Nursing Care Plans For Depression

[music] [narrator]: retirement is supposed tomark the beginning of our golden years, a chance to pursue newinterests and spend time with family. but for a growing number ofseniors the reality is bleaker. struggles with maintaininghealth, loss of family and work roles, and coping with the deathsof peers and loved ones has led to increasing levels of depression. with the number of seniors increasingevery year, this rise in depression among older adults presents a growingchallenge for our health care system.

[ina]: i find with even, even seniorfriends, the loneliness sometimes gets to them. because we are used tobeing very active in our lifetimes and then all of a sudden, it’s not there. [cynthia zubritsky]: there are very, very highrates of depression in older adults, 20-25%. it’s being untreated. [narrator]: this rise in depression amongolder adults has led to decreasing levels of functioning, reduced quality oflife, and worsening health conditions. [jerry johnson]: depression andanxiety disorders – what we sometimes call the generalized anxiety disorder –

are two of the most importantproblems that primary care physicians face. [joseph lurio]: from my standpoint, especiallywith my elderly patients, i talk about... the fact of depression as beingsomething that complicates medical problems. [narrator]: in fact, health care costs forseniors with depression are about 50% higher than for those without depression. one challenge is that older adults are notlikely to seek treatment for depression. [cynthia zubritsky]: i think the realissue for older consumers is a stigma issue. a lot of people grew up, that are inthis cohort, grew up thinking that if you were depressed itwas sort of your fault.

[connie]: most people who havedepression are afraid to admit it because they think someone’sgoing to think they’re crazy. [narrator]: fear of stigma amongolder adults is not the only inhibitor of successful diagnosis and treatment –providers often overlook signs of depression or are uncomfortable askingabout mental health issues. [virna little]: there was this bigmisconception that because these folks were maybe isolated, because they weren’t feelingwell sometimes or they had these chronic illnesses or just by virtue of being seniors– of course they were going to be depressed. [jerry johnson]: sometimes there’s a tendencyin medicine to focus on one part of the human.

to focus on the physicalpart and not the mental part. but, in fact, particularly inolder adults we see both so commonly, occurring at the same time that in order to provide high qualitycare, we really do have to be considerate of ways of treating the mentaland the physical concurrently. [narrator]: researchers around thecountry are finding ways to do it. the substance abuse andmental health administration’s center for mental health services hasidentified evidence-based practices (or ebps) in use around the country that are succeeding.

evidence-based practicesinclude psychotherapy interventions and the use of antidepressant medications. these can be used individually orin conjunction to improve symptoms. they can also be used withinmodels of outreach services and collaborative andintegrated mental and physical care. [joseph lurio]: one of the issueswas how to identify patients early on and how to provide the best kind of treatmentgiven time constraints in primary care. [nurse]: brown, mary. [narrator]: one model of care for diagnosingand treating depression in older patients

is impact, which stands for improvingmood, promoting access to collaborative care. the institute for family healthpartnered with the developers of impact to implement the model in new york city. [doctor gayle]: yes, it’s dr. gayle. [daniel blumkin]: the mission ofthe institute for family health is to deliver private practice level quality primary care to an indigent population. [virna little]: impact is acollaborative model of care that seeks to identify

and treat depression in older adults in a primary care setting. [clinic staff]: goodafternoon. how can i help you? [patient]: yes, goodafternoon. i’m here to see dr. gail [clinic staff]: okay...have a seat here, please. okay, can i just haveyour date of birth, please? [wendy barr]: the impact model helpspromote a holistic view of patient care by integrating depression screening into chronic disease management.

[virna little]: it is the first timethat there was a really publicized research-based model that supportedsomething, which is near and dear to me, which is the integration of primarycare and mental health services. [nurse]: today you’re here for yourphysical, and part of what we do here is we ask all patients comingin for a physical to fill out, or to answer questions about depression. [daniel blumkin]: project impact attractedme and our organization because it enabled us to provide services to our geriatricpopulation that were not being addressedpreviously.

