Treatment of depressive conditions in later life: real-world light for dark (or dim) tunnels.

Abstract

LONG PREDICTED AGE-DEMOGRAPHIC SHIFTS ARE NOW a reality. The “graying” of the US population will accelerate in the next few years as the first cohorts of the baby boom generation reach the chronological milestones traditionally used to define older age. So it is appropriate that increased attention be paid to improving the quality of life for seniors. The article by Ciechanowski et al in the current issue of THE JOURNAL and a recently published article by Bruce et al do just that by presenting findings from effectiveness trials for depression in the elderly. These studies represent important advances and warrant consideration of their broader context. Later life depression is a major public health problem. Depressive conditions in elderly persons are common, leading causes of functional disability and powerful risk factors for mortality from general medical conditions as well as suicide. Pharmacological and psychotherapeutic treatments for geriatric major depression are well supported empirically, although until recently much of this evidence stemmed from efficacy studies conducted in mental health settings. Even so, too few elderly persons with depression receive adequate therapy. Further complicating the picture is the heterogeneity of clinical states encompassed by the term depression. A large body of evidence from epidemiological studies demonstrates that most elders with clinically significant depressive symptoms do not meet diagnostic criteria for major depressive disorder. However, the cumulative functional morbidity of these so-called lesser conditions actually exceeds that of major depression among the elderly. Various diagnostic criteria have been proposed to capture these states, using terms such as minor, subsyndromal, or subthreshold depression. Some of these patients may have partially remitted (or partially recurrent) major depressive episodes, as it has become clear that such waxing and waning of symptoms is characteristic of the course of major depression. Other patients have a long-recognized condition known as dysthymic disorder, which consists of chronic depressive symptoms at a lower level of severity than major depression. However, the majority of older depressed adults have minor or other subsyndromal depressions that do not fit into the established categories of major depression or dysthymic disorder, with point prevalences ranging from 10% to 20% in the community or primary care settings and from 15% to 25% or greater in more medically ill groups, such as those residing in nursing homes. Data regarding longitudinal outcomes and biological, psychosocial, and functional correlates increasingly support the notion that minor and subsyndromal depressions are part of a spectrum of depressive illness severity. In other words, while major depression is a useful diagnostic construct, it may not be pathogenetically distinct from less-severe forms; thus, the dividing line, while allowing reliable diagnosis, may be an arbitrary one. In the midst of such diagnostic complexities, clinicians must make recommendations to patients based on the best available evidence on treatment outcomes. However, as recently as mid-2002, the evidence base for treatment of lessthan-major depression in the elderly was limited; the few extant randomized controlled trials focusing on elderly patients suggested that antidepressant medication or depression-specific counseling methods had relatively modest benefit. Subsequently, THE JOURNAL published important findings from the IMPACT (Improving Mood–Promoting Access to Collaborative Treatment) study by Unutzer et al. IMPACT’s on-site collaborative care model, using a depression care manager to support antidepressant medication treatment or brief psychotherapy, was effective in improving symptomatic and functional outcomes for older primary care patients with major depression or dysthymic disorder treated in the primary care setting. The recent publication of PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) in