Assessing and Treating Vulnerable Populations for Depressive Disorders

Assessing and Treating Vulnerable Populations for Depressive Disorders

Depression is a common diagnosis for many people all over the world. Certain populations may be disadvantaged or vulnerable when responding to patients’ needs. The population of older adults should be given special consideration. The goal of this project is to describe the causes and symptoms of depression, as well as how depression is diagnosed, medication treatments available, and special considerations for this vulnerable population.

Causes and Symptoms of Major Depressive Disorder

The Diagnostic and Statistical Manual of Mental Disorders, also known as the DSM-5, can be used to diagnose depression. A person must meet one or both of the following criteria, according to the DSM-5: a depressed mood or a loss of interest in almost all activities. They must also meet at least three or four of the following criteria: significant weight loss or change in appetite, sleep disruption, psychomotor change, fatigue, a sense of worthlessness or guilt, impaired thinking ability, or recurring thoughts of death. These symptoms must be clinically significant (Tolentino & Schmidt, 2018).

It is common for the elderly population to exhibit atypical signs of depression. These may include persistent and unexplained physical symptoms as well as behavioral changes such as irritability, anxiety, sadness, or cognitive symptoms (Avasthi & Grover, 2018).

There is no single cause of depression. In fact, depression may be caused by a combination of factors. However, there are risk factors for depression. Medical conditions, a genetic predisposition, stress, sleep problems, social isolation, a lack of exercise, and functional limitations are examples of these. Dementia is also a risk factor for depression and increases the risk of suicide in those who have the diagnosis (National Institute on Aging, 2021). Dementia symptoms may resemble depression. Furthermore, along with physical pain and male gender, older age is a risk factor for suicide (Avasthi & Grover, 2018).

How Is Depression Diagnosed in Elderly Patients?

Older adults, particularly those over the age of 65, are considered a vulnerable population. They are considered vulnerable due to their increased risk of age-related diseases such as Alzheimer’s and dementia, diabetes, heart disease, mobility issues, or a combination of these conditions. This can have an impact on their access to or ability to receive care (Mid- (American Regional Council, 2017).

There is no single tool for diagnosing depression in the geriatric population, but there are several tools for assessing the severity of depression, ranging from mild to severe. The PHQ-9 is one of these tools. It is a brief questionnaire that asks patients to rate their depression symptoms, such as hopelessness, difficulty concentrating, or appetite changes, on a scale of 0 (not at all) to 3. (nearly every day). There is also the Geriatric Depression Scale, which is designed for the elderly population. It asks similar questions but in a way that is relevant to the older generation, such as whether they are in good spirits or whether their lives have meaning (University of Washington, 2022). This is the most precise for the elderly population (Avasthi & Grover, 2018).

Medication Administration

For older adults, second-generation antidepressants are recommended. This is because these medications have fewer side effects. The American Psychological Association recommends combining psychotherapy and medication treatment (American Psychological Association, 2019).

Many medications have unwanted side effects. GGI upset and distress, weight loss, weight gain, anxiety, insomnia, hyponatremia, and sexual dysfunction are all possible side effects of SSRIs. Side effects of SNRIs may include gastrointestinal upset and distress, an increase in blood pressure, anticholinergic effects, and drowsiness (Avasthi & Grover, 2010). (2018).

These side effects may need to be discussed with each patient in order to determine the risks and benefits. Psychotherapy may also be necessary instead of or in addition to these medications, particularly if better adherence is desired. The risk of these medications, their interactions with other medications, and their effects on the patient’s comorbidities may also need to be weighed against the risk of not treating the depression (Lenze & Ajam, 2019). Cost may also be an issue, as many elderly people are on fixed incomes.

Considerations for Medication

Escitalopram, Sertraline, and Venlafaxine are FDA-approved antidepressants that are relatively safe for the elderly population (U.S. Food & Drug Administration, 2019). They have fewer medication interactions and side effects than other drugs in their class. The most important aspect of these medications should be, to begin with, a lower dosage and gradually increase it as needed.

