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Psychiatric consultation in the nursing home: Referral patterns and recognition of depression
Journal of Psychosomatic Research 53 (2002) 783 – 787
Psychiatric consultation in the nursing home: Referral patterns and recognition of depression Raphael J. Leoa,*, Constance Sherrya, Stacey DiMartinoa, Jurgis Karuzab,c a
Department of Psychiatry, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA b Department of Psychology, State University College at Buffalo, Buffalo, NY, USA c Finger Lakes Geriatric Educational Center at the University of Rochester, Rochester, NY, USA Received 17 April 2001; accepted 31 January 2002
Abstract Objective: To assess the accuracy of referrals to psychiatric consultants for depression (or depression-related disorders) among nursing home residents. Methods: Retrospective review of psychiatric consultations for nursing home residents in six facilities for a 3-year period. Reasons for referral, assigned diagnoses, rates of accuracy, sensitivity and specificity were examined to assess patterns of referral and recognition of clinical variants of depressive disorders. Results: Referrals for depression comprised 19.7% of all requested consultations. Of patients referred for depression, 74.2%
were diagnosed with a depressive disorder. Of all residents diagnosed with depressive disorders, 53.5% were referred for other reasons. Men were referred for evaluation of depression significantly more often than women. However, rates of diagnosis of depression did not appear to differ significantly between men and women. Conclusions: Nursing home staff often failed to recognize depression. Depressed residents are primarily referred for disruptive behaviors. Referrals for depression may be a secondary concern. D 2002 Elsevier Science Inc. All rights reserved.
Keywords: Depression; Geriatrics; Nursing Home; Consultation-Liaison Psychiatry
Introduction Among nursing home residents, depression is common as an affective response to illness, disability and adjustment to long-term placement, a symptom of medical illness and a clinical syndrome [1]. Depression rates among nursing home residents have been estimated to be between 6% and 24% [1 –7]. Depression among nursing home residents is associated with higher morbidity, increased requirements of available staff time along with increased mortality rates [3,5,8 – 14]. Comorbid depression among nursing home residents results in amplification of somatic symptoms, e.g., pain [9,12,15] and increased functional disability [9], may portend future cognitive deficits [16] and adversely impacts decisionmaking capacity pertaining to medical interventions and advanced directives [17]. Hence, recognition and treatment
* Corresponding author. Tel.: +1-716-898-4857; fax: +1-716-8985332.
of depression among nursing home residents may reduce patient distress, improve treatment compliance and reduce morbidity and mortality associated with medical illnesses. Unfortunately, depression is often untreated or poorly treated in nursing facilities [14,18]. Reasons for this include poor recognition of depression, inadequate time spent evaluating patients and inappropriate or inadequate trials of medications [5,14,18 – 20]. This study was conducted to assess the clinical perceptions of nursing home staff that prompt a referral for depression. Agreement between reasons for psychiatric referral and the diagnoses assigned by the psychiatric consultant in six nursing facilities were measured along with descriptive analysis of the patterns of referrals for depression.
Methods The psychiatric consultation service is based out of the Erie County Medical Center (ECMC) in Buffalo, NY. Consultations are provided for the skilled nursing facility
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R.J. Leo et al. / Journal of Psychosomatic Research 53 (2002) 783–787
at ECMC and five proprietary nursing facilities within Western New York. When a resident is referred, interviews and consultations are provided on-site. If hospitalization for medical/surgical reasons is required, the consultation service follows the resident hospitalized at ECMC, addresses any comorbid psychiatric and behavioral issues and facilitates eventual transfer back to the nursing home. Referrals for psychiatric consultation require a physician’s order for such a request, specifying the reason for the consultation. In reality, however, the physician’s order may actually be requested by nursing staff and social workers who have on-going contact with, and observe behavior changes among, the nursing home residents. A retrospective review of psychiatric consultations completed for residents during a consecutive 3-year period from January 1, 1997 to December 31, 1999 was undertaken. Copies of consultations kept on file with the psychiatric service were abstracted and coded for analysis. All consultation were completed by a single board-certified psychiatrist (R.L.) for purposes of ensuring consistency. Consultations included in the study were those completed for patients referred for assessment of depression or depressive symptoms or which indicated that a diagnosis of a depressive disorder was assigned. Depressive disorders consisted of Major Depression, Dysthymic Disorder, Depressive Disorder NOS, Depression due to general medical conditions or medication use, Adjustment Disorder with depressed mood, Adjustment Disorder with depressed and anxious mood, Bipolar I disorder-depressed and Dementia with depressive features. Data abstracted for analysis included demographic information, reason for consultation request (if other than for assessment of depression) and psychiatric diagnoses assigned at the time of consultation. c2 analyses and Fisher’s Exact Tests were performed to determine whether significant gender differences exist. Psychiatric evaluation of all nursing home residents was not possible. Defining all of the residents referred to the psychiatric consultation service as the ‘‘population,’’ sensitivity rates (true positives, i.e., residents correctly identified as depressed by staff, divided by the total numbers of iden-
tified depressed residents) and specificity rates (true negatives, i.e., residents correctly identified as nondepressed, divided by the total numbers of nondepressed residents) were calculated.
