Descartes Li, M.D. Clinical Professor University of California, San Francisco Depression disclosures None in the Asian Elderly 9/18/2017 Outline Learning Objectives Epidemiology By the end of the workshop, participants will be able to: • Describe common obstacles in the diagnosis and Obstacles to diagnosis treatment of depression in the Asian elderly Cultural aspects of communication • Describe cultural aspects of communication • Understand key differentiating features between Major Depression vs. Dementia Depression and Dementia 1
Outline Case Vignette Epidem iology An 80-year-old monolingual Chinese retired male Obstacles to diagnosis plumber is brought in by Cultural aspects of communication his wife for evaluation of depression. Depression vs. Dementia What is the likelihood he is depressed? Depression in Am ong Asian Depression in Am ong Aged Am ericans Asian Am ericans • Groups divided in to 18-29, 30-49, 50-65 Lifetim e rates: 1 2 -m onth rates • Age 50-65 tw ice as likely to have depressive or dysthymic episode 6 .9 % MDE 3 .4 % MDE • Immigration at age 41-65, three tim es 0 .9 % dysthymia 5 .2 % dysthymia more at risk for depression than 0-20, and two times 21-40. 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 Takeuchi et al. Lifetime and Twelve-Month Prevalence Rates of Major Depressive Episodes and Dysthymia Among Chinese Americans in Los Depressive Episodes and Dysthymia Among Chinese Americans in Los Angeles. Am J Psychiatry 1998; 155:1407–1414. Angeles. Am J Psychiatry 1998; 155:1407–1414. 2
Depression in Am ong Aged Prevalence Rate of Depression Asian Am ericans in Chinese elderly ( in China) • Population Study of Chinese Elderly in Chicago (PINE) study, • U.S. Chinese older adults aged 60 Community- Elderly medical years and above, n = 3159 dwelling elderly inpatients • phq-9 1 8 .1 % 1 1 .6 % P<0.001 Li N et al. Prevalence of depression and its associated factors among Chinese elderly people: A comparison study between community-based Dong X, Chen R, Li C, Simon MA. Understanding depressive symptoms among community-dwelling Chinese older adults in the population and hospitalized population. Psychiatry Res. 2016 Sep 30;243:87-91. doi: 10.1016/j.psychres.2016.05.030. Epub 2016 May 27. Greater Chicago area. J Aging Health. 2014;26:1155–1171. doi:10.1177/0898264314527611 Depression in Am ong Aged Depression in Am ong Aged Asian Am ericans Asian Am ericans Severity PHQ-9 Prevalence in 3 .5 % of the participants had suicidal score past tw o w eeks thoughts in the last 2 weeks. Minimal 1-4 3 7 .3 % Risk factors: Older age, being female, not being married , Mild 5-9 1 3 .3 % lower income, having been in the community for fewer Moderate 10-14 2 .8 % years, lower overall health status, poorer quality of life, and Severe > 15 1 .1 % worsening health status over the last year were positively correlated with any depressive symptoms. Dong X, Chen R, Li C, Simon MA. Understanding depressive symptoms among community-dwelling Chinese older adults in the 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 Greater Chicago area. J Aging Health. 2014;26:1155–1171. doi:10.1177/0898264314527611 3
Outline Case Vignette Epidemiology An 80-year-old monolingual Chinese retired male Obstacles to diagnosis plumber is brought in by Cultural aspects of communication his wife for evaluation of “low energy”. Depression vs. Dementia What is the likelihood he is depressed? Very likely Com m on problem s in evaluation Case Vignette and m anagem ent of depression in the Asian elder: An 80-year-old monolingual • Co-morbid medical problems Chinese retired male plumber is brought in by • Interview barriers: linguistic, cultural his wife for evaluation of • Differentiating between depression and low energy. What are the most dementia common obstacles in • Definition of depression and stigma your assessment? • Differentiating between major depressive disorder and “situational” depression 4
Com m on problem s in evaluation Case and m anagem ent of depression Vignette in the Asian elder: • Co-m orbid m edical problem s A 81-year-old monolingual • I nterview barriers: linguistic, cultural Vietnamese woman with recent heart attack presents • Differentiating betw een depression in your outpatient clinic with and dem entia depression for 4 weeks. She reports 5 pound weight loss, • Definition of depression and stigma little energy or interest in • Differentiating between major depressive life, poor sleep, feelings of worthlessness/ hopelessnes, disorder and “situational” depression and thoughts of death and suicide. Case Vignette Case Vignette ( continued) ( continued) Discussion: a. recent diagnosis (Adj rxn) She has been taking aspirin, atorvastatin, metoprolol, lisinopril b. this could be a recurrence (MDD) for the past four weeks. She also uses zolpidem (Ambien) c. Due to a General Medical Condition frequently to calm her nerves and for sleep. Her husband reports d. multiple medications can cause that her current depressive symptoms are very similar to the depression (Substance-induced Mood ones she experienced three years Disorder) earlier when she was hospitalized for depression. e. Overuse of zolpidem (Substance What are common causes of abuse) depressed mood? 5
Outline Cultural Identity Epidemiology Obstacles to diagnosis Cultural aspects of com m unication Depression vs. Dementia Cultural Aspects of Joy Luck Club, 3 m in Com m unication • Direct vs. indirect (video) • Verbal vs. non- verbal emphasis (taking the history) https://youtu.be/WhtjwGZlaew 6
Outline Elem ents of non-verbal com m unication • Kinesics (eye contact, Epidemiology facial expression) Obstacles to diagnosis • Proxemics Cultural aspects of communication • Paralanguage (silences, rhythm and time) Depression vs. Dem entia • 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 Major Neurocognitive Cognitive impairment Case Disorder due to depression Vignette Insight Not aware Aware and concerned Course Slow, often subtle (onset More rapid(onset over 71yo man over month/years) days and weeks) complains of poor memory Social and depressed skills Maintained Lost mood. Memory Loss of recent, not remote How would you memory. Random memory loss differentiate Effort between Fair Poor, or variable dementia and depression? Bottom Line: May not be distinguishable, or may be co-morbid 7
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