Managing depression and depressive symptoms.

A round-up on drug therapy -- and how to avoid its misuse

Assessing the presence of depressive illness and symptoms in nursing home residents is of critical importance, in that depression is the most frequently under-recognized problem in older adults. Secondly, the demented older patient has concurrent depression in at least one-third of cases. Depression in the elderly is not one disease, but rather the presentation of multiply-caused medical and psychiatric disorders and conditions, ranging from bereavement to malnutrition to hypothyroidism.

Most noninstitutionalized older persons are relatively satisfied with their lives and experience only transient fluctuations in their mood. In long-term care facilities, however, 10% to 20% of patients with no cognitive impairment have major depression and 30% to 40% with cognitive impairment have depressive symptoms.

Pseudodementia, which is a depression that presents as a cognitive impairment, occurs less frequently in older than in younger patients. Pseudodementia patients treated for depression recover most of their cognitive impairment. The more common finding in the nursing home is the patient who has both mild-to-moderate dementia via Global Deterioration Scale (GDS) rating of 3 to 5 and depressive symptoms. On successful treatment of their depressive symptoms, cognitive impairment remains.

The key symptoms of depression in older patients are listed in Table 1

Assessment Using Depression Scales

There are several self-administered scales that have proven useful in assessing TABULAR DATA OMITTED depression. The use of the Zung Self-Depression rating scale has been shown to increase the ability of primary care physicians to detect depression by 2.5 to 25-fold (Zung WWK. J Clin Psych 1990; 5 (6 Suppl):72-76). Individuals wishing to use this scale should contact Dr. Zung at Duke University Medical Center, Box 2914, Erwin Square, Suite 103, Durham, NC 27710.

The Prognosis of Depression and Depressive Symptoms

While recovery occurs in half or more of those with major depression, the persistence of depressive symptoms or a tendency toward them may be life-long. As many as one-third to one-half of those who recover have a relapse within one year.

Gradual removal of drugs that contribute to depression is essential to avoiding relapse. These include methyldopa, beta blockers, reserpine, and the other sympatholytics such as Tenex, Wytensin and Catapres.

Misdiagnosis

In a 1976 study reported in the Journal of the American Geriatrics Society (Vol. 34(3)), Miller and Elliott reported on their examining of the primary and secondary diagnoses of 100 consecutive nursing facility admissions. Sixty-four percent of the patients' primary diagnoses were inaccurate; 84% of the patients' secondary diagnoses were either lacking or inaccurate. The predominant diagnostic errors were mislabeling patients with dementia and missing depression. Misdiagnosis of this magnitude will, of course, result in poor, inadequate, or inappropriate treatment.

Pharmacotherapy

The drugs of choice for depression are tri- or tetracyclic antidepressants (TCA) and selective serotonin reuptake inhibitors (SSRIs). Before the current TCAs and SSRIs, amphetamines were used but their long term efficacy was poor. Similarly, methylphenidate (Ritalin) and pemoline (Cylert) may have been tried, but their chief long-term effect is reduction of appetite, weight loss and lowering the seizure threshold in the older patient.

TCA's work by blocking the reuptake of norepinephrine (NE) and/or 5HT (serotonin) by their respective amine pumps through central and peripheral nerve membranes. This increases the circulating level of the amine in the central nervous system. SSRIs are the newest group (fluoxetine and sertraline). SSRIs essentially "energize" the patient with retarded lethargic depression, the most commonly encountered type of depression in nursing home patients.

If antidepressant therapy is needed, there are recommended optimal daily doses for medically ill geriatric patients (Small G, J Clin Psych 1989; 50(7):27-33). Based on the studies reviewed:

TABLE 5
Depressive Target Symptoms Prevalence in Patients Prescribed
Antidepressants
Retarded, lethargic symptoms             73/91
Agitated, depressed mood                 27/91
Sleep deficit ?                          14/91
Decreased socialization/ADLS             88/91
Weight loss                              53/91
(note: see malnutrition below)
(Jw cooper, in prep)

TABULAR DATA OMITTED

Nortriptyline (Aventyl/Pamelor) - 30mg; Desipramine (Pertrofrane/Norpramin) - 10 to 25mg; Doxepin (Sinequan/Adapin) - 10 to 20mg.

Geriatrician Carl Salzman, MD, at a 1992 Harvard Geriatric Conference recommended that if fluoxetine (Prozac) is used in the elderly, the dose should be 10 to 20mg once to twice weekly due to the 7-9 day half-life of its active metabolite, norfluoxetine.

Significant antidepressant response often occurs later in elderly than in younger patients, and requires at least 6 to 12 weeks of therapy on a dose to assess efficacy. (NIH Consensus Conference, JAMA 1992; 268: 1018-1024; (26 Aug 92).

A recent pharmacoepidemiologic study of antidepressant usage in nursing home patients is outlined in Tables 2-6.

The data show that only one-third of patients with depressive symptoms or depression received benefit from antidepressant therapy, chiefly from desipramine, nortriptyline and fluoxetine. Over 60% of patients experienced unacceptable ADRs from antidepressant therapy. It should be noted, however, that the average drug doses used in this study are somewhat higher than those recommended by Small and Salzman. It is possible that reduced dosages would have reduced ADRs and maintained efficacy -- and this leads to some final reflections:

Depressive symptoms and depression in nursing homes suggest a need for:

1. Increased awareness of its prevalence, recognition of co-morbid states, alertness to contributing drugs, and increased use of self- or professional-assessment scales;

2. Pharmacotherapy should be prescribed only after eliminating possible contributions by drugs and disease -- and when prescribing, go low and slow; do not attempt to achieve targeted "therapeutic" serum levels, as per a lab slip!

3. Assess outcomes that improve quality of life with minimal adverse drug affects (e.g. more socialization, improved mood and sleep patterns, less time in bed, better ADL ratings).

4. Wait long enough -- at least 6 weeks -- before assuming that an antidepressant has not had an effect.

5. Remember the importance of the elixir of time and TLC (tender loving care!). Regular visits by family may be most important healing factor of all.

TABLE 1

Depressive Symptoms in the Elderly

depressed mood ________ worthless feelings/guilt ________ anhedonia and apathy __________& weight loss AND malnutrition __________& insomnia OR excessive lethargy __________or psychomotor agitation OR retardation _________or fatigue _____________difficulty thinking ______________ suicidal or death thoughts

Adapted from Blazer, D., New Engl. J. Med. 1989;320:164-166.

TABLE 3

Therapeutic Endpoints to Assess Antidepressant Efficacy and Improved Quality of Life (see table 1 for Efficacy Ratings)

-----Improved Socialization -----Improved Ability to Perform Activities of Daily Living -----Improved Affect and Lessened Depressive Symptoms

(JW Cooper, in prep)

TABLE 4

Unacceptable Adverse Drug Reactions (ADRs)

-----Oversedation -----Urinary Retention -----Blurred Vision -----Increased Agitation -----Falls and Fractures

(JW Cooper, in prep)

James W. Cooper, Pharm. PhD, is Professor and Assistant Dean at the University of Georgia College of Pharmacy, Athens, GA.