Treatment of Depression in Older Adults | Evidence-Based Practices

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[Narrator]: Retirement is supposed to mark the beginning of our golden years,
a chance to pursue new interests and spend time with family.
But for a growing number of seniors the reality is bleaker.
Struggles with maintaining health, loss of family and work roles,
and coping with the deaths of peers and loved ones
has led to increasing levels of depression.
With the number of seniors increasing every year, this rise in depression
among older adults presents a growing challenge for our health care system.
[Ina]: I find with even, even senior friends, the loneliness sometimes
gets to them. Because we are used to being very active in our lifetimes
and then all of a sudden, it’s not there.
[Cynthia Zubritsky]: There are very, very high rates of depression in older adults, 20-25%.
It’s being untreated.
[Narrator]: This rise in depression among older adults has led to decreasing levels
of functioning, reduced quality of life, and worsening health conditions.
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[Jerry Johnson]: Depression and anxiety disorders – what we sometimes call
the generalized anxiety disorder –
are two of the most important problems that primary care physicians face.
[Joseph Lurio]: From my standpoint, especially with my elderly patients, I talk about...
the fact of depression as being something that complicates medical problems.
[Narrator]: In fact, health care costs for seniors with depression are about 50% higher
than for those without depression.
One challenge is that older adults are not likely to seek treatment for depression.
[Cynthia Zubritsky]: I think the real issue for older consumers is a stigma issue.
A lot of people grew up, that are in this cohort, grew up thinking that
if you were depressed it was sort of your fault.
[Connie]: Most people who have depression are afraid to admit it
because they think someone’s going to think they’re crazy.
[Narrator]: Fear of stigma among older adults is not the only inhibitor
of successful diagnosis and treatment – providers often overlook signs of depression
or are uncomfortable asking about mental health issues.
[Virna Little]: There was this big misconception that because these folks were
maybe isolated, because they weren’t feeling well sometimes or they had these chronic
illnesses or just by virtue of being seniors – of course they were going to be depressed.
[Jerry Johnson]: Sometimes there’s a tendency in medicine to focus on one part of the human.
To focus on the physical part and not the mental part.
But, in fact, particularly in older adults we see both so commonly,
occurring at the same time
that in order to provide high quality care, we really do have to be considerate
of ways of treating the mental and the physical concurrently.
[Narrator]: Researchers around the country are finding ways to do it.
The Substance Abuse and Mental Health Administration’s
Center for Mental Health Services has identified evidence-based practices (or EBPs)
in use around the country that are succeeding.
Evidence-based practices include psychotherapy interventions
and the use of antidepressant medications.
These can be used individually or in conjunction to improve symptoms.
They can also be used within models of outreach services
and collaborative and integrated mental and physical care.
[Joseph Lurio]: One of the issues was how to identify patients early on
and how to provide the best kind of treatment given time constraints in primary care.
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[Nurse]: Brown, Mary.
[Narrator]: One model of care for diagnosing and treating depression in older patients
is IMPACT, which stands for Improving Mood, Promoting Access to Collaborative Care.
The Institute for Family Health partnered with the developers of IMPACT
to implement the model in New York City.
[Doctor Gayle]: Yes, it’s Dr. Gayle.
[Daniel Blumkin]: The mission of the Institute for Family Health
is to deliver private practice level quality
primary care to an indigent population.
[Virna Little]: IMPACT is a collaborative model of care
that seeks to identify
and treat depression in older adults
in a primary care setting.
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[Clinic staff]: Good afternoon. How can I help you?
[Patient]: Yes, good afternoon. I’m here to see Dr. Gail
[Clinic staff]: Okay... have a seat here, please.
Okay, can I just have your date of birth, please?
[Wendy Barr]: The IMPACT model helps promote a holistic view of patient care
by integrating depression screening
into chronic disease management.
[Virna Little]: It is the first time that there was a really publicized
research-based model that supported something, which is near and dear to me,
which is the integration of primary care and mental health services.
[Nurse]: Today you’re here for your physical, and part of what we do here
is we ask all patients coming in for a physical to fill out,
or to answer questions about depression.
[Daniel Blumkin]: Project IMPACT attracted me and our organization because it enabled
us to provide services to our geriatric population that were
not being addressed previously.
