Depression in older adults (65 years and older) is associated with emotional suffering, increases in health expenditures, morbidity, higher risk of suicide, and mortality from other causes.1–9 Depression is common and remains a significant problem for older adults.1,10,11 Major depression was identified by the World Health Organization as the fourth leading cause of disease.12,13 The cause of depression is poorly understood, but it is associated with changes in neurochemicals in the brain. Risk factors for depression include genetics, medical conditions, functional decline, disability, social isolation, and psychosocial stressors.14–16 Many of these factors are common among older adults.
Major depressive disorder (MDD) is a chronic form of severe depression with an episodic course, which is prevalent in older adults.14 Major depressive disorder is characterized by a number of persistent signs and symptoms, independently of age. According to the Diagnostic and Statistical Manual of Mental Disorders, for a patient to be classified as having MDD, he or she must present with sad mood and/or decreased interest or pleasure in activities, and present at least 4 more of the following symptoms most of the day, nearly every day for a minimum of 2 weeks17:
- significant changes in appetite or weight;
- sleep disturbances;
- restlessness or sluggishness;
- fatigue or loss of energy;
- lack of concentration or indecision;
- feelings of worthlessness or inappropriate guilt, and
- thoughts of death or suicide.
The prevalence of MDD increases across the continuum of settings as limitations and illness increase. Major depressive disorder affects 0.7% to 1.4% of community-dwelling older adults, 6% to 9% of primary care patients, 14% of older adults receiving home care, and 25% of nursing home residents.18–23
The increasing prevalence of MDD is consistent with the increase in limitations and illness across these settings. Therefore, not surprisingly, depression in older adults is associated with falls; it is common after stroke and other conditions that result in functional impairment and is associated with activity limitations, participation restrictions, and reduced quality of life.16,23–29 Depression among patients with stroke is associated with increased lengths of stay, less efficient use of rehabilitation services, and higher 12-month mortality rates.30–32 Thus, depression detection and referral are important components of care.
According to the 2011 American Physical Therapy Association Section on Geriatrics' guidelines on essential competencies in the care of older adults,33 physical therapists should be able to
- select and administer tests for cognition and depression (eg, Mini-Mental State Examination, Geriatric Depression Scale, Clock Drawing Test);
- differentiate between depression, delirium, and dementia on the basis of symptoms and comorbidities;
- adapt/modify communication and care delivery as needed; and
- determine need for referral.
However, many physical therapists may not be prepared to implement depression-screening activities that require organizational commitment and leaders to encourage and support the effort. A survey study evaluated the ability of 20 physical and 8 occupational therapists to recognize cognitive and affective disorders among 102 newly admitted geriatric patients.34 The physical and occupational therapists had difficulty identifying patients with cognitive and affective disorders. Although formal diagnosis of depression is not part of the role of these health care professionals, they are well positioned to improve detection and referral for suspected cases of depression in older adults.35–37
In this article, we provide an overview of evidence-based approaches for screening of suspected cases of depression in older adults by physical therapists and other non–mental health professionals and procedures to refer the suspected cases to primary care providers and/or mental health specialists for evaluation. The contents are based on a selective literature review; the results of previous studies conducted by the authors and others are discussed. We also provide resources and a tool to assist in communicating depression-related information to the primary care provider or mental health specialist. The content of this article is important to physical therapists because unrecognized and undertreated depression in older adults is a significant public health problem and older adults are often reluctant to seek health care for mental health problems.10,38 Medical costs for depressed older adults are estimated to be 50% higher than those for nondepressed older adults.3 Physical therapists provide care for a growing number of older adults. However, a number of barriers for depression recognition exist.
Screening patients for depression can help identify older adults in need of interventions and lead to improvements in their well-being and overall clinical status. Brief screens can be administered at minimal personnel cost and may lead to a decrease in overall health care costs.2,3 A number of barriers for depression recognition exist in the older adult population, including the misperception that depression occurs inevitably as a result of aging or medical illness, and as such is not treatable. Cognitive symptoms may be more prominent and can complicate depression detection, addressed later in this article. Screening activities do require training and practice, as detection of depression symptoms is often complicated by coexisting medical illness, pain, cognitive impairment, anxiety, and disability in the older adult population.39
In the home care setting, depression often remains unrecognized even when older adults receive home care services for other health care problems and are screened for depression.40,41 For example, when evaluating the concordance between a federally mandated depression item assessment and a research interview evaluation, nurses accurately recognized depression in only 1 of 3 older adults receiving skilled home care services.41 Multiple causes are found for underdetection, but in a survey study of home care, most nurses felt unprepared to conduct depression-screening activities.42
The US Preventive Task Force (USPTF) recommends that all individuals older than 60 years be periodically screened for depression.43 In terms of a specific approach for depression screening, the USPTF concluded, “There is little evidence to recommend one screening method over another, so clinicians can choose the method that best fits their personal preference, the patient population served, and the practice setting.” The USPTF recommends screening for depression in adults provided a system is in place for diagnosis, treatment, and follow-up. A challenge in all settings is providing needed training and a corresponding infrastructure for depression-screening procedures.
