More Older People Treated
By Paula Span, The New York
July 25, 2012
mother-in-law had suffered from depression for years,
it was clear in hindsight, and had denied it for
years, too. Only 73, she’d lost interest in doing much
of anything. In chronic pain after an earlier
accident, she was taking high doses of methadone. Last
November, she stunned her family by declining, at the
eleventh hour, to come to Thanksgiving dinner.
“I’d only seen her in a nightgown for a year
straight,” said Ms. Hill, 42, an accountant in
Atlanta. “She was just rotting away in bed, watching
TV and taking methadone.”
Depression in the elderly is a mixed picture these
For years, mental health specialists lamented that
depression was seriously underdiagnosed and
undertreated in the elderly. Laypeople saw it not as a
disease but as an inevitable part of aging. Doctors
missed it because depression didn’t always look the
way it did in younger patients — less sadness and
weepiness, more physical symptoms and disengagement.
Older people themselves often rejected help because
mental illness carried a stigma.
In primary care practices, Dr. Jürgen
Unützer and colleagues found in a large study
published in 2000, only 12 to 25 percent of older
people with probable depression were getting a
diagnosis and being treated.
Not anymore. Over the past decade, “we’ve seen a
really big increase in the recognition of depression
and the initiation of treatment,” said Dr.
Unützer, a geriatric psychiatrist now at the
University of Washington.
Why the change? He credits stepped-up education for
primary care doctors, new antidepressants that seniors
find easier to take and tolerate, and a recommendation
by the United States Preventive Services Task Force
that older adults be screened for depression when
there’s staff available for treatment and follow-up.
Under the Affordable Care Act, depression screening
became part of the free Welcome to Medicare visit for
new beneficiaries and of free annual wellness visits
Now, in primary care practices, about half of older
adults with depression have the condition diagnosed
and treated, Dr. Unützer said. A recent study
also shows higher diagnosis and treatment rates among
nursing home residents.
Over all, “that’s a very good thing,” Dr. Unützer
said. Then he delivered the less happy follow-up: “The
bad news is that a lot of these folks aren’t a lot
A study he published last year found that only 19
percent of elders with diagnosed depression who
received “usual care” in primary care practices showed
substantial improvement. “We find it more and we treat
it more, but we don’t treat it very well yet,” he
One apparent explanation: the setting. A great
majority of older people seek treatment through their
primary care doctors, few of whom are able to offer
much more than a prescription.
A Rutgers/Columbia team found last year that as
diagnosis rates climbed, more than two-thirds of older
patients with depression received antidepressants, but
the proportion receiving psychotherapy declined, to
less than 15 percent.
Yet not everyone responds to antidepressants. J. Craig
Nelson, director of geriatric psychiatry at the
University of California, San Francisco, has published
an analysis showing that the drugs’ efficacy in older
patients only modestly exceeds that of placebos.
Moreover, patients often need to try a series or
combination at varying doses to find a drug regimen
“We should treat this more like other medical
problems,” Dr. Unützer said. “If you have high
blood pressure or diabetes, we wouldn’t just ask,
‘How’s it going?’ We’d take your blood pressure or
your blood glucose. We’d keep making changes.” If
drugs alone didn’t provide relief, doctors would refer
to a specialist — in this case, a psychotherapist or
“Spending time, giving support, providing education to
people increases the response to the medication at any
age,” Dr. Nelson said. Yet it can still be difficult
to steer older patients toward mental health services.
The stigma remains. A pill seems easier.
One approach that has proved successful is to move
more comprehensive care for late-life depression into
existing offices and clinics. Dr. Unützer and his
team looked at these “collaborative care” practices,
in which a trained nurse or psychologist served as
“depression care manager,” working with patients to
develop treatments and monitor progress and to refer
them to psychiatrists when necessary.
Among 1,800 depressed people over age 60, a group
randomly assigned to collaborative care showed far
greater improvement. After a year, 45 percent had at
least a 50 percent reduction in depressive symptoms,
compared with that dismal 19 percent in usual care.
They reported less functional impairment, greater
quality of life.
The program reduced costs, too, because people with
depression pay more visits to doctors and emergency
rooms and are more frequently hospitalized. “It
increases complications associated with diabetes,” Dr.
Nelson said. “Increases mortality after a heart
attack. Increases mortality after a stroke.”
There’s an advocacy role for family members to play.
Talking to a primary care doctor may be a good way to
start treating depression, but in many cases that’s
not where to stop. It can take four or five tries to
calibrate the most effective medication, said Dr.
Unützer. Your relative might benefit from
collaborative care or psychotherapy. “You shouldn’t
give up,” he said, “until you find something that
makes you feel better.”
Ms. Hill’s mother-in-law offers a case in point. After
much discussion, her family united and got her into
treatment. She sees a psychiatrist, who prescribed
Cymbalta and is helping to wean her off methadone. A
therapist visits her twice weekly in her assisted
living apartment. “It has turned back the clock 10
years,” Ms. Hill said.
Last month, wearing a jaunty hat, her mother-in-law
came to a son’s birthday party, her first family
function in months. As treatment continues, “she’s out
in the world again,” her daughter-in-law said. “It’s
wonderful to see.”
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