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The Problem With Maslow's Hammer

  • William M. McDonald
    Correspondence
    Send correspondence and reprint requests to William M. McDonald, M.D.
    Affiliations
    Department of Psychiatry and Behavioral Sciences, JB Fuqua Chair for Late-Depression, Ruenette W. Harris Chair, Emory University School of Medicine, Atlanta, Georgia USA
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      Somewhere between 15% and 65% of elders living in nursing homes and residential care facilities have significant depression and anxiety
      • Vankova H
      • Holmerova I
      • Volicer L
      Geriatric depression and inappropriate medication: benefits of interprofessional team cooperation in nursing homes.
      and these symptoms have only intensified during the COVID-19 pandemic.
      • Dahab L
      • Dahab L
      • Abdelgadir K
      • et al.
      Effect of COVID-19 pandemic on depression and medications use on nursing home residents.
      Depression and anxiety are major contributors to decreased quality of life for older adults and are associated with poor health outcomes, social isolation, functional decline including premature death and increasing the burden on nursing home staff and caregivers.
      • van Asch IF
      • Nuyen J
      • Veerbeek MA
      • et al.
      The diagnosis of depression and use of antidepressants in nursing home residents with and without dementia.
      ,
      • Watt JA
      • Goodarzi Z
      • Veroniki AA
      • et al.
      Comparative efficacy of interventions for reducing symptoms of depression in people with dementia: systematic review and network meta-analysis.
      Mood disorders in late life are also often unrecognized clinically and more likely to have a complicated clinical course and incomplete recovery and.
      • Valiengo Lda C
      • Stella F
      • Forlenza OV
      Mood disorders in the elderly: prevalence, functional impact, and management challenges.
      Despite this urgent need in our communities, we continue to struggle with the appropriate interventions to manage these symptoms.
      For most residents in long term care facilities (LTCF), formal psychotherapy with a licensed therapist is not available and the primary treatment is pharmacotherapy. The percent of nursing home residents on antidepressants in U.S. nursing homes more than doubled between 1996 to 2006 from 21.9% to 47.5%.
      • Hanlon JT
      • Handler SM
      • Castle NG
      Antidepressant prescribing in US nursing homes between 1996 and 2006 and its relationship to staffing patterns and use of other psychotropic medications.
      This would seem to show that we are focusing more on treating depression, but often antidepressants are not prescribed following evidenced based guidelines.
      • Shah S
      • Schoenbachler B
      • Streim J
      • et al.
      Antidepressant prescribing patterns in the nursing home: second-generation issues revisited.
      ,
      • Brown MN
      • Lapane KL
      • Luisi AF
      The management of depression in older nursing home residents.
      Patients are prescribed suboptimal doses of antidepressants or antidepressants are targeted for the off-label treatment of insomnia, agitation (e.g., trazodone or mirtazapine) or chronic pain (e.g., amitriptyline).
      There has also been an increase in the off-label use of atypical antipsychotics in the U.S. perhaps in response to the Centers for Medicare and Medicaid Services (CMS) regulations regarding the use of benzodiazepines in nursing homes. These regulations have added scrutiny on the indiscriminate and long-term use of minor tranquilizers. Atypical antipsychotics are being used increasingly for a number of off-label indications including insomnia, agitation and dementia despite serious adverse side effects including hip fractures, orthostatic hypotension, and pneumonia and, in dementia patients, evidence for a decline in cognition and functional abilities as well as premature mortality.
      • Müller L
      • Noseda R
      • Bertoli R
      • et al.
      Off-label use of quetiapine in nursing homes: does medical specialty of prescribing physicians play a role?.
      Then there is the issue of how many medications our elderly residents are taking. Polypharmacy in long term care facilities was reviewed in 35 studies and the investigators found that 91% of LTCF residents were taking five or more medications and 65% of residents were taking 10 or more medications.
      • Jokanovic N
      • Tan EC
      • Dooley MJ
      • et al.
      Prevalence and factors associated with polypharmacy in long-term care facilities: a systematic review.
      Nursing home residents with advanced dementia were on a mean of 5.9 ± 3.0 daily medications (53.6% on antidepressants and 27.9% on antipsychotics) and even modest reductions only occur during the last week of life.
      Which brings us to Maslow's hammer: “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.”

      Maslow AH. The psychology of science: A reconnaissance. New York: Harper & Row 1966.

