R U T H S H I M , M D , M P H

A S S I S T A N T P R O F E S S O R , D E P A R T M E N T O F P S Y C H I A T R Y A N D B E H A V I O R A L S C I E N C E S

A S S O C I A T E D I R E C T O R O F B E H A V I O R A L H E A L T H , N A T I O N A L C E N T E R F O R P R I M A R Y C A R E

Effective Treatment of Depression in Older African Americans:

Overcoming Barriers

Objectives

To review the epidemiology of late life depression

To discuss racial/ethnic disparities in late life depression

To describe the depression care process

To examine evidenced-based treatment of depression in older adults

Overview of Depression

The leading cause of disability worldwide

4th leading cause of total disease burden

16.2% lifetime prevalence in the United States (conservative estimate)

6.6% 12 month prevalence in the US

Late-Life Depression

Depression is the most prevalent psychiatric diagnosis among the elderly

Prevalence in adults aged 65 and older in 2004:

17% of women

11% of men

Depression in elderly leads to increased disability, morbidity, and risk of suicide, poor adherence with medical treatments, increased mortality from medical illnesses

Late-Life Depression by Setting

Prevalence of major depression in older Americans

Community Settings (1-3%)

Primary Care Settings (5-9%)

Institutional Settings (12-30%)

Depression is more prevalent among younger adults, but older adults are less likely to be identified and treated

Diagnosing Depression in Older Adults

Depression should not be considered just a normal part of aging

Depression in older adults may look different than in younger adults

More anxiety and anhedonia symptoms

More physical health problems

More ambivalence about life

“Sadless depression”

Depression can be confused with dementia

“Pseudodementia”

Challenges in Late-Life Depression

Depression can be confused with the effects of multiple illnesses and the medications used to treat older adults

Comorbidities are the rule, not the exception

Advancing age results in loss of support systems (death of spouse, siblings, retirement, relocation), which increase the risk for depression

Disparities in Treatment Engagement and Retention

Older adults seek mental health treatment less than any other age group

50% of adults over 65 are in need of mental health services, only 20% receive treatment

Older adults prefer psychotherapy to pharmacotherapy, but are rarely follow up when given a referral to therapy

Barriers for African Americans Older Adults with Depression

African American older adults are less likely to receive an accurate diagnosis of depression compared to White older adults

African American older adults are less likely to receive empirically supported treatments for depression compared to White older adults

Barriers for African Americans

African American older adults suffer more psychological distress due to racism, discrimination, poverty, violence, etc.

African American older adults often have fewer psychological, social, and financial resources for coping with stress than White older adults

Comorbidities in Older Adults

Late-Life Depression

Doubles the risk of cardiac diseases

Increases the risk of death from medical illness

Reduces the ability to rehab from medical illness

Prevalence of Major Depressive Disorder in Chronic Disease

51%

42%

27% 23%

17% 16% 12% 11%

Challenges in Elderly Underserved, Low Income Populations

Poor access to care

Disability

Mild Cognitive Impairment

Dealing with Social Adversity

Depression in the Elderly and Suicide

Increased risk of suicide in elderly

Suicide rate in people ages 80 to 84 is twice that of the general population

Suicide in people age 65 and older is a major public health problem

Myths about Treating Late Life Depression

Mental health treatment is not effective

There is no cure for depression

Antidepressants are addictive and like street drugs

There are too many side effects with antidepressant medications

African American Older Adults

More likely to deal with depression through:

Informal support networks

Church

Primary care physicians

Depression in African Americans is less likely to be detected in primary care than it is in whites

Cultural Coping Strategies

Self-reliance

Keeping busy

Staying active in the community

Cooking and cleaning

Self-medicating – alcohol and nicotine

Pushing through the depression

Denial

Relying upon God

Racial/Ethnic Disparities Among Older Adults

African Americans seek treatment at half the rate of Whites

Attend fewer sessions when they do seek treatment

Tend to terminate treatment prematurely

Limited research shows African American older adults with depression are less likely:

To be in treatment

To intend to seek treatment in the future

To have ever sought mental health treatment for depression

Barriers to Treatment

Ageism

Shame/Stigma

Cultural Barriers

Fear/Distrust of the Treatment System

Lack of Knowledge

Lack of Insurance/Financial Barriers

Transportation

African Americans have greater negative attitudes toward seeking treatment (in some studies)

