Avoiding drug-induced depression in nursing home residents: depression is not inevitable--but it can be caused by our treatments.

Many individuals are admitted to acute, subacute, and long-term care facilities each year suffering from a depression that may never be recognized as a treatable illness by physicians, nurses, or other clinical practitioners. For some residents, however, depression can be created by clinical intervention. This article examines both occurrences of depression in nursing home residents.

Although the Epidemiologic Catchment Area Survey found that incidence of depression in the older adult general population was actually lower than for other age groups, (1) this may be an underestimate and have little bearing on long-term care facilities. Katz and Parmelee have estimated that the rates of depression within nursing home residents may dramatically exceed those found in the general population, involving some 30 to 50% of the nursing home population. (2)

In the general population it has been estimated that the older adult takes approximately four medications daily. Those within the long-term care setting take double that number, averaging approximately eight medications, with a large number of them strongly affecting the central nervous system. (3) What does this have to do with depression in the older adult? Possibly more than we'd like to think.

Before addressing pharmacogenesis of depression, however, consider another factor: Depression in the older adult is often more difficult to diagnose than in younger people. One reason is a prevailing misconception within general society, and even within the professional community, that older adults are supposed to be depressed, that it is a natural part of getting older. In fact, an older adult's functional status, or level of impairment thereof, is often more influential than mere aging in shaping a person's mood. (4,5) The residents of nursing homes usually have significant levels of debilitation, often arising from numerous chronic conditions. The complex nature of these conditions often frustrates physicians and treatment staff, often leading residents to have a sense of sadness or depression. (6,7)

We know, however, that improving the functional status of the individual, even through palliative measures, can often improve mood. This could include measures as simple as providing proper-fitting dentures to improve dietary intake, providing a mattress that enables the resident to rest and sleep better, or establishing and maintaining proper therapy or rehabilitative nursing to help the resident with maintaining movement and flexibility.

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Nevertheless, one major problem underlies all of the frustrations with helping older adults in nursing homes: The nursing home is an institutional environment that has become medicalized. Nursing homes are viewed as an extension of the acute-care industry, in which treatment means medical treatment, especially through the use of polypharmaceutical interventions. In fact, residents, family, and staff have come to believe that this is what skilled nursing facilities should be predicated on. Although some nursing facilities have tried recently to move beyond the medical model and adopt a more psychosocial environment (e.g., The Eden Alternative [TM]), most continue to exist as "institutions" firmly entrenched in the medical model. (8) These are environments that are exogenously conducive toward depression. (9)

Even with the modern emphasis on creating a more "homelike" environment, nursing facilities continue to exist as de facto extensions of the acute care medical industry, caring for those who are usually quite ill and severely compromised, with the paramount response being medical intervention. This is a sad and somber setting at best, making it all the more difficult to identify true depression in a resident. Think of how difficult it is for many on your staff to accurately code the section of the MDS differentiating depression from a sad or somber affect.

I have already mentioned that most older adults in nursing facilities are on approximately eight medications. Approximately half these medications are likely to have a depressant effect. (10) It has also been estimated that adverse drug reactions occur in 15 to 25% of older adults, with adverse reactions from psychoactive medications being implicated in 23% of nursing home residents. (11, 12) Many of the medications residents use can cause or mimic symptomatology of depression. For example, antihypertensive/cardiac drugs, such as calcium channel blockers, beta blockers, digitalis, and the cardiac glycosides, can cause depression yet may never be considered for this. Levodopa for Parkinson's disease and corticosteroids for inflammation are also associated with depression. Antineoplastics, such as Arimidex and tamoxifen, and even certain antibiotics, such as Bactrim, Flagyl, and Cipro, can induce depression or depressive-like symptoms. (13)

This should not be viewed as an indictment against using necessary medications. But the nursing home staff, including the physician, should be aware of the medications that residents are taking, and particularly their disposition toward affecting a resident's mood. It is also worth remembering that medications having depressogenic effects could counteract antidepressant drug therapy, and perhaps render it ineffective. A consulting pharmacist can be a strong asset in making these determinations for the facility. Often, changing a medication or lowering the dose, if possible, can in itself alleviate depression or depressive-like symptoms.

