Integrating depression detection Integrating depression detection and treatment into work with and treatment into work with older adultsolder adults

Peter A. Lichtenberg, Ph.D., ABPPPeter A. Lichtenberg, Ph.D., ABPPDirector, Institute of Gerontology &Director, Institute of Gerontology &Professor of PsychologyProfessor of PsychologyWayne State UniversityWayne State University

Perspectives on Old AgePerspectives on Old Age

To me old age is always 15 years To me old age is always 15 years older than I amolder than I am……

Bernard Baruch, age 84Bernard Baruch, age 84

How old would you be if you didn’t How old would you be if you didn’t know what age you were?know what age you were?

Satchel PaigeSatchel Paige

DSM-IV DSM-IV Major Depressive DisorderMajor Depressive Disorder

At least 5 of the following 9 symptoms have been present for a 2 At least 5 of the following 9 symptoms have been present for a 2 week period: (either a or b must be one of the 5 symptoms)week period: (either a or b must be one of the 5 symptoms) a. a. Depressed mood consistently - not transientDepressed mood consistently - not transient b. Loss of pleasure and interest in normally pleasurable activities b. Loss of pleasure and interest in normally pleasurable activities

(anhedonia)(anhedonia) c. Significant weight loss or gain (>5% body weight)c. Significant weight loss or gain (>5% body weight) d. Insomnia or hypersomnia d. Insomnia or hypersomnia e. Psychomotor agitation or retardatione. Psychomotor agitation or retardation f. Loss of energy, fatigue (even following a good night’s sleep)f. Loss of energy, fatigue (even following a good night’s sleep) g. Feelings of worthlessness, self-reproach, inappropriate guiltg. Feelings of worthlessness, self-reproach, inappropriate guilt h. Decreased ability to think or concentrateh. Decreased ability to think or concentrate i. Suicidal thoughts or attempti. Suicidal thoughts or attempt

There is nothing Minor There is nothing Minor about Minor Depressionabout Minor Depression

MAJORMAJOR Depressed mood or Depressed mood or

loss of pleasure loss of pleasure 4 additional symptoms4 additional symptoms Interfere with social or Interfere with social or

occupational functionoccupational function At least 2 week At least 2 week

durationduration

MINORMINOR SameSame

1 additional 1 additional symptomsymptom

SameSame

SameSame

Prevalence:Prevalence:Depression at Late LifeDepression at Late Life

ECA data: 1-month point prevalence is 10.0%ECA data: 1-month point prevalence is 10.0% 2.3% MDD 2.3% MDD 2.3% Dysthymia2.3% Dysthymia 1.5% Minor Depression1.5% Minor Depression 3.9% symptoms3.9% symptoms 20-30% subsyndromal or minor 20-30% subsyndromal or minor depression symptomsdepression symptoms 17-37% in PCCs 17-37% in PCCs Gatz and Smyer (1992) 1-year prevalence of all Gatz and Smyer (1992) 1-year prevalence of all

mental disorders (>64) at 20%-22%.mental disorders (>64) at 20%-22%. Comorbidity of anxiety disorder for an MDD Comorbidity of anxiety disorder for an MDD

presentation is 35%-45%presentation is 35%-45%

Prevalence of Major Depression in Prevalence of Major Depression in Older Adults By SettingOlder Adults By Setting

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Depression DetectionDepression Detectionin Primary Carein Primary Care

Major issue in geriatric primary careMajor issue in geriatric primary care

24 mos. study of HMO enrollees24 mos. study of HMO enrollees22::Mean age 75, 62% womenMean age 75, 62% women

16% prevalence of depression16% prevalence of depression 48% undetected48% undetected Least detected: Men 64-75 and all > 85Least detected: Men 64-75 and all > 85

