Good afternoon, everyone, and welcome to the monthly HCCI webinar and virtual office hours. Today's webinar will be presented by Dr. James Ellison, MPH, and is entitled Managing Depressive Disorders in Homebound Patients. My name is Danielle Feinberg, HCCI's Coordinator, Education and Research, and I will be your moderator for this event. For housekeeping, for the first portion of our webinar, just to go over a few things, we'll be dedicated to our formal presentation. While participants are welcome to submit questions, please know that we will address these at the end of the presentation and during the open virtual office hours following the webinar. The questions submitted do not need to be directly related to the topic of the webinar, but they can cover any topic you wish. If you'd like to submit a question, please do so by clicking on the questions box located on your screen. A copy of our presentation is available in the handouts box and can be saved by clicking on the name of the presentation and downloading it. Additionally, after the conclusion of our webinar today, all participants will receive a copy of the slide deck, questions and responses, and a recording of the presentation. At the conclusion of our virtual office hours, which immediately follows our presentation, we will send out a brief survey link via email. We definitely appreciate your feedback, and this gives us an opportunity to understand your needs and to decide on meaningful future webinar topics. Today we are joined by our moderator, Dr. James Ellison, MPH. Dr. Ellison is the Swank Foundation Endowed Chair in Memory Care and Geriatrics at Christiana Care Health System. He's a recognized clinician, researcher, and educator in geriatric and adult psychiatry with special expertise in geriatric mood and anxiety disorders and neurocognitive disorders. Dr. Ellison joined Christiana Care from McLean Hospital in Belmont, Massachusetts, where he had served as a director of the Geriatric Psychiatry Program, the Memory Disorders Clinic, and the Partners Health Care Fellowship in Geriatric Psychiatry. Without further ado, I'd like to turn it over to Dr. James Ellison. Thank you, and welcome to everybody. Good afternoon, and thanks for tuning in. We're going to talk today about depression in later life. We'll talk about the varied presentations and an assessment approach for different types of depressive disorders in elderly patients in the home care setting. And we'll also talk about effective treatment strategies and how to provide guidance to caregivers of homebound patients with depressive disorders. First, let's think about how big is the magnitude of this problem. Many of my residents feel that depression in later life is even more common than in younger folks, but that turns out not to be true. People actually become happier as they age overall, but there still is a significant rate of depressive symptoms in the older population. And depending where you look, people are more depressed in primary care settings, in long-term care, and homebound would probably be like something like the long-term care with a rate of up to 25% with major depressive disorder and a significantly larger number of people with milder sub-major depression features. There are risk factors recognized for depression in later life. Older individuals, women more than men, people with lower resources financially or social connections, people with chronic illnesses or psychiatric history of recurrent depression through life, or with cognitive impairment or sleep disturbance or pain being a very important risk factor, or people who've had negative life experiences, substance abuse should be in here, alcohol problems, smoking, and sedentary lifestyle are all recognized risk factors for late-life depression. The reason that we especially want to recognize depression is because it makes life less pleasurable and decreases the quality of life. It also increases the use of non-mental health services in medicine, twice as many doctor appointments, and increases polypharmacy as clinicians struggle to treat symptoms which may be related to depression or amplified other medical condition symptoms affected by the presence of depression. There also is an increased morbidity and mortality associated with depression, as well as, of course, the increased risk for suicide, and yet the sad thing is that more than half of depressed elders go untreated. Now in younger adults, the DSM-5 tells us that we diagnose depression by looking for a depressed mood, loss of interest or pleasure, plus at least four of these other symptoms that have been put together under the mnemonic SIG-E caps. We look for sleep, interest, guilt, energy, concentration, appetite, psychomotor retardation or agitation, or suicidal ideation or behavior, at least four of those, along with depressed mood or loss of interest or pleasure. I think that in the older population, we can see some different presentations of depression. It's very common in older adults with depressive symptoms to be below the threshold of a major depressive disorder, and that might mean only two symptoms or three symptoms rather than four symptoms, and we call the sub-threshold condition persistent depressive disorder. This is really similar to what used to be called dysthymic disorder. Late-life depression may be a somewhat different condition than depression in younger adults, although there certainly are individuals who have recurrence of early-onset mood disorder throughout life, and those episodes can become more frequent, longer in duration, and even more severe as one ages. But clinicians tend to see many new-onset depressions after age 60 or 65, and they can be associated with medical diseases that accompany aging or with the unique psychosocial stressors of later life that have to do with changes in status, relationships, losses, loss of mobility or function, decreased transportation, social isolation. There also are some physiologic theories, including