Screening a skilled nursing home population for depression.

The population resident in the skilled nursing home of a Veterans Administration Hospital on the 27th of June 1988 was screened for the presence of depression. Only 74% of the patients (59 of 80) were able to complete most of the screening battery: the Folstein Mini-Mental State Examination, the 15-item Geriatric Depression Scale, and the Hamilton Depression Scale. Thirty-four percent of the sample (20 of 59) met the criteria for a DSM-III-R psychiatric diagnosis; 22% (13 patients) had a major depressive disorder, and 12% (seven patients) had an adjustment disorder with depressed mood. The 15-item version of the Geriatric Depression Scale was more effective than the Hamilton Depression Scale as a screening instrument in this population of frail elderly veterans who had multiple and severe medical problems (end-stage cardiac disease, progressive myasthenia gravis, terminal pulmonary disease, and multiple cerebrovascular accidents) that limited verbal and nonverbal communication, as well as physical endurance.     

Major depression in elderly home health care patients

OBJECTIVE: Despite the growth of geriatric home health services, little is known about the mental health needs of geriatric patients seen in their homes. The authors report the distribution, correlates, and treatment status of DSM-IV major depression in a random sample of elderly patients receiving home health care for medical or surgical problems. METHOD: Geriatric patients newly admitted to a large, traditional visiting nurse agency were sampled on a weekly basis over a period of 2 years. The 539 patients ranged in age from 65 to 102 years; 351 (65%) were women, and 81 (15%) were nonwhite. The Structured Clinical Interview for DSM-IV Axis I Disorders was used to interview patients and informants. The authors reviewed the results of these interviews plus the patients' medical charts to generate a best-estimate DSM-IV psychiatric diagnosis. RESULTS: The patients had substantial medical burden and disability. According to DSM-IV criteria, 73 (13.5%) of the 539 patients were diagnosed with major depression. Most of these patients (N=52, 71%) were experiencing their first episode of depression, and the episode had lasted for more than 2 months in most patients (N=57, 78%). Major depression was significantly associated with medical morbidity, instrumental activities of daily living disability, reported pain, and a past history of depression but not with cognitive function or sociodemographic factors. Only 16 (22%) of the depressed patients were receiving antidepressant treatment, and none was receiving psychotherapy. Five (31%) of the 16 patients receiving antidepressants were prescribed subtherapeutic doses, and two (18%) of the 11 who were prescribed appropriate doses reported not complying with their antidepressant treatment. CONCLUSIONS: Geriatric major depression is twice as common in patients receiving home care as in those receiving primary care. Most depressions in patients receiving home care are untreated. The poor medical and functional status of these patients and the complex organizational structure of home health care pose a challenge for determining safe and effective strategies for treating depressed elderly home care patients.     

Comorbidity of depression and anxiety in nursing home patients

OBJECTIVES: To assess the occurrence and risk indicators of depression, anxiety, and comorbid anxiety and depression among nursing home patients and to determine whether depression and anxiety are best described in a dimensional or in a categorical classification system. METHODS: DSM and subthreshold anxiety disorders, anxiety symptoms, major and minor depression and depressive symptoms were assessed in 333 nursing home patients of somatic wards of 14 nursing homes in the north west of the Netherlands with the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and the Geriatric Depression Scale (GDS). Comorbidity was studied along a severity gradient. Logistic regression analyses were carried out to identify demographic, health-related, psychosocial and care-related correlates of anxiety and depression. RESULTS: The prevalence of pure depression (PD) was 17.1%, of pure anxiety (PA) 4.8%, and of comorbid anxiety and depression (CAD) 5.1%. Comorbidity increased dependent on severity of both anxiety and depression. Different patterns of risk indicators were demonstrated for PA, PD and CAD for the investigated baseline characteristics. CONCLUSIONS: Comorbidity of anxiety and depression is most prevalent in the more severe depressive and anxious nursing home patients. The gradual increase of comorbidity of anxiety and depression dependent on the levels of severity of depression and anxiety suggests that for nursing home patients a dimensional classification of depression and anxiety is more appropriate than a categorical one. The observed differences in patterns of risk indicators for PA, PD and CAD support a distinguishing of anxiety and depression. Future studies are needed to assess the effect of treatment of PA, PD and CAD in nursing home patients.     