ABCs of DepressionABCs of Depression

A = AffectA = Affect ApathyApathy

Feelings of worthlessnessFeelings of worthlessness

Sadness, angerSadness, anger

B = BehaviorB = Behavior Sleep, appetiteSleep, appetite

Social functioningSocial functioning

Fatigue, agitationFatigue, agitation

C = CognitionC = Cognition Negative thoughtsNegative thoughts

Lack of concentrationLack of concentration

J Fam Prac 03; S13

Major negative impacts Major negative impacts of depressionof depression

Pre-mature mortalityPre-mature mortality Increased physical disability—one of leading causes Increased physical disability—one of leading causes

in worldin world Link btwn depression and subsequent cognitive Link btwn depression and subsequent cognitive

declinedecline Lower quality of lifeLower quality of life Poorer relations with others/social network/supportPoorer relations with others/social network/support

Depression EtiologyDepression Etiology

BiologicalBiological

Depression Etiology: Depression Etiology: BiologicalBiological

NeurotransmittersNeurotransmittersSerotonin Serotonin

NorepinephrineNorepinephrine

DopamineDopamine

Neurotransmitters and Neurotransmitters and Mood, Cognition, & Mood, Cognition, & BehaviorBehavior

SerotoninSerotonin NorepinephrineNorepinephrine DopamineDopamine

MoodMood MoodMood MoodMood

AnxietyAnxiety AnxietyAnxiety AttentionAttention

ObsessionsObsessions AlertnessAlertness PleasurePleasure

CompulsionsCompulsions EnergyEnergy RewardReward

PanicPanic PainPain MotivationMotivation

WorryWorry ApathyApathy

EnergyEnergy

Neurotransmitter Neurotransmitter FunctionFunction

PathophysiologyPathophysiology

Neurochemical imbalanceNeurochemical imbalance Serotonin Serotonin NorepineprineNorepineprine DopamineDopamine

Results of SSRI Clinical Results of SSRI Clinical TrialsTrials

Effective in older adultsEffective in older adultsbut not that much more than placebo but not that much more than placebo

SSRI limitationsSSRI limitations Use of physically healthy eldersUse of physically healthy elders Major differences are side effects, not Major differences are side effects, not

efficacyefficacy Liver side effects a concern—especiallyLiver side effects a concern—especially

in eldersin elders

SSRIsSSRIs

Celexa 20 mg

www.drugs.com

Paxil 20 mg Paxil CR 25 mg

Prozac 20 mg Zoloft 50 mg

SNRISNRI

Effexor 25 mg

www.drugs.com

Cymbalta 20 mg

Effexor XR 75 mg

SARISARI

Serzone 50 mg

Serzone 100 mg

Trazodone 50 mg

NDRI and NaSSANDRI and NaSSA

Remeron 30 mgWellbutrin 75 mg

Wellbutrin SR 100 mg

Antidepressant Side Antidepressant Side EffectsEffects

TricyclicTricyclicss

SSRISSRI SNRISNRI NDRINDRI SARI/SARI/NaSSANaSSA

MAOIMAOI

Dry mouthDry mouth NervousneNervousnessss

NauseaNausea AgitationAgitation

NervousnessNervousnessDrowsinessDrowsiness WeaknessWeakness

Blurred visionBlurred vision AgitationAgitation Loss of appetiteLoss of appetite

Weight lossWeight lossNauseaNausea Dry mouthDry mouth DizzinessDizziness

ConstipationConstipation InsomniaInsomnia AnxietyAnxiety

NervousnessNervousnessHeadacheHeadache NauseaNausea HeadacheHeadache

Difficulty Difficulty urinatingurinating

HeadacheHeadache HeadacheHeadache

Blurred visionBlurred visionLoss of Loss of appetiteappetite

Weight lossWeight loss

DizzinessDizziness TremblingTrembling

Worsening Worsening glaucomaglaucoma

NauseaNausea Insomnia, bad Insomnia, bad dreams, dreams, tirednesstiredness

InsomniaInsomnia Liver problems Liver problems (serzone)(serzone)