the vascular depression hypothesis, which posits that late-life depression in some individuals relates to changes in perfusion of the brain and deterioration of subcortical fibers that connect the cortex to the subcortical areas and have to do with vegetative symptoms. There's also an inflammation hypothesis that's become interesting lately. Most of the older adults seek help for depression in primary care, and of course, people who are homebound and in home care are primarily looking to their primary care clinicians for help. We might see some confusing and disguised presentations of depression in addition to the sub-major depression presentation. One of these is called depression without sadness, and that's the grumpy, withdrawn, irritable, or apathetic older adult who may or may not have some associated cognitive symptoms as well related to the depression or independent. Sometimes somatic functioning is the focus of depression, and people have amplified pain or disability. And sometimes, as I run a memory clinic currently, we see people with a functional or psychogenic cognitive disorder, a cognitive disorder which really is related to depression, what used to be called the pseudodementia, but now we call it the dementia syndrome of depression, where people are convinced that they have a cognitive decline, and yet they can give you a very detailed explanation of all the things that they've forgotten, which makes you think that it's probably depression. Depression with psychotic features is about 10 times as common in the older population, and this would include mood-congruent hallucinations or delusions, often about poverty or terminal diseases, and then depression does also accompany the genuine neurodegenerative disorders like Alzheimer's disease and other dementias. And so we may see people developing depressive symptoms in about half of people with Alzheimer's disease and even more with vascular cognitive impairment. I mentioned vascular depression, and how we tell that apart from general nonvascular depression in an older patient is that we would see a combination of depressive symptoms, primarily apathy and withdrawal, more than sadness, aligned with poorer executive functioning, and sometimes a slower and more brittle response to antidepressant treatment with greater relapse risk. And typically in this patient with vascular depression, we will see capping of the ventricles on a FLIR MRI image, and so we'll see small vessel disease in this kind of a pattern which can be confluent or discrete subcortical lesions. In depression with psychotic features, we're interested in picking this up because of the increase in suicide risk as well as the higher rate of relapse. And a very important point that I'll touch on with treatment is that depression with psychotic features may not respond well to an antidepressant alone, or for that matter, to an antipsychotic alone, but typically requires the combination of these two drugs or ECT. And I mentioned depression in Alzheimer's dementia or other dementias, and the important point to make about diagnosing this is that we relax the criterion for depressed mood because some people with more significant cognitive impairment may show all the signs of depression and be the perfect picture of anhedonia and withdrawal and sadness without being able to articulate that that's what they feel. Masked depression can occur in dementia in a person who expresses their depressive feelings through behavior rather than being able to describe it because they lack the ability to give words to their feelings. And so we may see psychotic behavior or aggressive behavior directed at others or oneself or disruptive vocalizations like screaming at night or weight loss with refusal to eat. So how do we assess depression in an older adult? Many clinicians use the PHQ as a simple screening test. I always say the best test for depression is to just ask, are you depressed? Because if you don't ask, you'll never learn about it. But the PHQ is just a little bit more reliable than that simple question. And the PHQ involves asking during the past two weeks, have you had little interest or pleasure in doing things or have you been feeling down, depressed or hopeless? And as you can see here, the sensitivity is very good for these questions. The specificity less good unless you look for a score around four or above or some clinicians would use three. And you can see that that would require somebody to say, for example, that more than half the days they have these depressive symptoms. The GDS-15 is very popular. It's translated into many languages. It can be downloaded easily and it's in the public domain with no fee for use. A score of six or higher suggests a need for an evaluation for depression. And you can see that this test is characterized by a different type of question. It's not asking about the DSM, vegetative symptoms, but instead it focuses on cognitive attitudes and affects. If a person's quality of life is low as a result of depression, they'll feel that their life is empty. They're bored. They're in low spirits. They fear that things are bad. They feel helpless. They stay at home and so on. Now one of these questions is, do you feel you have more problems with memory than most people? And that can be a false positive if somebody does have cognitive difficulty. And then the question, do you think it's wonderful to be alive now? If a person answers no, we jump right into an assessment of suicide risk. That would also be true if a person feels their situation is hopeless or that they feel most people are better off than they are. The GDS again is pretty sensitive and pretty specific, but there are both false positives and false negatives. So the result of the screening test like this is followed up on if it's positive. And if you suspect depression, even with a negative GDS, which may be the case in a stoic person who doesn't like to share their feelings or doesn't have cognitive ability to express their