Late-life depression is a heterogeneous syndrome. Although depression in elderly patients is highly treatable, a number of factors or confounds create complexity in its overall management. Patient factors, such as medical illness, neuropsychiatric comorbidity, and race, may interact with provider factors to make management more complex. Outcomes and services research indicate that these factors, particularly medical illness, affect whether late-life depression is appropriately detected, diagnosed, and treated. Attention to such factors must be included in an agenda for mental health services research, with emphasis on the delivery of effective treatment to elderly patients with depression and improved outcomes in clinical settings.
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References
1.
1. Reynolds CF, Kupfer DJ., Depression and aging: a look to the future. Psychiatr Serv1999; 50: 1167–1172.
2.
2. Katz IR, Streim J, Parmelee P., Psychiatric-medical comorbidity: implications for health services delivery and for research on depression. Biol Psychiatry1994; 36: 141–145.
3.
3. Waxman HM, Carner EA, Klein M., Underutilization of mental health professionals by community elderly. Gerontologist1984; 24: 23–30.
4.
4. Higgins ES., A review of unrecognized mental illness in primary care. Prevalence, natural history, and efforts to change the course. Arch Fam Med1994; 3: 908–917.
5.
5. German PS, Shapiro S, Skinner EA, et al., Detection and management of mental health problems of older patients by primary care providers. JAMA1987; 257: 489–493.
6.
6. Gallo JJ, Ryan SD, Ford DE., Attitudes, knowledge, and behavior of family physicians regarding depression in late life. Arch Fam Med1999; 8: 249–256.
7.
7. Alexopoulos GS., Interventions for depressed elderly primary care patients. Int J Geriatr Psychiatry2001; 16: 553–559.
8.
8. Katon W, Schulberg H., Epidemiology of depression in primary care. Gen Hosp Psychiatry1992; 14: 237–242.
9.
9. Steffens DC, Skoog I, Norton MC, et al., Prevalence of depression and its treatment in an elderly population: the Cache County Study. Arch Gen Psychiatry2000; 57: 601–607.
10.
10. Uncapher H, Arean PA., Physicians are less willing to treat suicidal ideation in older patients. J Am Geriatr Soc2000; 48: 188–192.
11.
11. Blazer DG, Hybels CF, Simonsick EM, et al., Marked differences in antidepressant use by race in an elderly community sample: 1986–1996. Am J Psychiatry2000; 157: 1089–1094.
12.
12. Roberts RE, Kaplan GA, Shema SJ, et al., Does growing old increase the risk for depression?Am J Psychiatry1997; 154: 1384–1390.
13.
13. Lacro JP, Jeste DV., Physical comorbidity and polypharmacy in older psychiatric patients. Biol Psychiatry1994; 36: 146–152.
14.
14. Friedhoff AJ., Consensus development conference statement: diagnosis and treatment of depression in late life. In: Schneider LS, Reynolds CF III, Lebowitz BD, et al, eds., Diagnosis and treatment of depression in late life. Results of the NIH consensus development conference. Washington, DC: American Psychiatric Press. 1992: 491–511.
15.
15. Norris JT, Gallagher D, Wilson A, et al., Assessment of depression in geriatric medical outpatients: the validity of two screening measures. J Am Geriatr Soc1987; 35: 989–995.
16.
16. Okimoto JT, Barnes RF, Veith RC, et al., Screening for depression in geriatric medical patients. Am J Psychiatry1982; 139: 799–802.
17.
17. Borson S, Barnes RA, Kukull WA, et al., Symptomatic depression in elderly medical outpatients. I. Prevalence, demography, and health service utilization. J Am Geriatr Soc1986; 34: 341–347.
18.
18. Koenig HG, Meador KG, Cohen HJ, et al., Depression in elderly hospitalized patients with medical illness. Arch Intern Med1988; 148: 1929–1936.
19.
19. Rapp SR, Parisi SA, Walsh DA, et al., Psychological dysfunction and physical health among elderly medical inpatients. J Consult Clin Psychol1988; 56: 851–855.
20.
20. Koenig HG, Meador KG, Shelp F, et al., Major depressive disorders in hospitalized medically ill patients: an examination of young and elderly male veterans. J Am Geriatr Soc1991; 39: 881–890.
21.
21. Katz IR, Beaston-Wimmer P, Parmelee PA, et al., Failure to thrive in the elderly: exploration of the concept and delineation of psychiatric components. J Geriatr Psychiatry Neurol1993; 6: 161–169.
