Depression disclosures None in the Asian Elderly 9/18/2017 - - PDF document

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9/18/2017

Depression in the Asian Elderly

Descartes Li, M.D. Clinical Professor University of California, San Francisco

disclosures

None

Learning Objectives

By the end of the workshop, participants will be able to:

• Describe common obstacles in the diagnosis and

treatment of depression in the Asian elderly

• Describe cultural aspects of communication
• Understand key differentiating features between Major

Depression and Dementia

Outline

Epidemiology Obstacles to diagnosis Cultural aspects of communication Depression vs. Dementia

2 Outline

Epidem iology Obstacles to diagnosis Cultural aspects of communication Depression vs. Dementia

Case Vignette

An 80-year-old monolingual Chinese retired male plumber is brought in by his wife for evaluation of depression. What is the likelihood he is depressed?

Depression in Am ong Asian Am ericans

Survey of 1,747 adults, 18-65 years of age Predictive factors: social stress, measured by past traumatic events and recent negative life events.

Takeuchi et al. Lifetime and Twelve-Month Prevalence Rates of Major Depressive Episodes and Dysthymia Among Chinese Americans in Los

• Angeles. Am J Psychiatry 1998; 155:1407–1414.

Lifetim e rates: 1 2 -m onth rates

6 .9 % MDE 5 .2 % dysthymia

3 .4 % MDE 0 .9 % dysthymia

Depression in Am ong Aged Asian Am ericans

• Groups divided in to 18-29, 30-49, 50-65
• Age 50-65 tw ice as likely to have

depressive or dysthymic episode

• Immigration at age 41-65, three tim es

more at risk for depression than 0-20, and two times 21-40.

Takeuchi et al. Lifetime and Twelve-Month Prevalence Rates of Major Depressive Episodes and Dysthymia Among Chinese Americans in Los

• Angeles. Am J Psychiatry 1998; 155:1407–1414.

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Prevalence Rate of Depression in Chinese elderly ( in China)

Community- dwelling elderly 1 1 .6 % Elderly medical inpatients 1 8 .1 %

P<0.001

Li N et al. Prevalence of depression and its associated factors among Chinese elderly people: A comparison study between community-based population and hospitalized population. Psychiatry Res. 2016 Sep 30;243:87-91. doi: 10.1016/j.psychres.2016.05.030. Epub 2016 May 27.

Depression in Am ong Aged Asian Am ericans

• Population Study of Chinese Elderly

in Chicago (PINE) study,

• U.S. Chinese older adults aged 60

years and above, n = 3159

• phq-9

Dong X, Chen R, Li C, Simon MA. Understanding depressive symptoms among community-dwelling Chinese older adults in the Greater Chicago area. J Aging Health. 2014;26:1155–1171. doi:10.1177/0898264314527611

Depression in Am ong Aged Asian Am ericans

Dong X, Chen R, Li C, Simon MA. Understanding depressive symptoms among community-dwelling Chinese older adults in the Greater Chicago area. J Aging Health. 2014;26:1155–1171. doi:10.1177/0898264314527611

Severity PHQ-9 score Prevalence in past tw o w eeks Minimal 1-4 3 7 .3 % Mild 5-9 1 3 .3 % Moderate 10-14 2 .8 % Severe > 15 1 .1 %

Depression in Am ong Aged Asian Am ericans

3 .5 % of the participants had suicidal thoughts in the last 2 weeks.

Dong X, Chen R, Li C, Simon MA. Understanding depressive symptoms among community-dwelling Chinese older adults in the Greater Chicago area. J Aging Health. 2014;26:1155–1171. doi:10.1177/0898264314527611

Risk factors: Older age, being female, not being married , lower income, having been in the community for fewer years, lower overall health status, poorer quality of life, and worsening health status over the last year were positively correlated with any depressive symptoms.

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Case Vignette

An 80-year-old monolingual Chinese retired male plumber is brought in by his wife for evaluation of “low energy”. What is the likelihood he is depressed?

Very likely

Outline

Epidemiology Obstacles to diagnosis Cultural aspects of communication Depression vs. Dementia

Case Vignette

An 80-year-old monolingual Chinese retired male plumber is brought in by his wife for evaluation of low energy. What are the most common obstacles in your assessment?

Com m on problem s in evaluation and m anagem ent of depression in the Asian elder:

• Co-morbid medical problems
• Interview barriers: linguistic, cultural
• Differentiating between depression and

dementia

• Definition of depression and stigma
• Differentiating between major depressive

disorder and “situational” depression

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Com m on problem s in evaluation and m anagem ent of depression in the Asian elder:

• Co-m orbid m edical problem s
• I nterview barriers: linguistic, cultural
• Differentiating betw een depression

and dem entia

• Definition of depression and stigma
• Differentiating between major depressive

disorder and “situational” depression

Case Vignette

A 81-year-old monolingual Vietnamese woman with recent heart attack presents in your outpatient clinic with depression for 4 weeks. She reports 5 pound weight loss, little energy or interest in life, poor sleep, feelings of worthlessness/ hopelessnes, and thoughts of death and suicide.