feelings, you still would follow up on treating or evaluating further for depression. And we generally say if the mini mental status score is 15 or below, then the GDS score becomes less reliable. And in that situation, we might turn to the Cornell scale for depression and dementia, which is a way of operationalizing observations of an observer and a clinician about the DSM type of symptoms, the mood signs, the behavioral disturbance, the physical functions, and thoughts that are disturbed. And those are rated from zero to two and a sum of the score at the end is rated. Now doing the screening for symptoms is only the first step of assessment. The next thing is to think about medical conditions that might contribute because medical burden is very important in the older adult with depression. And number one among the medical conditions to think about is medications. People may be on excessive amounts of sleeping pills, benzodiazepines, over-the-counter anticholinergics, antihistamines, other medicines that have as a side effect fatigue or low mood or low energy. There may also be nutritional and metabolic disorders. And very often we see in the older population sleep disorders with non-restorative sleep. Sometimes, of course, neurologic disorders like the beginning of a cognitive decline. Next comes the laboratory assessment and a fairly simple panel of laboratory tests can eliminate the likelihood of one of the mimics of depression that we see medically outside of the polypharmacy or harmful medication issue. And the team has a question after it because many clinicians wouldn't consider neuroimaging a part of the workup for depression, but those who do are looking for vascular depression. Next, how do we treat depression in later life? And the important first point that I want to make here is that many older adults prefer to talk and to have a psychotherapeutic or counseling approach. There may be some options with a visiting psychotherapist or with a group or telemedicine or telepsychiatry, telecounseling that allows them to have counseling at home. There are several strategies that have been used with older adults that rely on a short-term treatment that's problem-solving and problem-oriented rather than digging deeply into very remote past life experiences. Cognitive behavior therapy focuses on how we think about ourselves and our experience and how we behave. One of the key issues in cognitive behavior therapy is to put pleasant events back into a person's life because as a person becomes depressed, they typically focus on survival mode which may mean getting rid of all of the things that are typically fun in their life. So we put those back in. Interpersonal therapy is for talking about roles and expectations and relationships. Problem-solving therapy identifies problems, outlines solutions, and works with the therapist on a plan about that. And engage is a new behavioral approach that focuses on, again, pleasant events and rewarding events that engage the reward system of the brain. It's important to think about physical activity because sedentary lifestyle increases depression and physical exercise actually is on a par for efficacy with antidepressants in a milder depression or a depression that's not psychotic. There is even one study that showed over 24 weeks that sertraline treatment led to a faster remission when exercise was added. In terms of pharmacology, all of the FDA-indicated antidepressants are pretty good for treating depression in older adults as they are in younger adults and the response rate is pretty similar and the remission rate is pretty similar. So we shouldn't be deterred from treating a person in later life with depression just because of their age. They have a good chance of responding. That said, none of the antidepressants is associated with response and everybody and the actual numbers can be kind of disappointing that 50% to 65% of people in a trial with one intention to treat drug are likely to respond and that means a 50% improvement. And 30% to 40% are likely to go into remission which means a 90% symptom decrease. The good news is that by augmenting or switching, mixing and matching different treatments including exercise, psychotherapy and so on, I think we can expect an 85% to 90% response rate and that's sort of on a par with ECT which I'll mention later. The antidepressants all have side effects and although the serotonin reuptake inhibitors are the usual go-to drug of first choice, they do have side effects for some individuals. So for example, some people are activated and can't sleep or have non-restorative sleep. Other people are sedated and fatigued and tired. It's very individual and I don't know of any way to predict. Weight gain can occur or weight loss and so in an older adult who is having trouble eating, you have to be sensitive to loss of appetite with these drugs. More typically what we see is an initial increase in weight followed by a leveling off and less overall weight gain than with the earlier groups of drugs, the tricyclics. Gastrointestinal symptoms do occur in many patients particularly at the beginning of treatment or after a dose increase and they can include gas, indigestion, diarrhea but usually are short-lived. And hyponatremia is more common in the older adult given a serotonin reuptake inhibitor. I think one study cited the figure of about 12%. It's always worth checking baseline sodium and checking after the person has been in treatment for a few months to make sure that that's not developing. Unfortunately in my practice, I've seen a number of people referred for cognitive symptoms after treatment of depression lowered their sodium and the real problem had become hyponatremia with some cognitive effects. Bruising is an issue with the serotonin reuptake inhibitors, usually not a problem but of course some of our patients are on anticoagulants and then it can be more of an issue and it can even be an issue of GI bleeding. Internal dysfunction with