Depression recognition and treatment in long-term care: future directions

With the rapid aging of the Western society, it is not surprising that the use of long-term care (LTC) services is expected to increase in future years. Whereas in 2000, 13 million Americans used at least one type of LTC service, this number is expected to more than double by 2050 [101]. The characteristics of LTC vary dramatically, with some LTC services being institutionally based (e.g., nursing homes, assisted living facilities and skilled nursing care), whereas others are home based.

Users of LTC also vary across settings, with some being more independent than others. Yet, all suffer from chronic conditions that limit their ability to perform self-care tasks. Many LTC users present not only with complex medical and cognitive needs, but also with significant mental health needs. Depression is a common occurrence in LTC settings, present in as many as 13% of the residents in assisted living [1], 27% of nursing home residents [2], and 13.5% of home-care users [3]. In order to fully appreciate the magnitude of depression in LTC, these rates should be contrasted with a point-prevalence rate of 4.4–2.7% in community dwelling older adults [4]. Given the major consequences associated with untreated depression, such as increased mortality and morbidity, longer hospital stays, and higher healthcare costs [5], the relative scarcity of research on depression recognition and treatment in LTC is surprising. Below, is a short description of existing knowledge and future directions for improving the recognition and treatment of depression in LTC.

Recognition of depression in LTC

Several screening instruments are available and recommended for use with older adults in LTC (e.g., the Geriatric Depression Scale and the Cornell Scale for Depression in Dementia). Yet, despite the availability of screening instruments, the recognition of depression in LTC is poor, with only 37–45% of patients diagnosed with depression by a psychiatrist recognized as depressed by staff [6].

A major barrier to accurate diagnosis of LTC residents is the complexity of this population. Because there often is an overlap between some of the somatic symptoms of depression (e.g., sleep disturbance and appetite disturbance) and many physical conditions, an exclusive approach is recommended. This approach argues that when making a depression diagnosis, one would consider only the purely cognitive and emotional symptoms of depression and disregard the somatic ones as they may represent medical conditions [7]. While, this approach is valuable, it may fail to recognize a substantial portion of older adults with depression who tend to present their depressive symptoms in a more somatic form. Another barrier to appropriate diagnosis of depression in LTC is the fact that a large segment of the LTC population presents with cognitive impairments. These individuals may not be able to provide reliable information on their condition. Furthermore, some of the neuropsychiatric symptoms of dementia, such as apathy or agitation, may resemble depressive symptomatology. As a result, clinician rating scales, such as the Cornell Depression Scale for Depression in Dementia or the Montgomery Asberg Depression Rating Scale, might be preferable relative to questionnaires that rely on patient’s self-report. Other barriers not specifically related to the LTC population, such as the stigma of mental illness and the tendency of older adults to seek medical care for mental health needs, also impair accurate recognition and subsequent treatment of depression in LTC.

In addition to the specific characteristics of LTC population, structural barriers also prevent appropriate recognition of depression in LTC. The major point of contact for a majority of LTC users is paraprofessional workers and not mental health clinicians who specialize in depression diagnosis and treatment. These paraprofessional workers often lack appropriate mental health training and are largely unequipped for the accurate recognition of depression in LTC [8]. Furthermore, many paraprofessional workers hold beliefs that are inconsistent with the majority view of depression. For example, in a recent study we found that paraprofessional workers were more likely to view depression as a normal phenomenon, held less accurate beliefs about signs and symptoms of depression, and were less familiar with the effectiveness of specific treatments for depression. These beliefs likely impair their ability and willingness to identify depression in LTC [9]. In support of this argument, research has shown that staff training results in an increased detection of depression and a trend towards more depression treatment and better outcomes [10].

Treatment of depression in LTC

Naturalistic studies have shown that depression in LTC is often left untreated or is ineffectively treated [1,11]. These findings are partially attributed to the numerous barriers for the appropriate recognition of depression discussed previously. Other factors, such as the medical complexity of a majority of LTC consumers and high polypharmacy use, also complicate any depression treatment provided in LTC. These risk factors are further complicated by the fact that many of the characteristics of the LTC environment promote isolation, powerlessness and dependency, and often trigger and maintain depression among LTC residents.

Nevertheless, there is an increasing body of research demonstrating the effectiveness of both pharmacological and nonpharmacological treatments for depression in LTC [12,13]. Antidepressant medications are an effective first-line treatment for late-life depression. However, given the fact that 33% of pharmacological trial participants discontinue treatment due to side effects [14] and the high polypharmacy use in LTC, nonpharmacological interventions are a particularly attractive option. One such option is problem-solving therapy, which was found to be effective in the treatment of depression in home-care older adults [15]. Nonetheless, the chronic nature of depression and the multiple barriers for appropriate recognition and treatment in LTC imply the use of a collaborative care model for the management of depression in LTC. Using interdisciplinary collaborative care models as a guide [16], the integration of depression care into LTC typically should consist of:

• • Case identification tools

• • Patient education tools

• • Access to consultation

• • Accessible treatments (including brief psychotherapy)

• • Ongoing monitoring of treatment outcome

One such example of a collaborative care model for the treatment of depression in LTC that has shown promise is the Senior Behavior Health Service project [17]. Another population-based multifaceted shared-care approach for the management of depression in nursing home also seems promising [18].

Summary

The LTC patient population presents with medical, functional, and cognitive issues that complicate the recognition and treatment of depression. This is further complicated by the nature of LTC in which care is provided primarily by paraprofessional workers, who have limited knowledge of depression and its treatments. Not surprisingly, naturalistic studies evaluating the recognition and treatment of depression in LTC are quite dim and indicate that much more needs to be done to improve the care of this high-need population. Current efforts should be made towards further evaluation of treatment modalities for depression in LTC as well as towards the dissemination of already effective models of care within LTC environments. The integration of depression care into LTC through collaborative care models that have already shown to be effective in the treatment of other chronic conditions including depression in primary care might be particularly useful.

Financial & competing interests disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this editorial manuscript.