Depression in an older adult

67 yo F, retired university lecturerPC/HPC:• 6 wk gradually worsening depressed mood,

impaired sleep, anorexia, anergia, poor concentration, quasi-suicidal thoughts.

• PMHx– Hashimoto’s thyroiditis 1980’s– Last few years of working only part time due to chronic fatigue.

• PFHx– Father stoker, died in 70’s– Mother alzheimer’s, still alive 98

• Meds– Thyroxine 100 mcg OD

• Lifestyle– Lifelong smoker (unsure how much)– 14 units alcohol/week– Married for 3 years in her 30’s, no close relationships since, no children– Came to Aus (from US) with hope of improvement in quality of life (doesn’t

mention when she came to Aus, perhaps recently).

• MSE– Appearance and behaviour: Mild psychomotor retardation

evident– Speech: mild speech latency– Mood: Sombre– Affect: Reduced affective reactivity– Thought: Range of negative cognitions– Perception: No psychotic symptoms present.– Cognitive function: MMSE 29/30– Insight: Geriatric depression scale 12/15

• Physical exam unremarkable

Assume she is suffering from an episode of major depression.

What additional information do you need?

• Why has she come in now?• Any secondary co-morbidities.• Want to try to determine which type of

depression it is.• More questions concerning the chronic

fatigue.

What investigations would you order and why?

• Exclude organic causes of depression.• General check up of her health.• Exclude substance abuse where possible.

Neuro – cerebrovascular disease, cerebral tumour, multiple sclerosis, Parkinson’s disease, Huntington’s disease, Alzheimer’s disease, epilepsy

Endocrine – hypothyroidism, hyperthyroidism, Cushing’s syndrome, Addison’s disease, hyperparathyroidism

Malignant diseaseInfections – infectious mononucleosis, herpes simplex,

brucellosis, typhoid, toxoplasmosisConnective tissue – systemic lupus erythematosusDrugs – reserpine, methyldopa, pehnothiazines, phenylbutazone,

corticosteroids, oral contraceptives, interferon

What investigations would you order and why?

• TFT, FBC, LFT, U&E

How would you gauge the severity of her depression?

• Hamilton Rating Scale for Depression• DASS• Etc..

How would you estimate her level of suicide risk?

• Look at suicide risk factors.– Static – Male, Age:15-29, >75, living alone, single,

widowed, separated, past self-harm, family history of suicide, alcohol or substance abuse, chronic medical illness

– Dynamic risk factors – depression, access to means, hope for the future, recent loss, shame humiliation

• Beyond Blue pamphlet has a bit of an algorithm for assessing suicide risk but fails to give it a scale.

• Various suicide risk scales, but none seem to be in our lectures or supplemental resources.

How would you work out whether she needed inpatient or out patient treatment?

Would you treat her with antidepressant medication? Which medication? What dose? What duration?

• Assuming she is having an episode of major depression:

• Yes.• SSRI or SNRI. Let’s say sertraline. Start at 50mg. May

increase (max 200mg).• 2-4 weeks is necessary to see a clinical response. If

effective continue for at least 6-12 months.• Without that assumption…

Would you arrange for her to be treated with psychotherapy? What type? How long for? How is it funded?

Yes.CBT. Between 10-20 sessions. Continuing therapy is

recommended for at least 6-12 months to avoid relapse.

Medicare covers up to 10 (lecture yesterday) sessions a year. Aimed at mild-moderate cases.

In what circumstances should she have ECT?

• When:– Rapid response is required– Drug therapies have failed– Past history of successful ECT– Patient preference is for ECT

What is the relevance, if any, of her past history of chronic fatigue?

• The chronic fatigue along with the depression may both be explained by an underlying cause.– Dysthymia – Hypothyroidism, poor management of

Hashimoto’s thyroiditis– Addison’s disease