Diagnosis and treatment of older adults with depression in primary care

Abstract

This article provides an overview of current challenges in the diagnosis and treatment of depressed older adults in primary care and considers suggestions for clinicians, researchers, and policy makers to improve care for this population. Despite the enormous toll of depression on individuals and society and the availability of effective treatments, depressed older adults remain largely untreated or undertreated. They rarely see mental health professionals, but have relatively frequent contact with primary care providers. In primary care, the chronic and recurrent nature of depression and a number of patient, provider, and policy-related barriers interfere with effective depression treatment. Recent research suggests that improving care for individuals with late life depression will require education and engagement of older adults and their primary care providers as active partners in caring for depression. It will also require additional human resources and systematic models of care dedicated to proactively managing depression as a chronic illness. Finally, it will require training of mental health professionals to effectively collaborate with their colleagues in primary care in treating depressed older adults. Further improvement in depression care would likely result from the implementation of true parity for mental health treatments for older adults.

Introduction

Major depression affects 5%–10% of older adults who visit a primary care provider Oxman et al 1990, Lyness et al 1999, Schulberg et al 1999. Arean and colleagues (1997) found that 11.5% of older adults seen in a primary care clinic serving multiethnic, poor, inner-city residents met criteria for major depression. Depression can become a chronic or recurrent problem for up to 50% of affected older adults Alexopoulos and Chester 1992, Callahan et al 1994a, Unutzer et al 1997, Cole and Bellavance 1997, Schulberg et al 1998, particularly in older adults with poor physical health (Geerlings et al 2000). Depression in older adults is responsible for tremendous individual suffering, functional impairment, and losses in health-related quality of life Alexopoulos et al 1996, Unutzer et al 2000. It has also been associated with increased health care costs, increased use of primary care visits, consultations, and laboratory studies, and longer hospital stays, even after adjusting for medical comorbidity Callahan et al 1994a, Luber et al 2000, Luber et al 2001, Unutzer et al 1997. Depression can also affect important health behaviors such as adherence to medical treatments (Ciechanowski et al 2000) and mortality through increased risk of suicide (Conwell et al 1996) and increased mortality from medical illnesses Bruce et al 1994, Penninx et al 1999, Penninx et al 2001. This article provides an overview of current challenges in the diagnosis and treatment of depressed older adults in primary care and considers suggestions for clinicians, researchers, and policy makers to improve care for this population.

Since the time of the National Institute of Health consensus statement on depression in late life (NIH 1992), there has been abundant evidence that a number of efficacious treatments exist for depressed older adults, including antidepressant medications, individual and group psychotherapy, and electroconvulsive therapy. Recent research by Reynolds and colleagues (1999) has demonstrated that long-term maintenance treatment with antidepressants can prevent recurrences of depression in older adults similar to younger adults. Less is known about the effectiveness of treatments for depressed older adults with comorbid medical illness in general medical settings Callahan et al 1996, Callahan 2001, Freudenstein et al 2001, Williams et al 2000a. Although not specifically designed for older adults, guidelines for the treatment of depression in primary care have been developed and disseminated by the Agency for Healthcare Research and Quality (AHCPR 1993); however, few depressed older adults receive guideline-concordant treatment for depression either in primary care or in specialty mental health care settings (Callahan 2001).

In addition to major depression, a number of depressive syndromes that do not meet DSM-IV diagnostic criteria for major depression are being increasingly recognized as common and associated with substantial disability (Koenig and Blazer 1996). These syndromes include dysthymia, bereavement, adjustment disorder with depressed mood, and minor depression. Together, they are about twice as common as major depression, but much less is known about the effectiveness of treatments for these problems Williams et al 2000b, Freudenstein et al 2001, Callahan 2001.

A number of studies have shown that older adults with mental disorders are significantly less likely than younger adults to receive specialty mental health care Waxman and Carner 1984, Shapiro et al 1984, Goldstrom et al 1987, Gurland et al 1996, Swartz et al 1998, Unutzer et al 1999a, Tschantz et al 2001 and rarely see mental health specialists Ganguli et al 1995, Cole and Yaffe 1996. In a study of six health maintenance organizations (Bartels et al 1997), older patients received fewer mental health specialty visits and fewer prescriptions for Selective Serotonin Reuptake Inhibitor antidepressants (SSRIs), but they were more likely to receive benzodiazepines than younger depressed patients. The long-term use of benzodiazepines in depressed older patients represents potential misuse as it is well known to be a risk factor for such adverse outcomes as cognitive impairment, sedation, falls, hip fractures, and other accidents (Wang et al 2001).

