with 32 percent who responded to medication.44 Thus, ECT may be both more effective and safer than the tricyclic antidepressants. It also has fewer side effects, but its major side effect, memory loss, although usually transient, creates special problems in a population in which memory loss is already a problem. Yet the efficacy of ECT is so marked that it might be considered the first form of treatment for some severely depressed patients, without waiting for the failure of drug therapy, as is now the case. Further research could yield rich dividends in establishing more precise indications for its use among the elderly.17,66

Primary care physicians are capable of treating most older depressed patients who come to them, but there are some circumstances in which physicians should seek consultation from a psychiatrist until they gain sufficient experience in managing antidepressant medications. Gottlieb28 recommends such consultation, preferably with a geriatric psychiatrist, and in some instances referral of patients with certain specific problems: major depression with delusional or other psychotic features; suicidal or homicidal ideation or a previous history of destructive behavior; treatment-resistant depression; symptoms (medical and neurological) that are difficult to distinguish from depression; and medical conditions that are made worse by depressive symptoms or antidepressant interventions.

The discussion above has considered the treatment of depression largely in terms of pharmacotherapy delivered by primary care physicians. Psychosocial therapies for depression in the elderly are also reasonably effective—and safer. Cognitive-behavioral treatment of depression has proved to be as effective as pharmacotherapy in less severe depressions, and it avoids the troublesome side effects of medication. A major limitation of such labor-intensive treatment is its cost. Even when delivered by nonphysicians, the fact that it is not reimbursable puts it beyond the reach of most elderly persons.

The issue of costs highlights the attractiveness of community-based programs that rely on volunteer or low-cost personnel more than on professional help. The experience of recent years has suggested that these approaches have merit, although few have achieved any degree of permanence and fewer yet have been evaluated. A common feature of these programs is their anticipation of stressful events, particularly bereavement, and their provision of supportive services.36,52,57 Controlled trials showed that one program of bereavement counseling achieved a significant decrease in morbidity,52 whereas a television-assisted approach produced some improvement in mood in the study participants.46 One innovative approach that deserves further exploration attempted to change negative attitudes

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