The underdiagnosis and undertreatment of depression in older adults has been well documented in recent years, and while certain gains have been made over the last decade, researchers say there is much room for improvement. A study appearing in the Journal of the American Geriatrics Society (2003;51:1718-1728) found that while rates of diagnosis for depression for patients aged 65 and older increased dramatically during the 1990s, "significant disparities by age, ethnicity, and supplemental insurance coverage persist in treatment of those diagnosed."
The researchers, led by Stephen Crystal, Ph.D., examined Medicare claims and interview data from 1992 through 1998 for nearly 21,000 recipients aged 65 and older who lived in community settings. They found that depression diagnoses more than doubled by 1998, to 5.8%. However, certain groups were significantly less likely to receive treatment: people aged 75 and older, people of "Hispanic or other" ethnicity, and people without supplemental insurance coverage. Hispanic beneficiaries who were diagnosed with depression received no treatment 43% of the time, compared with 31.9% of elderly white Medicare beneficiaries. People without supplemental insurance received no treatment 50.8% of the time, compared with 31.5% of beneficiaries with extra coverage. And 40.9% of diagnosed beneficiaries who were 80 and older received no treatment, compared with 24.4% of beneficiaries aged 65 to 69.
Even in the best of conditions, mental health treatment for late-life depression remains largely inadequate, as indicated by the disproportionate rate of suicide among the elderly. While adults 65 and older make up about 13% of the U.S. population, they account for 18% of suicides. According to the U.S. Surgeon General's Office, more than 70% of suicides in older patients occur within a month of a primary care visit, and more than 20% occur on the same day.
Mental health services for older people need to be integrated with primary care, Gary J. Kennedy, M.D., past-president of the American Association for Geriatric Psychiatry (AAGP), told Psychiatric Times. The interaction of mental and physical illnesses in older adults is so intimate that it is counterproductive to have separate systems. A number of studies funded by the National Institute of Mental Health and private organizations such as the John A. Hartford Foundation, the Robert Wood Johnson Foundation, and the John D. and Catherine T. MacArthur Foundation clearly indicate that there needs to be someone to manage the depression at the site where the patient receives primary care services, Kennedy said. Typically, that means co-locating a psychiatric social worker, master's level psychologist or psychiatric nurse with off-site support from a psychiatrist. But that arrangement is rare. "More often than not, the primary care physician is left to his or her own guesswork as to how to recognize the depression and how best to treat it," said Kennedy, who is also director of the division of geriatric psychiatry at Montefiore Medical Center in New York City.
Most primary care doctors have not been trained in how to use the most recently introduced antidepressants in older patients, "and they've certainly not been trained in even basic psychotherapy," he said. "So we're really asking the primary care physician to provide this mental health service when they're ill-prepared to do so."
The other complicating factor, Kennedy added, is that antidepressants aren't as easy to effectively prescribe as people like to think. In the best of studies, the first antidepressant prescribed helps only about 40% of patients. By contrast, the first selected antihypertensive medication lowers blood pressure adequately about 60% of the time. And that is where some of the treatment disparities arise. Patients who receive care in public clinics do not have integrated services and are not getting the kind of aggressive treatment that is warranted for major depression.
"I'm not faulting the primary care physicians," Kennedy said, "because to expect them to treat an illness for which they've not really been well trained, just like expecting me to treat hypertension, puts the patient and the physician at a disadvantage."
Older adults also feel more stigmatized about having a psychiatric diagnosis. "They're from a generation where psychiatric diagnosis implied schizophrenia or a state hospital," Kennedy explained. Younger patients, on the other hand, are more inclined to accept depression as a prevalent disorder that can be helped with medications and talk therapy.
When people do not get care, it's partly a function of the patient not telling the physician everything, Martha L. Bruce, Ph.D., M.P.H., of the department of psychiatry at the Weill Medical College of Cornell University, told PT. At the same time, clinicians can misinterpret what a patient says, especially if there are differences in ethnicity, culture or language. System issues such as what a system pays for and where services are located also create obstacles to care. These issues can create a significant deterrent, especially for low-income patients.