One option for depression screening is the Patient Health Questionnaire–2 (PHQ-2), which standardizes the assessment of the 2 cardinal symptoms of major depression (depressed mood and lack of interest or pleasure in activities) as seen in Figure 1.44 Patients with a PHQ-2 score of 2 or 3+ (depending on the patient population) should be referred for further evaluation.45,46 Scoring involves adding the results from the two items. For example, if a patient reported “Little interest or pleasure in doing things” and “feeling down, depressed, or hopeless” more than half the days over the past 2 weeks the total score is 4. The PHQ-2 with a cutoff score of 3 has 87% sensitivity and 78% specificity.47,48
The Patient Health Questionnaire–9 (PHQ-9) may be used in conjunction with the PHQ-2, increasing the reliability and validity of the findings.49 The PHQ-9 simply extends the PHQ-2 and corresponds to all 9 symptoms of major depression. An efficient strategy is to complete the PHQ-2 and then complete the 7 remaining symptoms for those with a positive initial screen.50 The PHQ-9 and cutoff scores are available online at: http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf. The PHQ-9 scores range from 0 to 27 (increasing score correlates with increasing depression severity) and each of the 9 items is scored from 0 to 3, indicating “how often a symptom is bothersome.” A PHQ-9 with a cutoff score of 10 had 88% sensitivity and 88% specificity for a major depression diagnosis in a large primary care population.49
A scale developed specifically for use with older adults that was found to provide reliable and valid results is the 15-item Geriatric Depression Scale (GDS-15).51,52 The GDS-15 has a yes-no format and is available in multiple languages. Scores range from 0 to 15; the higher the score the more likely the individual is experiencing depression. It had been used for community-dwelling, hospitalized, and institutionalized older adults but has diminished value as a depression-screening instrument in persons with dementia. The GDS-15 with a cutoff score of 6 has 94% sensitivity and 85% specificity in community-dwelling adults,53 and with a cutoff score of 5 has 72% sensitivity and 78% specificity in home care patients.54 The PHQ-2, PHQ-9, and GDS-15 can all be administered as a self-report or by interview. No matter which approach is used, the cutoff scores indicate when further evaluation by a primary health care provider or mental health provider is needed.
Detection of depression in persons with dementia can be complicated by a number of factors.55 First, “apathy” or a lack of motivation is common in persons with dementia. A lack of motivation does not necessarily indicate a depression disorder but does limit the person's engagement in activities and can complicate assessment.56 In differentiating “apathy” from “depression,” the trained clinician should assess the course of symptoms (ie, abrupt change would be associated with depression) and treatment responses. However, it is “often difficult to determine whether cognitive symptoms (e.g., disorientation, apathy, difficulty concentrating, memory loss) are better accounted for by a dementia or by a Major Depressive Episode.”17(p375)
Many individuals with Alzheimer disease and other forms of dementia are unable to provide reliable self-reports of emotional symptoms. In addition, caregivers may be unaware of behavioral symptoms associated with depression and may not communicate their observations to other members of the health care team. The Cornell Scale for Depression in Dementia (CSDD) is a validated and reliable depression severity measure.57 The American Geriatric Society Consensus Statement 2003 also recommends the CSDD as a screening instrument for depression among moderately to severely cognitively impaired individuals.58,59 The tool has been validated to rate depression symptoms over the entire range of cognitive impairment. The CSDD is administered via 2 semistructured interviews: 1 with an informant and 1 with the patient. A final decision regarding the presence or absence of symptoms is achieved by the clinician's judgment and integration of both sets of responses. Any clinician delivering the tool can ascertain the presence or absence of depressive symptoms, but then the patient needs to be referred to the appropriate specialist for further evaluation and treatment. Each of the CSDD 19 items is rated as absent (0), mild or intermittent (1), or severe (2), and the scores are added. Scores less than 6 indicate absence of significant depression symptoms, scores between 11 and 18 indicate probable major depression, and scores greater than 18 indicate definite major depression.
