Current and future public health is characterized by the increase of chronic and degenerative diseases, corresponding to the worldwide ageing of the population. The increasing prevalence of these conditions together with the long incubation period of the chronic diseases and the continual technological innovations, offer new opportunities to develop strategies for early diagnosis.
Public Health has an important mandate to critically assess the promises and the pitfalls of disease screening strategies. This MOOC will help you understand important concepts for screening programs that will be explored through a series of examples that are the most relevant to public health today. We will conclude with expert interviews that explore future topics that will be important for screening.
By the end of this MOOC, students should have the competency needed to be involved in the scientific field of screening, and understand the public health perspective in screening programs.
This MOOC has been designed by the University of Geneva and the University of Lausanne.
This MOOC has been prepared under the auspices of the Ecole romande de santé publique (www.ersp.ch) by Prof. Fred Paccaud, MD, MSc, Head of the Institute of Social and Preventive Medicine in Lausanne (www.iumsp.ch), in collaboration with Professor Antoine Flahault, MD, PhD, head of the Institute of Global Health, Geneva (https://www.unige.ch/medecine/isg/en/) and Prof. Gillian Bartlett-Esquilant (McGill University, Quebec/ Institute of Social and Preventive Medicine, Lausanne).
From the lesson
Public Mental Health and Screening in Ageing
This module explores the topics of public mental health and screening in the ageing population for neuropsychiatric conditions and physical impairments such as hearing loss. This module is given by several experts including Emiliano Albanese, assistant professor in public mental health in the Department of Psychiatry at the University of Geneva and the Director of the WHO Collaborating Center for Research and Training in mental health at the University of Geneva; Professor Christophe Bula who is the head of the geriatric and geriatric rehabilitation service at the Vaudois University Hospital Centre; Professor Armin von Gunten who is the head of the university service for geriatric psychiatry at the Vaudois University Hospital Service. A quiz will complete this module.
Professor of Public Health and Director of the Institute of Global Health (Faculty of Medicine, University of Geneva) and co-Director of Centre Virchow-Villermé (Université Paris Descartes) University of Geneva and Université Paris Descartes – Sorbonne Paris Cité
Fred Paccaud (In Partnership with UNIGE)
Professor of epidemiology and public health and Director of the Institute of social and preventive medicine Lausanne University Hospital
Gillian Bartlett-Esquilant
Professor of Epidemiology and Research and Graduate Program Director and Associate Chair for the Department of Family Medicine at McGill University. University of Lausannne and McGill University
Hello, I am Amin Fungunton.
Welcome to this video that aims to help you better
understand diagnosis and some general aspects of treatment of
depression in the elderly population so that you can
understand the challenge of screening in this population.
Depression is among the most frequently occurring disorder worldwide.
Approximately, 10% of the world population is
over 65 years of age and about 10% of them have depression.
In other words, about 1% of the world population is both old and depressed.
1% is late-life depression.
As you can see, this frequency is increased in general practice,
hospitals, and nursing home settings.
Depression usually starts at a young age and
many elderly patients with depression have had depression in the past.
Some elderly develop their first depressive episode after 65 years of age.
They have a late onset form of depression.
Depression is a syndrome defined by the presence of a number of
subjective and objective clinical features having lasted for at least two weeks.
Feeling depressed, having anhedonia,
which is the loss of pleasurable feelings,
having lost interest in things and
asthenia meaning lack of energy are core features of depression.
Other additional features include reduced self-esteem,
feelings of guilt, ideas about death or suicide,
attentional deficits, psychomotor slowing or on the contrary agitation,
a variety of sleep disorders and disorders of appetite and eating.
A major depressive episode is diagnosed if at least two core
and two additional features have been present for at least two weeks.
A major depressive episode may be light or of
increasingly severe intensity as the number of features increases.
As you can see in the table,
depression is similar but not entirely
identical in the elderly as compared to younger people.
In the elderly, feeling depressed is often less pronounced.
Patients have physical or memory complaints.
They lack motivation.
Agitation, alcohol, or drug abuse including
new onset abuse can be features of old-age depression.
Suicide is more frequent relative to younger people.
Depression is often post asymptomatic.
This means that it may not encompass
all features of depression as found in younger people.
Telling post asymptomatic depression from
some depressive symptomatology may be difficult in the elderly.
Besides, severity, duration and
the impact of a patient's life may help make the distinction.
Indeed, some functional impairment often accompanies old-age depression.
Importantly, even minor depression
may significantly impair daily functioning in the elderly.
There is hardly any decrease of functional impairment or anhedonia and
no temporal persistence of
depressive symptoms in cases that are not characteristic for depression.
The depressed are often apathetic.
Yet apathy often exists without
depressed feelings in the elderly and suggests a number of
other pathologies such as Subcortical Vascular Encephalopathy or Parkinson's disease.
Of course, these patients can also be depressed.
The causes of depression are numerous,
but hardly ever straightforward.
A linear causal model of the etiology of depression is inadequate.
