Clinical Review
Assessment and Treatment of Late-Life
Depression
Juliet A. Glover, MD, and Shilpa Srinivasan, MD
Abstract
• Objective: To review the identification, clinical assessment and treatment of patients with late-life depression.
• Methods: Review of the literature.
• Results: Depressive symptoms are present in up
to 1 in 4 older adults. Comprehensive evaluation of
depressive symptoms in this population often requires
a multidisciplinary and collaborative approach
between primary care, mental health, and other
ancillary providers. Key aspects include a detailed
history, physical and mental status examinations,
cognitive and functional status assessment, and suicide risk assessment. Treatment options include antidepressants, psychotherapy, and electroconvulsive
therapy.
• Conclusion: A systematic approach to evaluating
depressive symptoms in the elderly can enhance
timely recognition and treatment.
Key words: Late-life depression; clinical assessment; antidepressants; psychotherapy; electroconvulsive therapy.
T
he U.S. population is aging, and with this comes
the potential for increased health care needs.
In 2014, there were over 46 million Americans
age 65 and over (14.5% of the U.S. population). This
number is projected to increase to 88 million by the year
2050 [1]. One in 4 older adults suffers with depressive
symptoms that cause distress and functional impairment
[2]. The World Health Organization Global Burden
of Disease Study found depressive disorders to be the
leading cause of disability-adjusted life years (DALYs)
and the second leading cause of years lived with disability (YLDs). The burden of disease due to depressive
disorders increased by 37.5% between 1990 and 2010,
and 10.4% was attributable to aging [3]. These figures
underscore the importance of accurate assessment and
treatment of depression in the elderly. In this article, we
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review the identification, clinical assessment, and treatment of patients with late-life depression.
Diagnostic Criteria
Late-life depression (LLD) is defined as onset of depressive symptoms after age 65 years. The Diagnostic and
Statistical Manual of Mental Disorders, 5th edition
(DSM-5) criteria for major depressive disorder (MDD) is
unchanged from the DSM-IV, text revision (DSM-IVTR) criteria. In order to receive a diagnosis of major
depressive disorder, patients must exhibit depressed
mood and/or loss of interest plus 4 or more associated
symptoms, including changes in appetite, sleep disturbance, psychomotor agitation or retardation, fatigue,
inappropriate guilt or feelings of worthlessness, poor
concentration or indecisiveness, and recurrent thoughts
of death or suicidal ideation. Symptoms must be present
nearly every day for at least 2 weeks and cause clinically
significant distress or functional impairment [4]. Patients
who do not fully meet criteria but still exhibit clinically
significant distress may be diagnosed with various subsyndromal depressive disorders (Table 1).
Prevalence
It is estimated that 1% to 4% of community-dwelling
adults age 65 and older suffer from MDD, with women
more likely to be affected than men (prevalence of 4.4%
vs. 2.7) [2,5–7]. This estimate is low compared with
lifetime prevalence of almost 20% in the general adult
population [8]. However, when depressive symptoms that
do not meet criteria for MDD are considered, prevalence
rates increase up to 25% [2,9]. These estimates also vary
by clinical setting, with the highest rates (up to 40%)
among elderly patients in long-term care facilities [10,11].
From the Department of Neuropsychiatry and Behavioral
Sceince, University of South Carolina School of Medicine,
Columbia, SC.
Vol. 24, No. 3 March 2017 JCOM 135
Late-life depression
Table 1. Subsyndromal Depressive Disorders
Persistent Depressive Disorder (Dysthymia)
Depressed mood for at least 2 years + 2 of the following: (1) appetite
changes, (2) sleep disturbance, (3) low energy, (4) low self esteem,
(5) poor concentration/indecisiveness, (6) hopelessness
Other Specified Depressive Disorders
Recurrent Brief Depression
Depressed mood + at least 4 associated MDE symptoms lasting 2–13 days
and occurring at least monthly for 12 consecutive months
Short Duration Depressive Episode
Depressed mood + at least 4 associated MDE symptoms lasting 4–13 days
Depressive Episode with Insufficient Symptoms
Depressed mood + at least 1 associated MDE symptoms lasting at least
2 weeks
Unspecified Depressive Disorder
Clinically significant depressive symptoms that do not meet criteria for a
specific depressive disorder
MDE = major depressive episode. Data from reference 4.
While individuals with subsyndromal depression may
experience fewer symptoms than those with MDD, clinically significant distress persists, impacting health and
functional status. Depression is associated with overall
poor social or occupational functioning, cognitive decline,
increased health care utilization and cost, increased morbidity and mortality from medical illness, and increased
suicide mortality [5,9,10,12].
Identifying LLD
In order to make the diagnosis of LLD, the clinician
should be aware that clinical presentations may be varied,
and symptoms may not be readily evident [13]. LLD is
often under-recognized and under-treated, particularly
in busy primary care settings where concerns about physical symptoms may take precedence over screening for
behavioral health conditions [14]. Other barriers include
phenomenologic differences (prominence of executive
dysfunction, neurovegetative and somatic features) in
depressed older adults compared to younger counterparts, under-reporting of emotional symptoms, and
stereotypical views of emotional dysfunction being a
“normal” part of aging [15,16]. Recognition of risk factors for depression can aid in making the diagnosis. Risk
factors can be categorized as biological or psychosocial
in nature (Table 2) [17]. The most significant risk factors for depression in the elderly include female gender,
past history of depression, sleep disturbance, disability,
and bereavement [12]. Protective factors include physical
health, self-efficacy, social connectedness, and religious
involvement [17].
