Mood Disorders in Late Life
Abstract and Keywords
This chapter discusses how clinicians will need to prepare for a worldwide exponentially growing aging community by describing the current scope of practices with respect to the assessment and treatment mood disorders, including minor and major depression. Particularly for those in later life, the meaningful interpretation of standardized assessment scores requires consideration of medical and neurological complexities. Clinicians must be flexible not only with respect to characterization, but especially with respect to treatment, given the inherent challenges associated with access to care and the range of disability amongst these individuals. Indeed, these late-life individuals are typically assessed in a similar fashion to younger adults (which may obscure meaningful interpretations), making understanding the nuances underlying existing behavioral and pharmaceutical approaches an essential endeavor.
According to the World Health Organization (WHO), because of improved health care and the management of acute illness, the proportion of people age 65 and over is exceeding the growth of every other age cohort (Stanziano, Whitehurst, Graham, & Roos, 2010). In particular, the number of people living past the age of 80 will quadruple in 2050, and low- and middle-income countries will experience the most rapid increase in the aging population (WHO, 2013b). This growth in the geriatric population brings an increased need for clinicians trained in the specifics of geriatric medicine. However, a recent Institute on Medicine (IOM) report indicates that the rate of geriatrics-prepared clinicians is not keeping pace with the population growth (IOM, 2011), especially in the mental health arena (IOM, 2012). The shortage of geriatrics-prepared clinicians in mental health is a problem; for instance, depressive disorders are emerging as a leading cause of disability for older adults, second only to heart disease (Chapman & Perry, 2008) and are known to be the third leading contributor to the global disease burden, surpassing the psychotic disorders and dementia (Collins & Swartz, 2011). The dearth of professionals trained to work with older adults, combined with the growth in this population, places considerable burden on primary care providers to identify and treat late-life mood disorders. The purpose of this chapter is to provide generalists with an overview of mood disorders in late life, with a focus on how these disorders present in older populations, subcategories unique to older adults, and the treatment options for older adults.
Late-Life Geriatrics Defined
Researchers and health clinicians have historically considered the terms geriatrics and late life to apply to anyone over the age of 65. The origins of this definition come from the advent of socialized medicine and pensions. In an attempt to determine a cost-effective retirement age, in 1876, the United Kingdom selected 65 to be the age at which the population could collect pension and (p. 300) health benefits, owing to the fact that, at the time, very few people lived past that age (WHO, 2013a). This definition has recently come under some scrutiny regarding its utility in informing health care. In developed countries, people are living well into their 90s, and those who are 65 now are, as a group, considerably healthier than 65-year-olds were 40 years ago. A 65-year-old in developed countries is not physically or functionally the same as a 90-year-old, and assessment and treatment of mood disorders can sometimes be very different between 65–75-year-olds and 80–90-year-olds. In our review of the late-life depression literature, we have kept in mind these important differences regarding older adults. As practitioners working with older adults, it is likewise important to be aware of these differences.
Epidemiology of Mood Disorders in Late Life
In this section, we will review the current rates of major depression, dysthymia, and minor depression, and further discuss mood disorders specific to late life; namely, vascular depression and mood disorders in dementia. Mood disorders in medically ill populations are covered in Chapter 30 of this book.
Recent studies on the incidence of mood disorders in late life are scarce. One study found that the incidence of major depression in people 65 and older was less than 1%, though recurrence was much higher, with 3% experiencing a second major depression episode in late life; most late-life depression occurred in those with a history of depression in their earlier years (Luijendijk et al., 2008). The incidence of clinically significant depressive symptoms (including both dysthymia and minor depression) was 10% (Buchtemann, Luppa, Bramesfeld, & Riedel-Heller, 2012).
As was found in older epidemiological studies, the point prevalence of all mood disorders declines with age. Of those aged 65 and older, 1.6% suffer from major depression, and 5.2% from minor depression. Data from the National Comorbidity Survey Replication (Byers, Yaffe, Covinsky, Friedman, & Bruce, 2010) demonstrated a statistically reliable decline in the rate of depression with advancing age. Lowered prevalence may reflect, in part, selective mortality in which vulnerable depressed individuals die before reaching older age, or discomfort with admitting to having psychiatric symptoms. At least 6% of older primary care patients meet criteria for major depression, and another 6% have minor depression or dysthymia (O’Connor & Parslow, 2010).