[narrator]: the two key features ofthe impact model are screening for and tracking depression in a primary caresetting with a patient health questionnaire, and onsite collaborative carewith the patient’s physician. [virna little]: when a patient comes in, they are checked in at the front desk, they are then transferred to nursing for an intake or a triage process. and during that triage processwe’ve actually incorporated the patient health questionnaire-2 (phq-2). 0

[nurse]: okay, i have a fewpersonal questions to ask you. this is completely confidential andit’s for the use of the doctors only. okay. [nurse]: over the last two weeks have youbeen bothered by any of the following problems: little interest or pleasure in doing things... [eric gayle]: and if theyscore one question positive, it triggers us doing the phq-9. [nurse]: this is a form called phq-9 and ineed you to read this and fill this out. [eric gayle]: phq-9 is a patient healthquestionnaire that has nine questions

that are scored from 0 to 3. andthe patients themselves answer it. so you’re not diagnosing thepatient; they’re diagnosing themselves as to whether or not theyhave true depression or not. and often times they’rescoring with moderate depression, they are scoring 10 and above. and those are the patients thatusually you’re seeing much more frequently than you would expect to. these are the patients that are having moreproblems with their co-morbid conditions, their diabetes, their high bloodpressure and so on and so forth.

and once you start treating those patientswith scores of 10 and above in the phq-9, you start to see the improvementsin the rest of their wellbeing. [doctor]: well, my nurse told me that shegave you a patient health questionnaire for depression, so i’m just going to spenda couple of seconds and score to see how far along the curve you are. [regina epperhart]: we offer themproblem-solving therapy, we offer them meetings with our psychiatrist to follow upon any kind of psychopharmacology, and we also offer them just touching base once a month by phone because some peoplewho might not want these other interventions

we want to, you know, keep on ourradar and we want to make sure that we’re monitoring them on a monthly basis. [doctor]: i’m going to talk to you alittle bit about what the course of management is going to be. i’m going togive you the medication today and i’m going to ask that youfollow up with me in about two weeks. anytime during those two weeks ifyou’re having trouble with the medication, you can call me. i’m going to get our psychosocialservices colleague to sit with you. she’s going to be talking to you about thecourse of management she will have with you.

and i expect to see youagain in two weeks and... [joseph lurio]: because wehave the tools of the phq-9, i’m able to give a score, share that with the patient and then we can say, “well, you know, we tried this last time but even thoughyou say you’re feeling better, it doesn’t really seem likeyour score has improved. maybe we really shouldhave you talk to somebody.” [narrator]: the physician cancollaborate with the depression care manager

and psychiatrists who are located onsite. [regina epperhart]: in the projectimpact model the depression care managers can be either nurses orthey could be social workers. [care manager]: so out of allthose things that you mentioned, what is one that you would like to work on? [patient]: i’d like to goback to the way i used to be, where i used to look forwardto getting up in the morning, getting dressed and going outthere, being around people. i don’t feel that way anymore. i feellike... another day, i’ve gotta get dressed.

where am i going? i don’twanna go out. i don’t like that. i want... [care manager]: that energy. that energy... that i had. [regina epperhart]: we want to make sure firstthat they’re not in any danger to themselves and then we, you know, set up a protocolwhere we offer them problem-solving therapy. [care manager]: well, the goal that we canwork on is to get you back to where you were three weeks ago. that will be great, right? [patient]: yes.

