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Diagnosis and Treatment of Depression in Late Life

National Institutes of Health
Consensus Development Conference Statement
November 4-6, 1991

Conference artwork depicting abstract geometric shapes on a blue background.

This statement is more than five years old and is provided solely for historical purposes. Due to the cumulative nature of medical research, new knowledge has inevitably accumulated in this subject area in the time since the statement was initially prepared. Thus some of the material is likely to be out of date, and at worst simply wrong. For reliable, current information on this and other health topics, we recommend consulting the National Institutes of Health's MedlinePlus http://www.nlm.nih.gov/medlineplus/.

This statement was originally published as: Diagnosis and Treatment of Depression in Late Life. NIH Consens Statement 1991 Nov 4-6:;9(3):1-27.

For making bibliographic reference to the statement in the electronic form displayed here, it is recommended that the following format be used: Diagnosis and Treatment of Depression in Late Life. NIH Consens Statement Online 1991 Nov 4-6: [cited year month day];9(3):1-27.

Abstract

The National Institutes of Health Consensus Development Conference on Diagnosis and Treatment of Depression in Late Life brought together biomedical and behavioral scientists surgeons and other health care professionals as well as the public to address the epidemiology, pathogenesis, pathophysiology, prevention, and treatment of depression in the elderly and to alert both the professional and lay public to the seriousness of depression in late life, to its manifestations and useful treatments, and to areas needing further study. Following 2 days of presentations by experts and discussion by the audience, a consensus panel weighed the evidence and prepared their consensus statement.

Among their findings, the panel concluded that (1) depression in late life occurs in the context of numerous social and physical problems that often obscure or complicate diagnosis and impede management of the illness; (2) because there is no specific diagnostic test for depression, an attentive and focused clinical assessment is essential for diagnosis; (3) depressed elderly people should be treated vigorously with sufficient doses of antidepressants and for a sufficient length of time to maximize the likelihood of recovery; (4) electroconvulsive therapy and psychosocial treatments also can be effective in the treatment of elderly depressed patients; and (5) estimates of the prevalence of depression vary widely, but the highest rates are in nursing homes and other residential settings and staff in many of these facilities are not equipped to recognize or treat depressed patients.

The full text of the consensus panel's statement follows:

Introduction

Depression in the aging and the aged is a major public health problem. It causes suffering to many who go undiagnosed, and it burdens families and institutions providing care for the elderly by disabling those who might otherwise be able-bodied. What makes depression in the elderly so insidious is that neither the victim nor the health care provider may recognize its symptoms in the context of the multiple physical problems of many elderly people. Depressed mood, the typical signature of depression, may be less prominent than other depressive symptoms such as loss of appetite, sleeplessness, anergia, and loss of interest and enjoyment of the normal pursuits of life. There is a wide spectrum of depressive symptomatology as well as types of available therapies.

Because of the many physical illnesses and social and economic problems of the elderly, individual health care providers often conclude that depression is a normal consequence of these problems, an attitude often shared by the patients themselves. All of these factors conspire to make the illness underdiagnosed and, more importantly, undertreated.

During the past decade, significant progress has been made in understanding the diagnosis, treatment, and design of service delivery systems for depression in late life; however, important questions remain unanswered, and large numbers of depressed elderly people go untreated. The purpose of this consensus development statement is to examine what is known of the epidemiology, pathogenesis, pathophysiology, prevention, and treatment of depression in the elderly and to alert both the professional and lay public to the seriousness of depression in late life, to its manifestations and useful treatments, and to areas needing further study or research.

To help resolve questions surrounding these issues, the National Institute of Mental Health in conjunction with the Office of Medical Applications of Research and the National Institute on Aging of the National Institutes of Health convened a Consensus Development Conference on the Diagnosis and Treatment of Depression in Late Life on November 4-6, 1991. Following a day and a half of presentations by experts in the relevant fields and discussion from the audience, a consensus panel, chaired by Arnold J. Friedhoff, M.D., and comprising experts in psychiatry, psychology, neurology, nursing, social work, internal medicine, epidemiology, statistics, as well as a public representative considered the scientific evidence and formulated a consensus statement in response to the following six questions:

  • How does depression in late life differ from depression earlier in life? What are the sources of heterogeneity within late life depression?
  • How prevalent is depression in the elderly and what are its risk factors?
  • What constitutes safe and effective treatment for late life depression? What are the indications and contraindications for specific treatments?
  • What are the patterns of health services use for late life depression? What are the obstacles to the delivery of adequate treatment?
  • What are the benefits of recognizing and adequately treating depression in late life? What are the consequences of unrecognized or inadequately treated depression in late life?
  • What are the most promising questions for future research?

The following is the panel's report.

Question 1: How Does Depression in Late Life Differ From Depression Earlier in Life? What Are the Sources of Heterogeneity Within Late Life Depression?