Mood Disorders Specific to Late Life
Vascular depression is a subtype of major depression occurring only in late life, distinguished by white matter changes on magnetic resonance images (MRIs) of the brain, and poor performance on measures of cognitive control (Alexopoulos, Kiosses, Klimstra, Kalayam, & Bruce, 2002). It is estimated that 50% of older adults with major depression have vascular depression (Krishnan, Hays, George, & Blazer, 1998), and they are also more likely to have other vascular illnesses such as heart disease or diabetes. This subtype is also known to show a poor response to selective serotonin reuptake inhibitor (SSRI) medications (Alexopoulos et al., 2000) but to be quite responsive to behavioral interventions that target executive dysfunction (Arean et al., 2010).
Affective syndrome of Alzheimer’s disease:
Depression in the context of dementia is complicated. Depression can be a risk factor for dementia, is also a symptom of dementia, and is commonly co-occurring with dementia. Affective syndrome of dementia is characterized by apathy, the most common symptom, occurring in 60% of participants—followed by depressed mood, agitation, aggression, and irritability (Lyketsos, 2010).
Impact of mood disorders in late life:
Even though mood disorders are less common as we age, the consequences of these disorders in late life are devastating. Late-life depression (LLD) is a debilitating illness that is associated with increased healthcare costs, morbidity, and mortality. Depression puts older adults at high risk for suicide (Charney et al., 2003), with older adults being more likely to complete a suicide than any other age group (Conwell, Duberstein, & Caine, 2002). Recent studies have demonstrated that treating late-life mood disorders can offset the impact of the disorder, in particular among those who respond positively to treatment. Older adults who responded to depression treatment lived five years longer (Gallo et al., 2007) and had fewer all-cause health costs (Unutzer et al., 2008) in the five years after treatment response than those who did not respond to treatment.
The diagnostic criteria for major depression, dysthymia, and minor depression are the same for (p. 301) 65-year-olds as they are for 35-year-olds. However, older adults often suffer from a number of chronic illnesses and are susceptible to neurological conditions that complicate the diagnostic process. Often, a neurological and medical workup will be needed to support a diagnostic decision. Specialists in geriatric mental health often follow a team approach to care, and any assessment will include a medical workup and, in some cases, a neurological and neuropsychological assessment. Specialist clinics, such as the Mayo Clinic and the UCLA Geriatric Psychiatry Clinic, use a combination of medical and neurological evaluation, psychiatric evaluation, and family and collateral interviews before finalizing a diagnosis and prescribing a treatment plan. This multifaceted approach to psychiatric assessment is particularly beneficial in geriatric mental health.
Diagnostic and screening tools:
The assessment tools used for older adults are the same as those used in younger adults. For depression, instruments like the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) and the nine-item Patient Health Questionnaire (PHQ; Diez-Quevedo, Rangil, Sanchez-Planell, Kroenke, & Spitzer, 2001) are effective measures of depression in late life. The Geriatric Depression Scale (GDS; Yesavage et al., 1982) is also an effective, geriatric-specific depression tool. The most widely used instruments are the Folstein Mini-Mental Status Exam (MMSE; Cockrell & Folstein, 1988) and the Montreal Cognitive Assessment (MOCA; Dong et al., 2010). These tools are useful in clarifying whether or not memory complaints in older people with depression are a function of a disturbance in concentration (a symptom of depression) or disturbance in memory encoding (a symptom of dementia). These tools are merely cognitive screens and should not be used to make a diagnosis of dementia without a thorough medical and neurological workup.
