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REVIEWTreating depression in old age: the Sir Douglas Crawford Unit, Mossley Hill Hospital, Park Avenue, Liverpool L18 8BU, UK Address correspondence to D. N. Anderson. Fax: (q44) 151 729 0227 AbstractDepression affects 10±15% of people over 65 living at home in the United Kingdom. It is the commonest and the most reversible mental health problem in old age. Depression is associated with physical illness and disability,life events,social isolation and loneliness. Depression in old age carries an increased risk of suicide and natural mortality.
Recognition and simple intervention can reduce morbidity,demand on health and social services and the cost of community care. Despite a favourable response to treatment,depression remains largely undetected and untreated.
This represents a 2±3-fold increased risk of death compared with non-depressed elderly people,which is With a prevalence of 10±15% among the population not satisfactorily explained by known co-existing over 65 [1],depression is two to three times more common than dementia. Of depressed elders at home, Age is a risk factor for completed suicide. Depression about one-third have moderately severe disease. The is the most important psychiatric condition associated average general practitioner will have 30 active cases with successful [11] and attempted suicide in old age [12].
at any time and the minimum predicted incidence of 24 cases per 1000 per year [2] would produce 7±10 new Depression is not age-related and there is no reason to believe it to be part of normal ageing. It is more common among physically ill subjects in hospital and at home. About 25% of elderly people in general hospital Depression in late life is a largely undetected and wards are clinically depressed [3],and 30±40% of those untreated condition. No more than 10% of those in residential and nursing homes show clinically impor- detected in primary care will be offered anti- tant depressive symptomatology [4]. About one-third depressant treatment and less than 1% will be referred of older people routinely attending general practice to a psychiatrist [13]. In community studies,similar proportions of depressed patients are on antidepressants surgeries are depressed [5],as are 26±44% of those [2]. Depressed older people will consult their general receiving local-authority care in their homes [6]. Higher practitioner two to three times more often than non- rates of depression are found in people with dementia depressed elders,presenting opportunities to identify and other neurological disorders,particularly stroke and and treat depression. In general hospital wards,the detection of depression is also poor [3] and few patients Without treatment,depression in old age becomes will be referred for a psychiatric opinion [14].
a chronic disorder that produces high levels of morbidity In high-risk populations,the use of validated and mortality. Copeland et al. [2] found two-thirds screening instruments can improve levels of detection.
of those diagnosed with depression were either dead The best general-purpose instrument is probably the or psychiatrically ill after 3 years. The mortality rate Geriatric Depression Scale [15]. A shortened version, from natural causes 12 months after a depressive episode which takes only 5 min to complete,is acceptable to is about 12% and remains raised for up to 4 years [9].
primary-care attenders [16] (Appendix). The Geriatric Depression Scale is recommended for screening in depressed elderly patients [28]. ECT is the treatment of geriatric settings by the Royal College of Physicians and choice for psychotic depression. In a prospective study British Geriatrics Society [17] and for routine over-75 of major depression with psychotic features (de®ned health checks in primary care by the Royal College of according to the Diagnostic and Statistical Manual,third version,revised) [29],the outcome of patients accepting This poor medical response to depressed older ECT was compared with that of patients choosing people arises from several factors. Therapeutic nihilism pharmacotherapy with nortriptyline,perphenazine and based on misinformed preconceptions of age and psy- lithium [29]. After 8 weeks of treatment,88% of chiatric treatment may be common. Doctors may have the ECT group and 25% of the drug-treated group inadequate diagnostic skills and poor understanding of responded to treatment. Furthermore,the response to the concept of depressive disorder. Too often,depres- ECT was faster and the preferential response to ECT sion is considered a natural reaction to the vicissitudes was more marked than with younger patients.
of later life and is explained away as an inevitable and normal response. Ignorance of the associations of There is no evidence that age is a predictor of normal ageing make therapeutic apathy more likely with response to treatment. In naturalistic studies comparing older than younger depressed people.
