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MENTAL HEALTH
CHALLENGES

* Have you made any suicide attempts? (now or in the past?) DIFFERENTIAL DIAGNOSIS
* What is your intent regarding suicide now? Medical causes are numerous, with vascular, metabolic and nutri-
tional factors being at the top of the differential. As with younger
If early questions show interest in life/living, there is no need to patients, substance usage, primarily alcohol, is a common and often
proceed with more questions. undiagnosed cause of depressive illness. Typically, one does not in-
If there are specific plans, with intent, then definite action on the quire about this in geriatric patients, and patents are often not forth-
clinician’s part is indicated. Either involvement of family, emergency coming RE the amount of alcohol consumed daily. A high index
psychiatric consultation, emergency room evaluation, or involve- of suspicion and laboratory testing is usually required. Especially in
ment of police for an involuntary assessment are indicated. LLD, benzodiazepines and/or hypnotic use are commonly found,
and frequently are depressogenic. Often, they are overlooked in im-
SPECIAL SUBTYPES OF DEPRESSION portance as the patient has been taking the same dose for years, but
The absence of certain symptoms should be verified, as their because of a slowed metabolism their effect is much greater. Pa-
presence indicates further diagnostic involvement and/or specific tients will routinely “fight” decreasing them, but almost always ben-
treatment. efit from a slow reduction (over months.) If benzodiazepine dose
* Significant cognitive impairment may be a symptom of depres- is high, the decrease in fatigue and the improvement in mood is
sion, and/or a symptom of a neurocognitive disorder such as de- gratifying to both the patient and provider following slow tapering.
mentia. This is difficult to ascertain in the early diagnostic process
and is more of a “rule out” process than one based upon defini- Objective scales for diagnosing depression in the
tive factors. The term “pseudo-dementia” refers to a depressed geriatric population
patient with poor memory functioning, which clears upon treat- There are three scales commonly used in geriatric setting for
ment of depression. This is complicated as depressive symptoms screening or for objective follow-up for treatment.
may also accompany the onset of dementia. Collateral history * Geriatric Depression Scale with 30 questions.
from family may help clarify whether memory impairment or de- * Geriatric Depression Scale (short form) with 15 questions. These
pressive symptoms came first. However, the important factor is both have been found useful for research quantification but are
whether cognition improves along with depressive symptoms; if not used frequently in clinics.
it does, it was pseudo-dementia, if not the symptoms were indica- * Patient health questionnaire (PHQ – 9) has only nine questions.
tive of early dementia. This is the most commonly used of all the geriatric questionnaires.
* Delusions – fixed, false beliefs which are not modified by rational
discussion (i.e., believing you have a fatal illness in the absence of All of these questionnaires are self-administered, relatively easy
formal diagnosis) may be found in severe depression, bipolar ill- to score, and in the public domain. They should not be used to
ness and/or schizophrenia and will require treatment modification make a diagnosis of depression, but rather to screen for the need
or specialty referral. for a more thorough clinical assessment. They all may be used at
* Visual hallucinations, which tend to imply more drug usage/with- regular intervals to follow improvement following treatment.
drawal issues, brain structural disease, or delirium.
* Auditory hallucinations, may be found in severe depression, bipo- RISK FACTORS
lar illness and/or schizophrenia and will require treatment modi- Although the presence of risk factors do not make the diagnosis,
fication or specialty referral. they serve as indicators for increased clinical attention. Usually, the
more risk factors present, the more likely depressive illness will be
LABORATORY STUDIES found. Some risk factors in LLD are the same as risk factors for de-
As every physician knows, certain illnesses may include depres- pression in younger individuals; such as being female, single, having
sion among their presenting symptoms. In addition to a through chronic medical illness, substance abuse, and a personal or family
physical examination, basic laboratory screening should include history of mental illness. In the geriatric population; loss of a part-
CBC, U/A, thyroid function, comprehensive metabolic profile, and ner or family member, numerous medical illnesses, cognitive im-
levels of B12, vitamin D and folic acid. Borderline values of thyroid pairment, loss of significant sensory or motoric ability, loss of
hormone, B12, folic, or Vitamin D levels may not “cause” depres- independence (driving, mobility, independent living) and social iso-
sion but may impede improvement and should be normalized. lation are additional risk factors to be considered.
continued on page 20
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