Results Residents (n = 4323, 882 men and 3441 women) were admitted to the aforementioned facilities during the 3 years of this study. Psychiatric consultations were provided for 451 patients, 139 (30.8%) men and 312 (69.2%) women. Significantly more men (15.8%, 139/882) than women (9.1%, 312/3441) were referred for psychiatric consultation (c2 = 32.9, df = 1, P < .0001). Depression as a reason for referral Eighty-nine residents were referred for the assessment of depression, representing 2.1% (89/4323) of all nursing home residents admitted during the 3-year span of this investigation and 19.7% (89/451) of all residents referred for consultation. Significantly fewer women (1.5%, 53/ 3441) were referred for depression than men (4.1%, 36/ 882) (c2 = 21.2, df = 1, P < .0001). Forty-five percent of those referred for a suspected depression had a prior psychiatric evaluation or treatment prior to nursing home admission. Proportions of female (n = 28, 52.8%) and male residents (n = 12, 32.3%) referred for a presumed depression who had prior psychiatric evaluation/treatment were not significantly different (c2 = 2.6, df = 1, P = .11). Significantly more women (n = 15, 28.3%) than men (n = 2, 5.6%) had been previously diagnosed with depressive disorders (c2 = 5.78, df = 1, P < .02). Rates of diagnosis of depression Residents (142/451, 31.5%) referred to the consultation service were diagnosed with a depressive disorder. Females and males diagnosed with depression or depression-related
Table 1 Frequencies of patients referred for depression and diagnosed with depressive disorders Referred for Depression [n (%)] Entire sample Depressed Not depressed Total Female residents Depressed Not depressed Total Male residents Depressed Not depressed Total
Other reasons [n (%)]
Totals [n (%)]
66 (74.2) 23 (25.8) 89 (100)
76 (21) 286 (79) 362 (100)
142 (31.5) 309 (68.5) 451 (100)
35 (66) 18 (34) 53 (100)
57 (22) 202 (78) 259 (100)
92 (29.5) 220 (70.5) 312 (100)
31 (86.1) 5 (13.9) 36 (100)
19 (18.4) 84 (81.6) 103 (100)
50 (36) 89 (64) 139 (100)
False positives
False negatives
Sensitivity/specificity (%)
23
76
46.5/92.6
18
57
38/91.8
5
19
62/94.4
R.J. Leo et al. / Journal of Psychosomatic Research 53 (2002) 783–787
785
Table 2 Reasons for referral of residents diagnosed with depression (false negatives)a
Behavior problems Anxiety Suicide assessment Adjustment of psychotropics Confusion Psychosis Capacity Total a b c
Malesb [n (%)]
Femalesc [n (%)]
Total
9 5 4 1 0 0 1 20
46 3 3 6 4 2 0 64
55 8 7 7 4 2 1 84
(45) (25) (20) (5) (0) (0) (5) (100)
(71.9) (4.7) (4.7) (9.4) (6.3) (3.1) (0) (100)
(65.5) (9.5) (8.3) (8.3) (4.8) (2.4) (1.2) (100)
Fisher’s Exact Tests were performed when sample sizes were too small to allow for c2 analyses. One patient had two reasons for referral. Seven patients had two reasons for referral.
disorder were 92 (64.8%) and 50 (35.2%), respectively, which did not differ significantly ( P = .17). One man and 10 women, who were previously diagnosed with a depressive disorder, received a concurring diagnosis.
cificity rates were obtained, i.e., 94.4% and 91.8%, respectively. These are summarized in Table 1.
Accuracy rates, sensitivity and specificity of referrals for depression
Among patients diagnosed with depressive disorders, 62% (31/50) of men and 38% (35/92) of women were referred for assessment of depression. Significantly higher proportions of depressed men were referred for a suspected depression than were depressed women (c2 = 6.54, df = 1, P < .05). The reasons for referral for patients ultimately diagnosed as depressed but referred for reasons other than depression are summarized in Table 2. More than one reason for referral may have been applied to a patient. Of the false negative referrals, most were referred for behavior problems (65.5%). Comparisons among female and male residents revealed that only rates of referrals for anxiety were significantly different between the two groups (Fisher’s Exact Test, P < .05).
Among the 89 residents referred for depression, 66 (74.2%) were diagnosed with a depressive disorder (see Table 1). Sixty-six percent (35/53) of females and 86.1% (31/36) of males referred for depression were ultimately diagnosed with a depressive disorder. With regard to accuracy rates, referrals for depression were no more likely to yield a depression diagnosis for men versus women (c2 = 3.52, df = 1, P = .06). On the other hand, 76 residents (53.5%) diagnosed with depressive disorders were referred to the consultation service for reasons other than for assessment of depression (false negatives). In addition, 23 patients referred for depression were diagnosed with other psychiatric disorders (false positives). The sensitivity rate for all the subjects was 46.5%, while specificity was 92.6%. The sensitivity rates were higher for men (62%) than women (38%), whereas comparable spe-
Table 3 Diagnoses assigned to residents referred for depression (false positives)a
Dementia [n (%)] Alzheimer’s type Vascular type Due to head trauma NOS Anxiety disorders [n (%)] Adjustment disorders [n (%)] Bereavement [n (%)] Bipolar disorder [n (%)] Psychosomatic disorders [n (%)] Somatoform disorders [n (%)] Total [n (%)] a
Males
Females
Total
4 1 0 1 2 0 1 1 0 0 0 6
12 6 1 1 4 4 2 1 1 1 1 22
16 7 1 2 6 4 3 2 1 1 1 28
(66.7)
(0) (16.7) (16.7) (0) (0) (0) (100)
(54.5)
(18.2) (9.1) (4.5) (4.5)
(100)
(57.1)
(14.3) (10.7) (7.1) (3.6) (3.6) (3.6) (100)
Fisher’s Exact Tests were performed as sample sizes were too small to allow for c2 analyses.
