Depression and Anxiety

Depression is defined as a mood disorder characterized by a persistently depressed mood or loss of interest in activities which results in significant impairment in activities of daily living. Depression is a biological and psychological occurrence and is associated with increased morbidity and mortality. Depression can impact quality of life and can lead to suicide. Mood disorders are very common in patients with advanced life-threatening diseases and who have experienced recent traumatic life events such as the death of a spouse or family member. It is important to rule out any underlying medical cause, such as hypothyroidism, or medication-induced causes of depression (such as beta blocker usage, for example). Pseudodementia is a common feature of depression in geriatric patients; patients with depression will often answer “I don’t know” to questions without attempting to answer them despite no underlying memory loss.

The acronym SIGECAPS is useful when assessing a patient for depression. The mnemonic stands for the following:

• S = sleep changes
• I = interest loss (anhedonia)
• G = guilt
• E = energy lacking
• C = changes in concentration/memory
• A = appetite loss
• P = psychomotor agitation (i.e. fidgeting)
• S = suicidal ideation (desire to harm self)

In addition, should also inquire about (i.e. bipolar disorder):

• recent increased alcohol or drug use
• mania (extremely elevated and excitable mood)
• delusions (belief held despite evidence to contrary)
• auditory or visual hallucinations

As discussed in Chapter 3, a standardized depression screening needs to be performed as part of a depression assessment. Is the patient on an antidepressant? Does psychiatry or psychology follow the patient? If dementia is present, are there other behavior disturbances including depression? Has there been an attempt to perform a gradual dose reduction of any psychotropic medications?

Depression Screening: A standardized depression screening needs to be performed for a functional assessment. Is the patient on an antidepressant? Does psychiatry or psychology follow the patient? If dementia is present, are there other behavior disturbances including depression? Has there been an attempt to perform a gradual dose reduction of any psychotropic medications? A useful screening tool is the Patient Health Questionnaire-2 (PHQ-2). If the score on the PHQ-2 is 3 or greater, the Patient Health Questionnaire-9 (PHQ-9) should be completed. A screening test is offered to asymptomatic people who may or may not have a disease. A diagnostic test is ordered when a patient shows symptoms of a disease and additional evaluation is needed, or if a screening test is positive.

Once a diagnosis of depression (or, more appropriate major depressive disorder) is made, a treatment plan should be initiated including:

• Lab studies: TSH, B12, folate, RPR
• Treat with a selective serotonin re-uptake inhibitor (SSRI); can take up to 6 weeks to be fully effective
• Close follow up – 1-2 weeks as outpatient with PCP/geriatric psychiatrist
• Support groups for bereavement should be considered if there was a recent death of a close family member or friend

Psychotherapy has been shown to be effective for individuals who do not respond well to medications. Psychotherapy and medications have been shown to be more effective when used together than either used separately.

Depression in the elderly can be associated with loss in social roles, loss in autonomy or independence, loss of friends or relatives, loss of health and increase in sickness, financial hardships, and loss of cognitive or physical function. One should differentiate depression from major depressive disorder versus other causes such as adjustment disorder, bereavement, grieving, and dysthymia. Depression in the elderly is more likely to have a cognitive component, be associated with neurological findings, and have abnormal brain findings and is less likely to be associated with family history, not remit if associated with executive dysfunction, and likely to not stay in remission. Major depression is less likely if there is a situational component, if the symptoms are of a short duration, and if symptoms can be accounted for by other illness, dementia, or substance abuse. Alcohol does not cause clinical depression, though when intoxication is present, alcohol acts as a central nervous system (CNS) depressant. Alcohol dependence or abuse is often co-morbid with subclinical or clinical depression. Patients are unlikely to disclose alcohol misuse even if asked. If depression (or anxiety) did not precede alcoholism, medications are unlikely to help. Chapter 10 discusses alcohol abuse in more detail.

A grief reaction or bereavement is a normal reaction to a loss. It is normal to feel numbness, sorrow, or guilt, and these feelings lead to acceptance and moving forward. It is normal to see, feel the presence of, or hear a deceased friend or family member. A grief reaction is complicated if the symptom severity is analogous to clinical depression and includes thought of hurting one's self or is associated with weight loss. Complicated grief reactions require antidepressant treatments. Benzodiazepines can prolong normal or complicated grief and use should be avoided or minimized whenever possible.

Anxiety is defined as an intense, excessive, and persistent worry and fear about everyday situations. It is associated with physiological changes such as tachycardia, rapid and shallow breathing (hyperventilation), sweating, and fatigue. Anxiety is a normal emotional state. Anxiety is the most common psychiatric condition. Anxiety, like depression, can present clinically or sub-clinically. Anxiety disorders often lead to functional impairment. Anxiety can be screened for using GAD-7 (Generalized Anxiety Disorder 7-item scale). Anxiety disorders include generalized anxiety disorder, social anxiety disorder, specific phobias, panic disorder, and post-traumatic stress disorder. Former members of the military who served in active combat are quite likely to experience post-traumatic stress disorder.

Specific diagnostic criteria can be found in the Diagnostic and Statistical Manual of Mental Disorders (current edition is the 5th edition) and will not be discussed here. For the purposes of this discussion, "depression" and “anxiety” are an umbrella terms used to describe symptoms. There is significant overlap in the diagnostic criteria and treatment methods (such as SSRIs and psychotherapy) are very similar.

Comparison of Dementia, Delirium, and Depression

Dementia, delirium, and depression may seem to have similar presentations. A comparison of dementia, delirium, and depression can help narrow down the primary diagnosis, though two or all three may be present at once:

Review Questions

1. A 73-year-old female presents to her physician complaining of fatigue. She notes her husband passed away seven months ago and she has felt this way since his passing. After answering several questions with “I don’t know”, her physician decides to administer a Montreal Cognitive Assessment. She scores a 29/30, due to identifying the rhinoceros as a hippopotamus. Which of the following co-morbid psychiatric diagnoses is likely present?

A. Generalized anxiety disorder
B. Pseudodementia
C. Hypomania
D. Post-traumatic stress disorder
E. Mixed Alzheimer’s disease and vascular dementia with behavior disturbances

2. Which of the following non-pharmacological approaches should be tried for this patient before trying another medication?

A. Counseling/Therapy
B. Psychiatry referral
C. Electroconvulsive therapy
D. Physical therapy
E. Watchful waiting

3. The primary care physician decides to perform a Montreal Cognitive Assessment (MOCA). The patient successfully completes the trails drawing. He is unable to draw a cube. He is able to draw a clock with the correct contour, place the numbers correctly on the clock face, and draw the correct hands for the time "ten past eleven". He is able to name all three animals correctly. He is able to register and recall the five objects (face, velvet, church, daisy, and red). He is able to perform both the forward and backward digit span. He correctly taps his hand during the list of letters for each reading of the letter A. When performing serial 7s, he answers the following: 93, 86, 78, 71, 64. He is able to correctly repeat both sentences. He is only able to provide 3 out of the required 11 words that start with the letter F. When asked how a train and a bicycle are similar, he answers "they are both methods of transportation." When asked how watch and a ruler are similar, he answers "a watch tells time and a ruler measures distance". He is able to recall all five of the words provided previously. He is able to state the date, month, year, day, place, and city correctly. Which of the following is correct concerning his performance?

A. His score is 24/30.
B. His score is indicative of someone who may have cognitive impairment.
C. His score is diagnostic of a patient with Alzheimer's disease.
D. His assessment does not indicate that he has cognitive impairment.
E. More information is needed to draw a conclusion about the significance of his score.

Answers to Review Questions

1. B
2. A
3. D