The term "depression" has been variably used to describe either a symptom, a syndrome, or a disease. In the present consensus statement, depression is used in the broad sense to describe a syndrome that includes a constellation of physiological, affective, and cognitive manifestations. As listed in the current American Psychiatric Association Diagnostic and Statistical Manual (DSM-IIIR), criteria for the diagnosis of depression include: (1) changes in appetite and weight; (2) disturbed sleep; (3) motor agitation or retardation; (4) fatigue and loss of energy; (5) depressed or irritable mood; (6) loss of interest or pleasure in usual activities; (7) feelings of worthlessness, self-reproach, excessive guilt; (8) suicidal thinking or attempts; and (9) difficulty with thinking or concentration. Depression may range in severity from mild symptoms to more severe forms that include delusional thinking, excessive somatic concern, and suicidal ideation, over longer periods of time. The DSM-IIIR requires the presence of at least five of the symptoms listed above for a diagnosis of major depressive episode. Concurrent medical conditions are frequently present in elderly persons and should not preclude a diagnosis of depression.

The recognition of depression may be more difficult in late compared with early life. In the elderly age group, both clinicians and patients may incorrectly attribute depressive symptoms to the aging process. They may not fully appreciate the degree of impairment because of lower functional expectations in the post-retirement years. The particular constellation of symptoms may differ because elderly persons may more readily report somatic symptoms than depressed mood. Because both the patient and the evaluating clinician are often more concerned about concurrent medical conditions, depressive symptoms may be overlooked. Finally, the concomitant presence of dementia may compromise accurate recognition and reporting of symptoms. As a result, depression is often underdiagnosed in elderly people, despite a high frequency of potentially treatable depressive symptoms.

Depression in late life frequently coexists with multiple chronic diseases and disabilities, for example, cancer, cardiovascular disease, neurological disorders, various metabolic disturbances, arthritis, and sensory loss. These conditions create psychosocial concerns, medical and physiologic burdens, and functional disabilities that may directly contribute to the pathogenesis of depressive symptoms as well as complicate treatment. However, current data indicate that depressive symptoms may respond to treatment in many of these patients.

Depression in late life occurs in the context of numerous social, developmental, and biological diversities. Advancing age is accompanied by loss of important social support systems due to death of spouse or siblings, retirement, or relocation of residence. At the biologic level, there is variability in the regulation of homeostasis, organ system reserve, immunologic responsiveness, and body composition. These sources of heterogeneity have major implications for risk of illness, diagnosis, and treatment. For example, levels of antidepressant drugs and toxic metabolites may be disproportionately increased in the "old-old," making this subgroup particularly vulnerable to adverse side effects.

The presentation of the depressive syndrome may be heterogeneous with regard to constellation of symptoms, age at onset, and course. For example, elderly depressed patients may have experienced their first episode of depression either early or late in life. There is some evidence to suggest that late-onset depression is associated with a lower frequency of family history of depression but a higher frequency of cognitive impairment, cerebral atrophy, deep white matter changes, recurrences, medical comorbidity, and mortality. A combination of cross-sectional and longitudinal studies will be required to clarify the underlying biology and natural history of various subtypes of depression, including early- versus late-onset depression in elderly persons.

Despite an intensive search for biological and structural correlates of late life depression, no specific diagnostic test can be recommended for clinical practice. Impaired dexamethasone suppression of the hypothalamic-pituitary-adrenal axis (DST) is observed in late life depression but is not sufficiently specific to have diagnostic use. Similarly, response to thyroid-stimulating hormone, platelet monoamine oxidase activity, and platelet imipramine and alpha2 binding may be altered nonspecifically in a subset of patients. Clearly, further research is needed to refine diagnosis; at the present time, an attentive and focused clinical interview remains the mainstay for the evaluation and diagnosis of depression.

Question 2: How Prevalent is Depression in the Elderly and What Are Its Risk Factors?

According to the Epidemiologic Catchment Area Study, depressive symptoms occur in approximately 15 percent of community residents over 65 years of age. The prevalence of major depression among the elderly living in the community is usually estimated at less than 3 percent. The rates of major or minor depression among elderly people range from 5 percent in primary care clinics to 15 to 25 percent in nursing homes. The rates of new cases of depression in nursing homes are striking: 13 percent of residents develop a new episode of major depression over a 1-year period, and another 18 percent develop new depressive symptoms.

Estimates of the frequency of depression in the elderly exhibit wide variability due to the source of the sample, definition of depression, method of assessment, and experience of the rater. Epidemiologic studies provide critical information on the magnitude of depression in the general population and on the treatment patterns among depressed elderly. There is a sharp drop in the rates of treatment of depression among the elderly compared with younger adults. By one estimate, only about 10 percent of the elderly who are in need of psychiatric treatment ever receive this service.

The major social and demographic risk factors for depression in the elderly are generally similar to those of younger age groups: women; the unmarried, particularly the widowed; those with stressful life events; and those who lack a supportive social network have elevated rates of depression. In elderly people, the co-occurrence of physical conditions (e.g., stroke, cancer, dementia) and depression has been confirmed in numerous studies. Although depression may be an effect of such coexistent disorders, it might also enhance vulnerability to certain illnesses, particularly of the immune system.

The course of depression in elderly people is similar to that in younger people. Recurrence is a serious problem--up to 40 percent of people continue to experience depression over time. Longitudinal studies show that mortality rates by suicide and other causes are higher among elderly persons with depression compared with their nondepressed counterparts. This increased mortality cannot be completely accounted for by sociodemographic factors and preexisting physical illnesses. Some studies suggest that depression may increase the risk of death in unknown ways.