Accurate identification of LLD also requires recognition of the differences in the presentation of LLD com136 JCOM March 2017 Vol. 24, No. 3
pared with onset in earlier life. Depression in younger
adults is often marked by depressed mood and loss
of interest [18]. In contrast, older adults may present
with increased anger or irritability [5]. Younger adults
are more likely to report suicidal thoughts while older
patients report feelings of hopelessness and thoughts
of death [18]. LLD is often characterized by increased
somatic complaints, hypochondriasis, or pain [5,18,19].
Another major difference lies in the presentation of cognitive difficulties. Younger patients typically complain of
poor concentration or indecisiveness. Geriatric patients
may present with cognitive changes including objective
findings of slower processing speed and executive dysfunction on neuropsychological testing [17].
Depression rating scales may aid in identification of
LLD. They are not a substitute for clinical diagnosis but
can be useful as screening tools. Two commonly utilized
depression rating scales are the Geriatric Depression
Scale (GDS) and the Patient Health Questionnaire-9
(PHQ-9). GDS is a 30-item instrument developed specifically for older adults. Shorter 15-item, 5-item, and
4-item versions exist. The scale utilizes a Yes/No format
and can be self- or clinician-administered [20]. One
advantage of the GDS lies in its focus on psychological
and cognitive aspects of depression rather than neurovegetative symptoms that may overlap with medical illnesses
common in older adults [21]. The PHQ-9 is a 9-item
self- or clinician-administered screening tool designed for
use in primary care settings and has also been validated
in geriatric populations [22,23]. The 9 items on this scale
correspond to the DSM-5 criteria for major depression.
A shorter 2-item version (PHQ-2) has also been validated, and a positive screen on this test should prompt
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Clinical Review
administration of the full-length version. Both versions
have approximately 80% sensitivity and specificity in
detecting depression. An added advantage of PHQ-9
over GDS is that it can be useful in monitoring treatment
response over time [22,23]
Comprehensive Assessment of LLD
The comprehensive assessment of patients with LLD can
be carried out by health professionals in both mental
health or primary care settings. In a multidisciplinary
approach, psychiatrists and mental health professionals have collaborated with primary care providers using
depression care managers with successful outcomes in
managing depression in older adults [24,25]. Complete
evaluation of a patient with suspected LLD begins with
a history and physical and mental status examination.
Other essential components of the evaluation include
assessment of cognition, functional status, and suicide
risk. Laboratory and neuroimaging studies may be necessary as well. Due to the comprehensive nature of this
assessment, a multidisciplinary approach with collaboration between primary care, psychiatry, psychology, and
ancillary services such as social work may be necessary.
Multiple patient interactions may be required to complete
a thorough evaluation.
History and Mental Status Examination
As with many other psychiatric illnesses, LLD is a
clinical diagnosis. A careful history should be obtained
initially utilizing open-ended questions. This should
be followed by more directed questions as indicated to
elicit the presence of depressive symptoms. The history
should be obtained from the patient. A relevant collateral
informant can be invaluable in the assessment, especially
in cases where there is a comorbid neurocognitive disorder. However, the patient’s informed consent must
be obtained prior to obtaining collateral information
whenever possible. Psychosocial stressors that may have
precipitated or may be perpetuating symptoms should
be explored. Such stressors may include recent changes
in living situation, loss of social support, recent deaths,
or financial difficulties. Biological precipitants also need
to be explored including presence of physical illness,
depressogenic medications, and comorbid alcohol or
other substance use. The patient’s past psychiatric history, psychiatric hospitalizations, and past medication trials
should be ascertained. Any family history of depression,
other psychiatric disorders, substance use disorders, and
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Table 2. Depression Risk Factors
Biological
Psychosocial
Gender: F > M
History of depression
Chronic medical illness
Chronic pain
Sleep disturbance
Depressogenic medications, eg, opioids, benzodiazepines,
beta blockers
Social isolation
Marital status: single, divorced, widowed
Bereavement
Caregiver role
Low socioeconomic status/financial stress
Poor perceived health
Adapted from references 5,11,12, and 17.
suicide attempts should be documented. A full mental
status exam including cognitive assessment should be
completed [21,26].
Cognitive Assessment
Cognitive impairment can be associated with LLD and
may be due to the underlying depression or represent
a comorbid neurocognitive disorder. Furthermore, the
burden of medical illness as well as cerebrovascular and
cardiovascular risk factors have been linked to executive
dysfunction and reduced processing speed in individuals
with LDD [27,28]. Distinguishing between these can
be challenging; however, chronology of symptom onset
is often helpful. Depression is more likely the etiology of
cognitive impairment when depressive symptoms precede
onset of cognitive deficits. This type of cognitive impairment is termed dementia syndrome of depression and may
improve with treatment of depression [5]. Some patients
may progress to develop major cognitive decline, and it
remains unclear whether LLD represents a risk factor or
prodrome to developing a major neurocognitive disorder
[29]. On the other hand, if depression develops later in the
course of cognitive decline, there may be an underlying
neurocognitive disorder [17]. Up to 20% of individuals
with major neurocognitive disorder due to Alzheimer’s
disease also have major depression [11]. For these reasons,
concomitant assessment of cognition is essential to the
evaluation of the older adult presenting with depressive
symptoms [30]. Cognitive domains that may be affected
include learning and memory, language, attention, perceptual motor abilities, social cognition, and executive
function [4]. Many of these domains can be assessed
during the mental status examination, with brief cognitive
screening tools, or with formal neuropsychological testing.
Vol. 24, No. 3 March 2017 JCOM 137
Late-life depression
While there are numerous cognitive screening tools,
some commonly used, brief tools include the Mini-Cog,
the Folstein Mini-Mental State Exam (MMSE), and the
Montreal Cognitive Assessment (MoCA). The MiniCog consists of a 3-item registration, delayed recall, and
clock drawing test and has several advantages over other
screening tools. It is a brief test (taking approximately
3 minutes to administer) with good sensitivity and
specificity of 80% or greater. Compared with other
cognitive screening tools, it is less influenced by level of
education, language, or cultural background [31–33].
