Merilyn Liddell¹, Daniel O’Connor², Sandra Davidson³, David Clarke¹ and Stella Koritsas¹
¹ Department of General Practice, Monash University
² Department of Psychological Medicine
³ Department of General Practice, University of Melbourne
Project completion year
The prevalence of depression is much higher among elderly people living in aged care accommodation than it is amongst their peers living in the community.
The high rate of cognitive impairment among people living in aged care facilities can make it more difficult for general practitioners (GPs) to detect and treat depression.
However, it is also possible that GPs are less likely to attend to the mood state of patients in a nursing home than patients sitting in front of them in the consulting room.
Previous research has found that depression is poorly recognised among nursing home residents and that when it is identified, it is often poorly managed with inadequate dosage of antidepressant, inappropriate class of anti-depressant or insufficient time allowed for a treatment effect.
This study evaluated the effectiveness of an educational intervention for GPs in the recognition and management of depression among older people living in nursing homes.
Nine nursing homes, 13 GPs and 55 residents were recruited into the study.
GPs completed an interactive workshop, which included education on late-life depression and training in the use of the Cornell Scale for Depression in Dementia. Following the workshop, GPs reviewed their study patients using the Cornell Scale and altered their depression management accordingly.
One quarter of patients reviewed by GPs were diagnosed as having probable major depression and another third were assessed as having depressive symptoms.
Following the review, GPs made changes to the antidepressant medication of 29 per cent of patients.
- Antidepressant medication was introduced to 8 per cent of patients
- 5 per cent had the class of anti-depressant changed
- 13per cent had the dose of antidepressant medication changed
- and one patient had their anti-depressant medication discontinued.
Pre and post-intervention questionnaires indicated that GPs significantly improved their knowledge of late-life depression and that following the intervention, GPs were significantly more likely to ask their elderly patients about depression and to review them regularly.
Consistent with previous research, this study showed that training in late-life depression is sorely needed.
A fundamental part of this training was to highlight the need for regular monitoring of patients diagnosed with depression.
The proportion of residents presenting with probable major depression despite already being prescribed antidepressant medication indicates that existing treatments were ineffective for some patients and that this was not being recognised due to the lack of adequate monitoring.
It is impossible to know if the changes in patients’ treatment made in this study were effective in controlling depression status as a longitudinal follow-up was not built into the study protocol. However, the finding that 13 per cent of residents had the dosage of antidepressants increased suggests that the treatment changes were in the desired direction.
Implications for Policy and Practice
Using a brief screening tool and a depression algorithm, GPs identified that a quarter of their patients had Cornell Scale scores indicative of probable major depression that was either unrecognised or inadequately treated.
These results suggest that a GP-administered screening tool to identify depression is a practical application of scarce resources in the nursing home setting. Moreover, this intervention can be applied to the wider nursing home population by the provision of a brief GP-education session.
Regular screening for depression in nursing homes could be encouraged by facilities incorporating a tool, like the Cornell Scale for Depression in Dementia, into their standard assessment process; just as they would a falls, risk assessment or a continence assessment. The scale can be administered on admission of a new resident, routinely (e.g. annually), and as the need arises (when a change in behaviour occurs that may be associated with depression). Patients with repeat high scores may indicate the need for further assessment by a psychologist or psychogeriatrician.
All of the facilities involved in the study were provided with reports on the key findings of the study, including recommendations to incorporate the Cornell Scale for Depression in Dementia into their screening protocols.
About the Researchers
- Professor Merilyn Liddell is the Pro-Vice Chancellor, Monash Malaysia.
- Sandra Davidson, who was the project manager, commenced a PhD in the Department of General Practice at The University of Melbourne in 2006. She is investigating the relationship between social ties and use of the health care system among people with depression.
- Daniel O'Connor is working with Kate McSweeney on a 2006 beyondblue- funded study on the treatment of depression in nursing home residents.
- David Clarke continues to research depression in the medically ill setting and is Research Advisor for beyondblue.
- Stella Koritsas commenced a PhD in 2005 at the Centre for Developmental Disability Health Victoria. Her PhD focuses on factors that contribute to problem behaviour in people with disabilities, and the impact of problem behaviours on the psychological well-being of carers.
Davidson S., Koritsas S., O’Connor D., Clarke D., (2006). The feasibility of a GP led screening intervention for depression among nursing home residents, International Journal of Geriatric Psychiatry; 21: 1026-1030.