Depression in the elderly. Characteristics and clinical management

Major depression and clinically significant depressive symptoms occur commonly in the community-dwelling, medically ill, and institutionalized elderly. Both major depression and depressive symptoms need thorough evaluation and treatment because of the significant morbidity and mortality associated with these syndromes. Depression may be difficult to diagnose, especially in the medically ill elderly, because of the masking of depressive symptoms by somatic complaints or the presumption that symptoms are attributable to concurrent medical illness. Therefore, the clinician must be alert to the possibility of depression in the elderly patient. Although no specific diagnostic test is available, rating scales can be useful in screening for depression in the elderly patient. It is necessary to rule out medical illness or medications as contributing factors to depression. Psychotherapy and psychopharmacology, alone or in combination, are effective treatments for most elderly patients with depression. ECT is a safe and effective treatment for major depression in this population. Depression in the elderly is potentially a chronic and relapsing illness with significant associated medical and social morbidity. Because of their frequent contact with the elderly, nurses play a particularly important role in the diagnosis and treatment of depression. They need to recognize typical and atypical symptoms of depression and must be familiar with the potential side effects of antidepressant treatment. Close monitoring for these potential side effects can minimize disability. By working as a team with physicians, psychologists, and others, nurses have a necessary role in the care of the elderly depressed patient.     

Bipolar disorder

Bipolar disorder (manic-depressive illness) is a common, recurrent, and severe psychiatric disorder that affects 1% to 3% of the US population. The illness is characterized by episodes of mania, depression, or mixed states (simultaneously occurring manic and depressive symptoms). Bipolar disorder frequently goes unrecognized and untreated for many years without clinical vigilance. New screening tools have been developed to assist physicians in making the diagnosis. Fortunately, several medications are now available to treat the acute mood episodes of bipolar disorder and to prevent further episodes with maintenance treatment.     

Bipolar spectrum disorder: differential diagnosis and treatment

Bipolar disorder commonly presents as a recurrent mood disorder characterized by frequent depressive episodes. Although manic or hypomanic phases are required for the diagnosis to be made based on current diagnostic criteria, a wider expression of mood instability and other historical features or family history may suggest the presence of a bipolar spectrum illness. This article covers the diagnostic issues related to bipolar disorder and the spectrum concept of the illness. A new definition of bipolar spectrum disorder is suggested, and treatment principles and options are discussed. Primary care providers often encounter patients who have depression and mood problems, placing them in a key position for the diagnosis and treatment of this psychiatric illness.     

Depressive symptoms in HIV disease

Although depressive symptoms are common in people living with HIV/AIDS, their reported prevalence varies greatly across HIV-positive populations, ranging from 21% to 97%. Comparing these rates is complicated by the varied conceptualization of depression as a major depressive disorder (clinical depression) or depressive symptoms, and by the use of multiple methods of measurement. Knowledge of predictors of depressive symptoms can assist health care providers in the identification of those who are most at risk. Appropriate diagnosis, treatment, and referral are critical, because depressive symptoms have been associated with poorer disease outcomes. Additionally, self-management symptoms can be used to supplement more traditional treatment methods.     

On the relationship between chronic pain and depression when there is no organic lesion

Patients suffering from pain without evidence of either depression or organic lesions, or of any pathophysiological process to which the pain might be attributed, may be diagnosed as suffering from 'indeterminate pain.' The evidence in the literature which suggests that some of these cases might be due to a 'depressive equivalent' is examined. It is suggested that it is difficult, if not impossible, to formulate a diagnosis of depressive illness in patients who do not have clear symptoms of depression. However, there is evidence in the literature that a relatively high percentage of patients with chronic indeterminate pain appear to have a family history of depression and depressive spectrum disorders. Biological markers of depression also give some indication that certain of these patients may have a link with depressive illness as well as with pain. It is suggested that there is a need to explore the existence of a sub-group of patients with indeterminate pain in whom the mechanism of the pain may be related to the mechanism of depressive illness even though formal depressive symptoms are not found.     

