Clinical Review

Assessment and Treatment of Late-Life Depression

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

References

1. Vincent GK, Velkoff VA. The next four decades: the older population in the United States: 2010 to 2050. US Census Bureau: May 2010.

2. Koenig HG, Blazer DG. Epidemiology of geriatric affective disorders. Clinc Geriatr Med 1992; 8:235–51.

3. Ferrari AJ, Charlson FJ, Norman RE, et al. Burden of depressive disorders by country, sex, age, and year: findings from the global gurden of disease study 2010. PLoS Med 2013;10:e1001547.

4 .American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.

5 .Ellison JM, Kyomen HH, Harper DG. Depression in later life: an overview with treatment recommendations. Psychiatr Clin North Am 2012;35:203–29.

6. Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry 2005;62:1097–106.

7. Steffens DC, Skoog I, Norton MC, et al. Prevalence of depression and its treatment in an elderly population: the Cache County study. Arch Gen Psychiatry 2000;57:601–7.

8. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289:3095–105.

9. McKinney BC, Sibille E. The age-by-disease interaction hypothesis of late-life depression. Am J Geriatr Psychiatry 2013;21:418–32.

10. Djernes JK. Prevalence and predictors of depression in populations of elderly: a review. Acta Psychiatr Scand 2006;113:372–87.

11. Blazer DG. Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci 2003;58:249–65.

12. Cole MG, Dendukuri N. Risk factors for depression among elderly community subjects: a systematic review and meta-analysis. Am J Psychiatry 2003;160:1147–56.

13. Ritchie K. Late-life depression. European Psychiatry 2014;29:577.

14. Hegeman JM, de Waal MW, Comijs HC, et al. Depression in later life: a more somatic presentation? J Affect Disord 2015;170:196–202.

15. Lackamp J, Schlachet R, Sajatovic M. Assessment and management of major depressive disorder in older adults. Psychiatria Danubina 2016;28(Suppl 1):95–98.

16. Morichi V, Dell’Aquila G, Trotta F, et al. Diagnosing and treating depression in older and oldest old. Curr Pharm Des 2015;21:1690–8.

17. Fiske AJ, Wetherell JL, Gatz M. Depression in older adults. Annu Rev Clin Psychol 2009;5:363–89.

18. Balsis S, Cully JA. Comparing depression diagnostic symptoms across younger and older adults. Aging Ment Health 2008;12:800–6.

19. Hegeman JM, Kok RM, van der Mast RC, Giltay EJ. Phenomenology of depression in older compared with younger adults: meta-analysis. Br J Psychiatry 2012;200:275–81.

20. Mitchell AJ, Bird V, Rizzo M, Meader N. Which version of the geriatric depression scale is most useful in medical settings and nursing homes? Diagnostic validity meta-analysis. Am J Geriatr Psychiatry 2010;18:1066–77.

21. Blazer DG. The psychiatric interview of older adults. In: Blazer D, Steffens D, Busse E, editors. Textbook of geriatric psychiatry. 3rd ed. Arlington, VA: American Psychiatric Publishing; 2004.

22. Spitzer RL, Kroenke K, Williams JW. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA 1999;282:1737–44.

23. Richardson TM, He H, Podgorski C, et al. Screening for depression in aging services clients. Am J Geriatr Psychiatry 2010;18:1116–23.

24. Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev 2012 Oct 17.

25. Unutzer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting a randomized controlled trial. JAMA 2002;288:2836–45.

26. Silver I, Herrmann N. Comprehensive psychiatric evaluation. In: Sadavoy J, Jarvik L, Grossberg G, Meyers B, editors. Comprehensive textbook of geriatric psychiatry. 3rd ed. New York: W.W. Norton; 2004.

27. Rapp MA, Dahlman K, Sano M, et al. Neuropsychological differences between late-onset and recurrent geriatric major depression. Am J Psychiatry 2005;162:691–8.

28. Sheline YI, Barch DM, Garcia K, et al. Cognitive function in late life depression: relationships to depression severity, cerebrovascular risk factors and processing speed. Biol Psychiatry 2006; 60:58–65.

29. Barnes DE, Yaffe K, Byers AL, et al. Midlife vs late-life depressive symptoms and risk of dementia: differential effects for Alzheimer disease and vascular dementia. Arch Gen Psychiatry 2012;69:493–8.