these drugs is usually related to decreased libido or impaired orgasm and then the fall risk has been debated. Falls are increased in depression, falls are increased with various other medical complications of aging. There is a question whether falls might be increased even with the serotonin reuptake inhibitors to a slight degree. Our antidepressants are metabolized by the liver and the metabolites are eliminated through the kidney and older adults typically have reduced hepatic inactivation and renal elimination so we might start with a dose that's lower than the younger adult. However, it's important not to undertreat so if a person has no side effects and a partial response, the younger adult dose of the drug may be very appropriate. We worry also about interaction with drugs that have anticholinergic side effects because the older adult is more vulnerable to this and it produces cognitive as well as other side effects. So of the serotonin reuptake inhibitors, paroxetine is the one that's most anticholinergic. The average adult over 65 years old is on five prescribed medications and this heightens the risk of drug-drug interactions that could be pharmacodynamic or pharmacokinetic. Now cost is another issue in the older adult and adherence of course can depend upon affordability and patients can be ashamed of being unable to afford their medication and not tell you about their non-adherence which is financial. So it's important to ask about whether there are financial limitations for buying the medicine and whether adherence is good. Medicare unfortunately doesn't cover all the antidepressants and copay can be considerable even sometimes with a secondary or Medigap insurance. Therefore I generally recommend use the generically available antidepressants for trials number one, maybe two and probably even three because we're so lucky that we have a large number of generically available antidepressants and the ones that are currently not available generically are Trintellix which is Vortioxetine, Fetzima, Vibrid and MSAM. However these are all good antidepressants and might have their place for use just not first or second or generally third line. Generally we would start with Sertraline or S-Citalopram. Citalopram is an excellent drug that's been researched carefully and the only reason that I wouldn't always start with that is because the dose is not supposed to be above 20 milligrams per day per the FDA warning related to QTC prolongation. And so some patients will do better with a dose that's above 20 milligrams per day and at that point probably rather than increase the Citalopram I would switch over to S-Citalopram which is twice as potent and can be raised higher. The SNRIs have their own set of side effects related to that N which is for noradrenergic reuptake inhibitor as well as the serotonin. And they can increase blood pressure, anxiety, insomnia and some of them have discontinuation symptoms. Duloxetine has analgesic effects. We want to keep in mind as alternatives Bupropion which is more stimulating, less appetite increasing, less libido reducing or Mirtazapine which is more anxiolytic, better for sleep in some patients and increases appetite in some of our patients which can be helpful for the frail. Is Ketamine a good drug for the elderly? Unfortunately so far limited data are available and they're not very positive. This may change with the intranasal administration or eventually oral administration that might become available to us. But at present I'm not generally recommending people for Ketamine. ECT on the other hand is underused. It's been around for a long time. Psychiatrists know how to deliver ECT safely and it doesn't increase cognitive impairment typically for more than the brief period after treatments and during the treatment period after which there may be short term anterograde and retrograde amnesia usually clears. If a patient is elderly, delusional or catatonic or in an emergency that requires rapid response ECT has very good data supporting it and the newer approaches such as right unilateral or brief pulse treatment seem to have pretty limited side effects better than medicines for the older adult in a recent comparison. There are additional neurotherapies like repetitive transcranial magnetic stimulation which has been used effectively with older adults but cortical atrophy means that the brain is actually further away from the inside of the skull in an older adult and the magnetic field is attenuated quickly at that distance. There is a stronger approach to transcranial magnetic stimulation that may be more suitable for the elderly. These other things are more experimental. I almost said more expensive but of course they would be that too because they're experimental. So vagal nerve stimulation is approved for epilepsy. There's some use in depression. Transcranial direct current stimulation, magnetic seizure therapy and deep brain stimulation are not in general use but are being looked at. And in the demented patient, antidepressants tend to have a less robust effect which is really disappointing for depression because we see a lot of depressive symptoms in patients with cognitive impairment. The antidepressants are often a good treatment for agitation or behavioral difficulties. The response in large controlled trials for depression failed to show superiority of sertraline over placebo. And there are a number of other trials that found similar results but my feeling is that other studies support the idea that if the depression looks pretty much like a major depressive disorder, a trial of a serotonin reuptake inhibitor is probably worthwhile but the patient should be monitored and taken off the medicine if there isn't benefit. I'd like to say a few words about treatment resistance and this is my way of approaching that is first of all, assess the adequacy of prior treatment approaches, dose, duration, choice of drug, are there behavioral or environmental factors that are important