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Depression: Implications for State and Local Healthcare Programs

Late-Life Depression

Presenter:

Ira Katz, M.D.,Ph.D., Professor of Psychiatry, University of Pennsylvania, and Philadelphia VA Medical Center, Philadelphia, Pennsylvania


Late-life depression is quite different from depression in the nonelderly population. In the United States, there is a 15-percent prevalence rate of depression in elderly people living in the community and a rate of 30-40 percent among those residing in nursing homes. Major depression occurs in approximately 1-4 percent of the community-based elderly; this rate increases to 10-12 percent in medical care settings and 20-25 percent in nursing homes.

Depression has a significant impact on the elderly population, as it can lead to many serious problems, including:

  • Increased disability.
  • Cognitive impairment.
  • Pain.
  • Malnutrition.
  • Substance abuse.
  • Treatment refusal.
  • Suicide.

According to Dr. Katz, one of the most effective and important mechanisms to combat depression is to emphasize providing elderly people with rehabilitation for illness and injury. This is a concept that in some settings has been lost. Often older people become depressed as a result of injury or illness and therefore need to undergo rehabilitation. Depression has been shown to be a barrier to rehabilitation. Therefore, it is critical to address both illness and injury as well as depression simultaneously in order to prevent debilitation in elderly patients.

Currently, work is being carried out in several key multisite randomized studies of treatment strategies for elderly primary care patients with mental disorders:

  • SAMHSA/VA (Substance Abuse and Mental Health Services Administration/Department of Veterans Affairs)—Integrated versus referral care focusing on depression, anxiety, alcohol abuse.
  • IMPACT—Disease management versus usual care focusing on depression, choice of medication and psychotherapy available as a first line of treatment.
  • PROSPECT—Disease management versus enhanced care focusing on depression, specific medications, and psychotherapy as a second line of treatment.

These studies should provide information and recommendations on recognition and treatment of mental disorders in older primary care patients, provide an evidence base for the design of care systems and health policy for this population, and triangulate the effects of usual care compared with collaborative care for depression, compared with specialty referral.

Dr. Katz also discussed the importance of a variety of community programs that have been initiated to provide depression care for adults in later life. The Gatekeeper program in Maryland provides case identification in the community and referral to integrated aging/mental health services, while the PATCH model, which targets the elderly population in urban public housing sites, provides psychogeriatric assessment and treatment in city housing, which combines gatekeepers and public health nursing to care for this population.

References

Katz IR, Coyne JC. The public health model for mental health care for the elderly. JAMA 2000;283:2844-5.

Rabins V, Black BS, Roca R, et al. Effectiveness of nurse-based outreach program for identifying and treating psychiatric illness in the elderly. JAMA 2000;283:2802-9.


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