This article reviews depression in the nursing home elderly, emphasizing its significance as a clinical problem, and the psychiatrist's role in screening, recognition, and treatment.
WHY FOCUS ON DEPRESSION?
Depression is Common
The recent NIH Consensus Statement on the Diagnosis and Treatment of Depression in Late Life1 informs us that ". . . among the 1.5 million older people living in nursing homes, the prevalence of depression is high." Estimates of the prevalence of major depression range from 6% to 24%, and depressive symptoms that are either less severe or of shorter duration ("minor depression") range from 30% to 50%, depending on the assessment instrument used, the definition of depression, the type of facility, and the sample studied. High rates of depressive symptoms were found in United States public,2'3 private non-profit,4'5 and private for-profit nursing homes.6'7 Comparable rates were found in long-term care facilities in Australia,8'10 the United Kingdom,11,12 Japan,13 Spain,14 and Italy.15 These findings demonstrate that the problem is not restricted to any particular type of facility or to the American system of long-term care.
Depressive Symptoms Are Persistent
Although it may frequently appear reasonable to attribute depression in long-term care patients to a self-limited adjustment disorder, there is evidence that symptoms are, in general, persistent. Using the Geriatric Depression Scale (GDS),16 Katz et al17 found that the majority of long-term care residents who were evaluated at two time-points separated by 1 year had persistent depressive symptoms. Parmelee et al18 evaluated a separate sample of residents from the same long-term care facility also at two time-points (Tl and T2) separated by 1 year, and found that "only 29% of the Tl possible major depressives showed complete remission a year later, and more than 40% showed no categorical improvement. Similarly, more than one fourth of identified minor depressives showed no change after a year; almost 1 in 5 exhibited exacerbated depression."18(pM194)
Depression is Associated With Significant Medical Morbidity
Components of medical morbidity known to increase with depression include both pain and nutritional deficits. Pain intensity and number of localized pain complaints are greater in depressed nursing home residents even after controlling for functional disability, health status,19 and cognitive impairment.20'21 Moreover, depression can lead to proteincalorie undernutrition and weight loss. Recently, Morley and Kraenzle22 concluded that depression was the most common cause of weight loss in a community nursing home, accounting for 36% of cases. Katz et al23 found depression to be a common cause of subnutrition in the nursing home. In addition, subnutrition contributed to the chronicity of depression and to poor responses to treatment.24
Depression Increases Health Care Needs
In a study by Fries,25 depression was associated with increased nursing home staff care time even after controlling for physical illness and disability. This extends previous reports from other treatment settings, documenting an association between depression and increased health care needs.
Depression is Associated With Increased Mortality
Although the available literature consistently demonstrates that major depression in long-term care patients is associated with increased mortality,4'7·26'30 controversy exists about the mechanism by which it exerts its effects. Rovner et al7 found a 1.6-fold effect that persisted even after controlling for the level of disability and the number of medical diagnoses. Parmelee, Katz, and Lawton,26 however, found a 2.8-fold increase in mortality associated with major depression that could be accounted for by controlling for disability and ratings of physical illness severity. Thus, the findings of Rovner et al7 were consistent with the hypothesis that some patients were dying because they were depressed, while those of Parmelee et al26 suggest that patients were depressed because they were sick and dying.
A recent study lends support to the conclusion that depression can increase mortality directly. Samuels et al studied a group of patients with depression who were referred to a treatment study23 and found that the severity of core depressive symptoms (but not accompanying symptoms such as anxiety) predicted mortality, even when controlling for medical illness and disability.31
Depression is Treatable
Reynolds et al32 have demonstrated a treatment response of over 80% in elderly major depressive outpatients treated for recurrent episodes using combined pharmacotherapy (nortriptyline) and interpersonal psychotherapy. Katz et al24 found a significant drug/placebo difference in a doubleblind placebo-controlled study of nortriptyline for treatment of depression in elderly residential-care patients (58.5% on nortriptyline and 9.1% on placebo were much or very much improved).
SPECIAL PROBLEMS RELATED TO DEPRESSION IN LONG-TERM CARE
Depression Can Go Unrecognized
There may be problems with the reliable identification of depressed patients and assessment of their symptoms by nursing home staff Although Parmelee, Lawton, and Katz5 report a statistically significant correlation between staff ratings of depression and independent ratings of depression obtained using the GDS (r = .34; N = 370), the magnitude of the correlations is low. Rovner et al7 reported that nurses have a sensitivity of only 58% and specificity of 66% for identification of patients with psychiatric diagnosis of any depression, and a sensitivity of 65% and specificity of 62% for major depression. Ongoing education and the use of the GDS may be beneficial in screening.
Depression May Be Dismissed as Normal
Everyone who has discussed depression with nursing home residents and their families has been refuted with comments like, "Wouldn't you be depressed if you had no family, all those medical problems, and lived in a nursing home?" We respond by acknowledging that social isolation, medical comorbidity, and change of environment can certainly influence a person's affect and lead to depression; however, if we were depressed, we would hope that the depression would be recognized and treated.