[care manager]: and to get you frombeing depressed to feeling like your normal self again. and those baby stepsare called “self-management goals.” so they’re goals that youestablish for yourself. [regina epperhart]: and it gives thepatient the opportunity to come up with what some of their problemsare and how they even want to, you know, get through some ofthe barriers that they’re facing. the patient has a big say in, okay, sohow do we get from here to here to here to really, you know, slowly start to decrease these depressive symptoms.

and it all – it comes from them. [katarzyna haberko ]: it’s verydifficult for older adults to seek treatment, to seek counseling on their own. and to – the primary care office, it’s a very good entry point for the patients to be to be identified as depressed if they are, which usually olderadults would go undiagnosed. [care manager]: ...we help toreduce their depression... [joseph lurio]: what i found withthis particular model is that it did

identify patients before sometimes i wasaware that they were suffering from depression. [suzanne]: he told me theresults of his interview. the... i said you saw all that? he said yes. i said, well, i better think about itcause i wasn’t aware that i had a problem. but he thought i did andhe probably was right. and i enjoyed talking about my dailylife which has been changed so very much. and it was a wonderful experience. [regina epperhart]: most of these patientshave functioned well for most of their life, and they just really need someextra support now in how to get,

you know, from the problem to feeling better. [care manager]: i met with ms. brown. [doctor]: yeah. thanks for seeingher. i wanna see her in two weeks. how did your interaction go withher cause i’m concerned about? [care manager]: it went welland she’s willing to come in... [eric gayle]: now part ofthe challenge for me is finding the time to spend to manage this patient. and if i can reach across the hall

and get my social servicespecialist on board to say, “listen, i don’t have time rightthis minute. can you spend some time with this particularpatient while i go do that? by the time you’re finishedwith her, i can come back and perhaps discuss othermanagement of the patient, including medications and so forth,”it makes the flow so much easier. you’re not having the patient runningaround to different areas trying to find the services that you canprovide right on the premises. [regina epperhart]: i would say the numberone thing is getting the doctors on board

and the doctors to buy into the programand recognize how it’s going to both help their patients and,you know, help the practice. [joseph lurio]: having thesocial worker integrated into the whole process provided a strong support for the primarycare providers and also made it easier for them to intervene becausethey didn’t feel like they were carrying this whole burden on their own. [daniel blumkin]: the use of the screeningtools for project impact has enabled us to demonstrate theimprovement in the phq-9 scores

for the patients in the project. [eric gayle]: we like to measure things,and you can measure the phq-9 score, you can measure the diabetes evaluation and thehemoglobin a1c, whether or not they’re getting better. you can see that theblood pressure is getting better. all of these things make it moresatisfying in treating our patients. [katarzyna haberko ]: this program isvery easy to implement when it’s – once it’s rolling. it’s very simple to screenpatients and provide them with needed medication or counseling andsupport to improve their lifestyle. [joseph dilullo]: all thatintegration of the medical

information and the psychiatric can be very nicely utilized to form as accurate a picture ofthe patient’s diagnosis as possible. [linda tillman]: so it reallywas depression 101 to discuss what are the signs of depression, what is helpful for a patient toreduce their depression in order to help their medical condition so thepatient is not coming through the door every two weeks for another problem. [katarzyna haberko ]: if we can make it easierfor them to access services that they need,

i think that’s very exciting. [narrator]: integrated mental and physicalhealth care services have been proven to work to work well in reaching many older adults. but what about older adults who may be fallingthrough the cracks of primary health care? psychogeriatric assessment andtreatment in city housing (patch) is a mobile treatment program developed atthe johns hopkins hospital in baltimore. it targets olderindividuals with mental illness whose needs are not being met bythe traditional healthcare system. it combines the mobile treatmentmodel and the spokane gatekeeper model

and adds elements that addressthe medical and social challenges that are so prevalent in this group. [peter rabins]: people wholived in public housing sites had three times the rates of depression and several other psychiatric disorders as elderly people living in thecommunity. so we knew we had a very high risk, high prevalence population in public housing. [beatrice robbins]: we’re serving themost vulnerable elderly population. it’s the impoverished elderly

with mental illness who are socially isolated for the most part and whowon’t access traditional care. [nurse]: hello, good to see you again... [mary minor]: the persons thatwe work with for the most part are not going to seek traditional mental health services. [narrator]: with social, physical, andpsychiatric issues compounding each other, the needs of these olderadults often go unaddressed. [peter rabins]: and you come to realize thatthe best way to improve the quality of life

for seriously ill older individuals isto simultaneously try to address their social, medical, and mental health needs. [doctor]: now are you tired during the day? [resident]: i get tired. [doctor]: do you fall asleep – take catnaps? [resident]: yeah i do. [doctor]: sometimes, i know it’s hard butif you can keep yourself from doing that, you’ll probably sleep better at night. [resident]: that’s right.