Impaired Impaired thinkingthinking

Dry mouthDry mouth Dry mouthDry mouth

ConstipationConstipationInc blood Inc blood pressurepressure

OrthostasisOrthostasis Food Food interactioninteractionss

TirednessTiredness DiarrheaDiarrhea Sexual Sexual dysfunctiondysfunction

Dry mouthDry mouth

ConstipationConstipationMuscle painMuscle pain

Inc blood Inc blood pressurepressure

Sexual Sexual dysfunctiondysfunction

Inc heart rateInc heart rate

Inc blood Inc blood pressurepressure

SeizuresSeizures Weight gainWeight gain

OrthostasisOrthostasis

Inc heart rateInc heart ratePlatelet Platelet dysfunctiondysfunction

Inc cholesterolInc cholesterol ConstipationConstipation

Increasing reliance on meds Increasing reliance on meds with little evidence to support with little evidence to support itit

Response yes, remit no…Response yes, remit no… Antidepressant use doubled from 1996 Antidepressant use doubled from 1996

(5%) to 10.4% in 2006; switch from 2 or > (5%) to 10.4% in 2006; switch from 2 or > meds increased from 42% in 1997 to meds increased from 42% in 1997 to 60% in 2006; 3 meds from 16% to 33% 60% in 2006; 3 meds from 16% to 33% (Olfason et al., 2006) (Olfason et al., 2006)

Placebo and You:Placebo and You:22ndnd Generation Generation Antidepressants Antidepressants

Acute phase, parallel group, double blinded, placebo controlled with Acute phase, parallel group, double blinded, placebo controlled with random assignment, for 2random assignment, for 2ndnd generation antidepressants not associated generation antidepressants not associated with a med disorder and 60 or >. Cochrane and Medlinewith a med disorder and 60 or >. Cochrane and Medline

10 unique trials with 13 contrasts (N=2377 active drug and 1788 placebo)10 unique trials with 13 contrasts (N=2377 active drug and 1788 placebo) Response rates for Drug = 44.4%Response rates for Drug = 44.4% Response rate for Placebo=34.7%Response rate for Placebo=34.7% 10-12 weeks > 6-8 weeks10-12 weeks > 6-8 weeks Discontinuation rates highest for Drug. Discontinuation rates highest for Drug. 22ndnd generation meds work but effects are modest and vary. generation meds work but effects are modest and vary. For every 100 treated, 8 show a response and 5 remission in excess of For every 100 treated, 8 show a response and 5 remission in excess of

placeboplacebo TCAs perform about the same as 2TCAs perform about the same as 2ndnd generation meds generation meds Placebo rates vary 19-47%. Lots of heterogeneity: Nonspecific effectsPlacebo rates vary 19-47%. Lots of heterogeneity: Nonspecific effects Nelson et al., 2009 Nelson et al., 2009

Vascular Depression Vascular Depression HypothesisHypothesis

Vascular diseases Vascular diseases ““can predispose, can predispose, precipitate, or perpetuate a depressive precipitate, or perpetuate a depressive syndrome in many elderly patientssyndrome in many elderly patients””

AlexopoulosAlexopoulos99

Vascular disease can cause Vascular disease can cause microvascular brain tissue damage in microvascular brain tissue damage in frontal/subcortical areas of brainfrontal/subcortical areas of brain

DiabetesDiabetes Atrial FibrillationAtrial Fibrillation HypertensionHypertension SmokingSmoking ObesityObesity High cholesterolHigh cholesterol

Development of Development of Depressive DisordersDepressive Disorders

Hypertension, Diabetes, CAD, StrokeHypertension, Diabetes, CAD, Stroke Genetics, Neurological Disease, Stroke, Etc.Genetics, Neurological Disease, Stroke, Etc.

Frontal Striatal Lesions

Life Events

Vulnerability To Depression

Depressive Disorders

Social Support

Model of Risk Factors That Lead to Depressive Disorders

Adapted from Krishnan KRR. Biol Psychiatry. 2002; 52: 185-192

Vascular Burden StudyVascular Burden Study(Mast, MacNeill & Lichtenberg, Amer J Geriat (Mast, MacNeill & Lichtenberg, Amer J Geriat Psychiatry, 2004)Psychiatry, 2004)

SampleSample 680 consecutively admitted geriatric 680 consecutively admitted geriatric

rehab patients (age 60+)rehab patients (age 60+)

Separated into 3 groups:Separated into 3 groups: Stroke:Stroke: Pts with evidence of stroke, n=205 Pts with evidence of stroke, n=205 CVRF:CVRF: Pts with CVRFs but no stroke, n=353 Pts with CVRFs but no stroke, n=353 Non-vascular:Non-vascular: Pts with no stroke or CVRFs, Pts with no stroke or CVRFs,

n=122n=122

HypothesesHypotheses

1.1. Prevalence of depression will be Prevalence of depression will be greater among patients with vascular greater among patients with vascular disease (stroke and CVRFs) than disease (stroke and CVRFs) than among among non-vascular medical patients.non-vascular medical patients.