Reasons for referral
Diagnoses assigned to patients referred for depression (false positives) The diagnoses assigned to patients incorrectly referred for depression and ultimately diagnosed with another psychiatric condition are summarized in Table 3. Fifty-seven percent of those referred for suspected depression were diagnosed with dementia. No significant differences were observed in the frequencies of diagnoses assigned to women and men referred for depression but who were found to have another psychiatric condition.
Discussion Nearly 20% of all consultation requests during the 3 years of this study were for a suspected depression. Nursing home staff detect depression poorly, inappropriately suspecting it in one-fourth of patients referred for depression. They also failed to recognize a majority of residents with depression, i.e., referred for other reasons. Therefore, there
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are concerns that symptoms of depression may be overlooked or misinterpreted. Among patients referred for a suspected depression, 25.8% were not diagnosed with a depressive disorder (false positives). Staff may have attended to clinical signs or features of depression, e.g., sadness, irritability, flat or restricted affect, decline in self-care, etc., which can be present in other conditions, e.g., dementia, anxiety, etc. Previous research has suggested that patients with dementia may be misdiagnosed as having an affective disorder [21,22]. Nonpsychiatric staff may have been misled by symptoms of medical illnesses mimicking those of depression, e.g., fatigue, sleep and appetite disturbances, or by the prior psychiatric history of a depressive disorder. On the one hand, credit should be given to the staff for recognizing that a problem exists among nursing home residents warranting psychiatric evaluation. However, among patients diagnosed with depressive disorders, over 53% were referred for reasons other than the evaluation/ assessment of depression (false negatives). Clearly, it is not expected that nursing home staff would conduct a diagnostic assessment prior to generating the referral for psychiatric consultation. Nonetheless, ambiguous complaints, a tendency to somatize or to complain of cognitive deficits [23], as would occur in pseudodementia [24], can lead to patients being mislabeled, i.e., viewed as problematic but not depressed. It is conceivable that nonpsychiatric staff may recognize that a patient is distressed or displaying a change in behaviors, but the prospect that this may reflect an underlying depression may not have been entertained. Still, for other residents noted to display depressive symptoms, attributions that depressive symptoms are an expected reaction to illness or placement may interfere with appropriate referral to the consultation service [1]. Review of the reasons for referral of the false negatives (see Table 2) indicates that most depressed patients were referred for issues pertaining to ‘‘management’’ in the nursing facility. Concerns about patient safety, e.g., referrals for suicide assessment or confusion, or patient cooperation with treatment, e.g., referrals for behavior problems and capacity, may have been a more urgent concern than diagnosis or treatment of a possible underlying depression. Previous studies have likewise demonstrated that referring services focus on behavior problems/disruptive behaviors and disposition issues rather than identifying and treating underlying psychiatric disorders [19,25]. There tends to be little correlation with the reasons for consultation request and psychiatric conditions present [19]. The concern arises that the quietly depressed resident, whose overt behavior does not present difficulties for staff, may go unrecognized or untreated. Unfortunately, the retrospective nature of this study does not permit cross-validation of the diagnoses assigned to patients. Standardized scales or structured interviews were not employed and measures of intrarater reliability were not possible. In addition, even though a reason for a psychiatric referral is obtained at the time of consultation request, it
may be possible that little thought went into the reported reasons for referral. Consequently, one cannot always be certain of the validity of the documented reasons for referral in this study. In addition, true measures of sensitivity and specificity could not be ascertained, as all nursing home residents would have had to be assessed for depression, against which to compare referrals. Alternatively, it is possible that primary care physicians treating nursing home residents adequately assess, and treat, depression. The data presented here may only reflect referral patterns for those residents whose symptoms were ambiguous or whose depressions were deemed to be refractory, thereby prompting referral. Yet, the present data appear to be consistent with prior studies evaluating the assessment, and treatment, of depression in the nursing facility [5,14,18 – 20] and suggest that depression remains poorly recognized and inadequately treated. As to the issue of gender differences in patterns of referral, it is not possible by means of a chart review to determine what factors