the outcome of younger and older subjects treated by A study of antidepressant prescribing in primary routine clinical practice,elderly people fare well. Meats care found that older patients were less likely to receive et al. [30] demonstrated a better outcome for older newer antidepressants than younger people,while almost patients receiving clinically-determined treatment when half those on tricyclic drugs received therapeutically evaluated 12 months after an inpatient depressive episode. Sixty-eight percent of the elderly group were well,compared with 50% of younger subjects. Only 3.6% of the older patients had been continuously ill,although 16% had died (compared with 29 and 8% respectively, The treatment of depression in old age is,ideally,an Wilkinson et al. [31] reported a similar effect with inter-disciplinary process that recognizes psychosocial ECT. The oldest subjects showed the greatest degree of improvement of clinical symptoms and cognitive Life events,social adversity and physical ill health performance. Of 78 referred patients,72% of those over are important risk factors [20],and social isolation, 65 and 54% of those under 65 had a positive response to loneliness,physical impairment and disability are strong treatment. After 3 years,the superior response of predictors of depression in old age [21,22].
the elderly patients was maintained and increasing age The bene®t of a determined approach to antide- was a positive predictor of outcome [32].
pressant treatment with older people is demonstrated by Although there are no placebo-controlled trials,there Flint and Rifat [23],who report that 95% of 89 patients is some evidence that lithium augmentationÐthe completing a sequential treatment study responded,with addition of lithium saltsÐcan be effective in non- 84% doing so on an intention-to-treat basis.
responders [33]. Alternative augmentation strategies are Between 50 and 60% will respond to a single anti- considered in resistant cases,although these have not depressant intervention. A tricyclic antidepressant, selective serotonin re-uptake inhibitor or other new Studies of the natural history of late-life depression compound may be used. Older patients may take longer to respond to antidepressants and optimum bene®t before antidepressant treatment was available suggested can take 8±12 weeks [24]. Non-concordance is the most that the average time to spontaneous remission was 12±48 months. First-episode depression after age 60 has There have been few placebo-controlled antidepres- a 70% chance of recurrence within 2 years of remission sant studies involving older populations,but most [35]. Withdrawal of antidepressants after 4±8 months con®rm the superiority of active treatment [25]. Newer of continuation treatment resulted in recurrence of antidepressant compounds are as effective as older depression for two-thirds of elderly patients during tricyclic drugs,with almost all being compared in trials the following 12 months [36]. Maintenance treatment with tricyclic comparators [26]. Data from clinical trials with dothiepin 75 mg daily reduces recurrence for up to con®rm the high rate of side effects in older patients 2 years in comparison with placebo [37].
taking older antidepressants [25] and reveal the newer These studies indicate that maintenance treatment compounds to be usually better tolerated [26]. Tricyclic should be continued for 2 years after recovery from antidepressants are more likely to prove fatal if taken in a depressive episode in old age. For individuals who have overdosage than newer antidepressants [27].
had two or more episodes,treatment may need to be Between 70 and 80% of elderly depressed patients continued for several years or even inde®nitely. There are respond to electroconvulsive therapy (ECT),and treat- no data indicating the optimum dose of antidepressant ment is safe and life-saving for the most severely for maintenance,but evidence from studies with younger adults suggests that this should be the dose required to The role of lithium prophylaxis in elderly subjects has There is great potential and opportunity for detecting not been addressed satisfactorily in controlled studies, depression in older people. In addition to relieving great but an elderly subgroup in a mixed-age study bene®ted suffering,there is preliminary evidence that recovery from depression reduces service usage by older people Maintenance treatment with ECT has been used [52]. One study from inner London estimated that the successfully to prevent recurrence without patients monthly cost of services used by depressed elders living accumulating cognitive impairment [39].
at home was almost three times that of well elderly Antidepressant trials in elderly patients in general people,highlighting opportunities for cost savings [53].
medical wards are dif®cult to conduct [40],and often The simple prescription of an appropriate antidepressant produce inconclusive results [41,42]. The most success- drug to all elderly people meeting case-level criteria for ful study [43],purposely included seriously ill medical depression would be a beginning in tackling the most patients in a randomized placebo-controlled trial. By 8 reversible mental health problem in old age.
weeks,twice as many patients treated with ¯uoxetine 20 mg daily showed a treatment response (67% versus 38%). The greatest gain was found in the most seriously physically ill,although numbers in these groups were . Depression is the most common mental health small. Adverse effects were no greater for ¯uoxetine problem in old age and the most reversible cause than placebo,and active treatment was well tolerated.
of psychiatric morbidity and mortality in later life.