[Narrator]: The two key features of the IMPACT model are screening for
and tracking depression in a primary care setting with a patient health questionnaire,
and onsite collaborative care with the patient’s physician.
[Virna Little]: When a patient comes in,
they are checked in at the front desk,
they are then transferred to nursing
for an intake or a triage process.
And during that triage process we’ve actually incorporated
the Patient Health Questionnaire-2 (PHQ-2). 0
[Nurse]: Okay, I have a few personal questions to ask you.
This is completely confidential and it’s for the use of the doctors only.
Okay.
[Nurse]: Over the last two weeks have you been bothered by any of the following problems:
little interest or pleasure in doing things...
[Eric Gayle]: And if they score one question positive,
it triggers us doing the PHQ-9.
[Nurse]: This is a form called PHQ-9 and I need you to read this and fill this out.
[Eric Gayle]: PHQ-9 is a patient health questionnaire that has nine questions
that are scored from 0 to 3. And the patients themselves answer it.
So you’re not diagnosing the patient; they’re diagnosing themselves
as to whether or not they have true depression or not.
And often times they’re scoring with moderate depression,
they are scoring 10 and above.
And those are the patients that usually you’re seeing much more frequently
than you would expect to.
These are the patients that are having more problems with their co-morbid conditions,
their diabetes, their high blood pressure and so on and so forth.
And once you start treating those patients with scores of 10 and above in the PHQ-9,
you start to see the improvements in the rest of their wellbeing.
[Doctor]: Well, my nurse told me that she gave you a patient health questionnaire
for depression, so I’m just going to spend a couple of seconds and score to see how
far along the curve you are.
[Regina Epperhart]: We offer them problem-solving therapy, we offer them meetings
with our psychiatrist to follow up on any kind of psychopharmacology,
and we also offer them just touching base
once a month by phone because some people who might not want these other interventions
we want to, you know, keep on our radar and we want to make sure that we’re
monitoring them on a monthly basis.
[Doctor]: I’m going to talk to you a little bit about what the course of management
is going to be. I’m going to give you the medication today
and I’m going to ask that you follow up with me in about two weeks.
Anytime during those two weeks if you’re having trouble with the medication,
you can call me.
I’m going to get our psychosocial services colleague to sit with you.
She’s going to be talking to you about the course of management she will have with you.
And I expect to see you again in two weeks and...
[Joseph Lurio]: Because we have the tools of the PHQ-9,
I’m able to give a score,
share that with the patient
and then we can say, “Well, you know, we tried
this last time but even though you say you’re feeling better,
it doesn’t really seem like your score has improved.
Maybe we really should have you talk to somebody.”
[Narrator]: The physician can collaborate with the depression care manager
and psychiatrists who are located onsite.
[Regina Epperhart]: In the Project IMPACT model the depression care managers
can be either nurses or they could be social workers.
[Care manager]: So out of all those things that you mentioned,
what is one that you would like to work on?
[Patient]: I’d like to go back to the way I used to be,
where I used to look forward to getting up in the morning,
getting dressed and going out there, being around people.
I don’t feel that way anymore. I feel like... another day, I’ve gotta get dressed.
Where am I going? I don’t wanna go out. I don’t like that.
I want...
[Care manager]: That energy.
That energy... that I had.
[Regina Epperhart]: We want to make sure first that they’re not in any danger to themselves
and then we, you know, set up a protocol where we offer them problem-solving therapy.
[Care manager]: Well, the goal that we can work on is to get you back to where you were
three weeks ago. That will be great, right?
[Patient]: Yes.
[Care manager]: And to get you from being depressed to feeling like your normal
self again. And those baby steps are called “self-management goals.”
So they’re goals that you establish for yourself.
[Regina Epperhart]: And it gives the patient the opportunity to come up with
what some of their problems are and how they even want to,
you know, get through some of the barriers that they’re facing.
The patient has a big say in, okay, so how do we get from here to here to here
to really, you know, slowly start to decrease
these depressive symptoms.
And it all – it comes from them.
[Katarzyna Haberko ]: It’s very difficult for older adults to seek treatment,
to seek counseling on their own.
And to – the primary care office, it’s a very
good entry point for the patients to be
to be identified as depressed if they are,
which usually older adults would go undiagnosed.