determine whether a psychiatric consultation is requested in general and whether these factors differ for men and women specifically. Significantly more men than women were referred for psychiatric consultation. The expectation that rates of depression would be higher among women than men may have adversely affected the sensitivity rates observed here among women referred for depression. Consequently, any observed behavior change noted among female residents prompting psychiatric referral may have been erroneously ascribed to depression, thereby reducing sensitivity rates as compared with men. Rationale for on-site psychiatric consultation Depressive illness is widespread among elder persons, but prevalence rates for depression are higher among nursing home residents as compared with elders living in the community [26]. These findings suggest that nursing home patients may be particularly vulnerable to being overlooked for the referral, diagnosis and treatment of depression. As of 1995, there were 16,700 nursing homes in the United States and approximately 1.5 million nursing home residents [27]. Because the elderly constitute the largest growing segment of the population [28] and because hospitals expedite discharge compelling nursing facilities to assume a larger role in subacute care, it is anticipated that the number of individuals requiring nursing home care will increase dramatically [29,30]. The demand for psychiatric consultants in the nursing facility will likewise be expected for increase. Lately, compensation for psychiatric consultation within the nursing home has become increasingly restrictive. For example, in the United States, Medicare Part B will only compensate consultants if there has been adequate documentation in the medical record supporting evidence of a serious condition, e.g., depression, for which previous treatment attempts have failed. Such restrictions can potentially undermine the availability of on-site psychiatric consulta-
R.J. Leo et al. / Journal of Psychosomatic Research 53 (2002) 783–787
tions. Evaluation of the resident within the facility allows for direct observation of resident behaviors, interactions between staff and the resident, and allow for collateral information to be obtained from staff who have observed and interacted with the resident. Staff interview can delineate symptoms deemed problematic, clarify precipitants for problematic behaviors and characterize the nature and extent of patient involvement in activities as well as staff and peer interactions, which might not otherwise be gleaned from an office-based evaluation. Nursing home staff assessment of resident depression can be a valuable source of information for the consulting psychiatrist. Because nursing home staff spend large amounts of time with residents and have a longitudinal perspective of a resident’s behaviors, their assessment of resident depression tended to correspond with those psychiatric consultants [14]. Furthermore, the consultant, in addition to recommending appropriate laboratory investigation and use of psychotropics, can educate staff as to how to provide more therapeutic interventions to reduce patient distress [31]. The latter would also be less likely to occur if the patient were transferred to a psychiatrist’s office for evaluation and consultation. Heightened awareness of comorbid depression in nursing home residents is needed [32]. The psychiatrist, working collaboratively with geriatric physicians, social workers and nursing staff, can improve the recognition and treatment of depression among residents. This can take the form didactic instruction, case reviews and case discussion. Improved treatment of depression can, in addition to reducing distress, improve treatment compliance, reduce demands made on staff/support services and reduce morbidity and mortality associated with comorbid medical conditions [13,14,33].
References [1] Samuels SC, Katz IB. Depression in the nursing home. Psychiatr Ann 1995;25:419 – 24. [2] Baker FM, Miller CL. Screening a skilled nursing home population for depression. J Geriatr Psychiatry Neurol 1991;4:218 – 21. [3] Katz IR, Lesher E, Kleban M, Jethanandani V, Parmelee P. Clinical features of depression in the nursing home. Int Psychogeriatr 1989;1: 5 – 15. [4] Parmelee PA, Lawton MP, Katz IR. Psychometric properties of the geriatric depression scale among the institutionalized aged. Psychol Assess: J Consult Clin Psychol 1989;1:331 – 8. [5] Rovner BW, German PS, Brant LJ, Clark R, Burton L, Folstein MF. Depression and mortality in nursing homes. J Am Med Assoc 1991; 265:993 – 6. [6] Rovner BW, German PS, Broadhead J, Morriss RK, Brant LJ, Blaustein J, Folstein MF. The prevalence and management of dementia and other psychiatric disorders in nursing homes. Int Psychogeriatr 1990; 2:13 – 24. [7] Tariot PN, Podgorski CA, Blazina L, Leibovici A. Mental disorders in the nursing home: another perspective. Am J Psychiatry 1993; 150:1063 – 9. [8] Cohen-Mansfield J, Marx MS. Pain and depression in the nursing home: corroborating results. J Gerontol 1993;48:96 – 7. [9] Fries BE, Mehr DR, Schneider D, Foley WJ, Burke R. Mental dysfunction and resource use in nursing homes. Med Care 1993;31:898 – 920.