Case Vignette ( continued)

She has been taking aspirin, atorvastatin, metoprolol, lisinopril for the past four weeks. She also uses zolpidem (Ambien) frequently to calm her nerves and for sleep. Her husband reports that her current depressive symptoms are very similar to the

• nes she experienced three years

earlier when she was hospitalized for depression. What are common causes of depressed mood?

Case Vignette ( continued)

Discussion:

• a. recent diagnosis (Adj rxn)
• b. this could be a recurrence (MDD)
• c. Due to a General Medical Condition
• d. multiple medications can cause

depression (Substance-induced Mood Disorder)

• e. Overuse of zolpidem (Substance

abuse)

6 Outline

Epidemiology Obstacles to diagnosis Cultural aspects of com m unication Depression vs. Dementia

Cultural Identity Cultural Aspects of Com m unication

• Direct vs. indirect

(video)

• Verbal vs. non-

verbal emphasis

(taking the history)

Joy Luck Club, 3 m in

https://youtu.be/WhtjwGZlaew

7 Elem ents of non-verbal com m unication

• Kinesics (eye contact,

facial expression)

• Proxemics
• Paralanguage (silences,

rhythm and time)

• Objectics
• Emotional Expressivity

(“inhibited” or “repressed” in a cultural context)

https://en.wikipedia.org/wiki/Nonverbal_communication (basic Wikipedia introduction to the topic) https://www.helpguide.org/articles/relationships-communication/nonverbal-communication.htm Website developed with Harvard Health Publications, with several more useful links at the bottom

Outline

Epidemiology Obstacles to diagnosis Cultural aspects of communication Depression vs. Dem entia

Case Vignette

71yo man complains of poor memory and depressed mood. How would you differentiate between dementia and depression?

Major Neurocognitive Disorder Cognitive impairment due to depression Insight Not aware Aware and concerned Course Slow, often subtle (onset

• ver month/years)

More rapid(onset over days and weeks) Social skills Maintained Lost Memory Loss of recent, not remote memory. Random memory loss Effort Fair Poor, or variable

Bottom Line:

May not be distinguishable, or may be co-morbid

8 Montreal Cognitive Assessment Test (MoCA)

Google: “Mocatest.org”

Outline

Epidemiology Obstacles to diagnosis Cultural aspects of communication Depression vs. Dementia

San Francisco Bay Area Mental Heath Resources

Richm ond Area Multi-Services 3626 Balboa Street San Francisco, CA 94121 (415) 668-5955 www.ramsinc.org info@ramsinc.org Chinatow n/ North Beach Mental Health Services 729 Filbert Street Ph: 415-352-2000 Asian Com m unity Mental Health Services 310 - 8th Street, Suite 201 Oakland, CA 94607 (510) 451-6729 www.acmhs.org On Lok Senior Health Services 1333 Bush Street San Francisco, CA 94109 (415) 292-8888 www.onlok.org info@onlok.org

References

American Association of Retired Persons Minority Affairs Initiative. (1987). A Portrait of Older Minorities. Washington, DC: AARP . Hendricks, J., & Hendricks, C. D. (1986). Aging in Mass Society: Myths and Realities. Boston: Little, Brown and Co. Kii, T. (1984). Asians. In E. B. Palmore (Ed.), Handbook on the Aged in the United States. Westport, CT: Greenwood Press. Kim, P . (1990). "Asian-American Families and the Elderly." In M. S. Harper (Ed.), Minority Aging: Essential Curricula Content for Selected Health and Allied Health Professions. Health Resources and Services Administration, Department of Health and Human Services. DHHS Publication No. HRS-(P-DV-90-4). Washington, DC: U.S. Government Printing Office. Manuel, R., & Reid, J. (1982). "A Comparative Demographic Profile of the Minority and Nonminority Aged." In R. Manuel (Ed.),Minority Aging. Westport, CT: Greenwood Press. Sakauye, K. (1990). "Differential Diagnosis, Medication, Treatment and Outcomes: Asian American Elderly. " In M. S. Harper (Ed.), Minority Aging: Essential Curricula Content for Selected Health and Allied Health Professions (pp.-331-340). Health Resources and Services Administration, Department of Health and Human Services. DHHS Publication No. HRS (P-DV-90-4). Washington, DC: U.S. Government Printing Office.

• Culture, Illness and Care, by Kleinman A, Eisenberg L, and Good B. Annals of Internal Medicine, 1978,

88: 251-258.

• Behavioral Health Care of Asian Americans. Western Journal of Medicine Sept 2002; 176: 217-279.
• Working with Interpreters, by Faust, S, and Drickey R. The Journal of Family Practice, 1986, 22: 131-

138.

• Mental Health Care for Asian Americans and Pacific Islanders. – from Mental Health: Culture, Race, and
• Ethnicity. Supplement to Mental Health: A Report of the Surgeon General. (2001). U.S. Department of

Health and Human Services, Public Health Service.

• Working with Asian Americans: A Guide for Clinicians. Ed. Evelyn Lee. The Guilford Press 1997.

9 Thank you!