such as personality disorder or another diagnosis like alcohol or psychosis or neurodegenerative disorder and is the patient taking the medicine as prescribed. We also look for bereavement or other situational factors that may be important because complicated grief can be a reason for non-responsive depressive syndrome. A patient may feel guilty for example about the partner whom they've lost and may feel that they should have done more for that person or let them down in some way and that often needs to be worked through in a counseling type of discussion. Substance abuse is another thing that can be missed and many older adults are on benzodiazepines chronically or might be drinking alcohol to an extent that causes depressive symptoms. Pain as I mentioned is amplified by depression, but also pain can seem to induce depression and pain is associated with social isolation and limitation of functional performance and these can add to depression. So the things that we can do in a treatment-resistant depression are make sure the dose is optimized, the timing of the doses if there are side effects that can be affected by that. We might want to switch to a different class of drug or a different drug in the same class. We could add something and there are certain augmenters that are beneficial for older adults. We often add for example mirtazapine to another antidepressant to improve anxiety reducing effect or sleep or appetite, bupropion might be added to a serotonin reuptake inhibitor to increase, to reduce apathy and ECT can be added as well. And then just a word about maintenance treatment, very important in the older adult because they are more relapse prone, psychotherapy can reduce relapse. Just to put a person on an antidepressant until the depression is better and take them off of it is not necessarily the best approach because relapse rates are high. We recommend that a patient with late-life depression be asymptomatic for 6 to 12 months before the antidepressant is removed. Well one of the reasons that we worry about depression in later life of course is because of the risk for suicide and suicide attempts in older adults are kind of different. For one reason, firearms are much more typically used by men and women in the older age group and as a result of that and the seriousness of the attempts, 1 in 4 suicide attempts in older adults are fatal. That's compared to about 1 in 30 in younger adults. So the risk is mostly increased in the older white male and more increased in a person who has social determinants, isolation, pain, alcoholism, a newly diagnosed chronic illness or access to lethal means and many patients have guns in their homes and interestingly even many people with dementia have guns in their homes and a startling statistic is that many of those guns are loaded and accessible, not locked up. Risk factors for suicide also include depression and medical illnesses, particularly cancer and neurologic diseases and cardiovascular diseases. But many illnesses are linked with depression, for example, coronary artery disease, diabetes, end-stage renal disease and cancer and disease mechanisms also can produce depressive symptoms such as fatigue, loss of pleasure or enjoyment, sleep disturbance, appetite disturbance. So generally we want to treat a medical disorder as well as a depressive disorder and not assume that the depression will go away when the medical disorder is treated or that the medical disorder will be helped by treating the depression, both are targets. Now my last comments here are going to be about treating depression in the medical setting as opposed to the specific specialty of mental health. You probably are all familiar with the famous IMPACT study that was published now almost 20 years ago in which older adults were randomized to treatment as usual in primary care or treatment in which a nurse depression specialist was involved to follow the patients through a registry, measure which ones didn't respond to treatment, provide advice and short-term counseling and what was shown is that this enhanced approach to treating depression in primary care rivaled the kind of responses that you would see in a specialty setting and that was confirmed in other studies and depression certainly can be treated by primary care or home care clinicians. We don't need for a psychiatrist to do that but you have to really look for depression because it can appear atypically and in the older adult that's common and you have to think about the treatment differences, the risk factors, the different etiologies including medical and medication related, the different presentation that can be sub-threshold below major depressive symptoms or irritability or withdrawal or amplification of medical symptoms or focus on somatic symptoms including cognitive concerns. The assessment process which might be better using something like the GDS-15 in some patients and focusing on cognitions and affects rather than neurovegetative symptoms which are more nonspecific in the older population. The different treatment considerations and finally the prognosis, the higher relapse rate and the longer maintenance treatment. So remember to look for late life depression that's one of the most responsive chronic illnesses that we treat in later life and we can really help patients improve their quality of life through recognizing and treating. And there I'm going to turn this presentation back over to Danielle. Okay, give me one moment everyone. Always does this to me. Okay there we go, perfect. So thank you so much Dr. Ellison. Your knowledge on and experience with managing major depressive disorders is absolutely incredible and we are so moved to have you here with us today and sharing that information. We are going to move now from our formal presentation into our virtual office hours and as we do so I just want to let everyone know we're also being joined by Dr. Thomas Cornwell, HCCI's CEO and founder of Home Care Physicians, Dr. Paul