Mood assessment in dementia:
Assessment of mood disturbance in people with moderate to severe dementia is complicated and will require reliance on observation of behavior and reports from caregivers and other collateral informants. Two mood scales are useful for detecting mood disorders in those with cognitive impairments: the Cornell Scale for Depression (Amuk, Karadag, Oguzhanoglu, & Oguzhanoglu, 2003) and the Dementia Mood Assessment (Onega & Abraham, 1997). These scales are completed in an interview format with caregivers who know the patient very well and can describe changes in the patient’s behavior accurately.
Treatment of Mood Disorders in Late Life
As is true for assessment of late-life mood disorders, treatment approaches do not differ for the older adult, except in the case when medical and neurological conditions interfere with the effects of treatment. Both medication management and psychotherapy are effective, first-line treatments for late-life depression that require very little in the way of age-related modifications. Because the interventions for older adults are almost identical to the interventions used for younger adults, we will not go into detail about the mechanisms of change and therapeutic specifics, as those are covered well in Section VIII of this book. However, we will discuss the issues clinicians need to keep in mind when using psychiatric medications and psychotherapy with older adults, with particular attention paid to circumstances in which geriatric physiology, disability, and cognitive impairment are present.
Despite the considerable stigma associated with mental illness among older populations, older adults uniformly prefer psychotherapy to medication management when surveyed for treatment preferences. Even when each intervention is presented in a favorable light, the tendency is for 50–75% of older adults to select psychotherapy (Gum et al., 2010). There is little information to explain this phenomenon. Most speculate that the preference for psychotherapy has to do with an older person not wanting to take another pill. Others speculate that stated preferences on a survey do not always match actual choices made; as an example, in a large national study of depression treatment in older adults, 50% of the sample indicated a preference for psychotherapy, yet only 20% selected psychotherapy when they began the study.
Although research on psychotherapy for late-life bipolar disorder and dysthymia has not been conducted, numerous studies show that psychotherapy is effective in treating late-life major depression and minor depression (Mackin & Arean, 2005). Therefore, we focus this section on treatment of late-life depression. The evidenced-based psychotherapies for late-life depression are cognitive behavioral therapy (CBT), problem solving therapy (PST), and interpersonal therapy (IPT). While other treatment approaches, such as Life Review, have been researched, the evidence base for these treatments is limited and therefore will not be discussed here.
(p. 302) Cognitive-behavioral therapies:
(CBT; see also Chapter 35). In the following discussion, we address the specific considerations for the use of medications with older adults (see Chapter 33 for coverage of antidepressants in general adult populations). CBT is one of the most widely studied interventions for late-life depression (cf. Areán & Cook, 2002). CBT strategies in late-life depression do not differ from CBT in younger adults; behavioral techniques such as scheduling pleasant activities and cognitive restructuring are effective for older adults. The difference between doing CBT with an older adult and with a younger adult has more to do with the focus of therapy. Older adults are more likely than younger adults to focus on problems related to health, loneliness, and having societal value. Additionally, older adults also have life complications and problems that are distinct from those of younger adults and can be difficult to cope with. Caring for a spouse with dementia and not being able to find a viable job in a market that favors very young employees are common complaints that have a strong basis in reality. Therefore, the addition of mindfulness techniques may be particularly helpful in these types of painful, unchangeable situations (Segal, Williams, & Teasdale, 2002).
The emphasis on between-session assignments may present a challenge for older adults with memory complaints. Strategies to assist older adults in remembering these action plans include simplifying the action plans, developing a combined calendar and therapy notebook, and recording sessions for later review and better learning consolidation. Behavioral activation may be less challenging than cognitive restructuring for many older patients.
(IPT; see also Chapter 38). Interpersonal therapy is an empirically supported treatment for older adults with depression (Areán & Cook, 2002). IPT in older adults is associated with less dropout than is antidepressant treatment (Schneider, Sloane, Staples, & Bender, 1986). A majority of the larger clinical trials of IPT for late-life depression has integrated IPT with either medication management or pill placebo. Reynolds et al. (1999) found that IPT, in combination with nortriptyline, was effective in the treatment of initial and subsequent episodes of major depression, as well as in the maintenance of remission. However, among those with chronic or recurrent depression, maintenance IPT was not as effective as nortriptyline alone.