22.
22. Swantek SS, Goldstein MZ., Age and gender differences of patients with hip fracture and depression. Psychiatr Serv2000; 51: 1501–1503.
23.
23. Forsen L, Meyer HE, Sogaard AJ, et al., Mental distress and risk of hip fracture. Do broken hearts lead to broken bones?J Epidemiol Community Health1999; 53: 343–347.
24.
24. Glassman AH, Shapiro PA., Depression and the course of coronary artery disease. Am J Psychiatry1998; 155: 4–11.
25.
25. Speck CE, Kukull WA, Brenner DE, et al., History of depression as a risk factor for Alzheimer's disease. Epidemiology1995; 6: 366–369.
26.
26. NIH Consensus Development Panel. Diagnosis and treatment of depression in late life. JAMA1992; 268: 1018–1024.
27.
27. Rapp SR, Walsh DA, Parisi SA, et al., Detecting depression in elderly medical inpatients. J Consult Clin Psychol1988; 56: 509–511.
28.
28. Koenig HG, Meador KM, Cohen HJ, et al., Detection and treatment of major depression in older medically ill hospitalized patients. Int J Psychiatry Med1988; 18: 17–31.
29.
29. Davidson JR, Meltzer-Brody SE., The underrecognition and undertreatment of depression: what is the breadth and depth of the problem?J Clin Psychiatry1999; 60(Suppl 7), 4–9.
30.
30. Callahan CM, Hendrie HC, Dittus RS, et al., Improving treatment of late life depression in primary care: a randomized clinical trial. J Am Geriatr Soc1994; 42: 839–846.
31.
31. Valenstein M, Kales H, Mellow A, et al., Psychiatric diagnosis and intervention in older and younger patients in a primary care clinic: effect of a screening and diagnostic instrument. J Am Geriatr Soc1998; 46: 1499–1505.
32.
32. Koenig HG, George LK, Meador KG., Use of antidepressants by nonpsychiatrists in the treatment of medically ill hospitalized depressed elderly patients. Am J Psychiatry1997; 154: 1369–1375.
33.
33. Koenig HG, Goli V, Shelp F, et al., Major depression in hospitalized medically ill older men: documentation, management and outcome. Int J Geriatr Psychiatry1992; 7: 25–34.
34.
34. Lyness JM, Bruce ML, Koenig HG, et al., Depression and medical illness in late life: report of a symposium. J Am Geriatr Soc1996; 44: 198–203.
35.
35. Koenig HG, Kuchibhatla M., Use of health services by medically ill depressed elderly patients after hospital discharge. Am J Geriatr Psychiatry1999; 7: 48–56.
36.
36. Fulop G, Strain J, Vita J, et al., Impact of psychiatric comorbidity on length of hospital stay for medical/surgical patients: a preliminary report. Am J Psychiatry1987; 144: 878–881.
37.
37. Koenig HG, Shelp F, Goli V, et al., Survival and health care utilization in elderly medical inpatients with major depression. J Am Geriatr Soc1989; 37: 599–606.
38.
38. Verbosky LA, Franco KN, Zrull JP., The relationship between depression and length of stay in the general hospital patient. J Clin Psychiatry1993; 54: 177–181.
39.
39. Mossey J, Knott K, Craik R., The effects of persistent depressive symptoms on hip fracture recovery. J Gerontol1990; 45: M163–M168.
40.
40. Parikh R, Robinson R, Lipsey J, et al., The impact of post-stroke depression on recovery in activities of daily living over a two-year follow-up. Arch Neurol1990; 47: 785–789.
41.
41. Katz IR., On the inseparability of mental and physical health in aged persons. Lessons from depression and medical comorbidity. Am J Geriatr Psychiatry1996; 4: 1–16.
42.
42. Koenig HG, Kuchibhatla M., Use of health services by hospitalized medically ill depressed elderly patients. Am J Psychiatry1998; 155: 871–877.
43.
43. Koenig HG, George LK, Larson DB, et al., Depressive symptoms and nine-year survival of 1,001 male veterans hospitalized with medical illness. Am J Geriatr Psychiatry1999; 7: 124–131.
44.
44. Wulsin LR, Vaillant GE, Wells VE., A systematic review of the mortality of depression. Psychosom Med1999; 61: 6–17.
45.
45. Parmelee PA, Katz IR, Lawton MP., Depression and mortality among institutionalized aged. J Gerontol1992; 47: 3–10.
46.
