Note from the American Medical Directors Association (AMDA) and the National Guideline Clearinghouse (NGC): The original full-text guideline provides an algorithm on "Depression" to be used in conjunction with the written text. Refer to the "Guideline Availability" field for information on obtaining the algorithm, as well as the full text of the guideline, which provides additional details.
Does the patient have a history of depression or a positive result on a screening test for depression?
Available transfer information, including summaries and other referral data, as well as a patient and family history, can help to identify individuals who have a history of depression, other psychiatric disorder(s), psychiatric treatment or hospitalizations, or suicide attempts. Document in the admission medical record the presence of any of these conditions or events in the patient's history. Note, however, that genetic factors are less important in late-life depression.
Appropriate screening tools include:
- 10-Item Geriatric Depression Scale (GDS) (see Appendix 1 in the original guideline)
- Cornell Scale for Depression in Dementia (CSDD) (see Appendix 2 in the original guideline)
- Patient Health Questionnaire 9 (PHQ-9; see Appendix 3 in the original guideline)
- Staff Assessment of Resident Mood (PHQ-9-OV; see Appendix 4 in the original guideline)
Does the patient have signs or symptoms of depression?
If the patient has a history of depression, other psychiatric disorder(s), or a screening test result that indicates possible depression, members of the interdisciplinary team and direct care staff should observe him or her for current signs and symptoms of depression (see Tables 1 and 2 in the original guideline).
Does the patient have any risk factors for depression?
If the patient does not have current signs or symptoms of depression, evaluate him or her for risk factors (see table below) and document the findings in the patient's medical record. If the patient has risk factors, develop an interdisciplinary care plan that takes those risk factors into account and maintain a high index of suspicion for depression. If no risk factors are found, continue to monitor the patient periodically for the development of risk factors as well as for signs or symptoms of depression.
|Table: Some Risk Factors for Depression
- Alcohol or substance abuse
- Current use of a medication associated with a high risk of depression (see Table 5 in the original guideline)
- Hearing or vision impairment severe enough to affect function
- History of attempted suicide
- History of psychiatric hospitalization
- Medical diagnosis or diagnoses associated with a high risk of depression (see Table 6 in the original guideline)
- New admission or change in environment
- New stressful losses, including loss of autonomy, loss of privacy, loss of functional status, loss of body part, or loss of family member or friend
- Personal or family history of depression or mood disorder
Is it appropriate to perform a medical workup for factors possibly contributing to signs and symptoms of possible depression?
Although it is important to determine whether coexisting medical conditions or current medications may be contributing to the patient's depressive symptoms, the nature and extent of an appropriate medical workup will depend on the patient's condition, prognosis, and advance care directives, as well as on the expressed preferences of the patient or family.
For most patients in the long-term care (LTC) setting, a pertinent history and physical examination by the practitioner, the laboratory studies listed in Table 4 in the original guideline, and the standard interdisciplinary Resident Assessment Instrument process may yield findings that help with decision making.
Is the patient taking medications that might cause or contribute to depression?
(See Table 5 in the original guideline for list of medications that may cause symptoms of depression.)
If the interdisciplinary team feels that a particular drug may be a factor in the patient's depression (e.g., there is a temporal relationship between the initiation of the drug and the onset or worsening of depressive symptoms), the practitioner may decide to discontinue or to change the medication.
The practitioner should then document the reasons for the suspicion that this medication is causing or contributing to the patient's depression. It is equally important to document the reasons for continuing the drug if the practitioner judges that it is not contributing to the patient's depressive symptoms or considers the drug essential to treatment of the condition for which it was originally prescribed.
Does the patient have one or more conditions that may either increase the likelihood of depression or cause depressive symptoms?
Many medical and psychiatric diseases and conditions produce depressive symptoms or carry an independent risk for causing depression. These conditions need to be taken into account when a patient is assessed for depression (see Table 6 in the original guideline). A medical evaluation is important to determine the extent to which underlying medical problems cause or contribute to depressive symptoms.
Do the patient's signs and symptoms of depression resolve with treatment of comorbid condition(s)?
Take appropriate action if medical diagnoses or conditions are suspected of contributing to depressive symptoms or increasing the likelihood of depression.
Clarify the type of depressive disorder.
If the patient's depressed mood (dysphoria) or loss of interest or pleasure (anhedonia) has been present for at least 2 weeks and if either dysphoria or anhedonia has contributed to the patient's functional or social impairment or decline and if substance abuse or recent bereavement is not present, it is likely that the patient is suffering from a depressive disorder. Before this conclusion is reached, however, a health care practitioner should be consulted to distinguish a depressive disorder from other conditions or combinations of conditions, as discussed above.
Figure 1 in the original guideline (criteria for major depression from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision [DSM-IV-TR]) helps the attending practitioner and interdisciplinary team to discern whether the patient may have a depressive disorder. If at least five of the symptoms listed in Figure 1 are present for at least 2 weeks and if the patient has no history of a prior manic episode, then major depression is likely to be a correct diagnosis.
The scales listed as screening tools in Step 1 above may also be used to diagnose and monitor depression.
