Annals of Long Term Care

**sub**The Geriatric Syndrome of Late-Life Depression **endsub**
“The task,” began Gary J. Kennedy, MD, Professor of Psychiatry and Behavioral Sciences and Director, Division of Geriatric Psychiatry and Fellowship Training Program, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, “is to recognize the difficulties in treating depression, and the assumption is that the more you know about depression, the more sensitive you become about when to refer and when to start the patient on treatment from the onset.” While Dr. Kennedy agrees that it is important for primary care physicians and providers from other disciplines to lower the threshold at which they offer treatment for depression—the current trend in the treatment of depression—he warned that certain difficulties in treatment extend beyond this.

“Late-life depression,” stressed Dr. Kennedy, “should be viewed as one of the geriatric syndromes,” which also include incontinence, falls, cognitive impairment, and polypharmacy. “Realizing that late-life depression is a syndrome—that it’s a family of disturbances and problems, not all of which are simply mood disturbances—is important in forging a treatment that is really going to be effective,” he asserted.

Depressive symptoms are known to be more common than major depressive disorder in late life. While there is sufficient evidence that primary care providers have improved in recognizing major depression, the less obvious forms of depression still present a challenge in diagnosis and treatment, and are also far more prevalent. Dr. Kennedy reinforced that, in terms of symptoms, one need not be overtly depressed to have a major depressive disorder. Apathy and irritability are sufficient symptoms, and, in fact, more common characteristics of depression in older adults.

One of the difficulties associated with the treatment of depressive symptoms in older adults is their spontaneous recovery rate of about 50% observed within two years. This presents obvious challenges in evaluating the efficacy of the treatment that is administered to these adults. In addition, one must keep in mind that in determining whether the goal of treatment has been reached, “[one must] depend on the subjective impressions of the clinician, the patient, or the family,” warned Dr. Kennedy. This creates what he referred to as soft therapeutic endpoints. “We’re not looking at laboratory values. Furthermore, the terminology we use to describe depressive symptoms is less than a decade old, and I think we are still learning how to apply it.”

“Most older adults historically—and this may still be true—have been treated more often with a sedative/ hypnotic than with an antidepressant,” stated Dr. Kennedy. The problem is that, although definitive antidepressants are available as treatment, patients are still being administered sedatives. Of the antidepressant prescriptions that are dispensed, about half of them are either not filled or not refilled because of high cost. It is essential that the physician verifies that the patient can afford the drug prior to prescribing the medication. Dr. Kennedy quoted a number nearing 50% for patients who either show a partial response to treatment or one of outright failure (this number includes patients who did not take any or all of their medication).

Dr. Kennedy believes that the most effective approach to treatment of geriatric depression as a syndrome is the comprehensive approach, which encompasses definitive treatments for other conditions that the patient may have, as well as eliciting the support of the patient’s family. “The state of the art,” said the speaker, “is both psychotherapy and antidepressant medication. Together they yield much better results in efficacy.” He mentioned the need to improve pain management and palliative care in psychiatry, adding that the risk of an older person becoming dependent on a pain medication is probably negligible.