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Unmet needs in the diagnosis and treatment of mood disorders in later life
EDITORIAL Unmet Needs in the Diagnosis and Treatment of Mood Disorders in Later Life Introduction
M
ood disorders in later life are now recognized as a major public health problem. Depression is prevalent, persistent, disabling, and sometimes fatal, entailing the highest rates of suicide in the United States. At the same time, substantial progress has been made in the treatment of elderly people with mood disorders, especially major depression. The availability of good depression treatment services for the elderly is limited, however, and reimbursement for such services is inadequate. In October 2001, the National Depressive and Manic Depressive Association (National DMDA) convened a consensus development panel to review progress over the past decade in late life mood disorders. Participants reviewed the literature on risk factors, assessment, treatment, and services. Papers prepared by participants, published in this issue of Biological Psychiatry, offer impressive testimony to the progress of the field since the 1991 NIH Consensus Development Conference on the Diagnosis and Treatment of Late Life Depression (proceedings of which were published in the Journal of the American Medical Association in August, 1992), but also underscore that much remains to be done, both in research and in the improved delivery of mental health services to the nation’s elderly. The bridge between the science of old age depression, and the service of those who suffer from it, is not yet strong.
Risk Factors A number of biological risk factors have been identified for unipolar and bipolar mood disorders in old age, including genetic factors and medical illnesses, particularly vascular diseases. As reviewed by Krishnan (2002), most of these risk factors have been identified in crosssectional rather than longitudinal studies; hence, there is a need for long term epidemiologic and prevention studies (in the case of modifiable risk factors) to demonstrate conclusively that these are biological risk factors. There is also an important psychosocial substrate in old age depression, as reviewed by Bruce (2002). Severe life events and/or ongoing stressors, including spousal bereavement, care-giving burden, and loss of independence occasioned by medical illness, are among the best established psychosocial risk factors for depression in old age. Further research is needed into the roles of these risk factors in the onset and offset of depression in the elderly. © 2002 Society of Biological Psychiatry
For example, social isolation may mediate the impact of medical illness and dependency on depression, while coping skills may moderate or influence the strength of the relationship between spousal loss and depression. Understanding these pathways may help to identify appropriate targets for psychosocial intervention, or combined psychotherapeutic and somatic intervention. Suicide rates are higher in later life than in any other age group, especially among older white males. Conwell et al’s review (2002) of prospective cohort and retrospective case control studies indicates that affective disorder is a powerful independent risk factor for suicide in the elderly. Social ties and their disruption are also significantly and independently associated with risk for suicide in later life. An important question raised by this review is whether good depression treatment in the elderly will reduce the rate of suicide; or whether more specific treatments focused on suicidality per se will be necessary. In addition to suicide, there is substantial other mortality linked to depression and its attendant medical and psychosocial comorbidities, for example, in post-MI and post-CVA patients and in those who become depressed in the wake of care giving (Schulz et al 2002). Overall, depression appears to double the risk of mortality in these and like medical conditions. Comorbid psychiatric disorders in late life depression include alcohol abuse (in about a third), anxiety disorders (also in a third), and personality disorders (especially avoidant and dependent types). Overall, however, because the research database on comorbid psychiatric disorders in major and nonmajor depressions in older age is sparse; and because comorbid psychiatric disorders affect clinical course and prognosis and may worsen disability in late life depression, considerably more research is needed (Devanand 2002). In addition, as reviewed by Lyketsos and Olin (2002), depression is one of the most frequent psychiatric complications of Alzheimers disease, affecting as many as 50% of patients and having adverse consequences for patients and their families. Areas recommended for further research include the nosology of depression in AD, its natural history and course, the relationship between depression and associated excess disability, etiology, and treatment.