A recent national survey of 9585 adults (Young et al 2001) found that older adults with depressive and anxiety disorders were at particularly high risk of not receiving appropriate care. Almost all of the depressed older adults surveyed in this study reported at least one visit to a primary care provider during the prior 12 months (Tschantz et al 2001), but only 8% reported an outpatient visit to a mental health specialist. Only 3% of depressed older adults reported any inpatient mental health care and 1% reported an emergency room visit for a mental health diagnosis during the prior 12 months. With regards to specific treatments for depression, 19% reported receiving an antidepressant in the past year and 6% reported four or more visits that included some counseling or psychotherapy. Compared with younger adults with depression, rates of depression care were consistently lower in depressed older adults.

In a study of 1711 outpatients age 60 and older, Callahan and colleagues (1994b) found that only one in seven depressed patients in an academic urban ambulatory care clinic received treatment with an antidepressant. Only about half of the patients referred for psychiatric consultations followed up on such referrals. Unützer and colleagues (2000) found that few depressed older adults in a large staff model health maintenance organization (HMO) used specialty mental health services. Only 10%–18% of depressed older adults received any depression specific treatments in 1989 and 1993, respectively, although there was a substantial increase in the use of antidepressants during this time period, mostly attributable to the use of newer antidepressant medications that are better tolerated by older adults. Most of the treatment provided to participants in this study consisted of short-term treatments with antidepressant medications at low doses in primary care. Coyne and Katz (2001) point to a substantial increase in the use of antidepressants in recent years but also point out that many older adults who are prescribed an antidepressant never receive an adequate course of treatment. Others have found that adherence to antidepressant medications can be a particular challenge in depressed older adults Kamath et al 1996, Unutzer et al 1999a.

These studies confirm the fact that few older adults with depression use specialty mental health services and that most older adults who do receive care for depression are treated in primary care. Few depressed older adults receive evidence-based treatments for depression in primary care or specialty mental health care settings. In primary care, a number of barriers have been identified to the appropriate diagnosis and treatment of individuals with late life depression Raue and Meyers 1997, Unutzer et al 1999b, Callahan 2001.

Studies suggest that many depressed older adults are not recognized or diagnosed in primary care (Callahan et al 1994b; Gurland unpublished data; Caine et al 1996; Luber unpublished data). A number of reasons for this problem have been proposed, including differences in the presentation of depression between younger and older adults, limited knowledge about depression and attitudes that reduce the likelihood of recognition, and diagnosis of depression among older adults. Depressed older adults may be less likely than younger adults to endorse symptoms of depression (Gallo et al 1994). Primary care providers should be aware of this phenomenon and look for anhedonia, complaints of poor energy, or other somatic complaints as possible indicators of depression in older adults. Older adults and their physicians sometimes attribute symptoms of major depression to “normal aging,” grief, physical illness (Gallo et al 1994), or dementia (Rabins 1996) and assume that under such circumstances, treatment for depression will not help. Cole and colleagues (1997) have called this phenomenon the “fallacy of good reasons.” Older adults may also lack knowledge or information about depression and they may be particularly sensitive to the stigma associated with mental disorders such as depression Sirey et al 2001, Raue and Meyers 1997, Thompson et al 1989. Research also suggests that depressed older men may be particularly unlikely to be recognized and diagnosed for depression in primary care Crawford et al 1998, Stoppe et al 1999.

Other barriers to recognizing and diagnosing depression in older primary care patients include a complex differential diagnosis that includes grief and bereavement, common problems in older adults, and a number of medical conditions and medications that can cause or worsen depressive symptoms or compete for the primary care physician’s attention during a time-limited office visit. Medical conditions associated with depressive symptoms include neurologic disorders such as Parkinson’s disease, stroke, traumatic brain injury, dementia, and multiple sclerosis, endocrine disorders such as hypothyroidism, hyperthyroidism, Cushing’s disease and diabetes mellitus, chronic pulmonary disease, sleep apnea, and a number of rheumatologic diseases. Medications that can cause or worsen depression include corticosteroids, alcohol, benzodiazepines, narcotics, and other central nervous system depressants; levodopa; antihyptertensives such as reserprine or beta blockers; and certain cancer chemotherapeutic agents. In addition to a direct physiologic link between such medical conditions or medications and depression, Ormel and colleagues (1997) and others have shown that when chronic medical conditions begin to impair an older adult’s ability to function and care for himself or herself, they become associated with an increased risk of depression.