Sickle cell disease: a stigmatizing condition that may lead to depression

Individuals with a chronic illness such as sickle cell disease are at risk for depression. Moreover, they are at risk for untreated depression. Depression may go untreated because of the stigma and high rates of disability associated with this chronic illness that most often affects African Americans in the United States. The purpose of this cross-sectional study was to describe depressive symptoms using the Beck Depression Inventory Fast Screen in a sample of 232 African American adults with sickle cell disease. Respondents reported higher levels of depression (26%) and depressive symptoms (32%) than did the overall United States population (9.5%). All adults with chronic illnesses need to be screened for depression in primary care practice sites where the diagnosis and treatment of depression needs to be coordinated.     

SICKLE CELL DISEASE: A STIGMATIZING CONDITION THAT MAY LEAD TO DEPRESSION

Individuals with a chronic illness such as sickle cell disease are at risk for depression. Moreover, they are at risk for untreated depression. Depression may go untreated because of the stigma and high rates of disability associated with this chronic illness that most often affects African Americans in the United States. The purpose of this cross-sectional study was to describe depressive symptoms using the Beck Depression Inventory Fast Screen in a sample of 232 African American adults with sickle cell disease. Respondents reported higher levels of depression (26%) and depressive symptoms (32%) than did the overall United States population (9.5%). All adults with chronic illnesses need to be screened for depression in primary care practice sites where the diagnosis and treatment of depression needs to be coordinated.     

Depression. Nursing implications of a clinical and social problem

Depression is a phenomenon with concurrent personal, social, and clinical dimensions. Each person is affected by depression differently and expresses depressive symptomatology in a unique manner. Socially, the incidence of depressive illness in the general population is three times that of schizophrenia. The cost of depression in terms of lost days at work and treatment is estimated to be $29 billion in 1991. Diagnosing and treating depressive illnesses depend on the clinical manifestations of the illness and the assessment skills of the practitioner. Different treatment modalities such as psychotherapy, psychopharmacology, and electroconvulsive treatments can be effective singularly or in combination to assist the patient in regaining his or her functionality in daily life.     

Depression and alcoholism: clinical considerations in management

When alcohol abuse occurs with depression, both the substance abuse and the mood disorder necessitate treatment. These conditions may have some similar manifestations, making differential diagnosis difficult. Depressed alcoholics report more previous treatment for substance abuse, withdrawal symptoms, and marital problems than those without depression. They also incur greater loneliness, unemployment, and social ineptness. Depressive symptoms found commonly in this group include work inhibition, guilt, self-disgust, dissatisfaction, and social disinterest. A history of depression among relatives favors a dual diagnosis of alcoholism and depression. Distinguishing those alcoholics with specific depressive illness enhances the therapeutic efficacy. Alcohol abusers need treatment, but those with concomitant depression persisting well beyond detoxification often require antidepressant medications. In long-term care, lithium may reduce alcohol-related rehospitalizations. A strong doctor-patient relationship with or without pharmacotherapy promotes continuation in a therapeutic regimen. Involvement in Alcoholics Anonymous and disulfiram maintenance therapy are other deterrents to drinking relapse.     

Visual disfigurement and depression.

Approximately 10% of the population has a facial disfigurement, such as a scar, blemish, or deformity that severely affects the ability to lead a normal life, and 2 to 3% have a clearly visible blemish. They may experience depressive symptoms due to disfigurement, stressful life events, or other causes. Depression is a painful and costly disorder that is often unrecognized and untreated in specialty practices; it is linked with higher costs of care, lengths of stay, and rates of rehospitalization. Often, these individuals seek plastic surgery to repair the disfigurement, and depressive symptoms are not uncommon preoperatively, perioperatively, and postoperatively. In addition, depressive disorders exist among 20 to 32% of people with a medical disease. Major depression is a recurring and disabling illness that typically responds to treatment with psychotherapy, antidepressants, and social support. Nurses have a major role to play in screening for and detecting depression so it can be evaluated and referred for treatment. Nurses also provide education, psychosocial support, and advocacy for patients with depression. Identifying those with depressed symptoms allows the nurse to recommend treatment, offer referrals, and provide supportive interventions.     