2.2. Prevalence will not differ between Prevalence will not differ between stroke and CVRF groups.stroke and CVRF groups.

Results H1Results H1

Prevalence and severity of depression did not Prevalence and severity of depression did not differ significantly among the 3 patient differ significantly among the 3 patient groups.groups.  Non-vascular CVRF Stroke

DepressionGDS>10

30.3% 35.1% 36.4%

Mild depressionGDS 11-15

18.0% 23.2% 24.1%

Severe (GDS 16+)depression

12.3% 11.9% 12.3%

Results H1:Vascular BurdenResults H1:Vascular Burden

Presence of 2+ CVRFs was associated with Presence of 2+ CVRFs was associated with increased prevalence of depression in the increased prevalence of depression in the non-stroke group.non-stroke group.  No

CVRFsOne CVRF

Two or more CVRFs

Prevalence of depressionCVRF group

0/0 78/254 (30.7%)

46/99 (46.9%)

Prevalence of depressionStroke group

8/28 (28.6%)

39/97 (40.2%)

24/70 (34.3%)

Conclusions from StudyConclusions from Study

Concept of vascular burdenConcept of vascular burden Replication in sample of 600 community Replication in sample of 600 community

dwelling elders dwelling elders (Yochim, Mast & Lichtenberg 2003)(Yochim, Mast & Lichtenberg 2003)

Case Study—Vascular Case Study—Vascular DepressionDepression

78 YO WM recently retired; Diabetes, 78 YO WM recently retired; Diabetes, heart diseaseheart disease

Depression evident but physical Depression evident but physical limitations keep him from travelling the limitations keep him from travelling the way he wants toway he wants to

At age 80 begins falling, exhaustion, At age 80 begins falling, exhaustion, lower energy expenditure (frailty)lower energy expenditure (frailty)

Falls and dies at age 82Falls and dies at age 82

Activity Limitation TheoryActivity Limitation TheoryChange in activities mediates Change in activities mediates relationship between medical relationship between medical condition and depression.condition and depression.

Illness,Pain

ActivityRestriction

Depression

Depression & Function:Depression & Function:Exercise InterventionsExercise Interventions

InterventionsInterventions Weight-lifting 20 wks v lectures 10 wksWeight-lifting 20 wks v lectures 10 wks2020

13 major & 17 minor depressives, mean age 7113 major & 17 minor depressives, mean age 71 Follow-up at 20 weeks and 26 months Follow-up at 20 weeks and 26 months

Aerobics v resistance v education, 3 mosAerobics v resistance v education, 3 mos2121

439 knee osteoarthritics, mean age 69; 22% scored 439 knee osteoarthritics, mean age 69; 22% scored above BDI cutoffabove BDI cutoff

Follow-up at 3 months and 18 monthsFollow-up at 3 months and 18 months

Depression & Function:Depression & Function:Exercise InterventionsExercise Interventions

ResultsResults Both aerobic and resistance exercise reduced Both aerobic and resistance exercise reduced

depression, disability, paindepression, disability, pain Exercise more effective than educationExercise more effective than education Compliance best for low depression groupsCompliance best for low depression groups Adherence to exercise declined over timeAdherence to exercise declined over time

Case StudyCase Study 81 year old woman—healthy until enters 81 year old woman—healthy until enters

hospital for acute kidney failurehospital for acute kidney failure Dx. Multiple MyelomaDx. Multiple Myeloma ChemotherapyChemotherapy Depression evidentDepression evident Treatment works and allows her to return Treatment works and allows her to return

to gardening and hikingto gardening and hiking Depression disappearsDepression disappears