Successful treatment of depression requires engagement of the patient and, sometimes, family members as active partners in their treatment. This requires time, information, and communication skills that not all primary care providers have. Efficacious treatments such as antidepressant medications or psychotherapy have to be initiated. For antidepressants to be effective, they have to be titrated to an effective dose and taken for at least 8–12 weeks. During this initial treatment period, patients have to be closely observed for treatment adherence, side effects, worsening of depression, and thoughts of suicide. The risk of discontinuation of antidepressants during the initial 3 months is very high (Simon and Von Kroff 1992). Even under the best of circumstances, only about 50% of depressed older adults will have a complete response to any given antidepressant (AHCPR 1993). This requires close monitoring of treatment response, adjustment of treatments as needed, and a change to another antidepressant, referral for psychiatric consultation, or addition of psychotherapy if patients don’t respond to an initial medication trial.

All of this takes motivation, knowledge, expertise, time, and effort on the part of patients and primary care providers. It is rarely accomplished in usual primary care settings where few patients have more than two primary care visits during the 8-week period after initiating an antidepressant medication Simon et al 1993, Lin et al 1997. Patients may lack the necessary knowledge about depression or simply be too depressed and hopeless to actively participate in depression treatment. They may also be ambivalent about depression treatments because of the stigma attached to mental disorders (Sirey et al 2001). Primary care providers may lack the necessary knowledge, skills, or confidence to correctly diagnose or treat older adults with depression (Shah and Harris 1997), especially in the face of competing demands to address acute and chronic medical problems (Rost et al 2000). Providers may also be afraid to “open Pandora’s Box” and uncover emotional or psychological stressors that they do not feel equipped to handle during a routine 10–15 minute office visit. Few primary care providers have the time (Glasser and Gravdal 1997) and resources to follow patients as closely as is suggested by treatment guidelines (AHCPR 1993) to ensure that patients receive an adequate trial of a medication or psychotherapy. Psychiatric consultations or referrals to psychotherapy can be hard to arrange if trained mental health specialists do not practice within or close to the primary care clinic and if patients have to travel off-site or navigate complex administrative or financial barriers to see a mental health specialist. Limited integration and communication between primary care and specialty mental health providers can present additional barriers to effective treatment of depression in medically ill older adults. This may contribute to the fact that primary care providers may rely on medications to the exclusion of psychosocial interventions such as physician counseling, social interventions, or psychotherapy (Callahan 2001).

Other treatment barriers include financial barriers such as limited reimbursement of psychotherapy or antidepressant medications by Medicare. Currently, Medicare mental health benefits limit care in psychiatric hospitals to 190 lifetime days and require a 50% co-payment for outpatient psychotherapy services, while only a 20% co-payment is required for other medical outpatient services. For example, if a provider’s claim for an outpatient visit identifies depressive disorder (ICD-9 code 311) as the primary diagnosis, Medicare may reimburse only 50% of the Medicare approved amount. If the claim identifies a chronic medical or neurologic disorder as the primary diagnosis, Medicare will pay 80% of the approved amount. Although a prescription drug benefit for seniors has been a popular topic in recent political campaigns and debates, Medicare currently does not offer such a benefit. For the millions of older adults who do not have insurance coverage for prescription medications, the daily cost of newer antidepressants at $2–3 per pill may present a substantial barrier to depression care. Brown and colleagues (1995) have found that poverty and old age significantly decrease a depressed person’s likelihood to receive depression treatment. Such instrumental barriers as well as unique language and cultural barriers may present a particular challenge for depressed older adults from ethnic minority groups Gallo et al 1995, Brown et al 1995, Arean et al 1997, Unutzer et al 1999b.

A number of research groups have reported on training programs for primary care providers to improve the diagnosis and treatment of depression in primary care Rutz et al 1992, Tiemens et al 1999, Gerrity et al 1999, Thompson et al 2000. Some of these programs specifically target older individuals with depression Philip 1998, Livingston et al 2000. Other researchers have reported on programs to educate older adults about depression, including a psychoeducational workshop for older adults with recurrent major depression and their families (Sherill et al 1997) and a behaviorally oriented self-help group under the direction of a lay person (Thompson et al 1983). In addition, a number of screening instruments have been developed to facilitate the recognition of depression in primary care (Mulrow et al 1995). Some of these instruments have been specifically validated for the use in depressed older adults Radloff 1977, Yesavage et al 1983. Some of the more recently proposed instruments apply a two-stage screening and diagnostic procedure that facilitates both screening and diagnosis of depression in primary care Spitzer et al 1995, Spitzer et al 1999, Kroenke et al 2001. Glasser and Gravdal (1997) reported that 33% of the primary care providers they surveyed reported using screening instruments for depression in their practice. Numerous studies Callahan et al 1994b, Lin et al 1997, Whooley et al 2000 and a number of recent reviews Katon 1995, Lin et al 1997, Klinkman and Okkes 1998, Callahan 2001 have concluded that training of primary care providers, provision of informational support, and depression screening of older adults may improve recognition and initiation of depression specific treatments in primary care but that such efforts do not lead to persistent improvements in depression outcomes.