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[10] Katz IR, Beaston-Wimmer P, Parmelee PA, Friedman E, Lawton MP. Failure to thrive in the elderly: exploration of the concept and delineation of psychiatric concepts. J Geriatr Psychiatry Neurol 1993;6: 161 – 9. [11] Morley JE, Kraenzle D. Causes of weight loss in a community nursing home. J Am Geriatr Soc 1994;42:583 – 5. [12] Parmelee PA, Katz IR, Lawton MP. The relation of pain to depression among institutionalized aged. J Gerontol 1991;46:15 – 21. [13] Parmelee PA, Katz IR, Lawton MP. Depression and mortality among institutionalized aged. J Gerontol 1992;47:3 – 10. [14] Rovner BW. Depression and increased risk of mortality in the nursing home patient. Am J Med 1993;94(Suppl 5A):19 – 22. [15] Parmelee PA, Smith B, Katz IR. Pain complaints and cognitive status among elderly institution residents. J Am Geriatr Soc 1993; 41:517 – 22. [16] Parmelee PA, Kleban MH, Lawton MP, Katz IR. Depression and cognitive change among institutionalized aged. Psychol Aging 1991;6:504 – 11. [17] Gerety MB, Chiodo LK, Kanten DN, Tuley MR, Cornell JE. Medical treatment preferences of nursing home residents: relationship to function and concordance with surrogate decision-makers. J Am Geriatr Soc 1993;41:953 – 60. [18] Heston LL, Garrard J, Makris L, Kane RL, Cooper S, Dunham T, Zelterman D. Inadequate treatment of depressed nursing home elderly. J Am Geriatr Soc 1992;40:1117 – 22. [19] Loebel JP, Borson S, Hyde T, Donaldson D, Van Tuinen C, Rabbitt TM, Boyko EJ. Relationships between requests for psychiatric consultations and psychiatric diagnoses in long-term-care facilities. Am J Psychiatry 1991;148:898 – 903. [20] Teeter RB, Garetz FK, Miller WR, Heiland WF. Psychiatric disturbances of aged patients in skilled nursing homes. Am J Psychiatry 1976;133:1430 – 4. [21] Winstead DK, Mielke DH, O’Neill PT. Diagnosis and treatment of depression in the elderly: a review. Psychiatr Med 1990;8: 85 – 98. [22] Yesavage J. Differential diagnosis between depression and dementia. Am J Med 1993;94(Suppl 5A):23 – 8. [23] Grossberg GT, Hassan R, Szwabo PA, Morley JE, Nakra BRS, Bretscher CW, Zimny GH, Solomon K. Psychiatric problems in the nursing home. J Am Geriatr Soc 1990;38:907 – 17. [24] Wells CE. Pseudodementia. Am J Psychiatry 1979;136:895 – 900. [25] Borson S, Liptzin B, Nininger J, Rabins P. Psychiatry and the nursing home. Am J Psychiatry 1987;144:1412 – 8. [26] Lebowitz BD. Diagnosis and treatment of depression in late life: an overview of the NIH Consensus statement. Am J Geriatr Psychiatry 1996;4(Suppl 1):3 – 6. [27] National Center For Health Statistics. Advance data (Number 280). Hyattsville (MD): Public Health Service, 1997. p. 3. [28] U.S. Bureau of the Census. Population projections of the United States by age, sex, race, and Hispanic origin: 1995 to 2050. Current Population Reports, P25-1130, U.S. Government Printing Office, Washington, DC, 1996. [29] Manton KG, Soldo BJ. Dynamics of health changes in the oldest old: new perspectives and evidence. Milbank Meml Fund Q Health Soc 1985;63:206 – 85. [30] Soldo BJ, Manton KG. Health status and service needs of the oldest old: current patterns and future trends. Milbank Meml Fund Q Health Soc 1985;63:286 – 319. [31] Streim JE, Katz IR. The psychiatrist in the nursing home: part II. Consultation, primary care, and leadership. Psychiatr Serv 1995; 46:339 – 41. [32] Libow LS, Starer P. Care of the nursing home patient. N Engl J Med 1989;321:93 – 6. [33] Katon W, Von Korff M, Lin E, Simon G, Walker E, Bush T, Ludman E. Collaborative management to achieve depression treatment guidelines. J Clin Psychiatry 1997;58:20 – 3 (Suppl).
Psychiatric consultation in the nursing home: Referral patterns and recognition of depression Raphael J. Leoa,*, Constance Sherrya, Stacey DiMartinoa, Jurgis Karuzab,c a
Department of Psychiatry, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA b Department of Psychology, State University College at Buffalo, Buffalo, NY, USA c Finger Lakes Geriatric Educational Center at the University of Rochester, Rochester, NY, USA Received 17 April 2001; accepted 31 January 2002
Abstract Objective: To assess the accuracy of referrals to psychiatric consultants for depression (or depression-related disorders) among nursing home residents. Methods: Retrospective review of psychiatric consultations for nursing home residents in six facilities for a 3-year period. Reasons for referral, assigned diagnoses, rates of accuracy, sensitivity and specificity were examined to assess patterns of referral and recognition of clinical variants of depressive disorders. Results: Referrals for depression comprised 19.7% of all requested consultations. Of patients referred for depression, 74.2%
were diagnosed with a depressive disorder. Of all residents diagnosed with depressive disorders, 53.5% were referred for other reasons. Men were referred for evaluation of depression significantly more often than women. However, rates of diagnosis of depression did not appear to differ significantly between men and women. Conclusions: Nursing home staff often failed to recognize depression. Depressed residents are primarily referred for disruptive behaviors. Referrals for depression may be a secondary concern. D 2002 Elsevier Science Inc. All rights reserved.
Keywords: Depression; Geriatrics; Nursing Home; Consultation-Liaison Psychiatry
Introduction Among nursing home residents, depression is common as an affective response to illness, disability and adjustment to long-term placement, a symptom of medical illness and a clinical syndrome [1]. Depression rates among nursing home residents have been estimated to be between 6% and 24% [1 –7]. Depression among nursing home residents is associated with higher morbidity, increased requirements of available staff time along with increased mortality rates [3,5,8 – 14]. Comorbid depression among nursing home residents results in amplification of somatic symptoms, e.g., pain [9,12,15] and increased functional disability [9], may portend future cognitive deficits [16] and adversely impacts decisionmaking capacity pertaining to medical interventions and advanced directives [17]. Hence, recognition and treatment
* Corresponding author. Tel.: +1-716-898-4857; fax: +1-716-8985332.
of depression among nursing home residents may reduce patient distress, improve treatment compliance and reduce morbidity and mortality associated with medical illnesses. Unfortunately, depression is often untreated or poorly treated in nursing facilities [14,18]. Reasons for this include poor recognition of depression, inadequate time spent evaluating patients and inappropriate or inadequate trials of medications [5,14,18 – 20]. This study was conducted to assess the clinical perceptions of nursing home staff that prompt a referral for depression. Agreement between reasons for psychiatric referral and the diagnoses assigned by the psychiatric consultant in six nursing facilities were measured along with descriptive analysis of the patterns of referrals for depression.
