Depression in Older Adults: Unrecognized, Untreated

Fran Lowry

August 12, 2016

Too often, depression in individuals aged 60 years and older goes unrecognized and untreated or not treated appropriately, results of a large population-based study show.

"Our findings indicate that even in a central urban area of a country with an advanced healthcare system, depression in old age is often unrecognized and untreated," lead author Björn Karlsson, MD, PhD, from the Karolinska Institutet and Stockholm University, Sweden, and colleagues write.

"In addition, almost half of those with depression received potentially inappropriate drug treatment with anxiolytics or hypnotics," the investigators add.

The study was published in the August issue of the American Journal of Geriatric Psychiatry.

50% Go Unrecognized

The investigators note that in Sweden and most other European countries, depression is mainly managed in primary care settings. However, they note that a 2009 meta-analysis published in the Lancet showed that the diagnostic sensitivity of major depression in this setting was below 50% in individuals aged 65 years and older.

"Thus, half of those with major depression in old age seeking care are not recognized as depressed," the investigators write.

The researchers sought to estimate the prevalence of depression and depression treatment in a population-based sample of individuals aged 60 to 101 years and to identify the individual profile of those who received treatment.

The study included 3084 individuals without dementia who were participants in the Swedish National Study on Aging and Care in Kunsgholmen (SNACK-K) in Stockholm between 2001 and 2004.

Study participants were examined by experienced physicians who carried out a general medical examination and a semistructured psychiatric examination that included ratings of current psychiatric signs and symptoms according to the Comprehensive Psychopathological Rating Scale (CPRS).

Major depression was diagnosed according to DSM-5 criteria, and minor depression according to DSM-IV-TR criteria. Information about drug treatment and psychotherapy was collected during the examination and was based on self-report.

The researchers found that the prevalence of major depression was 0.8% (n = 25 participants); 5.1% (n = 157 participants) fulfilled the criteria for minor depression, for a total prevalence of 5.9%.

In the study population as a whole, the proportion who received treatment with antidepressant drugs was 8.3% (n = 256); such treatment was more common in women (9.9%) than men (5.6%; P < .001). Depression was also more common in those aged 81 to 101 years (10.5%) than in those aged 60 to 78 years (7.5%; P < .01).

Incorrect Diagnosis

Among the 182 individuals with any depression, fewer than one third received treatment with antidepressant drugs or psychotherapy. The results also showed that individuals with university education were more likely to receive psychotherapy than those with less education (P < .001).

However, almost half (46.2%) of the individuals with any depression were prescribed anxiolytic or hypnotic drugs.

Additionally, self-reported depression and anxiety were associated with increased odds for receiving depression treatment. For depression, the odds ratio (OR) was 27.6 (95% confidence interval [CI], 10.3 - 73.7; P < .001); for anxiety, the OR was 2.3 (95% CI, 1.5 - 7.4; P < .01).

Self-reported insomnia, on the other hand, was associated with decreased odds for receiving depression treatment (OR, 0.3; 95% CI, 0.1 - 0.9; P < .05).

"Insomnia is common in old age and also a symptom of depression," the authors write.

"Our finding might indicate that physicians, to a lesser extent, recognize depression in the presence of sleep disturbances. This is in line with previous findings that patients presenting with primarily somatic symptoms of depression are less likely to be recognized as depressed in primary care," they add.

The authors also note the strengths and limitations of their study. Strengths include its population-based design and the "comprehensive" examinations conducted by experienced physicians, including use of the CPRS.

Limitations include a 73% response rate and the possibility of selection bias, because individuals with depression may be less likely to participate in such a population-based study.

Also, the fact that individuals with dementia were excluded from the study may mean that the prevalence of depression was underestimated. The prevalence of depression might have been overestimated owing to the fact that the CPRS does not specify that depression symptoms be present for at least 2 weeks.

Another important limitation is the fact that information regarding participants' depression treatment was based on self-report.

Challenging to Interpret

"It is a little bit challenging to interpret these results, as they appear to assess for the presence of current symptoms, so it's hard to know if those patients with few or minor symptoms represent successfully treated depression or people who have never had depression," said Donovan Maust, MD, University of Michigan, Ann Arbor, who commented on the findings for Medscape Medical News. He was not involved in the study.

"Having said that, however, what is most striking to me, and what the authors don't seem to address at all, is that 207 patients with no depression are on antidepressants. In contrast, they find that 14 of those 25 adults with major depression who should be on an antidepressant are not," Dr Maust said.

"While it continues to be concerning that older adults with depression are not receiving appropriate treatment, there are far, far older adults who appear to be symptom free and are on a medication that they may not need," he said.

Also commenting on the study for Medscape Medical News, Iqbal "Ike" Ahmed, MD, clinical professor of psychiatry at the Uniformed Services University of Health Sciences, Bethesda, Maryland, and clinical professor of psychiatry and geriatric medicine at the University of Hawaii, Honolulu, noted that although the study was done in Sweden, he would not be surprised if the findings would have been similar in the United States.

"There is probably both underrecognition and undertreatment of depression in older adults, even more so than in the general population. The reasons for this may be factors related to the disease, the clinician, and the patient," Dr Ahmed told Medscape Medical News.

Barriers to Diagnosis, Care

"The disease factors are due to the atypical presentations of late-life depression, with less complaints of frank depression and more complaints of somatic symptoms, cognitive symptoms, such as memory complaints, more prominent anxiety and apathy.

"The clinician factors may be related to inadequate education and training on how to recognize and treat depression, and a shortage of time in busy primary care practices.

"The patient factors are related to stigma of being diagnosed with a psychiatric disorder and being more willing to be treated for somatic symptoms or sleep problems. These factors lead to not treating a very treatable condition with either psychotherapy or medication, and potentially inappropriate treatment with benzodiazepines and sedative-hypnotics for anxiety and sleep. These medications have significant side effects in the elderly, such as increased fall risk and memory problems," said Dr Ahmed.

This situation could be improved through greater efforts to reduce the stigma of mental illness as a whole, improved education for physicians at all levels, including medical school training, and through more widespread screening for depression with the use of questionnaires such as the Geriatric Depression Scale, he suggested.

"The Geriatric Depression Scale is very quick. It takes less than 5 minutes to do, and could even be done in the waiting room while the patient is waiting to see the doctor. The results could suggest that the patient needs to be evaluated in more detail for depression," Dr Ahmed said.

He also suggested improved reimbursement for primary care physicians who screen for depression.

"Right now, there is a disincentive to spend much time doing that, because of the lack of adequate reimbursement. If that were improved, it might help more primary care doctors who want to do mental health screening of their patients. So I think there are several different things which probably could be done to enhance the recognition and treatment of depression in older people," Dr Ahmed said.

The study was supported by the Ministry of Health and Social Affairs, Sweden, the Stockholm County Council and Municipality, and the Swedish Research Council. Dr Karlsson, Dr Maust, and Dr Iqbal report no relevant financial relationships.

Am J Geriatr Psychiatry. 2016;24:615-623. Abstract

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