46. Frasure-Smith N, Lesperance F, Talajic M., Depression and 18-month prognosis after myocardial infarction. Circulation1995; 91: 999–1005.
47.
47. Morris PLP, Robinson RG, Andrzejewski P, et al., Association of depression with 10-year post-stroke mortality. Am J Psychiatry1993; 150: 124–129.
48.
48. Schulz R, Beach SR, Ives DG, et al., Association between depression and mortality in older adults: the Cardiovascular Health Study. Arch Intern Med2000; 160: 1761–1768.
49.
49. Druss BG, Bradford WD, Rosenheck RA, et al., Quality of medical care and excess mortality in older patients with mental disorders. Arch Gen Psychiatry2001; 58: 565–572.
50.
50. Schulberg HC, Bryce C, Chism K, et al., Managing late-life depression in primary care practice: a case study of the health specialist's role. Int J Geriatr Psychiatry2001; 16: 577–584.
51.
51. Lesperance F, Frasure-Smith N., The seduction of death. Psychosom Med1999; 61: 18–20.
52.
52. Alexopoulos GS, Meyers BS, Young RC, et al., ‘Vascular depression’ hypothesis. Arch Gen Psychiatry1997; 54: 915–922.
53.
53. Steffens DC, Krishnan KR., Structural neuroimaging and mood disorders: recent findings, implications for classification, and future directions. Biol Psychiatry1998; 43: 705–712.
54.
54. Simpson S, Baldwin RC, Jackson A, et al., Is subcortical disease associated with a poor response to antidepressants? Neurological, neuropsychological, and neuroradiological findings in late-life depression. Psychol Med1998; 28: 1015–1026.
55.
55. O'Brien J, Ames D, Chiu E, et al., Severe deep white matter lesions and outcome in elderly patients with major depressive disorder. BMJ1998; 317: 982–984.
56.
56. Simpson S, Jackson A, Baldwin RC, et al., Subcortical hyperintensities in late-life depression: acute response to treatment and neuropsychological impairment. Int Psychogeriatr1997; 9: 257–275.
57.
57. Hickie I, Scott E, Mitchell P, et al., Subcortical hyperintensities on magnetic resonance imaging: clinical correlates and prognostic significance in patients with severe depression. Biol Psychiatry1995; 37: 151–160.
58.
58. Ballard CG, Bannister C, Oyebode F., Depression in dementia sufferers. Int J Geriatr Psychiatry1996; 11: 507–515.
59.
59. Lyketsos CG, Steinberg M, Tschanz JT, et al., Mental and behavioral disturbances in dementia: findings from the Cache County study on memory in aging. Am J Psychiatry2000; 157: 708–714.
60.
60. Thorpe L, Groulx B., Depressive syndromes in dementia. Can J Neurol Sci2001; 28(Suppl 1): S83–S95.
61.
61. Kales HC, Blow FC, Roberts JS, et al., Dementia, depression and coexisting dementia and depression: detection of diagnoses and 12-month health care outcomes. Am J Geriatr Psychiatry2001; 9(Suppl 1): 72.
62.
62. Lyketsos CG, Sheppard JME, Steele CD, et al., Randomized, placebo-controlled double-blind clinical trial of sertraline in the treatment of depression complicating Alzheimer's disease: initial results from the depression in Alzheimer's disease study. Am J Psychiatry2000; 157: 1686–1689.
63.
63. Teri L, Gallagher-Thompson D., Cognitive-behavioral interventions for treatment of depression in Alzheimer's patients. Gerontologist1991; 31: 413–416.
64.
64. Kales HC, Blow FC, Copeland LA, et al., Health care utilization by older patients with coexisting dementia and depression. Am J Psychiatry1999; 156: 550–556.
65.
65. Steele C, Rovner B, Chase GA, et al., Psychiatric symptoms and nursing home placement of patients with Alzheimer's disease. Am J Psychiatry1990; 147: 1049–1051.
66.
66. Lyketsos CG, Sheppard JM, Rabins PV., Dementia in elderly persons in a general hospital. Am J Psychiatry2000; 157: 704–707.
67.
67. Draper B., The diagnosis and treatment of depression in dementia. Psychiatr Serv1999; 50: 1151–1153.
68.
68. Flint AJ, Rifat SL., Anxious depression in elderly patients: response to antidepressant treatment. Am J Geriatr Psychiatry1997; 5: 107–115.
69.
