Depression is a major health issue among older adults receiving home-based services yet is underdiagnosed and undertreated, which can result in negative health outcomes. Despite the recognized need for improved mental health services, significant gaps and barriers exist that contribute to less than optimal home-based depression management interventions. Home healthcare clinicians are well positioned to drive this effort for improving depression care with enhanced learning. Thus, the purpose of this article is to provide guidelines on improving depression care in homebound older adults based on four clinical functions central to home healthcare: screening, assessment, medication management, and patient/family education.
Depression is a major health issue among older adults receiving home-based services and is characterized by injury-related falls (Byers et al., 2008; Stubbs et al., 2016), increased risk of hospitalization (Sheeran et al., 2010), greater medical comorbidity (Centers for Disease Control [CDC], 2015), higher healthcare utilization (Shao et al., 2011), and higher rates of suicidal ideation (Raue et al., 2007). The most recent national data report that 37.9% of Medicare beneficiaries who received home healthcare in 2013-2014 (N = 4,934,600) had a diagnosis of depression (CDC, 2016). This equates to 1,870,213 homebound individuals, a staggering number. The need for homebound services and effective depression management interventions will only increase over the next several decades as the number of Americans over age 65 is projected to more than double from 40.2 million in 2010 to 88.5 million in 2050 (Vincent & Velkoff, 2010).
Despite the recognized need for improved mental health services, there are significant gaps and barriers that contribute to less than optimal home-based depression interventions and mental health outcomes. Bao et al. (2014) conducted a qualitative study based on semistructured interviews with nurses and administrators from five home healthcare agencies in five states (N = 20) focused on Medicare policies. The researchers reported that several Medicare policies are misaligned with the need to improve depression care and are at odds with evidence-based depression care and the chronic nature of depression. For example, Bao et al. found that Medicare's homebound and “skilled” need eligibility criteria limited the nurses' ability to follow-up with depressed patients for a sufficient time. Although depression assessment is included on the Start-of-Care (SOC) Outcome and Assessment Information Set (OASIS-C1), follow-up assessment for depression in OASIS-C1 is lacking on several fronts: there is no follow-up assessment in OASIS-C1 during the 60-day episode, nor is it included in the OASIS-C1 at resumption of care after hospitalization, recertification for another 60-day episode, transfer to an inpatient setting, or at discharge. Moreover, Bao et al. noted that vendor-developed electronic health records do not support depression care in home-based services.
Other gaps and barriers identified in the literature revolve around how home healthcare nurses view their role in relation to depression care. A study conducted by Bao et al. (2015) reported that home healthcare nurses (1) did not consider depression care to be within their scope of practice; (2) reported a sense of low self-efficacy in addressing depression and engaging patients in depression care; (3) had misconceptions about the relationship between depression and the aging process (e.g., depression was a normal part of aging); (4) placed greater importance and urgency toward general medical conditions rather than depression or other mental health disorders; and (5) held beliefs about stigma related to depression and mental illness. Liebel and Powers (2015) also conducted a qualitative study on home care nurses' perceptions of depression care. Their findings were consistent with Bao et al. with the additional finding that most nurses reported feeling comfortable screening for depression but were ambivalent about their role in depression care management.
As we begin to better understand the mental health needs of homebound patients (and their caregivers), intervention models that target community-based providers are emerging that could lead to better identification and management of depression. One example is the Depression CARE for PATients At Home (Depression CAREPATH) (Bruce et al., 2011). The Depression CAREPATH intervention was designed specifically for use in home healthcare to manage depression as part of ongoing care for medical and surgical patients, with the care being delivered by nurses, physical therapists, and primary providers in the home. A key feature of the intervention is that rather than assigning depression care to a specialist (e.g., social worker), all primary clinicians are expected to manage depression as part of the routine care provided. Clinical protocols were developed as part of the Depression CAREPATH to guide home care clinicians and to help home healthcare agencies develop the infrastructure needed to implement and sustain the Depression CAREPATH intervention as part of routine care. Although it may not be possible for all home healthcare agencies to implement the Depression CAREPATH (according to CDC , there were 12,400 Medicare participating home care agencies in 2013-2014), there are several aspects of the clinical protocol that could be incorporated into routine care that has the potential to improve health outcomes for homebound older adults with depression, as well as increase detection of depression in those who do not have a formal diagnosis.