[Care manager]: ...we help to reduce their depression...
[Joseph Lurio]: What I found with this particular model is that it did
identify patients before sometimes I was aware that they were suffering from depression.
[Suzanne]: He told me the results of his interview.
The... I said you saw all that? He said yes.
I said, well, I better think about it cause I wasn’t aware that I had a problem.
But he thought I did and he probably was right.
And I enjoyed talking about my daily life which has been changed so very much.
And it was a wonderful experience.
[Regina Epperhart]: Most of these patients have functioned well for most of their life,
and they just really need some extra support now in how to get,
you know, from the problem to feeling better.
[Care manager]: I met with Ms. Brown.
[Doctor]: Yeah. Thanks for seeing her. I wanna see her in two weeks.
How did your interaction go with her cause I’m concerned about?
[Care manager]: It went well and she’s willing to come in...
[Eric Gayle]: Now part of the challenge for me is
finding the time to spend
to manage this patient.
And if I can reach across the hall
and get my social service specialist on board to say,
“Listen, I don’t have time right this minute. Can you spend some time
with this particular patient while I go do that?
By the time you’re finished with her, I can come back
and perhaps discuss other management of the patient,
including medications and so forth,” it makes the flow so much easier.
You’re not having the patient running around to different areas trying to find
the services that you can provide right on the premises.
[Regina Epperhart]: I would say the number one thing is getting the doctors on board
and the doctors to buy into the program and recognize how it’s going to both
help their patients and, you know, help the practice.
[Joseph Lurio]: Having the social worker integrated
into the whole process provided
a strong support for the primary care providers and also made it easier
for them to intervene because they didn’t feel like they were
carrying this whole burden on their own.
[Daniel Blumkin]: The use of the screening tools for Project IMPACT has enabled us to
demonstrate the improvement in the PHQ-9 scores
for the patients in the project.
[Eric Gayle]: We like to measure things, and you can measure the PHQ-9 score, you can
measure the diabetes evaluation and the hemoglobin A1c, whether or not they’re
getting better. You can see that the blood pressure is getting better.
All of these things make it more satisfying in treating our patients.
[Katarzyna Haberko ]: This program is very easy to implement when it’s – once
it’s rolling. It’s very simple to screen patients and provide them with needed
medication or counseling and support to improve their lifestyle.
[Joseph DiLullo]: All that integration of the medical
information and the psychiatric
can be very nicely utilized
to form as accurate a picture of the patient’s diagnosis as possible.
[Linda Tillman]: So it really was Depression 101 to discuss
what are the signs of depression,
what is helpful for a patient to reduce their depression in order to
help their medical condition so the patient is not coming through the door
every two weeks for another problem.
[Katarzyna Haberko ]: If we can make it easier for them to access services that they need,
I think that’s very exciting.
[Narrator]: Integrated mental and physical health care services have been proven to work
to work well in reaching many older adults.
But what about older adults who may be falling through the cracks of primary health care?
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Psychogeriatric Assessment and Treatment in City Housing (PATCH)
is a mobile treatment program developed at the Johns Hopkins Hospital in Baltimore.
It targets older individuals with mental illness
whose needs are not being met by the traditional healthcare system.
It combines the mobile treatment model and the Spokane gatekeeper model
and adds elements that address the medical and social challenges
that are so prevalent in this group.
[Peter Rabins]: People who lived in public housing sites
had three times the rates of depression
and several other psychiatric disorders
as elderly people living in the community. So we knew we had a very high risk,
high prevalence population in public housing.
[Beatrice Robbins]: We’re serving the most vulnerable elderly population.
It’s the impoverished elderly
with mental illness who are socially isolated
for the most part and who won’t access traditional care.
[Nurse]: Hello, good to see you again...
[Mary Minor]: The persons that we work with for the most part
are not going to seek
traditional mental health services.
[Narrator]: With social, physical, and psychiatric issues compounding each other,
the needs of these older adults often go unaddressed.
[Peter Rabins]: And you come to realize that the best way to improve the quality of life
for seriously ill older individuals is to simultaneously try to address their
social, medical, and mental health needs.
[Doctor]: Now are you tired during the day?