Cognitive behavioral therapy for depression in patients with heart failure: a critical review

Depression is a significant problem in patients with heart failure. Cognitive behavioral therapy (CBT) has been proposed as a potential non-pharmacological treatment for depression in patients with heart failure. The purpose of this review is to examine the evidence for the use of CBT in treating depression and depressive symptoms in patients with cardiovascular illness. In six of the ten studied reviewed, researchers found that CBT reduced depressive symptoms; however, the limitations of the studies prevent wide generalization of the results. There is insufficient evidence to support the use of CBT for the treatment of depressive symptoms in patients with cardiovascular illness at this time. Large randomized, controlled trials that demonstrate the efficacy of CBT are needed before nurses routinely refer patients with heart failure to CBT for the purpose of improving depression or depressive symptoms.     

Abnormal cardiovascular response to exercise in patients with PAD: Implications for management

The occurrence of peripheral vascular disease (PVD) in our aging population is of great proportion affecting approximately 20% of the population, which extrapolates to 8 to 12 million Americans. PVD is a progressive disease that almost always includes one or more comorbidities that impact greatly on severity and management of the disease. The age of disease onset can vary but most commonly presents at age 65 years and older. Depressive symptoms in the same age group occur in 30% to 60% of individuals with PVD. When a disabling disease such as PVD is combined with the already deteriorating effects of the aging process, the risk of these patients developing depression is greatly increased. The depressive symptoms in this population of patients are often unrecognized by their primary physician. This article reviews the potential mechanisms of depression, the effects of the combination of depression and a chronic illness such as PVD, the importance of recognizing depressive symptoms, and the available treatment options. The characteristics of PVD, including the effects on physical and mental health, the signs and symptoms of major depressive disorder, and the available screening tools used to evaluate a patient who may have depression, will also be discussed.     

Bipolar II disorder case study

When a patient suffering from bipolar II disorder is misdiagnosed as experiencing unipolar depression, the recommended treatment of the latter may precipitate a hypomanic or manic episode. Unchecked hypomanic symptoms may include risky behaviors, through which a patient could sustain irreparable damage to relationships, careers, and finances. Sometimes, patients are familiar enough with bipolar illness that they may anticipate or interpret inquiry regarding hypomanic symptomology (Goodwin & Jamison, 1990). Applying their own stigmas to bipolar illness, such patients may only admit to depressive symptoms to avoid a bipolar diagnosis (Goodwin & Jamison, 1990). Also, hypomanic symptoms can be nuanced and difficult to detect in patients who may misinterpret the elevated mood state as a return to good mental health rather than the pathologic condition it is. These and other factors, such as poor memory, substance use, physical problems, and co-morbid mental illnesses, contribute to the misdiagnosis and delayed diagnosis of bipolar II disorder for many patients (APA, 2013; Goodwin & Jamison, 1990). The astute clinician, however, can bypass the cascade of events leading up to the poor outcomes associated with unrecognized and mistreated hypomanic symptoms by committing to due diligence when assessing mood symptoms, depressed and elevated.     

The Diagnosis and Management of Bipolar I and II Disorders: Clinical Practice Update

Bipolar disorders, including bipolar I disorder (BP-I) and bipolar II disorder (BP-II), are common, potentially disabling, and, in some cases, life-threatening conditions. Bipolar disorders are characterized by alternating episodes of mania or hypomania and depression, or mixtures of manic and depressive features. Bipolar disorders present many diagnostic and therapeutic challenges for busy clinicians. Adequate management of bipolar disorders requires pharmacotherapy and psychosocial interventions targeted to the specific phases of illness. Effective treatments are available for each illness phase, but mood episode relapses and incomplete responses to treatment are common, especially for the depressive phase. Mood symptoms, psychosocial functioning, and suicide risk must, therefore, be continually reevaluated, and, when necessary, the plan of care must be adjusted during long-term treatment. Many patients will require additional treatment of comorbid psychiatric and substance use disorders and management of a variety of commonly co-occurring chronic general medical conditions.     

