Common Mental Disorders Depression - New Zealand Doctor

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Common mental disorders Few studies have addressed the identification of common mental disorders other than depression among older people in primary care. Two studies evaluated the use of assessment tools for a range of mental disorders in a primary care population restricted to older adults. Neither the Primary Care Evaluation of Mental Disorders (PRIME-MD) nor the Pain Disability Index (PDI-29) accurately identified mental disorders among frail older people receiving home care nursing services, 512 and neither the General Health Questionnaire (GHQ-28) nor the MMSE performed well among older patients at a GP practice. 513,514 Depression and dysthymia There was evidence that the GDS 514-517 is valid for detecting depression among older people. A shortened version of this instrument, the Geriatric Depression Scale, Short Form (GDS-15) appears to be of comparable accuracy to the longer version for detecting depression. 514,516,517 The Patient Health Questionnaire for depression is also widely used as a case-finding tool for depression in this population. It has been well-validated in a general adult population for case-finding, and in an older adult population for measuring response to treatment for depression and dysthymia. 321 Several studies have also found the Centre for Epidemiological Studies Depression Scale (CES-D) valid for detecting depression among older people, 514,516,518-520 though its accuracy for routine use in primary care populations has been questioned 521 and it was found poor at detecting dysthymia. 518 The Hospital Anxiety and Depression Scale (HADS) was not found to be valid for use in older people. 513 8.3 Assessing an older adult with cognitive impairment The patient or an informant may report cognitive symptoms, such as poor concentration, confusion or memory complaints. These can be the presenting features of depression, but the practitioner should also be alert for the possibility of early dementia. The relationship between dementia and depression is complex: they are often comorbid, and late-onset depression is a risk factor for dementia. 522 A recent US Preventive Services Task Force (USPTF) systematic review 523 noted that several instruments are valid for identifying cognitive impairment in primary care and nursing home populations, but that no single instrument is suitable for all situations. The MMSE is appropriate for assessing moderate cognitive impairment, but has limited sensitivity in highly functioning individuals, takes 7–10 minutes and has copyright restrictions. 523 The USPTF review proposes a number of options (see Appendix H: Assessing for Cognitive Impairment in Older Adults): a clock drawing test or the 112 Identification of Common Mental Disorders and Management of Depression in Primary Care
Chapter 8 Special issues: older adults/koroua/kuia Memory Impairment Screen are useful if time is restricted, with the proviso that these tools have limited sensitivity, especially for mild forms of impairment. 523 A study in a residential care setting found the GDS valid for identifying depression in residents with an MMSE score of 15 or more, 524 but it may not be practicable if cognitive impairment is marked. 525 An older adult presenting with possible cognitive impairment should be assessed for both dementia and depression using tools to assess cognitive function, 522 such as the MMSE and/or clock drawing test, as well as tools for depression such as the GDS or PHQ-9. 523 It is also considered by the GDT to be good practice to undertake a relevant physical examination, consider adverse drug effects, and undertake complete blood count and thyroid function tests when older adults present with depressive symptoms. Further, the practitioner should also consider checking creatinine and B12 and folate levels. Where there is a rapid change in cognitive status in an older person, delirium should be excluded by clinical examination. 526 This applies particularly in residential care, where delirium is relatively common. 527 Delirium is characterised by a disturbance of consciousness, usually fluctuating, and a change in cognition developing over a short period of time. 243 Australian guidelines on the assessment and treatment of delirium (Australian Health Ministers’ Advisory Council) can be found at http://www.health.vic. gov.au/acute-agedcare/ Where the practitioner suspects depression but some doubt remains, in the opinion of the GDT, it is reasonable to initiate antidepressant treatment and monitor the person’s response by clinical assessment and optional use of a monitoring tool, such as the PHQ-9. 320 However, antidepressant medication should not be continued in a confused older person unless there is clear clinical evidence of benefit. 8.4 Management of depression Approach to intervention In most respects, older adults/koroua/kuia with depression should be managed in a similar way to other adults/pakeke, and chronological age should not be a bar to specific therapies. 65 The evidence relating to specific interventions is presented in detail in later sections of this chapter. The available evidence supports offering older people/koroua/kuia the same range of psychological therapies as younger people. 65 Similarly, in terms of pharmacological therapy a SSRI is suitable as first-line antidepressant therapy in older people/koroua/kuia, as for other adults/pakeke. 65 Identification of Common Mental Disorders and Management of Depression in Primary Care 113
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Identification of Common Mental Dis
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Statement of intent Evidence-based
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Endorsements Te Ao Maramatanga New
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3.6 Clinical features of common men
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List of figures 3.1 When to refer a
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About the guideline Foreword The Ne
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About the guideline Guideline devel
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About the guideline Paediatric subg
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About the guideline Royal New Zeala
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Algorithm 1 Management of depressio
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Algorithm 2a Management of severe d
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Algorithm 2c Management of mild dep
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• limited access to psychiatrists
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Asian peoples About 7% of the New Z
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12-month period amongst adults atte
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Table 1.2 Prevalence of common ment
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1.4 Etiology of common mental disor
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The ‘hopelessness theory’ 94 co
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Sexuality Data from the Christchurc
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Since those who are affected by sui
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2.3 Managing depression: the steppe
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to informed consent. 152 There is a
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3 Recognition and assessment of com
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Chapter 3 Recognition and assessmen
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Good practice points Management of
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Box 4.1 Whänau Ora The concept of
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If the young person/rangatahi/tamar
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Exercise There was insufficient evi
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at any timepoint. Treatment as usua
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5 Recognition and assessment of com
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Page 145 and 146: 9 Models of care 9.1 Introduction V
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References 143. Dejesus RS, Vickers
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References 179. Shaffer D, Scott M,
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References 215. Garralda ME, Bowman
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References 249. Zwaanswijk M, Verha
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References 283. Linde K, Berner M,
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References 318. Henkel V, Mergl R,
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References 353. Rush AJ. STAR*D: wh
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References 386. Ward E, King M, Llo
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References 417. Kirsch I, Deacon BJ
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References 451. Zigmond AS, Snaith
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References 486. Appleby L, Warner R
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References 520. Irwin M, Artin KH,
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References 557. Agnew F, Pulotu-End
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Common Mental Disorders Depression - New Zealand Doctor

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