Depression treatment for the elderly

Conclusions

• Many elderly with depression do not benefit sufficiently from the use of antidepressants. In short-term studies, selective serotonin reuptake inhibitors (SSRIs) are not significantly more effective than placebo for elderly with depression. But for those who improved during treatment with SSRI, maintenance treatment up to one year can prevent relapse.
• The selective serotonin and norepinephrine reuptake inhibitor duloxetine has been evaluated specifically for recurrent depression in elderly and has a slightly better effect than placebo in the short term, but often causes adverse effects that may be problematic for the elderly.
• Psychotherapy in the form of problem-solving therapy may decrease depression symptoms for patients with poor health aged 65 years and over, but access to such treatment is lim­ited. More and larger studies on the effects of other psychotherapies and on the effects of physical activity, is warranted to elucidate their benefit and risk balance in depression of the elderly.
• Treatments that are effective, according to this evaluation, have not yet been evaluated in health economic studies. However, since the treatment cost per individual is often relatively low, it is likely that effective treatment is also cost-effective.
• The benefits and risks of depression treatment are insufficiently studied for the frail elderly aged 65 years and over. More knowledge is warranted to determine how treatment for depression can be individualized.
• Due to the lack of knowledge about effective depression treatment for the elderly, it is particularly important to monitor treatment outcome carefully and to reconsider treatment strategy when the patient do not recover.

Background

Depression in the elderly is a serious condition that can lead to a significant decline in quality of life and increased risk of dying prematurely. The condition is common, and with an aging population the problem is likely to increase. By 2020 depression is expected to be second only to heart disease, in its contribution to the global burden of disease, as measured by disability-adjusted life years. There are a number of treatment options for depression and several antidepressants and psychological treatments have shown to be effective for depression in adults. For severe depression, electroconvulsive therapy (ECT) is an effective treatment option and there is some evidence that physical activity is effective in mild depression. However, it is not clear that the research results for adults in general can be transferred to the elderly. This may be the case in particular for the very old and frail elderly. We have systematically evaluated the scientific literature regarding benefits and risks for the most common treatment options for people aged 65 years and over suffering from depression. Results from studies that investigate the treatments in the frail elderly, have been evaluated separately.

Purpose and method

The main purpose of this work was to evaluate the scientific evidence for the most common depression treat­ments in the frail elderly. In order to obtain a larger knowledge base we also included scientific evidence for people aged 65 years and over suffering from depression. The report is intended to provide support for the decision makers in healthcare and elderly care and the main target groups are actors within healthcare, elderly care and social services. Other important target groups are patient associations and the general public.

We have systematically evaluated randomised controlled studies in which all participants were aged 65 and over and were diagnosed with depression or had clinically relevant symptoms of depression. The treat­ments we evaluated were antidepressants, psychological therapy, physical activity, electroconvulsive therapy (ECT), light therapy and combinations of treatments. We have evaluated the effects on depressive symptoms, relapse into depression, quality of life, functional capacity, adverse events, mortality, morbid­ity and mortality in cardiovascular disease, suicide or suicide attempts, and the impact on kinship care.

This evaluation was performed according to the methods of SBU.

Ethical and social aspects

In absence of evidence on how depression in the elderly should best be treated, it is important to carefully monitor how the individual patient respond to treatment and also to periodically consider adjusting the treatment strategy when a non-response is evid­ent. It is also important to make a correct diagnosis before treatment in order to avoid overtreatment.

From societal perspective, depression in the elderly is costly if treatment is not given. International studies show that health care costs for older people with depression are at least twice as high as for those who are not depressed. In addition, the informal care and care given by relatives, increase sharply with age for people aged 65 years and older suffering from depression. Given that elderly in general already suffer from low quality of life, compared to a younger population, depression can lead to a very low overall quality of life.

The high costs and the loss of quality of life make it important to treat depression in the elderly. There are no health economic studies that illustrate the cost-effectiveness of the treatments that have a documented effect in this age group. The treatment cost for SSRIs, duloxetine and problem-solving therapy is low, and it is therefore likely that effective treatments also are cost effective.

Psychiatric care for the elderly is given lower priority witch is in conflict with current ethical principles. It is therefore important that personal, professional, or political interests are not allowed to influence priorities and clinical practice in a way that could discriminate against the elderly and the most vul­nerable groups.