Lewinsohnian Model of Lewinsohnian Model of DepressionDepression

Feelings and behavior are linkedFeelings and behavior are linked

Three decades of research support the Three decades of research support the behavioral model for persons including:behavioral model for persons including:

Young, middle-aged, & older adultsYoung, middle-aged, & older adults CaregiversCaregivers Demented eldersDemented elders

Behavioral Treatment of Behavioral Treatment of DepressionDepression

RationaleRationale

GoalGoal

TechniquesTechniques

WhatWhat the person does is the person does is related to related to howhow s/he feels s/he feels

To increase positive events To increase positive events and decrease negative onesand decrease negative ones

Relaxation, mood monitoring & Relaxation, mood monitoring & graphinggraphing

The Retirement The Retirement Research Foundation-Research Foundation-Institute of Institute of Gerontology ProjectGerontology Project

Integrating Mental Health in Occupational Integrating Mental Health in Occupational Therapy Practice with Older AdultsTherapy Practice with Older Adults

Cathy Lysack & Peter Lichtenberg (PIs), plus Cathy Lysack & Peter Lichtenberg (PIs), plus team of WSU experts in aging, and team of WSU experts in aging, and community partners.community partners.

The “DVD Box Set”The “DVD Box Set”

1. Introduction, Aging and Mental Health1. Introduction, Aging and Mental Health2. Understanding and Treating Depression2. Understanding and Treating Depression3. Medications for Treatment of Depression3. Medications for Treatment of Depression4. Family Caregiving4. Family Caregiving5. Falls, Balance and Exercise5. Falls, Balance and Exercise6. Driving Rehabilitation and Community Mobility6. Driving Rehabilitation and Community Mobility

Plus: Plus: - A CD with assessments, powerpoint slides, and - A CD with assessments, powerpoint slides, and

references/resources in pdf format.references/resources in pdf format.- A DVD with video of full patient assessments.- A DVD with video of full patient assessments.

Behavioral ActivationBehavioral Activation

Combines meaningful activity and Combines meaningful activity and pleasant eventspleasant events

Teaches patients that mood is related to Teaches patients that mood is related to what they are doingwhat they are doing

Does not require a big time investment to Does not require a big time investment to integrate into treatmentintegrate into treatment

Elements of Behavioral Elements of Behavioral ActivationActivation

Mood ratingsMood ratings Rationale Rationale Pleasant event BrainstormingPleasant event Brainstorming Identify barriers to implementationIdentify barriers to implementation Commit to making a changeCommit to making a change

Attitudes about talking with Attitudes about talking with older adult clients about moodolder adult clients about mood

Older adults are resistant to talking about their mood or Older adults are resistant to talking about their mood or sadness?sadness? Pre Post (True response)Pre Post (True response) 53% 16%* (30 OTs in training group)53% 16%* (30 OTs in training group) 45% (112 OTs in one day conference45% (112 OTs in one day conference

Combined data: (144 OTs)Combined data: (144 OTs) 40% did not know diagnostic criteria for depression40% did not know diagnostic criteria for depression 33% overestimated amount of depression in population they 33% overestimated amount of depression in population they

work withwork with

**These were statistically significant changes p<.05These were statistically significant changes p<.05

 Table 1 Demographic information N All Patients

Age (years) 384 80.1

Gender (female) 384 69.2

Heart Disease 384 49.2

Diabetes Mellitus 384 29.2

Dementia 384 19.0

CVA 384 11.8

Depression 384 10.5

Medications for depression or anxiety 384  19.2

Performance Indicator Descriptive Performance Indicator Descriptive DataData

High levels of comorbidity

 Table 2: Performance IndicatorsPre-training

(n = 199)Post-training

(n = 184)