Screening for depression and anxiety disorders in primary care patients

Mood and anxiety disorders are highly prevalent in primary health care. In this study we assessed performance of the Hospital Anxiety and Depression Scale (HADS) for screening of depression and anxiety disorders in a population of primary care patients. A total of 503 primary care patients consecutively admitted to the primary care medical center in Kaunas, Lithuania, completed the study. We found that the HADS subscale of depression (HADS-D) at a cutoff score of 6 or more showed the best performance screening for a major depressive episode diagnosed by means of the Mini International Neuropsychiatric Interview (MINI), with a sensitivity of 80%, specificity of 69%, positive predictive value of 80%, negative predictive value of 92%, and area under the receiver operating characteristic (ROC) curve of 0.75. Performance of the HADS-D against MINI diagnosis of dysthymia was weak. The HADS subscale of anxiety (HADS-A) at a cutoff score of 9 or more showed the best performance screening for MINI diagnosis of overall anxiety disorders, with a sensitivity of 77%, specificity of 75%, positive predictive value of 53%, negative predictive value of 90%, and area under the ROC curve of 0.76. These results suggest that in primary care patients HADS is an adequate screening instrument for the MINI diagnoses of major depressive episode, but not for dysthymia at a cutoff score of 6, and for anxiety disorders at a cutoff score of 9.     

Religious practice and depression among geriatric home care patients

OBJECTIVE: To examine the relationship between religious practice and depression in a sample of geriatric patients receiving homecare nursing services. METHODS: Patients were sampled weekly for six months from all those aged 65 to 102, and newly enrolled in a visiting nurse agency (N = 130). Depression was assessed by home interviews using the SCID and HRSD. Patients reported their religious service participation prior to receiving homecare and currently. Health status, disability, pain, social support and history of depression were also assessed. RESULTS: The current prevalence of DSM-IV Major Depressive Disorder (MDD) was significantly greater (p < .05), and depressive symptoms were more severe (p < .02), among those persons who had not attended religious services prior to receiving homecare. Logistic regression demonstrated that the effect of religious attendance remained significant when controlling for health status, disability, pain, social support and history of depression. A subsequent analysis compared three groups of patients. They were those who had: 1) Not attended religious services; 2) Stopped attending since homecare; 3) Continued attending. Data demonstrated significantly decreasing prevalence of MDD (p < .03) across the groups. CONCLUSIONS: Prevalence of DSM-IV Major Depressive Disorder and the severity of depressive symptoms were significantly lower among homecare patients who attend religious services. Because a large proportion of persons stop attending religious services after initiating homecare, it is suggested that visitation by clergy may improve depressive symptoms for these patients.     

Prevalence of depressive symptoms and depression in elderly Finnish home nursing patients and home help clients

Depressive symptoms in a population (N = 419) aged 65 years or over and receiving home nursing, home help or both were assessed by postal questionnaires including the Zung self-rating depression scale (SDS). Eighty-six percent participated, and 38 percent of both men and women scored 45 raw sumpoints or more in the SDS. The mean of the raw sumpoints was 42.1 (+/- 9.6) for men (N = 100) and 41.4 (+/- 9.0) for women (N = 238, the difference being nonsignificant. Home help clients scored less than home nursing patients or patients receiving both home nursing and home help. The population scoring 45 raw SDS sumpoints or more was investigated by a general practitioner, and the diagnosis of depression was made according to DSM III-criteria. The clinical investigations showed 26 percent of both men and women who participated to be depressive. Chronic depression was the most common class, followed by atypical depression. About two thirds of the depressive men and half of the depressive women were 'new' cases in that it had not been realized earlier that they suffer from depression. Atypical depression was the class where underdiagnozing was most evident. Among elderly men psychomotor retardation, libido loss, anorexia and indecisiveness and among elderly women psychomotor retardation, indecisiveness, emptiness and diurnal variation were common symptoms of depression.     

Clinical features of depression in the nursing home

The prevalence of depression among nursing home residents was estimated by screening a group of residents selected from a random sample on the basis of cognitive status; it ranged from 18-20% for major depression to 27-44% for other dysphoric states. Though individual patients were observed to change over a 6-month period, depression as assessed with the Geriatric Depression Scale was, in general, persistent. Major depression was clinically confirmed in 8 of 10 patients identified at screening. It was characterized by medical disorders that complicated diagnosis and treatment, and by increased mortality relative to the rest of the population.     

