Fuqua Center for Late-Life Depression

The Fuqua Center for Late-Life Depression was established in January 1999 following a one million dollar gift from the J.B. Fuqua Foundation. The Fuqua Center was charged with improving community awareness regarding depression in older adults while improving older adults’ access to treatment. This is accomplished through the Center’s clinical, research and community outreach and education initiatives. The Center believes that the mission of the Fuqua Center is best fulfilled by collaborating with community agencies that are responsible for serving older adults as well as departments within the University such as the Nell Hodgson Woodruff School of Nursing, Rollins School of Public Health and Candler School of Theology.

Clinical Services

The Fuqua Center provides psychiatric evaluations, medication management and on-site psychotherapy in 10+ assisted living facilities in the metro Atlanta area. The clinical nurse specialist provides regularly scheduled clinics in select facilities. The Fuqua Center also contracts with Hammond Glen Retirement Community to provide a bi-monthly psychoeducation group.

The Fuqua Center has entered into an agreement with Christian City Retirement Community to provide a bimonthly on-site psychiatric clinic for its assisted living and independent living residents. The Center will also provide group psychotherapy services to patients on the rehabilitation unit. The Fuqua Center is also piloting a program to provide clinical services to remote rural locations throughout Georgia through its telemedicine project.

Outreach and Education

In order to improve community awareness regarding late-life depression, the Fuqua Center community education efforts target community agencies, organizations and persons responsible for caring for older adults. Strong working relationships have been developed with local assisted living facilities, the National Mental Health Association of Georgia, the Academy of Family Physicians, the Atlanta Regional Commission Aging Services Division, the North Georgia Conference United Methodist Church and Bellsouth.

The Fuqua Center cosponsored with the University of Georgia and the Georgia State Departments of Social Work, Recognizing and Treating Older Adults Depression: A Medical/Social Work Approach. The program was broadcasted via the Georgia State Academic and Medicine System (GSAMS) distant learning network to seven sites in Georgia and 120 licensed clinical social workers, nurses and physicians attended. Both Drs. McDonald and Thompson presented in the program.

Eve Byrd, Chairs the Mental Health for Seniors Task Force which is a sub committee of the Pro-Health for Seniors Task Force which is overseen by the Atlanta Regional Commission Aging Services Division (ARC). The goals set forth by the Mental Health Task Force are to develop a format for the inclusion of mental health services in the statewide Aging Connection database which is managed by the ARC and to train the Information and Referral employees in the Atlanta region to recognize depression in the older adults they serve. The work of the task force is now being incorporated as a part of the statewide database by the ARC. In January 2002, the 12 metro Atlanta county Area Agencies on Aging Information and Referral employees will be trained. The same training, Is It Depression? Recognizing Mental Illness in Older Adults and What is the Right Referral Source? will be offered statewide to Area Agencies on Aging via the Fuqua Center website e-learning management system. The Fuqua Center has also been asked to train metro Atlanta Community Care Services case managers in the recognition and treatment of depression in older adults.

The Fuqua Center, the Emory Department of Pastoral Services at Wesley Woods, Emory Clergy Care and the North Georgia Conference of the United Methodist Church have kicked off a faith based educational initiative. The purpose of this initiative is to increase clergy and other key figures within faith based organizations awareness and understanding of depression in older adults while giving them clear ways of intervening in order to get the depressed person to the care they need. Between October 2001 and November 2002, the Fuqua Center will present at 12 North Georgia District meetings where as many as 120 churches will be represented. Each district will be given an overview of the topic and offered a more intense training program in their district as well as a web based e learning training. Each district will be encouraged to invite their colleagues from other religions and denominations to the training event.

The Fuqua Center provides an average of 5 community talks a month to physician organizations, assisted living, churches and senior organizations.

The Fuqua Center Information Line (1-877-498-0096) was established in May 2001 as a means for addressing calls from both lay persons and professionals requesting additional information and tools to screen for depression, and scientific based information on the treatment of depression in older adults, and assistance in accessing treatment. Because older adults are reluctant to seek treatment for depression and the availability of practitioner willing and capable of treating geriatric depression is limited, the Fuqua Center is compiling a statewide referral network. Persons included in the network are clinicians/agencies that are willing to diagnose, treat and/ or advocate for a patient in getting to a treatment site. Currently the Late-Life Depression referral network includes 79 clinicians/ agencies statewide. The referral network can be accessed via the toll free number or http://fuqua.emoryhealthcare.org.

Drs. McDonald and Thompson with Jocelyn Porquez, MSN, FNP, CS offer a mini Fellowship in Electroconvulsive Therapy to psychiatrists and nurses. Over the past 3 years approximately 10 courses have been conducted for physicians around the country and in Canada.

Finally, the Fuqua Center has become an active member of the Coalition of Advocates for Georgia’s Elderly (CO-AGE) lobbying the Georgia legislature regarding issues of priority to thousands of older Georgians. The Fuqua Center will play an active role in educating Georgia’s legislatures regarding prevalence of depression in older adults and the need for innovative ways of improving older adults’ access to psychiatric care.

