"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." Age Concern England¹.

"La dépression chez la personne âgée est souvent méconnue ou tardivement reconnue et insuffisamment traitée." ["Elderly depression is often misunderstood or recognised belatedly and inadequately treated."]².

These quotations from the literature of Elderly Depression could be multiplied ad lib. They represent serious problems in the relationship between doctors and elderly patients in primary care where depression is generally the place of initial diagnosis and treatment. Specialists, psychiatrists and hospitals will normally enter at a later stage, especially in countries where the GP acts as 'gatekeeper' to secondary and tertiary care.

On the one hand, Age Concern 's campaign expresses anger at the attitude of those doctors who have already diagnosed elderly depression or accepted the patients' self-diagnosis, but regard the condition as 'natural at your age'. This message - tantamount to 'Keeping a Stiff Upper Lip' - is close to a century out of date and will surely make nine out of ten elderly patients more depressed than when they first asked their doctor for help.

Obstacles to effective diagnosis

However, the concept of elderly depression as a natural phenomenon of ageing is probably less widespread than the sheer difficulty in general practice of accurately diagnosing the condition and the patient's type and stage of depression: minor, major, episodic or chronic, double depression , depressive symptoms, or at the borderline between depression and dementia. Most GPs are not trained in the intricacies of elderly depression, and the customary few minutes spent face-to-face by doctor and patient will tend to confirm each in their preconceived attitudes and provoke disagreement.

The observation that many of the present cohort of elderly patients will conceal their depression (not only from doctors but also from themselves) is widely reported. A fictional case study of a 78-year-old widower who has lost interest in life and eventually commits suicide, is described by Bruce & Pearson³. It illustrates what can go wrong when "depression remains unrecognized by the patient and the primary care physician". This patient is not visibly depressed but has withdrawn from previously enjoyable activities and from his responsibilities; his comorbidities make detection of depression more difficult and take priority in the doctor's limited time with the patient; and the fear of stigma induces the patient to deny depression.

The use of screening scales

The problem is not lack of knowledge. Numerous screening tools are available and are widely regarded as capable of detecting depression by doctors or nurses who have been trained to use them – but many fail to use them.

DSM-IV-TR [Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision] is perhaps the most widely known and relatively uncomplicated screen. It lists 9 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 period⁴.

A more elaborate tool, specifically designed for the detection of elderly depression, is the Geriatric Depression Scale [GDS], devised in 1983, which asks the patient to answer Yes or No to 30 questions and measures the number of 'depressed' answers: up to 5 is regarded as normal, 15 [+/-6] as mildly depressed, and 23 [+/-5] as severely depressed⁵.

GDS was simplified in 1986 to 15 questions with scores above 5 representing depression of ascending severity⁶. This shorter version is described as requiring little training to administer to those elderly persons who are "easily fatigued; have a short attention span; or have mild to moderate, though not severe, cognitive impairment." But some of the GDS questions, whilst appropriate for elderly Americans and many Europeans, can run into cultural problems elsewhere. Whilst preferring to stay at home "rather than going out and doing new things" is regarded as symptomatic of depression in elderly Americans, older Koreans may decide to 'go out and do new things' as a result of depression⁷. Simplification of scaled questionnaires and the vagaries of national character can lead to misleading conclusions about elderly depression.

The four questions of an even shorter version [GDS-4] are easy to administer, but of doubtful diagnostic validity and may be more suitable for excluding a diagnosis of depression⁸.

Fifteen years of frustration for doctors and patients

In studies conducted in the mid-1990s, it was reported in the U.S. that, among nursing home internists, "only 55% feel confident diagnosing depression, and 35% are confident prescribing antidepressants" and that "one third of family physicians are unaware of depression practice guidelines, and one fourth use screening tools." The authors concluded that "training in depression recognition and treatment may be critical for physicians to consider themselves skilled in managing depression"⁹.

That these findings were disappointing in the 1990s is an understatement. Yet recent evidence does not actually demonstrate radical improvement during the last 10-15 years.