30. Morimoto SS, Kanellopoulos D, Manning KJ, Alexopoulos GS. Diagnosis and treatment of depression and cognitive impairment in late life. Ann NY Acad Sci 2015;1345:36–46.

31. Borson S, Scanlan J, Brush M, et al. The mini-cog: a cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000;15:1021–7.

32. Brodaty H, Low LF, Gibson L, Burns K. What is the best dementia screening instrument for general practitioners to use? Am J Geriatr Psychiatry 2006;14:391–400.

33. Ismail Z, Rajji TK, Shulman KI. Brief cognitive screening instruments: an update. Int J Geriatr Psychiatry 2010;25:111–20.

34. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–98.

35. Vertesi A, Lever JA, Molloy DW, et al. Standardized Mini-Mental State Examination. Use and interpretation. Can Fam Physician 2001;47: 2018–23.

36. Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005;53:695–9.

37. Kiosses DN, Alexopoulos GS. IADL functions, cognitive deficits, and severity of depression: a preliminary study. Am J Geriatr Psychiatry 2005;13:244–9.

38. Alexopoulos GS, Vrontou C, Kakuma T, et al. Disability in geriatric depression. Am J Psychiatry 1996;153:877–85.

39. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. Web-Based Injury Statistics Query and Reporting System (WISQARS). Accessed 9 Feb 2016 at http://webappa.cdc.gov/sasweb/ncipc/dataRestriction_inj.html.

40. Corna LM, Cairney J, Streiner DL. Suicide ideation in older adults: relationship to mental health problems and service use. Gerontologist 2010;50:785–97.

41. Juurlink DN, Herrmann N, Szalai JP, et al. Medical illness and the risk of suicide in the elderly. Arch Intern Med 2004;164:1179–84.

42. Van Orden K, Conwell Y. Suicides in late life. Curr Psychiatry Rep 2011;13:234–41.

43. Conwell Y, Van Orden K, Caine ED. Suicide in older adults. Psychiatr Clin North Am 2011;34:451–68, ix.

44. Rudd MD, Berman AL, Joiner TE, et al. Warning signs for suicide: theory, research, and clinical applications. Suicide Life Threat Behav 2006;36:255–62.

45. Know the warning signs of suicide. American Association of Suicidology. Accessed 9 Feb 2016 at www.suicidology.org/resources/warning-signs.

46. Taylor W, Doraiswamy P. Use of the laboratory in the diagnostic workup of older adults. In: Blazer D, Steffen D, Busse E, editors. Textbook of geriatric psychiatry. 3rd ed. Arlington, VA: American Psychiatric Publishing; 2004.

47. Alexopoulos GS, Meyers BS, Young RC, et al. ‘Vascular depression’ hypothesis. Arch Gen Psychiatry 1997;54:915–22.

48. ADGAP Status of Geriatrics Workforce Study. Accessed 26 Dec 2016 at www.americangeriatrics.org/files/documents/gwps/Table%201_29.pdf.

49. Alexopoulos G. Late-life mood disorders. In: Sadavoy J, Jarvik L, Grossberg G, Meyers B, editors. Comprehensive textbook of geriatric psychiatry. 3rd ed. New York: W.W. Norton; 2004.

50. Alexopoulos GS, Reynolds CF, Bruce ML, et al. Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT study. Am J Psychiatry 2009;166:882–90.

51. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129–36.

52. Schotte CKW, Van den Bossche B, Doncker DD, et al. A biopsychosocial model as a guide for psychoeducation and treatment of depression. Depression Anxiety 2006;23:312–24.

53. Kupfer DJ, Frank E. The interaction of drug-and psychotherapy in the long-term treatment of depression. J Affect Disord 2001;62:131–7.

54. Katon W, Rutter C, Ludman EJ, et al. A randomized trial of relpase prevention of depression in primary care. Arch Gen Psychiatry 2001;58:241–7.

55. Kok RM, Nolen WA, Heeren TJ. 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;141:103–15.

56. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56–62.

57. Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry 1979;134:382–9.

58. Mukai Y, Tampi RR. Treatment of depression in the elderly: a review of the recent literature on the efficacy of single- versus dual-action antidepressants. Clin Ther 2009;31:945–61.

