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MDD not adequately recognized, treated in older adults, experts say

Thursday, May 10 2007 | Comments
Evidence Grade 0 What's This?
Major depressive disorder is underdiagnosed and undertreated in older adults, according to a panel of experts that included Dr. Sumer Verma, director of geriatric psychiatry education programs at McLean Hospital.

"If we are going to make a dent in this illness, we're going to have to learn to recognize it," Dr. Verma said. He noted that most older patients with MDD will be seen by their primary care physician rather than by a mental health professional, so it is imperative that primary care physicians can identify the disease.

The symptoms of MDD are physical (ie, energy, concentration, appetite, psychomotor, and sleep) as well as emotional (ie, sadness, interest, guilt, and suicidality), and physicians must learn to recognize the physical symptoms as those of depression rather than assuming they are symptoms of another chronic illness.

Dr. Jurgen Unutzer, professor and vice chair of psychiatry and behavioral sciences at the University of Washington, pointed out that older patients often do not show their depression by appearing sad, but rather, by no longer receiving pleasure in things they used to. If you ask an older patient "what's the last time you enjoyed something?" and they look at you blankly, they may likely be experiencing depression.

Dr. Unutzer also noted that late-life depression is complicated because it is rarely the only illness an older person has. For instance, 40% to 60% of patients with chronic pain also have depression, and it is sometimes hard to tell which disorder is causing which, he said.

Dr. Verma noted that, even when MDD is diagnosed and treated, it is often not treated for long enough.

"The treatment goal of depression has to be to treat it to remission, preferably recovery," he said, adding that drug therapy should continue for 4 to 9 months after a patient is in remission.

He noted that when treating older patients with MDD, it is important to "start low and go slow," but that physicians should not hesitate to increase doses and treat the disease aggressively to reach remission.

Manju Beier, senior partner at Geriatric Consultant Resources LLC, cautioned against decreasing a patient's dose once they seem to be responding to treatment. In long-term care facilities, this can be challenging because guidelines from the Centers for Medicare & Medicaid Services call for dose reductions in older patients. However, this should not be done with antidepressants, and physicians and others who work in LTC facilities need to educate those who support such dose reductions, she said.

To measure the effectiveness of a patient's antidepressant treatment and make appropriate modifications, Dr. Unutzer and Dr. Gary Kennedy, professor of psychiatry and behavioral sciences at the Albert Einstein School of Medicine, both suggested using the 9-item depression scale of the Patient Health Questionnaire. The questionnaire should be given regularly to monitor a patient's progress in the same way blood pressure is checked regularly to monitor a patient with hypertension, they said.

When a patient's depression is monitored, it is likely that the need for treatment changes will become evident. Dr. Kennedy pointed out that no matter what drug a patient is started on, there is a 50% chance it will not work. For this reason, patience is required when treating MDD, Beier said. Beier and Dr. Kennedy both cited the STAR*D trial as evidence that remission can be achieved after a first-line treatment fails. In the trial, patients with MDD were started on citalopram. Patients who did not adequately respond had their therapy augmented with another antidepressant and, if they still did not respond, were switched to bupropion, sertraline, or venlafaxine, all of which were found to be efficacious.

When deciding which drug should be used first for a geriatric patient with MDD, special attention should be paid to the drug's side effect profile, Beier said. She noted that, since older patients are often being treated for several illnesses, prescribers have to be aware of harmful interactions between drugs. For example, she cited potent CYP450 2D6 inhibitors such as fluoxetine and paroxetine as potentially dangerous to use with tramadol and codeine.

To compare the risks of different types of second-generation antidepressants, Beier suggested referring to the Agency for Healthcare Research and Quality's Comparative Effectiveness Review No. 7. Among other things, the review states that adverse events profiles are similar among second-generation selective serotonin reuptake inhibitors, but that the incidence rates of specific adverse events differ among drugs. For instance, there is a high amount of evidence that venlafaxine has a higher rate of nausea and vomiting than SSRIs as a class do.

According to Dr. Verma, patients will tolerate certain side effects if it means their depression will be successfully treated. He suggested finding the drug that is most efficacious for each patient, even if it means they will have some side effects.

Dr. Unutzer noted that supplementing usual depression care with a collaborative care model, such as the IMPACT model, can improve treatment outcomes. Under the IMPACT model, patients were involved in choosing their treatment, primary care providers prescribed those treatments, specially trained nurses acted as depression care managers, and psychiatrists performed weekly consultations with primary care practices. Data showed that the collaborative care model doubled the effectiveness of usual care for depression, while also being cost effective.

No matter what the approach, effective depression care is essential for older adults, Beier and Drs. Verma, Unutzer and Kennedy concluded.

"It's not okay to be depressed," Dr. Verma said. "Depression is a lethal illness."

By Laura Iadevaia

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