In Europe, Age Concern London's depression campaign of 2008 (Ref.1) expresses deep reservations about diagnosis and treatment of elderly depression in the UK, as does the Royal College of General Practitioners which refers to "a lack of clarity who should lead on the care of those with chronic, complex and disabling non-psychotic problems" and points out that, according to recent studies, "almost half of the patients who were prescribed antidepressants were not depressed"¹⁰.

In the Zaragoza Study, the condition of elderly depressed Spanish patients was followed up 4½ years after their initial interview, with predominantly negative outcomes in terms of mortality and morbidity. The authors concluded that "the great majority of the elderly depressed were untreated or inadequately treated"¹¹.

In the U.S, a study of videotapes of 385 appointments with elderly patients published in 2007, "found the median time spent discussing mental health was just two minutes…..more than half the patients whose survey responses suggested they were depressed never spoke with their doctors at all about their emotional state"¹².

Finally, a recent meta-analysis of 41 studies of depression (not confined to the elderly), published over the period 1990-2009, concluded that GPs correctly identified less than half of true cases of depression¹³. There is no clear sign that unassisted diagnosis in primary care has significantly improved over the last two decades.

Elderly patients in denial

Studies of elderly depression generally agree with the observation that many elderly patients, unlike younger ones, will deny being depressed and 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 is essentially a cultural phenomenon, widespread among elderly Western patients who regard being depressed as weak and contrary to the tenets of stoicism in which they were brought up and which makes them view with distaste the contemporary tendency of ‘letting it all hang out’. Above all, there is the problem of social stigma attached to the label of ‘depression’ and admitting their “need for help with psychiatric problems”¹⁴. Western physicians may judge the belief or pretence by elderly patients that their problems are physical (‘my bad back’, my insomnia’, ‘the pain in my arms’…) as a denial of depression, but for Chinese patients “the use of metaphors for mental distress is common and face-saving”, i.e. it is regarded as normal and laudable in their culture¹⁵.

Unless society takes active and effective steps to eradicate the 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 complexity of treatment

Late-life depression can have different causes, symptoms and treatment needs than that observed in younger persons. It is less likely to be grounded in family history, and more frequently associated with the medical and psychosocial problems of ageing or with cognitive deficit. Correctly distinguishing between depression and dementia is critical in determining effective treatment, because “the treatment and prognosis differ greatly between a major depressive disorder and dementia”¹⁶.

The three main methods of treating depression are medication with antidepressants, psychotherapy and electroconvulsive therapy [ECT]. They can be used additively or as alternatives. Although antidepressants are of proven efficacy, elderly patients do not respond as well (or take longer to respond) and are more prone to experience adverse interactions with co-prescribed drugs than younger patients¹⁷. They may also require lower doses, with uncertain impact on efficacy.

The length of treatment with medication and patients’ compliance is of crucial importance in producing effective results during the complex successive phases of depression which have been described as ‘The Five R’s’: Response, Remission, Relapse, Recovery and Recurrence:
“If depressed patients are non-compliant, they become more ill and may attempt suicide. Unfortunately, non-compliance is something that is seldom considered, often because the physician is concerned primarily with the neuropharmacologic effects of antidepressant drugs”¹⁸.

On the other hand, prolonged compliance with medication that is ineffective or produces serious side effects and adverse reactions must also be prevented. In other words, what is needed is greater ‘thoughtful’ compliance – a matter of management and, above all, trustful relations between doctor, patient and carer.

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 life¹⁹ - areas in which medication alone is less likely to be effective.

ECT may be recommended when neither medication nor psychotherapy have been successful, and particularly in cases of psychotic depression. National attitudes towards ECT differ materially across Europe. In Switzerland, for example, ECT is not favoured by the medical profession and used only in extreme cases.

The choice of treatment will depend on 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.

‘Usual care’ tends to start with medication. Whilst different types of modern antidepressants show similar levels of efficacy, there are some differences in side-effects and particularly in the propensity to interact adversely with other drugs prescribed for comorbidities – an important consideration in the treatment of elderly patients. Therefore, SSRIs [Selective Serotonin Re-uptake Inhibitors] are “the treatment of choice/the preferred first-line agents” for antidepressant treatment of late-life depression²⁰. Reviews also point to the usefulness but under-use of psychotherapy and to the relatively high level of safety and efficacy of ECT in elderly patients with severe or psychotic depression (Refs.20).