[peter rabins]: we developed the programabout 20 years ago after actually failing, to reach this populationthrough more traditional programs. and then the idea of providing both mobiletreatment, but also using what was called the gatekeeper model in which people inthe community were used to identify people who might need mental healthservices, we combined those two together and launched the program back in 1986. [narrator]: the “gatekeepers” for thepatch program are housing authority staff who have been trained to recognize potentialsigns of mental illness in older residents. [rebecca rye]: the nurseswill initially provide

educational programs for staff that work in the housing authoritybuildings and this would include managers, counselors, securitystaff, anybody that may come in contact with a resident that is illand in need of services. [maintenance staff]: how you doing ms.rachel? how’s the tub-shower we gave you? [resident]: huh? [maintenance worker]: the showertub we gave you, is that alright? [resident]: oh, it’s ok. [maintenance staff]: you like it?

[gail danik]: themaintenance staff is also involved. they may be the first contact in some cases. [maintenance staff]: i’m glad you can use it. [resident]: yeah. [maintenance staff]: alright. take care. [resident]: thank you very much. [maintenance staff]: alright. [fadeelah keyes]: the patchprogram has been very, very helpful with identifying as well as following up

on things that we identify to help people not be evicted, not be in theirunits without taking their meds, not being there without anyone to speakwith as far as making doctor appointments or even eating on a day-to-day basis. [gail danik]: once we’ve recognized, orthink that we’ve recognized a particular situation, then i call patch, ask themto come out, and they will do an intake to verify and then hopefully beginning to support that particular individual. [narrator]: the patch teams include a nurse,a geriatric psychiatrist, and a case manager

who bring services directlyto residents in their homes. once housing authority staff identify aresident who may be in need of services, a visit from a patch programnurse is usually the next step. [peter rabins]: the reason we’ve chosen atthe beginning to use nurses is because many of these patients turn out to have unmetmedical need as well as unmet psychiatric need. [mary minor]: we do amini-mental on everyone initially as well as a depression scale and a psychotic type of scale. [nurse]: do you know the name of theprogram that i’m with? it’s called patch.

[resident]: uh huh. [nurse]: yeah, patch. thebrochure i gave you... [beatrice robbins]: we’re askingdemographic information, medical history, psychiatric history, medication list ifit’s possible, then a general listing of, it’s sort of a yes/no listing of all possiblemedical diagnosis that the folks may have. [nurse]: did you bring this wholecard in when you went to see him? [resident]: yeah, i took this to the doctors. [nurse]: the pink one is called depakote. [resident]: depakote? i didn’t know the name.

[peter rabins]: the second element thenis to have a trained geriatric clinician make contact with the person,offer our services, do an assessment. [nurse]: that’s good. very good. [doctor]: so, we’ve got to get – so,have you been in the nursing home lately? a lot of times? [resident]: haven’t been there. [doctor]: that’s what miss mary was saying thatyou had to go to the nursing home a few times. [resident]: well yes,sometimes i do. it’s a habit. [doctor]: habit... yeah i gota lot of bad habits myself.

[sharon handel]: the minute you walk insomeone’s house you know more than you’ll ever learn in, you know, followingsomebody for years in a clinic. [doctor]: and then this one...how’s your reading? do you read ok? [beatrice robbins]: and the psychiatristdoes a standard psychiatric diagnostic visit and then together with theclient develops a treatment plan. and that’s when we decidewhether we really want to include the services of the case manager. [nurse]: you’ve done very well, actually. [doctor]: alright mr.williams, it was good meeting you.