Mention of mood or depression 66.3 77.7**

Depression screening 3.0 25.3**

Reporting mood to treatment team 25.5 31.5*

Referral to other health professional 7.5 13.7**

Mention of pleasant events or behavioral activation 9.0 16.1**

Report mood ratings of patient 6.0 11.8**

Identify pleasant events 5.6 15.0**

Get commitment from patient to attempt events 4.1 8.6**

Mention of cognitive functioning 70.0 88.8**

Cognitive screening 11.1 39.0**

Report cognitive functioning to treatment team 24.5 34.3**

Referral to other health professional because of cognitive functioning 5.6 6.1

Mention of caregiver 46.7 38.8*

Report on coping/stress of caregiver 2.6 5.9**

Referral of caregiver to sources of help  7.3 12.0 *

*=p<.05; **=p<.01

Performance Indicator Change Data

Case StudyCase Study 80 YO live alone woman, falls fractures hip80 YO live alone woman, falls fractures hip OT administers MLDT—mild cognition OT administers MLDT—mild cognition

problems, mild-moderate depressive sx.problems, mild-moderate depressive sx. Interviews woman about enjoyable activitiesInterviews woman about enjoyable activities Discovers woman loves to be read to and Discovers woman loves to be read to and

discuss poetrydiscuss poetry Depression recedes and woman makes Depression recedes and woman makes

gains and can return homegains and can return home

Worden’s Four Tasks of Worden’s Four Tasks of GriefGrief

1.1. Accept the reality of the lossAccept the reality of the loss

2.2. Work through the pain of griefWork through the pain of grief

3.3. Adjust to the environment Adjust to the environment in which the deceased is missingin which the deceased is missing

4.4. Emotionally relocate the deceasedEmotionally relocate the deceasedand move on with lifeand move on with life

BereavementBereavement

Bereavement: 800,000 people/year bereavement (20% MDD)Bereavement: 800,000 people/year bereavement (20% MDD) Key: What is depression; what is abnormal grief; and what is OK?Key: What is depression; what is abnormal grief; and what is OK?

Complicated Bereavement: V Code Complicated Bereavement: V Code Yearning for, preoccupation for, searching for, excessive Yearning for, preoccupation for, searching for, excessive

crying, disbelief regarding death and non-acceptance of death, as crying, disbelief regarding death and non-acceptance of death, as well as social isolation. Global functioning suffers. well as social isolation. Global functioning suffers.

Must generally return to pre-loss activities Must generally return to pre-loss activities Assess for depression and the above variablesAssess for depression and the above variables Texas Revised Inventory of Grief (26 items, 0-65) Texas Revised Inventory of Grief (26 items, 0-65) Inventory of Complicated Grief (18 items and score 25 or >) Inventory of Complicated Grief (18 items and score 25 or >)

Grief and DepressionGrief and Depression

Depression as a typical complication of griefDepression as a typical complication of grief2929

13.9% of newly bereaved had depressive 13.9% of newly bereaved had depressive symptoms after 2 years v 4% of married personssymptoms after 2 years v 4% of married persons

Percent of newly bereaved with depressive Percent of newly bereaved with depressive symptoms by month (no gender difference):symptoms by month (no gender difference):

33%

12%14%0%

20%

40%

Month 1 Month 12 Month 24

Early Loss and Late Life Early Loss and Late Life Expression in Poor EldersExpression in Poor Elders

SubjectsSubjects

FindingsFindings

109 older-old African Americans109 older-old African Americans

51% of respondents lost parent51% of respondents lost parentto death or desertion by age 16to death or desertion by age 16

Those with parental loss had:Those with parental loss had: Decreased education, social Decreased education, social

resources, and family satisfactionresources, and family satisfaction Increased depressive symptomsIncreased depressive symptoms

Case StudyCase Study 78YO woman loses husband and leg (below 78YO woman loses husband and leg (below

knee) in same month (diabetes)knee) in same month (diabetes) Enters psychotherapyEnters psychotherapy Excessive guilt, searching, waiting for husband Excessive guilt, searching, waiting for husband

to return—for monthsto return—for months Works through issues surrounding father’s Works through issues surrounding father’s

deathdeath Begins to get active and convinces adult Begins to get active and convinces adult

children to get jobs and help care for herchildren to get jobs and help care for her

Assessment, referral and Assessment, referral and “how to”“how to”

Screening for depression is importantScreening for depression is important Communicating with the clinical team is Communicating with the clinical team is

keykey Understanding basic approaches to Understanding basic approaches to

intervention is helpfulintervention is helpful

MLDT Emotional Status MLDT Emotional Status Measure: GDS-3Measure: GDS-3

Do you feel pretty Do you feel pretty worthless worthless the way the way you are now?you are now?