Like CBT, IPT in older adults is very similar to IPT in younger adults, with the main difference between age groups again being the focus of treatment. As is described in Chapter 38, interpersonal problems fall into these four categories: (a) grief, (b) interpersonal role disputes, (c) role transitions, and (d) interpersonal deficits. IPT with older adults tends to focus more commonly on grief (e.g., the loss of a loved one) and role transitions (e.g., retirement, Hinrichsen, 1997).
Problem solving therapy:
(PST; see also Chapter 36). PST has been widely studied as a behavioral intervention for late-life major depression and minor depression (Arean, Hegel, Vannoy, Fan, & Unuzter, 2008; Gellis, McGinty, Horowitz, Bruce, & Misener, 2007). Two meta-analyses have shown that PST is as effective as CBT and IPT, and PST seems to have less treatment dropout (Cuijpers, van Straten, Andersson, & van Oppen, 2008; Cuijpers, van Straten, & Warmerdam, 2007). Two versions of PST have been studied: the social problem solving therapy (SPST) and PST-Primary Care (PST-PC), adapted for primary care settings. PST has the advantage of being easily transportable into non–mental health practices. With proper training and guidance, it can be administered by non–mental health professionals (Hegel, Dietrich, Seville, & Jordan, 2004). As with CBT and IPT, PST does not differ in content as a function of age, but the types of problems patients choose to address are more likely to include health-related problems, social connection, and valued activities.
Although no research has examined PST for older adults with mild memory complaints, PST seems to be very effective for older adults with mild executive dysfunction, as is typical in vascular depression. Not only was PST found to be superior to supportive therapy, but based on the effect size of treatment (number needed to treat [NNT] = 4 for PST, versus supportive therapy comparison; NNT = 10 for SSRI versus supportive therapy), PST appeared to be more effective than SSRI medications in this population (Arean et al., 2010).
Adapting psychotherapy for older adults:
There has been no research to date that has actually studied whether age-related issues, such as disability, diminishing social network, or mild cognitive impairment, influence the effectiveness of psychotherapy in late-life mental illness (Niu & Areán, 2014). However, depending on the functional level of the client, we believe certain adaptations can facilitate the therapeutic process with older adults. Common adaptations include socializing older adults to the process of psychotherapy, being flexible with the therapeutic frame in regard (p. 303) to age-related changes in cognitive function, and accommodating medical, physical, and practical barriers to care (Coon, Rider, Gallagher-Thompson, & Thompson, 1999).
Pretreatment socialization includes providing education to older adults about the scope and process of psychotherapy, with an eye towards reducing any misconceptions about what therapy entails. Older adults, who may have experienced more traditional, long-term, and exploratory therapies, may need to be educated about the brief and problem-focused nature of evidence-based psychotherapies. Many studies have demonstrated that providing this education prior to treatment initiation increases engagement in and satisfaction with treatment (Latour & Cappeliez, 1994).
Gallagher-Thompson and Thompson (1996) suggest using strategies to reinforce information conveyed in treatment, using the “say-it, show-it, do-it” strategy. This involves first giving older patients a rationale for a new skill and elucidating its relevance to their problems, then demonstrating the new skill with a generic example, and ending with demonstrating the skill with a pertinent, patient-centered example. A useful technique to assist with the therapeutic process is to rely on the patient’s vast store of previous experiences. Life review, a technique commonly found in reminiscence therapies, is an excellent tool for linking new material to older patients’ past experiences.
Several practical and health-related barriers can influence the process in therapy. The addition of case management to overcome instrumental barriers to engaging in psychotherapy, such as helping patients find transportation and respite care for caregiving demands, can facilitate their attendance in therapy. Additionally, it may be important to relax the therapeutic process for frailer older adults, to accommodate fatigue, illness, and physical disabilities. The typical expectation that patients will attend weekly hour-long meetings in one’s mental health space will not work for many older adults, particularly the frailer among them. Accommodations such as telephone-based therapy, less frequent visits, and delivery of care in other healthcare systems frequently accessed by older adults can overcome these barriers to the treatment of depression.
