Depression and Coexisting Medical Disorders in Late Life
Weintraub, Daniel, Furlan, Patricia, Katz, Ira, Generations
Mental Health and Mental Illness in LaterLife
Does treatment of depression make a difference in overall health?
It has been approximately a decade since the NIH Consensus Statement on the Diagnosis and Treatment of Depression in Late Life (Schneider, Reynolds, and LebowitZ,1992) stated that the hallmark of geriatric depression was its coexistence with medical illness. Since that time, our understanding of this problem has matured, approaches to treatment have become clearer, and the questions addressed in our research have evolved.
In the past, it was important to ask whether it was possible to recognize and diagnose those instances of depression that occur in the context of medical illness, whether these had significant consequences, and whether they were treatable. We have learned that it is possible to recognize depression as it occurs across coexisting medical illnesses and care settings and that depressive disorders can be diagnosed as accurately as the other chronic medical disorders that are common in late life.
We have also learned that depression is associated with poorer health outcomes. Research has suggested that patients with depression are at increased risk for a range of illnesses that include diabetes, heart disease, osteoporosis, and Alzheimer's disease (Gallo et al., 2ooo; Pratt et al., 1996; Eaton et al., 1996; Speck et al., 1995; Michelson et al., 1996). There is also evidence that depression is associated with increases in the following outcomes: disability, rates of treatment refusal, care needs, care costs, and mortality across a number of medical conditions and treatment settings (e.g., Unutzer et al., 1997; Luber et al., 2001; Mossey, Knott, and Craik, i99o; Pennix et al., 2001). But research has also shown the efficacy of treatment. Treatment for depression can be effective in the presence of medical conditions as diverse as Alzheimer's disease, arthritis, chronic obstructive pulmonary disease, diabetes, cancer, heart disease, Parkinson's disease, and stroke (e.g., Roth, Mountjoy, and, Amrein,1996; Lyketsos et al., 2000;Puttini et al., 1988; Borson et al., 1992; Lustman et al., 2000; Costa, Mogos, and Toma, 1985; Strik et al., 2000; Andersen et al., i98o; Lipseyet et al.,1984).
Together, the cumulative findings have confirmed the importance of diagnosing and treating late-life depression and have suggested that treatment could play a pivotal role in the overall healthcare of aged individuals. The result has been advances in clinical care and significant changes in the nature of the questions facing the field.
One current question raised is, What are the best strategies for treating depression in the context of specific coexisting conditions (comorbidities), both with respect to specific medications and psychotherapies? Another concem is strategies for delivering care. Should it be in the medical treatment setting or through specialty mental health services? A third question concerns the extent to which treatment of depression improves health outcomes. Although the associations observed in previous research are important, the most critical question is whether treatment actually makes a difference, not just in depressive symptoms, but in overall health.
THE BEST TREATMENT APPROACHES
What are the best approaches for treating late-life depression in the presence of specific medical disorders? The available research suggests that, of those treatments that have been tested in older adults, all of the interventions that are effective in younger adults remain useful in the elderly. Clearly, treatment planning requires attention to interactions between drugs and also between the drugs and characteristics of the medical disorder. Such interactions can affect the safety of treatments. However, important questions remain about whether certain medical comorbidities affect the therapeutic benefits that can be derived from specific treatments for depression. …