Depression in later life PDF
Preview Depression in later life
O P L OxfOrd Psychiatry Library Depression in Later Life O P L OxfOrd Psychiatry Library Depression in Later Life Second Edition Robert C. Baldwin Consultant Old Age Psychiatrist and Honorary Professor of Psychiatry, Manchester Mental Health and Social Care Trust, Park House North Manchester General Hospital, Manchester, UK 1 3 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press 204 The moral rights of the authors have been asserted Impression: All rights reserved. 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Contents Symbols and abbreviations vii Introduction 2 Classification and epidemiology 3 3 Clinical features 4 Self-harm and suicide 2 5 Aetiology 25 6 Medical co-morbidity and depression in later life 37 7 Assessment and management 43 8 Depression in primary care 65 v 9 Prognosis 75 0 Prevention 79 Resources 83 Appendix The sample rating scales 89 Appendix 2 The geriatric depression scale 9 Appendix 3 The patient health questionnaire (PHQ-9) 93 Appendix 4 The World Health Organization well-being index 95 Appendix 5 The Hamilton rating scale for depression 97 Appendix 6 Montgomery and Äsberg depression rating scale 0 Appendix 7 Cornell scale for depression in dementia 05 Index 07 Symbols and Abbreviations α alpha ≥ equal to/greater than > greater than < less than % per cent ACE angiotensin-converting enzyme ADH antidiuretic hormone AIDS acquired immunodeficiency syndrome BABCP British Association of Behavioural and Cognitive Psychotherapies BAP British Association of Psychopharmacology bd bis in die (twice daily) CANMAT Canadian Network for Mood and Anxiety Treatments vii CBT cognitive behavioural therapy CG clinical guideline CHD coronary heart disease CNS central nervous system COPD chronic obstructive pulmonary disease CRF corticotropin-releasing factor CT computerized tomography DALY disability adjusted life year DEDS depression-executive dysfunction syndrome DSM Diagnostic and Statistical Manual ECG electrocardiogram ECT electroconvulsive treatment EEG electroencephalogram FSC fronto-striatal circuit GDS geriatric depression scale GHRF growth hormone-releasing factor GI gastrointestinal GP general practitioner HADS hospital anxiety and depression scale HDRS Hamilton depression rating scale HIV human immunodeficiency virus HPA hypothalamic-pituitary-adrenal S 5HT 5-hydroxytryptamine n o IADH inappropriate antidiuretic hormone ti a IAPT Improving Access to Psychological Therapies vi re ICD International Classification of Diseases b ab IPT interpersonal therapy d n kg kilogram a S L litre l o b lb pound m y MADRAS Montgomery-Äsberg depression rating scale S MAO-A monoamine oxidase A MAOI monoamine oxidase inhibitor MCI mild cognitive impairment mg milligram MHRA Medicines and Health products Regulatory Authority mmol millimole MoCA Montreal cognitive assessment viii MRI magnetic resonance imaging mRNA messenger ribonucleic acid ms millisecond NARI noradrenaline reuptake inihibitor NASSa noradrenaline and specific serotonin antidepressant NICE National Institute for Health and Care Excellence NSAID non-steroidal anti-inflammatory drug OMC orientation-memory-concentration PET positron emission tomography PHQ patient health questionnaire PST problem-solving treatment rCBF regional cerebral blood flow RCT randomized controlled trial rTMS repetitive transcranial magnetic stimulation SNRI serotonin/noradrenaline reuptake inhibitor SPECT single photon emission computerized tomography SSRI selective serotonin reuptake inhibitor TCA tricyclic antidepressant tds ter die sumendum (three times daily) TRH thyrotropin-releasing hormone UK United Kingdom US United States WML white matter lesion Chapter Introduction Lilly is 88, and her daily requests to be taken to see a doctor about her ‘stomach wind’ are wearing out her 60-year-old recently retired son, who is finding himself waking early in the morning with worry. John is 72 and devastated at the unexpected loss of his wife just before their 50th wedding anniversary. His family and friends are sympathetic, but, 6 months on, he is fretful, miserable and feels he will burden people by talking about it. Wong-Chai has had arthritis for the last 20 of her 75 years. Once proud and indomitable, she has lately found her joint pain unbearable and has wondered about ‘going to sleep and never waking up’. Raj is 85 and lately finds himself unable to concen- trate, so much so that he keeps losing things. His sleep and appetite are poor, and he has stopped going to the local day care centre. His doctor said it is his age, but his family fear the start of dementia. Jack, aged 76, has turned up in the emergency department, 1 feeling nauseous and dizzy. Recently, he has lost weight and feels very tired, lonely, and miserable. He admits to taking four sleeping tablets last night ‘just to get a bit of peace for the night’. The doctor tells him not to worry—that dose will not harm him. A week later, he is back with a serious paracetamol overdose. What links these vignettes is depressive disorder. Although dementia is regarded as the typical mental health condition of later life, in fact, depression is more common. Often overlooked, depression is a very serious problem in later life. It reduces the qual- ity of life and adds to the disability associated with all the major medical illnesses that afflict older people. It often complicates the course of dementia as well as being a risk factor for it. Epitomized by the statement ‘Who would not be depressed at that age?’, it is tempt- ing, but completely inaccurate, to assume that depression must be the norm in later life. In the main, health professionals see older people who are most susceptible to depression, those with frailty and chronic medical illnesses. The trap is to ‘normalize’ depression in ill older people, with the result that major depression can be overlooked. In reality, many older people live contentedly, with their quality of life improving with age (Netuveli et al. 2006). Of those who do become depressed, many have a diagnos- able mental health disorder, and there are interventions which can help significantly. There are already textbooks on depression; why then is one needed specifically for depression in later life? First, there is the self-evident fact that the world’s population is fast growing older. This brings with it increasing rates of many of the common health problems, including depression. Second, although depression in later life shares many of the core features with depression at other times, there are some important differ- ences. Third, late-life depression frequently occurs in the setting of significant medical morbidity which complicates both the diagnosis and treatment. Last, depression in this
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