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 the follow-up of recommendations by specialists and, as far as available resources permit and patients are willing, arranging for a combination of antidepressant treatment with psychotherapy.

In effect, the physician needs to bear in mind that there is not one depressive illness but many. “In the extreme, one could assert that each depressive illness is unique and individual. Elderly persons should not be exempt from that rule…. Ageing, in particular, calls for the necessity of the bio-psycho-social approach dear to psychiatrists”21.

Meanwhile, practical problems in ‘usual care’ need attention. The pitfalls of comorbidity and polypharmacy are widespread, damaging and distinctive in elderly depression. They will form the subject of the next article in this series.
 

Footnotes
[1] "Undiagnosed, untreated and at risk - the experience of older people with depression", London, August 2008
[2] A.-S. Rigaud, "Dépression et vieillissement", L'encéphale 34, juin 2008, Hors-série 2, S9-13 (author's translation)
[3] M. L. Bruce & J. L. Pearson, "Designing an intervention to prevent suicide: PROSPECT [Prevention of suicide in primary care elderly), Dialogues in Clin. Neuroscience 1[2], 100-113, 1999
[4] A. Mulkeen et al, "Screening tools for late-life depression: a review", Depression: Mind and Body 3[4], 150-157, 2008
[5] D. Williams, "Depression in the elderly", www.peaceandhealing.com/depression/elderly.asp , 2006
[6] J. I. Sheikh & J. A. Yesavage, "Geriatric Depression Scale: recent evidence and development of a shorter version", Clinical Gerontology 165-173, Haworth Press, New York 1986
[7] S. N. Greenberg, "How to try this: The Geriatric Depression Scale: Short Form", American J Nursing, 107[10], 60-69, October 2007
[8] "Geriatric Depression Scale", Patient UK, www.patient.co.uk/showdoc/40002438 , 30th June 2009
[9] D. A. Banazak et al, "Practice guidelines and late-life depression: assessment in long-term care", J. Gen. Intern Medicine 14, 438-440, 1999
[10] C. Chew-Graham, "Why is mental health a clinical priority for the RCGP?", Royal College of General Practitioners web site, 2009
[11] C. de la Cámara et al, "Depression in the Community: II. Outcome in a 4.5 years follow-up", Eur. J. Psychiat, 22[3], 141-150, 2008
[12] E. Nagourney, "Aging: Mental health overlooked in care of elderly patients", comment on Ming Tai-Seale article in December 2007 issue of J. Amer. Geriatrics Society, New York Times, 8th January 2008
[13] 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
[14] M. Evans & P. Mottram, “Diagnosis of depression in elderly patients”, Advances in Psychiatric Treatment 6, 49-56, 2000
[15] R.H. Lim and H. Ton, “Depression and Culture: Implications for the assessment and treatment of patients of diverse ethnicities”, Depression: Mind and Body 4[3], 2009
[16] A. Attupurath, R. C. Menon et al, “Late-Life Depression”, www.annalsoflongtermcare.com.content/late-life-depression , 16, Supplement 12th December 2008
[17] S. P. Roose & M. Miyasaki, “Antidepressant treatment of late-life depression”, Depression: Mind and Body 1[4] 118-124, 2005
[18] J. Jefferson, “Patient Compliance in Depression”, Amer. J. Managed Care, 6[2]Sup. S31-38, February 2000
[19] H. F. Durwen, “Depressionen im Alter, Neurogeriatrie 6[1], 3-8, 2009
[20] D. G. Blazer, “Depression in late life: Review and Commentary”, J. Gerontology, Medical Sciences 58A[3], 249-265, 2003; C. L. E. Katona & K. K. Shankar, “Depression in old age”, Reviews in Clin. Gerontology, 14, 283-306, 2004
[21] T. Gallarda, “Dépression de la personne âgée”, L’encéphale 33, S245-251, avril 2007, Hors-série 1[author’s translation]

Related articles:
Elderly Depression: Its Prevalence, Causes and Implications for Society 1/4
Elderly depression: The age factor in depression 2/4
Elderly depression: the pitfalls of comorbidity and polypharmacy 4/4