Table Of ContentGuidelines on Depression in
Older People
Practising the Evidence
Guidelines on Depression
in Older People
Practising the Evidence
Robert C Baldwin DM FRCP FRCPsych
Consultant Psychiatrist and Honorary Professor of Old Age Psychiatry
Manchester Mental Health and Social Care Trust
Manchester Royal Infirmary
Manchester
UK
Edmond Chiu AM MBBS DPM FRANZCP
Associate Professor in Psychiatry of Old Age
Academic Unit for Psychiatry of Old Age
University of Melbourne
St George’s Health Service
Kew, Victoria
Australia
Cornelius Katona MD FRCPsych
Professor of Psychiatry of the Elderly
University College London
London
UK
Nori Graham Bm BCh FRCPsych DUniv
Emeritus Consultant in Old Age Psychiatry
Royal Free Hospital
London
UK
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2002 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Version Date: 20130401
International Standard Book Number-13: 978-1-4822-0751-4 (eBook - PDF)
This book contains information obtained from authentic and highly regarded sources. While all reasonable
efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can
accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to
make clear that any views or opinions expressed in this book by individual editors, authors or contributors are
personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guid-
ance contained in this book is intended for use by medical, scientific or health-care professionals and is provided
strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s
medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of
the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be
independently verified. The reader is strongly urged to consult the drug companies’ printed instructions, and
their websites, before administering any of the drugs recommended in this book. This book does not indicate
whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole
responsibility of the medical professional to make his or her own professional judgements, so as to advise and
treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all
material reproduced in this publication and apologize to copyright holders if permission to publish in this form
has not been obtained. If any copyright material has not been acknowledged please write and let us know so we
may rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmit-
ted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented,
including photocopying, microfilming, and recording, or in any information storage or retrieval system, without
written permission from the publishers.
For permission to photocopy or use material electronically from this work, please access www.copyright.com
(http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Dan-
vers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a
variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of
payment has been arranged.
Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only
for identification and explanation without intent to infringe.
Visit the Taylor & Francis Web site at
http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com
Contents
Introduction 1
1 Signs and symptoms of depression in later life 7
2 Disease burden 13
3 Types of depressive disorder in later life 17
4 Prevalence of depressive disorder in later life 25
5 The aetiology of late life depression 29
6 Comorbidity and depressive disorder 39
7 Screening and assessment 47
8 Management 57
9 Course and outcome 95
10 Prevention 103
11 Executive summary 105
Appendices 127
Index 157
Introduction
Worldwide, life expectancy is increasing. Currently about 10% of the
world’s population is made up of older adults (aged 65 and above). This
figure is set to rise steadily, to as much as 30% in some societies (Mous-
saoui, 1999). For mental health this will mean an increase not only in
the neurodegenerative conditions, such as Alzheimer’s disease, but also
of depressive disorder. This affects about one in 10 people aged over 65,
making it the most common of the mental health disorders of later life.
In recognition of the global impact of depressive disorder, the World
Psychiatric Association (WPA) commissioned a major initiative under
the banner title of Prevention and Treatment of Depression (PTD),
bringing together psychiatrists from around the world. The teaching
modules that arose from the PTD venture, one of which specifically
addresses later life, are available on the WPA website:
http://www.wpanet.org/sectorial/edu4.html. In another WPA initiative a
major review of the evidence concerning all facets of depressive disorder
was undertaken. This has been published in book form under the title
Depressive Disorders, and includes a major review of depressive disorder
in later life (Chiu et al, 1999). The International Psychogeriatric Associ-
ation (IPA) too has acknowledged the importance of depressive disorder
by establishing a Mood Disorders Task Force.
The message from these initiatives is clear: there is robust evidence
showing that depressive disorder in later life is treatable, and that the
benefits of treatment, for the individual, families and society, are
2Guidelines on Depression in Older People
immense. Yet research continues to highlight low levels of detection and
treatment, especially in primary care. It seems that there is a gap
between knowing the evidence and implementing it. This book presents
a further development in WPA’s strategy and has been prepared under
the auspices of the WPA sections for Old Age Psychiatry and Affective
Disorders. The aim is to bridge the gap between knowledge and practice
by providing a concise summary of available evidence which will then
serve as guidance for practice.
Cole and Yaffe (1996), modifying an adaptation of a pathways model,
estimated that only about one in 10 older people with depression in the
community are referred for psychiatric care. Therefore the focus of this
book is primary care, because that is the setting where most depressive
disorder occurs and is managed. However, we have included sufficient
detail so that it will be of interest to psychiatrists, neurologists and spe-
cialists in geriatric medicine (including those in training), as well as
nurses and other practitioners whose work involves older people and
who wish to update their knowledge from a sound evidence base. The
busy reader can refer to the summary boxes and recommendations and
those who wish for more detail will find it in the text.