Chang, HCCI's Senior Medical and Practice Advisor and Medical Director for Home Care Physicians and Brianna Plensner, HCCI's Manager for Practice Improvement. We'll address your questions that were submitted either during the presentation and any that we may have received ahead of time. Again if you have any questions please feel free to type those in now. We are going to go into the virtual office hours portion and we've got roughly about 20 minutes for that. We did get a couple of questions so I do want to share those with everybody. The first question is best adjunct therapy after first line SSRIs? Would you like me to address that? Yes please Dr. Ellison. So the augmenters of antidepressants have not been studied as thoroughly in older adults as in younger adults. The use of lithium in younger adults was very popular but in older adults there's concern about cognitive or other side effects or renal or thyroid effects. But lithium is one option. It's not my first choice. Another option that's very popular, and this is more popular, is the use of a low dose of an antipsychotic that's designed as an augmenter of the antidepressants. And there are two of these in particular. There's aripiprazole, often started at 2 milligrams and can be given as high as 10 milligrams, but typically 2 to 5 would be the treatment range. Or brexpiprazole, a newer similar drug. Both of these have been studied in older adults as an augmenter and seem to be moderately effective. The reason that we are concerned about using antipsychotics in older adults is that especially in those with dementia or psychotic symptoms there's an increased risk of mortality that's from all causes and that is the cause of the boxed warning on the package insert. To start with, many clinicians therefore first try augmentation with one of the other antidepressants from a different class. So say the patient is on escitalopram and you optimize the dose to 20 milligrams, which is the maximum recommended dose, and you don't want to go up to 30 milligrams, although some clinicians might go off the off-label elevated dose following the cardiogram for QTC prolongation. If you wanted to augment the escitalopram, you might add 100 milligrams of bupropion if the patient's more apathetic or 7.5 to 15 to even 30 milligrams of mirtazapine if the patient's more anxious. So I'm kind of thinking out loud, but to summarize what I've said, adding another antidepressant depending on the symptoms or thinking about a low dose of one of the newer antipsychotics would be my first ways to go with augmenting. Excellent, thank you. There's another question for you, Dr. Ellison. Is it more effective to combine two low or med dose antidepressants? To combine two antidepressants? To lower med dose antidepressants rather than increase the dose of one? Oh, that's a great question. I have seen in recent years, in the past few years, some patients on an SSRI plus an SNRI or even two SSRIs, and that to my mind is not a rational pharmacotherapy. I would rather see, based on the evidence that I know of, the optimal dosing of one antidepressant and then if that doesn't work, a switch to another antidepressant if it's in that serotonergic group. The reason for this is there can be pharmacokinetic interactions between them. One might inhibit the metabolism of the other, and we might get elevated serotonin levels and what they call the serotonin syndrome where patients become confused, hypothermic, have motoric problems, and that's not what we want to happen. It would be an unusual approach. On the other hand, once the dose of the serotonergic drug has been optimized, either an SSRI or an SNRI, adding another antidepressant from a different class, specifically the bupropion or mirtazapine, each of which are the only members of their classes, that makes sense. That's rational pharmacotherapy. And building on that question, we have one come in that said, when you change from one SSRI to another, do you wean down one and slowly go up on the other or do you just switch? So that's a great question. When you switch from one serotonergic drug to another, the answer is it depends. You have to look at the elimination half-life of the drug that you're stopping and the drug that you're starting. And let's say that you're stopping fluoxetine, which is a common SSRI. It has an elimination half-life of around a week. So if you were to just stop it, it actually will wean itself off, but there's still a significant blood level and it's a 2D6 cytochrome enzyme inhibitor. So if you were to start another antidepressant that's metabolized by 2D6, you could risk overdosing the patient with serotonin reuptake inhibitor effect. So a drug like fluoxetine, you would let wash out for maybe a couple of weeks before you start the other antidepressant. On the other hand, let's say that you're going from the SNRI venlafaxine or the SSRI paroxetine. Both of these have very short half-lives, as we know, because of the likelihood of discontinuation symptoms when a dose is missed. And so for those drugs, I would lower the dose and cross taper onto the second drug. And that's the answer to this, is that the drug you're eliminating, if it's a long elimination half-life, wait longer, but if it's a short elimination half-life, you can cross taper more confidently. Perfect. Another question is, how long is an adequate trial period before declaring medication failure? In the older population, the trials have to be longer than in the younger population in general, and a trial would fail for one of two reasons. First of all, the patient might have unpleasant adverse effects, and in that case, if the effects are very unpleasant and the person doesn't want to wait a few days to see if they attenuate, then the trial is over. Now, some of the gastrointestinal side effects of the SSRIs are going to get better or there are things you can do about them that can reduce the intensity of those symptoms. On the other hand, if the patient is tolerating the medicine