69. Alexopoulos GS., Anxiety and depression in the elderly. In: Salzman C, Lebowitz B, eds., Anxiety in the elderly: treatment and research. New York: Springer. 1991: 63–77.
70.
70. Blazer D, Hughes DC, Fowler N., Anxiety as an outcome symptom of depression in elderly and middle aged adults. Int J Geriatr Psychiatry1989; 4: 273–278.
71.
71. Copeland JRM, Davidson IA, Dewey ME., The prevalence and outcome of anxious depression in elderly people aged 65 and over living in the community. In: Racagni G, Smeraldi E, eds., Anxious depression: assessment and treatment. New York: Raven. 1987: 43–47.
72.
72. Ben-Arie O, Swartz L, Dickman BJ., Depression in the elderly living in the community: its presentation and features. Br J Psychiatry1987; 150: 169–174.
73.
73. Lenze EJ, Mulsant BH, Shear MK, et al., Comorbid anxiety disorders in depressed elderly patients. Am J Psychiatry2000; 157: 722–728.
74.
74. Gallo JJ, Rabins PV, Iliffe S., The ‘research magnificent’ in late life: psychiatric epidemiology and the primary health care of older adults. Int J Psychiatry Med1997; 27: 185–204.
75.
75. Girling DM, Huppert FA, Brayne C, et al., Depressive symptoms in the very elderly—their prevalence and significance. Int J Geriatr Psychiatry1995; 10: 497–504.
76.
76. Beekman ATF, de Beurs E, van Balkom AJLM, et al., Anxiety and depression in later life: co-occurrence and communality of risk factors. Am J Psychiatry2000; 157: 89–95.
77.
77. Birkmayer W, Neumayer E, Riederer P., Masked depression in old age. In: Kielholz P, ed., Masked depression. Bern: Hans Huber Publishers. 1973: 158–176.
78.
78. Ormel J, Van den Brink W, Koeter MWJ, et al., Recognition, management, and outcome of psychological disorders in primary care: a naturalistic follow-up study. Psychol Med1990; 20: 909–923.
79.
79. Tollefson GD, Souetre E, Thomander L, et al., Comorbid anxious signs and symptoms in major depression: impact on functional work capacity and comparative treatment outcomes. Int Clin Psychopharmacol1993; 8: 281–293.
80.
80. American Academy of Family Physicians. Facts about family practice. Kansas City: Technical Communication Services. 1996.
81.
81. Iliffe S., Medication review for older people in general practice. J R Soc Med1994; 87: 11–13.
82.
82. Roose SP, Glassman AH, Walsh BT, et al., Tricyclic nonresponders: phenomenology and treatment. Am J Psychiatry1986; 143: 345–348.
83.
83. Flint AJ, Rifat SL., Two-year outcome of elderly patients with anxious depression. Psychiatry Res1997; 66: 23–31.
84.
84. Gaynes BN, Magruder KM, Burns BJ, et al., Does a coexisting anxiety disorder predict persistence of depressive illness in primary care patients with major depression?Gen Hosp Psychiatry1999; 21: 158–167.
85.
85. Van Valkenburg C, Akiskal HS, Puzantian V, et al., Anxious depressions: clinical, family history and naturalistic outcome—comparisons with panic and major depressive disorders. J Affect Disord1984; 6: 67–82.
86.
86. Coryell W, Endicott J, Andreasen NC, et al., Depression and panic attacks: the significance of overlap as reflected in follow-up and family study data. Am J Psychiatry1988; 145: 293–300.
87.
87. Coryell W, Endicott J, Winokur G., Anxiety syndromes as epiphenomena of primary major depression: outcomes and familial psychopathology. Am J Psychiatry1992; 149: 100–107.
88.
88. Clayton PJ, Grove WM, Coryell W, et al., Follow-up and family study of anxious depression. Am J Psychiatry1991; 148: 1512–1517.
89.
89. Adebimpe VR, Hedlund JL, Cho DW, et al., Symptomatology of depression in black and white patients. J Natl Med Assoc1982; 74: 185–190.
90.
90. Strakowski SM, Lonczak HS, Sax KW, et al., The effects of race on diagnosis and disposition from a psychiatric emergency service. J Clin Psychiatry1995; 56: 101–107.
91.
91. Jones BE, Gray BA., Problems in diagnosing schizophrenia and affective disorders among blacks. Hosp Community Psychiatry1986; 37: 61–65.
92.
