Am Fam Physician. 1998;57(4):818-820
In 1991, the National Institutes of Health issued a consensus statement about the diagnosis and treatment of depression in the elderly. Lebowitz and associates reviewed the conclusions of this statement in light of recent findings.
Depression that first occurs in late life is more likely to have a chronic course and is more likely to occur in women. In elderly patients, depression with cognitive impairment that improves with antidepressant treatment is also a predictor of irreversible dementia. Newer research is supporting the high prevalence rates (13 to 27 percent) of “subsyndromal” depression—that is, the presence of depressive symptoms that do not meet diagnostic criteria for major depression as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). In the long-term care population, subsyndromal depression may exist in as many as one half of the residents.
The reasons to diagnose and treat depression in the elderly are many: to hasten symptom remission, to prevent relapse, to improve the patient's quality of life, to improve functional status and to prevent premature death. Newer antidepressants, especially the selective serotonin reuptake inhibitors (SSRIs), have been compared with the older tricyclic antidepressants and have been found to be more effective. Both medications are beneficial in 60 to 80 percent of patients, but the SSRIs are associated with higher levels of tolerance, fewer dosage adjustments and greater acceptance among the elderly. Psychotherapy, in various forms, has also been shown to be efficacious in treating late-life depression. It may be especially useful in patients who cannot or will not take antidepressant medication. Treatment for late-life depression should continue for at least six months beyond recovery for patients with first-onset depression and for at least one year beyond recovery for those with recurrent depression. Some patients with recurrent depression may need lifelong treatment with antidepressants.
Suicide rates in elderly persons increased 9 percent between 1980 and 1992. Primary care physicians are less likely to be told by their patients about suicidal intent than psychiatrists, so it is particularly important for primary care physicians to be aware of the symptoms of depression (other than just mood disturbance) and to ask about suicidal ideation in patients with those symptoms. One important clue in the detection of depression is a complaint of a persistent sleep disturbance.
The authors conclude that, with vigilance, primary care physicians can recognize, diagnose and treat depression in the elderly in order to improve quality of life and maintain function at the highest levels possible.