I would start the patient on Escitalopram 5 mg PO every morning. This medication is generally well-tolerated and does not cause sedation. It has a low number of drug interactions (UpToDate, 2022).

I would start the patient on Sertraline at 12.5 mg PO every morning. The recommended dose is 25 mg every morning, which can be increased after four weeks. This medication is not sedating and has a low risk of cardiac side effects, so it may be worth considering if you have a history of heart disease (UpToDate, 2022).

I would start the patient on 37.5 mg of Venlafaxine once daily, preferably with food. This medication has a higher risk of gastrointestinal upset, so taking it with food may help mitigate this. This may be more useful in patients who did not respond to an SSRI previously and do not have hypertension problems (UpToDate, 2022).

Laboratory and comorbidity monitoring

Because the elderly frequently present with multiple comorbidities, it is critical to monitor both these and laboratory values. Following the start of medication, a four-week checkup should be scheduled, along with information about side effects to look out for and when to contact the provider. Because SSRIs can cause hyponatremia, renal function should be evaluated (Avasthi & Grover, 2018). If the patient’s renal function is normal, renal function panels should be checked at least every six months. BUN, creatinine, GFR, and electrolytes such as sodium, magnesium, potassium, and phosphorus are examples. These tests should be done at the four-week checkup and then every six months.

If the patient has hypertension, he or she does not need to be put on Venlafaxine (UpToDate, 2022). This can lead to an increase in blood pressure, which is currently being treated. A different SNRI should be used.

Many of these medications cause drowsiness as a side effect (UpToDate, 2022). With falls already being a major concern for the elderly population, this must be considered. Will these medications increase the risk of falling? Falls cause a slew of other problems, which is a major consideration for older adults and medication.

Particular Considerations

There are numerous special considerations that must be made for vulnerable populations. For example, HIPAA regulations must always be followed. Nothing about the patient can be shared with anyone other than the patient. There is an exception in the case of depression: if the patient is a danger to themselves or others. This should be communicated to the patient from the start, emphasizing the importance of the patient’s safety and well-being.

There is nothing that can be done for a patient that they do not want to be done, both legally and ethically. A family member may accompany the patient, but it is up to the patient to accept treatment, regardless of the family member’s concerns. Of course, as previously stated, if the patient is a danger to themselves or others, the patient must be committed to inpatient treatment, both legally and ethically.

Culturally, the entire patient must be considered. What is their history? In their experience, how have people viewed mental health? Do they fear being perceived as weak? Mental health has not always been prioritized. It must be communicated that it is acceptable to be sad and to express those feelings (Zisberg, 2017). Mental health is health, and it is critical to maintain that aspect as well.

There are numerous social determinants of health to consider when dealing with the elderly. These could be contributing to the patient’s depression diagnosis, affecting their overall health, or preventing them from receiving treatment for their depression diagnosis. For example, if the patient does not have enough money to buy food and medications, his or her medication adherence may be inadequate. They cannot pick up their medication or attend follow-up appointments if they do not have reliable transportation. If they do not have access to nutritious foods, their comorbidities may suffer (Healthy People 2030, n.d.)

Follow-up in the Community

East Arkansas Area on Aging is an excellent resource for the elderly. Their address is 2005 E Highland Drive, Jonesboro, AR 72401. Their primary goal is to promote aging independence and dignity. They can assist in obtaining rides to doctor’s appointments and medications, as well as in obtaining resources such as home health and caregivers (Area Agency on Aging, n.d.).

Jonesboro, AR, also has two hospitals that serve the surrounding areas. 4800 E. Johnson Avenue, Jonesboro, AR 72401 is the address for NEA Baptist. The address of St. Bernards Regional Medical Center is 225 E. Washington Avenue, Jonesboro, AR 72401. If anyone is experiencing a mental health crisis, they can go to one of these emergency rooms, where adequate mental health care will be provided.

Conclusion

Finally, it is critical to serve vulnerable populations and ensure that they receive the services they require. The elderly are especially vulnerable due to comorbid conditions, social determinants of health, and cultural influences that may cause them to delay seeking mental health care. Special considerations may be required when dealing with the population, particularly when prescribing medication. It is the responsibility of healthcare providers to treat these vulnerable populations and improve their mental and physical health.