59. Gildengers AG, Houck PR, Mulsant BH, et al. Course and rate of antidepressant response in the very old. J Affect Disord 2002;69:177–84.

60. Kozel FA, Trivedi MH, Wisniewski SR, et al. Treatment outcomes for older depressed patients with earlier versus late onset of first depressive episode. Am J Geriatr Psychiatry 2008;16:58–64.

61. Bains J, Birks J, Dening T. Antidepressants for treating depression in dementia. Cochrane Databse Syst Rev 2002;(4):CD003944.

62. Nelson JC, Devanand DP. A systematic review and meta-analysis of placebo-controlled antidepressant studies in people with depression and dementia. J Am Geriatr Soc 2011;59:577–85.

63. Mark TL, Joish VN, Hay JW, et al. Antidepressant use in geriatric populations: the burden of side effects and interactions and their impact on adherence and costs. Am J Geriatr Psychiatry 2011;19:211–21.

64. Frank C. Pharmacologic treatment of depression in the elderly. Can Fam Physician 2014;60:121–6.

65. Kennedy GJ, Marcus P. Use of antidepressants in older patients with co-morbid medical conditions: guidance from studies of depression in somatic illness. Drugs Aging 2005;22:273–87.

66. Sackheim HA, Kupfer DJ, Luther J, Fava M. Acute and longer-tern outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry 2006;163:1905–17.

67. Kok RM, Nolen WA, Hereen TJ. Outcome of late-life depression after 3 years of sequential treatment. Acta Psychiatr Scand 2009;119:274–81.

68. Whyte EM, Basinski J, Farhi P, et al. Geriatric depression treatment in nonresponders to selective serotonin reuptake inhibitors. J Clin Psychiatry 2004;65:1634–41.

69. Kok RM, Vink D, Hereen TJ, Nolen WA. Lithium augmentation compared with phenelzine in treatment-resistant depression in the elderly; an open, randomized, controlled trial. J Clin Psychiatry 2006;68:1177–85.

70. Kok RM. What is the role of medications in late life depression? Psychiatr Clin North Am 2003;36:597–605.

71. Wen XJ, Wang LM, Liu ZL,. Meta-analysis on the efficacy and tolerability of the augmentation of antidepressants with atypical antipsychotics in patients with major depressive disorder. Braz J Med Biol Res 2014;47:605–16.

72. Lenze EJ, Mulsant BH, Blumberger DM, et al. Efficacy, safety, and tolerability of augmentation pharmacotherapy with aripiprazole for treatment-resistant depression in late life: a randomised double-blind, placebo-controlled trial. Lancet 2015;386:2404–12.

73. Alexopoulos GS, Canuso CM, Gharabawi GM, et al. Placebo-controlled study of relapse prevention with risperidone augmentation in older patients with resistant depression. Am J Geriatr Psychiatry 2008;16:21–30.

74. Francis JL, Kumar A. Psychological treatment of late-life depression. Psychiatr Clin North Am 2013;36:561–75.

75. Gum AM, Arean PA, Hunkeler E, et al. Depression treatment preferences in older primary care patients. Gerontologist 2006;46:14–22.

76. Pinquart M, Duberstein PR, Lyness JM. Treatments for late-life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy. Am J Psychiatry 2006;163:1493–501.

77. Beck Institute for Cognitive Behavior Therapy. Accessed 28 Dec 2016 at www.beckinstitute.org

78. Beck AT. Cognitive therapy: nature and relation to behavior therapy. Behav Ther 1970;1:184–200.

79. Landrevile P, Landry J, Baillargeon L, et al. Older adults’ acceptance of psychological and pharmacological treatments for depression. J Gerontology B Psychol Sci Soc Sci 2001;56:P285–91.

80. Thompson LW, Gallagher D, Breckenridge JS. Comparitive effectiveness of psychotherapies for depressed elders. J Consult Clin Psychol 1987;55:385–90.

81. Gallagher-Thompson D, Steffen AM. Comparative effects of cognitive-behavioral and brief psychodynamic psychotherapies for depressed family caregivers. J Consult Clin Psychol 1994;62:543–9.

