Late life depression: undertreated?

Prevalence rate and correlates of depressive symptoms in older individuals: the Veneto Study

BACKGROUND

Depressive symptoms (DS) are very common in elders, particularly among women, and their prevalence rates vary widely across countries.

METHODS

A random sample of noninstitutionalized men (n = 867) and women (n = 1531), aged 65 years and older, from the Veneto region, northeastern Italy, were interviewed and participated in a brief physical examination in their homes. The prevalence rates of DS and the associated physical, social, and psychological factors were analyzed.

RESULTS

The overall prevalence rate of DS was 58% in women and 34% in men (p <.0001), but there was no significant trend with age. Women were at higher risk of DS (OR = 1.63) than men, even after adjusting for traditional risk factors, such as fair-poor self-rated health, sleep disturbances and use of sleep medications, lack of support from social and family network, and physical and cognitive impairment.

CONCLUSIONS

This study provides evidence that older women more frequently report DS than men, independently from the presence of traditional risk and associated factors. Cultural and lifestyle factors throughout life might explain this gender difference.

Is there a distinct subtype of major depression in the elderly?

Evidence for and against the notion of a specific subtype of depressive illness in the elderly is reviewed. There is little to support a distinction based on clinical features, neurobiological markers, treatment response or prognosis, but subtle organic cerebral change may predispose to late-onset depression in a significant minority of cases.

Prognosis of depression in the elderly. A comparison with younger patients

The prognosis of depression in the elderly was investigated in a mixed-age sample of 242 consecutive referrals, with DSM-III defined unipolar major depressive episode, to a specialist unit for mood disorders. Subjects were followed up at about 1 and 3.8 years. There was no significant difference in outcome between younger (under 40 years), middle aged (40-59 years) and older (60 years or more) depressed patients. For the 61 elderly subjects with depression, prognosis improved with time, with 25% having a lasting recovery at the first and 41% at the second follow-up. Early onset, recurrence, and poor premorbid personality were associated with a worse prognosis. Three (5%) elderly depressives had committed suicide and seven (11%) had died from natural causes by the second follow-up. Despite some methodological limitations, our findings suggest a more optimistic outlook and the need for longer, more assertive treatment for elderly, depressed patients.

Community psychiatric nursing and depression in elderly people

This paper invites community psychiatric nurses (CPNs) working with the elderly to examine their involvement with elderly people who are depressed. It does this by examining a selection of the more recent literature on the topic of depression in the elderly and discusses how this might inform and guide the CPN in his/her practice with this client group. Areas from within the literature which are examined in this paper are: the prevalence of depression in the elderly; problems of underdetection and undertreatment; classification; screening instruments; social factors in causation; prognosis following treatment; and psychological therapy. The literature is shown to have much to offer in aspects of CPN role such as: assessment and planning of care, including psychological therapy; liaison with, and education of, other professionals; screening; and primary prevention. The nursing literature of this CPN specialism, where it relates to depression, is also examined. Although developments in psychiatric services specifically for the elderly were mainly as a response to the illnesses causing dementia, this paper emphasizes that depression is the more common disorder in the elderly. It is suggested therefore that a CPN service should ensure that it is significantly orientated to the needs of this client group.

The prognosis of depression in old age

The 12-month outcome of 103 elderly depressed patients treated by psychiatrists in Perth, Western Australia, was good in 32-47% of cases, depending upon the stringency of the outcome criteria used. A higher than expected mortality was found, especially in men. No clear association was found between 12-month outcome and a variety of clinical variables at index admission, including chronic physical illness, severity of depression, and severe life events during follow-up. As the statistical power of this and other studies is small, it would be unwise at present to draw definite conclusions about the role of possible risk factors in the prognosis of depressed elderly. Vigorous treatment of the depressive illness and adequate after-care are important.

Lithium augmentation in geriatric depression

In the geriatric department of a Dutch psychiatric hospital the charts of 51 patients treated with lithium in addition to cyclic antidepressants were reviewed. A response was seen in 33 patients (65%). For patients with recurrent depressive episodes, a statistical trend was found towards more responders with more complete responses, compared to patients with first depressive episodes. During lithium augmentation, 10 patients suffered from severe adverse effects 12 times. In spite of adverse effects, with expert monitoring lithium augmentation can, in our opinion, be of value in the treatment of older depressed patients.

The prognosis of depression in the elderly

Controversy prompted a systematic and critical review of original research articles to determine the prognosis of depression in the elderly. A search of three computer databases for articles published from January 1980 to May 1989 and of the bibliographies of articles located revealed 10 reports, involving 990 subjects, that met the following inclusion criteria: original research, published in English or French since 1950, sample of at least 25 patients, inclusion of only patients over 60 years, mean follow-up period of 1 year or more and description of the patients' mental state during follow-up. The methods and study designs were then assessed with the use of the criteria for prognostic studies established by McMaster University Health Sciences Centre, Hamilton, Ont. All of the studies had serious, multiple flaws. Nevertheless, when the results were combined it appeared that at least 60% of the patients remained well or had relapses with recovery (mean follow-up 31.9 months); up to 25% remained continuously ill. Physical illness, cognitive impairment and severe depressive symptoms were frequently related to poor prognosis; most of the social factors studied were not related to prognosis. Future studies must pay attention to methods and design, particularly the composition of study populations, the assessment of outcomes and the control of extraneous prognostic factors.