Katon (1997), Callahan (2001), and others have suggested that efforts to educate primary care providers and screening for depression in primary care have to be combined with additional measures that focus on improving rates of evidence-based treatment for depression. Such measures may include an increased focus on patient education and activation as well as practice-based provider support mechanisms such as effective reminder systems, physician extenders who can help with tasks such as patient education or outcomes tracking, or improved access to mental health professionals who collaborate closely with primary care providers to care for depressed older adults Von Korff 2001, Callahan 2001. In recent years, a number of chronic disease management models that employ such methods have been shown to be effective in improving the quality and outcomes of depression care in mixed-age primary care populations Katon et al 1997, Wells et al 2000, Katzelnick et al 2000, Simon et al 2000, Hunkeler et al 2000, Rost et al 2000, Schulberg 2001. In these trials, mental health professionals or clinician care managers such as nurses work closely with the patients’ regular primary care providers to improve care for depression. Similar trials of collaborative care models for older adults with depression in primary care are currently underway Bruce and Pearson 1999, Alexopoulos and PROSPECT 2001, Unutzer et al 2001. Health care organizations may be able to substantially improve care for depressed older adults by developing, adapting, and disseminating such disease management models.

Further research is needed on the efficacy of treatments for subthreshold depressive syndromes Freudenstein et al 2001, Callahan 2001, Williams et al 2000b that represent the majority of late life depressions in primary care, on the feasibility and effectiveness of nonpharmacological interventions in primary care settings (Freudenstein et al 2001), and on the treatment of older adults with persistent depression and depression that does not respond to standard antidepressant trials. Until recently, most treatment trials with depressed older adults have excluded individuals with significant medical, mental, or substance abuse disorders. This is unfortunate because most depressed older adults have at least one such comorbid condition. Recent intervention studies Alexopoulos and PROSPECT 2001, Unutzer et al 2001 have started to include patients with such comorbid disorders and future treatment trials should explore the effectiveness of depression treatments among older adults with depression and comorbid medical disorders, dementia, chronic pain, alcohol or benzodiazepine misuse, multiple losses and bereavement, social isolation, and poverty, all problems that are common among depressed older adults in primary care. Research is also sorely needed on the quality of care and treatments for older adults with bipolar disorder who often present with depression or mixed episodes Young 1997, Bartels et al 2000.

Additional qualitative and quantitative research on barriers to care could further contribute to our efforts to improve the quality of care for older adults with depression. Examples of such barriers include practice-related barriers such as the separation of care for mental and medical disorders, policy-related barriers such as limited reimbursement for mental health services, and societal barriers such as attitudes and stigma related to mental illness that may be particularly important for older adults (Sirey et al 2001). Such research should focus on barriers in different types of primary care settings and unique barriers experienced by ethnic minorities and otherwise disadvantaged populations. Research should also investigate unique barriers to depression care for older men who are less likely than depressed women to be diagnosed and treated for depression in primary care despite the fact that they have the highest risk for completed suicide Crawford et al 1998, Stoppe et al 1999.

Researchers could partner with health care provider organizations and community organizations such as religious institutions, senior centers, public service agencies, senior housing facilities, consumer organizations such as the National Depressive and Manic Depressive Association (NDMDA) and American Association of Retired Persons (AARP), and the media to develop and study innovative programs to recognize and facilitate treatment for older individuals with depression in primary care. They should also work with professional organizations in primary care and specialty mental health care to develop and adapt successful training programs to improve the care of depressed older adults.

Additional advances in the care of depressed older adults could come from collaborations between the Centers for Medicare & Medicaid Services (CMS) and other health care payers, the Administration on Aging (AoA), the Substance Abuse and Mental Health Service Agency (SAMHSA), the National Institute of Mental Health (NIMH), the National Institute on Aging (NIA), the Agency for Healthcare Research and Quality (AHRQ), and other organizations funding research in aging. Such collaborative efforts could develop and evaluate new reimbursement models for depression-specific treatments such as psychotherapy, antidepressant medications, and care management, services that have been shown to be a central component of many successful quality improvement interventions for depression in primary care Katon et al 1997, Schulberg 2001, Callahan 2001, but that are not well funded under current reimbursement schemes for older adults.