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Essentials of Diagnosis
Depressed mood.
Loss of interest or pleasure in almost all activities.
Unintentional weight change, lack of energy, change in sleep pattern, psychomotor retardation or agitation, excessive guilt, or poor concentration.
Suicidal ideation or recurrent thoughts of death.
Somatic rather than mood complaints in the elderly.
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General Principles in Older Adults
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By 2020, depression will rank second only to cardiovascular disease as a cause of global disability and a major public health problem in older people. The prevalence of major depression is estimated at 1% to 2% for elders in the community and 10% to 12% for those in primary care settings. However, even in the absence of major depression as defined by Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) criteria, up to 27% of elders experience substantial depressive symptoms that may be relieved with intervention. For institutionalized elders, the rates of major depression are much higher: 12% for hospitalized elders and 43% for permanently institutionalized elders.
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The World Health Organization Primary Care Study reported that 60% of primary care clinic patients treated with antidepressant medication still met criteria for depression 1 year later, with similar efficacy rates for antidepressants reported in older adults and those younger than the age of 60 years. However, depression is often missed or inadequately managed in older adults, sometimes because of the belief that depression is an inevitable process of aging or because treatment may be risky or ineffective. Indeed, there are several reasons why optimal treatment of depression in the geriatric population may differ from that for younger populations. Higher rates of physical and cognitive comorbidity in older adults, different social circumstances, greater potential for polypharmacy, and age-related pharmacodynamic and pharmacokinetic susceptibility all suggest that this population should be considered separately.
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Women are twice as likely to experience major depression as men. Other risk factors include prior episodes or a personal family history of depression, lack of social support, use of alcohol or other substances, and a recent loss of a loved one. Several medical conditions are also associated with an increased risk of depression, including Parkinson disease, recent myocardial infarction, and stroke. These conditions share common threads of loss of control of body or mind, increasing dependence on others, and increased social isolation.
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Depression is associated with poorer self-care and slower recovery after acute medical illnesses. It can accelerate cognitive and physical decline and leads to an increased use and cost of health care services. Among depressed older adults who have had a stroke, rehabilitation efforts are less effective and mortality rates are significantly higher.
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Major depression is defined as depressed mood or loss of interest in nearly all activities (anhedonia) or both for at least 2 weeks, accompanied by a minimum of 3 or 4 ...