82. Wilson KC, Mottram PG, Vassilas C. Psychotherapeutic treatments for older depressed people. Cochrane Database Syst Rev 2008;(1):CD004853

83. Markowitz JC, Weissman MM. Interpersonal psychotherapy: past, present and future. Clin Psychol Psychother 2012;19:99–105.

84. Van Schaik A, van Marwijk H, Ader H, et al. Interpersonal psychotherapy for elderly patients in primary care. Am J Geriatr Psychiatry 2006;14:777–86.

85. Reynolds CF 3rd, Frank E, Perel JM, et al. Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. JAMA 1999;281:39–45.

86. Reynolds CF 3rd, Dew MA, Pollock BG, et al. Maintenance treatment of major depression in old age. N Engl J Med 2006;354:1130–8.

87. Blumenthal JA, Babyak MA, Moore KA, et al. Effects of exercise training on older patients with major depression. Arch Intern Med 1999;159:2349–56.

88. Krishnamurthy MN, Telles S. Assessing depression following two ancient Indian interventions: effects of yoga and ayurveda on older adults in a residential home. J Gerontol Nurs 2007;33:17–23.

89. Wang C, Bannuru R, Ramel J, et al. Tai Chi on psychological well-being: systematic review and meta-analysis. BMC Complement Altern Med 2010;10:23.

90. Cho KL. Effect of tai chi on depressive symptoms amongst Chinese older patients with depressive disorders: a randomized clinical trial. Med Sport Sci 2008;52:146–54.

91. Moritz S, Quan H, Rickhi B, et al. A home study-based spirituality education program decreases emotional distress and increases quality of life- a randomized, controlled trial. Altern Ther Health Med 2006;12:26–35.

92. Nyer M, Doorley J, Durham K, et al. What is the role of alternative treatments in late-life depression? Psychiatr Clin North Am 2013;36:577–96.

93. Petrides G, Fink M, Husain MM, et al. ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE. J ECT 2001;17:244–53.

94. Mankad MV, Beyer JL, Weiner RD, Krystal AD. Clinical manual of electroconvulsive therapy. American Psychiatric Publishing; 2010.

95. Kellner CH, Greenberg RM, Murrough JW, et al. ECT in treatment-resistant depression. Am J Psychiatry 2012;169:1238–44.

96. Flint AJ, Gagnon N. Effective use of electroconvulsive therapy in late-life depression. Can J Psychiatry 2002;47:734–41.

Electroconvulsive Therapy

ECT is indicated for the treatment of mood and psychotic disorders and has demonstrated efficacy in the treatment of severe depression [93]. It is typically initiated when patients fail to respond to pharmacotherapy and psychotherapy. Circumstances in which ECT can be considered first-line treatment include situations that require a rapid response (severe inanition, weight loss, or suicidality), situations where risks of ECT are lower than that of alternative treatments, previous positive response to ECT, or strong patient preference [94]. ECT is performed under general anesthesia and involves the induction of a generalized tonic-clonic seizure, which is theorized to enhance serotonergic, noradrenergic, and dopaminergic neurotransmission. A typical course of ECT involves treatments 3 times a week for an average of 6 to 12 treatments in total [95]. Elderly patients and those suffering from severe depression with psychotic features respond more robustly to ECT [93,96]. Estimated remission rates after an ECT series have been higher than 80% [93], making this modality the most effective treatment for severe depression to date.

Conclusion

As the population continues to age, clinicians are increasingly likely to encounter patients with late-life depression. A thorough evaluation includes not only assessment of depressive symptoms, but also cognitive, functional, and suicide assessment. Treatment options include pharmaco-therapy, psychotherapy, and in some cases electroconvulsive therapy. Utilization of assessment and treatment nuances unique to the geriatric population, with a multidisciplinary and collaborative approach involving primary care, mental health, and other ancillary providers, will serve to ultimately enhance patient care.

Corresponding author: Corresponding author: Juliet Glover, MD, Dept. of Neuropsychiatry and Behavioral Science, Univ. of South Carolina School of Medicine, 15 Medical Park, Suite 301, Columbia, SC 29203, Juliet.Glover@uscmed.sc.edu.

Financial disclosures: None reported.

Author contributions: conception and design, JAG, SS; drafting of article, JAG, SS; critical revision of the article, JAG, SS.