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Seniors With Late-Life Depression May Not Get Right Drug

Men more likely than women to get the correct medication

March 3, 2005 – A new study about the treatment of a little understood disease – late-life depression – indicates almost half of the senior citizen patients are being given the wrong drugs.

The research, conducted by Dr. Maida Sewitch at the McGill University Health Centre (MUHC) in Montreal and funded by the Canadian Institutes of Health Research (CIHR), followed the initial medication dispensed to over 5258 Quebec seniors, immediately following diagnosis of depression.

Almost all the seniors studied (84%) were given some form of medication, but incredibly only slightly more than half (55%) were given the recommended first-line antidepressants according to the Canadian Psychiatric Association. "The rest (45%) were given other drugs, some of which are known to be unhelpful for depression, especially in the elderly," explains Dr. Sewitch.

One medication--a group of psychotropic drugs known as benzodiazepines--was dispensed to nearly 2000 of the study's late-life depression patients. "There is evidence to suggest that this group of drugs may worsen depression or result in cognitive problems and falls in the elderly," says Dr. Sewitch.

The study also suggests that men--commonly diagnosed by psychiatrists in hospital settings--are more likely to receive guideline concordant medication than women--commonly diagnosed by general practitioners in out-patient settings. "These results highlight possible worrisome errors in the diagnosis and treatment of late-life depression," says Dr. Sewitch. "Further research is required in order to unravel the complexities."

The study documenting the treatment of late-life depression by Canadian health professionals will be presented today at the American Psychosomatic Society Annual Meeting in Vancouver, Canada. The study is the first to assess whether people diagnosed with late-life depression receive 'guideline concordant pharmacotherapy'--medication recommended in guidelines issued by the Canadian Psychiatric Association.

About the Research Institute of the McGill University Health Centre (RI MUHC)

The Research Institute of the MUHC is a world world-renowned biomedical and health-care hospital research centre. Located in Montreal, Quebec, the institute is the research arm of the MUHC, a university health center affiliated with the Faculty of Medicine at McGill University. The institute supports over 500 researchers, nearly 1000 graduate and post-doctoral students and operates more than 300 laboratories devoted to a broad spectrum of fundamental and clinical research. The Research Institute operates at the forefront of knowledge, innovation and technology and is inextricably linked to the clinical programs of the MUHC, ensuring that patients benefit directly from the latest research-based knowledge. For further details visit: www.muhc.ca/research.

About the McGill University Health Centre (MUHC)

The McGill University Health Centre (MUHC) is a comprehensive academic health institution with an international reputation for excellence in clinical programs, research and teaching. The MUHC is a merger of five teaching hospitals affiliated with the Faculty of Medicine at McGill University––the Montreal Children's, Montreal General, Royal Victoria, and Montreal Neurological Hospitals, as well as the Montreal Chest Institute. Building on the tradition of medical leadership of the founding hospitals, the goal of the MUHC is to provide patient care based on the most advanced knowledge in the health care field, and to contribute to the development of new knowledge.

Depression in elderly may be caused by hardened arteries

Some late-life depression is likely to be caused by narrowing and hardening of the brain arteries rather than any chemical or emotional imbalance, reported research in December of 2000 in the Journal of Neurology, Neurosurgery and Psychiatry.

Researchers from the Institute for the Health of the Elderly at the University of Newcastle upon Tyne carried out post mortem examinations on the brains of 40 people. Twenty of them had had a least one major episode of depression.

There was no evidence of dementia or Alzheimer's disease in the brain tissue: depression is very common among sufferers of these conditions.

But there was an excess of sclerosis-narrowed and hardened vessels-in the arteries supplying the brain and within the brain tissue itself of those who had been depressed.

Depression is common after a heart attack or stroke, and previous research has indicated that depression more than triples the risk of dying within the subsequent six months after a heart attack. The authors conclude that their results support the idea of "vascular depression" in which vascular disease in some way predisposes, precipitates, and perpetuates depression.

Team care doubles benefits of depression treatment for older adults

A team care approach more than doubles the effectiveness of depression treatment for older adults in general medical settings, according to a UCLA/Dartmouth study released in December of 2002. The findings show the benefits of a model primary care program to treat late life depression.

The study followed 1,801 depressed older adults from primary care clinics in California, Indiana, North Carolina, Texas and Washington for one year. Half were assigned to care as usual and the other half were assigned to a new model of team care, an approach Dartmouth Medical School investigators helped develop.

The model program, Improving Mood -- Promoting Access to Collaborative Treatment (IMPACT), assigned patients age 60 and older to a depression care manager -- specially trained nurses or psychologists-- in their usual primary care clinic. The managers worked with a consulting psychiatrist, and in close collaboration with the patients' regular physicians for up to 12 months to educate and support patients, track symptoms and side effects, assist with changes in antidepressant treatment and provide counseling.

The IMPACT care model was significantly more effective than usual care for depression at each of the eight participating sites, the study found. Almost half of the participants assigned to the IMPACT program reported a 50 percent or greater reduction in depression symptoms at 12 months, compared with 19 percent of those in usual care.

"Most of the patients in usual care received prescriptions for antidepressant medications from their primary care physicians, but it may not be enough for physicians to diagnose depression and write a prescription. We found that, with the added support and the close follow-up provided by the IMPACT team, patients felt better, functioned better, and enjoyed life more fully than patients treated in usual care," said Dr. Jόrgen Unόtzer, associate professor of psychiatry at the David Geffen School of Medicine at UCLA who directed the study coordinating center at the UCLA Neuropsychiatric Institute.

"As a psychologist working in primary care I am particularly pleased that this collaborative treatment model was also able to make an effective counseling intervention available to older patients who preferred this approach over medication," said Dr. Mark Hegel, associate professor of psychiatry and community and family medicine at Dartmouth Medical School, a co-author who trained and supervised the depression care managers in the counseling intervention aspect of the study.

"Patients assigned to the IMPACT intervention, when they preferred a counseling approach, were six-times more likely to receive counseling, usually a very brief and practical type of counseling called problem solving treatment, than patients assigned to the usual care condition. Collaborative team care makes counseling an option in primary care; an option not typically available without this approach."

Other findings include:

IMPACT patients reported less depression, less impairment in day-to-day functioning and greater improvements in quality of life at three-, six- and 12-month evaluations.

IMPACT patients had closer follow-up and more frequent adjustments in medications.

IMPACT patients were more likely to receive desired counseling.

The average cost of providing IMPACT services totaled $550 per person for 12 months, modest, say the investigators, given total annual Medicare spending of over $ 6,000 for each depressed enrollee.

While late life depression can be treated successfully with antidepressant medications or counseling, few older adults receive effective treatment. Many may view depression as a "normal" part of the aging process, not a medical illness that can or should be treated.

Serious physical illness linked to suicide in later life

Most people who commit suicide late in life suffer from depression, but the role of physical illness is less clear. A study published in June 2002, BMJ found that serious physical illness also carries an increased risk of suicide in elderly people.

Researchers in Sweden examined the records of 46 men and 39 women, aged 65 years and over, who had committed suicide. They compared these with 84 men and 69 women of the same age, living in the same area (controls). Interviews were also conducted with relatives of the suicide victims and control persons.

They found that impaired vision, neurological disorders, and malignant disease were all independently associated with suicide. When the sexes were analysed separately, serious physical illness seemed to be a stronger predictor in men than in women.

Many elderly people who commit suicide consult their doctor a short time before their death, but many fail to communicate their despair, say the authors. Further research should focus on the detection and treatment of depression and suicidal ideation in the context of physical disease, they conclude.

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