Assessment of Depression in Old Age Diagnostic and nosologic challenges intrinsic to late life depression include the impact of co-existing medical and 0006-3223/02/$22.00 PII S0006-3223(02)01464-6
146
BIOL PSYCHIATRY 2002;52:145–147
cognitive disorders and their interference with symptom and syndrome ascertainment. Nonetheless, as argued by Alexopoulos and colleagues (2002), we need improved characterization of depressive syndromes contributed by specific medical disorders to improve effective strategies for prevention and treatment. Depression care managers, working with primary care physicians, can improve the recognition and treatment of depressed elderly through training in the use of validated instruments and treatment algorithms. As emphasized by Schwenk (2002), additional challenges to the diagnosis of depression in primary care elderly patients include the fact that depression does not compete well for patient and family time and energy with other medical problems and medical comorbidity. In fact, primary care patients may be more comfortable with and accepting of depression being framed as an expectable chronic disease, rather than as a psychiatric brain disease associated with cultural and generational stigma. In this context, Charlson and Peterson (2002) highlight the need for further research into the relationships between depression and other chronic medical disorders, especially in reference to disability, mortality, and treatment responsivity.
C.F. Reynolds and D.S. Charney
Mental Health Services for Older Depressed Patients Notwithstanding the advances over the past decade in both the somatic and psychosocial, as well as combined, treatment approaches to mood disorders in old age, there remain major challenges and obstacles to disseminating best treatment practices. We know what to do, but we don’t know how to get it done and how to get it paid for. Schwenk (2002) emphasizes the need for new approaches to collaborative care, including telephone monitoring, nurse clinician outreach, and improved availability of mental health consultation in primary care. Unutzer (2002) strikes a similar theme, noting that in primary care geriatric medicine, the chronic and recurrent nature of depression in old age and a number of patient, provider, and policy-related barriers interfere with effective depression treatment. In his view, a view which was widely shared by conference participants, improved care of the depressed elderly patient will require education and engagement of older patients and their primary care physicians, additional human resources to proactively manage depression as a chronic illness in old age, training of mental health professionals to effectively collaborate with primary care colleagues, and improved reimbursement of mental health services in later life.
Treatment of Depression in Old Age The comprehensive review by Salzman and colleagues (2002), demonstrates that antidepressants and electroconvulsive therapy are effective and safe treatments for elderly patients; and that differences in efficacy and side effects appear to be slight among the various types of antidepressants. Additional controlled clinical trials enrolling very old patients and frail elderly are still needed. The scholarly review by Area´ n and Cook (2002), of psychosocial treatments indicates that cognitive behavioral therapy and interpersonal psychotherapy (combined with antidepressant medication) have the largest database of evidence in support of their efficacy for the treatment of depression in later life. Additional needed research includes early preventive intervention in poststroke depression and similar medical situations (Whyte and Mulsant 2002), as well as the pressing need for controlled scientific evidence for the optimal management of bipolar disorders in later life. As emphasized by Scolnick’s (2002) long term perspective, the science and development challenges for the discovery and development of new medicines for treating depression in old age are complex. Nonetheless, because the science of understanding the brain is expanding at a rapid rate, the time is ripe for a serious war on mental illness, like the war on cancer of the 1970s.
Summary: the Five Ds of Depression in Old Age Treatment works, but mood disorders in old age remain a big public health issue. Disability, decline, diminished quality of life, demands on care givers (both lay and professional) and discriminatory reimbursement policies are the five Ds of depression in old age. If we are to bridge science and service, partnerships among researchers, clinicians, governmental agencies, third party payers, patients, and family members will be essential to further progress in the next 10 years. Otherwise, during this time, the contribution of depression to the global burden of illness related disability will continue its inexorable increase, particularly in the developed economies with their growing population of older people. Charles F. Reynolds, III University of Pittsburgh Medical Center Western Psychiatric Institute and Clinic 3811 O’Hara Street Pittsburgh, PA 15213 Dennis S. Charney National Institute of Mental Health Bethesda, MD
Editorial
References Alexopoulos GS, Borson S, Cuthbert BN, Devanand DP, Mulsant BH, Olin HT, Oslin D (2002): Assessment of late life depression. Biol Psychiatry 52:164 –174. Anonymous (1992): NIH consensus conference. Diagnosis and treatment of depression in late life. JAMA 268:1018 –1024. Area´ n PA, Cook BL (2002): Psychotherapy and combined psychotherapy/pharmacotherapy for late life depression. Biol Psychiatry 52:290 –300. Bruce ML (2002): Psychosocial risk factors for depressive disorders in late life. Biol Psychiatry 52:175–184. Charlson M, Peterson JC (2002): Medical comorbidity and late life depression: What is known and what are the unmet needs? Biol Psychiatry 52:226 –235. Conwell Y, Duberstein PR, Caine ED (2002): Risk factors for suicide in later life. Biol Psychiatry 52:193–204. Devanand DP (2002): Comorbid psychiatric disorders in late life depression. Biol Psychiatry 52:236 –242.