Medical realities aside, let's return to addressing misconceptions about depression in the elderly. First, it is not normal for older adults to be depressed. Second, we should not delude ourselves into believing that the nursing facility, even though in some cases "Edenized" and more homelike, is not an institutional environment conducive to breeding depression; because of the sheer burden of illness and disability it confronts, the nursing home will never be totally dissociated from its institutional status. Third, changing the mind-set of the clinical staff and putting theory into practice are two different things. It takes time to address medications regarding their potential for creating depression, and it often becomes much easier to simply superimpose Prozac or Zoloft onto a resident with a pharmacologically induced depression, wait to see if it works and, if it doesn't, try something else.

There is no discounting the frustration that leads to this. (7) Statements such as the following are not uncommon:

* "The high-level steroids may be causing the change in mood, but let's face it, they need the steroids or else."

* "Given their age and being as sick as they are, wouldn't you be depressed?"

* "What do you expect me to do? They're depressed, but at least they're not in pain."

Even if we know better, actually implementing best practices may be the most difficult challenge to surmount in dealing with clinical depression in the nursing home population. However, with hard work, diligence, and consistency, this problem can be overcome, allowing for a sound clinical understanding of pharmacologically induced depression in the nursing home population and an appropriate clinical response.

References

1. Regier DA, Boyd JH, Burke JD, Jr., et al. One-month prevalence of mental disorders in the United States. Based on five Epidemiologic Catchment Area sites. Archives of General Psychiatry 1988; 45:977-86.

2. Katz IR, Parmelee PA. An overview of depression in long-term and residential care: Advances in research and treatment. In: Rubinstein RL, Lawton MP, eds. Depression in Long Term and Residential Care: Advances in Research and Treatment. New York: Springer Publishing Co., 1997: 1-28.

3. Ferrini AF, Ferrini RL. Health in the Later Years. 3rd ed. Boston: McGraw-Hill Publishing Co., 2000.

4. Waxman HM, Carner EA, Blum A. Depressive symptoms and health service utilization among the community elderly. Journal of the American Geriatrics Society 1983;31:417-20.

5. Aneshensel CS, Frerichs RR, Huba GJ. Depression and physical illness: A multiwave, nonrecursive causal model. Journal of Health and Social Behavior 1984;25:350-71.

6. Lebowitz BD, Pearson JL, Schneider LS, et al. Diagnosis and treatment of depression in late life. Consensus statement update. Journal of the American Medical Association 1997;278:1186-90.

7. Adams WL, Mcllvain HE, Lacy NL, et al. Primary care for elderly people: Why do doctors find it so hard? The Gerontologist 2002;42:835-42.

8. Deaton G, Johnson CJ, Johnson RH, Winn P. The Eden Alternative: An evolving paradigm for long term care. The Southwest Journal on Aging 1998;14:133-6.

9. Goffman E. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Garden City, N.Y.: Anchor Books, 1961.

10. Blow FC. Substance abuse among older adults. Treatment Improvement Protocol (TIP) Series 26. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, Center For Substance Abuse Treatment, 1998.

11. Butler RN, Lewis MI, Sunderland T. Aging and Mental Health: Positive Psychosocial and Biomedical Approaches. 5th ed. Boston: Allyn & Bacon Publishing Co., 1998.

12. Joseph CL. Alcohol and drug misuse in the nursing home. International Journal of Addictions 1995;30:1953-84.

13. Tomb D. Psychiatry. 5th ed. Baltimore: Williams & Wilkens, 1999.

BY BRIAN GARAVAGLIA, PHD

Brian Garavaglia, PhD, is a long-term care administrator in Ferndale, Michigan, and a gerontologist specializing in dementia and addictions in older adults. He has worked in geropsychiatry for 17 years and teaches at colleges in the Detroit metropolitan area. For further information, phone [phone]. To comment on this article, please send your e-mail to [e-mail]. For reprints in quantities of 100 or more, call [phone].