Because contraindications to tricyclic antidepressants are . Without treatment,depression follows a chronic common in this population [40],selective serotonin course with high morbidity and mortality.
reuptake inhibitors would be the drugs of ®rst choice for . Detection is poor and treatment of any sort is offered to a minority of cases,but age is not an adverse predictor of response to treatment and elderly subjects have a better outcome than younger patients in some . In high-risk populations,such as physically ill patients,screening with the Geriatric Depression The psychotherapies have been slow to develop for Scale improves detection. In this context,selective elderly people because of ageist assumptions [44]. There serotonin re-uptake inhibitors are the preferred choice.
is evidence of clinical applicability,and interpersonal . Every older person with depression should be con- psychotherapies can be effectively employed with older sidered for antidepressant drug treatment or referral people [45]. Family therapy can be valuable and the bene®ts have been described in case studies,although there have been no controlled trials [46].
Cognitive behavioural psychotherapy is the most evaluated psychological approach. It is more effective This review was produced as an occasional paper for the than occupational therapy,routine nursing care and Faculty of Old Age Psychiatry of the Royal College of waiting list controls in randomized studies [47,48]. In Psychiatrists and endorsed by the executive committee.
comparative studies,cognitive behavioural psychother- The author would like to thank Bob Baldwin,Cornelius apy,behavioural and psychodynamic approaches have Katona and Ken Wilson for helpful comments on early similar ef®cacy and are superior to no treatment [49].
In a randomized placebo-controlled trial,cognitive behavioural psychotherapy was more effective than low- dose lithium or placebo in the 12-month prophylaxis of 1. Katona CLE. The epidemiology of depression in old age. In Studies of treatment and outcome have usually Katona CLE. Depression in Old Age. Chichester: John Wiley, involved secondary or tertiary care populations.
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Received 30 September 1999; accepted in revised form 12 J Geriatr Psychiatry 1997; 12: 1189±94.
44. Ardern M. Psychotherapy and the elderly. In: Holmes C, Howard R eds. Advances in Old Age Psychiatry: chromosomes to community care. Peters®eld: Wrightson Biomedical,1997; 45. Garner J. Psychotherapy and Old Age Psychiatry. Report to the Executive Committee of the Faculty of Old Age Psychiatry of the Royal College of Psychiatrists,London, Answer all the following questions by ringing either `Yes' or `No' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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47. Zerhusen JD,Boyle K,Wilson W. Out of the darkness: group cognitive therapy for the elderly. J Psychosoc Nurs Are you in good spirits most of the time? Are you afraid that something bad is going 48. Campbell JM. Treating depression in well older adults: use of diaries in cognitive therapy. Issues Mental Health Nurs 49. Morris RG,Morris LW. Cognitive and behavioural Do you prefer to stay at home,rather than approaches with the depressed elderly. Int J Geriatr 50. Wilson KCM,Scott M,Abou-Saleh MT et al. Long-term Do you think it is wonderful to be alive now? effects of cognitive behavioural therapy and lithium therapy on depression in the elderly. Br J Psychiatry 1995; 167: 653±8.
51. Blanchard MR,Waterreus A,Mann AH. The effect of Do you feel that your situation is hopeless? primary care nurse intervention upon older people screened as depressed. Int J Geriatr Psychiatry 1995; 10: 289±98.
52. Cullen M,Blizzard R,Livingston G et al. The Gospel Oak Project 1987±1990: provision and use of community services.
Score 1 point for each italicized answer; a total score of 6±15 suggests

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