BIOL PSYCHIATRY 2002;52:145–147
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Krishnan KRR (2002): Biological risk factors in late life depression. Biol Psychiatry 52:185–192. Lyketsos CG, Olin J (2002): Depression in Alzheimer’s disease: Overview and treatment. Biol Psychiatry 52:243–252. Salzman C, Wong E, Wright BC (2002): Drug and ECT treatment of depression in the elderly, 1996 –2001: A literature review. Biol Psychiatry 52:264 –281. Schulz R, Drayer RA, Rollman BL (2002): Depression as a risk factor for non-suicide mortality in the elderly. Biol Psychiatry 52:205–225. Schwenk TL (2002): Diagnosis of late life depression: The view from primary care. Biol Psychiatry 52:157–163. Scolnick E (2002): Discovery and development of antidepressants: A perspective from a pharmaceutical discovery company. Biol Psychiatry 52:154 –156. Unu¨ tzer J (2002): Diagnosis and treatment of older adults with depression in primary care. Biol Psychiatry 52:282–289. Whyte EM, Mulsant BH (2002): Post-stroke depression: Epidemiology, pathophysiology, and biological treatment. Biol Psychiatry 52:253–263.
M
ood disorders in later life are now recognized as a major public health problem. Depression is prevalent, persistent, disabling, and sometimes fatal, entailing the highest rates of suicide in the United States. At the same time, substantial progress has been made in the treatment of elderly people with mood disorders, especially major depression. The availability of good depression treatment services for the elderly is limited, however, and reimbursement for such services is inadequate. In October 2001, the National Depressive and Manic Depressive Association (National DMDA) convened a consensus development panel to review progress over the past decade in late life mood disorders. Participants reviewed the literature on risk factors, assessment, treatment, and services. Papers prepared by participants, published in this issue of Biological Psychiatry, offer impressive testimony to the progress of the field since the 1991 NIH Consensus Development Conference on the Diagnosis and Treatment of Late Life Depression (proceedings of which were published in the Journal of the American Medical Association in August, 1992), but also underscore that much remains to be done, both in research and in the improved delivery of mental health services to the nation’s elderly. The bridge between the science of old age depression, and the service of those who suffer from it, is not yet strong.
