Spotlight

MOOD DISORDERS IN LATE LIFE: A NEW IPA TASK FORCE

Robert Baldwin and Thea Heeren

At a symposium in Nice, the IPA task force on depression in the elderly critically reviewed the evidence for the benefit of antidepressants and psychological treatments. IPA wishes to thank Professor Anthony Mann for his work in raising the profile of depression. This work must continue and the baton has been handed on to Professors Bob Baldwin and Thea Heeren, as co-chairs of the new IPA Mood Disorders Task Force. Below are their thoughts.

According to the World Health Organization, depression will be the leading illness associated with negative impact and disease burden by 2020. Currently, as a cause of morbidity it ranks alongside the eight most disabling medical conditions, including heart disease. In older people the impact of depression is even greater. It is the single most important predictor of suicide in older people; is a major cause of disability and poor quality of life; it interacts with physical disorder to worsen outcomes; and it increases healthcare utilization and healthcare costs (Lebowitz et al, 1997). It is also common—more common than dementia, with prevalence in the community of 10– 15% rising to about one half of residents of nursing and residential homes (Chiu et al, 1999). Notably among older people, sub threshold depression (‘minor’ depression) outnumbers major cases by a factor of three or four to one. This should be placed in the context of a growing body of evidence that “minor” depression is by no means trivial, associated as it is with similar risk factors, morbidity and outcomes as major cases (Judd et al, 1998).

Yet there are reasons to be positive about depressive disorder in older people. It is the most treatable of the mental disorders of late life and there is a large and growing evidence base to guide physicians on the most appropriate management. Among these are two consensus documents from the National Institutes of Health (Schneider et al, 1991; Lebowitz et al, 1997), two documents reproduced under the imprimatur of the World Psychiatric Association (Chiu et al, 1999; WPA, 1999), and a recent Expert Consensus
Guideline from the United States (Alexopoulos et al, 2001).

Many questions remain. What is the explanation for the very low rates of antidepressant prescribing among older people identified as depressed in a community? A poor level of detection is certainly one possible reason, but might it also be that most primary care depression is for ‘minor’ or sub threshold cases—cases for which there is a lack of evidence as to the most appropriate treatment? Is it because of the legacy of research such as the influential Epidemiological Catchment Area study suggesting that depressive disorder dwindles with age, has resulted in it being demoted from the public health and resource allocations agendas—a point of view argued previously in the Bulletin by Anthony Mann.

We know a lot about what causes depressive disorder in older people but new data are emerging which link late-onset cases to cerebrovascular disease. Morbidity may arise not only from mood disorder but also from brain-based apathy and a dysexecutive syndrome. How common is vascular depression? Does it predispose to poorer outcomes, or even dementia as early evidence suggests? Alongside this rather specialized area, there is an explosion of epidemiological data concerning depressive symptoms and depressive disorder in older people. As researchers delve deeper into their databases more focused questions arise, such as the role of cultural factors in immigrant populations and the role of acculturation in ethnically diverse groups.

The Geriatric Depression Scale (GDS) has been translated into numerous languages and even has its own Website at www.stanford.edu/~yesavage/ GDS.html. In practice, there are 1, 4, 5, 10, 12, 15 and 30-item versions, all claiming validity in particular patients groups or settings. What is the best advice to give to those in primary care and other settings who wish to develop screening programs?

Effective treatments exist. But what are the optimum treatments for minor depression and vascular depression? Importantly, if we can delineate sub-types of depression (vascular, minor/major, psychotic, etc), can we link them to particular treatments or treatment modalities? There are also concerns that evidence from drug trials fail to replicate real-world situations where advanced age, frailty and co-morbidity are the rule. Evidence for the efficacy of psychological treatments in late life depression exists but there is less of it compared to antidepressants and in comparison to younger adults they are far less frequently available. Psychological therapies such as Cognitive Behavioral Therapy, Inter-Personal Therapy and psychodynamic therapies have arisen from a particular (largely Western) mode of thought. How culturally sensitive are they? In most parts of the world, the family and local community remain the greatest resource available to an older person but there is a paucity of evidence of their therapeutic use in late life depression. Lastly, public opinion about electroconvulsive therapy is frequently negative, but for many geriatric psychiatrists it remains an important treatment option. What is the current status of its role in treatment?

