Elderly depression is a rapidly growing problem of ageing populations in the world’s developed countries, particularly in Europe and Japan. Previous articles in this series, have looked at medical treatment and psychotherapy for elderly depression. Knowledge of these has advanced rapidly, but adoption into clinical practice has been slower. It is harder to apply solutions to the social causes of elderly depression like loneliness and loss. So although we have a broad understanding of ‘where we can go from here’ in elderly depression, it has to be said that we are not actually going there fast enough.

At this point, let us summarize what we know about elderly depression from other articles in this series, so we know what we are dealing with.

• Elderly depression is an increasingly costly and troubling problem.
• Prevalence of elderly depression is increasing, especially among those in institutions and nursing homes (many of whom could be treated out in the community).
• Risk factors for depression differ between young and older patients and between the ‘newly elderly’ and ‘oldest old’.
• Patients are often not diagnosed accurately, or early enough, with elderly depression.
• Comorbidity and polypharmacy (having many illnesses and being on many medications) are common in elderly depression.
• Advancing age need not be an obstacle to effective treatment of elderly depression, but more care should be taken of side effects, dosage problems and patients not taking their tablets.
• Stepped care (with guidelines for successive treatment) is a sound principle but good idea, but health professionals often don’t stick to the guidelines.
• Elderly depression can respond better when antidepressants and psychotherapy are combined, but it can be hard to access the latter.
• Experience in the US shows that collaborative care, involving teams of health professionals, can be a winner in the treatment of elderly depression in terms of both clinical success and cost effectiveness.
• The challenge now is – can collaborative care be adopted among Europe’s very different health care systems?

It is not as if policy makers in Europe are unaware of the growing public health problem of elderly depression. But there is a lack of focus in turning knowledge into action. In the US, expert opinion regards collaborative care research as positive and conclusive and would like to see this approach adopted more widely. Europe lags behind the US in collaborative care, and there is no specific focus upon elderly depression. 

Nevertheless, there have been some good examples of trials of collaborative care in The Netherlands, the UK and Germany. The British and Dutch studies looked at cost-effectiveness, which is valuable given differences in costs, pricing, reimbursement and health insurance policies between the US and Europe. It’s possible the results of these trials will eventually open the door to collaborative care for elderly depression in Europe’s health systems. Switzerland is well placed to take up collaborative care because of its pioneering approach to, and experience of, managed care. In Switzerland there is HMO/HAM - a combined Health Maintenance Organisation and Hausarzt (family doctor) Model - which aims to maintain the relationship between the doctor and patient, while providing integrated care management at lower cost through HMOs. Switzerland is set to incorporate access to managed care in the next phase of its health reforms. If this happens, it will provide a strong platform for the type of collaborative care we want for elderly depression. The need for improvement in ‘recognising, treating and preventing depression’ in Switzerland’s basic health insurance has recently been underlined by opinion leaders.

In summary, it would be desirable to extend trials from The Netherlands and the UK to additional Member States of the European Union; to extend Swiss managed care towards collaborative care for depression; and to include a range of elderly patients for more specific exploration of the impact of collaborative care on their specific problems arising from comorbidity and polypharmacy. That, we believe, is where we should be going from here in the interests of Health Aging.

Source:

The professional version of this article.

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