Screening for depression in a primary care setting in Vietnam

A Vietnamese Depression Scale (VDS) was developed in 1982 in the United States and has been used as a screening tool for depression and as the basis for a standardized interview to assess depression in the Vietnamese refugee populations. In this current study, the VDS was used in Ho Chi Minh City, Vietnam, to assess depression in patients who were already diagnosed with depression by Vietnamese psychiatrists and in patients presenting at a local primary care clinic. Of the 177 primary care clinic patients, 8.4% met the criteria for clinical depression based on the VDS. Results indicate a higher risk for depression among married and/or less than high school educated individuals. Discrepancies were found between the depression diagnosis by Vietnamese psychiatrists and VDS screening results. Among the participants interviewed who met the VDS criteria for depression, culture-specific phrases such as "desperate," "going crazy," and "low spirited and bored" were highly associated with symptoms of depression.     

Disruptive vocalization and depression in older nursing home residents

Screaming and other types of disruptive vocalization are commonly observed among nursing home residents. Depressive symptoms are also frequently seen in this group, although the relationship between disruptive vocalization and depressive symptoms is unclear. Accordingly, we sought to examine this relationship in older nursing home residents. We undertook a controlled comparison of 41 vocally disruptive nursing home residents and 43 nonvocally-disruptive nursing home residents. All participants were selected to have Mini-Mental State Examination (MMSE) scores of at least 10. Participants had a mean age of 81.0 years (range 63-97 years) and had a mean MMSE score of 17.8 (range 10-29). Nurse ratings of disruptive vocalization according to a semioperationalized definition were validated against the noisy behavior subscale of the Cohen-Mansfield Agitation Inventory. Subjects were independently rated for depressive symptoms by a psychiatrist using the Dementia Mood Assessment Scale, the Cornell Scale for Depression in Dementia, and the Depressive Signs Scale. Vocally disruptive nursing home residents scored significantly higher than controls on each of these three depression-in-dementia scales. These differences remained significant when the effects of possible confounding variables of cognitive impairment, age, and sex were removed. We conclude that depressive symptoms are associated with disruptive vocalization and may have an etiological role in the generation of disruptive vocalization behaviors in elderly nursing home residents.     

The impact of depression and anxiety on well being, disability and use of health care services in nursing home patients

OBJECTIVE: To determine the impact of depression and anxiety on well being, disability and use of health care services among nursing patients. METHODS: The study-population consisted of 350 elderly nursing home patients from 14 nursing homes in the Netherlands. Well being, disability, use of health care services (i.e. assistance in ADL, paramedical care, number of medications) and depression and anxiety and other relevant characteristics (gender, age, education, marital status, urbanization, cognition, morbidity, social support) were measured cross-sectionally. Associations of well being, disability and use of health care services with independent baseline characteristics were assessed with bivariate and with multivariate analyses. RESULTS: Presence of depression and/or anxiety was associated with significantly less well being, but not with more disability. Presence of depression and/or anxiety was also significantly associated with four of the seven indicators of health care service use measured in this study: less assistance in ADL, more consultation of medical specialists, a higher mean number of medications and more use of antidepressants. CONCLUSION: Presence of depression and/or anxiety has a statistically and clinically significant negative impact on well being, but not on disability. Future studies should focus on interventions for improving the detection, diagnosis and treatment of depression and/or anxiety in the nursing home.     

The substitution of nursing home for inpatient psychiatric care

Although the era of deinstitutionalization of the aged from state mental facilities and of the rapid growth of the nursing home industry appears to have ended, the question remains of the extent to which nursing home care is substituted for psychiatric care. To study this question, the numbers per capita of Medicaid program recipients of inpatient psychiatric care for each state in the period 1979–82 was regressed on numbers per capita of Medicaid nursing home recipients, numbers of nursing home beds per capita, and the percentage aged. As expected, psychiatric care is negatively related to bed supply, positively to nursing home recipients and to percentage aged; and the relationship to nursing home recipients is stronger in states with undersupplies of beds. These findings are interpreted to show that nursing home care is substituted for inpatient psychiatric care, depending on bed supply, the generosity of the Medicaid program, and the level of demand for care.The research in this article was partially supported by the National Center for Health Services Research (Grant No. H504042) and the National Institute of Mental Health (Contract No. 278-84-0017-SP). The views presented are those of the author, and should not be attributed to the funding agencies.