Depression Care Process

Step 1: recognition and diagnosis

Step 2: patient education

Step 3: treatment

Step 4: monitoring

Step 1: Recognition and Diagnosis

The clinician suspects that a patient may be depressed

Patient may self-identify

Patient may present with somatic complaints

Clinician may use screening tools

Formal assessment must be done to confirm the diagnosis

Step 2: Patient Education

Clinician and staff education patient about depression and the care process

Engage the patient

Determine patient preference for treatment

Patient Education

EXTREMELY IMPORTANT

Stigma and lack of education will lead many people to avoid treatment

Information about what depression is (and is not)

Steps involved in treatment

How antidepressants work – common questions and answers

What to expect from psychological counseling

Step 3: Treatment

Clinician and patient select the appropriate management approach

Three Phases of Treatment

Acute – aims to minimize depressive symptoms and achieve remission

Continuation – tries to prevent return of symptoms during current episode

Maintenance – focus is to prevent lifetime return of new episodes

Treatment for Depression in Elderly

Medication

Psychotherapy

Electroconvulsive therapy (ECT)

Antidepressant Medications

Medications are equally effective in older adults

SSRIs are well tolerated

May take longer to start working

May need to start at lower doses in elderly

Tricyclic antidpressants

Orthostatic hypotension – increased risk of falls

Urinary retention

Less well tolerated at effective doses

Anticholinergic effects

Cardiac side effects

Antidepressant Medications

SSRIs Fluoxetine

Sertraline

Paroxetine

Citalopram/Escitalopram

SNRIs Venlafaxine/Desvenlafaxine

Duloxetine

Other Antidepressants Mirtazapine

Bupropion

Psychotherapy

In general, many African Americans prefer psychotherapy (in theory) to medication

Referral and follow through is often difficult

Access to effective therapy is limited in underserved populations

Limited providers

Insurance limitations

Psychotherapy Preference

Although preferred, few older African Americans use this option

50% copayment for outpatient psychotherapy under Medicare

Less practical – weekly appointments

Electroconvulsive Therapy

Extremely effective in older adults

Barriers include access/availability

Effective when medications are contraindicated, or when there has been limited response to medication

Stigma regarding ECT limits availability of this therapy

Step 4: Monitoring

The clinician and support staff monitor compliance with the plan and improvement in symptoms/function

Modify treatment as appropriate

Goal is remission

Stepped-Care

Aims to provide the most effective but least intrusive treatment appropriate to an individual's needs

Assumes that the course of the disorder is monitored and referral to the appropriate level of care is made depending on the person’s difficulties

Each step introduces additional interventions

Higher steps normally assume interventions in previous steps have been offered and/or attempted

The Stepped-Care Model

Conclusions

Late life depression is a major public health problem that must be addressed

Racial/ethnic disparities exist in the diagnosis and treatment of late life depression

Late-life depression is treatable and recovery is possible

Specific treatment of depression should be tailored to fit the unique needs of African American older adults

References

1. Alston, M.H., S.H. Rankin, and C.A. Harris, Suicide in African American Elderly. Journal of Black Studies, 1995. 26(1): p. 31-35.

2. Blazer, D.G. and C.F. Hybels, Origins of depression in later life. Psychological medicine, 2005. 35(09): p. 1241-1252.

3. Comer, R.J., Abnormal psychology. 2009: Worth Pub. 4. Conner, K.O., et al., Mental health treatment seeking among older adults with depression: the impact of

stigma and race. American Journal of Geriatric Psych, 2010. 18(6): p. 531. 5. Conner, K.O., et al., Barriers to treatment and culturally endorsed coping strategies among depressed

African-American older adults. Aging & mental health, 2010. 14(8): p. 971-983. 6. Conner, K.O., et al., Attitudes and beliefs about mental health among African American older adults

suffering from depression. Journal of Aging Studies, 2010. 24(4): p. 266-277. 7. Cooper, L.A., et al., The acceptability of treatment for depression among African-American, Hispanic,

and white primary care patients. Medical Care, 2003. 41(4): p. 479. 8. Gallo, J.J., L. Cooper-Patrick, and S. Lesikar, Depressive symptoms of whites and African Americans

aged 60 years and older. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 1998. 53(5): p. P277.

9. Gum, A.M., et al., Depression treatment preferences in older primary care patients. The Gerontologist, 2006. 46(1): p. 14.

10. Unützer, J., et al., Depression treatment in a sample of 1,801 depressed older adults in primary care. Journal of the American Geriatrics Society, 2003. 51(4): p. 505-514.

11. Wang, P.S., P. Berglund, and R.C. Kessler, Recent care of common mental disorders in the United States. Journal of General Internal Medicine, 2000. 15(5): p. 284-292.

12. Young, A.S., et al., The quality of care for depressive and anxiety disorders in the United States. Archives of General Psychiatry, 2001. 58(1): p. 55.

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