Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0DEPRESSION AFTER STROKE 427Treatment of Depression in Older People with Physical DisabilitySube Banerjee 1 and Florian A. Ruths 21Institute of Psychiatry, London, and 2 Queen’s Resource Centre, Croydon, UKTHE CASE FOR TREATMENTAs discussed elsewhere, depression is the most common mentaldisorder in the over-65s, with a prevalence of 13–16% 1,2 .Itisaserious disorder, associated with profound decrease in quality oflife 3 , suicide 4 , non-suicidal excess mortality unexplained byphysical disorder 5 , and excess health and social service use notexplained by disability 6,7 . Depression in the elderly also has asubstantial financial impact, costing community health and socialservices in the UK in excess of £1 billion/year in depressiondependentservice use 8 .Depression in the elderly therefore has a serious impact on thepeople suffering from it, their families, and health and socialservices. Despite this, it is a consistent finding that few olderpeople with depression receive appropriate treatment fromprimary or secondary care services. Only 10–20% of cases ofdepression are prescribed antidepressants 7,9,10 , with no evidence oftheir receiving non-drug treatment instead. The reasons for thislack of appropriate action is unclear, some implicating low GPrecognition 11 and some a lack of action when depression isfound 12 . Whatever the mechanism, there are clear discontinuitieson the path from contact, through recognition to action 13 .Older people with physical illness or disablement are a high-riskgroup for the development of depression 14 . One particular highriskgroup consists of those maintained at home, receiving socialservice home care; 26% of these have clinical depression 15 and,adjusting for age and gender, they have twice the prevalence ofdepression of the general elderly population, with a four-foldexcess of the most severe forms 7 . One possible determinant oftherapeutic inactivity may be a perception that depression isuntreatable in frail older people, and an important element inclinical behaviour change is evidence of the effectiveness ofintervention. Meta-analyses suggest that antidepressants haveefficacy in the treatment of depression in those with a variety ofphysical illnesses 16 , with the same sort of effect sizes as thoseobserved in the physically well. However, the evidence for theeffectiveness of treatment for depression in the disabled elderly issparse, since they are often systematically excluded from drugtrials 17 . We therefore completed a randomized controlled trial(RCT) to investigate whether depression in home-care clients wastreatable by community old age psychiatric services 18 .THE EFFECTIVENESS OF OLD AGE PSYCHIATRICCOMMUNITY TEAM INTERVENTIONSixty-nine cases of depression were identified by screening thehome-care population and randomly allocating them to treatmentas usual by their GP, or to treatment by the local old agepsychiatric community team, with blind follow-up at 6 months.There was a powerful treatment effect, with 58% of theintervention group recovering, compared with only 25% of thecontrol group (adjusted odds ratio 9.0 [95% CI, 2.1–41.5]). Theintervention was pragmatic, involving the multidisciplinary teamformulating an individualized management plan and this beingimplemented by a research worker working as a generic teammember. Analyses were carried out on an intention-to-treat basis.This study’s results suggest that therapeutic nihilism, based onan assumed poor response to treatment in the disabled elderly,may not be justified. There are similarly encouraging data for thegeneral population of older adults with depression from GPpractice-based community psychiatric nurse intervention 19,20 andnurse-based outreach programmes 21 . However, all these interventionsare complex and delivered by secondary care services, andare therefore not directly transferable into primary care settings.Given that there may be 500 000 disabled older adults withclinically significant depression in the UK alone at any one time,secondary care intervention for all is not feasible. It would also beunnecessary if depression in the disabled elderly were to bemanaged successfully by primary healthcare teams. These arequestions which require further research.Elements of Effective InterventionThe dysjunction in the system of care from disorder to recognitionto action has been outlined above. What, therefore, does thismean for the formulation of effective interventions for olderpeople with depression, and where might change be focused bestto achieve maximum health gain? These questions can beaddressed by considering the pathway from depressed state toresolution, using the data we have for disabled elderly home-carerecipients.Figure 1 presents a simple model. In it, the outcome ofdepression depends on two parameters, the natural history of thedisorder and the effectiveness of intervention. The extent to whichan intervention is deployed depends on there being bothrecognition and action. In Figure 1, the data from the homecarestudies are applied to a standard population of 100. In thefirst stage, the current 15% rate of any active management fordepression in this population 7 is applied to divide the group into a‘‘treated’’ and a ‘‘not treated’’ group. The second stage is to applythe spontaneous recovery rate of 25% to the ‘‘not treated’’ groupand the 60% recovery rate from our RCT with active managementto the ‘‘treated’’ group 18 . When these filters are applied, onlyRecoveredTreatedNotrecovered100Depression15% 85%RecoveredNot treated60% 40% 25% 75%Figure 1Notrecovered9 6 21 64