Depression is a serious illness affecting approximately 3% to 6% of adults over age 65 in the United States. Also depression affects a much higher percentage of people in hospitals and nursing homes. Depression in late life can be a relapse of an earlier depression, But when it occurs for the first time in older adults, it usually is a consequence of a medical illness. With coexisting medical illness, depression can be more difficult to recognize and also more difficult to endure.however A majority of the people diagnosed with depression in primary care settings, , do not meet the diagnostic criteria for major depressive disorder.
Fatigue, lack of energy and sleep problems associated with medical conditions often mimic depressive symptoms and makes difficult the diagnose of depression in primary care settings, in older adults. Furthermore, losses of friends and loved ones and a shrinking social network in old age result in diminished social involvement, which is a common feature of depression. These problems of old age are sometimes difficult to distinguish from depressive symptoms.
The challenge of correctly identifying depression in primary care is compounded by the fact that depressed patients seen in these settings have less-clear-cut symptom profiles than those seen in specialty mental health settings, mainly because their symptoms are less severe or disabling. Some patients diagnosed with depression in primary care may meet the criteria for dysthymia or adjustment disorder with mood symptoms. Others may have mild depressive symptoms that don't reach the threshold for diagnosis of major depressive disorder. Many such patients would benefit from supportive counseling or lifestyle modification. In some cases, watchful waiting with regular follow-up may be appropriate. Yet the majority of primary care patients diagnosed with depression are simply prescribed antidepressants.
The guidelines discourage routine use of antidepressants for persistent subthreshold depressive symptoms or mild depression. However, clinicians may consider these medications for patients with a history of moderate or severe depression, subthreshold symptoms lasting 2 years or longer, and subthreshold symptoms or mild depression that persists after low-intensity psychosocial interventions. Medications (typically selective serotonin-reuptake inhibitors) or high-intensity psychosocial interventions, such as individual cognitive behavioral therapy or interpersonal therapy, alone or combined with medications, may be considered as a third step for patients with no response to low-intensity psychosocial interventions and those with moderate-to-severe depression. When medication has been started, the guidelines recommend continuing it at a therapeutic dose for at least 6 months after remission of an episode.
With the looming shortage of geriatric mental health care providers, general medical clinicians' role in managing older adults' mental health problems will probably increase. A nuanced approach to depression diagnosis and treatment may improve the management and outcome of geriatric depression in primary care settings. Incorporating the stepped-care approaches into generalists' training and making low-intensity psychosocial interventions more widely available may help prepare clinicians to more effectively meet future needs.
Effective treatments—including psychopharmacologic, psychotherapeutic (behavioral or counseling), and complementary and alternative therapies—and combinations of these are available for depressed patients identified in primary care settings. Cognitive-behavioral therapy (CBT) and interpersonal therapy are psychotherapeutic approaches used in the treatment of patients with major depressive disorder, with documented beneficial outcomes.
In general, evidence-based recommendation for treatment of moderate to severe depression in the primary care setting in elderly patients involves a combination of pharmacotherapy and psychotherapy, and for the treatment of mild to moderate depression, psychotherapy alone.