Although home healthcare nurses identified deficits in their depression care knowledge (Bao et al., 2015; Liebel & Powers, 2015), they are, nevertheless, well positioned to drive this effort for improving depression care with enhanced education. For example, home healthcare nurses oftentimes witness psychosocial issues (e.g., financial, family, and environmental) during their home visits that may contribute to depression or complicate self-care management of depression. Home healthcare nurses have the clinical skills to assess for depression, to help initiate treatment, and to follow-up with the patient and their primary care provider/psychiatrist. They manage multiple chronic conditions and have a solid understanding of the interrelationship between physical and mental health. Finally, patient and family education is the hallmark of what home healthcare nurses do that can result in improved depression self-management and independence. Because home healthcare nurses provide greater than 85% of all skilled home-based services (Brown et al., 2007), they are the most logical healthcare profession to provide depression care.
Based on these premises, the purpose of this article is to provide guidelines on improving depression care in homebound older adults based on four clinical functions central to home healthcare nursing: screening, assessment, medication management, and patient/family education.
Assessment of Depression in Homebound Patients
Depression in older adults is complex and can be difficult to identify. Assessing for depression can be complicated because of medical conditions or medications that can cause symptoms of depression (such as weight loss, fatigue, sleep disturbances, and cognitive changes) or medical conditions that have a high level of comorbidity with depression (such as cancer, cardiovascular disease, diabetes, neurological disorders, and arthritis) (O'Connor et al., 2009). However, home healthcare nurses have many tools that can facilitate their assessment of depression in homebound patients. First, home healthcare nurses can assess for risk factors of depression in their older patients (Table 1), medications that are known to cause iatrogenic depression (Table 2) as well as medical conditions that have a high level of comorbidity with depression (Table 3). In addition, the Diagnostic Statistical Manual-5 (2013) has evidence-based criteria and symptoms for the assessment of major depressive disorders (Table 4). Although these diagnostic criteria are critical, depression and sadness may not be the predominant symptom of depression in older adults. Rather, physical complaints, such as pain and headaches are often more common and the primary symptoms of depression in this age-group (Table 5).
Screening for Depression in Homebound Patients
Home healthcare nurses are already screening for depression at the SOC, using the OASIS-C1. The two-item Patient Health Questionnaire (PHQ-2) is used to screen for depression, and if the patient screens positive, symptoms are then assessed using the nine-item Patient Health Questionnaire (PHQ-9) to determine depression severity (Tables 6 and 7). The PHQ-9 can be used for ongoing assessment of depression and response to treatment during the patient eligibility period.
Medication Management: Antidepressants
The most common treatment for depression in homebound older adults is antidepressant medication. The most frequently prescribed antidepressants are selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors. Other classifications that are also effective include norepinephrine-dopamine reuptake inhibitors, mixed serotonin agonists/antagonists, and alpha 2-adrenergic receptor antagonist. Although tricyclic antidepressants have been extensively studied in the treatment of geriatric depression, older adults are more likely to experience side effects because of age-related pharmacokinetic alterations in drug absorption, binding, distribution, metabolism, and excretion (Alexopoulos et al., 2005) (Table 8).
It is estimated that approximately one in three homebound older adults will be on an antidepressant at the start of home care (Shao et al., 2011), yet a significant number will still be experiencing clinically significant depressive symptoms (Bruce et al., 2007). There are several reasons the homebound older adult may not be responding to the antidepressant medication(s), with medication nonadherence being the most significant contributing factor. Homebound older adults are especially vulnerable to nonadherence because they have higher morbidity rates combined with cognitive and social problems (Table 9). One of the most critical aspects of antidepressant medication management is a collaborative relationship with the prescribing provider who is responsive to information the home healthcare nurses share regarding the patients depression management.
Patient education is particularly important for depression and depression treatment, as both are subject to myths, preconceptions, misinformation, and stigma (Bruce et al., 2011). The more patients and families know about what depression is, what causes it, and how to treat it, the more likely they will follow the prescribed medication and treatment plan, monitor symptoms, and communicate their progress to the home healthcare nurse (Bruce et al., 2011). The home healthcare nurse can play a critical role in dispelling myths and misconceptions about depression (Table 10), helping patients and families understand that depression is a medical disease that is treatable and that treatment works best when patients are adherent (Bruce et al., 2011). Providing patient education material on depression that identifies the symptoms of depression and underlying biology, risk factors, and treatment options will better prepare patients and families for depression self-management (Table 11).
Many homebound older adults experience depressive symptoms that are clinically significant and can adversely impact health outcomes. Evidence suggests that depression in homebound older adults is underdiagnosed and undertreated. Home healthcare nurses are well positioned to not only assess for depression (which they do at admission to home care), but to also evaluate for risk factors, contributing medical comorbidities and medications that can either lead to depression or interfere with skilled care and home treatment. However, training and educating home healthcare nurses to screen for and implement care management interventions for depression is insufficient, and places an even greater burden of responsibility on the nurse. Changes in Medicare reimbursement and financial incentives for home healthcare agencies must be implemented to fully realize the benefits of on-going depression assessment for homebound older adults (Schirmer, 2015).
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