Established antidepressant medications have been subjected to many clinical trials for late-life depression. The first question that usually arises is: Do antidepressants work for late-life depression? That is, are they proven to be more efficacious than placebo? The answer to this question is somewhat complex. First, several clinical trials in older adults with major depressive disorder have shown greater response to antidepressants than to placebo, including studies of fluoxetine (Tollefson, Bosomworth, Heiligenstein, Potvin, & Holman, 1995), duloxetine (Raskin et al., 2007), vortioxetine (Katona, Hansen, & Olsen, 2012), and paroxetine. Second, several large clinical trials in late-life depression have failed to show greater response (significant at p < 0.05) to antidepressants than to placebo, in studies of escitalopram (Bose, Li, & Gandhi, 2008), citalopram (Roose et al., 2004), and bupropion extended release (Hewett et al., 2010).
The reason for this heterogeneity in late-life depression clinical trials is not completely known, but meta-analyses of this topic have not concluded that any one antidepressant or antidepressant class is more efficacious than any other for late-life depression (Kok, Nolen, & Heeren, 2012; Tedeschini et al., 2011). Instead, more recently it has been suggested that certain courses of depression in older adults may be more efficaciously treated by antidepressants. Findings from a meta-analysis (Nelson, Delucchi, & Schneider, 2013) showed that older adults with more severe and chronic depression were effectively treated with antidepressants. This might suggest that less severe and briefer episodes of depression are better treated by non-pharmacological means; although this, too, is not completely known. In any event, while the question “Do they work?” has been answered (with a “yes”), the probably more important question “For whom do they work?” has yet to be answered and may well remain uncertain for the foreseeable future.
Medication Classes for Late-Life Depression
(see also Chapter 33)
These tend to be the first-line medication treatment for older adults. This is based on their efficacy for both depression and anxiety symptoms (which tend to co-occur), generally good tolerability, and relative lack of safety concerns, although this last is controversial, as discussed below.
A number of safety concerns have arisen with the use of SSRIs in older adults, leading some to propose that SSRIs (and serotonin and norepinephrine reuptake inhibitors [SNRIs]) be included in the Beers list of potentially inappropriate medications for older adults (Fick & Semla, 2012), and that they should be included in the list of bone-deleterious medications (like glucocorticoids) requiring additional monitoring (Haney, Warden, & Bliziotes, (p. 304) 2010). These various assertions await more definitive evaluation through an RCT. Similarly, hyponatremia due to the syndrome of inappropriate antidiuretic hormone has been seen in older adults with SSRIs, with a rate as high as 10% (Fabian et al., 2004). It should be noted that this effect is typically transient and rarely clinically significant. Nevertheless, patients suffering from excess fatigue or confusion soon after starting an SSRI (or SNRI) should be monitored for hyponatremia.
Some observational reports have suggested an elevated suicide risk for older adults with SSRI use (Juurlink, Mamdani, Kopp, & Redelmeier, 2006). However, the large FDA meta-analysis showed less treatment-emergent suicidality in older adults taking an SSRI, compared to those taking placebo (Stone et al., 2009). The resulting FDA warning label regarding suicidality with SSRIs is specific to children, adolescents, and young adults. This, of course, does not reduce the need for suicide risk-monitoring with depressed elderly patients, particularly early in treatment (Chapter 6 discusses suicide in more detail).
A recent FDA report has warned of the risk of cardiac conduction QTc interval prolongation with citalopram, an effect that appears to be dose-related (http://www.fda.gov/Drugs/DrugSafety/ucm297391.htm). Part of this warning was a recommendation that citalopram not be prescribed at a dose >20 mg for those aged 60 and older. This recommendation has been sharply criticized because of the lack of case reports of citalopram-induced cardiotoxicity and the likelihood that these dose recommendations would inhibit its effective use (Vieweg et al., 2012). At present, this controversy is unresolved.