Research

Transcranial Magnetic Stimulation (TMS)

Over the past year we have continued to enroll patients in a double blind placebo controlled study of TMS. Our study will be completed in the next 2-3 months and will be the first report of a double blind placebo controlled study of stimulation on both the right and left prefrontal cortex. Our other studies have only stimulated the left prefrontal cortex and theoretically stimulating both sides will increase response. We have offered patients up to four weeks of treatment and have found a response rate for 4 weeks TMS of up to 75% of patients (i.e., 75% of patients who get four weeks of treatment have a drop in their depression scores of at least 50%). These are very ill patients- most have failed at least 5 antidepressants and half have failed ECT.

We also continue to enroll patients in two other studies for maintenance TMS and TMS in dementia patients. Maintenance TMS is used in patients if they respond to TMS then relapse and want to come back for treatments once a week. Maintenance TMS is not working as well as we would like so we are modifying the procedure. TMS has been used in one patient with Alzheimer's disease and worked very well. The patient had a marked improvement in behavioral problems. We are in the process of writing this up as a case report.

We continue to be collaborators with Neurology in two TMS projects in patients with Parkinson's disease and depression. One project is sponsored by the VA Medial Center, and the second by the National Institute of Health. These projects have just started and it is too early to report any meaningful results.

Over the past year we have screened over 700 patients over the phone, interviewed another 200 patients and enrolled 70 patients in TMS studies making the Emory Center one of the most active in the country.

Dr. Thompson made a presentation on the TMS research to the national meeting of the American Association of Geriatric Psychiatry and Dr. McDonald wrote articles for Depression and Anxiety and the American College of Neuropsychiatry.

Electroconvulsive Therapy

The National Institute of Mental Health RO-1 in acute and maintenance ECT is ongoing. Patients over age 65 years with severe major depression are randomized to receive either ECT or a medication trial. If they receive ECT then after ECT they either get maintenance medication or maintenance ECT. An interesting facet of this study is that we are not just looking at how these patients do clinically but also looking at the costs of these treatments. We have enrolled 175 patients in 3 years and we will continue to enroll patients until we reach 200 patients (probably January of 2002). Dr. Thompson presented the initial findings to the American Psychiatric Association annual meeting this past May

Parkinson's disease

Dr. McDonald is involved in two NIH studies with the Department of Neurology investigating depression in Parkinson's disease. In one grant the, effects of transcranial magnetic stimulation and ECT on depression and PD is being investigated. In the second grant the effect on mood of deep brain stimulation is being investigated.

Future Projects:

Dr. McDonald submitted an R-21 multi-center grant with Irene Richards of the University of Rochester to examine depression in Parkinson's disease. Although depression is second only to tremor as the most common neurological condition in PD, no one has ever conducted a large scale prospective placebo-controlled trial of antidepressant therapy in PD. In a change from tradition our hope is that this grant will be funded jointly by the National Institute of Neurological Disease and Stroke (which usually funds grants in PD) and National Institute of Mental Health (which funds depression research). The score on the grant was just received and the prospects for funding appear excellent.
We also have received funding to use positron emission tomography (PET) to determine if metabolic patterns in depressed patients can predict which patients will respond to TMS. Theoretically the TMS treatments stimulate the neurons in the part of the brain that the magnet is placed over. In depression, patents are thought to have decreased neuronal activity over the left prefrontal cortex and the magnet has been applied over that area to stimulate those neurons. But what about the patients who do not respond? Perhaps they are in the minority and do not have decreased neuronal activity in their left prefrontal cortex. What if the stimulus was applied to a different area- perhaps over the right prefrontal cortex- where there is an actual deficit in neuronal activity as shown by the metabolic pattern with PET and guided by the MR images? These strategies will be investigated in the pilot trial.
Dr. McDonald has developed a consortium of researchers in several sites around the country to investigate the efficacy of TMS in the treatments of depression. Dr. McDonald and Emory will be the lead site (Dr. Szuba of the University of Penn will be the co-investigator) for a multi-center trial of TMS in depression funding by a private company.

Dr. McDonald submitted a grant application to the National Suicide Foundation to examine suicidal ideation and depression in elderly personal care home residents with multiple medical problems. Again the approach will be to examine the interaction of medical illness, dementia and depression to determine appropriate pharmacological and psychosocial interventions.

Dr. Thompson submitted a grant application to the National Alliance of Research in Schizophrenia and Depression to study the side effects and efficacy of a new form of ECT, bifrontal electrode placement. Bifrontal placement of the electrodes has been shown to have fewer cognitive (e.g., memory) side effects than traditional ECT and yet to have equal efficacy.

Also, pilot data is being collected regarding the outcomes of depressed older adults receiving group therapy and depression in caregivers of patients receiving ECT.

 

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