[Resident]: I get tired.
[Doctor]: Do you fall asleep – take catnaps?
[Resident]: Yeah I do.
[Doctor]: Sometimes, I know it’s hard but if you can keep yourself from doing that,
you’ll probably sleep better at night.
[Resident]: That’s right.
[Peter Rabins]: We developed the program about 20 years ago after actually failing,
to reach this population through more traditional programs.
And then the idea of providing both mobile treatment, but also using what was called
the gatekeeper model in which people in the community were used to identify people
who might need mental health services, we combined those two together
and launched the program back in 1986.
[Narrator]: The “gatekeepers” for the PATCH program are Housing Authority staff
who have been trained to recognize potential signs of mental illness in older residents.
[Rebecca Rye]: The nurses will initially provide
educational programs for staff
that work in the Housing Authority buildings and this would include
managers, counselors, security staff, anybody that may come in contact
with a resident that is ill and in need of services.
[Maintenance staff]: How you doing Ms. Rachel? How’s the tub-shower we gave you?
[Resident]: Huh?
[Maintenance worker]: The shower tub we gave you, is that alright?
[Resident]: Oh, it’s ok.
[Maintenance staff]: You like it?
[Gail Danik]: The maintenance staff is also involved.
They may be the first contact in some cases.
[Maintenance staff]: I’m glad you can use it.
[Resident]: Yeah.
[Maintenance staff]: Alright. Take care.
[Resident]: Thank you very much.
[Maintenance staff]: Alright.
[Fadeelah Keyes]: The PATCH program has been very, very helpful
with identifying as well as following up
on things that we identify to help people
not be evicted, not be in their units without taking their meds,
not being there without anyone to speak with as far as making doctor appointments
or even eating on a day-to-day basis.
[Gail Danik]: Once we’ve recognized, or think that we’ve recognized a particular
situation, then I call PATCH, ask them to come out, and they will do an intake
to verify and then hopefully beginning to
support that particular individual.
[Narrator]: The PATCH teams include a nurse, a geriatric psychiatrist, and a case manager
who bring services directly to residents in their homes.
Once housing authority staff identify a resident who may be in need of services,
a visit from a PATCH program nurse is usually the next step.
[Peter Rabins]: The reason we’ve chosen at the beginning to use nurses is because many of
these patients turn out to have unmet medical need as well as unmet psychiatric need.
[Mary Minor]: We do a mini-mental on everyone initially
as well as a depression scale
and a psychotic type of scale.
[Nurse]: Do you know the name of the program that I’m with? It’s called PATCH.
[Resident]: Uh huh.
[Nurse]: Yeah, Patch. The brochure I gave you...
[Beatrice Robbins]: We’re asking demographic information, medical history,
psychiatric history, medication list if it’s possible, then a general listing of,
it’s sort of a yes/no listing of all possible medical diagnosis that the folks may have.
[Nurse]: Did you bring this whole card in when you went to see him?
[Resident]: Yeah, I took this to the doctors.
[Nurse]: The pink one is called Depakote.
[Resident]: Depakote? I didn’t know the name.
[Peter Rabins]: The second element then is to have a trained geriatric clinician
make contact with the person, offer our services, do an assessment.
[Nurse]: That’s good. Very good.
[Doctor]: So, we’ve got to get – So, have you been in the nursing home lately?
A lot of times?
[Resident]: Haven’t been there.
[Doctor]: That’s what miss Mary was saying that you had to go to the nursing home a few times.
[Resident]: Well yes, sometimes I do. It’s a habit.
[Doctor]: Habit... yeah I got a lot of bad habits myself.
[Sharon Handel]: The minute you walk in someone’s house you know more than you’ll ever
learn in, you know, following somebody for years in a clinic.
[Doctor]: And then this one... how’s your reading? Do you read ok?
[Beatrice Robbins]: And the psychiatrist does a standard psychiatric diagnostic visit
and then together with the client develops a treatment plan.
And that’s when we decide whether we really want to include
the services of the case manager.
[Nurse]: You’ve done very well, actually.
[Doctor]: Alright Mr. Williams, it was good meeting you.
[Resident]: Same here, same here. Nice talking to you.
[Nurse]: See you later. [Doctor]: Bye.
