ReviewDepression and the older medical patient—When and how to intervene
Section snippets
Introduction and methods
There has been a growing recognition of the prevalence and impact of depression in older patients, particularly those with physical illness. This paper reviews the recent literature on depression in the medically ill older patient, focusing on both epidemiological and management studies. After a general overview of depression in the elderly (and specifically in the physically ill), we focus on a number of conditions for which comorbid depression is prevalent in this age group. Where possible,
Epidemiology
Large scale epidemiological surveys report that depression affects about 5% of those 65 and older [1]. There has, however, been recent concern regarding clinicians’ ability to correctly identify which older adults are depressed, with validation studies using structured interviews only confirming major depressive episodes in about 18% of older adults whom clinicians felt may be depressed [2]. This is much poorer than similar studies of younger adults, presumably because of the difficulty
Epidemiology
Developing physical illness in old age has long been recognised as a major risk for depression [8], [9]. For example, Pfaff et al. [10] demonstrated that depression was 3–4 times more likely to occur amongst older adults with the highest number of medical comorbidities and the greatest level of functional impairments.
General issues
First, a number of approaches for the management of depression in the older medical patient have been explored. While the majority of studies have focused on antidepressants in
Cardiac disease
There is a complex inter-relationship between depression and coronary heart disease (CHD), with evidence for both an increase in CHD in those with depression, and increased morbidity and mortality in CHD patients who become depressed. With regard the former, the large prospective US Nurses’ Health Study [17] reported on outcomes of depression in over 63,000 women without a prior history of CHD or stroke. This study found that depressive symptoms were associated a greater likelihood of the later
Epidemiology
Depression is common in patients with stroke, with a prevalence of almost 20% in inpatients and 23% in outpatients [39]. A population-based study of subjects aged 85 years and older in Scandinavia [40] found that 43% of those with a history of stroke were depressed. A history of both stroke and ongoing depression was associated with greater 5-year mortality compared with stroke alone. It was previously believed that the location of a stroke was important in the aetiology of post-stroke
Epidemiology
Depression is commonly associated with cancer [46]. A recent major meta-analysis [47] found rates of major depression of 16% in oncology and haematology inpatient and outpatient settings. Some aspects of cancer may increase the risk of depression; for example older patients with metastases were 2.2 times more likely to be depressed, while those with cognitive impairment were 3.6 times more likely [48].
Treatment
A recent systematic review and meta-analysis identified nine RCTs of antidepressants in the
Epidemiology
A recent meta-analysis estimated that the prevalence of interview-defined depression for those with chronic kidney disease (CKD) was 20%, with those on dialysis having a higher prevalence of 23% [53]. As with many chronic diseases, the reasons for this high level of co-morbidity are likely to be mixed, but factors such as shared social and biological risk factors and the dramatic impact of renal failure and dialysis on independence and quality of life are likely to be of major importance [54].
Epidemiology
Fan et al. found that 41% of COPD subjects had at least mild to moderate depressive symptoms, with the most severely depressed being at increased risk of respiratory hospitalisation [63], [64]. Those with the highest depression symptom scores had a significantly increased 3-year mortality rate (odds ratio [OR] 2.7) and were more likely to experience dyspnoea and have a low body mass index. Few patients had received treatment for depression.
Management
There have been few trials of treatments for depression
Epidemiology
Major depression is commonly associated with Parkinson's disease with a prevalence of 8–17% (depending upon the population studied [69]). Differentiation between depression and Parkinson's disease can be difficult as patients with Parkinson's disease without depression may also manifest with similar symptoms of psychomotor retardation and reduced facial expression. Depression has been reported to be more prevalent in those with more advanced Parkinson's disease and in those with associated
Conclusions
Depression amongst older adults with physical illness is a common, but complex problem. It can be difficult for clinicians to identify which patients are depressed, with many common features of depression easily confused with non-specific symptoms of old age or co-morbid physical illness. However, correctly diagnosing depression in this patient group is vital as it can have a dramatic impact on quality of life and is consistently shown to be associated with poorer physical health outcomes. As
Contributors
Philip B. Mitchell and Samuel B. Harvey drafted the manuscript.
Competing interests
The authors declare no conflict of interest.
