Depression in the elderly

Background Depressive and anxiety disorders are prevalent and cause substantial morbidity. While effective treatments exist, little is known about the quality of care for these disorders nationally. We estimated the rate of appropriate treatment among the US population with these disorders, and the effect of insurance, provider type, and individual characteristics on receipt of appropriate care. Methods Data are from a cross-sectional telephone survey conducted during 1997 and 1998 with a national sample. Respondents consisted of 1636 adults with a probable 12-month depressive or anxiety disorder as determined by brief diagnostic interview. Appropriate treatment was defined as present if the respondent had used medication or counseling that was consistent with treatment guidelines. Results During a 1-year period, 83% of adults with a probable depressive or anxiety disorder saw a health care provider (95% confidence interval [CI], 81%-85%) and 30% received some appropriate treatment (95% CI, 28%-33%). Most visited primary care providers only. Appropriate care was received by 19% in this group (95% CI, 16%-23%) and by 90% of individuals visiting mental health specialists (95% CI, 85%-94%). Appropriate treatment was less likely for men and those who were black, less educated, or younger than 30 or older than 59 years (range, 19-97 years). Insurance and income had no effect on receipt of appropriate care. Conclusions It is possible to evaluate mental health care quality on a national basis. Most adults with a probable depressive or anxiety disorder do not receive appropriate care for their disorder. While this holds across diverse groups, appropriate care is less common in certain demographic subgroups.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/481702/yoa20071.pdf

The Quality of Care for Depressive and Anxiety Disorders in the United States

Comparative validity of three screening questionnaires for DSM-IV depressive disorders and physicians' diagnoses.

Background. Adolescent obesity is a strong predictor of adult obesity, and adult obesity has been associated with depression, especially in women. Studies have also suggested an association between depression in adolescence and higher body mass index (BMI) in adulthood. Whether depression leads to obesity or obesity causes depression is unclear. Objective. To determine in longitudinal analyses whether depressed mood predicts the development and persistence of obesity in adolescents. Methods. A prospective cohort study of 9374 adolescents in grades 7 through 12 who completed in-home interviews for the National Longitudinal Study of Adolescent Health. Assessments were made at baseline (1995) and at follow-up 1 year later. Depressed mood was assessed with the Center for Epidemiologic Studies Depression Scale. BMI (kg/m2) was calculated from self-reported height and weight. BMI percentiles and z scores were computed using the 2000 Centers for Disease Control and Prevention growth charts. Obesity was defined as BMI ≥95th percentile, overweight as BMI ≥85th percentile and Results. At baseline, 12.9% were overweight, 9.7% were obese, and 8.8% had depressed mood. Baseline depression was not significantly correlated with baseline obesity. Among the 9.7% who were obese at follow-up, 79.6% were obese at baseline, 18.6% were overweight at baseline, and 1.8% were normal weight at baseline. Having depressed mood at baseline independently predicted obesity at follow-up (odds ratio: 2.05; 95% confidence interval: 1.18, 3.56) after controlling for BMI z score at baseline, age, race, gender, parental obesity, number of parents in the home, and family socioeconomic status. This finding persisted after controlling further for the adolescents’ report of smoking, self-esteem, delinquent behavior (conduct disorder), and physical activity. After controlling for all these same factors, depressed mood at baseline also predicted obesity at follow-up among those not obese at baseline (odds ratio: 2.05; 95% confidence interval: 1.04, 4.06) and follow-up BMI z score among those obese at baseline (β = 0.11; standard error β = 0.05). In contrast, baseline obesity did not predict follow-up depression. Conclusions. Depressed adolescents are at increased risk for the development and persistence of obesity during adolescence. Understanding the shared biological and social determinants linking depressed mood and obesity may inform the prevention and treatment of both disorders.

A Prospective Study of the Role of Depression in the Development and Persistence of Adolescent Obesity

ContextSuicide rates are highest in late life; the majority of older adults
who die by suicide have seen a primary care physician in preceding months.
Depression is the strongest risk factor for late-life suicide and for suicide's
precursor, suicidal ideation.ObjectiveTo determine the effect of a primary care intervention on suicidal ideation
and depression in older patients.Design and SettingRandomized controlled trial known as PROSPECT (Prevention of Suicide
in Primary Care Elderly: Collaborative Trial) with patient recruitment from
20 primary care practices in New York City, Philadelphia, and Pittsburgh regions,
May 1999 through August 2001.ParticipantsTwo-stage, age-stratified (60-74, ≥75 years) depression screening
of randomly sampled patients; enrollment included patients who screened positive
and a random sample of screened negative patients. This analysis included
patients with a depression diagnosis (N = 598).InterventionTreatment guidelines tailored for the elderly with care management compared
with usual care.Main Outcome MeasuresAssessment of suicidal ideation and depression severity at baseline,
4 months, 8 months, and 12 months.ResultsRates of suicidal ideation declined faster (P =
.01) in intervention patients compared with usual care patients; at 4 months,
in the intervention group, raw rates of suicidal ideation declined 12.9% points
(29.4% to 16.5%) compared with 3.0% points (20.1% to 17.1% in usual care [P = .01]). Among patients reporting suicidal ideation,
resolution of ideation was faster among intervention patients (P = .03); differences peaked at 8 months (70.7% vs 43.9% resolution; P = .005). Intervention patients had a more favorable course
of depression in both degree and speed of symptom reduction; group difference
peaked at 4 months. The effects on depression were not significant among patients
with minor depression unless suicidal ideation was present.ConclusionsEvidence of the intervention's effectiveness in community-based primary
care with a heterogeneous sample of depressed patients introduces new challenges
related to its sustainability and dissemination. The intervention's effectiveness
in reducing suicidal ideation, regardless of depression severity, reinforces
its role as a prevention strategy to reduce risk factors for suicide in late
life.

https://jamanetwork.com/journals/jama/articlepdf/198310/JOC32219.pdf

Reducing Suicidal Ideation and Depressive Symptoms in Depressed Older Primary Care Patients: A Randomized Controlled Trial

The Depression Guideline Panel of the Agency for Health Care Policy and Research in 1993 published recommendations for treating major depression in primary care practice that were often based on studies of tertiary care psychiatric patients. We reviewed reports of randomized controlled trials in primary care settings published between 1992 and 1998. This evidence indicates that both antidepressant pharmacotherapy and time-limited depression-targeted psychotherapies are efficacious when transferred from psychiatric to primary care settings. In most cases, the choice between these treatments should depend on patient preference. Studies to date suggest that improving treatment of depression in primary care requires properly organized treatment programs, regular patient follow-up, monitoring of treatment adherence, and a prominent role for the mental health specialist as educator, consultant, and clinician for the more severely ill. Future research should focus on how guidelines are best implemented in routine practice, since conventional dissemination strategies have little impact.

A J Rush

Papers

Treating Major Depression in Primary Care Practice: An Update of the Agency for Health Care Policy and Research Practice Guidelines