A final concern with SSRIs regards bleeding risk, as these drugs are known to inhibit platelet function. A large pharmaco-epidemiological study concluded that there was a significantly increased risk of upper GI bleed with SSRI use, which translated into one GI bleed per 318 years of SSRI exposure in older adults (Loke, Trivedi, & Singh, 2008). This risk was more likely in individuals with a history of upper GI bleed and those concurrently using NSAIDs. In spite of the lack of clinical trial evidence, this risk appears real and should be considered against benefits.
Serotonin-norepinephrine reuptake inhibitors:
This term applies to the medications venlafaxine, duloxetine, and milnacipran. All are considered effective first-line agents, as well as “switch” agents when first-line (e.g., SSRI) treatment is ineffective. Duloxetine has been shown in two separate placebo-controlled studies to be “pro-cognitive” in late-life depression; that is, producing an improvement in memory as well as antidepressant benefits. The clinical significance of this is unknown.
This norepinephrine and dopamine reuptake inhibitor is commonly used both as monotherapy in late-life depression, in part because of its very different side effect profile, which does not include weight gain, sedation, or sexual impairment, and as an augmentation treatment (Dew et al., 2007). This medication has a relatively narrow therapeutic index (as demonstrated by the increased seizure risk at doses > 450 mg) and has been shown to increase the risk of falls in older adults when combined with the cytochrome P450 2B6 inhibitor paroxetine (Joo et al., 2002). These problems are easily avoided with expert clinical use; otherwise, its main limitation seems to be treatment-emergent anxiety.
Aripiprazole and quetiapine augmentation:
These FDA-approved augmentation strategies have not been well tested in older adults, although a large study of aripiprazole augmentation for late-life depression is near completion. Concerns have arisen related to the possibility that the use of these medicines can increase mortality in dementia, as well as symptoms of Parkinsonism and tardive dyskinesia (Jeste & Maglione, 2013). The relationship of such risks with the relatively low doses of these medications in depression is unknown.
Tricyclic antidepressants have been extensively tested in older adults, with no evidence of superior efficacy to SSRIs (Mulsant et al., 2001). Their use is less popular because of a variety of safety and tolerability concerns, among these their anticholinergic and sedating properties and their tendency to cause orthostatic hypotension, all of which are of particular concern in older adults.
Mirtazapine is termed a “noradrenergic and specific serotonin antidepressant”; it is a serotonin 1A partial agonist and enhancer of adrenergic and serotonin transmission. This unique pharmacological profile provides a different side effect profile marked generally by tolerability, with the two main side effects being sedation and increased appetite. For these reasons, mirtazapine is often preferred in certain groups of older adults, notably those with reduced appetite and those intolerant of SSRIs. Its strong antihistaminergic effects are of concern, as they are believed to increase the risk of cognitive impairment and delirium, in addition to their known sedative effects. These effects seem to be (p. 305) person-specific and relatively uncommon, given its nighttime dosing, and mirtazapine appears to be low in adverse effects even in older adults with dementia.
Monoamine oxidase inhibitors are rarely used in older adults due to safety and tolerability concerns, including sedation, orthostatic hypotension, narrow therapeutic index, and problems with dietary and medication co-administration. These drugs tend to be low on a treatment algorithm in late-life depression.
Other medications have been considered in the augmentation treatment of late-life depression. These have included lithium, stimulants, and donepezil. There are few data to guide these suggestions. One large-scale study of donepezil augmentation of antidepressant medication in late-life depression found that it increased the rate of relapse from depression relative to placebo combined with antidepressant medication (Reynolds et al., 2011). Lithium is difficult to tolerate and use safely in older adults, and stimulants tend to cause or exacerbate anxiety as well elevations in pulse and heart rate. Thus, the risks and tolerability of these drugs must be weighed against their potential benefits.
