Depression In The Elderly: The Best Treatment Approach Literature Reviews Examples
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Introduction. Analysis of Research Topic.
Depression is one of the most wide-spread problems in the elderly. Described as one of the significant contributors to the old age disability, affecting functionality in all significant domains, and being one of the leading causes of suicide in people aged over 65, depression in the elderly remains one of the public health challenges both in developed and developing countries (Holroyd-Leduc & Reddy, 2011).Despite the accumulated evidence on different treatment strategies, the approaches to the best ways of depression treatment in elderly remain controversial. The purpose of this review is to determine the effectiveness and safety of different modalities for treatment of depression in the elderly patients.
Search terms and criteria were established for the main research question: what evidence-based treatment options can be recommended to treat depression in elderly patients? To answer the question, Cochrane Library, EMBASE, OVID Medline, and PsychINFO between September 2011 and February 2014 were searched for systematic reviews, case studies, observational studies and randomized controlled trials. Search terms included: depression AND elderly, depression NEAR treatment, depression NEAR elderly, “depression in the elderly”, “depression tteatment in elderly”, depress*, (depression AND elderly) AND (pharmacological OR non-pharmacological), “pharmacologic treatment of depression”, drugs treatment AND depression, elderly patients AND depression, “elderly with depression”. 5 articles were selected based on the search criteria, 2 literature reviews, 1 case study, 1 observational study and 1 randomized control trial. Oxford Centre of Evidence-Based Medicine Scale (2009) was used to evaluate the quality and the evidence level of each article.
Analysis of literature
The review of Hardy (2011) outlines the main methods of identifying depression in elderly population and the strategies used to cope with the depression, based on UK experience. The article target audience are practice (community) nurses who should be able to detect depression in geriatric population, with a quick referral to physician. Building its argument on both National Institute for Clinical Excellence (NICE) framework and world-used general instruments (Geriatric Depression Scale, Patient Test Questionnaire-9, etc.), the author also suggests tailor-made practical tools of assessment of depression based on the range of symptoms such as sexual dysfunction, bowel, appetite, general appearance, psychological and cognitive changes. These symptoms can vary widely in different patients, so additional practical algorythm with exclusion criteria for physical depression causes (dementia, hypothyroidism) and additional simple risk assessment tool to detect suicide intention\major depressive episodes is suggested by the author. However the both NICE guidelines which the author’s treatment strategy overview is based on, are not specific for the targeted population (aged 65 and over), with one being focused on general treatment in adults and a second targeted at adults with any chronic disease. Based on these guidelines, the author suggests individually modified physical activity programs (accounting for the health status of the patient, the appropriate screening for any comorbidities like diabetes, anaemia etc.), peer support programs in social groups, individual guided self-help and computerized cognitive behavioural therapy (CBT) as main treatment strategies. The author supports the suggestion of physical activity, individualized self-help and peer support programmes as depression treatment for the elderly, only and entirely by the existing UK practice, while scarce research evidence data are given for computerized CBT for people aged 65 and over. For pharmacological treatment, more impressive evidence from clinical trials suggesting selective serotonine reuptake inhibitors (SSRI) are effective in 8 out of 10 patients is given. However these data are again derived from general population research and may be only partly applicable to older population as the risk of side effects the author mentions (nausea, diarrhoea, dizziness, agitation, insomnia, tremor, sexual dysfunction and risk of bleeding) can be higher in elderly patients due to multiple comorbidities. In general, it is a review article with Evidence level 5, with body of evidence based predominantly on expert opinion (only one RCT applicable to general population) and extrapolating the evidence from general studies to the elderly population.