Medication                  Benefits                         Side Effects                                       Considerations

Escitalopram           Sertraline                   Venlafaxine	▪    Not many medication interactions ▪     Not sedating	▪    Hyponatremia (low sodium in blood)	▪     Labs will need to be checked to monitor   kidney function
	▪    Not many medication interactions ▪     Lack of cardiovascular side effects	▪     May cause nausea and diarrhea	▪     Labs will need to be checked to monitor   kidney function   ▪     Take this medication with food to avoid   stomach upset.
	▪     Particularly useful for “melancholic mood”   ▪     Useful when not responsive to SSRIs (another class of   antidepressants)	▪     Increase in blood pressure ▪     May cause nausea	▪     Blood pressure monitoring   ▪     Take this medication with food to avoid   stomach upset.

Prescriptions

Escitalopram 5 mg by mouth every morning for depression  quantity: 30 Refills: 0 9/20/2022

Paige Bellinger Sertraline 12.5 mg by mouth every morning for depression Quantity: 30 Refills: 0 9/20/2022

Paige Bellinger Venlafaxine 37.5 mg by mouth every morning for depression Quantity: 30 Refills: 0 9/20/2022

Paige Bellinger

References

American Psychological Association. (2019, August). Depression treatments for older adults.  Clinical Practice Guideline for the Treatment of Depression. https://www.apa.org/depression-guideline/older-adults#:~:text=Medications,combining %20it%20with%20interpersonal%20psychotherapy.

Area Agency on Aging. (n.d.). Quality care and services from East Arkansas area agency on aging. https://www.e4aonline.com/

Avasthi, A., & Grover, S. (2018). Clinical Practice Guidelines for Management of Depression in Elderly. Indian journal of psychiatry, 60(Suppl 3), S341–S362. https://doi.org/10.4103/0019-5545.224474

Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved [date graphic was accessed], from https://health.gov/healthypeople/objectives-and-data/social-determinants-health

Lenze, E. J., & Ajam Oughli, H. (2019). Antidepressant Treatment for Late-Life Depression: Considering Risks and Benefits. Journal of the American Geriatrics Society, 67(8), 1555–1556. https://doi.org/10.1111/jgs.15964

Mid-American Regional Council. (2017, September). Vulnerable Populations. https://marc2.org/healthdata/vpopulations_age.htm

National Institue on Aging. (2021, July 07). Depression and older adults.

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 Criteria and Depression Severity: Implications for Clinical Practice. Frontiers in psychiatry, 9, 450. https://doi.org/10.3389/fpsyt.2018.00450

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For this assignment, you will develop a patient medication guide for the treatment of depressive disorders in a vulnerable population (your choice for one vulnerable patient population to choose from: children, adolescents, older adults, dementia patients, pregnant women, or one not listed of your choice!). Be sure to use language appropriate for your audience (patient, caregiver, parent, etc.). You will include non-copyright images and/or information tables to make your patient medication guide interesting and appealing. Limit your patient medication guide to 5 pages. You will create this guide as an assignment; therefore, a title page, introduction, conclusion, and reference page are required. You must include at least 3 scholarly supporting resources outside of your course-provided resources.

In your patient guide, include a discussion on the following:

• The depressive disorder causes and symptoms
• How is depression diagnosed for the vulnerable population of your choice, and why is this population considered vulnerable?
• Medication treatment options including risk vs benefits, side effects, FDA approvals for the vulnerable population of your choice
• Medication considerations of medication examples prescribed (see last bullet item)
• What is important to monitor in terms of labs, comorbid medical issues, with why important for monitoring
• Special Considerations (you must be specific, not general, and address at least one for EACH category; you must demonstrate critical thinking beyond the basics of HIPPA and informed consent!): legal considerations, ethical considerations, cultural considerations, social determinants of health
• Where to follow up in your local community for further information
• Provide 3 examples of how to write a proper prescription that you would provide to the patient or transmit to the pharmacy.

APA Format

Min 5 pages