Methods The psychiatric consultation service is based out of the Erie County Medical Center (ECMC) in Buffalo, NY. Consultations are provided for the skilled nursing facility
0022-3999/02/$ – see front matter D 2002 Elsevier Science Inc. All rights reserved. PII: S 0 0 2 2 - 3 9 9 9 ( 0 2 ) 0 0 3 3 4 - 3
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R.J. Leo et al. / Journal of Psychosomatic Research 53 (2002) 783–787
at ECMC and five proprietary nursing facilities within Western New York. When a resident is referred, interviews and consultations are provided on-site. If hospitalization for medical/surgical reasons is required, the consultation service follows the resident hospitalized at ECMC, addresses any comorbid psychiatric and behavioral issues and facilitates eventual transfer back to the nursing home. Referrals for psychiatric consultation require a physician’s order for such a request, specifying the reason for the consultation. In reality, however, the physician’s order may actually be requested by nursing staff and social workers who have on-going contact with, and observe behavior changes among, the nursing home residents. A retrospective review of psychiatric consultations completed for residents during a consecutive 3-year period from January 1, 1997 to December 31, 1999 was undertaken. Copies of consultations kept on file with the psychiatric service were abstracted and coded for analysis. All consultation were completed by a single board-certified psychiatrist (R.L.) for purposes of ensuring consistency. Consultations included in the study were those completed for patients referred for assessment of depression or depressive symptoms or which indicated that a diagnosis of a depressive disorder was assigned. Depressive disorders consisted of Major Depression, Dysthymic Disorder, Depressive Disorder NOS, Depression due to general medical conditions or medication use, Adjustment Disorder with depressed mood, Adjustment Disorder with depressed and anxious mood, Bipolar I disorder-depressed and Dementia with depressive features. Data abstracted for analysis included demographic information, reason for consultation request (if other than for assessment of depression) and psychiatric diagnoses assigned at the time of consultation. c2 analyses and Fisher’s Exact Tests were performed to determine whether significant gender differences exist. Psychiatric evaluation of all nursing home residents was not possible. Defining all of the residents referred to the psychiatric consultation service as the ‘‘population,’’ sensitivity rates (true positives, i.e., residents correctly identified as depressed by staff, divided by the total numbers of iden-
tified depressed residents) and specificity rates (true negatives, i.e., residents correctly identified as nondepressed, divided by the total numbers of nondepressed residents) were calculated.
Results Residents (n = 4323, 882 men and 3441 women) were admitted to the aforementioned facilities during the 3 years of this study. Psychiatric consultations were provided for 451 patients, 139 (30.8%) men and 312 (69.2%) women. Significantly more men (15.8%, 139/882) than women (9.1%, 312/3441) were referred for psychiatric consultation (c2 = 32.9, df = 1, P < .0001). Depression as a reason for referral Eighty-nine residents were referred for the assessment of depression, representing 2.1% (89/4323) of all nursing home residents admitted during the 3-year span of this investigation and 19.7% (89/451) of all residents referred for consultation. Significantly fewer women (1.5%, 53/ 3441) were referred for depression than men (4.1%, 36/ 882) (c2 = 21.2, df = 1, P < .0001). Forty-five percent of those referred for a suspected depression had a prior psychiatric evaluation or treatment prior to nursing home admission. Proportions of female (n = 28, 52.8%) and male residents (n = 12, 32.3%) referred for a presumed depression who had prior psychiatric evaluation/treatment were not significantly different (c2 = 2.6, df = 1, P = .11). Significantly more women (n = 15, 28.3%) than men (n = 2, 5.6%) had been previously diagnosed with depressive disorders (c2 = 5.78, df = 1, P < .02). Rates of diagnosis of depression Residents (142/451, 31.5%) referred to the consultation service were diagnosed with a depressive disorder. Females and males diagnosed with depression or depression-related
Table 1 Frequencies of patients referred for depression and diagnosed with depressive disorders Referred for Depression [n (%)] Entire sample Depressed Not depressed Total Female residents Depressed Not depressed Total Male residents Depressed Not depressed Total
Other reasons [n (%)]
Totals [n (%)]
66 (74.2) 23 (25.8) 89 (100)
76 (21) 286 (79) 362 (100)
142 (31.5) 309 (68.5) 451 (100)
35 (66) 18 (34) 53 (100)
57 (22) 202 (78) 259 (100)
92 (29.5) 220 (70.5) 312 (100)
31 (86.1) 5 (13.9) 36 (100)
19 (18.4) 84 (81.6) 103 (100)
50 (36) 89 (64) 139 (100)
False positives
False negatives
Sensitivity/specificity (%)
23
76
46.5/92.6
18
57
38/91.8
5
19
62/94.4
R.J. Leo et al. / Journal of Psychosomatic Research 53 (2002) 783–787
785
Table 2 Reasons for referral of residents diagnosed with depression (false negatives)a
Behavior problems Anxiety Suicide assessment Adjustment of psychotropics Confusion Psychosis Capacity Total a b c
Malesb [n (%)]
Femalesc [n (%)]
Total
9 5 4 1 0 0 1 20
46 3 3 6 4 2 0 64
55 8 7 7 4 2 1 84
(45) (25) (20) (5) (0) (0) (5) (100)
(71.9) (4.7) (4.7) (9.4) (6.3) (3.1) (0) (100)
(65.5) (9.5) (8.3) (8.3) (4.8) (2.4) (1.2) (100)
Fisher’s Exact Tests were performed when sample sizes were too small to allow for c2 analyses. One patient had two reasons for referral. Seven patients had two reasons for referral.