The rate of completed suicides for older people was higher than that of the general population in 1988. For example, although suicide rates in the general population were 12.4/100,000, rates in 80- to 84-year-olds were 26.5/100,000 persons. Elderly white men are at highest risk. More than three-fourths of these persons had visited a primary care physician within the month before their suicide. Generally, they were suffering from their first episode of major depression, which was only moderately severe, yet the depressive symptoms went unrecognized and untreated.

Question 3: What Constitutes Safe and Effective Treatment for Late Life Depression? What Are the Indications and Contraindications for Specific Treatments?

Given its pernicious effects, most agree that a major depressive episode or recurrent depressive illness require treatment in all age groups, including the elderly. What is not as readily apparent is the need for treatment of less severe or reactive depressions. These conditions negatively affect quality of life and are associated with increased risk of comorbid medical illnesses and clinical depression. Consequently, they should not be discounted as "normal and acceptable" features of aging and do warrant the early attention of clinicians.

The goals of treatment for depression include: (1) decreasing symptoms of depression, (2) reducing risk of relapse and recurrence, (3) increasing quality of life, (4) improving medical health status, and (5) decreasing health care costs and mortality. The two major categories of treatment for depression include biological therapy (e.g., pharmacotherapy, electroconvulsive therapy) and psychosocial therapy. At the present time, by far the largest body of data is available for biological therapy. Clearly, more research is needed for psychosocial as well as combined biological and psychosocial therapies. These studies should address compliance, side effects, quality of life, and relief of depressive symptoms; they should also identify which subgroups of patients are more likely to benefit from specific therapies.

Pharmacotherapy:

Treatment of Acute Depression There is now evidence from approximately 25 randomized, double-blind trials that antidepressants are more effective than placebo in the treatment of acute depression. Approximately 60 percent of patients clinically improve, but many of them retain significant residual symptomatology.

Available information from randomized controlled clinical trials in elderly patients is meager compared with that for younger patient groups. The number of patients in research studies drops off sharply after the sixth decade of life. There are very few studies of treatment of depression in the very old (80+), one of the most rapidly growing segments of our population. Therefore, clinical recommendations are primarily extrapolated from experience with young or middle-aged adults or based on a small number of elderly patients. There also is little research with elderly medically ill depressed patients; therefore, available evidence may be difficult to generalize to typical elderly patients presenting for treatment in clinical settings.

Most of the antidepressants are thought to be equally effective in elderly adults. The most commonly used and studied antidepressants have been nortriptyline and desipramine because they have a more favorable side effect spectrum than traditional antidepressants such as amitriptyline and imipramine. Most clinicians avoid these latter two medications because they cause significant orthostatic hypotension, which can cause falls and fractures, and because elderly patients are especially sensitive to their anticholinergic, cardiovascular, and sedative side effects.

Based primarily on clinical experience, many clinicians favor the newer antidepressants trazodone, bupropion, and fluoxetine because they have fewer anticholinergic and cardiovascular side effects. Contrary to widespread clinical opinion, the use of monoamine oxidase inhibitors, especially phenelzine, has been generally found to be safe and effective, but they have not been widely used for the treatment of geriatric depression.

There also is little known about patient factors that predict response, including clinical symptoms, demographics, subtype, comorbidity, or radiologic findings. However, there is considerable evidence that response depends on adequate length of treatment, dose, and blood level of medication. Significant antidepressant response in elderly patients often occurs later than in younger patients and requires at least 6 to 12 weeks of therapy.

Full clinical response is primarily dependent on achieving therapeutic doses that produce adequate blood levels. The measurement of plasma levels in elderly patients is even more important than in younger patients because of the increased importance of attaining appropriate therapeutic levels but remaining below levels associated with toxicity. Medication compliance by elderly people is especially important and difficult. It has been estimated that 70 percent of patients fail to take 25 to 50 percent of their medication. Lack of compliance, producing wide fluctuations in plasma levels, has been shown to be predictive of poor outcome.

Maintenance Treatment

There is an increasing recognition that the majority of major depressions are recurrent; therefore, the central issue in treatment is the prevention of recurrence. Although there are relatively few clinical trials of maintenance treatment in elderly patients, continuation of antidepressants has been shown to confer significantly greater protection against recurrence than placebo. Although clinicians often reduce doses during the maintenance phase, preliminary evidence suggests that continuation of the dose and plasma level that was effective in the acute treatment phase offers increased protection against recurrence. Evidence suggests that treatment should be maintained for 6 months after remission from a first episode of major depression and 12 months or longer after a second or third episode. Approximately 80 percent of patients maintained on doses that lead to their recovery maintain their remission over extended followup.

Electroconvulsive Therapy (ECT)

ECT has an important role in the treatment of depression in elderly adults. The most recent study conducted by the National Institute of Mental Health indicated that patients over 61 constitute the largest age group who receive ECT. The evidence for short-term efficacy of ECT is strong. However, relapse after effective ECT is frequent, and alternative treatment strategies, including maintenance ECT, or maintenance antidepressants post-ECT, require further study. ECT is often stated to be safer than antidepressants, although this has not been documented in controlled trials. Limited data suggest that advancing age heightens the probability of transient post-ECT confusion, especially in the very old. Additional risk factors include receiving psychotropic medication during ECT, concurrent major medical illness, and preexisting cognitive deficits.