Prevention of recurrence of depression with antidepressants:
Three confirmatory relapse prevention trials, one with nortriptyline, one with escitalopram, and one with paroxetine plus augmentation treatments, have demonstrated that long-term antidepressant treatment (i.e., more than one year) prevents the recurrence of depression (Gorwood, Weiller, Lemming, & Katona, 2007; Reynolds et al., 2006; Reynolds III et al., 1999). These maintenance studies extend to late-life depression the finding across numerous studies that antidepressants have powerful relapse-prevention benefits. These benefits extend to quality of life in addition to symptomatic remission (Lenze et al., 2002). Of particular note is the study by Gorwood et al. (2007), which showed a robust relapse-prevention effect of escitalopram (9% relapse rate for escitalopram vs. 33% for placebo over 24 weeks).
Antidepressant use in dementia:
Depression is a common co-occurring problem in older adults with dementia. A 2011 meta-analysis of placebo-controlled trials concluded that antidepressants were only marginally effective (Nelson & Devanand, 2011). Even this cautious conclusion is further qualified by the fact that the large-scale confirmatory studies that have been conducted specifically to demonstrate efficacy of antidepressants have failed to do so (Banerjee et al., 2011; Rosenberg et al., 2010). Reflecting the observation above about the ability to detect relapse prevention vs. acute effects of antidepressants, it is worth considering the possibility that limitations in our ability to detect changes in depression in demented individuals is the cause of these negative findings. Nevertheless, it is clear that there is little evidence to support the use of antidepressants for depression in dementia.
Barriers to adequate antidepressant adherence in older adults include stigma, fears, and misconceptions about depression and its treatment. These barriers may be especially relevant in some racial minority groups. Identifying and targeting these barriers at the outset of antidepressant treatment prescription is likely to improve adherence, improving the likelihood of response and sustained remission.
Other Somatic Treatments
Electroconvulsive therapy (ECT, see Chapter 34) is commonly used for severe, treatment-resistant, and psychotic depression in older adults. The chief merits of ECT for late-life depression is that it is safe and often effective, has a more rapid response than medication, and may be even more helpful in older adults (aged 60–74) than in young adults (Tew et al., 1999). The chief concerns about ECT are its tendency to cause cognitive impairment during the course of treatment, its relatively high burden given that it is a procedure that needs to be done repeatedly (compared to taking a pill daily), and its often short-lived benefit, with high relapse rate by six months after stopping it. Despite these concerns, there is a consensus, at least within geriatric psychiatry, that ECT is the treatment of choice, or at least high in the treatment algorithm, for very severe depression and psychotic depression (for a review on the merits and faults of ECT in older adults, see Dombrovski & Mulsant, 2007).
Access to Care
Older adults are underrepresented in the mental health care system (Pu, Bai, & Chou, 2013), largely due to problems of access owing to the dearth of geriatric-prepared clinicians who have experience managing late-life mood disorders. Also as stated previously under Adapting psychotherapy for older adults , several practical barriers may make attendance to regular mental health meetings untenable for an older patient. Fortunately, there have been (p. 306) numerous studies investigating ways to improve access to care for older patients; these include the integration of mental health services into primary care medicine and home health care, guided self-management techniques (e.g., bibliotherapy), and telemedicine.
Integrating mental health services into primary care medicine has been found to increase access to care among older adults across socioeconomic and ethnic groups (Areán, Gum, Tang, & Unutzer, 2007). Additionally, care delivered in these settings was more effective than care delivered outside these settings, largely due to the inability of older adults to attend consistent mental health appointments (Ayalon, Fialova, Areán, & Onder, 2010). For patients who cannot attend a meeting in primary care medicine, telephone-based therapy, home-based therapy, and self-administered therapy using written materials (bibliotherapy) are also effective treatment options (Ciechanowski et al., 2004; Scogin, 1998). Several studies show that distance therapies result not only in good treatment outcomes, but in better adherence to treatment as well (Wang et al., 2007).
Clinicians will need to prepare for an aging world by learning best practices in working with those over the age of 65. Although the assessment and treatment of late-life mood disorders is similar to assessment and treatment among younger adults, considerations of medical and neurological complexities will need to be taken into consideration. For some older adults, access to care is a critical issue, and clinicians, and the healthcare system, must be flexible to the challenges that caregiving, disability, and instrumental barriers create for accessing high quality care.
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