Therapy with Older Adults

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This week’s case study assessment of a 69-year old widowed African-American male who self-presented for psychiatry evaluation would befit the diagnosis of Major Depressive Disorder (MDD), recurrent, unspecified (F33.9). MDD is characterized by the exhibition of symptoms of extreme sadness, hopelessness, or emptiness accompanied by a variety of physical, cognitive, and emotional symptoms. According to the DSM-5 coding the client must have experienced at least five of the following symptoms for at least two weeks: depressed mood, lack of interest or pleasure, appetite change or weight change, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, decreased concentration, recurrent thoughts of death and suicidal ideation. In the case study, the client is experiencing (1) loss of joy being with his family, (2) difficulty falling asleep, (3) spends the day lying on the couch (4) feeling tired all the time, (5) stopped going to his volunteer job, hence the diagnosis of MDD.

Tests and tools for MDD diagnosis

According to Ng et al., (2016) the clinical tool for diagnosing major depression in older adults as the one presented in the case study is the Geriatric Depression Scale (GDS). This is a 30-item depression questionnaire specifically designed for use in older adults. The GDS assesses the affective and cognitive aspects of major depression, but intentionally omits assessment for somatic symptoms. The questionnaire is easy to use because the items require a yes-no response. A score ≥ 11 on the GDS has a 84% sensitivity and 95% specificity for major depression in elderly patients.  (Ng et al., 2016).

One laboratory method of diagnosing MDD as outlined by Smith et al., (2013) is the dexamethasone suppression test (DST. Dexamethasone administration at a low dose (1–2 mg), should reduce corticotropin levels and lead to decreased cortisol levels in healthy individuals, but in many depressed patients, cortisol levels remain elevated. Another lab test developed as a screening technique and as a more objective way of diagnosing the people with depression is the phosphate level blood test. Verma et al., (2012) reported that people with depression have less ethanolamine phosphate in their blood.

The differential diagnosis to consider would be Mood Disorder due to known physiological condition with depressive features (F06.31). The client has an underlying condition of prostate cancer. He is in denial of the severity of his diagnosis and is uncomfortable about the eminent death of his father. These factors very well contribute to his depressive feelings.

Treatment Modalities

The standard guidelines treatment options for management of depression can be divided into antidepressants, electroconvulsive therapy (ECT) and psychosocial interventions. Antidepressant medication may be used as initial treatment modality for patients with mild, moderate, or severe depressive episode. Because this client has had negative response to antidepressants, it is necessary to investigate the reason why. If it was for non-compliance then the treatment plan would be based on need for supervision. Guatam et al., (2017), pointed out that careful evaluation is to be done to decide about the treatment that is most safe and effective. If failed treatment was due negative response then the option for ECT would be appropriate for this client. According to Singh & Kar (2017) ECT has mood stabilizing property superior than pharmacotherapy in the management of depressive episodes in some resistant clients. Along with antidepressants, it is always necessary to incorporate psychotherapy with psychoeducation for optimal outcomes. I would ensure that the client attends therapy sessions.

Is depression a part of normal ageing?

Whereas studies have shown the trends of causes of depressive symptoms in older adults attributable to physiological effects of some medications, loss of independence, or to a recent bereavement, none have definitive theories confirming that depression is a normal part of ageing. However, other scholars have found that older adults with late onset depression are more likely to have vascular risk factors, cognitive deficits and subsequently more likely to develop dementia. The client in the case study has underlying situations that are contributing to his depression such as familial history in his mother, anxiety related to the looming death of his father and history of spousal loss.

References

Gautam, S., Jain, A., Gautam, M., Vahia, V. N., & Grover, S. (2017). Clinical Practice Guidelines for the management of Depression. Indian journal of psychiatry, 59(Suppl 1), S34–S50. https://doi.org/10.4103/0019-5545.196973

Ng, C. W., How, C. H., & Ng, Y. P. (2016). Major depression in primary care: making the diagnosis. Singapore Medical Journal, 57(11), 591–597. https://doi.org/10.11622/smedj.2016

Singh, A., & Kar, S. K. (2017). How Electroconvulsive Therapy Works?: Understanding the Neurobiological Mechanisms. Clinical Psychopharmacology and Neuroscience: The Official Scientific Journal of the Korean College of Neuropsychopharmacology, 15(3), 210–221. https://doi.org/10.9758/cpn.2017.15.3.21

Smith, K. M., Renshaw, P. F., & Bilello, J. (2013). The diagnosis of depression: current and emerging methods. Comprehensive Psychiatry, 54(1), 1–6. https://doi.org/10.1016/j.comppsych.2012.06.006

Verma, R. K., Kaur, S., & David, S. R. (2012). An instant diagnosis for depression by blood test. Journal of Clinical and Diagnostic Research : JCDR, 6(9), 1612–1613.https://doi.org/10.7860/JCDR/2012/4758.2579