[resident]: same here, samehere. nice talking to you. [nurse]: see you later. [doctor]: bye. [narrator]: in addition toaddressing the medical and psychiatric needs of their patients, the patch teamcan include a case manager to address social and financial challenges thatmay exacerbate their other needs. [case manager]: her certificationinterview with mobility is scheduled for the 24th of march. so that’salready been set up as well so... [narrator]: buck weeks is a patch casemanager who works with the treatment team to address these challenges.

[case manager]: you get socialsecurity each month... for your money? [resident]: mmm hmm... [beatrice robbins]: so he’ll come in andhelp with entitlements, transportation, making arrangements for meals, i mean thelist is endless for what he does. [case manager]: do youremember discussing that? [buck weeks]: what i help do is workas part of the team with the nurses and the psychiatrist coordinatingservices for the people we serve, helping take care of medical appointments,monitoring medical appointments, helping solve any problems with benefits, entitlements,and resolve any conflicts that occur.

[case manager]: ...and this is just so youknow how they came up with that number. [resident]: ok, now. [buck weeks]: sometimes there’s not awhole lot of communication between different doctors, differentservices, and the family. and when people are getting older they’re having trouble remembering who they spoke to, who told them what. they don’t always accurately relaythe information to other doctors, other family members.

so by being in touch with every treatmentteam member and being able to be like the hub, it gives me a chance to make surethat all the services are complete. [narrator]: not all residents are immediatelyreceptive to services – even services that are brought directly to their homes.the nurses and case managers have found that developing a relationship with the clientand being able to help them with even one of their problems can help make thatclient more interested in other services. [rebecca rye]: they will let a nurse in thedoor. many people are used to home health nurses coming out or public health nursescoming out and if you somehow find a way to help them with something that theythink is necessary which usually is not

their medical illness ortheir psychiatric illness. then you have a way in to get therest of their needs addressed. so sometimes it takes awhile to establish a rapport. do you know where your wife is buried? [resident]: sure don’t. if they could help you find outwhere your wife is buried... ...and maybe having your niece ornephew go find where she is... [resident]: i would like to know... i think that’s a good idea.

[mary minor]: time spent listening, hearingwhat someone’s saying, knowing them over time, so that you actually can anticipate oreven name what others just are not seeing. i think that’s a key piece topersons beginning to stabilize. because often times they don’tfeel that they’ve been heard. [rebecca rye]: if we can initially get medicalproblems or their social problems treated then they’re more receptive togetting the psychiatric problems treated. [narrator]: the goal of patch is to stabilizeolder adults through in-home treatment and then transition them to traditionalmental health services after 6 months. [theresa neal]: once patch becomes involvedwith a resident, we see them coming out more,

we see them coming out more, we see them interacting more, in the lobby area with our staff. [wilber]: when they come in i’m cheerful,i’m happy. i know they going to be there. especially, i know she be there every tuesday. [peter rabins]: and we found that wecould decrease rates of depression and depressive symptoms by about 20%in the buildings we intervened in, whereas the buildings that we did not intervene in actually depression rates

went up over two years. [gail danik]: without the patchprogram, i could see individuals being placed in nursing homes. i can see individuals becoming homeless because of dementia. i can see individuals simply shutting down. [peter rabins]: as anation, as a healthcare system, here’s a group of people wecan make a huge difference with by relatively simple but focused programs and i’m proud of the state andthe city that for almost 20 years

they’ve been willing tosupport this from the state level. [marie ickrath]: people canbe treated. people can have full and good lives... but not if they’re nottreated, if they’re not identified. [peter rabins]: we hear thisall the time, that we make, that we’ve made a difference in people’s lives and we’ve improved their quality oflife and that helps us keep going. [narrator]: depression doesnot have to be a part of aging. the impact and patch models are justtwo examples of the many practices

that are being put to use tosuccessfully identify and treat depression. if you would like moreinformation about evidence-based practices for treatment of depression in older adults, go to samhsa.gov/shin or call 1-877-samhsa-7. [trudy]: i think people shouldrealize that because you’re older it doesn’t mean you have to be depressed. [music]