Geriatric Depression: Diagnosis and Treatment

GENERATIONS A common but underdiagnosed condition. Clinically significant depression in later life is common, yet it is often underdiagnosed in primary care settings, acute medical and surgical facilities, and long-term care facilities. The pathways to depression in later life include chronic medical and neurologic illnesses and their associated disability, psychosocial stressors (such as bereavement, caregiving, retirement, or interpersonal disputes), cerebrovascular disease and associated risk factors (high blood pressure, diabetes, smoking, increased serum lipids), and perhaps some genetic liability. The consequences of depression in old age include suicide, especially in white men ages 75 and older; alcohol dependence; cognitive impairment; amplification of disability associated with medical illness; increased rates of healthcare utilization; and increased rates of mortality following heart attack, stroke, and cancer (for review, see Reynolds et al., 2001). DIAGNOSING DEPRESSION IN OLD AGE The hallmarks of depression in old age are its coexistence with medical illness and its association with cognitive impairment. And it is these very factors that can lead clinicians, patients, and caregivers to overlook or fail to diagnose depression. The most important symptoms in diagnosing depression in an older patient include sad, downcast moods; fiequent tearfulness; and recurrent thoughts of death and suicide. Other important symptoms include diminished interest in pleasurable activities and hobbies, feelings of hopelessness or worthlessness, a sense that life is empty, feelings of guilt, avoidance of social interactions, feelings of helplessness, psychomotor agitation (restlessness, fidgeting) or retardation, difficulty making decisions, and difficulty initiating new projects. Clinicians should also pay attention to reports of family history of mood disorder, appetite change or weight loss, feeling worse in the morning, fatigue or loss of energy, insomnia or hypersomnia, fear that something bad is going to happen, difficulties with memory or concentration, and preoccupation with poor health or physical limitations. As we have recently reviewed (Harman et al., in press), the 1999 Surgeon General's Report on Mental Health decries the fact that depression remains underdiagnosed (U.S. Department of Health and Human Services, 1999), especially among elders. This underdiagnosis may reflect the primary care provider's lack of confidence in diagnosing depression (Unutzer et al.,1999) and the tendency for older adults to use somatic complaints to describe what are actually symptoms of depression (Gallo, Rabins, and Anthony, 1999). In addition, although African American patients have a lower reported prevalence and incidence rate of depression (Kessler et al., 1994), these findings may actually be the result of providers recording depression diagnoses less often among elderly African American patients because of cultural stereotypes (Cooper-- Patrick et al., 1999). The causes of racial differences in diagnosis rates merits further study (Harman et al., in press). Given the many demands for a physician's attention and time, depression often gets less attention during primary-care visits when the patient has several medical problems (Rost et al., 2000). Finally, many clinicians have received inadequate training in interviewing psychiatric patients, a factor that comes into play especially when clinicians suspect that patients may not accept a diagnosis of depression. TREATING DEPRESSION IN OLD AGE We recently conducted a survey of fifty academic geriatric psychiatrists nationwide to develop expert consensus guidelines for the management of depression in old age (Alexopoulos et al., 2001). For more severe depression, most experts recommend combining an antidepressant medication with psychotherapy. Electroconvulsive therapy is an alternative, especially in psychotic depression. …