Psychosocial Treatments

A comprehensive system of care necessitates the inclusion of psychosocial treatments because of the broad range of functional and social consequences of depression in elderly people. Biological treatments will not be able to resolve all of the problems associated with depression in the elderly. For example, significant and continuing life events, altered life roles, lack of social support, and chronic medical illnesses might well require psychosocial support and new coping skills. Also, some patients will strongly prefer non- biological interventions, and others will not be suitable for biological treatment because of side effects, interactions between drugs, and comorbid medical conditions.

There are only a handful of controlled studies on the efficacy of psychosocial interventions with elderly people dealing primarily with cognitive behavior therapy, behavior therapy, interpersonal therapy, and short-term psychodynamic therapy. These treatments are all moderately effective and have durable effects with outpatient volunteers in comparatively good physical health. There are no clear comparisons with placebo or pseudotreatment control groups, with the old-old, or with medically ill elderly.

Marital and family interventions have not been adequately studied. Marital therapy has been found to be effective in treating depression in younger adults, and social support is a particularly important factor for elderly people. There are some promising strategies for treatment of family caregivers of the frail elderly who themselves often experience high levels of burden and are highly vulnerable to depression.

A number of problems in the use of psychosocial treatments require study. Many elderly people do not see themselves as depressed and/or will not admit to it and reject referrals to mental health professionals. Special effort might be needed to engage these individuals in treatment. Patients with significant physical illness and disabilities (e.g., visual and hearing impairment) and cognitive impairment may require special approaches. Special consideration should also be given to the dissemination of any programs that prove effective so that therapists and caregivers to the elderly are sensitized to the ability of elderly people to respond to active psychosocial interventions. Senior centers, nutrition programs, volunteer services, and other community-based programs should be integral components of any comprehensive psychosocial intervention system.

Special Populations

The evidence is contradictory concerning whether concurrent medical illness has an adverse effect on response to pharmacotherapy. Although medical comorbidity probably results in increased vulnerability to side effects, vigorous but careful treatment is still indicated. However, there are very few controlled trials of treatment of secondary depressions after the medical condition is stabilized. Also, patients with known brain lesions should be treated with the same guidelines and doses as patients without known brain lesions, except as specifically contraindicated. Based on the limited data available, these patients can be expected to respond as well as patients with primary depressions.

The prevalence of major depression in nursing home populations is high and is generally unrecognized and untreated. These patients respond equally well to standard doses of antidepressants, although their medical fragility can lead to treatment-limiting side effects in as many as one-third of these patients.

About 800,000 persons are widowed each year, most of them are old and experience varying degrees of depressive symptomatology. Most do not need formal treatment, but those who are moderately or severely dysphoric appear to benefit from self-help groups or various psychosocial treatments. Remarkably, a third of widows/widowers meet criteria for a major depressive episode in the first month after the death, and half of these remain clinically depressed 1 year later. These depressions respond to standard antidepressants, although there is limited research as to when in the course of these depressions antidepressant medications should be instituted or how medications should be combined with psychosocial treatments.

Question 4: What Are the Patterns of Health Services Use for Late Life Depression? What Are the Obstacles To Deliver Adequate Treatment?

The majority of older adults living in the community (approximately 85 percent) are seen by a primary care physician at least once a year, yet at the same time, it is known that there is considerable unrecognized, undiagnosed, and untreated depression among these people. Why is this so? A number of factors are implicated: There is first the stigma attached to mental illness and psychiatric treatment, a stigma still powerful among the elderly and often shared by members of their family, friends, and neighbors. There is also the character of the condition itself: depressed older people may not report depression because they have no hope for help.

There are "ageist" attitudes among health care providers: sometimes these attitudes are expressed in a relative unwillingness to listen to older people, and sometimes ageist attitudes are reflected in professional pessimism, in the belief that depression is a natural accompaniment of old age, and in actual aversion to having older people as patients.

Older people often do not present their complaints to their primary care physicians in ways that make the diagnosis and treatment of depression straightforward. If the clinicians recognize that their patients are depressed and do need treatment, the intervention may often be limited. There also are problems of compliance: older patients and their families may not understand depression and its course and the importance of taking medications as prescribed. Or, they may become noncompliant because of drug-induced side effects.

Other factors may compromise the prescribed medical regimen: concurrent medical illnesses can interfere with the antidepressant response or the attainment of adequate dosages. Alcoholism and other substance abuse may undercut pharmacotherapy; unhappy life events-- bereavement, poverty, isolation--may adversely affect the patient's motivation to comply. There are many other obstacles in the way of patients receiving the care they need. There is the lack of linkages between the health care, mental health, and social service systems and the diversity of the professionals staffing these systems--primary care physicians, psychiatrists, psychologists, nurses, social workers, pastoral counselors, etc. There also is the complexity of the systems, with different gates to service, eligibility requirements, funding streams, and methods of payment. These characteristics of our service systems make the search for help an onerous journey and one beyond the capability of many older people.

