Depression in the Elderly--A Closer Look Is Needed

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You may have seen the magazine ads that talk about "senior sadness"--as though taking a beloved grandchild for an afternoon in the park is the antidote for what ails grandma or grandpa. Fact of the matter is that late-life depression, often chronic or recurrent, is a key quality-of-care issue and can result in significant functional impairment and suffering. Yet few depressed older Americans receive effective treatment by their primary care providers. Two recent studies took a look at the issue of depression and the elderly and offer some insights into care management.

The first, a long-term study that focused on people age 70 and older, found that depression is more dangerous for elderly men than women. "Depression may be an early sign of impending physical decline," says study author Kaarin Anstey, Ph.D., of the Center for Mental Health Research at Australian National University. "Or it may incur a physiological response that predisposes individuals to cardiovascular disease or cancer" (November/December 2002 Psychosomatic Medicine).

After taking into account factors such as smoking, alcohol and medical conditions, researchers concluded that depression was associated with mortality for men but not for women. "Our findings confirm previous studies showing that late-life depression occurs more often in women, but has greater negative outcomes for men," according to Anstey. The researchers further postulate that depression may be a precursor of cardiovascular disease or dementia or may occur in concert with these conditions.

The second study, published in the Journal of the American Medical Association (December 11, 2002), found that collaboration is key to treating late-life depression. According to research at the UCLA Neuropsychiatric Institute, personalized therapy and monitoring by a depression care manager can significantly reduce symptoms and costs of severe and mild depression in older adults.

In a diverse group of people age 60 and older, collaboration between patient, primary- and specialized-care providers, and a medical professional called a care manager cut depressive symptoms in half for 45 percent of the group, compared with 19 percent in a similar group of adults receiving conventional care for depression through their primary care providers.

What were the critical elements and levels of the collaborative care? Nothing different, say the study authors, than the "key components of evidence-based models for chronic illness care: collaboration among primary care practitioners, patients and specialists on a common definition of the problem, development of a therapeutic alliance, a personalized treatment plan that includes patient preferences, proactive follow-up and outcomes monitoring by a depression care manager, targeted use of specialty consultation, and protocols for stepped care."

Specifically, the full range of intervention care for depression in this study included collaboration between a person's primary care provider and specialist, as well as regular assessment by a personal depression care manager. In consultation with a primary care practitioner, the patient could choose for his or her main treatment either antidepressant medication or psychotherapy. The Impact (Improving Mood-Promoting Access to Collaborative Treatment) program also increased or switched medication, or included extra therapy, if patients didn't respond to the initial care plan.

Despite the rise in use of antidepressants during the past 10 years, the treatment of late-life depression remains largely ineffective.

The study suggests that depression may play a role in causing health changes in men and that "...treating depression in very old adults may reduce the risk of mortality." says study author Kaarin Anstey, Ph.D.

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