Given the strong relationship between physical illness and depression in older adults, medical hospitalization provides an opportunity to diagnose and treat elderly patients with depression. Nearly 40 percent of medically ill elderly patients who are hospitalized experience some form of depression, although only a small proportion of these patients are recognized as being depressed and only about 50 percent of those with major depression receive treatment. The majority of these depressions do not resolve on their own and may persist for many months after hospital discharge. Koenig and associates examined antidepressant and benzodiazepine use as prescribed by nonpsychiatrists before, during and after acute hospitalization in older patients with depression.
A total of 153 hospitalized patients 60 years of age or older were identified by an intensive psychiatric interview and included in the study. Following discharge, the patients were contacted by telephone four times at 12-week intervals to inquire about medication use. Overall, 40.5 percent of the patients received antidepressants at some time during hospitalization or during follow-up after discharge, 25.5 percent of patients received benzodiazepines and 34 percent of patients received neither. During hospitalization, 39.9 percent of patients received benzodiazepines, and 54.1 percent of these patients received new prescriptions. Of the 114 patients with depression who were not receiving antidepressants on admission, only 15 (13.2 percent) started antidepressant therapy while in the hospital.
Of the 62 patients treated with antidepressants, 45.2 percent (28 patients) received amitriptyline and 14.5 percent (nine patients) were treated with other tricyclics, a tetracyclic or a monoamine oxidase inhibitor. Thus, newer and older antidepressants were used with equal frequency. Amitriptyline was prescribed at an average dosage of 48.6 mg per day (a dosage likely to be subtherapeutic even in frail elderly patients). Fluoxetine was prescribed at an average dosage of 28.2 mg per day (a dosage considered to be excessive in many frail elderly patients). Of the 91 patients with depression who were not prescribed antidepressant therapy before or during hospitalization, only 11.0 percent (10 patients) received antidepressant therapy at some time during the one-year follow-up period. In those patients who received antidepressant therapy at discharge, there was little indication that these dosages were titrated up according to patient response.
Comparing the results of this study with results of a study conducted in 1987, the current study did not show that elderly patients with depression were more likely to receive antidepressants. The current study found that these patients received benzodiazepines almost twice as often as patients in 1987. This finding was disturbing because of the association between benzodiazepine use and an increased risk of falls and hip fractures. Amitriptyline was the most commonly prescribed antidepressant in the current study, although it has been associated with strong anticholinergic, antihistaminic and beta-adrenergic blocking properties as well as adverse cardiac conduction events. According to two recent studies, treatment with amitriptyline is considered inappropriate for elderly patients.
The authors conclude that greater attention should be paid to the identification and appropriate treatment of elderly patients with depression. This study evaluated the prescribing habits of nonpsychiatrists in a large teaching hospital. Further educational interventions are needed to ensure that elderly patients receive proper therapy for depression.