Although the picture can be bleak one for the depressed older person in the community, there are even more immediate treatment needs among those in long-term care settings. For example, among the 1.5 million older people living in nursing homes, the prevalence of depression is high. Despite the special vulnerability among the old in nursing homes and despite the federal regulation that a facility must ensure that, "A resident who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services . . .," few nursing homes have the staff capability to intervene in appropriate and timely fashions. In the nursing home, as in the community, depression goes unrecognized, undiagnosed, and untreated.

There are fiscal problems also: high copayments and constraints on reimbursement may limit the interest of providers and institutions in Medicare patients. In the long-term care system, the requirement that there be appropriate treatment for patients with psychological problems does not carry with it funding for the treatment.

The central role that families play in the lives of the majority of older people has been well documented by researchers and is a fact well known to clinicians accustomed to having older patients brought to them by concerned spouses, adult children, and other relatives. Particular attention must be paid to the elderly without families. Essential functions performed by families on behalf of functionally dependent elders (the orchestration of services, help with activities of daily living, etc.) must be taken over by others (e.g., staff and volunteers of neighborhood-based social agencies).

What can be done to ensure that depressed older people have access to the mental health care they need?

  • All health care providers should participate in continuing education programs designed to increase their knowledge about and skill in recognition of depression and in initiation of treatment. These educational programs should include attention to ageist attitudes. Particular emphasis should be placed on necessity of referral to mental health specialists at various points in the treatment continuum.
  • Resources must be invested in outreach and case-finding initiatives to address the current fragmentation within our care delivery system, making case recognition a feasible goal. Special efforts should be directed at outreach and case identification in minority communities where the elderly may have particular problems in securing the help they need. The professionals cannot wait for depressed older people to come to them; they must instead be active and aggressive in their efforts to reach those in need of help. Multidisciplinary research and treatment teams are recommended to address the critical needs of depressed elderly people.
  • Training programs for care providers, including nursing staff and "hands on" staff, in both community and institutional settings must be directed at identification of the behavioral manifestations of depression and improvement of the care provided.
  • Innovative outreach and social service delivery models, including adult day care and senior citizens programs, should be encouraged, and information about them should be disseminated to professionals and other staff engaged in provision of mental health services to the elderly.

Question 5: What Are the Benefits of Recognizing and Adequately Treating Depression in Late Life? What Are the Consequences of Unrecognized or Inadequately Treated Depression in Late Life?

The ability to think, to feel, to interact with others, to share a sense of purpose, to work, to love, to experience gratification, to care for others, and to maintain self-responsibility are precious human attributes that elderly people strive to maintain. In few circumstances are these elements of our experience and capacity so broadly and deeply challenged as with depressive disease.

Depression in mild and severe forms afflicts substantial numbers of our elderly population. Failure to realize that their despair is an illness deprives the person of insight into his or her condition and prevents seeking of help. The unwitting acceptance by society of depression as natural to aging closes the door of opportunity for gaining effective intervention.

There are clear and specific benefits to recognizing and treating depression in the older people. The evidence to date, though not always specifically derived from the elderly, is compelling in the following ways: (1) treatments of demonstrated efficacy in young and middle-age adult cohorts are also effective in elderly cohorts; (2) ECT and drug treatments can be safely administered to most patients with advantageous benefit/risk ratios; (3) psychosocial aspects of care are essential, and preliminary study of some forms of psychosocial therapy support their use; and (4) depression tends to be long lasting in elderly adults, even when it begins in the wake of serious personal loss or physical illness, and the mortality rate is high. A wait-and- see approach is not tenable in moderate and severe depression and may be undesirable even in mild cases. Treatment will not be effective in all cases, but the majority will receive substantial therapeutic effect with the following benefits:

  • Partial or complete remission of the broad range of symptoms associated with depression.
  • Amelioration of pain and suffering associated with physical illnesses.
  • Enhancement of general mental, physical, and social functioning and personal well-being.
  • Minimization of cognitive disability, a particular fear in the elderly.

Put simply, depression can ruin a person's life, but treatment is effective.

What are the consequences of failure to recognize and treat depression in elderly people? Many of our senior citizens will live their final years in despair and suffering without any appreciation of their affliction or the understanding and comfort of those most dear to them. Professional help is not often sought or offered, and depression is not likely to be brief. The likely consequences are loss of personal happiness and severe strain on living circumstances. Depression may trigger a shift from home to a nursing facility or may shift the person from a warm and respected friend or loved one to an isolated individual with lost status. Untreated depression costs money because physical illnesses require more medical services, living arrangements become institutional, and employment is lost. These costs should be substantially preventable with presently validated case recognition and treatment techniques. New research data are needed to extend these techniques and to measure social and economic benefits of treatment. Personal benefits of symptom reduction are well documented and compelling.

Question 6: What Are the Most Promising Questions for Future Research?