and you've optimized the dose and they're not getting better, you would want to probably see some effect after no more than four weeks of optimal dosing. Now, at the same time, studies have shown that some patients don't respond until even 10 weeks have gone by, but most patients are not going to be happy waiting 10 weeks for a response. So I think we catch most of the responders by having an optimal dose for four weeks, and if there's no improvement at that point, thinking about augmenting or switching to another drug. If there's a partial response, maybe augmenting. If there's no response, switching. Excellent. Thank you, Dr. Ellison. Another question that's been posed is, what are the quality measures related to depression? What are some of the national benchmarks we should be aware of? Oh, I'm not sure I know the answer to that question. Is there somebody else who knows? I know that we want to make sure to ask about depression in the annual wellness visit, and that's sometimes being measured in different institutions. But what else might somebody else have? Yeah, screening. This is Tom Cornwell. Screening is a common quality metric for a lot of ACOs, for MIPS, and that's obviously a process measure. There's been a lot of work done on quality indicators by Bruce Leff at Hopkins and Christine Ritchie, who's now at Harvard, and one of their quality metrics is to not only screen, but have treatment started. Again, it doesn't recommend what that treatment is, but just that if the screening is positive, the screening positive is addressed. Anyone else? Dr. Chang? Yeah, at Home Care Physicians, we use EPIC, and EPIC has a PHQ-2, which expands to a PHQ-9, depending on the responses of the patient. So that's part of our screening tool that we use to assess our patient. Dr. Ellison, I actually have a follow-up question regarding that. In terms of not only screening, is there a tool that you use to track the efficacy of your intervention? Do you use the PHQ-2 as a measure not only for screening? You know, this is a great question, because in psychiatry, we've been talking about measurement-based treatment and making sure that you not only treat and measure symptoms at the beginning, but that actually outcome is improved if subsequent quantitative tools like PHQ-2 or 9 or the GGS-15 is used. And so it would certainly make sense to follow in the, you know, PHQ-2 or one of the other screening tools. Okay, another question raised. Are you aware of novel programs that offer home-based psychotherapy or that train community health workers in PST, CBT, or other evidence-based therapies? The workforce shortage is severe, leading to an over-reliance on psychotropics. Yes, I thought it was only here, but evidently it's everywhere. And I'm being silly, but of course, this is a national problem that there's a shortage of psychotherapists who work with older adults who accept Medicare, for example, who are skilled in the therapies that are known to be effective in older adults. But I'm heartened by seeing more and more advertisements of telecounseling services that can deliver therapy into a person's home via the telephone or via something like FaceTime or Skype, you know, that's appropriate software. And so I think we will see more such services developing, but in answer to your question, I think there's a limit. There are limited resources at present. This is Brianna. If I can just piggyback on that from each CCI, I totally agree. A workforce shortage is a huge problem, but I definitely would recommend your practices, you know, do your research in your local area. I know DuPage County is fortunate enough to have an in-home counseling service for seniors. I actually did just recently learn about a resource called ZenCare with the zeas and zebras. They are an online platform for mental health professionals that they do some screening for quality, and they have resources in Chicago, New York City, Austin, Connecticut, Rhode Island, Seattle, New Jersey, Washington, D.C., and Westchester. Currently right now, New York City and Boston have actually in-home therapy resources, but the rest do have tele-video conferencing therapy sessions. You can view the counselors' profiles, their rates, if it's outside of Medicare, and all of that information. So they do have a pretty good database that's not completely nationally, but is one other resource for you. But certainly work with your local social workers to gather all those resources and make sure that your practice staff has access to kind of a robust list for what your area might have for mental health support. Thank you. Do you, I'm sorry, another question, I apologize. Do you still recommend ruling out bipolar disorder before starting a patient on antidepressants that has never been on psych meds before? Well, that's a very informed question because we know that about 40% of people with bipolar disorder who've never been on an antidepressant before are at risk for developing a manic response, and sometimes that happens, typically very quickly, but it can happen later in treatment as well. We're somewhat protected in this situation by knowing that it's relatively uncommon for somebody to have a first manic episode in later life, or for a bipolar person to have their first mood disorder in later life, although something like 20% do have it over 60, over age 60. And I would be attuned to a family history of bipolar disorder to a past response of observation with an antidepressant, to evidence of kind of hyperthymic temperament, person is a very high achiever, full of energy, life of the party, going strong all the time. Those would be things that would tip me off that there might be a risk of that, and then I just watch very carefully. But in general, I would be just screening for that in the history, but less worried than in a younger population. Okay. Another question, and thank you, that's an excellent answer. Another question, interested in innovative strategies to help homebound patients access