disorder were 92 (64.8%) and 50 (35.2%), respectively, which did not differ significantly ( P = .17). One man and 10 women, who were previously diagnosed with a depressive disorder, received a concurring diagnosis.
cificity rates were obtained, i.e., 94.4% and 91.8%, respectively. These are summarized in Table 1.
Accuracy rates, sensitivity and specificity of referrals for depression
Among patients diagnosed with depressive disorders, 62% (31/50) of men and 38% (35/92) of women were referred for assessment of depression. Significantly higher proportions of depressed men were referred for a suspected depression than were depressed women (c2 = 6.54, df = 1, P < .05). The reasons for referral for patients ultimately diagnosed as depressed but referred for reasons other than depression are summarized in Table 2. More than one reason for referral may have been applied to a patient. Of the false negative referrals, most were referred for behavior problems (65.5%). Comparisons among female and male residents revealed that only rates of referrals for anxiety were significantly different between the two groups (Fisher’s Exact Test, P < .05).
Among the 89 residents referred for depression, 66 (74.2%) were diagnosed with a depressive disorder (see Table 1). Sixty-six percent (35/53) of females and 86.1% (31/36) of males referred for depression were ultimately diagnosed with a depressive disorder. With regard to accuracy rates, referrals for depression were no more likely to yield a depression diagnosis for men versus women (c2 = 3.52, df = 1, P = .06). On the other hand, 76 residents (53.5%) diagnosed with depressive disorders were referred to the consultation service for reasons other than for assessment of depression (false negatives). In addition, 23 patients referred for depression were diagnosed with other psychiatric disorders (false positives). The sensitivity rate for all the subjects was 46.5%, while specificity was 92.6%. The sensitivity rates were higher for men (62%) than women (38%), whereas comparable spe-
Table 3 Diagnoses assigned to residents referred for depression (false positives)a
Dementia [n (%)] Alzheimer’s type Vascular type Due to head trauma NOS Anxiety disorders [n (%)] Adjustment disorders [n (%)] Bereavement [n (%)] Bipolar disorder [n (%)] Psychosomatic disorders [n (%)] Somatoform disorders [n (%)] Total [n (%)] a
Males
Females
Total
4 1 0 1 2 0 1 1 0 0 0 6
12 6 1 1 4 4 2 1 1 1 1 22
16 7 1 2 6 4 3 2 1 1 1 28
(66.7)
(0) (16.7) (16.7) (0) (0) (0) (100)
(54.5)
(18.2) (9.1) (4.5) (4.5)
(100)
(57.1)
(14.3) (10.7) (7.1) (3.6) (3.6) (3.6) (100)
Fisher’s Exact Tests were performed as sample sizes were too small to allow for c2 analyses.
Reasons for referral
Diagnoses assigned to patients referred for depression (false positives) The diagnoses assigned to patients incorrectly referred for depression and ultimately diagnosed with another psychiatric condition are summarized in Table 3. Fifty-seven percent of those referred for suspected depression were diagnosed with dementia. No significant differences were observed in the frequencies of diagnoses assigned to women and men referred for depression but who were found to have another psychiatric condition.
