In addition, when depressed, older people often minimize a complaint of sadness and instead become markedly hypochondriacal. Hypochondriasis is defined by DSM-IV and International Classification of Disease, Tenth Revision (ICD10) criteria in terms of disease conviction and disease phobia. DSM-IV states a “preoccupation with a fear of belief of having a serious disease based on the individual’s interpretation of physical signs of sensations as evidence of physical illness.”15 It can be difficult to disentangle symptoms due to hypochondriasis from those due to a physical illness.16 Sometimes this leads to overinvestigation, as with the depressed patient with the heart disease who develops noncardiac chest pain secondary to anxiety and repeatedly requests more tests. On other occasions, underlying illness may be obscured, as when an acutely depressed patient with a tension headache becomes convinced of a brain tumor whereas underlying occult gastrointestinal malignancy turns out to be the real problem.
Screening for depression in high-risk groups might improve detection. A number of validated and age-appropriate depression screening tools are available. One specifically for older people is the Geriatric Depression Scale (GDS) (Table 2).17 Because the GDS minimizes the number of somatic depressive items, there is no need to upwardly adjust the cut-off score.
The Patient Health Questionnaire 9 (PHQ-9) is a screening tool for depression in the primary care setting.18 A score of 10 or higher has a sensitivity of 88% and a specificity of 88% for major depression. It is a validated tool for telephone screening of depression in primary care, takes less than 5 minutes, and can be used to assess severity of depression.19
Treatment
General principles
Effective treatment modalities are available for late-life depression, and successful treatment is associated with improved psychological and physical well-being, quality of life, social functioning, and possibly, reduced health care use and lower mortality. The principles of treatment are the same for all ages. The goals of treatment are outlined in Table 3.
Although the longer-term prognosis may be relatively uncertain, patients with medical comorbidity can respond just as well to antidepressants as physically healthy patients.20,21 Suicide risk can be reduced by timely treatment of depression and by reducing any likely means in high-risk patients. An example concerns the availability of firearms which are increasingly used by older men to commit suicide.22,23 Outcomes are improved by building a therapeutic relationship in which the patient receives adequate information about depression and in which misapprehensions about antidepressant therapy are addressed.
Depression is treated in 3 phases.
• The aim of the acute phase (usually the first 12 weeks) is to achieve remission (that is, no symptoms remain). Residual symptoms predict chronicity and relapse.
• In the continuation phase, prevention of return of symptoms (relapse) is the goal. Older patients with MDD commonly require up to 12 months of continuation treatment.
• The aim of the maintenance (prophylaxis) phase (generally beyond 12 months) is to prevent a new episode. SSRIs and some psychological therapies have been shown to work for up to 3 years in elderly patients with MDD.7
Nonpharmacological therapy
Psychotherapies, such as cognitive-behavioral therapy, behavioral therapies, reminiscence and life review, interpersonal psychotherapy, and problem solving, are as effective as antidepressants for patients with mild to moderate depression.24,25 Individual choice is important because there is evidence that physically unwell older patients with depression are likely to refuse antidepressant drug therapy because of fear of drugs.26 Treatments are usually provided over 6 to 12 weekly sessions and require only commonsense modifications for medically unwell patients (such as pacing sessions to avoid fatigue).
Increasingly, collaborative care models (CCM) are being used in the United States to treat late-life depression. CCM involves close collaboration between a case manager (usually a specialist mental health nurse or a clinical psychologist, either of whom deliver a brief psychological intervention), the local primary care physician, and a psychiatrist. CCM only works if there is regular and timely access to the psychiatrist who can offer advice about the most appropriate pharmacological treatment and next step treatments in patients who do not respond to initial management. CCM is effective in treating depressed patients with comorbid physical illness.27 Unutzer and colleagues28 investigated the longer-term cost effects of CCM for late-life depression in a 4-year follow-up study. Their findings confirm a previous 2-year follow-up indicating that CCM reduces health care use by older patients (including those with comorbidity) compared with usual care.
A recent systematic review suggests that physical exercise (walking or other aerobic exercise) may help reduce depressive symptoms in older people.29 Physical exercise may be considered as first-line treatment for older patients with mild depression.
Despite adverse publicity, electroconvulsive therapy (ECT) remains the most effective treatment for depression in older adults. Efficacy rates are as good as or better than those of younger adults.30 ECT is currently reserved for treatment-resistant depression or for those whose life or health is threatened by severe depression. However, ECT therapy should not be overlooked where available.31 A study of mixed-aged patients reported that virtually all patients experienced a relapse after ECT if not given ongoing medication.32 A combination of nortriptyline(Drug information on nortriptyline) plus lithium(Drug information on lithium) offered the best protection.
Other treatments include deep brain stimulation and vagus nerve stimulation, but clearly these are highly specialized and reserved for patients with refractory depression.33 Still limited but more widely available is repetitive transcranial mag-netic stimulation, which is effective for moderate depression and possibly attractive for patients with medical comorbidity.34 However, there is a paucity of evidence for its use in later-life depression and the frequent treatment sessions may be problematic.