Funding
The authors have received no funding for this article. The research activities of Philip Mitchell are funded by an Australian National Health and Medical Research Council Program Grant (1037196).
Provenance and peer review
Commissioned and externally peer reviewed.
References (71)
- et al.
Efficacy of treatment in older depressed patients: a systematic review and meta-analysis of double-blind randomized controlled trials with antidepressants
J Affect Disord
(2012) - et al.
Psychiatric aspects of chronic physical disease
Medicine
(2008) - et al.
A review of the effectiveness of antidepressant medications for depressed nursing home residents
J Am Med Dir Assoc
(2012) - et al.
A structural multidisciplinary approach to depression management in nursing-home residents: a multicentre, stepped-wedge cluster-randomised trial
Lancet
(2013) - et al.
Depression and risk of sudden cardiac death and coronary heart disease in women: results from the Nurses’ Health Study
J Am Coll Cardiol
(2009) - et al.
Depression, antidepressants, and the risk of coronary heart disease: a population-based cohort study
Int J Cardiol
(2013) - et al.
The association of depression with platelet activation: evidence for a treatment effect
J Thromb Haemost
(2009) - et al.
Depression in heart failure a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes
J Am Coll Cardiol
(2006) - et al.
Depression, antidepressants, and long-term mortality in heart failure
Int J Cardiol
(2013) - et al.
Safety and efficacy of sertraline for depression in patients with CHF (SADHART-CHF): a randomized, double-blind, placebo-controlled trial of sertraline for major depression with congestive heart failure
Am Heart J
(2008)
Safety and efficacy of sertraline for depression in patients with heart failure: results of the SADHART-CHF (Sertraline Against Depression and Heart Disease in Chronic Heart Failure) trial
J Am Coll Cardiol
A double-blind, placebo-controlled treatment trial of citalopram for major depressive disorder in older patients with heart failure: the relevance of the placebo effect and psychological symptoms
Contemp Clin Trials
High mortality among heart failure patients treated with antidepressants
Int J Cardiol
Poststroke depression: prevalence, diagnosis, treatment, and disease progression
Biol Psychiatry
Depression after stroke and lesion location: a systematic review
Lancet
Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies
Lancet Oncol
Prevalence of depression in chronic kidney disease: systematic review and meta-analysis of observational studies
Kidney Int
Multiple measurements of depression predict mortality in a longitudinal study of chronic hemodialysis outpatients
Kidney Int
Treatment of depression and effect of antidepression treatment on nutritional status in chronic hemodialysis patients
Am J Med Sci
Association between depression and death in people with CKD: a meta-analysis of cohort studies
Am J Kidney Dis
Epidemiology, diagnosis, and management of depression in patients with CKD
Am J Kidney Dis
Update on psychotropic medication use in renal disease
Psychosomatics
Selective serotonin reuptake inhibitors and risk of upper GI bleeding: confusion or confounding?
Am J Med
Effects of medical and psychological treatment of depression in patients with COPD – a review
Respir Med
Pramipexole for the treatment of depressive symptoms in patients with Parkinson's disease: a randomised, double-blind, placebo-controlled trial
Lancet Neurol
High occurrence of mood and anxiety disorders among older adults: The National Comorbidity Survey Replication
Arch Gen Psychiatry
Diagnosing depression in older adults in primary care
N Engl J Med
Depression, antidepressant use and mortality in later life: the health in men study
PLoS ONE
Prognosis of depression in old age compared to middle age: a systematic review of comparative studies
Am J Psychiatry
Antidepressant use and risk of adverse outcomes in older people: population based cohort study
BMJ
Effects of a stepped-care intervention programme among older subjects who screened positive for depressive symptoms in general practice: the PROMODE randomised controlled trial
Age Ageing
Growing old and getting sick: maintaining a positive spirit at the end of life
Aust J Rural Health
Medical morbidity and severity of depression in a large primary care sample of older Australians: the DEPS-GP project
Med J Aust
Pharmacological interventions for people with depression and chronic physical health problems: systematic review and meta-analyses of safety and efficacy
Br J Psychiatry
Comorbidity of chronic disease and potential treatment conflicts in older people dispensed antidepressants
Age Ageing
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