Residents who are cognitively intact, disabled, and physically ill are aware of their dependence on others and are at increased risk of developing depression. Nursing home residents can and should grieve their losses; however, these Stressors do not predetermine that the person will develop depression. Moreover, depression is the most common reversible psychopathology in the nursing home, and treatment can decrease the patient's suffering and improve the quality of life.
Symptoms of Depression Can Be Variable and Ambiguous
The presentation of depressive symptoms in nursing home residents may range from classical melancholia to a presentation of fewer or less severe symptoms, as in the case of dysthymia or minor depression.
Somatic complaints are common in the presentation of depression in elderly patients, but may be difficult to evaluate in patients with high medical comorbidity. The differential diagnosis of somatic complaints includes not only depression, but any underlying medical or neurological condition such as infection, trauma, subnutrition, pain, occult malignancy, medications, hypoxia, and metabolic disturbances.
Anxiety may be the most prominent symptom in some elderly depressed patients. In residential care patients, anxiety rarely occurs in the absence of depression and can usually be considered an associated symptom of a depressive disorder. Again, although attribution of anxiety symptoms to depression should be strongly considered, medical causes for symptoms must be investigated.
In the nursing home, as elsewhere, increasing recognition of all types of depression is important. There have been numerous discussions of the concern that using DSM-III, DSM-III-R, or DSM-IV criteria for major depression in patients with significant medical illness could lead to false positive diagnoses and low specificity. The diagnosis can be made more rigorous through the use of modified criteria if high specificity is desired, but increased sensitivity may be a better formula for initiating psychiatric consultation and evaluation.
Depression Can Be Manifest Primarily by Agitation and Related Behavior Problems
Depression may lead to behavioral symptoms such as agitation33 or refusal of care.34 Agitation may lead to treatment with neuroleptics without attention to the underlying depression. This practice was discussed in a study by Heston et al,35 which suggested that nursing home residents with a diagnosis of depression in the medical record were more likely to be treated with neuroleptics or benzodiazepines, and that only 10% received appropriate antidepressant medications.
Depression Can Be Manifest Primarily by Withdrawal
While the squeaky wheel may get the grease, the underrecognized "quiet" depressions also impair patients' quality of life. They may not, however, come to the attention of the staff because the patient's behavior is not disruptive. Social isolation, withdrawal from activities, and decreased social interaction may all be signs of depression in the nursing home resident.
Depression Occurs in Both Cognitively Intact Patients and Those With Dementia
Depressive symptoms can occur in patients with variable degrees of cognitive impairment, and may be more difficult to recognize in the patient with probable dementia. Depression may be a treatable cause of cognitive impairment (as in depressive pseudodementia). However, findings from recent work by Alexopolous et al36 demonstrate that geriatric depression with reversible dementia may be a harbinger of irreversible dementia. Most patients with depression and cognitive impairment suffer from two relatively independent problems. Current evidence supports the use of screening instruments such as the GDS in detecting depression in those with mild to moderate degrees of dementia as well as in cognitively intact patients.18,24,37,38
SCREENING, RECOGNITION, AND TREATMENT
OBRA regulations39 have established procedures for the identification of patients with depression using staff ratings of behavior on the Minimum Data Set (MDS) for Resident Assessment. These are followed by evaluations using standardized Resident Assessment Protocols (RAPs). Implementation of these measures precedes substantial empirical data supporting their sensitivity and reliability.40 Phillips et al41 found decreased reliability of the MDS in assessing communication skills, vision, and hearing in cognitively impaired patients compared with cognitively intact patients. Given that the GDS has been validated in the nursing home,42 it can serve as a standard against which to calibrate the MDS. The nurses who complete the MDS may also administer the GDS to more intact patients to confirm and refine their clinical judgment; they can then use this experience in evaluating more cognitively impaired patients.
Other identification methods include informal input from any facility staff member or family member who has a concern about behavioral change or depression in the nursing home resident. It is often this type of concern that catalyzes proper identification and treatment of psychopathology.
"Minor Depression" Can Be a Focus for Treatment and Prevention
In nursing home elders and congregate apartment dwellers, Parmelee, Katz, and Lawton18 found that the 1-year incidence of major depression was 5.6% and that of minor depression was 6.3% among those with no depression at baseline. The incidence of major depression was 16.2% among those with minor depression at baseline, suggesting that minor depression can be a risk factor for major depression. Thus, minor depression is important both as a source of distress and excess disability, and as a risk factor for major depression.
We recommend that minor depressive symptoms should be treated initially with the nonpharmacological approaches described below If the minor depressive symptoms persist and are distressing or disabling to the patient, then pharmacological treatment should be considered as a form of preventive medicine as well as treatment.