[Narrator]: In addition to addressing the medical and psychiatric needs
of their patients, the PATCH team can include a case manager to address
social and financial challenges that may exacerbate their other needs.
[Case manager]: Her certification interview with mobility is scheduled for the
24th of March. So that’s already been set up as well so...
[Narrator]: Buck Weeks is a PATCH case manager who works with the treatment team
to address these challenges.
[Case manager]: You get social security each month... for your money?
[Resident]: Mmm hmm...
[Beatrice Robbins]: So he’ll come in and help with entitlements, transportation, making
arrangements for meals, I mean the list is endless for what he does.
[Case Manager]: Do you remember discussing that?
[Buck Weeks]: What I help do is work as part of the team with the nurses
and the psychiatrist coordinating services for the people we serve,
helping take care of medical appointments, monitoring medical appointments, helping
solve any problems with benefits, entitlements, and resolve any conflicts that occur.
[Case manager]: ...And this is just so you know how they came up with that number.
[Resident]: Ok, now.
[Buck Weeks]: Sometimes there’s not a whole lot of communication between
different doctors, different services, and the family.
And when people are getting older
they’re having trouble remembering
who they spoke to, who told them what.
They don’t always accurately relay the information to other doctors,
other family members.
So by being in touch with every treatment team member and being able to be like the hub,
it gives me a chance to make sure that all the services are complete.
[Narrator]: Not all residents are immediately receptive to services – even services
that are brought directly to their homes. The nurses and case managers have found
that developing a relationship with the client and being able to help them with even one
of their problems can help make that client more interested in other services.
[Rebecca Rye]: They will let a nurse in the door. Many people are used to home health
nurses coming out or public health nurses coming out and if you somehow find a way
to help them with something that they think is necessary which usually is not
their medical illness or their psychiatric illness.
Then you have a way in to get the rest of their needs addressed.
So sometimes it takes a while to establish a rapport.
Do you know where your wife is buried?
[Resident]: Sure don’t.
If they could help you find out where your wife is buried...
[Resident]: Yeah.
...and maybe having your niece or nephew go find where she is...
[Resident]: I would like to know...
I think that’s a good idea.
[Mary Minor]: Time spent listening, hearing what someone’s saying, knowing them over time,
so that you actually can anticipate or even name what others just are not seeing.
I think that’s a key piece to persons beginning to stabilize.
Because often times they don’t feel that they’ve been heard.
[Rebecca Rye]: If we can initially get medical problems or their social problems treated
then they’re more receptive to getting the psychiatric problems treated.
[Narrator]: The goal of PATCH is to stabilize older adults through in-home treatment
and then transition them to traditional mental health services after 6 months.
[Theresa Neal]: Once PATCH becomes involved with a resident, we see them coming out more,
we see them coming out more,
we see them interacting more,
in the lobby area with our staff.
[Wilber]: When they come in I’m cheerful, I’m happy. I know they going to be there.
Especially, I know she be there every Tuesday.
[Peter Rabins]: And we found that we could decrease rates of depression
and depressive symptoms by about 20% in the buildings we intervened in,
whereas the buildings that we did not
intervene in actually depression rates
went up over two years.
[Gail Danik]: Without the PATCH Program, I could see individuals being placed
in nursing homes. I can see individuals
becoming homeless because of dementia.
I can see individuals simply shutting down.
[Peter Rabins]: As a nation, as a healthcare system,
here’s a group of people we can make a huge difference with
by relatively simple but focused programs
and I’m proud of the state and the city that for almost 20 years
they’ve been willing to support this from the state level.
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[Marie Ickrath]: People can be treated. People can have
full and good lives...
but not if they’re not treated, if they’re not identified.
[Peter Rabins]: We hear this all the time, that we make,
that we’ve made a difference in people’s lives
and we’ve improved their quality of life and that helps us keep going.
[Narrator]: Depression does not have to be a part of aging.
The IMPACT and PATCH models are just two examples of the many practices
that are being put to use to successfully identify and treat depression.
If you would like more information about evidence-based practices
for treatment of depression in older adults,
go to samhsa.gov/shin or call 1-877-SAMHSA-7.
[Trudy]: I think people should realize that because you’re older
it doesn’t mean you have to be depressed.
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