Do you feel that your life is Do you feel that your life is empty?empty?

Do you often feel downhearted andDo you often feel downhearted and blueblue??

MLDT GDS-3 Decision MakingMLDT GDS-3 Decision Making

If just one GDS-3 item is answeredIf just one GDS-3 item is answered

YES,YES,

A complete evaluation forA complete evaluation for

depression is recommendeddepression is recommended

Items from the Geriatric Items from the Geriatric Depression Scale: Items 1-5Depression Scale: Items 1-5

1.1. Are you basically satisfied with your life?Are you basically satisfied with your life?2.2. Have you dropped many of your activities and Have you dropped many of your activities and

interests?interests?3.3. Do you feel that your life is empty?Do you feel that your life is empty?4.4. Do you often get bored?Do you often get bored?5.5. Are you in good spirits most of the time?Are you in good spirits most of the time?

Items from the Geriatric Items from the Geriatric Depression Scale: Items 6-Depression Scale: Items 6-1010

6.6. Are you afraid that something bad is going to happen Are you afraid that something bad is going to happen to you?to you?

7.7. Do you feel happy most of the time?Do you feel happy most of the time?8.8. Do you often feel helpless?Do you often feel helpless?9.9. Do you prefer to stay home rather than going out and Do you prefer to stay home rather than going out and

doing something?doing something?10.10. Do you feel you have more problems with memory Do you feel you have more problems with memory

than most?than most?

Items from the Geriatric Items from the Geriatric Depression Scale: Items 11-15Depression Scale: Items 11-15

11.11. Do you think it is wonderful to be alive?Do you think it is wonderful to be alive?12.12. Do you feel pretty worthless the way you are now?Do you feel pretty worthless the way you are now?13.13. Do you feel full of energy?Do you feel full of energy?14.14. Do you feel your situation is hopeless?Do you feel your situation is hopeless?15.15. Do you think most people are better off than you are?Do you think most people are better off than you are?

GDS score greater than or equal to 5 raises suspicion as to depressionGDS score greater than or equal to 5 raises suspicion as to depression

Communicating results of Communicating results of screeningscreening

Integrated Care and its role in treating Integrated Care and its role in treating older adultsolder adults

Integrated CareIntegrated Care

Interdisciplinary Health Care that Interdisciplinary Health Care that emphasizes a high degree of emphasizes a high degree of collaboration in:collaboration in:

Patient evaluationPatient evaluation Treatment planningTreatment planning Outcome evaluationOutcome evaluation

2007 American Psychological Association Presidential Task Force

Individual Assessments

Shared information Team goals

Intervention plan & strategies

Individual Delivery of Care

Practice ModelsPractice Models

Fully Integrated Care - part of treatment Fully Integrated Care - part of treatment team coordinated behavioral and medical team coordinated behavioral and medical care (i.e. response to illness, Rx develop/ care (i.e. response to illness, Rx develop/ situational issues, management chronic)situational issues, management chronic)

Consultant Model – evaluation & physician Consultant Model – evaluation & physician consultation, brief interventionsconsultation, brief interventions

Co-Location Model- essentially specialty Co-Location Model- essentially specialty mental health care in same location as mental health care in same location as primary careprimary care

Case for Integrated CareCase for Integrated Care- Supported research evaluations- integrated care more Supported research evaluations- integrated care more

sessions, than enhanced referral (Bartels et al, 2004) sessions, than enhanced referral (Bartels et al, 2004)

- Evidence # studies of reduced symptoms, improved life Evidence # studies of reduced symptoms, improved life quality (see Aredin, 2003; Skultety & Zeiss, 2006)quality (see Aredin, 2003; Skultety & Zeiss, 2006)

- Reduced stigma and increased knowledge re behavioral Reduced stigma and increased knowledge re behavioral health health