While Hardy (2011) review deals mainly with non-pharmacological ways of support, another review of Frank (2014) is focused on pharmacological treatment of depression in the elderly. The framework used by the author is the 2006 Canadian Coalition for Seniors’ Mental Health (CCSMH) guideline on the assessment and treatment of depression. The author builds its argument on those age-specific recommendations properly referencing the evidence level for each type of medications used to treat depression. The case study which the author bases its illustrative examples upon reveals the most common symptoms of depression (sleep changes, anxiety, cognitive deterioration), demonstrates the diagnostics process and outlines the depression treatment by phases (acute, continuation and prophylaxis). However this phased approach is described only for the example case of a patient with unipolar major depressive episode without psychotic features, while for those with psychosis or frailty the protocols can differ. The author emphasizes the meaning of social and environmental context for each patient, stating the importance of socialization and psychotherapy (Level A recommendations). Still, while pharmacological approach to depression treatment is not affected by age (apart from side effects which are common in the elderly population), behavioural therapies for the old age can differ. The author attaches a well-structured and detailed table of antidepressant medications with appropriate dosage (serotonine-norepinephrine reuptake inhibitors (SNRIs), SSRIs, tricyclic antidepressants) underlining that antidepressant choice should be made individually based on psychotic condition, previous response and comorbidities of the patient. Still the author does not present the detailed recommendations stipulating the first- and second-line choices for pharmacological treatment of the elderly patients based on specific conditions and comorbidities (severe behavioural symptoms, severe sexual dysfunction, frailty) as it is done in the corresponding framework. The appropriate evidence level for each type of pharmacological interventions, in accordance with CCSMH guideline, is not mentioned, except for side effects, titration and monitoring. Electroconvulsive therapy is given its place as a life-saving treatment in case of suicidal thoughts (Level D), and the criteria for psychiatric referral are properly outlined. The overall quality of the article is good though it lacks proper references to evidence level of specific pharmacological interventions, with the body of evidence graded as Level 1a (based on many 1+ evidence level target population studies and demonstrating consistency of results).
The research of systematic activation method (SAM) as a non-pharmacological way of depression treatment is presented by Clignet et al. (2012) in a single case report. The method is applied to 77-year-old woman with a major depressive disorder admitted to health care facility. The framework for the method is reactivation as an important nursing intervention, tailored by the authors to the needs of the depressed elderly and based on Activity Scheduling (AS) as a behavioral treatment for depression. While some modifications of AS exist, the authors develop its technique from the original AS concept incorporating elements of socialization, social skills training and cognitive restructuring on the basis of increasing pleasant activities. The use of stepwise approach which gradually introduced mood monitoring, introducing and planning pleasant activities, use of external resources with activity experiment and consolidation, prevented the elderly patient from being overwhelmed. For the patient, the described sequence of steps served a motivational intervention having given her impetus to get control over her activity level and to decrease its dependency on her mood, with a growing degree of self-motivation to pleasant activities. Though a 6-weeks-follow up session demonstrated the patient’s increased level of depression, it strongly correlated with decline in her activity levels. The authors’ conclusion on activity integration in the patients’ daily life as an effective treatment strategy however has limitations. It illustrates the effectiveness of a specific (CAM) intervention in one specific cognitively healthy and motivated person at the stage of recovery from one specific disease (major depressive episode without psychotic features).The patients with other depressive disorders (e.g. bipolar disorder or accompanying psychotic features), avoidant or cognitively impaired can either demonstrate opposite results or refuse from participation. This study evidence strength is rated as Level 3b ( single case report), and although CAM showed promising results in striking the balance between zero activity level and imposed activities, to prove its effectiveness, studies of another design (observational or RCT) with larger population involvement are necessary.
The two-year observational study of Magnil et al.(2013) explores the role of disease clinical course, risk and prognostic factors affecting the treatment effectiveness in the cohort of 302 patients aged 60 and older, from one primary care centre. The study is based on nursing intervention techniques such as depression screening with the use of 3 methods: standard questionnaires like Primary Care Evaluation of Mental Disorders or Montgomery-Asberg Depression-Rating Scale, self rating (MADRS-S) and a screening consultation with a clinican to confirm the diagnosis of “possible depression”, and the patients with mild or moderate depression were followed up for 2 years. Though the authors give no details on pharmacological, psychological, or combination of both treatment strategies in the patients, the research contains significant finding of lack of leisure activities increasing the severity of depression in long-term (2 years) perspective. The inclusion of such activities in everyday schedule is positively associated with reduction of depression risk and speed of recovery, corroborating findings of Clignet et al. (2012). Though more than 50% of patients screened positive by all screeing methods, the correlation between depression course ( remitting, stable, fluctuating) and severity (mild or moderate) with prognostic factors is limited to the known prognostic factors, without those which might have been revealed by patients’ screening on admission and discharge. Though the study is longitudinal and of high quality (Evidence level 2b), the number of participants is small and larger studies are necessary to assess the importance of leisure activities as an important prognostic factor.