Training programs can improve the quality and consistency of depression screening. An educational and support package has been developed and tested to improve depression and anxiety screening rates among patients after stroke.60 Screening rates among 30 consecutive admissions before and after the intervention were compared demonstrating that depression screening improved (23%; odds ratio, 2.7).60 The authors stated that improvements in depression and anxiety screening rates require systematic protocols considering organizational factors, staff, and training.60
The “Training in the Assessment of Depression” (TRIAD) interactive course was developed to improve depression detection and care provided to depressed and medically ill older adults receiving home care services. The TRIAD provides information about older adult depression, patient-interviewing techniques, and instruction on how to facilitate referral of a positive depression screen.35,36 The TRIAD is offered to home health care nurses and therapists to improve their ability to identify symptoms of depression and make appropriate referrals for further evaluation. The TRIAD includes training on how to assess for suicidal ideation and a Depression Tool Kit. The Depression Tool Kit provides information about antidepressant use in older adults, suggestions on how to facilitate a depression referral, patient education, and other resources. The TRIAD can be accessed at http://www.geriu.org/uploads/applications/DepressionInHomecare/DinHomecare.html, without any cost to complete the training program. The TRIAD has been updated to be consistent with the revised OASIS (mandatory Medicare documentation), which now offers the PHQ-2 as an assessment tool for depression screening (www.MentalHealthTrainingNetwork.org).
The TRIAD was evaluated in a randomized controlled trial; it improved the detection of depression symptoms in older adults receiving home care services and led to a greater number of appropriate referrals than usual care or a minimal educational intervention.36 In 2011, TRIAD was recognized by the American Academy of Nursing's Raise the Voice campaign, which promotes solutions to health care challenges and transforms the way care is provided. Although TRIAD was developed for the home care setting, nurses and therapists in a variety of health care settings may benefit from this program (see Table 1 for the list of online resources).
COMMUNICATING DEPRESSION SYMPTOMS AND RELATED INFORMATION
Barriers for depression evaluation and treatment include failure to efficiently and effectively communicate depression-related information.61 When physicians were asked whether home care nurses routinely presented the information needed to decide on depression treatment, they reported that the nurses did not routinely provide the duration and severity of depression symptoms.61 On the contrary, nurses reported that, in many cases, physicians either were not available or did not make any treatment changes for patients who needed it. Another study found that information was provided in only 2 of 35 MDD cases transitioning back to home.62
Facilitators for depression evaluation and treatment include organizational support and standardized procedures for referrals, and communication of complete, concise, organized, and understandable depression-related information. Therefore, a structured communication approach for nurses and therapists was developed to convey depression-related information.63
When making a referral for a positive depression screen, it is important to provide clinical information so an informed decision regarding the next needed action can occur. The following suggested information content, organizational format, and example come from “Nuts and Bolts: Organization for Depression Case Presentation”63:
- Identify Patient: I am calling you about your patient Mr./Ms. ________whom I suspect has depression.
- Age, Marital Status, Race, Gender
- Current Symptoms (duration, pervasiveness)
- Suicidal Ideation
- Psychiatric History (if any)
- Psychosocial (living situation, social support, stressors)
- Medical illness and medications (dose for psychotropics)
- Recommendation for further evaluation by physician or Mental Health (MH) specialist.*
Example: “I am Mary Smith from ABC Agency. I am calling you about your patient Mr Arthur Jones who I suspect has depression. Mr Jones is a 66-year-old married, white man. He reports a depressed mood, most days nearly every day for the last 6 to 7 months. He has lost interest in activities such as watching his favorite sporting events. He denies thoughts about death or suicide. He denies a psychiatric history. Mr Jones is a retired teacher, lives with his wife of 30 years and underwent bilateral hip replacement 2 months ago. Medical illnesses: osteoarthritis, diabetes. Medications include sertraline (Zoloft) 50 mg by mouth every day without side effects, and alprazolam 0.25 mg by mouth as needed q8hours (he takes this once or twice a day); both were started 1 month ago at the rehabilitation facility. Insulin glargine (Lantus) 50 units subcutaneously every day at bedtime, and acetaminophen (Tylenol Extra Strength) 2 tablets q4-6hours as needed pain. I would recommend having a psychiatric nurse evaluate the patient.”
Before using the suggested standardized format, clinicians should first provide their names and the name of the agency or facility before discussing an individual case. This format can also be incorporated into written communication. Clinicians are often surprised when using the format by how efficiently they were able to provide the needed information (ie, in <2 minutes).
