Treatment of depressive disorders may involve psychopharmacology, psychotherapy, or both. Studies have shown that for mild depression, psychotherapy was more effective than placebo. For major depressive disorder (illness), psychopharmacologic treatment was more effective than psychotherapy alone. The most effective treatment with better long-term outcomes has been achieved with psychopharmacologic treatment combined with psychotherapy.

Treatment of a depressive disorder must begin with a comprehensive evaluation of the older person to rule out associated medical or physical conditions that may present as depressive illness or complicate the treatment of depression. A minimum evaluation of the older depressed patient should include a careful physical examination and laboratory studies including a complete blood cell count with differential; electrolyte determination; glucose, blood urea nitrogen, calcium, phosphorous, total protein, and serum albumin levels; liver function tests; and thyroid function tests. An electrocardiogram should be obtained. Current medications, (prescribed, over-the-counter medications, and those medications borrowed from neighbors and friends) should be reviewed.

Psychopharmacologic Treatment

The psychopharmacologic treatment of depressive disorders has advanced. Pharmacologic options now include cyclic antidepressants, monamine oxidase inhibitors, and the newer serotonin reuptake-inhibiting antidepressants. The selection of a specific antidepressant is determined by the older person’s symptoms and the side effect profile of the medication. The presence or absence of sleep problems, significant complaints of decreased energy, and the presence of cognitive difficulties are important considerations in the selection of specific medications.

Additional considerations in the treatment of depression are the presence of associated medical illnesses and medications prescribed for their treatment. The choice of an antidepressant medication in this case will be based on both the side effect profile of the antidepressant and the avoidance of potential drug-drug interactions. Because of the physiologic changes of aging (decreased renal blood flow, decrease in total body water, decrease in total lean body mass, decrease in microsomal enzyme activity, and an increase in total body fat), the doses of antidepressants used in the elderly are usually one third to one half the dose prescribed in younger patients.

The approach to the titration of an antidepressant is based on the caveat of starting with a lower dose and slowly increasing it, monitoring the older person for therapeutic response, and side effects. This approach has been summarized as “starting low and going slow(ly).” In some cases, older patients will require antidepressant doses similar to persons in their 30s and 40s. Obtaining blood levels of antidepressants in nonresponding elderly, depressed patients can be helpful in determining whether to increase the prescribed antidepressant or to move to the addition of lithium carbonate to augment the antidepressant effect of the initial medication. Unless the older person has had a history of successful treatment with a monoamine oxidase inhibitor in the past, monoamine oxidase inhibitors are not the first treatment of choice. As noted earlier, electroconvulsive therapy is the treatment of choice for the delusionally depressed older patient and the cachectic, profoundly withdrawn or actively suicidal elderly patient. Although a large body of literature exists on depressive illness, further studies on the efficacy of psychopharmacologic treatment of depression, particularly in the frail, US, ethnic, minority elderly are indicated.

Psychotherapeutic Treatment

Psychological development continues throughout the life cycle. Chronological age may or may not be comparable to the person’s development age. The physician and poet, William Carlos Williams, described the older patient’s mobilization to “reach for what can be added in later life.” Gould stated that elders in contact with their inner core presented with the inevitable hazards of late life faced these developmental stressors with greater strength and were able to bounce back. Their sense of meaning resided within them and was not an external sense of meaning based on power and status. The maintenance of self-esteem may be adaptively accomplished by the elder. The psychosocial perspective of self-esteem noted that several strategies were used by older persons to defend against the erosion of their self-esteem (Table 4).

The psychotherapeutic treatment of depressive illness in the elderly should be based on the biopsychosocial model conceptualized by Engle. The therapist needs to be sensitive to the intrapsychic processes of the older person and facilitate the patient’s recognition and understanding of these psychological processes. The biological sphere has an increased effect due to the physiologic changes of aging and the associated development of physical illnesses. Clarification of the social network and social supports of the older patient as well as the various social interactions of the patient will enable the therapist to assess the extent to which the older patient is at risk to feelings of isolation or alienation. The redefinition of meaningful activity and the establishment of new goals in the context of retirement from work is an important psychological task. A successful redefinition of roles will establish new directions and goals for the older, retired individual.

Niederehe noted that psychotherapeutic intervention in the elderly was more likely to be based on psychodynamic and socioenvironmental principles. As late-life depression has been associated often with risk factors such as stressful life events, family conflict, and the absence of social resources (family support and relations with confidants), these factors partially influence the specific therapeutic intervention selected. Niederehe also noted that the significant clinical literature that existed on the value of various psychosocial treatments in the elderly were predominantly theoretical articles, description of techniques, and reports of individual treatment cases. He found few articles that met acceptable methodological standards for psychotherapy outcome research and encouraged further work in this area.

Recently published practice guidelines for major depressive disorder in adults by the American Psychiatric Association suggest specific criteria for US psychiatrists and other mental health professionals to use in the selection of a behavioral, psychodynamic, or group psychotherapy approach to the psychotherapeutic treatment of depression. Because of the potential for relapse, the continuation of antidepressant medication beyond a 9-month period of treatment will need to be discussed with the patient in the context of his or her prior history of depressive illness and response to treatment. It is recommended that the full therapeutic dose of medication that produced a therapeutic response should be continued for a minimum of 16 to 20 weeks after remission of symptoms has been achieved.

Although controversial in the US, electroconvulsive therapy is the most effective treatment for major depressive disorder. In 50% of patients nonresponsive to anti-depressants, electroconvulsive therapy has produced a satisfactory response.

Conclusion

This article reviewed the epidemiologic data on the prevalence of major depressive disorders in community resident elderly and compared international prevalence rates of depressive symptoms (4.4% to 12.6%). The prevalence rate for major depressive disorder among US residents aged 55 years and older was reported to range from 0.81 % to 1.9% among community residents and from 12% to 42% among the medically ill elderly.

Specific factors associated with a report of depressive symptoms were identified from the literature: poor physical health due to medical illness; physical disability; single marital status due to being widowed, divorced, or separated; a restricted support networks resulting in social isolation; bereavement; poverty; and education ≤4 years.

The importance of recognizing alternative presentations of depressive disorder in the elderly was emphasized. Three presentations of late-life depression were described: masked depression, pseudodementia, and delusional depression. Four types of depressive illness in the older US residents were reported by the literature: major depressive disorder, dysthymia, depressive symptoms secondary to medical illness that did not met DSM-IV criteria for a depressive disorder, and a mixed depression anxiety syndrome.

Specific concerns for the treatment of depressive disorder with psychopharmacology and psychotherapy were discussed. Antidepressant medications were needed to facilitate the biochemical readjustment of neurotransmitter levels. Psychotherapy facilitated the reactivation of prior effective, psychological coping capacities, and reworked the destructive thought patterns associated with major depressive disorder for a patient with an uncomplicated major depression. The importance of considering the social network and social roles of the elder person was emphasized. The importance of continuing an antidepressant at the full therapeutic dose for a minimum of 16 to 20 weeks after remission of symptoms was emphasized. Finally, the effective role of electroconvulsive therapy in the treatment of late-life depressive disorders was described.

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