The MMSE is a longer screening tool consisting of
19 items and requires about 10 minutes to administer.
Unlike the Mini-Cog, performance on the MMSE can
be affected by level of education and cultural background.
However, the MMSE can be administered serially to monitor changes in cognition over time [34,35]. The MoCA
is a 10-minute cognitive screening tool first developed to
detect mild cognitive impairment (MCI) [36]. The MoCA
consists of 7 subscore sections covering visuospatial/
executive function, naming, memory (delayed recall),
attention, language, abstraction, and orientation. The
total score is 30, and 1 point is added to the score if
the testing subject has less than high school/12 years
of education. The MoCA has demonstrated better sensitivity than the MMSE for the detection of MCI [36].
Elderly patients with depression often perform poorly on
these cognitive screening tests due to apathy and poor
effort.
Functional Assessment
The diagnosis of LLD requires that symptoms cause
significant distress or interfere with functioning. A functional assessment is especially important in the evaluation
of the older adult in that it allows clinicians to determine
an individual’s ability to live independently and attend
to daily needs. Basic activities of daily living (ADLs)
include bathing, dressing, grooming, toileting, and selftransferring. Instrumental activities of daily living
(IADLs) include more complex daily activities such as preparing meals, administering medications, driving, managing finances, and using simple electronics such as the
telephone or remote control [26]. Impairment in IADLs is
associated with increased depression severity. Conversely,
the severity of depressive symptoms along with associated
cognitive impairment predicts IADL impairment [37].
The Philadelphia Multilevel Assessment Instrument is a
tool that can aid in the assessment of ADLs and IADLs
138 JCOM March 2017 Vol. 24, No. 3
and has been utilized in studies examining disability in
depressed elderly patients [37,38]. Other available scales
to quantify functional status include OARS Physical
Activities of Daily Living, OARS Instrumental Activities
of Daily Living Scale, and Direct Assessment of Functional Status Scale [26].
Suicide Assessment
Assessment for suicidality is an integral part of all psychiatric evaluations and is especially important in the
evaluation of the depressed older adult. According to the
Centers for Disease Control and Prevention, the suicide
rate for individuals age 65 and older is 16.6 per 100,000,
a figure that is comparable to that for individuals 18–64
years of age [39]. Non-Hispanic Caucasian males age
85 and older have the highest rate of completed suicide
(56.5 per 100,000), underscoring the importance of a
thorough suicide assessment [39]. Suicidality can range
from passive thoughts of death and wishing that one
were not alive, to active thoughts of self-harm with plan
and intent. A Canadian study found 2% of communitydwelling adults age 55 and older had suicidal thoughts
over a 12-month period and, of these, 28% had major
depression [40]. A suicide assessment begins with inquiring about the presence of suicidal thoughts, plans, and
intent. The 3 most frequently used methods of completed
suicide in the elderly are firearms (28%), hanging (24%)
and poisoning (21%) [41]. Access to weapons or other
lethal means of self-harm such has hoarding of medications should be ascertained.
A complete suicide assessment requires attention to
suicide risk factors, protective factors, and warning signs
of impending suicide. Risk factors for suicide in the older
adult include mood disorders, chronic medical illnesses
and associated functional impairment, chronic pain, and
psychosocial factors such as social isolation [42]. Mood
disorders are present in 54% to 87% of cases of completed
suicide, with major depression being the most common
[42]. Chronic medical illness and pain can result in
functional impairment leading to feelings of excessive
guilt or being a burden to loved ones. Protective factors such as social connectedness, spirituality, religious
beliefs, and cultural attitudes against suicide may serve as
buffers against these risk factors [43]. Warning signs of
impending suicide may indicate preparations for suicide
and include feelings of hopelessness or lack of purpose,
feeling trapped, talking about death, threatening suicide,
agitation, social withdrawal, increased substance use and
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Clinical Review
reckless behavior. Warning signs should prompt action to
ensure the safety of the individual [44,45].
Physical Examination, Laboratory Studies, and
Neuroimaging
Evaluation of LLD is not complete without a physical
examination and ancillary studies to identify underlying
medical conditions possibly contributing to or mimicking
depressive symptoms. Routine laboratory studies include
complete blood count, complete metabolic panel, thyroid
studies, and urine drug screen. Signs and symptoms of
underlying medical conditions may necessitate further
laboratory studies [46]. Neuroimaging may reveal signs
of cerebrovascular disease which can predispose, precipitate, or perpetuate depression in older adults [47].
Treatment
Treatment of LLD can take many forms and occur in
various settings. Geriatric psychiatrists have expertise
in the assessment and treatment of mental illness in the
elderly. Workforce estimates for 2010 revealed 1 geriatric psychiatrist per 10,000 adults age 75 and over. This
figure is estimated to decrease to 0.5 per 10,000 by the
year 2030, underscoring the importance of increasing
the knowledge base of clinicians across specialties who
provide care to the depressed elderly [48]. The primary
care setting is often the locus of care for depression in
older adults; however, studies suggest that patients are
often left untreated or undertreated [49]. Collaborative
care models whereby mental health care is integrated
into primary care have been shown to improve outcomes.
The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) study found that use of
care managers to assist primary care providers in identification of depression, offer algorithm-based treatment
recommendations, monitor symptoms and medication
side effects, and provide follow-up yielded improvement
in outcomes. Patients in the intervention group were
more likely to receive pharmacotherapy or psychotherapy,
achieve remission, and showed greater decline in suicidal
ideation [50]. Similar results were found in the Improving Mood-Promoting Access to Collaborative Treatment
(IMPACT) study in which intervention patients treated
under a collaborative care model showed lower depression severity, less functional impairment, and greater
reduction in depressive symptoms [25].
