BMJ | 1 OCTOBER 2011 | VOLUME 343 683 CLINICAL REVIEW For the full versions of these articles see bmj.com Department of Mental Health Sciences, University College London, London W1W 7EJ, UK Correspondence to: J Carter j.carter@ucl.ac.uk Cite this as: BMJ 2011;343:d5219 doi: 10.1136/bmj.d5219 Depression in older adults Joanne Rodda, Zuzana Walker, Janet Carter Depression is a major contributor to healthcare costs and is projected to be the leading cause of disease burden in middle and higher income countries by the year 2030. w1 Depression in later life, traditionally defined as age older than 65, is associated with disability, increased mortality, and poorer outcomes from physical illness. Most clinicians will encounter older patients with depression in their day to day practice, but although treatment is as effective for older patients as for younger adults, the condition is often under-recognised and under-treated. According to WHO data, proportionately more people aged over 65 commit suicide than any other age group, and most have major depression. Older people who attempt suicide are more likely to die than younger people, while in those who sur- vive, prognosis is worse for older adults. 1 With a progressively ageing population worldwide, identification and treatment of depression in older adults becomes increasingly important, especially as older patients may have different presentations and needs than younger ones. We consider recent systematic reviews, meta-analyses, and randomised controlled trials to provide generalists with an understanding of current approaches to the diagnosis and management of patients who develop late life depression. What is late life depression and who gets it? Traditionally, the age of 65 has been used to differentiate between “older” and “younger” adults, although there is no set point at which an individual becomes “older” and assessment and care must be based on individual need. Arbitrary definitions of “late life” and differences between studies in terms of diagnostic criteria and populations sampled have produced varying reports of prevalence. Individuals with late life depression represent a hetero- geneous group with symptoms that may fall anywhere on a spectrum ranging from sub-threshold mood disorder to major depression. A recent comprehensive meta-analysis using studies with moderate to high methodological qual- ity showed that the point prevalence of major depression in over 75s ranged from 4.6% to 9.3% 2 whereas rates for sub-threshold depressive symptoms (those failing to reach diagnostic criteria) ranged from 4.5% to 37.4%. A related meta-analysis in people aged over 55 found that sub-threshold depressive symptomatology was two to three times more prevalent than major depression. 2 Most depres- sive episodes in late life will be a recurrence rather than a first ever episode w2 and the increased female to male ratio is in line with that in younger adults. Prevalence rates of depression are increased in brain disorders including dementia, Parkinson’s disease, and stroke, and also in systemic disease, for example diabetes mellitus and cardiovascular disease (box 1). Prevalence estimates for depression in Alzheimer’s disease cluster around 30% but range from 0% to 86%, w3 reflecting the dif- ficulty associated with definition and diagnosis of depres- sion in dementia. How is depression diagnosed in older patients? Box 2 lists the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for diagnosis of a major depres- sive episode. Ideally diagnosis is based on clinical interview, observation of the patient’s behaviour, and a collateral his- tory from relatives and care givers. When taking a back- ground history it is important to identify factors that may precipitate and maintain depression. The main risk factors for late life depression are comorbid physical illness, cogni- tive impairment, functional impairment, lack or loss of close social contacts, and a previous history of depression (box 1), according to the findings of large community based studies. The risk assessment is important in any psychiatric pres- entation, and in patients with depression the main area of risk is suicide. Methodologically sound controlled studies have identified some key risk factors for suicide, listed in box 3. Follow the link from the online version of this article to obtain certified continuing medical education credits SUMMARY POINTS Depression in older adults is associated with an increased risk of death and disability Cognitive and functional impairment and anxiety are more common in older than in younger adults with depression Older adults with depression are at increased risk of suicide and are more likely than younger adults to complete suicide Depression is associated with cognitive impairment and an increased risk of dementia A selective serotonin reuptake inhibitor should be the first line pharmacological treatment for depression for most older adults, including those with chronic physical illness Psychological and drug treatment is as effective in older as in younger adults Subthreshold depressive symptoms that substantially affect older patients’ lives are common and management with psychosocial and drug strategies may be effective and prevent further deterioration SOURCES AND SELECTION CRITERIA We based the review on searches of PubMed, EMBASE, and the Cochrane Database of Systematic Reviews using the search terms “depression”, “elderly”, “aged”, and “old age” published between 2006 and 2011 and limited to English language. We focused on well conducted systematic reviews, meta-analyses, and randomised controlled trials. bmj.com Previous articles in this series Ж Cognitive assessment of older people (BMJ 2011;343:d5042) Ж Functional assessment in older people (BMJ 2011;343:d4681) Ж Assessing and helping carers of older people (BMJ 2011;343:d5202) Ж Fall assessment in older people (BMJ 2011;343:d5153) bmj.com/video Ж Functional assessment in their home doc2doc Ж Depression—lost in translation. Discuss on BMJ Group’s medical community, powered by doc2doc http://bit.ly/ o10012