Depression in older adults
BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4922 (Published 28 November 2018) Cite this as: BMJ 2018;363:k4922
- Philip Wilkinson, consultant psychiatrist, honorary senior clinical lecturer in psychiatry1,
- Catherine Ruane, former carer2,
- Katie Tempest, member of research user group3
- 1Oxford Health NHS Foundation Trust and Department of Psychiatry, University of Oxford, UK
- 2Leeds, UK
- 3Research Institute, Primary Care and Health Sciences, Keele University, Staffordshire, UK
- philip.wilkinson{at}psych.ox.ac.uk
Around the world we are witnessing a continued upward trend in life expectancy with the proportion of people aged over 80 years growing fastest. Depressive disorders are common across the life course and depressive symptoms are present in up to a third of older adults. Depression in older people is associated with more functional and cognitive impairment than depression in younger adults1 and carries significant costs for the person, the family, and the NHS. Comorbid physical illness, poor social support, and bereavement are known to increase risk of developing depression.23
With increasing age, the course of depression worsens: in a recent large cohort study of adults aged 18 to 88 years, people aged 70 and above experienced greater symptom severity compared with younger adults and a greater likelihood of still having a diagnosis of depression after two years, even after adjusting for physical illness and antidepressant use.4 Persistent severe depression is also known to be linked to the onset of dementia.5
In 2004, an editorial6 in The BMJ called for investment in new management approaches and research to improve outcomes in late life depression. There remains, however, a paucity of randomised controlled trials of both pharmacological and psychological interventions in the acute treatment of depression. Although studies show treatment efficacy similar to that in younger adults, participants are mainly the “younger old.”7 There is very limited evidence for the effectiveness of treatment for depression in people aged over 75 years, older adults with chronic depression, or for long term treatments to prevent recurrence.8 Despite this, antidepressants are prescribed for longer periods in older people than in younger people,9 while observational data indicate that all classes of antidepressants, including newer drugs, are associated with increased risks of adverse events such as falls and seizures in older people.10 Despite the Improving Access to Psychological Treatments programme now offering non-pharmacological treatments geared specifically to the needs of older people, uptake has been lower than by younger adults.11
A different approach
Collaborative Care interventions for depression incorporate a structured management plan, frequent symptom monitoring, simple psychological interventions, and enhanced communication between primary and secondary care. The editorial6 published by The BMJ in 2004 proposed Collaborative Care to help older people with depression, especially those with chronic physical and social problems, and there have been recent positive findings from a large UK trial.12
Although it is understood that loneliness can play a role in late life depression, more work is needed to refine and evaluate psychosocial interventions that combat isolation. These include both befriending programmes13 and peer support schemes led by people who have themselves experienced depression. Better understanding of the role of cerebrovascular disease and inflammatory mechanisms in late life depression might also pave the way for novel biological treatments.14
Family (unpaid) carers of older people with depression experience a level of burden akin to that in carers of people with dementia, and remission of depression is associated with reduced carer stress and burden.15 Unlike intervention trials in dementia, however, studies into depression in older adults rarely measure carers’ physical and mental wellbeing. Carers have positive contributions to make: they are in a unique position to observe and recognise the evolving symptoms in the older person with depression and so they are pivotal to the recognition of the early symptoms of relapse. The carer is also a constant therapeutic ally when an older adult moves from home to hospital or residential care where depression may not be recognised.1617
A life course disorder
In 2006, Scott called for a “paradigm shift to recognise that depression is a life course disorder.”18 For older people with depression this would mean a shift from the current symptom focused management of acute depressive episodes to a chronic illness approach offering sustained support, a focus on physical and psychosocial functioning, and greater public involvement. In recent years, public policy in the UK has helped to raise the profile of dementia and to promote research and education but, so far, late life depression has not received this attention. There have been some recent initiatives in patient and carer information, however, including a Royal College of Psychiatrists video (www.rcpsych.ac.uk/mental-health/problems-disorders/depression-in-older-adults) and the MindEd online programme sponsored by Health Education England (https://mindedforfamilies.org.uk/older-people).
The current evidence base for the management of depression does not meet the needs of an ageing population, many of whom will experience chronic or recurring depression. Research is needed to guide the use of long term person centred interventions, whether antidepressants, psychological therapies, or psychosocial interventions. Such research must evaluate harms as robustly as benefits. The challenge, however, does not end with developing effective interventions: depression in older adults needs a higher profile, akin to dementia, led by patients, carers, and clinicians, and following the established principles of chronic disease management.
Acknowledgments
We are grateful to Carolyn Chew-Graham for her comments on this editorial.
Footnotes
Not commissioned, peer reviewed
Competing interests: PW and CR are members of the NICE Depression in adults: treatment and management (update) Guideline Development Committee; PW is a co-author of one module in the MindEd online depression programme that is hyperlinked and co-author of the Cochrane review cited in this paper.