Just as a collaborative care model can lead to improved
outcomes, the overall strategy of treating depression
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must be multifaceted. The biopsychosocial model of
disease first described in the 1970s emphasizes biological and psychosocial determinants of illness that must be
addressed when treatment is considered [51]. This
includes nonmodifiable biological factors such as age,
gender, and genetic predisposition that may affect treatment options, as well as modifiable biological factors such
as comorbid medical illness, medications, or substance use
disorders. Psychological factors that can affect depressive
symptoms include coping skills and defense mechanisms
in the face of stressful life events. Social factors including
the role of culture, environment, and family dynamics in
disease presentation must be considered as well [52].
Pharmacologic Treatment of LLD
The primary pharmacologic treatment for depression is
antidepressants. Treatment consists of 3 phases—acute,
continuation, and maintenance. In the acute phase, the
goal is remission of current symptoms and restoration
of function. The continuation phase, extending up to 6
months after remission, aims to prevent relapse back into
a depressive episode. Maintenance therapy is geared at
preventing recurrence of future depressive episodes [53].
Studies have found a 50% risk of relapse after 1 episode
of depression and 80% after 2 episodes. Up to 20% will
develop chronic symptoms. For this reason, maintenance
therapy is often necessary for recurrent depression [54].
Studies have demonstrated antidepressants to be
superior to placebo in the treatment of geriatric depression. Table 3 summarizes commonly prescribed antidepressants and usual geriatric doses. A large meta-analysis
of 51 double-blind randomized controlled trials with
depressed patients age 55 and older without comorbid
dementia found antidepressants to be superior to placebo
in achieving both response (48%) and remission (33.7%)
[55]. Response was defined as greater than 50% decrease on
depression rating scales such as the Hamilton Depression
Rating Scale (HAM-D) or the Montgomery Åsberg
Depression Rating Scale (MADRS), both of which are
considered gold standards in antidepressant clinical trials
[56,57]. Remission was defined as a score less than 7 or
10 on the HAM-D (depending on the version used) or less
than 12 on the MADRS. This study found no difference
in response and remission rates between tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors
(SSRIs), and other antidepressants (serotonin norepinephrine reuptake inhibitors [SNRIs], bupropion, mirtazapine,
nefazodone, trazodone, and several other antidepressants
Vol. 24, No. 3 March 2017 JCOM 139
Late-life depression
Table 3. Commonly Prescribed Antidepressants and Geriatric Dosing
Class/Mechanism of Action
SSRI
Agent
Geriatric Starting Dose
Citalopram
Escitalopram
10 mg
20 mg
5 mg
10 mg
Fluoxetine
10 mg
40 mg
Paroxetine
10 mg
20–40 mg
25–50 mg
100–200 mg
Sertraline
SNRI
Target Dose
Desvenlafaxine
Duloxetine
Levomilnacipran
Venlafaxine XR
25 mg
50 mg
20–40 mg
30–60 mg
20 mg
40–120 mg
37.5–75 mg
150–225 mg
150 mg
150–300 mg
NDRI
Bupropion XL
SSRI + 5-HT partial agonist
Vilazodone
10 mg
40 mg
Central alpha 2 antagonist + 5-HT antagonist
Mirtazapine
7.5 mg
15–45 mg
SSRI + 5-HT agonist and antagonist
Vortioxetine
5 mg
20 mg
5-HT = 5-hydroxytryptamine (serotonin) NDRI = norepinephrine dopamine reuptake inhibitor; SNRI = serotonin norepinephrine reuptake
inhibitor; SSRI = selective serotonin reuptake inhibitor. Data from reference 65.
not available in the United States) [55]. Similar results
regarding efficacy were found by Mukai and Tampi in a
systematic review comparing older patients with major
depression prescribed SSRIs or dual-acting agents (SNRIs
and TCAs). This study also found similar efficacy between
single- and dual-acting antidepressants [58].
While cognitive impairment may affect antidepressant
efficacy, age does not appear to be a determinant. Gildengers et al examined antidepressant response in young,
middle, and older-old patients and found no significant
difference in response rates [59]. Early onset versus late
onset of first depressive episode also does not predict
antidepressant response in patients age 55 and over [60].
There is scant evidence for efficacy of antidepressants in
depressed patients with neurocognitive disorders. A 2002
Cochrane review with 4 studies in the meta-analysis
(n = 137) concluded that there was weak support for antidepressant efficacy in this population [61]. A 2011 metaanalysis with 330 participants also yielded inconclusive
results [62]. The paucity of evidence for antidepressant
efficacy in depressed patients with neurocognitive disorders should prompt careful consideration of potential
benefits versus adverse effects.
Antidepressants are generally well tolerated in older
adults. Side effects vary by medication and contribute to
discontinuation in up to 25% of new users (versus 22%
for new users who discontinue for reasons other than
side effects) [63]. Potential adverse effects shared by most
140 JCOM March 2017 Vol. 24, No. 3
SSRIs and SNRIs include GI disturbance (nausea, diarrhea or constipation), sexual dysfunction, headache, and
sleep disturbance [64,65]. In addition, abrupt discontinuation can precipitate serotonin withdrawal syndrome
characterized by sensory disturbance (paresthesia, tremor, and irritability) as well as headache, lightheadedness,
diaphoresis, insomnia, and agitation. Other medicationspecific side effects include risk of seizure with bupropion
and sedation with mirtazapine [65].
Despite superiority of antidepressants to placebo in
treating depression, up to one-third of patients may not
respond to a trial of antidepressants. Sequential treatment
protocols such as switching to a different antidepressant or
augmentation can increase the proportion of antidepressant responders [66–68]. Studies have found particularly
favorable response to augmentation with lithium, with
one study achieving a 33% remission rate in treatmentresistant geriatric depression [67,69]. Other pharmacologic
augmentation strategies include the addition of mood stabilizers such as lamotrigine, antipsychotics (aripiprazole,
olanzapine, quetiapine, and risperidone), and psychostimulants [70–73]. Electroconvulsive therapy (ECT) is a
nonpharmacologic option for treatment-resistant depression that will be reviewed later.