It is the type and intensity of a stressor,
along with a person's individual level of
vulnerability that determines whether or not depression develops.
There is hardly any stressor that is by itself the single cause of depression.
Stresses and vulnerability factors may be biological,
psychological or social in nature.
Biological factors are for instance a somatic disease such as Parkinson's disease,
vascular disease with or without reduced dependency,
drugs or alcohol abuse.
Psychological and social factors may
be loss of a family member or of one's social status,
a personal conflict, specific personality traits, and many others.
Depression is a brain disorder and
major hyper metabolic changes can be observed in depression.
In lasting and untreated depression,
the number of days of untreated depression
correlates positively with hippocampal atrophy.
There may be a bidirectional relationship between
this type of brain changes and depression.
As for the younger population,
major depression is more of a syndrome than a disease.
Depending on specific clinical or temporal features,
different types of depression may be distinguished.
Of course, bipolar disorder is among the more important ones also in the elderly.
If an elderly person presents with first episode depression,
an underlying vascular brain disease may indicate vascular depression.
Early stage dementia of
different etiologies ought to be considered in the case of late onset depression.
Depression can be prodromal,
meaning an initial presentation of dementia,
and is a frequent feature of mild cognitive impairment that may evolve to its dementia.
Depressive and cognitive features often co-exist.
This should prompt an investigation to
determine if the patient has dementia with effective features.
Depression with cognitive impairment as depression can be
neurotoxic or both dementia and depression.
These distinctions are critical as depression can be efficiently
treated once the correct diagnosis is made.
The high prevalence, the suffering and the high potential for effective treatment
should prompt the clinician to screen for depression in all of their elderly patients.
This is an example of a tool to screen for depression.
Asking a patient whether they often feel discouraged or sad has a 70% sensitivity
and a 90% specificity that
a positive answer is motivated by the presence of a depressive episode.
Unfortunately, depression in the elderly is often not diagnosed.
However, overdiagnosis and inappropriate treatment has also become an issue.
If screening for depression is positive,
further investigations including thorough history taking psychiatric and somatic status,
a complete laboratory parameters as well as
an ECG are required to establish a diagnosis of depression,
depression type, psychiatric and physical co-morbidities
as well as a baseline to initiate treatment.
The aims of the treatment is to complete remission of depression and to prevent suicide.
Treatment is global and considers physical,
functional and social needs the patient may have.
The initial phase is characterized by a close temporal follow up.
Prescribing an antidepressant and asking
the patient to come back in three weeks is not appropriate.
Indeed, the risk of suicide may be high in this initial phase of treatment.
Generally speaking, the risk to commit suicide and to die of
it is much higher in the elderly as compared to the younger population.
Depression and old age besides
alcohol dependency and male sex are among the more important risk factors for suicide.
Psycho-social support may be necessary.
Psychological and biological treatments are available for depression.
Psychological treatments include psycho-education and
various forms of psychotherapy such as cognitive behavior therapy,
interpersonal psychotherapy or psychodynamic psychotherapy.
Biological treatments include antidepressants mainly serotonin,
re-uptake inhibitors, and others.
Electroconvulsive therapy, repeated Transcranial Magnetic Stimulation, and others.
Many of these treatments have a high evidence-base for effectiveness.
Treating depression requires psycho-education, prescribing of medication,
and having psychotherapeutic competence that may need to be
combined depending on the type of depression and the patient's needs.
For instance, severe non-psychotic depression
may require a combined drug and psychotherapeutic approach,
while severe psychotic depression may require
an antidepressant and an anti-psychotic or Electroconvulsive treatment.
Patients with severe depression or with bipolar disorder are usually
referred to a geriatric psychiatrist
or a general psychiatrist used to treating elderly patients.
Referral to a psychiatrist does not only depend on the patient and their disease,
but also on the referring physician's competencies.
Some of the frequently observed mistakes in screening and treatment of
depression include not enough of an initial follow up,
absence of a global approach, inadequate drug dozing,
or prolonged treatment in the absence of
efficacy and the absence of psycho-social support.
Thus, treatment of depression in the elderly may be complex and must take into account
the particularities of the type of depression at the multi-morbidity of the patients.
It often requires multidisciplinary competence.
However, addressing deepening treatment issues is not part of this lecture.
Transferring a patient to a geriatric psychologist
may be appropriate in the case of diagnostic difficulties or doubts.
Severe depression, particularly when there are psychotic features,
when there is a major risk to physical health for
instance refusal to eat or risk of suicide exists.
It is also indicated in the presence of
co-morbidities that are difficult to treat or after treatment failure.
Antoine FlahaultProfessor of Public Health and Director of the Institute of Global Health (Faculty of Medicine, University of Geneva) and co-Director of Centre Virchow-Villermé (Université Paris Descartes)
Fred Paccaud (In Partnership with UNIGE)Professor of epidemiology and public health and Director of the Institute of social and preventive medicine
Gillian Bartlett-EsquilantProfessor of Epidemiology and Research and Graduate Program Director and Associate Chair for the Department of Family Medicine at McGill University.
