Depression in the elderly is under-reported

New York City's Department of Health and Mental Hygiene this week announced that depression in senior citizens is "a serious and under diagnosed condition."

An innovative, year-old program at Montefiore Medical Center may offer a model for identifying and treating the homebound elderly with depression. The program trains all of its home care agency staff - nurses, social workers and therapists - to identify patients with depression and refer them to a Montefiore psychiatrist who provides treatment in the patient's home.

"This is the only program in greater New York in which a geriatric psychiatrist is integrated into a home care agency," said Gary Kennedy, MD, director of the initiative and chief of Montefiore's Geriatric Psychiatry program. "Even though one in eight elderly home care patients suffers from depression, few home care agencies incorporate mental health services into their programs - and fewer still provide psychiatric care.

"In our first year of this program, home care nurses, social workers and therapists referred 200 patients and 130 were seen by a psychiatrist," said Dr. Kennedy. "A majority of the patients were elderly and we were successful in reducing their depression."

The three-year experimental program is funded by the UJA Federation of New York, which provided a $150,000 subsidizing grant in 2005.

"The Montefiore Home Health Agency cares for more than 5,000 patients annually and we can estimate that as many as 678 elderly patients could suffer from depression," said Dr. Kennedy. He based this estimate on a study in the American Journal of Psychiatry in 2002, that showed on average 13.5 percent of home care patients suffer from depression. The results to date of Montefiore's new program will be reported at the American Association for Geriatric Psychiatry's annual meeting in March.

"Key to the program's success is training our staff to recognize depression," said Paula Marcus, MD, project psychiatrist in Montefiore's Division of Geriatric Psychiatry. Each nurse, social worker and therapist receives four hours of specialized training sessions.

"Without this training, home care providers would have difficulty making accurate assessments of depression and suicidal tendencies among older home care patients," said Dr. Marcus.

The nurses are trained under a special program operated by the Cornell Home Care Research Partnership. A Montefiore psychiatrist is present at each training session. This establishes a relationship between that psychiatrist and the Home Health Agency staff being trained.

"Depression among elderly home care patients can develop for any number of reasons, but frequently it is a result of a disability (such as a hip fracture), memory loss or loss of a loved one," said Dr. Kennedy. "If a home care nurse recognizes depression, she or he refers the patient to one of the agency's social workers, who consults with a program psychiatrist. Patients with active suicidal tendencies, psychosis and those thought to need medication are referred for psychiatric evaluation," said Dr. Kennedy. "Without psychiatric help, these patients tend to deteriorate physically, as well. They tend to cut back on eating, exercise, socializing and taking their medications. This is what we are working to prevent, loss of quality of life and deteriorating physical health."

Dr. Kennedy says that Medicare and Medicaid currently reimburse for these psychiatric visits, but the level of reimbursement is not adequate. "While inadequate reimbursement may be one factor discouraging psychiatric home care, not having the home care agency staff trained to recognize depression is a larger, more pervasive problem," said Dr. Kennedy.