Management of depression in later life

Depressive disorder is the most frequent psychiatric illness of older people (Beekman et al, 1999). It has a negative impact on quality of life, adds significantly to disability from physical disorder (Penninx et al, 2000) and is the leading cause of suicide in older people. It is also an independent predictor of mortality (Cuijpers & Smit, 2002). Although effective treatment exists, depression is not well recognised and often not optimally managed (Baldwin et al, 2002). This article updates an earlier review of the subject (Katona, 1996). Prevalence in older people In a meta-analysis the prevalence of clinically significant depression among older people living in the community was 13.5 % (Beekman et al, 1999). Important determinants of prevalence are disability and handicap so, unsurprisingly, rates are at least doubled among patients in hospital or nursing homes. There are possible neurobiological links between depression and stroke, Parkinson’s disease and the dementias (vascular dementia having the highest rate of comorbid depression), but also a high rate of depressive symptoms in a range of chronic medical disorders, including heart disease (Ariyo et al, 2000) and chronic obstructive pulmonary disease (Yohannes et al, 1998). Assessing depression in later life Special factors to take into account when assessing depression in older people are listed in Box 1. The skills of history-taking, conducting a mental state examination, physical evaluation and organisation of relevant investigations are no less important than in other branches of psychiatry. Given the increased likelihood of finding an organic condition contri-buting to depression with advancing age, these skills are arguably more important. Boxes 2 and 3 list the more important causes of organic depressive episodes. Management of depression in later lif