It would be impossible in a short book to document all the evidence
that exists on the topic of late-life depression; nor is there any need to,
as there are excellent reviews and articles. Our approach therefore has
been to start with key documents in which we believe the most import-
ant evidence has already been summarised. Two of these have already
been referred to: the WPA Prevention and Treatment of Depression
(PTD) Module for the Elderly, published in 1999, and the review pub-
lished as a book chapter in Depressive Disorders, commissioned by the
World Psychiatric Association. Also included are the British Association
of Psychopharmacology (BAP) updated evidence-based guidelines
(Anderson et al, 2000); the National Institutes of Health Diagnosis and
Treatment of Depression in Later Life Consensus Statement, published
in book form in 1991, summarised in the Journal of the American Medical
Association in 1992 and updated in 1997; and lastly, Pharmacotherapy of
Depressive Disorders in Older Patients, the findings of an expert group
from the United States (Alexopoulos et al, 2001). These references are
Introduction 3
listed in Appendix A, and are referred to in the text by abbreviations:
PTD, WPA, BAP, NIH and EXP, respectively.
One of the authors, RCB, then conducted a literature search on
MEDLINE, EMBASE, Cinahl and Psychinfo databases for the years
1998–October 2001 inclusive. This period was chosen because two of the
key documents, NIH and WPA, were current to the years 1997 and 1998,
respectively. The search strategy used all the terms relevant to depressive
disorder and dysthymia combined with the keywords ‘aged’, ‘elderly’,
‘geriatric’ and ‘senile’. The reliability of the search was examined by
cross-checking all 1998 references from the WPA document with the
new search to see if it had detected them; it had. Only original research
papers were included in the search. The 1000 or so articles were then
organised under the chapter headings matching those of the PTD initi-
ative. A list of evidence-based statements, i.e. those supported by the
existing literature and the new search, was then drawn up by RCB and
circulated for comment to the other authors. This cycle was repeated,
with the agreed levels of evidence and recommendations for practice
(see below) added on the last cycle.
In order to prioritise the evidence we have used a widely adopted
grading of evidence, along with recommendations that follow from this
(after Shekelle et al, 1999, and adopted by Anderson et al, 2000, BAP).
This is summarised in Box 0.1. Levels of evidence are specified, with the
highest level accorded to meta-analyses of randomised controlled trials.
An alphabetical grading system, A–D, is then applied to arrive at the
overall strength of recommendations. However, the latter reflects the
evidence on which it is based, not necessarily its importance in practice.
Recommendations with a weaker evidence base are often helpful in
addressing areas where clinical decisions have to be made. We are also
conscious that this system lends itself less well to some areas of research
such as epidemiological and cohort studies and that there is therefore a
tendency to artificially down-rate evidence of this kind.
The structure of each chapter begins with factual information about
the evidence, then a summary box of evidence-based statements, fol-
lowed by recommendations for practice. At the end of each chapter we
highlight newer, emerging themes and questions for the future. We
4Guidelines on Depression in Older People
Box 0.1 Categories of evidence and strength of
recommendations
Categories of evidence for causal relationships and treatment
(Shekelle et al, 1999)
Ia Evidence from meta-analysis of randomised controlled trials
Ib Evidence from at least one randomised controlled trial
IIa Evidence from at least one controlled study without random-
isation
IIb Evidence from at least one other type of quasi-experimental
study
III Evidence from non-experimental descriptive studies, such
comparative studies, correlation studies and case–control
studies
IV Evidence from expert committees reports or opinions and/or
clinical experience of respected authorities
Strength of recommendation
A Directly based on category I evidence
B Directly based on category II evidence or extrapolated recom-
mendation from category I evidence
C Directly based on category III evidence or extrapolated recom-
mendation from category I or II evidence
D Directly based on category IV evidence or extrapolated recom-
mendation from category I, II or III evidence.
hope that this approach will also serve to highlight research priority
areas.
Clearly it is not possible to cite all the references that were scrutinised,
but we have listed some of the more important and/or illustrative ones,
along with others that seem to represent potentially important avenues
for future inquiry. These are listed alphabetically in Appendix B.Most of
the references in this list are newer, but some older work is cited as
Introduction 5
needed, although we have kept referencing of this kind to a minimum
as there are a number of good general texts (listed in Appendix C) that
discuss classic or older material. For busy clinicians, and as a quick refer-
ence, we have reproduced the evidence boxes and recommendations in
the Executive summary.
We are aware that books written by experts sometimes contain more
dogma and opinion than fact. Throughout we have tried to avoid
making statements that cannot be backed by evidence. Where there are
issues which are uncertain or which remain unresolved, we have tried to
make that clear.
chapter 1
Signs and symptoms of
depression in later life
The symptoms of depressive disorder
In Box 1.1, taken from ICD10 (WHO, 1993), the features of depressive
disorder are listed under core symptoms and additional symptoms.
Similar symptoms are used in DSMIV (American Psychiatric Associ-
ation). The following distinguish major depressive disorder from under-
standable sadness:
(cid:2) Duration:symptoms are present for at least 2 weeks;
(cid:2) Lack of fluctuation:symptoms occur on most days, most of the time;
(cid:2) Intensity: must be of a degree that is definitely not normal for that
individual.
In addition to these, in classifactory systems such as ICD10 and DSMIV
whether or not an individual can be said to have depressive disorder is
determined by (a) the presence and number of core symptoms, and (b)
the number of additionalsymptoms.
(cid:2) For milddepressive episode:
– Two core symptoms
– At least four additional symptoms
(cid:2) For moderatedepressive episode:
– Two core symptoms
– At least six additional symptoms