Risk Factors A number of biological risk factors have been identified for unipolar and bipolar mood disorders in old age, including genetic factors and medical illnesses, particularly vascular diseases. As reviewed by Krishnan (2002), most of these risk factors have been identified in crosssectional rather than longitudinal studies; hence, there is a need for long term epidemiologic and prevention studies (in the case of modifiable risk factors) to demonstrate conclusively that these are biological risk factors. There is also an important psychosocial substrate in old age depression, as reviewed by Bruce (2002). Severe life events and/or ongoing stressors, including spousal bereavement, care-giving burden, and loss of independence occasioned by medical illness, are among the best established psychosocial risk factors for depression in old age. Further research is needed into the roles of these risk factors in the onset and offset of depression in the elderly. © 2002 Society of Biological Psychiatry
For example, social isolation may mediate the impact of medical illness and dependency on depression, while coping skills may moderate or influence the strength of the relationship between spousal loss and depression. Understanding these pathways may help to identify appropriate targets for psychosocial intervention, or combined psychotherapeutic and somatic intervention. Suicide rates are higher in later life than in any other age group, especially among older white males. Conwell et al’s review (2002) of prospective cohort and retrospective case control studies indicates that affective disorder is a powerful independent risk factor for suicide in the elderly. Social ties and their disruption are also significantly and independently associated with risk for suicide in later life. An important question raised by this review is whether good depression treatment in the elderly will reduce the rate of suicide; or whether more specific treatments focused on suicidality per se will be necessary. In addition to suicide, there is substantial other mortality linked to depression and its attendant medical and psychosocial comorbidities, for example, in post-MI and post-CVA patients and in those who become depressed in the wake of care giving (Schulz et al 2002). Overall, depression appears to double the risk of mortality in these and like medical conditions. Comorbid psychiatric disorders in late life depression include alcohol abuse (in about a third), anxiety disorders (also in a third), and personality disorders (especially avoidant and dependent types). Overall, however, because the research database on comorbid psychiatric disorders in major and nonmajor depressions in older age is sparse; and because comorbid psychiatric disorders affect clinical course and prognosis and may worsen disability in late life depression, considerably more research is needed (Devanand 2002). In addition, as reviewed by Lyketsos and Olin (2002), depression is one of the most frequent psychiatric complications of Alzheimers disease, affecting as many as 50% of patients and having adverse consequences for patients and their families. Areas recommended for further research include the nosology of depression in AD, its natural history and course, the relationship between depression and associated excess disability, etiology, and treatment.
Assessment of Depression in Old Age Diagnostic and nosologic challenges intrinsic to late life depression include the impact of co-existing medical and 0006-3223/02/$22.00 PII S0006-3223(02)01464-6
146
BIOL PSYCHIATRY 2002;52:145–147
cognitive disorders and their interference with symptom and syndrome ascertainment. Nonetheless, as argued by Alexopoulos and colleagues (2002), we need improved characterization of depressive syndromes contributed by specific medical disorders to improve effective strategies for prevention and treatment. Depression care managers, working with primary care physicians, can improve the recognition and treatment of depressed elderly through training in the use of validated instruments and treatment algorithms. As emphasized by Schwenk (2002), additional challenges to the diagnosis of depression in primary care elderly patients include the fact that depression does not compete well for patient and family time and energy with other medical problems and medical comorbidity. In fact, primary care patients may be more comfortable with and accepting of depression being framed as an expectable chronic disease, rather than as a psychiatric brain disease associated with cultural and generational stigma. In this context, Charlson and Peterson (2002) highlight the need for further research into the relationships between depression and other chronic medical disorders, especially in reference to disability, mortality, and treatment responsivity.
C.F. Reynolds and D.S. Charney
Mental Health Services for Older Depressed Patients Notwithstanding the advances over the past decade in both the somatic and psychosocial, as well as combined, treatment approaches to mood disorders in old age, there remain major challenges and obstacles to disseminating best treatment practices. We know what to do, but we don’t know how to get it done and how to get it paid for. Schwenk (2002) emphasizes the need for new approaches to collaborative care, including telephone monitoring, nurse clinician outreach, and improved availability of mental health consultation in primary care. Unutzer (2002) strikes a similar theme, noting that in primary care geriatric medicine, the chronic and recurrent nature of depression in old age and a number of patient, provider, and policy-related barriers interfere with effective depression treatment. In his view, a view which was widely shared by conference participants, improved care of the depressed elderly patient will require education and engagement of older patients and their primary care physicians, additional human resources to proactively manage depression as a chronic illness in old age, training of mental health professionals to effectively collaborate with primary care colleagues, and improved reimbursement of mental health services in later life.
