Diagnosis and treatment of geriatric depression

Geriatric depression is a common psychiatric illness affecting as many as one-third of the older population. With the growing number of elderly in many countries of the world, the morbidity and mortality associated with untreated and partially treated depression is of great concern from both a medical and economic perspective. Depression in the elderly often presents with more somatic or anxious features and less of the subjective sadness expressed by younger groups. In addition, in the elderly, depressive-spectrum disorders (which include minor depression, dysthymia, mixed anxiety/depression, bereavement-related depression and even suicidal ideation) are generally under-recognised and undertreated by health professionals. The clinical mismatch between high prevalence but undertreatment stems from patient and physician attitudes toward depression as a 'normal' response to aging and loss, diagnostically confusing medical illness-related symptomatology, and noncompliance with prescribed treatment. Furthermore, late-onset depression may hold special prognostic value in the elderly, with the relationship between late-onset depression and cerebrovascular events and progressive dementing illness being particularly strong. Therapeutically, then has been a recent expansion in the pharmacological tools that can be used to treat depression. A variety of new agents are now available that have adverse effect, pharmacodynamic and target-receptor profiles that differ from the older agents. For example, newer drugs that block the serotonin (5-hydroxytryptamine; 5-HT) transporter have supplanted older agents that cause more frequent and toxic adverse effects. These newer agents have also focused attention on the impact of polypharmacy on the hepatic cytochrome P450 system, which is responsible for drug metabolism and elimination. Electroconvulsive therapy and psychotherapy remain effective nonpharmacological treatments for geriatric depression. Generally, the opportunities for therapeutic intervention in geriatric depression suggest that greater diagnostic attention and more widespread application of treatments for this increasingly prevalent disorder continue to be needed.