It is unacceptable for depression to be dismissed as a natural consequence of ageing. Never again should a GP explain to an older person that depression is something they should expect at their age.

So says Age Concern, England, highlighting the difficulties in the relationship between doctors and elderly patients with depression.  An even more widespread issue in elderly depression is the difficulty of diagnosing it in primary care. It’s not just depression itself that has to be diagnosed but also its type and stage, so treatment can be tailored appropriately.  Quite often, neither the doctor nor the patient will actually recognise depression for what it is.  There are many screening tools for depression but often they are not used.  One of these lists nine depressive symptoms and indicates major depression in the presence (for at least two weeks) of 5 or more of the symptoms which must include 'depressed mood' and 'loss of interest'.  Minor depression requires the presence of 2-4 of the 9 indicators over the same period.  There are other scales, some specifically geared towards elderly depression.  

Research going back to the mid-1990s suggests that many health care professionals don’t know how to diagnose depression.  This state of affairs has not really improved, according to more recent studies in London, Spain and the United States.  Evidence suggests that  many elderly patients, unlike younger ones, will deny being depressed and may even reject a professional diagnosis of depression. This appears often to be a generational characteristic of past and recent cohorts of patients aged 65+, and raises the intriguing question whether or not this will continue to be the mindset of the new wave of ageing baby-boomers.  Denial of depression is common where the condition is seen as weakness.   Above all, there is the problem of social stigma attached to the label of ‘depression’ and admitting  need for help.   Unless society takes active and effective steps to eradicate this sense of stigma, doctors and nurses will continue to face difficult problems in diagnosing elderly depression, communicating a positive diagnosis to patients in denial, and persuading them to accept and persist with treatment.

The three main methods of treating depression are medication with antidepressants, psychotherapy and electroconvulsive therapy [ECT], either alone or in combination. Elderly patients do not respond as well (or take longer to respond) to antidepressants, compared to younger people, and are more prone to adverse interactions with other drugs.  However,  psychosocial therapy can be particularly useful in relieving elderly depression that is related to loss and bereavement, adjustment to change, subjective grief and social isolation: it can rekindle hope and open new perspectives in late life - areas in which medication alone is less likely to be effective.  Choice of treatment will depend upon whether the patient initially presents with mild, moderate or severe depression. It can range from ‘usual care’ (unstructured in primary care settings) to carefully structured ‘stepped’ or ‘collaborative’ care which will be discussed in a subsequent article.

Overall, GPs play a cardinal role in the diagnosis and treatment of elderly depression. Much depends on their ability and persistence in diagnosing accurately and ensuring that diagnosis leads to appropriate treatment including follow-up of recommendations.   Practical problems in ‘usual care’ also need attention.  For instance,  the pitfalls of comorbidity (having more than one disease, for example, depression and heart disease) and polypharmacy (taking a lot of medications) are widespread, damaging and distinctive in elderly depression. They will form the subject of the next article in this series. 

Selected sources:  
"Geriatric Depression Scale", Patient UK, 30th June 2009 
A. J. Mitchell, A. I. Vase & S. Rao, "Clinical diagnosis of depression in primary care: a meta-analysis", Lancet 374, 609-619, 22nd August 2009 

Related Article
Elderly and depression: How to understand Depression in the elderly 1/6
Elderly depression: The age factor in depression 2/6
Elderly depression: the pitfalls of comorbidity and polypharmacy 4/6
Elderly Depression : New approaches to the management of elderly depression 5/6
Elderly Depression : where do we go from here? 6/6