The grades of evidence (A1, A2, B1, B2, C1, C2, D) are defined at the end of the "Major Recommendations" field.
Individuals/Patients at Risk for Depression
The following characteristics increase the risk of major depression (American Psychiatric Association [APA], 2000). (Evidence Grade = A1).
- A prior episode of major depression
- Severe psychosocial events (stressors), such as death of a loved one, marital separation, divorce
- Chronic general medical conditions
- Substance dependence issues
- A family history of depressive disorders
- Being female
- Loss of independent functioning (Rovner & Ganguli, 1998)
- Acutely disabling conditions (e.g., stroke, myocardial infarction [MI]) (Alexopoulos et al., 1997; Lespérance, Frasure-Smith, & Talajic, 1996)
- Physical disability (Bruce et al., 1994)
Assessment Criteria
Any individual over age 60 should be screened for depression periodically. The American Geriatrics Society (AGS) recommends depression screening two to four weeks after admission to a nursing home and then repeated screening at least every six months after admission. In all nursing homes, residents should be screened at least every six months (AGS & American Association for Geriatric Psychiatry [AAGP], 2003; Snowden, Sato, & Roy-Byrne, 2003).
Depression screening every six months in older persons with dementia or as mandated by regulatory requirements.
Description of the Practice
The following assessment is a three-step procedure that can be used across health care settings to screen for the presence of depressive symptoms. This is a screening guideline, not a diagnostic process. Positive screens should be followed with a diagnostic evaluation by a skilled health care provider.
Implementation of the evidence-based guideline requires administration of the Mini-Mental State Exam (MMSE) (Folstein, Folstein, & McHugh, 1975), and either the Geriatric Depression Scale Short Form (SGDS) (Sheikh & Yesavage, 1986) or the Cornell Scale for Depression in Dementia (CSDD) (Alexopoulos et al., 1988) depending on level of cognitive functioning.
- The MMSE is a widely used cognitive functioning assessment that screens for dementia. Its short, ten-minute administration allows the administrator to quickly screen for cognitive deficits.
- The Geriatric Depression Scale (GDS) is a depression screening tool that takes about five minutes to administer and has been validated for community-dwelling, hospitalized, and institutionalized older adults (Koenig et al., 1988; Lesher & Berryhill, 1994; Sheikh & Yesavage, 1986).
- The CSDD is a depression severity tool that can also be utilized for screening. The tool has been validated to rate depressive symptomalogy over the entire range of cognitive impairment (Alexopoulos et al., 1988).
In order to implement this guideline, we first suggest that a series of five patients be assessed by the user with the supervision of a mental health expert (Cohen, Hyland, & Kimhy, 2003; Schnelle et al., 2001; Teresi et al., 2001).
Step 1: MMSE (Folstein, Folstein, & McHugh, 1975). (Evidence Grade = C1):
- Assess for cognitive impairment using the MMSE (See Appendix A.1 in the original guideline document).
- If the patient scores 24 or above, you may need to refer to the Research Translation and Dissemination Core (RTDC) guideline Detection of Depression in the Cognitively Intact Older Adult (Piven, 2005). (See also the National Guideline Clearinghouse [NGC] summary of the RTDC guideline.)
- If the patient scores below 24 on the MMSE, establish whether this reflects an acute change in mental status or rather the patient's baseline cognitive function or expected progressive mental status changes associated with Alzheimer's disease and other forms of dementia. An acute change in cognition requires immediate medical attention.
- If score reflects baseline cognitive function or expected progressive mental status changes, continue with Step 2.
Step 2: Depression Screen:
- Depression screening can be conducted at various periods during a standard assessment. Particularly good opportunities present themselves after assessment of functional status, the experience of pain, or use of coping strategies.
- If the patient scores 15 to 23 on the MMSE, administer the SGDS (See Appendix A. 2 in the original guideline document) (McCabe et al., 2006; Lesher & Berryhill, 1994; Sheikh & Yesavage, 1986). (Evidence Grade = C1).
- If the patient scores below 15 on the MMSE, administer the CSDD (See Appendix A.3 in the original guideline document) (Alexopoulos et al., 1988). (Evidence Grade = C1).
Because many patients with dementia may be unable to reliably report emotional symptoms, the CSDD derives information from interviews with both the patient and an informant. This approach is consistent with the Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association, 2000: Fourth Edition, Text Revision (DSM-IV TR) (APA, 2000) where all sources of information are used as necessary to make a clinical judgment. Research has confirmed the value of informant reports of symptoms of depression when assessing older adult patients (McAvay et al., 2004). (Evidence Grade = C1). The informant should be a close family member or other individual who knows and has frequent contact with the patient (e.g., nurse, social worker, home health aide) (Alexopoulos, 2002).
Step 3: Referral
- Referral of positive screens
- For SGDS scores of 6 or greater, notify primary health care provider of immediate need for further evaluation, treatment, or referral for clinically significant depression (i.e., probable or definite major depression).
- For CSDD scores of 11 or greater, notify primary health care provider of immediate need for further evaluation, treatment, or referral for clinically significant depression (i.e., probable or definite major depression).
- Procedure for negative screens
- For SGDS scores below 6, reassess individual in one month if clinically indicated. If not, perform screening process in six months.
- For CSDD scores below 11, reassess individual in one month if clinically indicated. If not, perform screening process in six months.
Definitions:
Evidence Grading
A1: Evidence from well-designed meta-analysis or well-done systematic review with results that consistently support a specific action (e.g., assessment, intervention or treatment)
A2: Evidence from one or more randomized controlled trials with consistent results
B1: Evidence from high quality evidence-based practice guidelines
B2: Evidence from one or more quasi experimental studies with consistent results
C1: Evidence from observational studies with consistent results (e.g., correlational descriptive studies)
C2: Inconsistent evidence from observational studies or controlled trials
D: Evidence from expert opinion, multiple case reports, or national consensus reports