Educating older adults about depression and depression treatment and referring those suspected of being depressed to proper care are essential. Referral sources for evaluation of a positive depression screen include the patient's primary care physician and mental health specialists such as psychiatrists, psychologists, psychiatric nurses, and social workers. The attitudes and beliefs of the older adult must be considered. Older adults with a positive depression screen may not be motivated (ie, apathy) or reluctant to receive further evaluation. Common concerns are the stigma associated with mental illness, worry about additional treatments, concerns about cost, difficulty with mobility, and limited transportation.10,38 In general, older adults often find physical illness to be more acceptable than psychiatric illness,64 and individuals from different cultural backgrounds may vary in the words or expressions they use to describe their emotions and symptoms.39 These challenges decrease the likelihood that the older adult will follow through with a mental health referral. Further investigation of a positive screen will determine whether a formal diagnosis of a depressive disorder is present. When a patient with a currently prescribed antidepressant has a positive depression screen, the clinician may incorrectly assume that further evaluation is not needed.40 However, a depression screen is clinically meaningful whether or not patients are currently taking antidepressants. If a patient is still depressed when being treated, it indicates the need to be evaluated as a different treatment approach is indicated. A good approach to increase the acceptability of further evaluation is to use the language of the patient (eg, “feeling low or down” instead of “depressed”) and discuss mental health referral in the context of other medical conditions. For example, poststroke depression negatively affects functional recovery after discharge.65 Depressed patients have 3 times greater odds (95% CI: 2-5) of being noncompliant with treatment recommendations than nondepressed patients.66 Thus, proper referral needs to be ensured for optimal recovery and rehabilitation outcomes. Involving family members in the discussion is helpful because spending time with a depressed person can be frustrating and confusing. Family members should be provided with information about the medical illness of depression and its treatment so they know what to expect and can provide support. A number of resources are available providing targeted family education about depression and its treatment (eg, www.familyaware.org). In addition, it is critical to use appropriate patient educational materials (ie, targeted to language and health literacy skills) about depression and the need for a referral for further evaluation. Patients often need a great deal of encouragement and support to follow through with appointments for mental issues that they may not feel are essential.
MANAGING DEPRESSION IN OLDER ADULTS
Inadequate treatment of depression in older adults is common and results in ongoing depressive symptoms. In one study of 299 older adults with depression, receiving home and community-based services, 40% were persistently and 28% were intermittently depressed over a year.67 Similar to other chronic illnesses, depression and its treatment require ongoing monitoring and management. Several empirically validated treatment options are available for depression in older adults, but these often remain underutilized. Pharmacologic treatment, short-term psychotherapies, and a combination of the two are effective and safe for treatment of depression in older adults.59 These treatments, however, are effective only if administered at a proper dosage and schedule. Also, a meta-analysis demonstrated that exercise interventions can also significantly reduce depressive symptoms (n = 137; effect estimate: −2; 95% CI: −1 to −3).68
Adults of all ages often do not receive depression treatment or receive inadequate treatment, resulting in ongoing depressive symptoms. Thirty-two percent of adults (18 years or older),69 and 77% of older adults (older than 65 years) with MDD,18 were not receiving depression treatment when needed. Even for those patients being treated with antidepressants, continued monitoring for symptoms and dosage adjustments, consistent with evidence-based practice, often does not occur.70,71 This situation is comparable to starting a blood pressure–lowering treatment but not measuring blood pressure at a later time to see the effect.
DEPRESSION INFORMATION RESOURCES
Table 1 presents online resources including information about depression in older adults, performing assessments, patient and family education, making referrals, and depression care. Recognizing the consequences of inadequately treated depression in older adults, the Centers for Medicare & Medicaid Services recently prioritized depression assessment and care in nursing homes and home care settings.72 Assessment and management of depression in older adults can be conceptualized in the following 4 steps:
- Step 1. Accurate depression recognition and screening is needed. But assessment is only the FIRST step in caring for depression;
- Step 2. Depression-related information needs to be conveyed to the patient's physician or mental health specialist for further evaluation;
- Step 3. Depression treatment needs to be initiated or adjusted as indicated;
- Step 4. Ongoing monitoring of both symptoms, and patient adherence to treatment is required.
Depression is a common and significant problem for older adults. It is related to disability and affects rehabilitation participation, treatment compliance, and outcomes. Older adults are often reluctant to seek health care for mental health problems. Physical and occupational therapists are well positioned to improve detection and referral for suspected cases of depression in older adults. However, they have difficulty identifying patients with depression. Depression detection and referral are important components of care. We hope that this review will promote the incorporation of evidence-based screening and referral of suspected cases of depression in older adults into routine practice of physical therapists and other non–mental health professionals.
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* Reprinted from reference 63 with permission of Elsevier. All reprint requests should be made to the copyright holder.