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Am Fam Physician. 1998;57(5):1096-1098

Depression is the most common psychiatric disorder in the elderly population. The prevalence is from 8 to 10 percent in geriatric medical outpatients. Primary care physicians accurately recognize less than one half of patients with depression, resulting in potentially decreased function and increased length of hospitalization. Meldon and associates conducted a cross-sectional observational survey to determine the prevalence of depression in elderly patients presenting to the emergency department and to assess the recognition of depression by emergency physicians.

A total of 259 patients older than 65 years of age who presented to the emergency department of a large urban public hospital over a three-month period and who gave oral consent were included in the study. Each patient completed a verbally administered Koenig Scale to identify depression. This scale requires simple yes/no responses to 11 questions. A predetermined cutoff score of 4 was used to identify depression. Demographic data were also collected for each patient. Recognition of depression by the emergency physician was assessed by means of retrospective chart review. The patients' charts were also reviewed for any notation indicating that the emergency department physician recognized depression.

Seventy of the 259 patients (27 percent) who were tested scored at or above the cutoff score for depression. Demographic data correlating with depression included patients who categorized their health as poor and patients living in nursing homes. Emergency physicians failed to recognize depression in all 70 patients.

The Koenig Scale is easy to administer, and sensitive and specific in diagnosing major depressive disorder. The low rate of detection may have been the result of a lack of physician awareness of the high prevalence of depression among elderly patients and their concentration on somatic complaints.

Self-rated depression scales are limited because they do not reliably distinguish between depressive symptoms alone and major depressive disorder. This is probably not a critical point because depressive symptoms alone are a significant clinical and public health problem. Depressive symptoms have also been noted to be underreported by elderly black men.

The authors conclude that screening for depression in the emergency department is critical in subgroups of patients with a particularly high prevalence of depression, including elderly patients, especially those living in nursing homes or reporting poor general health. The Koenig Scale is a potential tool to help physicians rapidly identify depressed patients.

editor's note: Recognition of the high incidence of depression in elderly patients is an obligation of the family physician. The morbidity associated with depression in this population includes decreased ability to function, feelings of poor health, increase in frequency and length of hospitalizations, and changes in mental status. Having the patient complete a brief questionnaire helps cue the physician to inquire further about depression, as should clinical presentations that include typical symptoms of depression or multiple, difficult-to-explain somatic complaints. Screening for depression can be performed by clinical staff members other than the physician. Pharmacologic treatment for depression is safe and successful in most of these patients.—r.s.

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