Depression in later life

Dr Carolyn Chew-Graham outlines what should be done to improve diagnosis of depression in older patients.

Depression is the most common mental health problem in older people. One in four people aged 65 and over have symptoms of depression, much of which could be prevented.

Like most mental health problems, it attracts stigma and is often wrongly seen as an inevitable part of ageing by both older people and healthcare practitioners.

Depression frequently co-exists with long-term physical conditions and is itself associated with physical limitation, increased use of healthcare provision and higher mortality.

Older people have the highest suicide rate among women and the second highest among men.

In contrast with younger people, self-harm in older people usually signifies mental illness, mostly depression, with high risk of completed suicide.

Low levels of detection and treatment of depression in later life have been highlighted in primary care, where evidence suggests a relapsing or chronic course.

Identifying depression
Detection of depression may be poor if primary care clinicians lack the necessary consultation skills or confidence to diagnose later life disorders correctly.

GPs may be wary of opening a Pandora's box in time-limited consultations, they may collude with the patient that feeling miserable is normal considering the physical problems the patient has, and may have limited expectations of treatment.

In addition, two thirds of older people with serious depression have symptoms that fit poorly with current classifications of mood disorders, which reflect symptoms in younger people.

In contrast, older people may present symptoms of tiredness, insomnia and varied physical symptoms, pain in particular. The primary care clinician may attribute these symptoms to organic disease or forgetfulness. Forgetfulness may lead to a concern that the patient has cognitive impairment and/or early dementia.

Interventions
Once detected, depression in older people is treatable by antidepressants and/or talking therapies, such as counselling.

Older people may be distrustful of tablets and may prefer psychological interventions, which have been shown to be effective in people with later life depression and anxiety.

Such therapeutic options are often unavailable in primary care because of upper age limits to certain services.

The UK population aged over 60 will rise from 21.2 per cent now to 29.4 per cent by 2050. It is resting on health and social care services to respond to the changing needs produced by such demographic changes.

Clinicians need an ability to develop an empathic relationship with the person and not to normalise the symptoms, to assess risk, particularly of suicide, and develop an increased confidence in the management of older people with depression.

Challenging attitudes
Referrals to other team members, the voluntary sector, statutory services and secondary care are also invaluable to improving the problem. In addition, we need to increase awareness of depression among older people and their carers.

Last summer, Age Concern and Help the Aged launched 'Down, but not out', a national campaign to highlight these issues.

Working with the RCGP and other primary care health professionals, the charities have designed and developed an online interactive programme to improve the detection and treatment of depression by GPs and other primary care professionals (see Resources).

The programme asks participants to identify the barriers that can stand in the way of depression being correctly diagnosed, such as negative attitudes about ageing.

The RCGP would encourage GPs and practice nurses to 'take the challenge' as part of their personal and practice learning. For GPs, it can contribute to appraisal and revalidation.

Patient population
The practice might then consider their role in preventing depression within their patient population. The over-75 health checks, now rarely used, offer an opportunity to check vision and hearing because these sensory deteriorations can often lead to isolation and loneliness.

Targeting help at known trigger points for depression, such as following bereavement or moving into a care home, is key to the overall prevention approach.

In addition, GP practices could link up with a local Age Concern befriending scheme to signpost older people who may benefit from a social intervention service because of a life-changing experience.

  • Dr Chew-Graham is a GP and senior clinical lecturer in primary care at the University of Manchester and RCGP clinical champion, mental health.

Resources

UK Inquiry into Mental Health and Well-Being in Later Life - www.mhilli.org

Age Concern's Take the Challenge online interactive programme - www.takethechallenge.org.uk

Awareness of depression leaflets for older people and their friends and family are also available.

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