Clinical Review

Assessment and Treatment of Late-Life Depression

Journal of Clinical Outcomes Management. 2017 March;24(3)

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Physical Examination, Laboratory Studies, and Neuroimaging

Evaluation of LLD is not complete without a physical examination and ancillary studies to identify underlying medical conditions possibly contributing to or mimicking depressive symptoms. Routine laboratory studies include complete blood count, complete metabolic panel, thyroid studies, and urine drug screen. Signs and symptoms of underlying medical conditions may necessitate further laboratory studies [46]. Neuroimaging may reveal signs of cerebrovascular disease which can predispose, precipitate, or perpetuate depression in older adults [47].

Treatment

Treatment of LLD can take many forms and occur in various settings. Geriatric psychiatrists have expertise in the assessment and treatment of mental illness in the elderly. Workforce estimates for 2010 revealed 1 geriatric psychiatrist per 10,000 adults age 75 and over. This figure is estimated to decrease to 0.5 per 10,000 by the year 2030, underscoring the importance of increasing the knowledge base of clinicians across specialties who provide care to the depressed elderly [48]. The primary care setting is often the locus of care for depression in older adults; however, studies suggest that patients are often left untreated or undertreated [49]. Collaborative care models whereby mental health care is integrated into primary care have been shown to improve outcomes. The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) study found that use of care managers to assist primary care providers in identification of depression, offer algorithm-based treatment recommendations, monitor symptoms and medication side effects, and provide follow-up yielded improvement in outcomes. Patients in the intervention group were more likely to receive pharmacotherapy or psychotherapy, achieve remission, and showed greater decline in suicidal ideation [50]. Similar results were found in the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) study in which intervention patients treated under a collaborative care model showed lower depression severity, less functional impairment, and greater reduction in depressive symptoms [25].

Just as a collaborative care model can lead to improved outcomes, the overall strategy of treating depression must be multifaceted. The biopsychosocial model of disease first described in the 1970s emphasizes biological and psychosocial determinants of illness that must be addressed when treatment is considered [51]. This includes nonmodifiable biological factors such as age, gender, and genetic predisposition that may affect treatment options, as well as modifiable biological factors such as comorbid medical illness, medications, or substance use disorders. Psychological factors that can affect depressive symptoms include coping skills and defense mechanisms in the face of stressful life events. Social factors including the role of culture, environment, and family dynamics in disease presentation must be considered as well [52].

Pharmacologic Treatment of LLD

The primary pharmacologic treatment for depression is antidepressants. Treatment consists of 3 phases—acute, continuation, and maintenance. In the acute phase, the goal is remission of current symptoms and restoration of function. The continuation phase, extending up to 6 months after remission, aims to prevent relapse back into a depressive episode. Maintenance therapy is geared at preventing recurrence of future depressive episodes [53]. Studies have found a 50% risk of relapse after 1 episode of depression and 80% after 2 episodes. Up to 20% will develop chronic symptoms. For this reason, maintenance therapy is often necessary for recurrent depression [54].