 

  • Improve diagnosis and identification of those elderly persons most likely to benefit from specific treatments--biological, psychosocial, or combinations thereof.
  • Clarify the relationship between subcortical brain abnormalities, depressive and cognitive symptomatology, and early- versus late-onset depression in the elderly.
  • Clarify the pharmacokinetic changes in the very old and the prognostic value of metabolic subtyping.
  • Clarify the cause and effect relationship between depression and medical illness.
  • Initiate prospective cross-sequential studies to identify general risk factors (including life stress and specific illnesses and disabilities) and their relationship to the course of depression.
  • Study the basis for differential occurrence of depression and suicide rates in demographic subgroups.
  • Determine whether ECT is effective as a continuation and maintenance treatment in late life depression.
  • Study the treatment of pathological grief. Which psychological and pharmacological treatments are effective, and when in the course of grief should they be used?
  • Conduct clinical trials and observational studies of treatment in the very old, the elderly in minority and underserved communities and in institutional settings, and the elderly with medical illness.
  • Develop and evaluate psychosocial treatments that are specifically linked to the needs of the elderly. Determine how psychosocial and biological treatments may complement or provide alternatives to each other.
  • Develop demonstration projects focused on innovative models of care delivery, particularly those that emphasize coordinated services and outreach efforts to depressed elderly people.
  • Carry out long-term clinical trials with broad-based assessment of outcome (including economic and social impact) to determine the extent to which effective recognition and treatment benefit patients and society.
Conclusions and Recommendations

Depression in late life occurs in the context of numerous social and physical problems that often obscure or complicate diagnosis and impede management of the illness. There is no specific diagnostic test for depression so that an attentive and focused clinical assessment is essential for diagnosis. Because elderly depressed people often do not present themselves for evaluation or because their depressive symptoms are not typical, the illness is underdiagnosed and undertreated. This is particularly true when it is secondary to physical illness, even though these secondary depressive symptoms also respond to treatment.

Estimates of depression in elderly people vary widely as a function of setting, threshold of diagnosis, and definition of depression; however, there is a consensus that the size of the problem is underestimated. The highest rates are found in nursing homes and other residential care settings. Risk factors appear to operate similarly in young and old, although the hallmark of depression in older people is its comorbidity with medical illness. The course of recovery and frequent recurrence is similar in young and old; however, suicide is dramatically increased in elderly depressed, as is mortality from other causes.

Depressed elderly people should be treated vigorously with sufficient doses of antidepressants and for a sufficient length of time to maximize the likelihood of recovery. Maintenance treatment with antidepressants should be continued with the same doses that produced remission of the acute episode. ECT is often effective for depression in the elderly but is generally underused or unavailable. Psychosocial treatments can also play an essential role in the care of elderly patients who have significant life crises, lack social support, or lack coping skills to deal with their life situations. These approaches may also be indicated in patients who cannot or will not tolerate biologic treatments.

The system of care currently provided to elderly depressed persons is inadequate, fragmented, and passive. Ageist attitudes among some health care providers compromise their ability to recognize depression in their elderly patients and to intervene in an appropriate and timely fashion. The prevalence of depression is particularly high among patients in nursing homes, but staff in many of these facilities are not equipped to recognize or treat depressed patients.

Families and primary care physicians remain at the front line in recognizing depression and facilitating patient access to professional help; however, large numbers of elderly people live alone, have inadequate support systems, or do not have contact with a primary care physician. The isolation of these individuals compounds their depression, and specialized efforts are needed to locate and identify them and to provide in-home care relevant to their needs. Although lack of services is a major problem, a greater problem may be our inability to deliver services to those community-dwelling elderly people who need them the most.
 

Consensus Development Panel

Arnold J. Friedhoff, M.D.
Panel and Conference Chairperson
Professor, Department of Psychiatry
Director, Millhauser Laboratories
New York University School of Medicine
New York, New York
James Ballenger, M.D.
Chairman and Professor
Department of Psychiatry and Behavioral Sciences
Director, Institute of Psychiatry
Medical University of South Carolina
Charleston, South Carolina
Alan S. Bellack, Ph.D.
Professor of Psychiatry
Director of Clinical Psychology
East Pennsylvania Psychiatric Institute
Medical College of Pennsylvania
Philadelphia, Pennsylvania
William T. Carpenter, Jr., M.D.
Director, Maryland Psychiatric Research Center
Professor of Psychiatry and Pharmacology
Department of Psychiatry
University of Maryland School of Medicine
Baltimore, Maryland
Helena Chang Chui, M.D.
Associate Professor of Neurology
Geriatric Neurobehavior and Alzheimer Center
Rancho Los Amigos Medical Center
University of Southern California
Los Angeles, California
Rose Dobrof, D.S.W.
Director, Brookdale Center on Aging
Hunter College
New York, New York
Joyce J. Fitzpatrick, Ph.D., R.N., F.A.A.N.
Professor and Dean of Nursing
Frances Payne Bolton School of Nursing
Case Western Reserve University
Cleveland, Ohio
Rudolph Freeman, Jr., M.D.
Private Practice in Geriatric Psychiatry
Medical Director, Adult Inpatient Unit
Riverside Regional Medical Center
Newport News, Virginia
George R. Heninger, M.D.
Associate Chairman for Research
Professor of Psychiatry
Yale University School of Medicine
New Haven, Connecticut
Philip W. Lavori, Ph.D.
Associate Chairman for Research
Department of Psychiatry and Human Behavior
Brown University
Providence, Rhode Island
Kathleen Ries Merikangas, Ph.D.
Director, Genetic Epidemiology Research Unit
Associate Professor of Psychiatry and Epidemiology
Yale University School of Medicine
New Haven, Connecticut
Raymond Raschko, M.S.W.
Director of Elderly Services
Spokane Community Mental Health Center
Spokane, Washington
Martha Storandt, Ph.D.
Professor of Psychology
Department of Psychology
Washington University
St. Louis, Missouri
Mark E. Williams, M.D.
Associate Professor of Medicine
Director Program on Aging
University of North Carolina School of Medicine
Chapel Hill, North Carolina