Psychotherapeutic and Psychosocial Interventions
Psychotherapeutic interventions have demonstrated efficacy in the treatment of geriatric depression, including but
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Clinical Review
not limited to cognitive behavioral therapy (CBT), interpersonal therapy (IPT), problem-solving therapy (PST),
reminiscence and life review, and brief psychodynamic
psychotherapy [74]. Some older adults may prefer psychotherapy to pharmacologic treatment (57% vs. 43%) [75].
Potential benefits of psychotherapy include ability to directly address psychosocial stressors that may precipitate or perpetuate depressive symptoms. In addition, psychotherapy is
associated with few to no side effects and avoids drug interactions. Barriers to employing psychotherapy may include
cost and access to trained psychotherapists [76]. Efficacy
of several psychotherapeutic approaches in the care of older
depressed adults has been examined. CBT, brief psychodynamic psychotherapy, and IPT will be briefly reviewed here.
CBT. Cognitive therapy was first described by Aaron Beck
in the 1960s [77]. It is a highly structured therapy built
on the premise that beliefs and assumptions an individual
holds can influence emotions and behavior. CBT aims
to identify maladaptive belief systems, test the validity of
these cognitive distortions, and help individuals formulate
more realistic cognitions [78]. Symptom improvement
results from addressing these cognitive aspects as well
as integration of behavioral activation and skills training
to overcome maladaptive behavioral patterns [78]. CBT
approaches have been applied to older adults with depression and results show acceptability [79] and efficacy in this
population [80–82]. A 2008 Cochrane review (n = 153)
found CBT to be superior to waitlist controls [82].
Brief psychodynamic psychotherapy. Brief psychodynamic psychotherapy, unlike highly structured CBT,
aims to alter behavior by examining how past experiences
and unresolved conflicts influence current emotions and
behavior. While studies on application to the treatment
of geriatric depression are scarce, limited data demonstrate efficacy in treating geriatric depression [81] and
no significant difference in outcomes when compared to
CBT [82].
IPT. Like CBT, IPT is a structured time-limited psychotherapeutic treatment approach first developed in the
late 1960s by Klerman and Weissman [83]. IPT focuses
on the impact of interpersonal relationships on depressive
symptoms and examines 4 domains: interpersonal conflict, interpersonal deficits, role transitions, and grief [74].
Studies have shown efficacy of IPT in reducing
depressive symptoms in the elderly when compared to
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usual care [84]. Reynolds et al found IPT combined with
nortriptyline (a tricyclic antidepressant) to be superior
to either nortriptyline alone or IPT alone in preventing
recurrent depressive episodes [85]. Interestingly, a similar
study investigating the efficacy of IPT in combination
with paroxetine (an SSRI) failed to show added benefit
of IPT in preventing recurrence, suggesting that further
studies are needed [86].
Psychosocial interventions are integral in the care of
the elderly depressed patient. Studies have shown positive
benefits of aerobic exercise on depressive symptoms [87].
Yoga, Tai Chi, and other mindfulness-based exercises
can increase sense of emotional and physical wellbeing
[88–90]. Spirituality, religious beliefs, and involvement
with a faith group may be protective against development of mental illness while at the same time provide
avenues for increased social connectedness [91]. These
and other avenues for socialization should be encouraged as part of the treatment plan for older depressed
patients [92].
Electroconvulsive Therapy
ECT is indicated for the treatment of mood and psychotic disorders and has demonstrated efficacy in the
treatment of severe depression [93]. It is typically initiated when patients fail to respond to pharmacotherapy
and psychotherapy. Circumstances in which ECT can
be considered first-line treatment include situations that
require a rapid response (severe inanition, weight loss,
or suicidality), situations where risks of ECT are lower
than that of alternative treatments, previous positive
response to ECT, or strong patient preference [94]. ECT
is performed under general anesthesia and involves the
induction of a generalized tonic-clonic seizure, which
is theorized to enhance serotonergic, noradrenergic,
and dopaminergic neurotransmission. A typical course
of ECT involves treatments 3 times a week for an average of 6 to 12 treatments in total [95]. Elderly patients
and those suffering from severe depression with psychotic features respond more robustly to ECT [93,96].
Estimated remission rates after an ECT series have been
higher than 80% [93], making this modality the most
effective treatment for severe depression to date.
Conclusion
As the population continues to age, clinicians are increasingly likely to encounter patients with late-life depression.
Vol. 24, No. 3 March 2017 JCOM 141
Late-life depression
A thorough evaluation includes not only assessment of
depressive symptoms, but also cognitive, functional, and
suicide assessment. Treatment options include pharmacotherapy, psychotherapy, and in some cases electroconvulsive therapy. Utilization of assessment and treatment
nuances unique to the geriatric population, with a multidisciplinary and collaborative approach involving primary
care, mental health, and other ancillary providers, will
serve to ultimately enhance patient care.
Corresponding author: Corresponding author: Juliet Glover,
MD, Dept. of Neuropsychiatry and Behavioral Science, Univ.
of South Carolina School of Medicine, 15 Medical Park, Suite
301, Columbia, SC 29203, [email protected].
Financial disclosures: None reported.
Author contributions: conception and design, JAG, SS;
drafting of article, JAG, SS; critical revision of the article,
JAG, SS.
References
1. Vincent GK, Velkoff VA. The next four decades: the older
population in the United States: 2010 to 2050. US Census
Bureau: May 2010.