therapies such as PST, BA, CBT, given workforce shortage of mental health providers who do house calls, also strategies to address loneliness in geriatric depression in homebound. Well, that's a big problem. And one of the interesting things, we live in a time when social media are being used not only by younger adults, but also by older adults, and many older adults are on Facebook or other types of social media. And the data in younger adults that we hear about sometimes is that use of the social media can be associated with increased depressive symptoms. But there are some people who are homebound who actually find sharing their experience, liking other people's posts, having their posts liked, is very mood lifting and helpful and positive. So that's one thing, social media. And maybe others have something else to offer here as well. I know a while back at Home Care Physicians, we actually helped, through our health system, start a faith-based, church-based respite care program, where a social service agency trained churches to do respite care in their area. They had to agree to see all comers in their communities. But that is some things that can be done to try to decrease social isolation in our homebound patients. And this would be with volunteer visitors? Exactly. Yeah. So no hands-on. But it was both respite for caregiver, I mean, that's what it mostly was, was to have someone be with them and then have the cell phone number for the caregivers, if anything were to happen, so that they can come back right away. But that way, if they did not feel comfortable when they went out shopping and things like that. But it also was a senior-friendly program to give the senior a little more socialization. Okay, perfect, thank you. One more question is, and before we go into this last question, I just want to take a moment to remind everybody that we do have our HCC Intelligence Resource Center. If we don't get to your question today, or if you have additional questions once you receive the archives of these slides, you can reach in through our hotline. We do our webinars every third Wednesday of the month, along with our virtual office hours. And then we also have our tools and tip sheets. And please feel free to either utilize one or all of our resources. And then upcoming events too, just to quickly put that out there. We do have a joint conference with NPEN in February of 2020. And if you're from the Midwest, Arizona in February, sounds amazing. We have our essential elements of home-based primary care, as well as our advanced applications of primary care. And then, like I said, our HCC Intelligence webinars. And our next one will be self-care, avoiding burnout, and maximizing you and your team on Wednesday, January 15th. We do have just a couple more moments, so I want to squeeze in our last few questions, if possible. This question says, please address depression with delusional features in older adults. Yes, depression with delusional features is about 10 times as common in older adults, and is certainly a very dangerous situation. It can lead to suicide more often. It's more likely to relapse. The episodes are harder to treat. And in many cases, the optimal treatment is going to end up being ECT. But a lot of patients will respond to the combination of an antidepressant, and any of the ones we've talked about, and an antipsychotic. And the antipsychotic typically would be one of the second-generation, high-potency ones, such as risperidone, or aripiprazole, or olanzapine. And that's what I have to say. OK. And our final question, as we were kind of talking about different medications and transitioning, there was an inquiry about your feelings, or the thoughts around cannabis as a medication. Well, we're hearing a lot about medical marijuana, and unfortunately, we don't have any studies that show that it's an effective antidepressant in later life. We don't know that for dronabinol, and we don't know that for cannabidiol, or CBD oil, or the other preparations. There's a lot of interest in using these for anxiety, and there's some preliminary research using cannabinoids for treatment of behavioral disturbance in cognitive, neurocognitive disorders. But as an antidepressant, I don't think we have the evidence yet to recommend that. All right. Thank you. Lastly, as we wrap this up, I also want to make everybody aware of our consulting services. We can reach out with providers, practice managers, other professionals. Again, you can reach out to us via phone or email. All of these will be available to you. Oops, excuse me. And we are almost at 5 o'clock, so I just want to, as we wrap up, I want to thank Dr. Ellison so much for his incredible information that he shared with us, as well as answering all of your questions today. Thank you to Dr. Cornwell, and Dr. Chang, and Brianna for their time during our virtual office hours. And thank you to all of you. I know it's kind of busy holiday season, and we really appreciate you taking time out, coming out to join us, and having the opportunity to ask your questions. There will be a follow-up email within the next few days, which will include a link to the archive recording and handouts, and we will work to get the questions and answers posted. You can also visit our HCC Intelligence page. And please don't forget that there will be a short survey emailed to you after this presentation. We really do value your input and feedback on everything. If you have any questions about future webinars, e-learning modules, learning events, consulting services, or upcoming anything with HCCI, please visit our website. Thank you to everyone, and have a wonderful holiday season. Bye-bye. Thanks, Dr. Ellison. Thank you. It's my privilege to join you. Thank you so much, Dr. Ellison. Thank you very much. Bye.

webinar

Dr. James Ellison

managing depressive disorders

homebound patients

older adults

depressive symptoms

risk factors

assessment tools

treatment strategies

comprehensive approach