Steven Littlehale

Editor’s note: This article has been modified from its original format to place more focus on policy implications.

Previously, I reported that the rate of depression as indicated on the five-day MDS was 4.9%. This seemed profoundly low. However, unlike a certain songstress in a nun’s outfit, when I’m doubting and confused, I don’t go to the hills; instead, I turn to the professional literature.

In this case, I’m looking at studies on depression in the skilled nursing population and on the PHQ-9 itself. 

Several studies, such as those from the American Geriatrics Society and American Association for Geriatric Psychiatry and the Journal of Affective Disorders, have reported rates of depression from 20% to 46% among elderly nursing home patients. While their study populations don’t align perfectly with those assessed on the five-day MDS, the disconnect with that 4.9% figure in the previous paragraph is undeniable.

Depression in the nursing home is linked with rehospitalization and correlated with higher length of stay. Several F-tags directly and indirectly relate to depression management, and there is a QM reporting on long-stay residents who have symptoms of depression. Globally, the cost for treating depression and other mental illnesses will exceed $60 trillion by 2030 (World Bank Group and World Health Organization).

Why the disconnect between the literature and reality? Is it the PHQ-9 itself? Several authors, including the principal investigators on the MDS 3.0, report high validity between the PHQ-9 and other standard industry assessments (Saliba et al., 2012). That said, as recently as May of this year, the PHQ-OV’s validity was called into question. From my own professional experience managing similar studies, there is a disconnect between a “research nurse” and a “reality nurse.” Both are equally qualified, but the “reality nurse” has a plethora of competing priorities and often isn’t specifically trained on the items the “research nurse” devotes study to (in this case, administering structured psychiatric tools). The same holds true for social workers.

The stigma associated with depression, and mental illness in general, may also impact our ability to identify these symptoms in our population. It might be easier to attribute symptomatic behaviors to dementia, delirium, or “normal aging” than brand our elders as depressed. Have you ever fallen back on the thought, “Well, wouldn’t you be depressed being in a nursing home?” In truth, the circumstances that bring most elders to us are often traumatic, even tragic, and are frequently combined with loss of function and home.

PDPM offers us an opportunity to “up our game” when it comes to proper assessment and care of people with depressive symptoms and depression. Caring for people with depression costs more, and is reimbursed more under PDPM, sometimes more than $40 per day. Do you have the competencies in-house to do these assessments accurately, particularly in elders with complicating comorbidities? How comfortable are you with managing depression? What non-pharmacological engagement activities — like singing, sewing, or caregiving do you have at your disposal?

Steven Littlehale is a gerontological clinical nurse specialist, chief innovation officer at Zimmet Healthcare Services Group, and chief clinical officer emeritus at PointRight Inc.