Diagnosis And Management Of Depression In Older People

Depression in older people cannot be dismissed as unimportant, not least because suicide in older people is much higher than in younger people (Kinsella & Velkoff, 2001; Pearson & Brown, 2000; WHO, 2001), but also because depression in later life appears to have a negative impact on life expectancy, with an increased risk of death that may not be completely accounted for by physical ill health (Ames & Allen, 1991) or by suicide (Burvill & Hall, 1994). Unfortunately, depression in older people is often overlooked, as it is commonly assumed that depression is a natural consequence of the losses experienced by older people in terms of emotional attachments, physical independence and socio-economic hardship (Laidlaw, 2001). The 'understandability phenomenon' (Blanchard, 1996) or the 'fallacy of good reasons' (Unutzer et al., 1999) is the notion that depression in older people is in some way to be expected and is a normal part of ageing. Assumptions such as these can influence the expectations of client, therapist and physician alike, resulting in a sense of the hopelessness of treatment (Unutzer et al., 1999). Seeing depression as understandable produces shared therapeutic nihilism and lowers expectations for treatment in both the providers and recipients of care (Montano, 1999).

Treatment for depression in older people is commonly managed by GPs in primary care (Rothera et al., 2002). McDonald (1986) demonstrated that GPs were able to identify depressive symptoms in primary-care settings; however, in very few cases was diagnosis translated into treatment or referral to other agencies. Crawford et al. (1998) report that GPs were aware of depression in a little over one-half of their patients aged 65 years and above, but that men living alone, those with the least education and those with visual impairment were much less likely to be identified by GPs as depressed. Levels of active treatment were very low, the majority of older people receiving little or no treatment for their depression. For those patients receiving treatment, this consisted mainly of antidepressants.

When GPs use antidepressants to treat depression in older people, they usually prescribe subtherapeutic dosages (Heerenetal., 1997;Isometsaetal., 1998;Orrelletal., 1995).Nelson (2001) comments that, although there is good evidence for the efficacy of pharmacotherapy, due to changes in metabolism in older people, there is an increased risk of toxicity from antidepressants, especially tricyclic antidepressants (TCAs), and that makes this class of drugs less tolerable. However, even newer types of antidepressants, such as the selective serotonin reuptake inhibitors (SSRIs), can cause water retention (the consequences include headaches, lethargy and, in more severe cases, confusion), weight loss and balance problems (Nelson, 2001). Balance problems are potentially very difficult to tolerate in older people, especially for older women, who, due to osteoporosis, are at increased risk of hip fractures after falls. Mittmann et al. (1997) noted that, although it is commonly stated that older adults tolerate SSRIs better than TCAs, their meta-analysis of the safety and tolerability of antidepressants suggested there were no differences in the rates of adverse events with the different classes of antidepressants. Interestingly, Mittmann et al. (1997) also note that while older adults generally do not tolerate TCAs very well, those who can tolerate these medications generally have a good treatment outcome.

Despite a fear of side effects from antidepressant medications, such as cardiac arrhythmias (Ryynanen, 1993) and problems to do with tolerability of medications, treatments with recognised efficacy for the alleviation of depression, such as cognitive behavioural therapy (CBT), are often not recognised by GPs as viable options for older adults with depression. The provision of psychological treatment for depression in older people is hampered by factors such as a lack of knowledge among GPs regarding the effectiveness of psychotherapy with older people (Collins et al., 1997; Laidlaw et al., 1998), the low numbers of trained geriatricians and psychogeriatricians and the continuing legacy of Freud's assertion that older people lack the mental plasticity to change or to benefit from psychotherapy (Lovestone, 1983). Service providers have also tended to neglect the psychological needs of older people, so that older adults expect to receive physical treatment for a range of psychological difficulties (Woods, 1995).

Another reason that older people have traditionally been underserved in terms of psychological treatment is the pervasive idea that older people do not want to take part in psychotherapy sessions (Lebowitz et al., 1997). Landreville et al. (2001) investigated the acceptability of psychological and pharmacological treatments for depression in older people. Using a series of case vignettes, older people reported cognitive, cognitive-behavioural and antidepressant medications as being acceptable treatments for late-life depression. Interestingly, the acceptability of treatment types varies according to the level of severity of depression symptoms; for more severe depression symptoms, older people rated cognitive therapy as more acceptable than antidepressants.

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