2. Koenig HG, Blazer DG. Epidemiology of geriatric affective
disorders. Clinc Geriatr Med 1992; 8:235–51.
3. Ferrari AJ, Charlson FJ, Norman RE, et al. Burden of depressive disorders by country, sex, age, and year: findings
from the global gurden of disease study 2010. PLoS Med
2013;10:e1001547.
4 . American Psychiatric Association. Diagnostic and statistical
manual of mental disorders. 5th ed. Arlington, VA: American
Psychiatric Publishing; 2013.
5 . Ellison JM, Kyomen HH, Harper DG. Depression in later life:
an overview with treatment recommendations. Psychiatr Clin
North Am 2012;35:203–29.
6. Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major depressive disorder: results from the National
Epidemiologic Survey on Alcoholism and Related Conditions.
Arch Gen Psychiatry 2005;62:1097–106.
7. Steffens DC, Skoog I, Norton MC, et al. Prevalence of depression and its treatment in an elderly population: the Cache
County study. Arch Gen Psychiatry 2000;57:601–7.
8 . Kessler RC, Berglund P, Demler O, et al. The epidemiology of
major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289:3095–105.
9. McKinney BC, Sibille E. The age-by-disease interaction
hypothesis of late-life depression. Am J Geriatr Psychiatry
2013;21:418–32.
10. Djernes JK. Prevalence and predictors of depression in populations of elderly: a review. Acta Psychiatr Scand 2006;113:372–87.
11. Blazer DG. Depression in late life: review and commentary. J
Gerontol A Biol Sci Med Sci 2003;58:249–65.
12. Cole MG, Dendukuri N. Risk factors for depression among
142 JCOM March 2017 Vol. 24, No. 3
elderly community subjects: a systematic review and metaanalysis. Am J Psychiatry 2003;160:1147–56.
13.Ritchie K. Late-life depression. European Psychiatry
2014;29:577.
14. Hegeman JM, de Waal MW, Comijs HC, et al. Depression
in later life: a more somatic presentation? J Affect Disord
2015;170:196–202.
15. Lackamp J, Schlachet R, Sajatovic M. Assessment and management of major depressive disorder in older adults. Psychiatria Danubina 2016;28(Suppl 1):95–98.
16. Morichi V, Dell’Aquila G, Trotta F, et al. Diagnosing and
treating depression in older and oldest old. Curr Pharm Des
2015;21:1690–8.
17. Fiske AJ, Wetherell JL, Gatz M. Depression in older adults.
Annu Rev Clin Psychol 2009;5:363–89.
18. Balsis S, Cully JA. Comparing depression diagnostic symptoms across younger and older adults. Aging Ment Health
2008;12:800–6.
19. Hegeman JM, Kok RM, van der Mast RC, Giltay EJ. Phenomenology of depression in older compared with younger
adults: meta-analysis. Br J Psychiatry 2012;200:275–81.
20. Mitchell AJ, Bird V, Rizzo M, Meader N. Which version of
the geriatric depression scale is most useful in medical settings
and nursing homes? Diagnostic validity meta-analysis. Am J
Geriatr Psychiatry 2010;18:1066–77.
21. Blazer DG. The psychiatric interview of older adults. In:
Blazer D, Steffens D, Busse E, editors. Textbook of geriatric
psychiatry. 3rd ed. Arlington, VA: American Psychiatric Publishing; 2004.
22. Spitzer RL, Kroenke K, Williams JW. Validation and utility of
a self-report version of PRIME-MD: the PHQ primary care
study. Primary Care Evaluation of Mental Disorders. Patient
Health Questionnaire. JAMA 1999;282:1737–44.
23. Richardson TM, He H, Podgorski C, et al. Screening for
depression in aging services clients. Am J Geriatr Psychiatry
2010;18:1116–23.
24. Archer J, Bower P, Gilbody S, et al. Collaborative care for
depression and anxiety problems. Cochrane Database Syst Rev
2012 Oct 17.
25. Unutzer J, Katon W, Callahan CM, et al. Collaborative care
management of late-life depression in the primary care setting
a randomized controlled trial. JAMA 2002;288:2836–45.
26. Silver I, Herrmann N. Comprehensive psychiatric evaluation.
In: Sadavoy J, Jarvik L, Grossberg G, Meyers B, editors. Comprehensive textbook of geriatric psychiatry. 3rd ed. New York:
W.W. Norton; 2004.
27. Rapp MA, Dahlman K, Sano M, et al. Neuropsychological
differences between late-onset and recurrent geriatric major
depression. Am J Psychiatry 2005;162:691–8.
28. Sheline YI, Barch DM, Garcia K, et al. Cognitive function in
late life depression: relationships to depression severity, cerebrovascular risk factors and processing speed. Biol Psychiatry
2006; 60:58–65.
29. Barnes DE, Yaffe K, Byers AL, et al. Midlife vs late-life depressive symptoms and risk of dementia: differential effects for
Alzheimer disease and vascular dementia. Arch Gen Psychiatry
2012;69:493–8.
www.jcomjournal.com
Clinical Review
30. Morimoto SS, Kanellopoulos D, Manning KJ, Alexopoulos
GS. Diagnosis and treatment of depression and cognitive
impairment in late life. Ann NY Acad Sci 2015;1345:36–46.
31. Borson S, Scanlan J, Brush M, et al. The mini-cog: a cognitive
‘vital signs’ measure for dementia screening in multi-lingual
elderly. Int J Geriatr Psychiatry 2000;15:1021–7.
32. Brodaty H, Low LF, Gibson L, Burns K. What is the best dementia screening instrument for general practitioners to use?
Am J Geriatr Psychiatry 2006;14:391–400.
33. Ismail Z, Rajji TK, Shulman KI. Brief cognitive screening instruments: an update. Int J Geriatr Psychiatry 2010;25:111–20.
34. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”.
A practical method for grading the cognitive state of patients
for the clinician. J Psychiatr Res 1975;12:189–98.
35. Vertesi A, Lever JA, Molloy DW, et al. Standardized MiniMental State Examination. Use and interpretation. Can Fam
Physician 2001;47: 2018–23.
36. Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal
Cognitive Assessment, MoCA: a brief screening tool for mild
cognitive impairment. J Am Geriatr Soc 2005;53:695–9.
37. Kiosses DN, Alexopoulos GS. IADL functions, cognitive
deficits, and severity of depression: a preliminary study. Am J
Geriatr Psychiatry 2005;13:244–9.
38. Alexopoulos GS, Vrontou C, Kakuma T, et al. Disability in
geriatric depression. Am J Psychiatry 1996;153:877–85.
39. Centers for Disease Control and Prevention. National Center
for Injury Prevention and Control. Web-Based Injury Statistics Query and Reporting System (WISQARS). Accessed 9
Feb 2016 at http://webappa.cdc.gov/sasweb/ncipc/dataRestriction_inj.html.
40. Corna LM, Cairney J, Streiner DL. Suicide ideation in older
adults: relationship to mental health problems and service use.
Gerontologist 2010;50:785–97.
41. Juurlink DN, Herrmann N, Szalai JP, et al. Medical illness and the risk of suicide in the elderly. Arch Intern Med
2004;164:1179–84.
42. Van Orden K, Conwell Y. Suicides in late life. Curr Psychiatry
Rep 2011;13:234–41.
43. Conwell Y, Van Orden K, Caine ED. Suicide in older adults.
Psychiatr Clin North Am 2011;34:451–68, ix.
44. Rudd MD, Berman AL, Joiner TE, et al. Warning signs for
suicide: theory, research, and clinical applications. Suicide Life
Threat Behav 2006;36:255–62.
45. Know the warning signs of suicide. American Association of
Suicidology. Accessed 9 Feb 2016 at www.suicidology.org/
resources/warning-signs.
46. Taylor W, Doraiswamy P. Use of the laboratory in the diagnostic workup of older adults. In: Blazer D, Steffen D, Busse
E, editors. Textbook of geriatric psychiatry. 3rd ed. Arlington,
VA: American Psychiatric Publishing; 2004.
47. Alexopoulos GS, Meyers BS, Young RC, et al. ‘Vascular depression’ hypothesis. Arch Gen Psychiatry 1997;54:915–22.
48. ADGAP Status of Geriatrics Workforce Study. Accessed 26
Dec 2016 at www.americangeriatrics.org/files/documents/
gwps/Table%201_29.pdf.
49. Alexopoulos G. Late-life mood disorders. In: Sadavoy J, Jarvik
L, Grossberg G, Meyers B, editors. Comprehensive textbook
www.jcomjournal.com
of geriatric psychiatry. 3rd ed. New York: W.W. Norton;
2004.
50. Alexopoulos GS, Reynolds CF, Bruce ML, et al. Reducing
suicidal ideation and depression in older primary care patients:
24-month outcomes of the PROSPECT study. Am J Psychiatry 2009;166:882–90.
51. Engel GL. The need for a new medical model: a challenge for
biomedicine. Science 1977;196:129–36.
52. Schotte CKW, Van den Bossche B, Doncker DD, et al. A biopsychosocial model as a guide for psychoeducation and treatment of depression. Depression Anxiety 2006;23:312–24.
53. Kupfer DJ, Frank E. The interaction of drug-and psychotherapy in the long-term treatment of depression. J Affect Disord
2001;62:131–7.
54. Katon W, Rutter C, Ludman EJ, et al. A randomized trial of
relpase prevention of depression in primary care. Arch Gen
Psychiatry 2001;58:241–7.
55. Kok RM, Nolen WA, Heeren TJ. Efficacy of treatment in
older depressed patients: a systematic review and meta-analysis
of double-blind randomized controlled trials with antidepressants. J Affect Disord 2012;141:103–15.
56. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56–62.
57. Montgomery SA, Asberg M. A new depression scale designed
to be sensitive to change. Br J Psychiatry 1979;134:382–9.
58. Mukai Y, Tampi RR. Treatment of depression in the elderly: a
review of the recent literature on the efficacy of single- versus
dual-action antidepressants. Clin Ther 2009;31:945–61.
59. Gildengers AG, Houck PR, Mulsant BH, et al. Course and
rate of antidepressant response in the very old. J Affect Disord
2002;69:177–84.
60. Kozel FA, Trivedi MH, Wisniewski SR, et al. Treatment
outcomes for older depressed patients with earlier versus late
onset of first depressive episode. Am J Geriatr Psychiatry
2008;16:58–64.
61. Bains J, Birks J, Dening T. Antidepressants for treating depression in dementia. Cochrane Databse Syst Rev
2002;(4):CD003944.
62. Nelson JC, Devanand DP. A systematic review and meta-analysis of placebo-controlled antidepressant studies in people with
depression and dementia. J Am Geriatr Soc 2011;59:577–85.
63. Mark TL, Joish VN, Hay JW, et al. Antidepressant use in
geriatric populations: the burden of side effects and interactions and their impact on adherence and costs. Am J Geriatr
Psychiatry 2011;19:211–21.
64. Frank C. Pharmacologic treatment of depression in the elderly. Can Fam Physician 2014;60:121–6.
65. Kennedy GJ, Marcus P. Use of antidepressants in older patients
with co-morbid medical conditions: guidance from studies of
depression in somatic illness. Drugs Aging 2005;22:273–87.
66. Sackheim HA, Kupfer DJ, Luther J, Fava M. Acute and
longer-tern outcomes in depressed outpatients requiring one
or several treatment steps: a STAR*D report. Am J Psychiatry
2006;163:1905–17.