Speakers

George S. Alexopoulos, M.D.
"Biological Correlates of Late Life Depression"
Associate Professor of Psychiatry
Cornell University Medical Center
White Plains, New York
Dan G. Blazer II, M.D., Ph.D.
"Epidemiology of Depressive Disorders in Late Life"
J.P. Gibbons Professor of Psychiatry Department of Psychiatry
Duke University Medical Center
Durham, North Carolina
Eric D. Caine, M.D.
"Clinical and Etiological Heterogeneity of Mood Disorders in the Elderly"
Professor of Psychiatry and Neurology
Department of Psychiatry
University of Rochester Medical Center
Rochester, New York
Yeates Conwell, M.D.
"Suicide in the Elderly"
Associate Professor of Psychiatry
Department of Psychiatry
University of Rochester School of Medicine
Rochester, New York
Paul T. Costa, Jr., Ph.D.
"Depression as an Enduring Disposition"
Chief, Laboratory of Personality and Cognition Gerontology Research
Center National Institute on Aging
Baltimore, Maryland
Ellen Frank, Ph.D.
"Long-Term Prevention of Recurrence in the Elderly"
Associate Professor of Psychiatry and Psychology
University of Pittsburgh School of Medicine
Western Psychiatric Institute and Clinic
Pittsburgh, Pennsylvania
Linda K. George, Ph.D.
"Social Factors and Depression in Late Life"
Professor, Department of Psychiatry
Duke University Medical Center
Durham, North Carolina
Gary L. Gottlieb, M.D., M.B.A.
"Barriers to Care of Older Adults With Depression"
Associate Chairman
Department of Psychiatry
Ralston-Penn Center
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Joel B. Greenhouse, M.P.H., Ph.D.
"Meta-analysis Review From a Psychiatric Statistical Perspective"
Associate Professor of Statistics
Carnegie Mellon University
Pittsburgh, Pennsylvania
Barry J. Gurland, M.D.
"The Impact of Depression on Quality of Life of the Elderly"
John E. Borne Professor of Clinical Psychiatry
Director, Columbia University Center for Geriatrics and Gerontology
New York, New York
Ira R. Katz, M.D., Ph.D.
"Depression in the Residential Care Elderly"
Professor of Psychiatry
Director, Division of Geriatric Psychiatry
Medical College of Pennsylvania
Philadelphia, Pennsylvania
Sidney Klawansky, M.D., Ph.D.
"Meta-analysis on the Diagnosis and Treatment of Depression in Late Life"
Lecturer Health Policy and Management Technology Assessment Group
Harvard School of Public Health
Boston, Massachusetts
Andrew F. Leuchter, M.D.
"Brain Structural and Functional Correlates of Late Life Depression"
Assistant Professor
University of California at Los Angeles
Los Angeles, California
Elaine Murphy, M.D.
"The Course and Outcome of Depression in Late Life"
Professor of Psychogeriatrics
Division of Psychiatry
United Medical Schools Guys Hospital
London, England
George Niederehe, Ph.D.
"Psychosocial Therapies With Depressed Older Adults"
Head, Geriatric Treatment Research
Mental Disorders of the Aging Research Branch
National Institutes of Mental Health
Rockville, Maryland
James M. Perel, Ph.D.
"Pharmacokinetics of Therapeutics, Toxic Effects, and Compliance"
Professor of Psychiatry, Pharmacology and Graduate Neuroscience
Director, Clinical Pharmacology Program
Western Psychiatric Institute and Clinic University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
Burton V. Reifler, M.D., M.P.H.
"Depression: Diagnosis and Comorbidity"
Professor and Chairman
Department of Psychiatry and Behavioral Medicine
The Bowman Gray School of Medicine
Winston-Salem, North Carolina
Charles F. Reynolds III, M.D.
"Overview: Diagnosis and Treatment of Depression in Late Life"
Professor of Psychiatry and Neurology
Western Psychiatric Institute and Clinic University of Pittsburgh
Pittsburgh, Pennsylvania
A. John Rush, M.D.
"Overview of Treatment Options in the Depressed Elderly"
Betty Jo Hay Chair in Mental Health
Professor, Department of Psychiatry
University of Texas Southwestern Medical Center
Dallas, Texas
Harold A. Sackeim, Ph.D.
"The Use of Electroconvulsive Therapy in Late Life Depression"
Chief Department of Biological Psychiatry
New York State Psychiatric Institute
New York, New York
Carl Salzman, M.D.
"Pharmacological Treatment of Depression in the Elderly"
Associate Professor of Psychiatry
Massachusetts Mental Health Center
Boston, Massachusetts
Lon S. Schneider, M.D.
"Meta-analysis Review From a Clinical Researcher Perspective"
Associate Professor of Psychiatry and Neurology
University of Southern California
Los Angeles, California
Senior Scientific Advisor
National Institute of Mental Health
Alcohol, Drug Abuse, and Mental Health Administration
Rockville, Maryland
Linda Teri, Ph.D.
"Cognitive-Behavior Therapy With Depressed Older Adults"
Associate Professor Department of Psychiatry and Behavioral Sciences
University of Washington School of Medicine
Seattle, Washington
Sidney Zisook, M.D.
"Diagnostic and Treatment Considerations in Depression Associated With Late Life Bereavement"
Professor
Director of Research and Training, Outpatient Psychiatric Services
University of California at San Diego
San Diego, California