Treatment of Depression in Old Age The comprehensive review by Salzman and colleagues (2002), demonstrates that antidepressants and electroconvulsive therapy are effective and safe treatments for elderly patients; and that differences in efficacy and side effects appear to be slight among the various types of antidepressants. Additional controlled clinical trials enrolling very old patients and frail elderly are still needed. The scholarly review by Area´ n and Cook (2002), of psychosocial treatments indicates that cognitive behavioral therapy and interpersonal psychotherapy (combined with antidepressant medication) have the largest database of evidence in support of their efficacy for the treatment of depression in later life. Additional needed research includes early preventive intervention in poststroke depression and similar medical situations (Whyte and Mulsant 2002), as well as the pressing need for controlled scientific evidence for the optimal management of bipolar disorders in later life. As emphasized by Scolnick’s (2002) long term perspective, the science and development challenges for the discovery and development of new medicines for treating depression in old age are complex. Nonetheless, because the science of understanding the brain is expanding at a rapid rate, the time is ripe for a serious war on mental illness, like the war on cancer of the 1970s.
Summary: the Five Ds of Depression in Old Age Treatment works, but mood disorders in old age remain a big public health issue. Disability, decline, diminished quality of life, demands on care givers (both lay and professional) and discriminatory reimbursement policies are the five Ds of depression in old age. If we are to bridge science and service, partnerships among researchers, clinicians, governmental agencies, third party payers, patients, and family members will be essential to further progress in the next 10 years. Otherwise, during this time, the contribution of depression to the global burden of illness related disability will continue its inexorable increase, particularly in the developed economies with their growing population of older people. Charles F. Reynolds, III University of Pittsburgh Medical Center Western Psychiatric Institute and Clinic 3811 O’Hara Street Pittsburgh, PA 15213 Dennis S. Charney National Institute of Mental Health Bethesda, MD
Editorial
References Alexopoulos GS, Borson S, Cuthbert BN, Devanand DP, Mulsant BH, Olin HT, Oslin D (2002): Assessment of late life depression. Biol Psychiatry 52:164 –174. Anonymous (1992): NIH consensus conference. Diagnosis and treatment of depression in late life. JAMA 268:1018 –1024. Area´ n PA, Cook BL (2002): Psychotherapy and combined psychotherapy/pharmacotherapy for late life depression. Biol Psychiatry 52:290 –300. Bruce ML (2002): Psychosocial risk factors for depressive disorders in late life. Biol Psychiatry 52:175–184. Charlson M, Peterson JC (2002): Medical comorbidity and late life depression: What is known and what are the unmet needs? Biol Psychiatry 52:226 –235. Conwell Y, Duberstein PR, Caine ED (2002): Risk factors for suicide in later life. Biol Psychiatry 52:193–204. Devanand DP (2002): Comorbid psychiatric disorders in late life depression. Biol Psychiatry 52:236 –242.
BIOL PSYCHIATRY 2002;52:145–147
147
Krishnan KRR (2002): Biological risk factors in late life depression. Biol Psychiatry 52:185–192. Lyketsos CG, Olin J (2002): Depression in Alzheimer’s disease: Overview and treatment. Biol Psychiatry 52:243–252. Salzman C, Wong E, Wright BC (2002): Drug and ECT treatment of depression in the elderly, 1996 –2001: A literature review. Biol Psychiatry 52:264 –281. Schulz R, Drayer RA, Rollman BL (2002): Depression as a risk factor for non-suicide mortality in the elderly. Biol Psychiatry 52:205–225. Schwenk TL (2002): Diagnosis of late life depression: The view from primary care. Biol Psychiatry 52:157–163. Scolnick E (2002): Discovery and development of antidepressants: A perspective from a pharmaceutical discovery company. Biol Psychiatry 52:154 –156. Unu¨ tzer J (2002): Diagnosis and treatment of older adults with depression in primary care. Biol Psychiatry 52:282–289. Whyte EM, Mulsant BH (2002): Post-stroke depression: Epidemiology, pathophysiology, and biological treatment. Biol Psychiatry 52:253–263.