Educational Objectives: To help clinicians recognize and treat older persons who experience and present with the trilogy of depression, pain, and substance use.
This presentation will focus on one Canadian psychiatric facility's experience in treating older adults who present with depression (anxiety), pain, and use of substances. The authors examined the prevalence of the trilogy in persons 65 and older, by using data from the Resident Assessment Instrument for Mental Health (RAI-MH). The RAI-MH is a standardized data collection system that is intended to identify key clinical issues related to patient care planning, quality improvement, and outcome measurement, which are ultimately linked to resource utilization and funding. This instrument has gained in international recognition. Data analyzed from 792 cases of Version 1 of the Minimum Data Set for Mental Health (MDS-MH) showed the prevalence of the trilogy to be approximately 3%. Co-morbid prevalence of depression and pain (no substance use) was 16.3%; depression and substance use (no pain) was 3.2%; and pain and substance use (no depression) was 3.4%. Although these data are not strikingly high the authors, as clinicians, feel that the trilogy is a phenomenon worthy of study and understanding since the co-existence in an older person makes their care and treatment more complex. The more complex a person, the greater the need for a more in-depth, holistic, interdisciplinary perspective. Even one person presenting with this trilogy on an in-patient geriatric psychiatry unit can make for an interesting, educational challenge to the interdisciplinary team. Mrs. C. is one such person who had experienced this phenomenon on admission to an in-patient geriatric psychiatry unit. She presented with many complex issues that required a holistic interdisciplinary team perspective. She has lived and experienced a long psychiatric history with many hospitalizations. Now at age 84 she presented with polysubstance abuse (codeine, benzodiazepines), chronic pain syndrome, major depression, and generalized anxiety disorder. She had been treated in the past for alcoholism and bouts of depression. She had received ECT during some admissions. She suffers from osteoarthritis and has a colostomy from a previous bowel rupture. There are many losses in her life including strained family relations. The presenters will illustrate how the trilogy was manifested in Mrs. C. The interplay of human connections that developed between Mrs. C. and the caring interdisciplinary team was instrumental in assisting in her recovery. It is acknowledged that Mrs. C. and the treatment team worked very hard and collaboratively together to assist her in her recovery. She had gained valuable insight into her pain-depression-substance abuse cycle. The authors believe that more research, education, and clinical narratives concerning the trilogy need to be conducted and shared. It is postulated that this complex interplay of conditions will require more resources in the future.
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