The last research, a randomized controlled trial by Preschl et al. (2014) on life-review computer-based therapy illustrated the effectiveness of combination of a recognized therapeutic approach (life review) with new media (e-mental health Butler system). Life-review therapy aims to balance positive and negative reminiscences as related to successful aging and e-therapy is used as a successful supplement to face-to-face therapy. All 36 study participants with elevated levels of depressive symptoms were randomized to a treatment group or a waiting-list control group, and completed the assessment after the therapy. The outcomes estimated in the study were depression, well-being, self-esteem, and life satisfaction and reminiscence types. The statistical analysis demonstrated significant reduction of depressive symptoms in the intervention group compared to the control group (pre to post: d = 1.13; pre to follow-up: d = 1.27; and group time effect pre to post: d = 0.72), and increase in well-being as well as decrease in obsessive reminiscence (well-being: d = 0.70; obsessive reminiscence: d = 0.93). The low sample size and the selection method (self-selection based on recruitment advertising), as well as the homogeneity of the participants (previous psychotherapy experience, no comorbidities) were the limitations of the study which do not allow the extrapolation of its effect on the general population. Still, medium-to high effect sizes in this high quality (Evidence level 1b) RCT imply that life-review computer-based therapy can be recommended as depression treatment in the elderly.
Summary of findings
All studies demonstrate that as agreed by experts the management of depression in the elderly depends on many factors ( severity of the symptom, previous history, comorbidities, patients’ willingness to participate and patients’ preferences) depending on which different options from non-pharmacological methods (psychotherapy) to pharmacological treatment and electroconvulsive therapy, can be used (Flaherty & Resnick, 2014 ). While mild-to moderate depression can be treated by behavioral therapies, socialization and increase of leisure activities, with adding antidepressants as last resort, moderate and severe depression with suicidal thoughts can require the earlier decision on antidepressants and\or electroconvulsive therapy as treatment strategy (Flaherty & Resnick, 2014). The evidence strength of 5 articles studying these different treatment strategies is summarized in Table 1.
While pharmacological methods of depression treatment in the elderly do not differ much from those in general population ( SSRIs, SNRIs and tricyclic antidepressants), they require more careful attention to possible side effects, previous history and comorbidities and should be applied based on degree of severity of depression. The non-pharmacological interventions should be tailored to different patient categories with depressive disorders. Cognitive behavioral therapies proved its effectiveness, and specific techniques like computer-based life reviews can be effective tools to reduce the severity of depression and to increase life satisfaction. The strong adverse correlation between the level of leisure activities and depression risk corroborates the evidence on significance of CAM as an effective method of depression treatment. Further research is necessary to define the most effective non-pharmacological interventions to fight depression in the elderly population.
1. Clignet, F., van Meijel, B., van Straten, A., Lampe, I., & Cuijpers, P. (2012). The Systematic Activation Method (SAM) in Depressed Elderly: A Case Report.Perspectives In Psychiatric Care, 48(1), 25-33. doi:10.1111/j.1744-6163.2010.00297.
2. Flaherty, E., & Resnick, B. (Eds.). (2014). Geriatric nursing review syllabus: A core curriculum in advanced practice geriatric nursing (4th ed.). New York, NY: American Geriatrics Society.
3. Frank, C. (2014). Pharmacologic treatment of depression in the elderly. Canadian Family Physician, 60(2), 121-126.
4. Hardy, S. (2011). Depression in the elderly: ways to offer support. Practice Nursing, 22(10), 520-525.
5. Holroyd-Leduc, J., & Reddy, M. (Eds.). (2012). Evidence-based geriatric medicine: A practical clinical guide. Hoboken, NJ: Blackwell Publishing.
6. Magnil, M., Janmarker, L., Gunnarsson, R., & Björkelund, C. (2013). Course, risk factors, and prognostic factors in elderly primary care patients with mild depression: A two-year observational study. Scandinavian Journal Of Primary Health Care, 31(1), 20-25. doi:10.3109/02813432.2012.757074
7. Oxford Centre of Evidence-Based Medicine (2009). Oxford Centre of Evidence-Based Medicine – Levels of Evidence. Retrieved from: http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/
7. Preschl, B., Maercker, A., Wagner, B., Forstmeier, S., Baños, R. M., Alcañiz, M., Botella, C. (2012). Life-review therapy with computer supplements for depression in the elderly: A randomized controlled trial. Aging & Mental Health, 16(8), 964-974. doi:10.1080/13607863.2012.702726
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