Discussion Nearly 20% of all consultation requests during the 3 years of this study were for a suspected depression. Nursing home staff detect depression poorly, inappropriately suspecting it in one-fourth of patients referred for depression. They also failed to recognize a majority of residents with depression, i.e., referred for other reasons. Therefore, there
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are concerns that symptoms of depression may be overlooked or misinterpreted. Among patients referred for a suspected depression, 25.8% were not diagnosed with a depressive disorder (false positives). Staff may have attended to clinical signs or features of depression, e.g., sadness, irritability, flat or restricted affect, decline in self-care, etc., which can be present in other conditions, e.g., dementia, anxiety, etc. Previous research has suggested that patients with dementia may be misdiagnosed as having an affective disorder [21,22]. Nonpsychiatric staff may have been misled by symptoms of medical illnesses mimicking those of depression, e.g., fatigue, sleep and appetite disturbances, or by the prior psychiatric history of a depressive disorder. On the one hand, credit should be given to the staff for recognizing that a problem exists among nursing home residents warranting psychiatric evaluation. However, among patients diagnosed with depressive disorders, over 53% were referred for reasons other than the evaluation/ assessment of depression (false negatives). Clearly, it is not expected that nursing home staff would conduct a diagnostic assessment prior to generating the referral for psychiatric consultation. Nonetheless, ambiguous complaints, a tendency to somatize or to complain of cognitive deficits [23], as would occur in pseudodementia [24], can lead to patients being mislabeled, i.e., viewed as problematic but not depressed. It is conceivable that nonpsychiatric staff may recognize that a patient is distressed or displaying a change in behaviors, but the prospect that this may reflect an underlying depression may not have been entertained. Still, for other residents noted to display depressive symptoms, attributions that depressive symptoms are an expected reaction to illness or placement may interfere with appropriate referral to the consultation service [1]. Review of the reasons for referral of the false negatives (see Table 2) indicates that most depressed patients were referred for issues pertaining to ‘‘management’’ in the nursing facility. Concerns about patient safety, e.g., referrals for suicide assessment or confusion, or patient cooperation with treatment, e.g., referrals for behavior problems and capacity, may have been a more urgent concern than diagnosis or treatment of a possible underlying depression. Previous studies have likewise demonstrated that referring services focus on behavior problems/disruptive behaviors and disposition issues rather than identifying and treating underlying psychiatric disorders [19,25]. There tends to be little correlation with the reasons for consultation request and psychiatric conditions present [19]. The concern arises that the quietly depressed resident, whose overt behavior does not present difficulties for staff, may go unrecognized or untreated. Unfortunately, the retrospective nature of this study does not permit cross-validation of the diagnoses assigned to patients. Standardized scales or structured interviews were not employed and measures of intrarater reliability were not possible. In addition, even though a reason for a psychiatric referral is obtained at the time of consultation request, it
may be possible that little thought went into the reported reasons for referral. Consequently, one cannot always be certain of the validity of the documented reasons for referral in this study. In addition, true measures of sensitivity and specificity could not be ascertained, as all nursing home residents would have had to be assessed for depression, against which to compare referrals. Alternatively, it is possible that primary care physicians treating nursing home residents adequately assess, and treat, depression. The data presented here may only reflect referral patterns for those residents whose symptoms were ambiguous or whose depressions were deemed to be refractory, thereby prompting referral. Yet, the present data appear to be consistent with prior studies evaluating the assessment, and treatment, of depression in the nursing facility [5,14,18 – 20] and suggest that depression remains poorly recognized and inadequately treated. As to the issue of gender differences in patterns of referral, it is not possible by means of a chart review to determine what factors determine whether a psychiatric consultation is requested in general and whether these factors differ for men and women specifically. Significantly more men than women were referred for psychiatric consultation. The expectation that rates of depression would be higher among women than men may have adversely affected the sensitivity rates observed here among women referred for depression. Consequently, any observed behavior change noted among female residents prompting psychiatric referral may have been erroneously ascribed to depression, thereby reducing sensitivity rates as compared with men. Rationale for on-site psychiatric consultation Depressive illness is widespread among elder persons, but prevalence rates for depression are higher among nursing home residents as compared with elders living in the community [26]. These findings suggest that nursing home patients may be particularly vulnerable to being overlooked for the referral, diagnosis and treatment of depression. As of 1995, there were 16,700 nursing homes in the United States and approximately 1.5 million nursing home residents [27]. Because the elderly constitute the largest growing segment of the population [28] and because hospitals expedite discharge compelling nursing facilities to assume a larger role in subacute care, it is anticipated that the number of individuals requiring nursing home care will increase dramatically [29,30]. The demand for psychiatric consultants in the nursing facility will likewise be expected for increase. Lately, compensation for psychiatric consultation within the nursing home has become increasingly restrictive. For example, in the United States, Medicare Part B will only compensate consultants if there has been adequate documentation in the medical record supporting evidence of a serious condition, e.g., depression, for which previous treatment attempts have failed. Such restrictions can potentially undermine the availability of on-site psychiatric consulta-
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tions. Evaluation of the resident within the facility allows for direct observation of resident behaviors, interactions between staff and the resident, and allow for collateral information to be obtained from staff who have observed and interacted with the resident. Staff interview can delineate symptoms deemed problematic, clarify precipitants for problematic behaviors and characterize the nature and extent of patient involvement in activities as well as staff and peer interactions, which might not otherwise be gleaned from an office-based evaluation. Nursing home staff assessment of resident depression can be a valuable source of information for the consulting psychiatrist. Because nursing home staff spend large amounts of time with residents and have a longitudinal perspective of a resident’s behaviors, their assessment of resident depression tended to correspond with those psychiatric consultants [14]. Furthermore, the consultant, in addition to recommending appropriate laboratory investigation and use of psychotropics, can educate staff as to how to provide more therapeutic interventions to reduce patient distress [31]. The latter would also be less likely to occur if the patient were transferred to a psychiatrist’s office for evaluation and consultation. Heightened awareness of comorbid depression in nursing home residents is needed [32]. The psychiatrist, working collaboratively with geriatric physicians, social workers and nursing staff, can improve the recognition and treatment of depression among residents. This can take the form didactic instruction, case reviews and case discussion. Improved treatment of depression can, in addition to reducing distress, improve treatment compliance, reduce demands made on staff/support services and reduce morbidity and mortality associated with comorbid medical conditions [13,14,33].
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