Older adults are at an increased risk for depression, but they are often misdiagnosed or undertreated. Primary care physicians play an integral role in identifying and treating depression in these high-risk patients, appropriately screening them using the Patient Health Questionnaire (PHQ-9), and using the findings to develop a comprehensive treatment plan.
Increased risk in older adults and undertreatment
In January 2016, the U.S. Preventive Services Task Force (USPSTF) issued an updated recommendation statement on screening for depression in all adults over the age of 18, including pregnant and postpartum women. The statement recommends that screening be done in the primary care setting, with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.
According to the USPSTF, depression is one of the leading causes of disability in adults. Because it is more common in people who have other illnesses or whose function becomes limited, and 80% of older adults have at least one chronic health condition, the risk for depression is especially significant in this population. In addition to feelings of hopelessness stemming from physical conditions like Parkinson’s disease, stroke, and Alzheimer’s disease, certain life changes common for older people can also increase the risk for depression or exacerbate existing depression. Examples include: moving to a retirement community, children moving away, spouses or close friends passing away, and loss of independence. Along with the high rate of depression in older adults comes disproportionate suicide rate — while older adults make up 12% of the U.S. population, they account for 18% of all suicide deaths.
Unfortunately, depression in older adults often goes undetected. Both health care providers and the patients themselves may mistake common depressive symptoms such as fatigue, trouble sleeping, and appetite loss for natural effects of the aging process.
Screening with the PHQ-9
The PHQ-9 is a reliable, efficient tool for assessing and monitoring the severity of depression in behavioral health patients, serving as a strong base for diagnosis and coordination of follow-up care. The questionnaire, which can be completed by the patient in minutes, rates the frequency of depressive symptoms. A non-scored follow-up question on the PHQ-9 assesses the degree to which the patient’s depression has affected his or her level of function. The treating physician can score the results of the questionnaire rapidly, and can administer the PHQ-9 multiple times throughout the course of treatment to monitor improvement or worsening of depressive symptoms.
Referral for treatment
In most cases, older adults see a notable improvement in their symptoms when provided with an appropriate treatment plan. The care for a patient diagnosed with depression will likely involve collaboration between the PCP and behavioral health practitioners. Treatment plans vary, depending on the frequency and severity of these depressive symptoms; for those with only mild depression (a score of five to nine on the PHQ-9), the recommended course of action is a “watchful waiting” approach, with another PHQ-9 screening being administered at a follow-up appointment. Antidepressant medications are not indicated for the treatment of mild depression. The treatment plan for patients with moderate to severe depression may consist of referring the patient for psychotherapy, prescribing antidepressants, or a combination of both.
How Optum/UBH can help your patients — For complex clinical situations, Optum/UBH is available to provide consultative assistance. Practitioners can call the Optum/UBH Physicians Consultation Service at 800-292-2922. To refer a patient for behavioral health services and to facilitate the coordination of care, call Optum at 888-777-4742.