There is increasing recognition in other depressed cohorts that maintenance treatment offers secondary prevention against future relapses and recurrences of depression. We can extrapolate the need for maintenance treatment of depression in the elderly longterm care patients, but we must recognize that further research is needed to develop guidelines about what constitutes proper maintenance treatment in a population marked by concurrent medical disability and frequent acute illnesses.
ALTERNATIVE ROLES FOR THE PSYCHIATRIST
After an individual patient is recognized as depressed, the psychiatrist may enter into the patient's care at any of several different points. In one model, the primary care physician completes the medical evaluation and begins pharmacological treatment of milder and uncomplicated depression with generally well-tolerated agents such as SSRIs or buproprion. (Venlafaxine, another new antidepressant, may also be useful in this context, but there is little information about its use in older patients.) In this model, the psychiatrist is consulted if there are adverse effects or a lack of response to the first agent selected. The psychiatrist should also be consulted if the depressive symptoms are complicated by delusions, hallucinations, suicidal risk, medical treatment refusal, or nutritional deficits.
Treatment Options for Depression in the Nursing Home Resident
An alternative model would involve psychiatric consultation and/or treatment from the onset in all patients. The psychiatrist would manage the necessary medical evaluation, pharmacological treatment trials, and continued monitoring for depressive symptoms and beneficial and adverse effects of treatments.
Recent work by Roose et al43 has suggested that although the SSRIs are easier to use than classical tricyclics, they may be less effective in older patients with severe depression and significant medical illness. Although there are no comparable data on nursing homes, there may be concerns that this observation may also apply to the frail elderly. These concerns underscore the importance of continued monitoring of depressive symptoms even after adequate dosages of the drug have been given, to recognize when patients have not responded and to trigger modification of the treatment plan as needed.
In either model, specific psychotherapies are recommended. Unfortunately, however, they may not be uniformly available. One method, cognitive behavioral therapy, has been studied in the nursing home,44,45 but further research is needed to determine if it is effective. Mobilization of other less specific psychosocial interventions such as physical, occupational, recreational, music, and activities therapy may also be beneficial. In addition to specific psychotherapies, the psychiatrist and nursing home staff can help to improve the social network and increase the activities in which the patient is involved. For more intact residents, modification of the interpersonal environment should focus on interventions designed to give residents an increased sense of control.46 For the more impaired, the task may be to achieve an optimal match between environmental demands and the residents' capabilities.47
The Table outlines the two major evaluative and treatment categories used for depression in the nursing home. Psychosocial and biomédical evaluations should, in general, be initiated in parallel. Psychosocial evaluation includes an analysis of the environmental and interpersonal factors involved in the patient's symptom presentation. The biomedical evaluation consists of any appropriate diagnostic testing that will help attribute the patient's symptoms to a general medical condition or assess the risks of somatic treatments.
The treatment approaches, consisting of psychosocial and biomédical therapies, may also be done in parallel. Specific psychotherapies can include cognitive, behavioral, or interpersonal therapy. Less specific psychosocial interventions can include any behavioral approach that will potentially aid the patient to develop a sense of control or to improve interpersonal relationships in the context of the nursing home milieu. The biomédical treatment will address any identified primary medical disorder, adjustment of any medications, and discontinuation of any nonessential substances that may be impairing patient functioning. Pharmacotherapeutic treatments for mild and uncomplicated depression can begin with a well-tolerated "first line" antidepressant such as an SSRI or buproprion, unless the patient has a history of favorable response to an alternative agent. If initial pharmacotherapy fails, TCAs may be indicated.
Suggestions for treatment-resistant depression have been described elsewhere48 and include multiple drug therapy and augmentation with lithium, thyroid hormone, or psychostimulants, as well as psychiatric hospitalization and the administration of ECT. Further research using these approaches in nursing home patients with medical disability is recommended. Antidepressant trials with any agent should include enough drug for enough time before being considered a treatment failure.
Continued monitoring of depressive symptoms after any therapeutic intervention has been initiated is extremely important. Treatment in the hospital setting may be necessary for complex pharmacological management, ECT, crisis intervention, or drug treatment of depression in a patient with active medical problems.
Depression is a common disease adversely affecting the quality of life in a large number of nursing home elders.49 Morbidity, disability, mortality, and resource utilization from medical conditions all increase when they are coupled with depression. Depression is often underrecognized and may be dismissed as normal. The presentation of symptoms in this cohort often includes anxiety and somatic complaints. Agitation and screaming may also signify depression in patients with and without cognitive impairment. Use of the MDS and GDS along with increased education of facility staff may help to improve reliable identification of depression.
The psychiatrist may begin involvement early on at the identification phase and be involved in the medical workup, pharmacological and psychosocial treatments, and continued monitoring for depressive symptoms. Continued symptom monitoring is extremely important for recognition of nonresponse to the initiated treatments. Alternatively, the psychiatrist may become involved after the patient has failed treatment initiated by the primary care physician, or if the patient has depression complicated by behavioral disturbance, psychosis, suicidal risk, treatment refusal, or nutritional deficits.
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Treatment Options for Depression in the Nursing Home Resident