20th July 2023

Depression

Background

Depression is common in the older population, affecting 22% of men and 28% of women over the age of 65. It affects those for whom depression was diagnosed earlier in life and those who develop depression in their later years.

Risk factors include chronic illness, female sex, older age, psychosocial issues, and a personal history of depression.

Assessment and Diagnosis

Diagnosis in older adults may be more challenging, and it is thought that depression is underdiagnosed in this population. In addition, depression is associated with increased morbidity.

Depression presents with a variety of symptoms which can be psychological, physical, and social. Psychological symptoms include low mood, diminished interest or pleasure in activities, loss of energy or motivation and feelings of worthlessness. Physical symptoms include weight loss, significant changes in appetite and sleep disturbance. Social symptoms include withdrawing from friends and family and difficulties at home or work. In severe depression, there may also be features of psychosis.

The current NICE guidance refers to both DSM-IV and ICD-10 classification systems which are used to aid formal diagnosis, with its preferred system as DSM-IV. These systems have now been upgraded to DSM-V and ICD-11, respectively, though the NICE guideline has not yet been updated to reflect this.

Shared criteria of both systems are that they require one symptom to be either low mood or anhedonia, symptoms should be present for most of the day for at least two weeks and symptoms have a significant impact on function. They differ in the threshold number of symptoms and the ICD-11 includes hopelessness as a characteristic symptom, whereas it does not feature in the DSM-V. It is also worth noting that the updated DSM-V has removed bereavement as an exclusion and instead recommends clinical judgement, however the ICD-11 still includes it, with a certain threshold that must be met to diagnose a depressive episode superimposed on normal grief.

The classification criteria help determine the severity of depression (mild, moderate, and severe), based on the number of symptoms, along with the degree of functional impairment.

These diagnostic criteria are the same for older adults, as they are for younger patients. However, there are other tools that can help recognise and diagnose depression in older people. These include the Geriatric Depression Scale, Cornell Scale for Depression in Dementia, Patient Health Questionnaire-9.

The British Geriatric Society (BGS) gives guidance on Comprehensive Geriatric Assessment which includes reviewing the person’s mood and mental health. The BGS highlight the importance of exploring if the patient has any suicidal thoughts, as older adults with depression are at higher risk of completed (fatal) suicide than younger adults.

Management

The management of depression in older patients is similar to that recommended for adults, however there are some additional considerations. NICE provides a separate guideline for those with a chronic physical health problem, which is likely to be relevant to the older population.

All patients should be asked about suicidal ideation and intent in order to assess risk and ensure appropriate support and treatment is put in place.

Management should be guided by the clinical needs, patient preference and treatment history. Treatment options range from guided self-help, group-based therapies to individual counselling and pharmacological management.

When considering pharmacological treatment options, it is important to consider the patient’s medical history, current medications, and any previous experience of antidepressants. The patient should also be informed about potential adverse events associated with pharmacological treatment e.g., discontinuation symptoms and relevant side effects.

Generally, selective serotonin reuptake inhibitors (SSRI) are used first line, such as citalopram. In all patients, but particularly older adults, it is important to consider the increased risk of bleeding associated with SSRIs. Medications should also be prescribed at age-appropriate doses.

It is also crucial to assess suicide risk, as those at high risk will need closer monitoring when starting treatment.

Response to treatment should be reviewed in the first 2-4 weeks, however the person should be assessed sooner if there is a particular risk of suicide or pharmacological treatment has been started for a person aged 18-25 years.

To prevent relapse, antidepressants should be continued for at least 6 months after remission of symptoms.

For severe depression or refractory depression, electroconvulsive therapy can be considered.