Diagnosing and Treating Depression in Older and Oldest Old

Abstract

Depression is very common in older people and it is associated with negative consequences such as functional decline, increased morbidity and mortality and higher healthcare costs. Despite this, it is still underdiagnosed and undertreated and the issue is particularly relevant for people older than 80 years. The main reasons for underdiagnosis are: atypical presentation, concomitant cognitive decline, inadequate diagnostic tools, and prejudice that depression is a normal part of ageing. On the other hand, the main reasons for undertreatment are: multimorbidity, concerns about adverse events and drug interactions, lack of confidence in the efficacy and safety of pharmacological and non-pharmacological treatments in the oldest old depressed patients, who are underrepresented in clinical studies. The new antidepressants are the drugs most frequently used, due to their perceived more favorable safety profile than older antidepressants. Psychotherapy is equally effective but less frequently used and should request some adaptive strategies for the peculiarities of octogenarians. Electroconvulsive therapy is limited to severe psychotic late-life depression resistant to other treatments. In light of the heterogeneity of people aged 80 years and over, with multiple and different medical, functional, socioeconomic problems, a multidimensional approach is probably the most suitable both for diagnosis and treatment, in order to develop an individualized care plan. These considerations should guide the formulation of future research studies, specifically tailored for the oldest depressed patients.

Evidence for underuse and overuse of antidepressants in older adults: Results of a large population‐based study

“…In addition, recent research describes concomitant cognitive decline, inadequate diagnostic tools, and the prejudice that depression is a normal part of aging as the main reasons for underdiagnosis of depression in older adults. 41 However, it is remarkable that out of 163 elderly persons with depression, only 100 (61.4%) reported a recent diagnosis of depression. This underlines the fact that health care providers need an increased awareness of signs of depression in the elderly.…”

“…In addition, recent research describes concomitant cognitive decline, inadequate diagnostic tools, and the prejudice that depression is a normal part of aging as the main reasons for underdiagnosis of depression in older adults 41. The risk for possible misdiagnosis is high particularly in those participants that consult physicians for somatic complaints of depression such as sleeping disorders 40 -symptoms frequent in elderly people.…”

Approval of psychotherapy and medication for the treatment of mental disorders over the lifespan. An age period cohort analysis

“…Looking specifically at attitudes towards psychotherapy and pharmacotherapy, a study among depressed primary care patients in the USA indicated a preference for counselling or psychotherapy over antidepressant medication (Gum et al 2006), which corresponds to population studies that consistently show stronger preferences for psychotherapy over pharmacotherapy (Schomerus et al 2012). However, only very few older persons with depression receive psychotherapy, most patients of older age receiving treatment are taking antidepressant medication (Morichi et al 2015). On the one hand, this is simply because guidelines for geriatric depression recommend antidepressant medication as an initial treatment (Alexopoulos, 2011), probably still reflecting the false belief that older persons do not benefit from psychotherapy.…”

Early Symptom Trajectories as Predictors of Treatment Outcome for Citalopram Versus Placebo

“…Major depressive disorder (MDD) in the elderly has many negative consequences, including functional decline and a higher risk for other illnesses, such as dementia, and its healthcare costs are high (1, 2, 3). The current gold standard for the treatment of MDD is antidepressant medications (ADM) (4), but even with maximal treatment many patients fail to experience sustained remission of their depression (5).…”