The Second Fifty Years Promoting Health and Preventing Disability (1992) / Chapter Skim
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Depression
Depression
Pages 202-223
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From page 202... ...
Depression is seriously underdiagnosed and often misdiagnosed. Vast resources are expended in fruitless diagnostic searches, in medical treatment of somatic symptoms without a detectable basis, and in neglect of the underlying, treatable psychiatric disorder.
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From page 203... ...
The most striking feature of recent studies is the very low prevalence of depression among elderly persons who do not have associated medical problems. The highest figures are lower than those for younger persons, and studies explicitly comparing the prevalence of depression across age groups have led to a growing consensus that major depressive disorders (in contrast to symptoms)
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From page 204... ...
The fact that physical illness and disability not only influence depression but are often inextricably intertwined with it further complicates an understanding of these problems. High rates of depression and of depressive symptoms have been found in select populations for example, among the elderly in nursing homes, where illness and disability are complicated by clepenclency and the Toss of personal control.
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From page 205... ...
Social stressors, such as stressful life events, cause major depressive illness.
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From page 206... ...
5. Although social stressors lead to major depressive illness, this relationship is buffered by perceived social support.
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From page 207... ...
Patients and their families usually seek help from primary care physicians, and these care givers supply a greater proportion of the care of depressed elderly individuals than any other group of health workers. In addition, depression is one of the most common problems seen in their practices, occurring in as many as 30 percent of their patients.
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From page 208... ...
Earlier concerns that tricyclic antidepressants might induce arrhythmias, however, were probably unwarranted; in fact, they may even reduce arrhythmias. Other side effects are anticholinergic ones such as dry mouth, blurred vision, and urinary retention, a problem of particular concern in the elderly.
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From page 209... ...
Current practice is to start these medications at one-third to one-half the standard dosage and to increase it carefully thereafter.6i These problems warrant caution in the use of tricyclic antidepressants, but the experienced clinician can still use them to good effect.24 Electrocardiographic monitoring during the course of treatment greatly reduces carcliovascular risks, and recognition of the various side effects permits rapid response to problems that may clevelop. Still, the many side effects of tricycTic antidepressants raise the question of whether there may not be other, safer medications.
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From page 210... ...
GottTieb28 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.
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From page 211... ...
A survey in North Carolina revealed that no more than 8 percent of mentally impaired persons were receiving any professional mental health services, even though 20 percent of them were receiving psychotropic medication from their primary care physicians.8 The inadequacy of professional mental health care is even more striking among minority groups. A survey of an elderly Hispanic population with a high prevalence of depressive disorders showed that not a single person had ever received any professional mental health care, or even any antidepressant medication, even though at least 75 of them were judged to be suffering from a major depression.38 COSTS An understanding of the costs of mental illness in general and of depression in particular lags far behind knowledge of the treatment of these disorders.
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From page 212... ...
Its disabling effects were comparable to those of a serious heart condition and greater than those of most of the seven other medical conditions.68 Only arthritis was judged to be more painful, and only serious heart conditions resulted in more days in bed. An important and surprising finding of the study was the extent of the disability experienced by persons with depressive symptoms who did not meet the full criteria for a depressive clisorcler: these patients suffered from disability as severe as that of patients who did meet the full criteria.68 The reasons for this unexpected finding are unclear; it may have been a result of the additive effect of chronic medical conditions.
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From page 213... ...
Given the costs of underdiagnosis of psychiatric disorders and the inadequacy of psychiatric treatment, introducing psychiatric programs into medical care of the elderly should realize major cost savings. Four studies provide convincing evidence of the value of outpatient psychiatric treatment.
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From page 214... ...
Suicide is second only to lung cancer as a potentially preventable disorder, and there is usually considerable warning before a suicide attempt. Twothirds of persons who take their lives have communicated their intent to at least one person, and most of them have consulted a physician hours to weeks before their suicide.55 Consultation with suicidal patients often presents physicians with a golden intervention opportunity, as most patients will tell their physicians of their plans if they are asked.
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From page 215... ...
Private insurance coverage of psychiatric disorders is also severely limited: only 53 percent of private policies cover inpatient mental illness expenses in the same
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From page 216... ...
Furthermore, current practices lead to a serious imbalance in the type of site at which services are rendered, with expensive inpatient treatment being favored over more economical outpatient services. The limitation of support for outpatient care of psychiatric disorders, with its potential for the cost savings conferred by avoidance of hospitalization, is particularly short-sighted.
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From page 217... ...
RECOMMENDATIONS Services Insurance Providers (Governmental and PrivateJ Despite the recent removal of the Medicare limitation on outpatient care, inadequate reimbursement for psychiatric care in both the public and private sectors contributes to the (misJcliagnosis of depression as physical illness and, as a consequence, inadequate treatment. The committee's major service recommer2clatior~ is the removal of discriminatory Jimitations of reimbursement for psychiatric care.
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From page 218... ...
for their application should be developed and assessed. These instruments should then be used to determine the prevalence, incidence, costs, and symptom severity of depression in elderly populations, including the institutionalized, the medically ill, and community samples stratified according to socioeconomic status.
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From page 219... ...
Ecincation The committee's major recommendation regarding education is to develop programs to train physicians to detect and treat mental disorders' including depression, in the elderly. In addition, older persons should be informed that depression is an illness that can be successfully treated and that it may occur in the absence of a depressive mood.
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From page 220... ...
Incidence of mental illness in the aged: Unmasking the effects of diagnosis of chronic brain syndrome. Journal of the American Geriatrics Society 1977; 8:371-375.
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From page 221... ...
Chronic mental patients in nursing homes: Reexamining data from the National Nursing Home Study. Hospital and Community Psychiatry 1986; 37:269-272.
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From page 222... ...
E., Jr. Functional status and well-being of patients with chronic conditions: Results from the Medical Outcomes Study.
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From page 223... ...
D., Greenfield, S., and Ware, J E., Jr. The functioning and well-being of depressed patients: Results from the Medical Outcomes Study.
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