Planning Committee

Barry D. Lebowitz, Ph.D.
Planning Committee Cochairperson
Chief, Mental Disorders of the Aging Research Branch
Division of Clinical Research
National Institute of Mental Health
Alcohol, Drug Abuse, and Mental Health Administration
Rockville, Maryland
Charles F. Reynolds III, M.D.
Planning Committee Cochairperson
Professor of Psychiatry and Neurology
Western Psychiatric Institute and Clinic University of Pittsburgh
Pittsburgh, Pennsylvania
Lon S. Schneider, M.D.
Planning Committee Cochairperson
Associate Professor of Psychiatry and Neurology
University of Southern California
Los Angeles, California
Senior Scientific Advisor
National Institute of Mental Health
Alcohol, Drug Abuse, and Mental Health Administration
Rockville, Maryland
Eric D. Caine, M.D.
Professor of Psychiatry and Neurology
Department of Psychiatry
University of Rochester Medical Center
Rochester, New York
Marsha Corbett
Director Office of Scientific Information
National Institute of Mental Health
Alcohol, Drug Abuse, and Mental Health Administration
Rockville, Maryland
Jerry M. Elliott
Program Analyst
Office of Medical Applications of Research
National Institutes of Health
Bethesda, Maryland
John H. Ferguson, M.D.
Director, Office of Medical Applications of Research
National Institutes of Health
Bethesda, Maryland
James L. Fozard, Ph.D.
Chief, Longitudinal Studies Branch
National Institute on Aging
Gerontology Research Center
National Institutes of Health
Baltimore, Maryland
Arnold J. Friedhoff, M.D.
Panel and Conference Chairperson
Professor, Department of Psychiatry
Director, Millhauser Laboratories
New York University School of Medicine
New York, New York
Linda K. George, Ph.D.
Professor Department of Psychiatry
Duke University Medical Center
Durham, North Carolina
William H. Hall
Director of Communications
Office of Medical Applications of Research
National Institutes of Health
Bethesda, Maryland
Ira R. Katz, M.D., Ph.D.
Professor of Psychiatry
Director, Division of Geriatric Psychiatry
Medical College of Pennsylvania
Philadelphia, Pennsylvania
George Niederehe, Ph.D.
Head, Geriatric Treatment Research
Mental Disorders of the Aging Research Branch
Division of Clinical Research
National Institute of Mental Health
Alcohol, Drug Abuse, and Mental Health Administration
Rockville, Maryland
Jane L. Pearson, Ph.D.
Research Psychologist
Mental Disorders of the Aging Research Branch
Division of Clinical Research
National Institute of Mental Health
Alcohol, Drug Abuse, and Mental Health Administration
Rockville, Maryland
Burton V. Reifler, M.D., M.P.H.
Professor and Chairman
Department of Psychiatry and Behavioral Medicine
The Bowman Gray School of Medicine
Winston-Salem, North Carolina
Linda Teri, Ph.D.
Associate Professor
Department of Psychiatry and Behavioral Sciences
University of Washington School of Medicine
Seattle, Washington

Conference Sponsors

National Institute of Mental Health Alcohol, Drug Abuse, and Mental Health Administration
Alan Leshner, Ph.D. Acting Director
National Institute on Aging
National Institutes of Health
Gene D. Cohen, M.D., Ph.D. Acting Director
Office of Medical Applications of Research
National Institutes of Health
John H. Ferguson, M.D. Director

Supplemental Information for NIH Consensus Statement on Diagnosis and Treatment of Depression in Late Life

Since the NIH Consensus Statement on Diagnosis and Treatment of Depression in Late Life was issued, additional information has become available that supplements the original statement.

The recommendations of the panel remain current. In addition, the journal article referenced below describes new findings in the areas of onset and course of late life depression; gender and hormonal issues; comorbidity and disability; new medications, psychotherapies, and approaches to long term treatment; impact of depression on health services and health care resource use; late life depression as a risk factor; and heterogeneity in symptoms of depression.

 

  • Lebowitz BD, Pearson JL, Schneider LS, Reynolds CF, Alexopoulos GS, Bruce ML, Conwell Y, Katz IR, Meyers BS, Morrison MF, Mossey J, Niederehe G, Parmelee P. Diagnosis and treatment of depression in late life: consensus statement update. JAMA. 1997;278(14):1186-1190.

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