The prognosis for an acute episode of depression is good but the longer term response is brittle. What are the best strategies for keeping people well? Particularly in non-specialist settings such as primary care and medical wards, the outcome appears especially poor, even though effective treatments exist. Why is this and what can be done about it? Most studies of prognosis focus on symptomatic improvement, but there is little data about social recovery, recovery of role and effects on relationships. Some studies do and some do not report an increased risk of dementia after depression. What personal and illness characteristics point to an increased risk of dementia in any given patient? Various evidence points to an increased mortality attached to having depression but there is no single explanatory theory for this. Emerging evidence linking depression to cardiovascular morbidity and mortality may provide some of the answers. Do older depressed people die from a broken heart? The final tragedy of depression in later life is suicide, but strategies to reduce suicide remain elusive. Would improved recognition and treatment in primary care make a difference?

It is one thing to have effective treatments, but implementing them is another matter. In younger adults, a large amount of recent research has gone into identifying which models of care result in most improvement for depressed patients in the community. Investigating models of enhanced care has hardly begun in regard to older depressed patients and is urgently needed.

Prevention is better than cure. How should we educate today’s young to be tomorrow’s healthy elders? Speculatively regular exercise (including ‘exercising’ the brain), good cardiovascular care and perhaps postmenopausal hormone replacement may protect against later life depression. Much more research is needed, however. In established cases of depression, the challenge is to prevent recurrence—but with which treatments and for how long?

Task Force Plans

These questions will not be answered overnight, but they should be brought to the attention of the public and health care professionals. The goals that the task force has set are:

(1) to create an international platform for researchers of late-life mood disorders and promote cooperation,

(2) to determine a research agenda, and

(3) to raise awareness of the importance of late-life depressive illness as a public health issue.

We will start with an expert panel discussion on the Internet about the issues outlined here. A first presentation of the results will be given at the Chicago Congress in 2003.

References

Alexopoulos, GS, Katz, IR, Reynolds, CF 3rd, Carpenter, D, Docherty, JP. (2001) The expert consensus guideline series: pharmacotherapy of depressive disorders in older patients. Postgraduate Medicine Special Report 2001 (October) 1-86. McGraw Hill, Minneapolis.

Chiu, E, Ames. D, Draper, B, Snowdon, J.. (1999) Depressive disorders in the elderly: a review In (Eds. Maj, M, Sartorius, N. Depressive Disorders John Wiley & Sons Ltd. 313-363.

Judd, LL, Akiskal, HS, Maser, JD, Zeller, PJ, Endicott, J, Coryell, W, Paulus, MP, Kunovac, JL, Leon, AC, Mueller, TJ, Rice, JA, Keller, MB (1998) A prospective 12-year study of subsyndromal and syndromal depressive symptoms in unipolar major depressive disorders. Archives of General Psychiatry 55:694-700.

Lebowitz, BD, Pearson, JL, Schneider, Ls et al (1997) Diagnosis and treatment of depression in late life. JAMA 278:1186-1190.

Mann, A (2001) Why do we allow a classification of depression that materially disadvantages older people. IPA Bulletin 18:14-15.

Schneider, LS, Reynolds, CF 3rd, Lebowitz, BD, Friedhoff, AJ. (1991) Diagnosis and Treatment of Depression in Late Life. American Psychiatric Press Inc Washington, DC.

World Psychiatric Association (1999) WPA International Committee for Prevention and Treatment of Depression. Depressive Disorders in Older Persons NCM Publishers Inc, NY.

Reprinted from IPA Bulletin, Volume 19, Number 2

 

Thea Heeren is medical director of the Department of Old Age Psychiatry of the regional general psychiatric hospital in The Netherlands. Dr Heeren is a member of the IPA Board of Directors and the IPA Bulletin’s assistant editor for The Netherlands. She may be contacted at t.heeren@altrecht.nl
Robert Charles Baldwin is a Consultant in Old Age Psychiatry, Central Manchester Healthcare NHS Trust, and Lead Consultant for Young Onset Dementia (Manchester). He is a member of IPA’s Board of Directors.