Does the patient's clinical situation require psychiatric support?
Depression can often be managed readily by primary care practitioners who follow appropriate protocols and guidelines. Effective psychiatric support may not be readily available in the LTC setting. In some cases, however, psychiatric support is helpful (see Table 7 in the original guideline). If possible, consultation with a geriatric psychiatrist or a psychiatrist with expertise in geriatrics should be obtained when there is uncertainty about the diagnosis of depression, when a patient fails to respond to multiple trials of antidepressant therapy or to augmentation therapy, or when a severe or urgent situation exists.
Patients who are suicidal or homicidal, those who are refusing to eat or drink because of depression, or those whose symptoms include delusions, hallucinations, or agitation are candidates for consultation with a geriatric psychiatrist. A specialist consultation may also be helpful for patients who have been unresponsive to an adequate trial of an antidepressant and for those who have multiple, complex coexisting illnesses.
Does the patient's depression exhibit serious psychiatric or behavioral complications that may pose a risk to the patient or to others?
Serious grief or bereavement issues and psychiatric disorders other than depression may complicate a depressive episode. Other complicating behavioral comorbidities may include alcohol dependency, substance abuse, and dementia. A consultant with specific expertise in the psychiatric disorders of older adults may be helpful in evaluating the patient for complications of depression.
It is important to determine if the patient is psychotic, severely agitated, aggressive (i.e., potentially dangerous to self or others), neurovegetative, or suicidal. If any of these conditions are present, referral to a geriatric psychiatric unit or consultation with a psychiatrist who has expertise in the care of older adults may be considered, unless the facility's interdisciplinary team has experience in dealing with such patients.
Implement appropriate and evidence-based nonpharmacologic or complementary treatment for the patient's depression.
General facility-wide approaches that should be available to all patients who can participate include the following:
- Minimize institutional aspects of the environment (e.g., encourage patients to decorate their living spaces with personal items)
- Facilitate interaction with family members and friends important to the patient
- Provide opportunities for patients to engage in spiritual or religious activities if they so desire
- Encourage engagement in socialization and structured, meaningful physical and intellectual activities that are age- and gender-appropriate
- Ensure that care is resident-centered and incorporates the wishes and desires of the individual
- Encourage prompt, positive, genuine relationships between residents and staff as an additional source of social support.
|Table: Most Common Nonpharmacologic Interventions for Depression
- Cognitive-behavioral therapy
- Interpersonal therapy
- Problem-solving therapy
|Psychosocial and other interventions
- Activation (socialization, engagement in productive activity)
- Bereavement groups
- Family counseling
- Light therapy
- Participation in social events
|Adapted from Alexopoulos et al. Pharmacotherapy of Depressive Disorders in Older Patients. The Expert Consensus Guideline Series: A PostGraduate Medicine Special Report. 2001. New York: McGraw-Hill.
Prescribe appropriate pharmacologic treatment for the patient's depression.
The decision to initiate drug therapy assumes that the interdisciplinary team is already working to establish a therapeutic milieu and that the facility is prepared to manage drug therapy. The practitioner should discuss the rationale for adding pharmacotherapy to the patient's regimen with team members as well as with the patient and his or her family. This discussion should include the goals of drug therapy and potential drug side effects.
The major classes of antidepressants, with representative examples of each class, are listed in Table 11 of the original guideline, and include the following:
- Selective serotonin reuptake inhibitors [SSRIs]
- Tricyclic antidepressants
- Dopamine norepinephrine reuptake inhibitor (bupropion)
- Serotonin norepinephrine reuptake inhibitors [SNRIs]
- Serotonin modulator (trazodone)
- Norepinephrine serotonin modulator (mirtazapine)
Refer to the original guideline for additional discussion of the various drug classes and treatment strategies for different types of depression.
Implement appropriate adjunctive treatment for the patient's depression.
Electroconvulsive therapy (ECT) is a safe treatment with no absolute contraindications to its use. ECT should be considered if the patient's condition is rapidly deteriorating or if antidepressant medication is not tolerated or has failed. ECT should be conducted only in an appropriately equipped setting under the supervision of an experienced psychiatrist and anesthesiologist.
Monitor the patient's response to treatment for depression.
Document approaches, timetables, and goals of treatment in the interdisciplinary care plan and progress notes. Goals of treatment may include, but need not be limited to, the following:
- Resolution of signs and symptoms of depression
- Improvement of scores on the GDS, CSDD, PHQ-9, or PHQ-9-OV
- Improvement in attendance at and participation in usual activities
- Improvement in sleep patterns
Monitor the patient carefully for side effects specific to each class of medication as well as for interactions between antidepressants and other classes of medications. Establish and document drug dosages, titration schedules, and frequency of testing to check drug levels as appropriate.
Refer to the original guideline for discussion of the following topics:
- Duration of treatment
- Strategies for overcoming treatment resistance
- Depression and medical comorbidities
Measure the facility's performance in the management of depression.
Review the management of patients with depression through the facility's quality improvement processes. Indicators that a facility may wish to use to measure the success of its efforts to manage depression are suggested in Table 16 of the original guideline.