Screening for depression across the lifespan: a review of measures for use in primary care settings

Depression is a common psychiatric disorder in children, adolescents, adults, and the elderly. Primary care physicians, not mental health professionals, treat the majority of patients with symptoms of depression. Persons who are depressed have feelings of sadness, loneliness, irritability, worthlessness, hopelessness, agitation, and guilt that may be accompanied by an array of physical symptoms. A diagnosis of major depression requires that symptoms be present for two weeks or longer. Identifying patients with depression can be difficult in busy primary care settings where time is limited, but certain depression screening measures may help physicians diagnose the disorder. Patients who score above the predetermined cut-off levels on the screening measures should be interviewed more specifically for a diagnosis of a depressive disorder and treated within the primary care physician's scope of practice or referred to a mental health subspecialist as clinically indicated. Targeted screening in high-risk patients such as those with chronic diseases, pain, unexplained symptoms, stressful home environments, or social isolation, and those who are postnatal or elderly may provide an alternative approach to identifying patients with depression.     

The many faces of bipolar disorder. How to tell them apart

Bipolar disorder is a chronic disease characterized by depressive, manic or hypomanic, and mixed episodes. Bipolar disorder may be confused with unipolar depression, because patients with bipolar disorder are usually symptomatic with depression rather than mania. Bipolar disorder may also be misdiagnosed as schizophrenia, since both disorders can present with psychotic symptoms. For children, the principal differential diagnostic consideration is ADHD. Making the correct diagnosis has important prognostic and treatment implications. Comorbidities with personality disorders, substance and alcohol abuse or dependence, and anxiety disorders complicate assessment, treatment, and recovery. Effective pharmacotherapy and maintenance monitoring are critical in order to minimize the risk of relapse and associated disability, morbidity, and mortality.     

Avatar-based depression self-management technology: promising approach to improve depressive symptoms among young adults

Major depressive disorder is prevalent among American young adults and predisposes young adults to serious impairments in psychosocial functioning. Without intervention, young adults with depressive symptoms are at high risk for worsening of depressive symptoms and developing major depressive disorder. Young adults are not routinely taught effective depression self management skills to reduce depressive symptoms and preempt future illness. This study reports initial results of a randomized controlled trial among young adults (18–25 years of age) with depressive symptoms who were exposed to an avatar-based depression self-management intervention, eSMART-MH. Participants completed self-report measures of depressive symptoms at baseline and at 4, 8, and 12 weeks follow-up. Participants who received eSMART-MH had a significant reduction in depressive symptoms over 3 months, while individuals in the attention-control condition had no change in symptoms. In this study, eSMART-MH demonstrated initial efficacy and is a promising developmentally appropriate depression self-management intervention for young adults.     

Uncoupling the dopamine D1-D2 receptor complex: a novel target for antidepressant treatment

Depression, or major depressive disorder (MDD), is a serious mental illness that causes substantial worldwide disability. Current antidepressant medications mostly target the serotonin and norepinephrine neurotransmitter systems. These drugs are ineffective in many patients, and there are limited options for treatment-resistant depression. The dopamine neurotransmitter system has recently been identified as another modulator of mood and depressive symptoms, and a recently discovered interaction between the dopamine D1 and D2 receptor may be a novel antidepressant target.     

Assessment and treatment strategies for depressive disorders commonly encountered in primary care settings.

Frequently overlooked, depression is a very common complex disorder that causes significant morbidity and mortality. This article provides a review of three commonly encountered depressive disorders in primary care settings: adjustment disorder with depressed mood, dysthymia and major depression. Since many individuals minimize the affective symptoms of depression, clinicians must maintain a high index of suspicion when clients present with vague somatic complaints, such as fatigue, headache, constipation and difficulty sleeping. To reach an accurate diagnosis, a thorough history, physical examination and appropriate laboratory studies should be performed. Numerous rating scales are presented to aid assessment. Common intervention strategies for the treatment of depressive disorders include education, drug therapy, and supportive individual and family counseling.