67. Kok RM, Nolen WA, Hereen TJ. Outcome of late-life depression after 3 years of sequential treatment. Acta Psychiatr Scand
2009;119:274–81.
Vol. 24, No. 3 March 2017 JCOM 143
Late-life depression
68. Whyte EM, Basinski J, Farhi P, et al. Geriatric depression
treatment in nonresponders to selective serotonin reuptake
inhibitors. J Clin Psychiatry 2004;65:1634–41.
69. Kok RM, Vink D, Hereen TJ, Nolen WA. Lithium augmentation compared with phenelzine in treatment-resistant depression in the elderly; an open, randomized, controlled trial. J
Clin Psychiatry 2006;68:1177–85.
70. Kok RM. What is the role of medications in late life depression? Psychiatr Clin North Am 2003;36:597–605.
71. Wen XJ, Wang LM, Liu ZL,. Meta-analysis on the efficacy and
tolerability of the augmentation of antidepressants with atypical antipsychotics in patients with major depressive disorder.
Braz J Med Biol Res 2014;47:605–16.
72. Lenze EJ, Mulsant BH, Blumberger DM, et al. Efficacy,
safety, and tolerability of augmentation pharmacotherapy with
aripiprazole for treatment-resistant depression in late life: a
randomised double-blind, placebo-controlled trial. Lancet
2015;386:2404–12.
73. Alexopoulos GS, Canuso CM, Gharabawi GM, et al. Placebocontrolled study of relapse prevention with risperidone augmentation in older patients with resistant depression. Am J
Geriatr Psychiatry 2008;16:21–30.
74. Francis JL, Kumar A. Psychological treatment of late-life depression. Psychiatr Clin North Am 2013;36:561–75.
75. Gum AM, Arean PA, Hunkeler E, et al. Depression treatment
preferences in older primary care patients. Gerontologist
2006;46:14–22.
76. Pinquart M, Duberstein PR, Lyness JM. Treatments for
late-life depressive conditions: a meta-analytic comparison
of pharmacotherapy and psychotherapy. Am J Psychiatry
2006;163:1493–501.
77. Beck Institute for Cognitive Behavior Therapy. Accessed 28
Dec 2016 at www.beckinstitute.org
78. Beck AT. Cognitive therapy: nature and relation to behavior
therapy. Behav Ther 1970;1:184–200.
79. Landrevile P, Landry J, Baillargeon L, et al. Older adults’
acceptance of psychological and pharmacological treatments for depression. J Gerontology B Psychol Sci Soc Sci
2001;56:P285–91.
80. Thompson LW, Gallagher D, Breckenridge JS. Comparitive
effectiveness of psychotherapies for depressed elders. J Consult
Clin Psychol 1987;55:385–90.
81. Gallagher-Thompson D, Steffen AM. Comparative effects of
cognitive-behavioral and brief psychodynamic psychotherapies for depressed family caregivers. J Consult Clin Psychol
1994;62:543–9.
82. Wilson KC, Mottram PG, Vassilas C. Psychotherapeutic treatments for older depressed people. Cochrane Database Syst
Rev 2008;(1):CD004853
83. Markowitz JC, Weissman MM. Interpersonal psychotherapy: past, present and future. Clin Psychol Psychother
2012;19:99–105.
84. Van Schaik A, van Marwijk H, Ader H, et al. Interpersonal
psychotherapy for elderly patients in primary care. Am J Geriatr Psychiatry 2006;14:777–86.
85. Reynolds CF 3rd, Frank E, Perel JM, et al. Nortriptyline
and interpersonal psychotherapy as maintenance therapies for
recurrent major depression: a randomized controlled trial in
patients older than 59 years. JAMA 1999;281:39–45.
86. Reynolds CF 3rd, Dew MA, Pollock BG, et al. Maintenance
treatment of major depression in old age. N Engl J Med
2006;354:1130–8.
87. Blumenthal JA, Babyak MA, Moore KA, et al. Effects of exercise training on older patients with major depression. Arch
Intern Med 1999;159:2349–56.
88. Krishnamurthy MN, Telles S. Assessing depression following two ancient Indian interventions: effects of yoga and
ayurveda on older adults in a residential home. J Gerontol
Nurs 2007;33:17–23.
89. Wang C, Bannuru R, Ramel J, et al. Tai Chi on psychological
well-being: systematic review and meta-analysis. BMC Complement Altern Med 2010;10:23.
90. Cho KL. Effect of tai chi on depressive symptoms amongst
Chinese older patients with depressive disorders: a randomized clinical trial. Med Sport Sci 2008;52:146–54.
91. Moritz S, Quan H, Rickhi B, et al. A home study-based spirituality education program decreases emotional distress and
increases quality of life- a randomized, controlled trial. Altern
Ther Health Med 2006;12:26–35.
92. Nyer M, Doorley J, Durham K, et al. What is the role of alternative treatments in late-life depression? Psychiatr Clin North
Am 2013;36:577–96.
93. Petrides G, Fink M, Husain MM, et al. ECT remission rates
in psychotic versus nonpsychotic depressed patients: a report
from CORE. J ECT 2001;17:244–53.
94. Mankad MV, Beyer JL, Weiner RD, Krystal AD. Clinical
manual of electroconvulsive therapy. American Psychiatric
Publishing; 2010.
95. Kellner CH, Greenberg RM, Murrough JW, et al. ECT in treatment-resistant depression. Am J Psychiatry 2012;169:1238–44.
96. Flint AJ, Gagnon N. Effective use of electroconvulsive therapy
in late-life depression. Can J Psychiatry 2002;47:734–41.
Copyright 2017 by Turner White Communications Inc., Wayne, PA. All rights reserved.
144 JCOM March 2017 Vol. 24, No. 3
www.jcomjournal.com