      Abraham Maslow was a prominent psychologist in the twentieth century and this axiom was intended to encourage individuals to become more resilient by expanding their coping strategies. But this axiom could equally apply to all of us who care for the frail elderly in residential care homes. We often rely on medications as our primary therapeutic intervention and the data would show that medications may be overprescribed or not prescribed according to the evidence-based literature.
      Do we really believe there is “a pill for every ill”
      • Lam CL
      • Catarivas MG
      • Lauder IJ
      A pill for every ill?.
      ?
      Clearly a subgroup of long-term care residents suffer from moderate to severe depression or primary anxiety disorders and may need aggressive pharmacotherapy and in some cases inpatient hospitalization and/or electroconvulsive therapy. There should be a system in place where these patients are identified early and receive appropriate treatment.
      There is a larger group of residents who would readily ascribe to various degrees of loneliness, loss of purpose, social isolation, unresolved grief, anxiety about finances and fear of dying. Many of our LCTF residents move due to necessity, and not by choice. These elders may meet criteria for mild to moderate depression but would probably not respond to an antidepressant alone.
      In this issue of the journal, Almeida et al.
      • Almeida OP
      • Patel H
      • Valasquez D
      • et al.
      Behavioural activation in nursing homes to treat depression (BAN-Dep): results from a clustered, randomised, single-blinded, controlled clinical trial.
      explore an alternative model for treating elders in long term care settings. In this model they prescribe another tool in the long-term care setting- caregivers providing Behavioral Activation (BA). The model Almeida et al. describe empowers caregivers to recognize and treat symptoms of depression and anxiety. BA is manualized and requires minimal psychological sophistication to implement in this setting. BA can also be applied in populations with mild to moderate dementia which was present in 55%–65% of the target population in this study. Residents with physical limitations were also included in the study making BA an ideal therapeutic intervention in the LTC environment.
      What is missing in this study is a measure of staff satisfaction. Although the primary endpoints of a decrease in depression and anxiety were not met, the training for caregivers with a focus on individualized care for the residents provides immeasurable benefits. Providing training to caregivers gives them skills to recognize depression and empowers them to identify appropriate residents for BA vs. those who needed a higher level of care. This is a level of care that personalizes treatment dependent of the resident's needs.
      There are several impediments to providing nonpharmacological treatment for residents in long term care facilities in the U.S. due to the present reimbursement structure for medical care. Medicare and Medicaid provide fees for skilled services (i.e., provider must have professional medical training and be licensed) and usually does not reimburse for other services such as custodial care (bathing and dressing) which may be where reimbursement for BA with LTC caregivers would fall. There is progress. In 2018, the Centers for Medicare and Medicaid (CMS) allowed for healthcare benefits in Medicare Advantage plans that would improve functional recovery and decrease the need for services. This type of program could be reimbursed under that coverage but that is far from certain. We should all advocate for this coverage.
      We need to continue to investigate and refine nonpharmacological interventions to treat depression and anxiety symptoms in LTCF's to improve the lives of our patients and provide needed treatment options. We can only work with the tools we are given, and we need more tools.

      Author contributions

      William M. McDonald, M.D. is the sole contributor of this editorial.

      Data Statement

      The data has not been previously presented orally or by poster at scientific meetings.

      Disclosures

      William M. McDonald, M.D. is a member of the American Psychiatric Association (APA) Council on Research representing ECT and Neuromodulation Therapies. Dr. McDonald is compensated as the chair of the DSMB for an NIA sponsored multicenter study. He is on the Board of Skyland Trail and 3Keys. He is a paid consultant for Signant Health and Sage Therapeutics. He has received past funding from the Stanley Foundation, Soterix, Neuronetics, NeoSync and Cervel Neurotherapeutics. He is a deputy editor of the American Journal of Psychiatry and on the editorial boards of the American Journal of Geriatric Psychiatry and Personalized Medicine. He has endowed chair funded by the JB Fuqua Foundation. He is an employee of Emory University School of Medicine.

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      Linked Article

      • Behavioral Activation in Nursing Homes to Treat Depression (BAN-Dep): Results From a Clustered, Randomized, Single-Blinded, Controlled Clinical Trial
        The American Journal of Geriatric PsychiatryVol. 30Issue 12
        • Preview
          Depression is a common clinical syndrome among older adults living in residential aged care facilities (RACFs). Clinically significant symptoms of depression, as measured by the Geriatric Depression Scale (GDS-15), were present in 49 (50.5%) of 97 older adults recently admitted to an aged care facility in Australia,1 with data from the US National Nursing Home Survey suggesting that a depressive disorder affects at least 1 in every 3 residents.2 Despite its high prevalence, the presence of depression among aged care residents may go unnoticed, so that appropriate treatment may not be made available.
        • Full-Text
        • PDF
      • The Promise of Behavioral Activation to Treat Depression in Nursing Homes
        The American Journal of Geriatric PsychiatryVol. 30Issue 12
        • Preview
          Hundreds of randomized trials have shown that psychological interventions are effective in the treatment of depression.1 That is also true in older adults. Although the effects of psychological treatments are significantly less effective in children and adolescents, there are no significant differences in effects between age groups when patients have reached adulthood.2 Psychotherapy is as effective in older adults as it is in younger adults, and there is now enough evidence that it also works equally well in older old adults (75 and older).
        • Full-Text
        • PDF