Mohammed T. Abou-Saleh

420 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYdepressed. The lack of effort and motivation caused by depressionmay be regarded as ‘‘not trying’’ or ‘‘giving up’’ by nurses andrehabilitation staff, who withdraw from this group of patients formore emotionally rewarding non-depressed elderly subjects on thesame ward.The elderly as a group have approximately twice as manyadverse drug reactions as younger adults 70 . They are frequentlyalready on polypharmacy, so drug interactions are a realpossibility. It is therefore important that physicians are advisedand supported by the psychiatric services in the use of safe, welltoleratedantidepressants and other treatments to reduce theimpact of this disease on both the individual and society.Electroconvulsive therapy (ECT) is an effective treatment ofdepression 71,72 . The response to treatment in older people is betterthan in the young 73,74 . With the increasing safety of anaesthesia,very few patients, even those with severe physical disease, areunable to tolerate a course of treatment. It is more rapid in effectthan medication alone, but the improvement is rarely sustainedunless antidepressants are also given to prevent relapse.A review of psychological treatments in chronic illness 75 foundvery little empirical evidence of benefit when therapeutic interventionswere applied indiscriminately. However, some evidencewas found to show benefit in patients with somatization disordersrather than physical illness, and also that brief interventionsfollowing the onset of acute physical illness reduced longer-termpsychological morbidity. A suggested general approach to thetreatment of physically ill depressed patients is:1. Investigate and give appropriate treatment to all physicalproblems, either curative treatment or to minimize persistentmorbidity. Explain the illness, treatment and prognosis to thepatient in as much detail as he/she wishes. Make sure theexplanation is understood and repeat as often as necessary.2. Give general social support, e.g. home help services, financialassistance if relevant, or residential or nursing home care.3. Give psychological support—encouragement, continued interestin the patient, e.g. outpatient follow-up. Support groupsare often beneficial for chronic conditions such as rheumatoidarthritis, Parkinson’s disease, etc.4. Consider antidepressant therapy if the symptoms are sufficientlysevere that they would be considered to warrantmedication if seen in a patient without physical problems.Monitor the response to treatment; this may take 7–8 weeks 76 .If no response is seen to a therapeutic dosage of antidepressant,consider a trial of an alternative antidepressant oradjunctive treatment, or specialist referral.PROGNOSISLittle is known of the prognosis of psychiatric disorder identifiedin the medical setting 77 , except that concomitant physical illnessis a poor prognostic factor. Psychiatric disturbance oftenpersists 78–80 , especially in patients with a previous history ofpsychiatric disorder. Those with affective disorder on admissionhave increased mortality and make greater demands on medical,social and psychiatric services 77,81 .In one series of consecutive acute medical admissions 80 , fewerthan 45% of those patients with concomitant depression hadreceived antidepressants at all, 20% had been given benzodiazepines,and less than 25% had been treated for more than oneweek. The authors concluded that an effective treatment fordepression in elderly patients needed to be found, with widespreadeducation of geriatricians in the diagnosis and treatment ofdepression.In psychiatric patients, relapse has been linked with superveningphysical illness 82 . The presence or development of cerebralor any other irreversible physical disorder indicates poor futuremental health in the great majority of patients, as well as thelikelihood of early death 83 .The prognosis of the physical illness, for both morbidity andmortality, is also inextricably linked with that of the depression.Increased mortality from physical illness, especially cardiovasculardisease, has been reported 84,85 . This excess of deaths issignificantly associated with groups who have been only partiallytreated, e.g. have not responded to antidepressants 86 , especially inolder men 87 .Explanations for the apparent association of physical illnesswith poor treatment outcome might include 88 :1. Age as a confounding factor—most of the trials of treatmentin the physically ill are in the elderly.2. Medically ill patients may be given inadequate doses ofantidepressants because of problems with side effects or overcautiousphysicians.3. Different subtypes of depression exist, some medicationresponsive,some not. Organic mood disorder (depressioninduced by physical illness or a specific organic factor) hasbeen shown to have a worse prognosis at 4 year follow-up 89 .The prognosis of depression in the physically ill elderly istherefore dependent on accurate diagnosis, intensive treatment,follow-up and early treatment of any relapses 82,84,90 . Increasedself-esteem and ability to cope will reduce demand on families andpossibly on services. No studies have yet convincingly identifiedpredictors of response in physically ill populations, although preexistingdepression prior to admission with physical problemsappears to predict persistent depression, rather than if thedepression develops in hospital 78,91 .SUICIDESuicide is the most dramatic of poor outcomes, and the elderly areover-represented in suicide statistics. Although the elderly are lesslikely to attempt suicide, they are more likely to complete it 92,93 .The presence of physical illness, especially if associated withchronic pain and disability, increases the risk; elderly men livingalone are at the highest risk. The individual’s adjustment to illhealthand his associated feelings of hopelessness and demoralizationare obviously important 94 . Many elderly suicide victims aresuffering from their first episode of major depression, which istypically only moderately severe but the diagnosis is missed 95 , andthe potential for recovery following intervention therefore lost.Depression has been linked to decreased compliance and tovoluntary refusal of life-saving essential medical treatments 96,97 .This may reflect either conscious or unconscious suicidalmotivation.SERVICE IMPLICATIONSIt is important to note that the aging population itself is growingolder, with large numbers of very old individuals. It is this old-oldgroup who have the highest physical and psychiatric morbidityand who make the greatest demands on services.Undergraduate teaching programmes must be tightly integratedin order for students to develop a holistic approach to the elderly,together with an understanding of the psychosocial and economicfactors that will affect presentation and treatment. Joint postgraduatemeetings between the two specialties are becoming morecommon and should be encouraged, each maintaining theirseparate identities and training but working closely together inclinical practice.