1 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
Transcript
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9/18/2017
Depression in the Asian Elderly
Descartes Li, M.D.Clinical ProfessorUniversity 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
EpidemiologyObstacles to diagnosis
Cultural aspects of communicationDepression vs. Dementia
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Outline
EpidemiologyObstacles to diagnosis
Cultural aspects of communicationDepression 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 Among Asian Americans
Survey of 1,747 adults, 18-65 years of agePredictive 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.
Lifetime rates: 12-month rates
6.9% MDE5.2% dysthymia
3.4% MDE0.9% dysthymia
Depression in Among Aged Asian Americans
• Groups divided in to 18-29, 30-49, 50-65 • Age 50-65 twice as likely to have
depressive or dysthymic episode• Immigration at age 41-65, three times
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
11.6%
Elderly medical inpatients 18.1%
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 Among Aged Asian Americans
• 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 Among Aged Asian Americans
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
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
EpidemiologyObstacles to diagnosis
Cultural aspects of communicationDepression 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?
Common problems in evaluation and management 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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Common problems in evaluation and management 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
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, lisinoprilfor 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 ones 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 Conditiond. multiple medications can cause
depression (Substance-induced Mood Disorder)
e. Overuse of zolpidem (Substance abuse)
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Outline
EpidemiologyObstacles to diagnosis
Cultural aspects of communicationDepression vs. Dementia
Cultural Identity
Cultural Aspects of Communication
• Direct vs. indirect(video)
• Verbal vs. non-verbal emphasis(taking the history)
Joy Luck Club, 3min
https://youtu.be/WhtjwGZlaew
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Elements of non-verbal communication
• 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)
Website developed with Harvard Health Publications, with several more useful links at the bottom
Outline
EpidemiologyObstacles to diagnosis
Cultural aspects of communicationDepression vs. Dementia
Case Vignette71yo 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 over 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
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Montreal Cognitive Assessment Test
(MoCA)Google: “Mocatest.org”
Outline
EpidemiologyObstacles to diagnosis
Cultural aspects of communicationDepression vs. Dementia
San Francisco Bay Area Mental Heath Resources
Richmond Area Multi-Services3626 Balboa Street San Francisco, CA 94121 (415) 668-5955 [email protected]
Chinatown/North Beach Mental Health Services729 Filbert StreetPh: 415-352-2000
Asian Community Mental Health Services310 - 8th Street, Suite 201 Oakland, CA 94607 (510) 451-6729 www.acmhs.org
On Lok Senior Health Services1333 Bush Street San Francisco, CA 94109 (415) 292-8888 [email protected]
ReferencesAmerican 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.
