2 WEEKS, HAVE YOU FELT DOWN, DEPRESSED,
HOPELESS?' [DEPRESSED MOOD]
• Q2: 'OVER THE PAST 2 WEEKS, HAVE YOU FELT LITTLE INTEREST OR PLEASURE
IN DOING THINGS?' [ANHEDONIA]
• A POSITIVE RESPONSE TO EITHER QUESTION (SN= 97%, SP= 67%): ASSESS
FOR A DEPRESSIVE DS
• ALSO: GERIATRIC DEPRESSION SCALE, GDS (>5 SUGGESTS
DEPRESSION) AVAILABLE AS A FREE APP
PHQ: patient health questionaire
BMJ Best Practice: Dec,2016
Feb 2017 9Taif, SA

10. WORKUP: DON'T MISS
• TSH
• VIT D3
• VIT B12
• FOLATE
Feb 2017 10Taif, SA

11. MANAGEMENT
• CONSIDER: COMORBID CONDITIONS AND DRUG INTERACTIONS
• ANTICHOLINERGIC LOAD: BEERS CRITERIA (POTENTIALLY INAPPROPRIATE PRESCRIBING)
• COMBINED: PSYCHOTHERAPY + SOMATIC THERAPY ---- PHYSICAL EXERCISE
• SOMATIC THERAPY: DRUGS + BRAIN STIMULATION
• DRUGS: CITALOPRAM, S-CITALOPRAM, SERTRALINE, MIRTAZAPINE, TRAZODONE ---- LONGER
DURATIONS
• ALSO: ANALGESICS, FOLIC ACID, VIT D, VIT B12, L-THYROXIN, ARIPIPRAZOLE,
METHYLPHENIDATE, LITHIUM
• AVOID: TCA, PAROXETINE, BZD
• BRAINS STIMULATION: ECT, TMS Feb 2017 11Taif, SA

12. Feb 2017 12Taif, SA