92. Strakowski SM, Shelton RC, Kolbrener ML., The effects of race and comorbidity on clinical diagnosis in patients with psychosis. J Clin Psychiatry1993; 54: 96–102.
93.
93. Flaskerud JH, Hu L., Relationship of ethnicity to psychiatric diagnosis. J Nerv Ment Disord1992; 180: 296–303.
94.
94. Bell CC, Mehta H., The misdiagnosis of black patients with manic-depressive illness. J Natl Med Assoc1980; 72: 141–145.
95.
95. Fabrega H, Mezzich J, Ulrich RF., Black-white differences in psychopathology in an urban psychiatric population. Compr Psychiatry1988; 29: 285–297.
96.
96. Adebimpe VR., Race, racism, and epidemiological surveys. Hosp Community Psychiatry1994; 45: 27–31.
97.
97. Strakowski SM, McElroy SL, Keck PE, et al., Racial influence on diagnosis in psychotic mania. J Affect Disord1996; 39: 157–162.
98.
98. Brown C, Schulberg HC, Madonia MJ., Clinical presentations of major depression by African Americans and whites in primary care medical practice. J Affect Disord1996; 41: 181–191.
99.
99. Simon RJ, Fleiss JL, Gurland BJ, et al., Depression and schizophrenia in hospitalized black and white mental patients. Arch Gen Psychiatry1973; 28: 509–512.
100.
100. Mukherjee S, Shukla S, Woodle J, et al., Misdiagnosis of schizophrenia in bipolar patients: a multi-ethnic comparison. Am J Psychiatry1983; 140: 1561–1574.
101.
101. Mulsant BH, Stergiou A, Keshavan MS, et al., Schizophrenia in late life: elderly patients admitted to an acute-care psychiatric hospital. Schizophr Bull1993; 19: 709–721.
102.
102. Fabrega H, Mulsant BH, Rifai AH, et al., Ethnicity and psychopathology in an aging hospital-based population. J Nerv Ment Dis1994; 182: 136–144.
103.
103. Leo RJ, Narayan DA, Sherry C, et al., Geropsychiatric consultation for African Americans and Caucasian patients. Gen Hosp Psychiatry1997; 19: 216–222.
104.
104. Koenig HG, Meador KG, Goli V, et al., Self-rated depressive symptoms in medical inpatients: age and racial differences. Int J Psychiatry Med1992; 22: 11–31.
105.
105. Coleman D, Baker FM., Misdiagnosis of schizophrenia among older, black veterans. J Nerv Ment Dis1994; 182: 527–528.
106.
106. Baker FM., Misdiagnosis among older psychiatric patients. J Natl Med Assoc1995; 87: 872–876.
107.
107. Husaini BA, Moore ST., Arthritis disability, depression, and life satisfaction among black elderly people. Health Soc Work1990; 25: 253–260.
108.
108. Delehanty SG, Dimsdale JE, Mills P., Psychosocial correlates of reactivity in black and white men. J Psychosom Res1991; 35: 451–460.
109.
109. Blazer DG, Landerman LR, Hays JC, et al., Symptoms of depression among community-dwelling elderly African-American and white older adults. Psychol Med1998; 28: 1311–1320.
110.
110. Bazargan M, Bazargan S, King L., Paranoid ideation among elderly African American persons. Gerontologist2001; 41: 366–373.
111.
111. Kales HC, Blow FC, Bingham CR, et al., Race and inpatient psychiatric diagnoses among elderly veterans. Psychiatr Serv2000; 51: 795–800.
112.
112. Sirey JA, Meyers BS, Bruce ML, et al., Predictors of antidepressant prescription and early use among depressed outpatients. Am J Psychiatry1999; 156: 690–696.
113.
113. Zubenko GS, Mulsant BH, Rifai AH, et al., Impact of acute psychiatric inpatient treatment on major depression in late life and prediction of response. Am J Psychiatry1994; 151: 987–994.
114.
114. Neighbors HW, Jackson JS., The use of informal and formal help: four patterns of illness behavior in the black community. Am J Community Psychol1984; 12: 629–644.
115.
115. Kales HC, Blow FC, Bingham CR, et al., Race, psychiatric diagnosis, and mental health care utilization in older patients. Am J Geriatr Psychiatry2000; 8: 301–309.
116.
116. Cooper-Patrick L, Powe NR, Jenckes MW, et al., Identification of patient attitudes and preferences regarding the treatment of depression. J Gen Intern Med1997; 12: 431–438.
